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 Information1. Student First NameMiddle NameStudent Last Name2. Student's Date of Birth3. Grade of Student4. Student's Home Phone Number5. Mailing Address (Apt # / Street) Mailing Address CityMailing Address StateMailing Address Zip Code6. Birthplace of Student (City, State, Zip code)7. Gender of Student Male Female8. Ethnicity - Is the student Hispanic or Latino? Yes No9. Race - What is the student's race? Asian (A) Black or African American (B) American Indian/Alaskan Native (I) Native Hawaiian/Other Pac Islander (P) White (W)Legal 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.10. First NameLast Name11. Email address of the person completing the registration12. As 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.13. Parent/Guardian #1 First/Last Name14. Parent/Guardian #1 Cell Phone NumberParent/Guardian #1 Home/Additional Phone Number15. Parent/Guardian #1 email address15.5 Parent/Guardian #1 Place of EmploymentParent/Guardian #1 Employment Phone Number16. Parent/Guardian #1 AddressAddress Line 1CityStateZip Code17. Relationship to StudentParent / Guardian #2 Contact Information This is a legal parent/guardian with whom the student lives.18. Parent/Guardian #2 First/Last Name19. Parent/Guardian #2 Cell Phone NumberParent/Guardian #2 Home/Additional Phone Number20. Parent/Guardian #2 email addressParent/Guardian #2 Place of EmploymentParent/Guardian #2 Employment Phone Number21. Parent/Guardian #2 AddressAddress Line 1CityStateZip Code22. Relationship 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 Information23. With whom does the child being enrolled live? Mark all that apply. Father Mother Step-father Step-mother Guardian OtherIf "Other," please specify:24. 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 No25. I 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 #326. To whom may the child be released?Court Orders27. If the student is under court order, please provide the following information from the court order.CustodyGuardianshipEd. Rights28. Is 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 Person29. Is 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)30. Emergency Contact #1 - First/Last Name31. Emergency Contact #1 -Home Phone numberEmergency Contact #1 - Cell Phone numberEmergency Contact #1 - Other Phone number32. Emergency Contact #1 Relationship33. If you are registering multiple students, can this contact be used with all students? Yes No34. If this contact is only for some of the students, list those for whom the contact may be used.Emergency Contact #2 (Non-Parent)35. Emergency Contact # 2 - First/Last Name36. Emergency Contact #2 -Home Phone numberEmergency Contact #2 - Cell Phone numberEmergency Contact #2 - Other Phone number37. Emergency Contact #2 Relationship38. If you are registering multiple students, can this contact be used with all students? Yes No39. If this contact is only for some of the students, list those for whom the contact may be used.Emergency Contact #3 (Non-Parent)40. Emergency Contact # 3 - First/Last Name41. Emergency Contact # 3 - Home Phone numberEmergency Contact # 3 - Cell Phone numberEmergency Contact # 3 - Other Phone number42. Emergency Contact #3 Relationship43. If you are registering multiple students, can this contact be used with all students? Yes No44. If this contact is only for some of the students, list those for whom the contact may be used.Special Education Services45. Has the student received any special education services? Yes No46. Does the student have a 504 Agreement? Yes No47. Does the student have an IEP? Yes No48. Does the child receive ESL services? Yes No49. Does the child receive Hearing Impaired Services? Yes No50. Does the Child receive speech services? Yes No51. Was the student in the process of an evaluation for Special Education services prior to registering at Muncy? Yes No52. List 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 ServicesAgencyDateOtherAgencyDate53. Has 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 Name54. List 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 355. Muncy 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.56. 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) 57. 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
