york city sd registration€¦ · welcome to the school district of the city of york. please...

Last Updated: 1/18/19 1 of 7 York City SD Registration.xlsx

1. Original or certified copy of Certificate of Birth (Birth Certificate)2. Immunization Documentation (Shot Records)3. Photo Identification of Parent/Guardian4. Proof of Residency Documentation:

If you own your residence, you will need ONE of the following:*Mortgage Bill, Deed or Property Tax Bill*Signed Settlement Statement/Bill of Sale*Current Utility Bill for Electric, Gas, Oil, Water/Sewer, Landline Telephone, TV/Internet or Trash

(A Cell Phone bill is not acceptable.)

If you rent your residence you will need ONE of the following:*Signed Lease/Rental Agreement*Current Utility Bill for Electric, Gas, Oil, Water/Sewer, Landline Telephone, TV/Internet or Trash

(A Cell Phone bill is not acceptable.)

If your residence is not in your name you will need ALL of the following:

*Photo Identification of the Residence Holder*One of the above Proof of Residency documents of Residence Holder from either the Own or Rent section.

If your student is not residing with a parent/guardian:*Notarized Affidavit Statement*Photo Identification of the Residence Holder*One of the above Proof of Residency documents of Residence Holder from either the Own or Rent section.

Before you complete this packet, please consider completing our online registration form instead. It is quicker and easier and may enable you to save a trip to the District Administrative Office.

Visit WWW.YCS.K12.PA.US and click on the Registration link in the menu bar!

Welcome to the School District of the City of York. Please complete all pages. Please bring the completed pages, along with the following documents to the Central Administration building located at 31 N.Pershing Avenue, York.

The School District of the City of York requires Proof of Residency per the Pennsylvania Department of Education for enrollment into our district. Proper Proof of Residency must be submitted at time of enrollment as well as for any change of address within the district. The district reserves the right to deny enrollment to any family that cannot provide proof of residence within our district borders, with accordance of the McKinney-Vento guidelines.

*Dated and Signed Letter from Residence Holder stating living situation. Must include parent/guardian's name as well as the student's name on the letter.

School District of the City of YorkRegistration Packet

SCHOOL DISTRICT OF THE CITY OF YORK31 NORTH PERSHING AVENUE, YORK, PA 17401

PHONE (717) 845-3571 FAX (717) 849-1394WWW.YCS.K12.PA.US/

SUPERINTENDENT: DR. ERIC HOLMESDISTRICT REGISTRARS:

YARIL CRUZ AT EXT 4029 AND EVA CURET AT EXT 4025EMAIL: [email protected] OR [email protected]


Student Demographics:Last Name: Gender: Male or Female

First Name: Birthdate: / /

Middle Name: Home Phone:

Suffix (Jr., III,): Grade Level:

Birth Country Birth City/State:

Student's Physical Address:Address 1: Address 2:

City: County:

State: Zip: Housing: Own Rent Lease Unknown

Parent/Guardian Contact Information:

Home Phone:

First Name: Cell Phone:

Work Phone:

Email:

City: Relationship Type:

Zip: Student Lives With?: Yes or No

Employer: Receive Mailings?: Yes or No

Home Phone:

First Name: Cell Phone:

Work Phone:

Email:

City: Relationship Type:

Zip: Student Lives With?: Yes or No

Employer: Receive Mailings?: Yes or No

*If student lives with a Foster Parent or Other non-parental adult, a Foster Placement Letter or Affidavit of Residency must be supplied.

State:

Address 1:

Address 2:

Last Name:

Last Name:

Address 1:

Address 2:

State:


Race/Ethnicity Information: Please circle to indicate the race and ethnicity of the student.

Black/African American Hispanic White AsianMulti-Racial Native Hawaiian/Pacific Islander American Indian/Alaskan Native

Demographic Information

Is the student a Foreign Exchange Student? Yes or No Is the student a single parent? Yes or No

Are either or both parents active in the U.S. Military? (AirForce, Navy, Army or Marines) Yes or No

Special Programs and/or Services:

Has your child ever been evaluated or received special education services? Yes or No

504 Plan Individual Education Plan (IEP)

Hearing Support Vision Support

Physical therapy (PT) Social Worker

Gifted (GIEP) Speech/Language Support

Occupational therapy (OT) Other Support/Services

Yes or No Date of Document:

Yes or No Date of Document:

Yes or No Agency Name:

Former School Information

Has this student ever attended York City School District? Yes or No Date last attended? / /

Last District this student was enrolled at:

Building:

Address:

City & State: Zip:

Date of W/D: / /

Signature of Parent/Guardian: Date:

Do you have a copy of your child's most recent school evaluation? (if applicable)

Does your child receive agency support?

