New Student Registration - Single StudentNew Student Registration: Single Student In addition to completing the on-line registration, a meeting must be scheduled to complete and sign additional documents. These enrollment requirements will include: 1. Proof of the child's birth. Any one of the following constitutes acceptable documentation: birth certificate, notarized copy of birth certificate, baptismal certificate, copy of the record of baptism-notarized or duly certified and showing the dates of birth, notarized statement from the parents or another relative indicating the date of birth, a valid passport, a prior school record indicating the date of birth. 2. Documentation of immunizations required bylaw. Acceptable documentation includes the child's immunization record, a written statement from the former school district or from a medical office that required immunizations have been administered, or that a required series is in progress, or verbal assurance from the former school district or medical office that the required immunizations have been completed, with records to follow. 3. Proof of residency. Acceptable documentation includes a deed, a lease, current utility bill, current property tax bill, current driver's license, DOT identification card. A district may require that more than one form of residency confirmation be provided. However, school districts and charter schools should be flexible in verifying residency, and should consider what information is reasonable in light of the family's situation. 4. Parent registration statement (Expulsion affirmation statement) 5. Home Language Survey. All students seeking first time enrollment in a school shall be given a home language survey in accordance with requirements of the U.S. Department of Education's Office for Civil Rights.Student InformationFirst NameMiddle NameLast NameStudent's Date of BirthGrade of StudentStudent's Home Phone NumberMailing Address (Apt # / Street) Mailing Address CityMailing Address StateMailing Address Zip CodeBirthplace of Student (City, State, Zip code)Gender of Student Male FemaleEthnicity - Is the student Hispanic or Latino? Yes NoRace - What is the student's race? White (Non-Hispanic) (W) Black or African American (B) Asian (A) American Indian/Alaskan Native (I) Native Hawaiian/Other Pac IslanderLegal Guardian Registrant Information If the student is living with a resident adult other than a parent, please go to the For Parents/"New Student Registration" section of the Muncy School District Website to complete Attachment B. Print the completed form, have it notarized, and bring it to the registration meeting. If a court or dependency order or custody agreement is used as the basis for enrolling the child, a copy of said document must be provided.First NameLast NameEmail address of the person completing the registrationAs the person registering the child, what is your relationship? Natural Mother Natural father Guardian OtherIf "Other," please specify:Parent / Guardian #1 Contact Information This is the legal parent/guardian with whom the student lives.Parent/Guardian #1 First/Last NameParent/Guardian #1 Cell Phone NumberParent/Guardian #1 Home/Additional Phone NumberParent/Guardian #1 email addressParent/Guardian #1 Place of EmploymentParent/Guardian #1 Employment Phone NumberParent/Guardian #1 AddressAddress Line 1CityStateZip CodeRelationship to StudentParent / Guardian #2 Contact Information This is a legal parent/guardian with whom the student lives.Parent/Guardian #2 First/Last NameParent/Guardian #2 Cell Phone NumberParent/Guardian #2 Home/Additional Phone NumberParent/Guardian #2 email addressParent/Guardian #2 Place of EmploymentParent/Guardian #2 Employment Phone NumberParent/Guardian #2 AddressAddress Line 1CityStateZip CodeRelationship to StudentStep-Parent/Guardian #1 Contact InformationStep-Parent/Guardian #1 First/Last NameStep-Parent/Guardian #1 Phone NumberStep-Parent/Guardian #1 Additional Phone NumberStep-Parent/Guardian #1 Place of EmploymentStep-Parent/Guardian #1 email addressStep-Parent/Guardian #1 AddressAddress Line 1CityStateZip CodeRelationship to StudentStep-Parent/Guardian #1 Employment Phone NumberStep-Parent/Guardian #2 Contact InformationStep-Parent/Guardian #2 First/Last NameStep-Parent/Guardian #2 Cell Phone NumberStep-Parent/Guardian #2 Home/Additional Phone NumberStep-Parent/Guardian #2 email addressStep-Parent/Guardian #2 Place of EmploymentStep-Parent/Guardian #2 Employment Phone NumberStep-Parent/Guardian #2 AddressAddress Line 1CityStateZip CodeRelationship to StudentAdditional InformationWith whom does the child being enrolled live? Mark all that apply. Father Mother Step-father Step-mother Guardian OtherIf "Other," please specify:Is any parent/guardian currently an active duty member of a branch of the armed forces (Army, Navy, Marine Corps, Coast Guard) including FULL-TIME Reserve or National Guard duty? Yes NoI would like to add the following email addresses for receiving school and student information from Muncy