Central Enrollment Office
306 South Dixie Drive - Door #5
Vandalia, Ohio 45377
Office 937-415-6410 Fax 937-415-6462
ALL OF THE FOLLOWING MUST BE PRESENTED AT THE TIME OF REGISTRATION
Completed student enrollment packet (including ESL & Special Education forms)
Student’s certified birth certificate (hospital birth record and photocopies not accepted)
-If the parent’s current last name is different from the name listed on the birth certificate due to a legal name change
(divorce, marriage, etc.) documentation (marriage license or certificate, court order) of the change must be presented.
Identification of custodial parent/guardian enrolling student
-Driver’s license or state issued photo identification
Immunization record (Dates student’s immunizations were administered)
Proof of Custody
-Copy of custody papers, in the event of legal separation or divorce; when a student resides in the Vandalia-Butler City
School District with a divorced parent who has legal custody, the parent must present a complete copy of the court ordered
custody agreement which indicates the parent enrolling the student is the residential custodian of the student.
-Copy of custody papers in the event of a student being court placed with a non-parent (foster placement, guardian, etc.)
who resides in the Vandalia-Butler City School District.
Proof of Residency
-If you own/are purchasing your home, documentation can be obtained from the Montgomery County Recorder’s office.
Recent purchases may require proof using sale closing documents if the purchase has not been recorded at the time of
-If you are renting, a lease/rental agreement that is signed by tenant and landlord must be presented. The agreement must
list renter’s name, rental property address, landlord’s name, address, and telephone number.
-If you are in the process of building a new home, a sworn statement may be presented to the Superintendent. This
statement must be notarized and include the location of the home under construction and state your intent to live there. A
notarized statement from the builder confirming the home is under construction at the indicated location is also required.
The construction period may not exceed 90 days. A final review of the construction site may also be required.
-If you are living with another person or subleasing (without a formal lease agreement), you will need the property owner or
legal representative to complete a Residency Affidavit (available from the Enrollment Office). This is then subject to review
and approval by the district Attendance Administrator.
-We reserve the right to require additional documentation in the form of a phone, utility, or water bill, etc. as necessary.
Individualized Education Plan (IEP)
-If your child has an IEP from their previous school, you will need to provide a copy of the IEP upon enrollment. Please note
that the scheduling of a student, eligible for special education services, may possibly be delayed until or adjusted after the
receipt of the most current/valid IEP.
-If your child is interested in participating in any athletic activity during the school year, please contact the Athletic Office at
937-415-6384 immediately after enrollment is completed for the paperwork/information your student will need in order to
1/12 VBCS Central Enrollment
Understanding Residency Requirements
The schools of the Vandalia-Butler City School District shall be tuition free to all school residents
between five and twenty-one.
Preschoolers enrolled through Vandalia-Butler City Schools to attend Northview School must reside in the
Vandalia-butler School District.
A student is considered a resident if he/she resides with a parent or parents or person or governmental
agency with legal custody whose place of residence is within the boundaries of the District.
A legal residence is one where the parents/guardians and children engage in major family life activities
such as eating, sleeping, receiving mail, voting, etc.
A student, at least 18 but not 22 years of age, who resides in the district, lives apart from his/her parents
and who supports himself/herself by his/her own labor is eligible for entrance.
A child may attend the district as a resident for a period not to exceed sixty days on the sworn statement of
an adult resident of the district that he/she has initiated legal proceedings for custody. A copy of the
application form and a copy of the form listing the date and time of the hearing must be presented.
*I understand that if my child (children) attends the schools while not being eligible to do so tuition free, I
will be responsible for tuition at a rate set by the Treasurer of the Vandalia-Butler City Schools according to
law, plus administrative costs, court costs, and any attorney fees incurred in the collection of these sums and
that the student will immediately be withdrawn from the Vandalia-Butler City School District.
I have read and understand the above statements.
8/08 VBCS RESIDENCY REQUIREMENT
STUDENT REGISTRATION FORM
Information supplied on this form is required under provisions of Ohio Law and the Ohio Department of Education. It is in no way an effort
to trespass upon the personal affairs of parents. Your cooperation in completing this form is appreciated.