I hereby grant the York City School District permission to collect data concerning my child such as:identifying attendance and test data, levels of achievement (grades), and report of teachers, counselorsand administrators.

If yes, please indicate the service and most recent date below. Please circle any and all services/programs that your child has received in the past and list the most current date of services if known.

Do you have a copy of your child's current IEP, GIEP or 504 plan? (if applicable)


Parental Registration Statement regarding Suspension and Expulsion from Previous District

If this student has not been or is presently suspended or expelled from another school, please complete all blanks and sign below:


If this student has been or is presently suspended or expelled from another school, please complete all blanks and sign below:

Name of School: Date of suspension/expulsion:

Reason for suspension/expulsion:


Weapon Violation - Expulsion Agreement


I, ________________________________________________, do hereby swear or affirm that I am the parent, guardian, or person having control of the student who is registering as a student in the School District of the City of York. Ifurther affirm that this student has not ever been suspended or expelled from any public or private school of thisCommonwealth or any other state for an act of offense involving weapons, alcohol or drugs, or for the willfulaffliction of injury to another person or for any act of violence committed on school property.

I, ________________________________________________, do hereby swear or affirm that I am the parent, guardian, or person having control of the student who is registering as a student in the School District of the City of York. Ifurther affirm that this student has been suspended or expelled from any public or private school of thisCommonwealth or any other state for an act of offense involving weapons, alcohol or drugs, or for the willfulaffliction of injury to another person or for any act of violence committed on school property.

Section 13.1317.2 commonly known as Act 26 of the Pennsylvania School Code provides that the Board ofSchool Directors of the School District of the City of York shall Expel, for a period of not less than one (1) year, anystudent who is determined to have brought or is in possession of a weapon on any school property, any school-sponsored activity or any public conveyance providing transportation to a school or school-sponsored activity.The Superintendent MAY, on a case-by-case basis, recommend less than the minimum one (1) year expulsion. This law applied regardless of whether such action was intentional, negligent or merely inadvertent.

The term "weapon" includes, but is not limited to: any knife, cutting instrument, cutting tool, nunchaku,firearm, shotgun, rifle, and any other object, tool, instrument or implement capable of inflicting serious bodilyinjury, and any object not normally considered a weapon, but which object was used, attempted to be used, orthreatened to be used to inflict bodily injury.

This notice is to inform you of Act 26 and the expulsion provisions of the Act. I have read and understand the conditions of this Agreement.

Prior to admission to any school entity, the parent, guardian or other person having control or charge of astudent shall, upon registration, provide a sworn statement or affirmation stating whether the pupil waspreviously suspended or expelled from any public or private school of this Commonwealth of any other state forany act of offense involving weapons, alcohol or drugs, or for the willful affliction of injury to another person orfor any act of violence committed on school property. The registration shall be maintained as part of thestudent's disciplinary records. Any willful false statement made under this section shall be a misdemeanor of thethird degree.


Signature of Student: Date:


Students 18 years and Older

Signature of Student: Date:

Photo/Media Release


Yes, I hereby grant permission to the School District of the City of York to use photographs, interviews, movies or videotapes of my child for school district publications or local media coverage.

No, I do not grant permission to the School District of the City of York to use photographs, interviews, movies or videotapes of my child for school district publications or local media coverage.

Should I violate any of the terms or conditions of this policy, I understand that I may lose all network privileges on the computer systems of the SchoolDistrict of the City of York and may also be subject to further disciplinary action; this action may include suspension or expulsion from school.

As parent/guardian of the previously mentioned student, I have read the district’s Internet, Computers and Network Resource Acceptable Use Policy andFormal Contract. I understand that this access is designed for the purpose of supporting improved learning and instruction but that the district cannotrestrict access to all controversial material. I will not hold the district or its employees responsible for materials this student may acquire on the network.Further, I accept full responsibility for the supervision if and when my child’s use is not in a school setting. I hereby give my permission for the previouslymentioned student to use district networks/Internet access until revoked in writing by me and further certify that the information contained on this formis correct.

I have read the district’s Internet, Computers and Network Resource Acceptable Use Policy. I understand and will abide by all rules, policies, procedureand applicable laws governing the use of district network/Internet. I further understand that violation of the regulations will not be acceptable and mayconstitute a criminal offense. Should I commit any violation, my access privileges may be revoked, and school disciplinary and/or legal action may be taken against me.

