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Dodge County Middle School New Student Enrollment
Este documento contiene informacion importante para la escuela. Si usted necisita esta information en Esponol por favor
de llamar el Directorio de escolar Dodge en la Oficiana. El numero es 478-374-3783. Gracias
Date:________________
Grade:________ Age:_________ Date of Birth:________________
Sex:___________
Student Name:________________________________________________________________
LAST
FIRST
MIDDLE
----------------------------------------------------------------------------------------------------------------------------- ------------------------------------Directions: Read the definition below and mark the choice that indicates this student’s heritage.
Ethnicity, not race: Is this student Hispanic/Latino? (Choose only one)
_____ No, not Hispanic/Latino (Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race, are considered Hispanic or Latino.)
_____ Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other
Spanish culture or origin, regardless of race.)
What is the student’s race? (Choose one or more)
Read the descriptions below and mark the choice that indicates this student’s race. Regardless of what you selected above, please
continue to answer the following by choosing one or more choices to indicate what you consider your student’s race to be.
_____ American Indian or Alaska Native (A person having origins in any of the original peoples of North and South
America (including Central America and who maintains tribal affiliation or community attachment.)
_____ Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand, and Vietnam.)
_____ Black or African American (A person having origins in any of the black racial groups of Africa.)
_____ Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.)
_____ White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
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Social Security Number:___________________________
Address:________________________________ Home Phone Number:_________________
________________________________
________________________________
Is this address in Dodge County?___________
Student Lives With:________________________ Relationship:_______________________
Father:_____________________________Employer:______________________ Work Phone:_______________
Mother:____________________________Employer:_______________________Work Phone:_______________
Person to Contact in an Emergency:_____________________________________Phone:________________________
Last School Attended:________________________________Date last enrolled___________
School Address:________________________________
________________________________
School Phone:________________________________
Is Student in any of the following programs?
____Hearing ____Vision ____Band
Does Student take any Medications?______________________________________________
_____Special Education ____Speech ____Gifted
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Has the Student ever attended a Dodge County School? _____ Which One?_________________
Did the Student attend a Pre-K program, public or private, before entering Kindergarten? ___yes ___no
If so, what was it: _____ Public Pre-K
_____Private Pre-K
REQUIRED INFORMATION:
Disciplinary History:
(a) Is student currently suspended or expelled from last school attended?__________
(b) Did student withdraw from school to avoid suspension/expulsion?_____________
(c) Has the student ever been suspended or expelled for being convicted of, adjudicated to have
committed, indicted for or having information filed for, the commission of any felony or any
delinquent act which would be a felony if committed by an adult?____________
If the answer to any of the above questions is YES, give the reason for the
suspension/expulsion and the date on which the suspension/expulsion ends or
ended__________________________________________________________________
Georgia Law,O.C.G.A. Section 20-2-670, requires that a transferring student applying for admission to a
grade higher than sixth grade to present a certified copy of his or her academic transcript and
disciplinary record from the school previously attended.
Language History:
Student’s Country of Birth:_____________________(If not the USA, answer the following questions):
1. What date did the student first enter any USA School?__________ _____________________________
2. Has this student been attending school in the USA more than three full academic years? Yes___ No___
3. Have you ever worked or come here with the intention of working in the fields, poultry and meat
processing plant, pulpwood timber industry, fishing or any other agricultural job? Yes___No___
4. How many families live in your house?______ Is this temporary? Yes___No___
5. Is language other than English used in the home? Yes___No___
6. Did student have a first language other than English? Yes___No___
7. Does the student speak a language other than English most of the time? Yes___No___
8. Is YES to question 5, 6, or 7, what is the language?____________________________________________
I understand that my child will not be enrolled in Dodge County School System until all records from previous
schools are received. I further understand that my child may be found ineligible for enrollment at this time based
on information about current suspensions or expulsions obtained from the student's record. I certify that the
information provided above is true to the best of my knowledge.
Parent/Guardian Signature:_______________________________________________
Date:______________________
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For Office Use:
_____Birth Certificate _____Georgia Immunization _____Georgia Vision & Hearing _____Discipline Record
_____Home Language Survey, Internet form, & Code of Conduct form completed
_____ Proof of Dodge County Residency of Parent or Guardian
_____Complete School Records Requested on:______________________ Complete School Records Received on:___________________
_____Completed Parent / Administration Conference _____Student Given Agenda _____Enrolled in Power School / SE info complete
_____Homeroom Assignment____________________________
_____Grades in Power School
_____GTID number