VALLEY VIEW LOCAL SCHOOLS
STUDENT ENROLLMENT FORM 2014-15
SCHOOL
USE
______ Valley View Primary School
______ Valley View Intermediate School
______ Valley View Junior High School
______ Valley View High School
ONLY
STUDENT ID _________________ GRADE ____ ENROLLMENT DATE _______________
LEGAL NAME _____________________________________________________________________________
(Last)
(First)
(Middle)
___________________
Called Name
RESIDENT ADDRESS ________________________________________________________________________ Apt. #__________
CITY______________________________________________ PHONE _____________________________
Unlisted Yes
No
DATE OF BIRTH _____/_____/__________ BIRTHPLACE CITY _______________________ GENDER Male Female
SOCIAL SECURITY # __________________
ETHNIC INFORMATION (required by Federal Law): Select one or more races from the following five racial groups:
____American Indian/Alaska Native ____Asian ____Black/African American ____Native Hawaiian/ Other Pacific Islander
____White
Homeless Status: Yes No (If yes, give explanation) _____________________________________________________________
US Citizen: Yes No
Exchange Student: Yes No
Is English the student’s native language? Yes
No
Does the student have a current: IEP ___Yes ___No
Country: _______________________
Is English the only language spoken in the student’s home? Yes
No
504 Plan ___Yes ___No
Has the student received Special Education Services in the past: ___Yes
___No
What service(s) ______________________________
PARENT/GUARDIAN INFORMATION
Circle one:
Father
Mother
Grandparent (Power of Attorney POA attach)
Guardian
Foster Parent (attach Court Papers)
PARENT/GUARDIAN #1 ____________________________________________________________________________________________
Address: ______________________________________________________ City: ______________________ Zip Code: ___________
Phone: _________________________ Cell Phone: ________________________ Pager: ______________________________
Employer: __________________________________________________
Address: ________________________________________________ City/Zip ______________________ Phone ____________
Your Email Address: ___________________________________________________________________________
Circle one:
Father
Mother
Grandparent (Power of Attorney POA attach)
Guardian
Foster Parent (attach Court Papers)
PARENT/GUARDIAN #2 ____________________________________________________________________________________________
Address: ______________________________________________________ City: _______________________ Zip Code: ____________
Phone: _________________________
Cell Phone: _________________________
Pager: ____________________________
Employer: __________________________________________________
Address: ________________________________________________ City/Zip _______________________ Phone _____________
Your Email Address: ___________________________________________________________________________
OFFICIAL USE ONLY:
______ Birth Certificate
______ Social Security Card
______ Proof of Residency
______ Immunization Records
3/14
______ Custody Papers
______ Court Order
______ Grades/Transcripts
______ IEP/ETR
______ Tuition Student
______ MVCTC
______ Withdrawal Papers
______ Transportation
______ Locker Number
______ Other
CUSTODIAL INFORMATION
It is Ohio State Law that each student provide a certified copy of any child custody order or decree, which has been issued with
respect to the student, the custodial parent of such a student, must also provide the Board of Education with a certified copy of
any later court orders, which modify the original custody order or decree. [ORC 3313.672(b)]
Please check one of the following statements that apply to your child:
___ A. Child lives with natural parent(s) or with legally adoptive parents.
___ B. Parents are divorced or legally separated; child resides with parent that has legal custody by court order. Parent must
provide a copy of court-ordered custody agreement showing which parent is Residential Custodian of child for school purposes.
If this is your situation, you must provide the school with a copy of the court order within 30 days from today
___ C. Parents are divorced or legally separated; child resides with parent that DOES NOT have legal custody. If this is your
situation, you must obtain legal custody within 60 days, and provide a letter stating you are in the process of obtaining
custody
___ D. Child lives with a Grandparent who has Power of Attorney POA or Caretaker Authorization Affidavit which allows the
child to attend the district where the grandparent resides tuition free ORC 3109 must attach a copy of this form.
___ E. Child lives with a Grandparent. In this particular circumstance, a student under the age of twenty-two, who is in the
custody of the parent(s), resides with a grandparent and does not require special education can attend the district where the
grandparent resides tuition-free as long as the Boards of Education of both districts agree that good cause exists for such
attendance. ORC 3313.64
___ F. Child lives with a Guardian who has been granted legal custody by court order. If this is your situation, you must
provide the school with a copy of the court order upon enrollment.
___ G. Child lives with a Guardian who HAS NOT been granted legal custody by court order. If this is your situation, you
must obtain legal custody within 60 days and provide a letter stating you are in process of obtaining custody.
___ H. Child lives with Foster Parents. If this is your situation, you must have all necessary court orders, proof of district
responsibility for educational cost and name of previous school at the time of enrollment. Your child will NOT be
enrolled without meeting all of these requirements.
___ I. Child is 18 years of age or older and lives apart from his/her parents or guardian.
___ J. Tuition Student (you must obtain a tuition agreement with current rates and payment schedule from the Board Office)
Name and Address of Natural Parents at time of Custody change to Guardian
Name __________________________________ Address ______________________________________________________
SCHOOL HISTORY
School previously attended: ______________________________________________________________________________
School address: _______________________________________________________________________
Has student ever attended any school in this district? Yes No
Name of building attended in district: _____________________________________ Year last attended: _____________
FAMILY INFORMATION
Names of school age brother(s)/sister(s) now living at home
First Name
Last Name
___________________________________________
___________________________________________
___________________________________________
Date of Birth
_____________
_____________
_____________
Grade
____
____
____
Building
_________________________________
_________________________________
_________________________________
I CERTIFY THAT THE INFORMATION PROVIDED TO THE BEST OF MY KNOWLEDGE IS TRUE. If false or misleading
information is given regarding residency, back tuition may be assessed and student withdrawn from school. It is the
responsibility of the parent/guardian to notify the building principal upon a change of address or living conditions. Failure to
comply could lead to tuition charges, school records withheld and/or athletic eligibility voided.
SIGNATURE ____________________________________________________________ DATE _______________________