The School District of the City of York develops various publications to promote and inform the public of programs and achievements throughout thedistrict. These may include, but are not limited to, the district newsletter, school calendar, annual report, presentation and web site announcements. Thismay also include coverage by local media including newspaper and television. We are sensitive to the needs of children and to the privacy of parents, andwill take steps to treat public relations matters appropriately. I understand and agree that there will be no compensation for use of these written or visual materials. I also agree to release and discharge the SchoolDistrict of the City of York from all claims and demands, of any nature whatsoever, arising from or with respect to, the use of any photographs, interviews,movies or videotapes of my child.This permission and release will continue to be in effect until I give the School District of the City of York written notice to terminate my permission, ifgranted below.

Students under the age of 18.

The internet is a worldwide network of telecommunications. There are thousands of resources on the internet. You will find libraries, governmentagencies, universities, group discussions, software, technical information and millions of people who are part of this network. Your student account allowsyou to use these resources. The purpose of your student account is to enable you to participate in curricular activities at school using the internet. Thedistrict maintains a software filter to prevent the most inappropriate aspects of the internet from reaching school computers.

It is expected that students behave in accordance with the social and cultural norms of their community according to the following guidelines:*School internet use is under the direct supervision of the school staff and students are required to use it properly. They must behave responsibly,ethically and courteously while online.*The use of or the display of obscene or illegal materials, or indulging in activities in support of such activities is prohibited.*Abuse of the Acceptable Use Policy will result in the suspension or termination of student's access to the internet.*The use of your network account for non-school related activities is not acceptable.*Copying or using unauthorized copies of commercial software is not acceptable.*This agreement shall remain in force for the current school year unless revoked by either party by giving notice in writing.*No participation in any form of cyber bullying will be tolerated and will result in the loss of access, as well as any appropriate discipline.

Internet, Computer and Network Resources - Acceptable Use PolicyYour son or daughter will receive access to the internet in order to participate in curriculum projects that will be developed by some of your child'steachers. Your child will reach the internet through computer applications provided by the School District of the City of York. We ask you to review thisdocument with your child and to sign the consent form. Your child's teacher has already discussed this policy with your child, or will do so when classesbegin.

Prohibitions and student ethics policy guidelines


Student Information (Parents/Guardians should complete this section):Child’s first name:

Child’s last name:

Child’s Date of Birth: (Month/Day/Year)

Questions for Parents or Guardians1. Is a language other than English spoken in the child’s home? No Yes (language)

2. Does your child communicate in a language other than English? No Yes (language)

3. What is the language that your child first learned to speak?


Interpreter Provided No Yes

Where is the student currently living? (Please choose one.)In permanent housing In a hotel or motel

Transitional housing In a car, park, bus, train or campsite

In a shelter

Registration Certification:The information included in the form is accurate and correct to the best of my knowledge.


Name of LEA: York City School District Name of School:

ALL newly registering students regardless of race, nationality, or language origin MUST complete this form. Federal lawrequires that all Local Education Agencies (LEAs) utilize a non-biased procedure for identifying which students are potentialEnglish Learners (ELs) in order to provide appropriate language instruction educational programs and services. Given thisresponsibility, LEAs have the right to ask for the information contained on this and other forms associated with the identificationprocess.

The answer you give below will help the district determine what services you or your child may be able to receive under theMcKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in schooleven if they do not have the documents normally needed, such as proof of residency, school records, immunization records orbirth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation andother services.

Note to Schools/LEAS: If the student is NOT living in permanent housing, please complete a McKinney-Vento form and forward to Yaril Cruz or Eva Curet.

Printed name of parent, guardian or student (for unaccompanied homeless youth)

With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as "doubled-up". Is this Permanent Temporary

DateSignature of parent, guardian or student (for unaccompanied homeless youth)

/ /

Home Language Survey

Residency Questionnaire

HealthRequirements

CompleteHealthHistoryForm

ImmunizationsRequiredforEntry:

4DosesofTetanus*(1doseafter4thbirthday)

4DosesofDiphtheria*(1doseafter4thbirthday)

3DosesofPolio

3DosesofHepatitisB(Properlyspacedandatappropriateage)

2DosesofMeasles**

2DosesofMumps**

1DoseofRubella**

2DosesofVaricellaorhistoryofChickenpoxDisease

*UsuallygivenasDTP,DTAP,TDAP,DTorTD

**UsuallygivenasMMR

Childrenentering7thgradeneedthefollowing:

1DoseofTetanus,Diphtheria,AcellularPertussis(TDAP)if5yearshavepassedsincelastTetanusimmunization.

