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Welcome to Skyline Elementary!
Things you will need to bring with you to enroll your child in school:
* Complete and up-to-date shot records
* Copy of Birth Certificate
* Copy of Social Security Card
* Proof of Residency (i.e. tax statement, utility bill, real estate contract)
* Copy of IEP/Evaluation Report (if applicable)
Skyline Elementary School Supply List
2012-2013
Kindergarten
Pencils – 12, regular size
Glue Sticks: 8 Large Size
Crayons: 4 boxes Crayola Brand (16 or 24 count)
Colored Pencils: Box of 12
Scissors: Fiskars brand, not pointed
Kleenex: 2 large boxes (175 ct. or more)
1 - Red and blue folding mat for rest time (these are about $5.00 at Walmart)
2 containers of wet wipes (100 ct. or more)
Backpack or book bag to carry papers home.
1st Grade
2 boxes of Crayons (24 count)
Erasers (1 pkg. pencil tip erasers and 2 large pink erasers)
Backpack (no backpack on wheels or suitcases on wheels)
24 pencils (to be passed out by teacher as needed)
3 large boxes of Kleenex
Scissors
Elmer’s School Glue
Plastic school box
One large box of wet wipes
Colored pencils
2 box of ziplock bags (1 small and 1 large)
2 pocket folders
*Please put your child’s name on all supplies except pencils.
2nd Grade
12 Colored Pencils
2 Large Glue Sticks
1 pair of Scissors
2 boxes 24 ct. Crayons
1 Art Box
1 – 12 pack of #2 Pencils (to be distributed by teacher as needed)
1 package Wide-ruled Notebook Paper
1 box of Wet Wipes
1box of Kleenex
1 box of Gallon-size Ziploc Bags
1 box of Sandwich-size Ziploc Bags
1 Spiral 70-sheet Notebook
*Your child will also need a backpack to bring items to and from school.
School Supply List
3rd Grade
48 Pencils
1 box of tissues
1 Glue bottle
1 Glue stick
2 boxes 24 ct. Crayons
1 package Colored Pencils
1 package Colored Markers
Scissors
3 Composition Notebooks
1 package Wide-ruled notebook paper
1 package of pencil top erasers
2 large pink erasers
2 highlighters
2 red pens
GIRLS: small Ziplock baggies and wet wipes
BOYS: large Ziplock baggies and paper towels
OPTIONAL: Clipboard with attached storage.
NO ART BOXES.
4th Grade
3 Notebooks (wide-lined)
1 package Loose leaf paper (wide-lined)
2 packages Pencils (24 ct.) not mechanical
Erasers
Crayons
Glue
Scissors
Markers
Art Supply Box
2 boxes Kleenex
1 box Ziplock Bags
Colored Pencils
1 package Wet Wipes
1 bottle Sanitizer
3 Folders
Student Enrollment
2012-2013
Student’s Social Security #____________________________
Date Entered________________________
Must Have
Teacher ___________________________________________
Grade______________________________
Name________________________________________________________________
Last
First
Boy Girl

Middle
Home Address ____________________________________________________________________________
Rte.
Box
City
Home Phone # ______________________________
State
Zip
County you Live In ________________________
Emergency Name and Phone # _______________________________________________________________
Date of Birth ___________________ Place of Birth ____________________________ Age _____________
Ethnicity:
Hispanic/Latino or of “Spanish Origin” Non-Hispanic
Race (only if marked Non-Hispanic):
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
Has your family moved within the past six years to obtain temporary or seasonal farm-related work?
Yes No
Is English the primary language spoken in your home?
Yes
No
(If no, what is the primary language? ___________________________________________________________)
Parent Information
Parent/Guardian email address (if available):
Father’s Name __________________________
Place of Employment ______________________________
Work Phone _____________________________________
Mother’s Name _________________________
Place of Employment ______________________________
Work Phone _____________________________________
If Applicable
Step-Father’s Name _____________________
Place of Employment ______________________________
Work Phone _____________________________________
Step-Mother’s Name ____________________
Place of Employment ______________________________
Work Phone _____________________________________
Guardian’s Name ______________________
Place of Employment ______________________________
Work Phone _____________________________________
With Whom Does the Child Reside:
Mother
Father
Step-Mother
 Step-Father
Other __________________________
Please list all children presently living in your home from oldest to youngest.