School District in relation to my child(ren). These are in addition to the email addresses listed in the parent/guardian information.Email #1Email #2Email #3To whom may the child be released?Court OrdersIf the student is under court order, please provide the following information from the court order.CustodyGuardianshipEd. RightsIs the student in a non-court ordered emergency shelter care? Yes NoIf the answer above regarding emergency shelter cares was "Yes", list the date and contact person.DateContact PersonIs the student ordered into…?Group Home (1306) Yes NoFoster Care (1305) Yes NoDateContact PersonName/address of Natural Parent(s)Information about SiblingsSibling #1First/Last Name of SiblingBirth date of SiblingGrade of SiblingSibling #2First/Last Name of SiblingBirth date of SiblingGrade of SiblingSibling #3First/Last Name of SiblingBirth date of SiblingGrade of SiblingSibling #4First/Last Name of SiblingBirth date of SiblingGrade of SiblingSibling #5First/Last Name of SiblingBirth date of SiblingGrade of SiblingEmergency Contact Information Parents will be called first. List those who should be called when parents cannot be reached.Emergency Contact #1 (Non-Parent)First/Last NameHome Phone numberCell Phone numberOther Phone numberRelationshipIf you are registering multiple students, can this contact be used with all students? Yes NoIf this contact is only for some of the students, list those for whom the contact may be used.Emergency Contact #2 (Non-Parent)First/Last NameHome Phone numberCell Phone numberOther Phone numberRelationshipIf you are registering multiple students, can this contact be used with all students? Yes NoIf this contact is only for some of the students, list those for whom the contact may be used.Emergency Contact #3 (Non-Parent)First/Last NameHome Phone numberCell Phone numberOther Phone numberRelationshipIf you are registering multiple students, can this contact be used with all students? Yes NoIf this contact is only for some of the students, list those for whom the contact may be used.Special Education ServicesHas the student received any special education services? Yes NoDoes the student have a 504 Agreement? Yes NoDoes the student have an IEP? Yes NoDoes the child receive ESL services? Yes NoDoes the child receive Hearing Impaired Services? Yes NoDoes the Child receive speech services? Yes NoWas the student in the process of an evaluation for Special Education services prior to registering at Muncy? Yes NoList the Agency and Dates that the student received any of the following prior treatment or support services or treatments within the last two years.Inpatient HospitalizationAgencyDateOutpatient CounselingAgencyDateDrug and Alcohol TreatmentAgencyDateVocational RehabilitationAgencyDateResidential PlacementsAgencyDateGroup Home ServicesAgencyDateOtherAgencyDateHas the student been involved with any of the following agencies within the last two years?Children and YouthCurrentPastContact Person's NameMH/MRCurrentPastContact Person's NameProbationCurrentPastContact Person's NameDrug and AlcoholCurrentPastContact Person's NameOtherCurrentPastContact Person's NameList the names of any previous schools or Head Start programs the student has attended, beginning with the most recent.School 1 - Most Recent (Last school attended)School 2School 3Muncy School District is increasing its use of electronic communication for both school information and student information. For this reason, it is important to have correct e-mail addresses on file. Misdirected email(s) may result in the exposure of sensitive student information to those without a legitimate educational interest in the information. In an effort to avoid misdirected emails, please indicate your preference. I give my permission to Muncy School District to use electronic communications for both school information and student information. I do not give my permission to Muncy School District to send student information using electronic communications. OtherIf "Other," please specify:I affirm that the information provided on this application is true and accurate. I acknowledge this registration is not complete until approved by the District Administration. (Enter your name below) Enter date of enrollment application Completing this form is only one part of the registration process. Registration must be completed with Mrs. Kim Hill before any child may begin attending school. Please be prepared to submit the following documents to the Muncy District Office: Proof of Birth Immunization Record Proof of Residency (Utility Statement, Lease/Rental Agreement, Valid Drivers License, Tax Statement) Custody Documentation (if applicable) Copy of the Child's IEP (if applicable) You will also receive a registration email containing: a Parental Registration Statement (Attachment A), a Home Language Survey, and an Internet & Technology Acceptable Use Policy that must be reviewed and signed for each registered child. Please call 570-546-3125, ext. 2040 with any questions.Submit Form