PLEASE PRINT—PARENT/GUARDIAN SHOULD COMPLETE ALL INFORMATION EXCEPT FOR SCHOOL USE ONLY BOX.
SCHOOL USE ONLY
Student ID# _______________________ School: BUTLER MORTON SMITH DEMMITT HELKE MURLIN
Admission Date ____/____/________ Admission Reason Code ________ Grade _________ Custody Indicator ________
Previous School District_____________________________________________ IRN#_________________ L/R/E___________________
STUDENT DATA STUDENT ADDRESS
(LEGAL NAME AS IT APPEARS ON BIRTH CERTIFICATE) Student Home Phone (_____)________-_________ Unlisted? Y ___ N___
Last Name __________________________________________________________ Street Address ___________________________________________________________
First Name ___________________________ Middle Name _________________ City ____________________________________ Zip Code __________
Gender: (circle one) F or M Mailing Address (if different from above)
Date of Birth: Month __________ /Day ________ /Year _______ PARENTAL CUSTODIAL HISTORY
Never Married____________ Married____________
Birth City _____________________________________________ Separated________ Divorced___________
Indicate country, if child was born outside the U.S. Parent Deceased: ______Mother ______Father
______________________________________________________ Removed from parent’s custody by court order_______
____ Mother ____ Father
____ Step-Mother ____ Step-Father
____ Guardian / Foster Parent ____ Guardian / Foster Parent
Last Name _________________________ First Name __________________ Last Name ______________________First Name ___________________
Address if different than student’s: _________________________________ Address if different than student’s: _______________________________
Employer _____________________________________________________ Employer ___________________________________________________
Work Phone ________________________ Ext _____________ Work Phone _________________________ Ext _____________
Cell Phone __________________________ Cell Phone ___________________________
RESIDENCY COURT ORDERED PLACEMENT
Student lives with (check one) Proof of legal custody is required upon enrollment
____ Mother Only ____ Father Only ____ Mother Only ____ Father Only
____ Mother & Father ____ Mother & Stepfather ____ Joint Custody / Shared Parenting ____ Guardian (complete VBS FC-1)
____ Father & Stepmother ____ Foster Parent ____ Foster Parent (complete VBS FC-1)
____ Court Appointed Guardian(s)/Grandparent(s) ____ Host Parent ____ Grandparent POA/Caretaker Affidavit
Names, Birthdates & Ages of Other SIBLINGS in Vandalia Schools
Has this student been previously enrolled in Name Birth date Age Grade
Vandalia-Butler City Schools? _____________________________ ____/____/________ ______ ______
No ____ Yes______ _____________________________ ____/____/________ ______ ______
If yes, what year? ________What Building? __________ _____________________________ ____/____/________ ______ ______
Signature of Parent/Legal Guardian X______________________________________________ Date: _________________
3/10 VBCS REGISTRATION WHITE—Student Records CANARY—Central Office EMIS
Ethnicity/Race Data Collection Form
(Required by Federal regulations)
Student Name: ________________________________________________
The United States Department of Education has issued guidelines regarding the collection of data on race and ethnicity
for public school students. The federal government, which requires all states to collect this information, has developed
a new way to report ethnicity and race that includes new categories.
If the following questions are not answered by the parent or guardian, the District Enrollment Officer will use
observation identification to determine the student’s designation. The determination will be reported to the parent or
Part I - Is this student of Hispanic/Latino heritage? (Choose only one)
____ No, not Hispanic/Latino
____ Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American or other
Spanish culture or origin, regardless of race.)
The above question is about ethnicity, not race. No matter what you selected above, please continue to answer the
following by checking one or more options to indicate what you consider your student’s race to be.
Part II - Race (Choose one or more, regardless of Ethnicity)
____ American Indian or Alaskan Native
____ Black or African American
____ Native Hawaiian or Other Pacific Islander
Parent/Guardian Signature__________________________________________ Date______________
FOR OFFICE USE ONLY
Parent/Guardian chose not to complete Ethnicity/Race information and determination was made by VBCS Enrollment.