Name
Age
__________________________________ ______
Name
______________________________
Age
_______
__________________________________ ______
______________________________
_______
__________________________________ ______
______________________________
_______
__________________________________ ______
______________________________
_______
Please list all persons authorized to pick up your child.
_________________________________________________________________________________________
Name
Phone Number
Name
Phone Number
__________________________________________________________________________________________
Name
Phone Number
Name
Phone Number
Transportation Data Form
Parent/Guardian Name: ________________________________________________________
Address: ____________________________________________________________________
Home Phone Number: _________________________________________________________
Name and Number of Person to Contact in case of emergency:
________________________________________________________________
Please list all school age children in your household that ride the bus:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
A.M. Bus # ____________________
If other please specify:__
Is this pick-up from
or
other ?
________________________________________________________
Directions from pick-up point to school:
______
home
______________________________
____________________________________________
______________________________________
__
P.M. Bus # _____________________
If other please specify: ___________
Is this drop-off at
home
or
other ?
_______________________________________________
Directions from school to drop-off: (Need only complete if different than above)
Hickory County R-1
Safe Schools Act Student Discipline Enrollment Information
Date___________________________________
In accordance with the Missouri Safe Schools Act of 1996, this district requires that parents provide criminal
and school disciplinary information. To implement that law, this district’s Board policy requires that the
following questions be answered by parents/legal guardians enrolling students.
Student Name ________________________________________________________________
Date of Birth _______________________________
Social Security # ___________________________
Parent/Legal Guardian______________________________________________________________________
Address of Parent/Legal Guardian ___________________________________________________________
1. Is the above student presently under suspension or expulsion from another school district?
YES NO
If yes, please describe__________________________________________________________________
2. Has the above student been convicted or charged with any of the following crimes: Please check all that
apply and indicate offense.)
1.
First degree murder under #565.020, RSMo
2.
Second degree murder under #565.021, RSMo
3.
First degree assault under #565.050, RSMo
4.
Forcible rape under #566/030, RSMo
5.
Forcible sodomy under #566.060, RSMo
6.
Robbery in the first degree under #569.020, RSMo
7.
Distribution of drugs to a minor under #195.212, RSMo
8.
Arson in the first degree under #569.040, RSMo
9.
Kidnapping, when classified as a class A felony under #565.100, RSMo
In accordance with #167.171, RSMo no student may be readmitted or enrolled in the school who has been
convicted of or charged with an act which if committed by an adult would be one of the above. Nothing in the
law shall prohibit the readmittance or enrollment of any student if a charge has been dismissed, or when a
student has been acquitted of any of the above offenses.