1DoseofMeningococcalConjugateVaccine(MCV)

PhysicalExam

DentalExam

Aphysicalexamisrequiredforallchildrenenteringschoolforthefirsttime,upontransferfromanotherschoolifthereisnorecordofaphysicalexam,andforentranceinto6thand11thgrades.Thisexaminationmaybecompletedbythechild'sphysicianormaybecompletedduringtheschoolyearbytheschoolphysician,freeofcost.Ifyouwouldliketheexamtobedonebytheschoolphysicianandwouldliketobepresentforit,pleaseletyourschoolnurseknow.Theprivatephysician'sformisattached.

Adentalexamisrequiredforallchildrenenteringschoolforthefirsttime,upontransferfromanotherschoolifthereisnorecordofadentalexam,andforentranceinto3rdand7thgrades.Thisexaminationmaybecompletedbythechild'sdentistormaybecompletedduringtheschoolyearbytheschooldentist,freeofcost.Ifyouwouldliketheexamtobedonebytheschooldentistandwouldliketobepresentforit,pleaseletyourschoolnurseknow.Theprivatedentalformisattached.

HealthHistory:

Hasyourchildeverbeendiagnosedortreatedforanyofthefollowing?

Allergy(food) Allergy(medication) Allergy(insect/animal) Allergy(environmental)

ADHD/OCD Asthma BoneFractures Chickenpox

Concussion Diabetes HeartDisease Hemophilia

Hernia(Rupture) KidneyDisease Pneumonia RheumaticFever

Scoliosis SeizureDisorder TB(child) TB(family)

Transfusion/BloodDisorders WhoopingCough Other

Hasyourchildhadanyofthefollowing:(pleaseprovidedetailsifavailable.)

Unusualproblems: Atbirth:

Sincebirth:

RecurringIllnesses:

Surgeries:

EmotionalProblems:

SeriousAccidents:

Listanyillnessorhealthproblemswhichyouoryourfamilyphysicianfeelshouldbeknowntoschoolauthorities:

DailyPrescribedMedications:

Name Dosage: Frequency PrescribingDoctor Reason




nicolesnyder

Typewritten Text

nicolesnyder

Typewritten Text

Student's Name:_______________________________________________________________________

nicolesnyder

Typewritten Text

nicolesnyder

Typewritten Text

Hasyourchildeverreceivedanybloodorbloodproducts? Yes No Pleaseprovidedetails:

Doesyourchildhavevisionproblems? Yes No Doeshe/shewearglassesorcontacts? Glasses Contacts

Doesyourchildhavehearingproblems? Yes No Doeshe/shewearahearingaid? Yes No

HasyourchildeverhadChickenPox? Yes No Anychronicskinconditions? Yes No Details:

Atthepresenttime,isyourchildundermedicaltreatmentforanyongoingcondition(s)? Yes No Details:

Permission:Bysigningthisformyouaregivingpermissionforthefollowing:

Acetaminophen(Tylenol) Yes No Benadryl Yes No Caladryl(Calamine)Lotion Yes No

Ibuprofen(Advil) Yes No StingKillSwabs Yes No ThroatSpray/CoughDrops Yes No

Tums/Antacid Yes No

SignatureofParent/Guardian: Date:

HealthInformation

HealthInsurance: YesorNo Plan:

FamilyPhysician: PhoneNumber:

FamilyDentist: PhoneNumber:

PreferredHospital: PhoneNumber:

SignatureofParent/Guardian: Date:

TheSchoolDistrictoftheCityofYorkmayexchangemedicalanddentalinformationwithyourchild'sphysiciananddentistandmaysharehealthinformationwithotherprofessionals,asneeded,insupportoftheeducationprocess.

Youreleasefromliabilityandgivepermissionforschoolpersonneltoadministerfirstaid,emergencymedicalcareandmedicationaccordingtoschoolpolicyandphysicianstandingorders.

Overthecountermedicationthatyourchildmayreceiveatschool:(Circleyesorno)

Igivepermissionfortheschoolnurse/healthaidetosharepertinentmedicalinformationaboutmychildwithhis/herteacherorotherschooldistrictpersonnelwhenitisinthebestinterestofmychild'shealth.

INEXTREMEEMERGENCYITMAYBENECESSARYTOTRANSPORTYOURCHILDTOTHENEARESTHOSPITAL.IgivepermissiontothestaffoftheYorkCitySchoolDistricttotransport,ormakearrangementsforthetransportationofmychildtoreceiveemergencymedicalcareintheeventthatpersonslistedabovecannotbecontacted.

york city sd registration€¦ · welcome to the school district of the city of york. please...

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