Mi Athletic Agent Registration Court Forms

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Mi Athletic Agent Registration Court Forms Powered By Docstoc
					                                                       Glenwood Middle School
                                                            595 Chatham Road
                                                            Chatham, IL 62629
                                                         Telephone (217) 483-2481

NEW to the district Pre-Registration Checklist
Required by State of Illinois

PROOF OF RESIDENCY Must present proof of residency within the District by providing the required
number of documents from each of the following categories:
             Category I Show one of the following
             Most recent property tax bill and proof of payment, e.g. canceled check or Form 1098 (homeowners)
             Mortgage papers (homeowners)
             Signed and dated lease and proof of last month's payment, e.g. canceled check or receipts (renters)
             Letter from manager and proof of last month's payment, e.g. canceled check or receipt (trailer park residents)
             Letter of residence from landlord in lieu of lease (7:60-E1)
             Letter of residence to be used when the person seeking to enroll a student is living with a District resident (7:60-E2)
             Category II Show two of the following
             Driver's license
             Vehicle registration
             Voter registration
             Most recent cable television and/or credit card bill
             Current public aid card
             Current homeowners/renters insurance policy and premium payment receipt
             Most recent gas, electric, and/or water bill
             Current library card
             Receipt for moving van rental
             Mail received at new residence


         Copy of current physical/copy of immunization records
         Social Security number
         Must present a certified or registered birth certificate for the student
         “In Good Standing” transfer form from previous school.
         Anyone with a Custody Order Seeking to Enroll a Student Presents court order, agreement, judgment, or decree that
         awards or gives custody of the student to any person (including divorce decrees awarding custody to one or both parents).

Bring the following:                                                   Previous School
                  Recent Report Card

                  Test Scores (Achievement, ISAT)                      PARENT/GUARDIAN NAME:

                  IEP (Individual Educational Plan)

                  Complete the New Student Registration Packet         PHONE NUMBERS: Where you can be reached
_____________________________________                                  Home:
       STUDENT NAME:                                GRADE              _____________________________________________________

                      Glenwood Middle School
                          Registration Form

                                                                                    Date: __________________________

Name: _________________________________________________                                   Male       Female         Grade: ______
                  Child’s first          full middle             last

Child lives with: (please circle)        Father        Mother       Step Father         Step Mother         Other: __________

______________________________________ ____________________________ ______________________________
               (Responsible Male)             (Relation to Child)             (Work Place)

                  Responsible Male Work #: ____________________________________ Cell #: ______________________________________

______________________________________ _____________________________ _____________________________
                  (Responsible Female)                            (Relation to Child)                               (Work Place)

                  Responsible Female Work #: ____________________________________ Cell #: _____________________________________

________________________________________________________                            ___________________________________
                              (Child’s Home Address)                                                (City, State, Zip)

________________________________________________                        _________________________________________
                       (Child’s Home Phone)                                               (Child’s Social Security Number)

__________________________________________                          _________________________________________
                  (Child’s Birth Date)                                                   (Child’s Place of Birth)

Parents e-mail address: __________________________________________________________________

Emergency Contact: __________________________________________ Phone: __________________

School last attended: ___________________________________________________________________
                                              (Name of School)                            (Address of School)

Was child enrolled in any type of Special Education or Speech therapy services? If yes, please list:


List any medical problems/medications: ____________________________________________________


Ethnic Origin: (please circle one)            1        AMER INDIAN/ALASKAN NATIVE
                                              2        ASIAN AMERICAN/PAC ISLANR
                                              3        BLACK, NON-HISPANIC
                                              4        HISPANIC
                                              5        WHITE, NON-HISPANIC
                                              6        MULTIRACIAL
BALL-CHATHAM C.U.S.D. #5                          217/483-2481 Fax 217/483-4940


I request that all records listed below for

be sent to:     Glenwood Middle School
                595 Chatham Road
                Chatham, IL 62629

Date:                                   Parent signature:

                                        Guardian signature:

                                        Student signature:

Records include:

_____           Personal information sheet
_____           Test records
_____           Health and accident reports
_____           Elementary courses, grade, and attendance
_____           Secondary courses, grades, and attendance
_____           Activities, honors and awards
_____           All Special Education Records
_____           Other

School attended:
                                        Ball-Chatham Community Unit School District #5
                                                 HOME LANGUAGE SURVEY

**Please complete and return this survey with the registration materials.**

Student’s Name:
                                           (Last Name)                    (First Name)                    (MI)

Today’s Date:                                                              School:

Grade:                                                           Birthdate:

Sex:                  Male                 Female              Phone:

Place of Birth (City, State, Country):
The Illinois School Code and the Emergency Immigration Act, Title VI of the Education Amendments of 1984 (p.L. 98-5II), states that each school district shall administer a
home language survey to each and every student entering the district’s schools for the first time. Your help is needed to meet this information requirement.