Enrollment Officer_____________________________________________________ Date_____________
1/2010 VBCS Race/Ethnicity Form
STUDENT HEALTH INFORMATION
FOR SCHOOL PERSONNEL
Name of Student _________________________ Date of Birth _____________
School Name __________________ Teacher/grade ________ School year_____
Please check those which apply:
Bee Sting (severe reaction) Diabetes
Food (severe reaction) Hemophiliac
_____________________ Vision Impaired
Medication (any drug Orthopedic
_____________________ Physical Handicap
My child has no medical problems that you need to be concerned with.
Parent/Guardian signature ____________________________ Date ________
VBCS Student Health Information 4/18/2011
Student Disciplinary Status
Dear Parents and Students,
Ohio House Bill 64, in effect since September 1994, clearly states that a student currently under
an expulsion order from another school district may not register in a new district until the
Therefore, please answer the following question:
Are you currently under an expulsion order or suspension order from any other school district?
Student Name:_____________________________________ Date of Birth:____________
Student Signature:__________________________________ Date:___________________
(For Middle and High School students only. Parent/guardian may sign for primary students.)
As parent/legal guardian of this student, you have my permission to obtain all information regarding
disciplinary status to confirm the student’s responses above.
Parent/Guardian Signature:______________________________ Date:___________________
Failure to provide accurate information will result in immediate dismissal.
7/07 VBCS DISCIPLINE STATUS
Special Education Form
Student Name:_____________________________________ Date of Birth:____________
_______ Student is NOT currently receiving special education services.
If checked, you do not have to fill out the rest of the form – just sign at the
_______ Student IS currently receiving special education services and being served on an
IEP – Individualized Education Plan.
If checked, please fill out the rest of the form and sign at the bottom.
_______ I have provided current copy of the IEP.
_______ I do not have a current copy of the IEP.
_______ I have provided a copy of the Multi-factored Evaluation (MFE)
_______ I do not have a current copy of the MFE
_______ I have signed the record release form giving my permission to release special
education information to the Vandalia-Butler City Schools’ Pupil Services
Parent/Guardian Signature Date
CC: Pupil Services Secretary
Applicable Building Personnel
7/07 VBCS SPECIAL EDUCATION ENROLLMENT
Second Language Information
Student Name ____________________________________________________________
Family Name First Name Middle Name
For Parents/Guardians, please answer the following questions:
1. What language did your child speak when he/she first learned to talk?
2. What language does your child use most frequently at home?
3. What language do you use most frequently to talk with your child?
4. What language do the adults at home use most often?
5. How long has your child attended school in the United States?
If English is a second language in your home, please complete the following:
English as a Second Language services are available at designated schools in the district. ESL is an educational
program designed to help your child attain English language proficiency so that he or she can participate
effectively in classrooms in which English is the language of instruction.
Has your child ever received ESL services? Yes_____ No _____
If yes, in what grades? ______________________________________________
In what school districts? ____________________________________________
What date did your child first enter a U.S. school? ________________________
For building office use.
Please notify ESL Staff if a language other than English is identified in the above questions.
7/08 VBCS ESL
Emergency Medical Authorization Form O.P.C.3313.712
20___ - 20___ School Year
The purpose of this form is to enable parents/guardians to authorize the provision of emergency medical treatment for a child who becomes ill or injured while under
school authority when parents or guardians cannot be reached.
Student Name____________________________________ Date of Birth____________________ Grade______________
Street Address______________________________________ City____________________ State Ohio Zip___________
Parent/Guardian Name______________________________________ Main/Home Phone _________________________
Parent/Guardian Work Phone__________________________ Parent/Guardian Cell Phone__________________________
ADDITIONAL EMERGENCY CONTACT INFORMATION
Parent/ Guardian will always be contacted first in the event of an illness/emergency. Please list in order how additional contacts are to be made when we are unable to
reach parent/guardian. If you need to list more than three contacts please attach a separate sheet to this form with the information.