I attest that all the above information is correct and true:
____________________________________________
(Parent/Legal Guardian Signature and Date)
Hickory County R-1
Student Enrollment Checklist
Parent/Guardian
Name: ______________________________
Address: ____________________________
City/State: ___________________________
Zip: ___________ Phone: ______________
Student
Name: ____________________________________
Address: __________________________________
City/State:_________________________________
Zip: ______________ Phone: _________________
Date of Birth ______________________________
Address Verification – Parent/Guardian (Attach Copy of Document)
Tax Bill – Personal Property/Real Estate
Lease Signed by Both Parties
Real Estate Contract Signed by All Parties
Utility Bill
Utility Deposit Receipt
Other _________________________________________
Basis for Admission of Student (Section 167.020, RSMo)
Resides with Parent in District
Resides with Legal Guardian in District – Copy of Court Order Must be Attached
Student is less than 21 years of age and lacks a fixed, regular and adequate nighttime residence
(homeless child) because student is
living on the street, in a car, abandoned building or other form of shelter not
designated as a permanent home
living in a community shelter facility
living in transitional housing for less than one year
Student is less than 21 years of age and has a permanent or temporary home in the district and
is an orphan or has only one parent living
parents do not contribute to his or her support
Student’s parents own real estate in the district provided
80 acres or more are used for agricultural purposes
parent’s residence is on real estate
at least 35% of the real estate is in the district
parent notified district on or before June 30th that student would be attending
school in the district
(To be eligible for admission all 4 conditions above must be met)
Transportation hardship as agreed by both districts
Additional information supporting admission decision (address, location of where student is living, etc.)______
____________________________________________________________________________________________________________
Waiver Information
Student Denied Admission
Waiver Requested
Date of Denial____________________________
Date of Request __________________________
Waiver Requested by
Parent or Legal Quardian
Student – Must be at Least 18 Years Old
Reason for Waiver Request
Parent is Teacher Under Contract with the District or other Regular Employee of District
Student is Living with Unrelated Person for Reasons other Than Attending School in the District
Student is Living With Grandparents or Other Relative for Reasons Other Than Attending School in the District
Name of Person/Relative _____________________________________________________________________
Relationship _______________________________________________________________________________
Address __________________________________________________________________________________
City/State/Zip Code _________________________________________________________________________
Phone Number _____________________________________________________________________________
Reason Why Student is Living With Person/Relative ____________________________________________
Other Hardship or Good Cause Basis for Waiver (Can not Be Athletics) Explain:
_______________
Waiver Hearing Date (Must be Within 45 Days of Request) _______________________________________
Student Admitted Pending Decision on Waiver Request
Date Student Admitted _________________________
Waiver Granted
Date _______________________________
Waiver Denied
Date _______________________________
Date of Student Permanent Admission: ___________________________________
Hickory County R-1
Student Enrollment Affidavit
Name of Student: _______________________________________________________________
Address: ______________________________________________________________________
Telephone Number: _____________________________________________________________
Parent Guardian Name: __________________________________________________________
I am the parent/legal guardian of __________________________________________________ and I am
providing this affidavit in support of the enrollment of my child in the Hickory County R-1 school district. My
child is not currently under suspension or expulsion from any school district he/she has previously attended. I
understand that it is a criminal offense (class B misdemeanor - Section 167.023 RSMO) to give false
information concerning prior disciplinary actions taken against my child. I also understand that if this school
district admits my child based on false information which I gave, I may be required to pay the school district for
its costs in educating my child. (Section 167.023 RSMO)
_______________________________________________
Parent/Guardian Signature
Date: __________________________________________
Subscribed and sworn to before me, a
______________________________, 20_______.
notary
public
on
the
_________
__________________________________________
, Notary Public
My Commission Expires:
Commissioned in
County, Missouri
day
of
H
Hiicckkoorryy C
Coouunnttyy R
R--11
*Skyline Elementary*
Mr. Mark Beem
Rte. 1 Box 838
Urbana, Missouri 65767
Phone 417/993-4225
Fax 417/993-0216
Superintendent
Mrs. Tammy Smith
K-4 Counselor
Mr. Jason Pursley
K-6 Principal
Request for Release of Student Records
We are requesting records for:
Student’s Name: _______________________________________________________________
Grade: ______ Date of Enrollment: _
__________ Date of Birth: ___________________
The following information should be included:
Academic Records (Grades & Achievement Test Scores)
Health & Immunization Records
Attendance Records
Discipline Records
Psychological/Education Testing
SPECIAL EDUCATION RECORDS Including Current I.E.P & Evaluation Information. (If
needed, please forward this request on to the appropriate office in the district.)
Records Should Be Sent To:
Hickory County R-1
ATTN: Lisa Mitchell, Registrar
Rte. 1 Box 838
Urbana, Missouri 65767
This transfer is provided for in the Family Educational Rights and Privacy Act of 1974, as amended June 17,
1976. The new regulations no longer require an acknowledgment for the parent or eligible student that he or
she has received notification before records may be released to other educational institutions.
Previous School Attended:
School Name: _________________________________________
Address: _____________________________________________
City, State & Zip: ______________________________________
Phone/Fax Number :____________________________________
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