My child speaks ENGLISH ONLY:                                               YES                  NO

If YES, Stop Here!
If no, please continue to PART B.


1.        What was the first language your child learned?

2.        What language do you (parent/guardian) use most frequently to speak to your child?

3.        Which language does your child use the most when he/she:
           a. Talks to you                          b. Talks to friends

Please share any information about your customs, country, etc. that will help us to educate your child:
                                                   Glenwood Middle School 2009
                                             Insurance/Emergency Contact Information

Last Name ___________________________________ First Name _________________________________ MI _______

Grade     6    7    8                          Home Phone ______________________________________________________

Student Address ____________________________________________________________________________________

Mother’s Name ____________________________________________________ Work # _________________________

Father’s Name ____________________________________________________ Work # __________________________

Mother’s Cell # __________________________________ Father’s Cell # ______________________________________

Contact ____________________________________ Relationship ____________________________ Phone __________

Insurance Waiver
          In order to participate in Glenwood co-curricular activities, each participant must have a current accident insurance policy in force
that will cover him/her during the school year.
          Parents who have current coverage on their child must file the statement with the office. Parents who do not have a current policy
may purchase a plan from a local or area agent.
          I prefer my son/student be taken to ______________________________ hospital.

Medical Release
         In the event my son/daughter requires emergency medical attention, I give permission to school representatives to seek necessary
services. I will be notified at the earliest opportunity.

Disclaimer of Liability
          The Ball-Chatham School District, staff and athletic department do not assume any liability for any injuries incurred while a student
is participating in co-curricular activities or while a student travels to/from activities.
          A student participating in co-curricular activities and using equipment and facilities of the Ball-Chatham School District does so at
his/her own risk. Sports are physical in nature and those who elect to participate in athletics must recognize the injuries may occur which
could be crippling for life.
          The Ball-Chatham School district and staff shall not be liable for any damages arising from personal injury sustained by the
participant. The participant and his/her parents assume full responsibility for any damages or injuries which may occur during practices,
contests, activities, travel to/from activities and so herby fully and forever exonerate and discharge the Ball-Chatham School District, athletic
department, staff, Board of Education, employees, and agents from any and all claims, demands, damages, rights, anticipated, or
unanticipated, resulting from or raising out of participation in athletics/activities and in the use of school district facilities or while a member
of a tea, club, or organization.

Confirmation of Insurance
       I understand the Disclaimer of Liability. I have an insurance policy that covers my son/daughter while participating in Ball-
Chatham School district co-curricular activities.

Name of Insurance Company ________________________________________________ Policy # ___________________________

         All students participating in athletics must have a current (within calendar year) physical on file with the school nurse BEFORE
being allowed to try out. The physical must be current through the entire sport season in which he/she participates.

         I affirm that the information on this form is correct. I give permission for my son/daughter to participate in co-curricular activities.
I acknowledge that I have read and fully understand the co-curricular code in the student handbook and support any penalties that may be

Parent’s Signature _____________________________________________________ Date ______________________
                         Glenwood Middle School


                          Grade: (circle one)           6    7   8


       I have received the GMS Student Agenda, which includes Academic information, the
 Acceptable Computer Usage Policy, the Disciplinary Code and Guidelines, Attendance Policy,
 Medical Information, Student Transportation Information, General Information, and the
 Extra-Curricular Code. I acknowledge that I have been/will be assigned a GMS locker for use
 during the school year. By accepting this privilege I authorize the school administration to
 search my locker in accordance with the Search and Seizure policy found in the Student
 Agenda. I understand that if I do not cooperation with these policies I will be subject to
 disciplinary action. I acknowledge that students may be videotaped while on district provided
 transportation, as well as, while on school grounds. Annual permission must be granted for
 GMS to use your child’s Biometric fingerprint. Check boxes below:

    Yes, I give permission for my directory information and picture to be release
for all media purposes (includes yearbook, PTO Student directory, web,
newspaper, television, athletic rosters and programs etc.)

     No, I do not give permission for my directory information and picture to be
released for all media purposes (includes yearbook, PTO Student Directory, web,
newspaper, television, athletic rosters and programs, etc.), except to those
entities to which the school has a legal obligation to do so.

                             Biometric Fingerprint Permission
         (annual permission must be granted for GMS to use your child’s Biometric fingerprint)

    Yes, to Biometric fingerprinting                             No, to Biometric fingerprint

  Student Signature: ________________________________________ Date: _________

  Parent Signature: _________________________________________ Date: __________

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