CONTACT 1 CONTACT 2 CONTACT 3
Name Name Name
Relationship Relationship Relationship
Home Phone Home Phone Home Phone
Work Phone Work Phone Work Phone
Cell Phone/Pager Cell Phone/Pager Cell Phone/Pager
PART I OR II MUST BE COMPLETED
Part I to Grant Consent
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor __________________________________________________ Phone______________________________
Dentist __________________________________________________ Phone______________________________
Medical Specialist _________________________________________ Phone______________________________
Local Hospital ____________________________________________ Insurance___________________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above
named doctor or by another licensed physician or dentist (providing the designated physician or dentist is not available); and (2) the transfer of the child to any hospital
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity for such surgery, are
obtained prior to the performance of such surgery.
Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairments to which a physician should be alerted:
This information may be shared with school personnel if it is pertinent to my child’s health and safety, educational progress, and/or behavioral management plan.
Part II to Not Grant Consent
I DO NOT GIVE CONSENT for emergency medical treatment for my child. In the event of illness or in the event of illness or injury requiring emergency treatment, I
wish the school authorities to take the following action:
Signature: Parent/Guardian____________________________________________ Date:____________________________
Vandalia-Butler City School District
PERMISSION FOR FIELD TRIPS
The purpose of this form is to secure permission from parents so that their child/children may participate in Board of Education sponsored field trips. This permission
will be for a school year. The classroom teacher will be responsible for notifying the parents prior to all field trips.
Permission is granted for ______________________________________to go on field trips under the supervision of a Vandalia-Butler School professional staff
Parents will be notified prior to all field trips during the applicable school year.
1/10 VBCS EMERGENCY MEDICAL
REQUEST FOR TRANSPORTATION TO/FROM A SITTER
SCHOOL YOUR CHILDREN ATTEND(S) ____________________________________________________
(ONE FORM NEEDED FOR EACH SCHOOL)
NAME OF STUDENT(S) ___________________________________________ GRADE_________
NAME OF PARENT OR GUARDIAN________________________________________________________
HOME PHONE NUMBER___________________ WORK PHONE NUMBER__________________________
SITTER’S NAME___________________________________ PHONE NUMBER_____________________
PICKUP: I am requesting that the above named children be picked up at the bus stop closest
to: (Circle One)
The home address listed above.
The sitter’s address listed above.
RETURN: I am requesting that the above named children be returned to the bus stop closest
to: (Circle One)
The home address listed above
The sitter’s address listed above
SIGNATURE OF PARENT OR GUARDIAN: ___________________________________
NOTE: The above request is most easily honored if the pickup and return are to the same address
or if the sitter’s address and the parent’s address are on the same bus route. When such is
not the case, it may not be possible to honor the request. However, in all cases, the
arrangement “must be” on a regular basis i.e. the same schedule each week.
ACTION BY THE TRANSPORTATION DEPARTMENT DATE_______________________
( ) Approved and drivers notified.
( ) Not approved. Reason: ___________________________________________________
3/10 VBCS Transportation Sitter
April 1, 2011
Dear Kindergarten Parent/Guardian,
Each year the Vandalia-Butler City Schools, in cooperation with the Vandalia and Butler Township Police
Department and Fire Department, offer a “Passport to Safety” program. This pre-kindergarten program is to be
held for all registered kindergarten students in the Vandalia-Butler City School District.
The program is designed to help children become better acquainted, and familiar with school experience and school
safety. Over the five-day period (two hours daily), the children will receive information and instruction on making
friends, good health habits, avoiding strangers, traffic, bus, pedestrian, fire and pool safety, and an introduction to
A special program will be held for parents on Monday and Friday of the week your child attends the program.
During the Friday program, children will demonstrate skills learned that week on the game board. This
demonstration is very informal. Please feel free to bring camcorders and cameras, and to move about the room
during the demonstration to better see and hear.
As parents, you will receive an overview of the program, information presented to the children, and an overview of
materials to be distributed throughout the week. If you cannot attend on Monday and Friday with your child,
please make arrangements for an adult to accompany him or her.
If your preference is for your child to attend the morning session, it is important that you return the Passport to
Safety registration form, along with your child’s other school registration forms, as soon as possible. The morning
slots fill up quickly and registration is on a first-come first-serve basis. We will keep the numbers of children in
morning and afternoon sessions balanced in fairness to the instruction of all children. If your child is unable to
attend during the week designated for his/her school, you may register him/her for a different building. It is best,
however, for children to attend in their own home school.
If you have any questions regarding the Passport to Safety Program, please contact Rose Suman at 415-6411 or
Director of Curriculum & Instruction
Please retain this section as a reminder of
your child’s Passport to Safety date, time,
Date: ____________ Time: ________
KINDERGARTEN REGISTRATION PASSPORT TO SAFETY 2011
PASSPORT TO SAFETY 2011 IDENTA-KID PROJECT / BUS TRIP
Registration Form Dear Parent/Guardian,
Child’s Name:__________________________________________________ During Passport to Safety your child will have the opportunity to participate in the
(last) (first) IDENTA-KID PROJECT, which includes fingerprinting. All information will be
presented to you in the form of a “Passport to Safety” parent book. Even though some
Male:_____ Female:_____ Date of Birth:_______/_______/_______ may already have participated in the IDENTA-KID PROJECT, we encourage you to
have this updated record made for our files. In order for your child to participate, you
need to sign the form below.
Registered for Kindergarten at _______________________ for 2011-2012.
(name of school)
In addition, we need for you to sign the second form below for participation in the Bus
Safety Program for your child to take the bus trip during the bus safety session.
Child’s Address: ________________________________________________
Laura L. Bemus
Director of Curriculum & Instruction
Child resides with: ___Both Parents ___Mother ___Father ___Other
Permission for IDENTA-KID PROJECT 2011
Parent/Guardian Name(s): _______________________________________ The Vandalia/Butler Township Police Department, with the help of others in our
community, will be bringing the IDENTA-KID PROJECT to the Vandalia-Butler City
Schools “Passport to Safety Program”.
Primary Contact Phone Number: __________________________________
The following affidavit must be completed prior to fingerprinting your child.
Secondary Contact Name: ________________________________________
Secondary Contact Phone Number: ________________________________ (last) (first) (middle)
I understand that the Vandalia-Butler City Schools IDENTA-KID PROJECT will be fingerprinting children
Secondary Contact Address: ______________________________________ at Passport to Safety. I hereby approve of and consent for the above named child to be fingerprinted.
Please indicate a date and time preference. NO CONFIRMATIONS WILL Parent/Guardian Signature Date
BE SENT. You will only be contacted if chosen time slot is full.
Permission for Bus Safety Program 2011
Vandalia-Butler City Schools has arranged for an approved local bus trip for the
DATE SCHOOL TIME students participating in the Passport to Safety Program in August 2011.
____ Aug. 22 – 26 Demmitt ES ____ 9 – 11 a.m. _____________________________________________________
____ 12 – 2 p.m. (last) (first) (middle)
Teacher in Charge of Trip: Passport to Safety Instructor
____ Aug. 8 – 12 Helke ES ____ 9 – 11 a.m.
____ 12 – 2 p.m. We expect the instructor to take all reasonable precautions. We further understand that all staff members and
the Board of Education are not to be held responsible in case of an accident.
____ Aug. 8 – 12 Murlin Hts. ES ____ 9 – 11 a.m. Parent/Guardian Signature Date
____ 12 – 2 p.m.
**ATTENTION KINDERGARTEN PARENTS ONLY**
To assist with placement and the development of our Kindergarten class lists, please fill
this form out and return it with your child’s registration packet.
*****THIS INFORMATION IS CRUCIAL TO HAVE CLASS LISTS READY
FOR PARENTS THE FIRST OF AUGUST*****
Transportation method to and from school:
Please check how your child will be coming and going from school.
Bus ____ ______
Daycare ____ ______
Walk/Parent will bring ____ ______
Sitter ____ ______
Latchkey ____ ______
Daycare, if applicable: name__________________________
Sitter, if applicable: name_____________________________
**If you are using a sitter and your child will need bus service, so be sure you have
filled out a Request for Transportation to/from Sitter Form.
3/10 VBCS KG Transportation