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New Student Registration Form of 1 Revised July 2012

McComb School District - Student Registration

Date____________Grade______School Year_______________School_________________________________________

Student Name________________________________________Age______Race_______________Gender: M____F____

SS#_____-____-______DOB____________Home Telephone_________________Work Telephone___________________

Birth Certificate#_________________Immunization Complete? Yes___No___ Verified By Initials___________________

Address________________________________________City____________________State_____Zip________________

Mail Addr_______________________________________City____________________State_____Zip________________

Live in McComb City Limits? Yes___No___ (Office Use Only) Township & Range_____________________________

Transportation: Bus___ (Office Use Only) Bus#______ Walk____Car____Other____ _____________________________

Previous School/Pre-School Attended: ______________________________________Telephone____________________

Addr___________________________________________City____________________State_____Zip________________

Reason for withdrawal: __________________________________________Last day in school______________________

Previously attended McComb School District? Yes___No___ If yes, when? _____________________________________

Did student receive special services (Speech, SPED, Gifted, etc…)? Yes___No___ List _____________________________

Was student ever expelled from a school he/she attended? Yes___No___ If yes, when? __________________________

Does student have siblings at McComb School District? Yes___No___ If yes, please name_________________________

________________________________________________________________________________________________@

Student currently lives with: Mother___ Father___ Legal Guardian___ (copy of legal papers required) Other___

Marital Status: Single___ Married ___ Divorced ___ (copy of custody papers required) Separated___

Parent/Guardian Signature___________________________________________________Date_____________________

Father/Guardian Name________________________

Addr________________________________________

Employer___________________Tele#____________

Email______________________Cell#_____________

Mother/Guardian Name________________________

Addr________________________________________

Employer___________________Tele#____________

Email______________________Cell#_____________

Emergency Contact(1)__________________________

Addr________________________________________

Home#_____________Work/Cell#________________

Relationship to Student_________________________

Emergency Contact(1)__________________________

Addr________________________________________

Home#_____________Work/Cell#________________

Relationship to Student_________________________

Residency Registration Form Page 1 of 1 Revised July 2012

McComb School District – Residency Registration

TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN

School Name________________________________________Grade_____________School Year____________________

Student Name______________________________________________________________________________________ (A separate form is required for each student)

Parent/Guardian Name_______________________________________________________________________________

Address_________________________________________City________________________State____Zip_____________ (P.O. Box or Route # is not acceptable for an address)

MailAddr________________________________________City________________________State____Zip_____________

(if different from above)

Student lives with: Both Parents____ Mother____ Father____ Legal Guardian____

I hereby certify that the information given above on this form is a true and correct statement of my legal residence. Should my legal residence change while the above listed student is enrolled in the above cited school district, I will promptly notify the appropriate officials of this school district. Further, I understand that a student is not legally enrolled until this form is completed and signed by the parent or legal guardian with whom the student resides. I understand that a student admitted under false information is not legally enrolled and is subject to penalty.

Parent/Guardian Signature_______________________________________Date____________Telephone_____________

TO BE COMPLETED BY SCHOOL

___A. Documents provided to me by the Parent/Legal Guardian (Minimum of two required):

_____1. Filed Homestead Exemption Application Form

_____2. Mortgage Documents or Property Deed

_____3. Apartment or Home Lease Agreement

_____4. Utility Bill____________________________Specify (Only one accepted)

_____5. Valid Drivers License

_____6. Voter Precinct Identification

_____7. Automobile Registration

_____8. District Representative Personal Visit _____________________________________________ Signature Date

_____Other Documentation____________________________________________________________ (Describe)

___B. Student is living with legal guardian and a certified copy of the Court Decree, or petition is pending, was

received declaring the district resident to be the legal guardian of the student and further declaring that the

guardianship was formed for a purpose other than establishing residency for school district attendance purposes.

_____________________________________________ ___________________________________________ Date School Representative

Health History Form Page 1 of 1 Revised July 2012

McComb School District – Health History Form

Student__________________________________ School_______________________________________ Grade_______________

Date of Birth_________________________ Gender M____ F____ Race______________________ SS# _______-______-_______

Physical Address______________________________________________________City_________________________State_______

Mother/Guardian______________________________Home#________________Work#______________Cell#________________

Employment_____________________________________________Address_____________________________________________

Father/Guardian_______________________________Home#________________Work#______________Cell#________________

Employment_____________________________________________Address_____________________________________________

To Parent/Guardian: In order to serve your child in case of Accident or Illness, it is necessary to furnish the following information for emergency contact.

List two local relatives or neighbors who will assume temporary care of your child in case you cannot be reached:

Student Insurance Coverage

___ Medicaid – Medicaid Number________________________________________ ___CHIPS – CHIPS Number______________________________________________ ___NO COVERAGE ___Private Insurance – Insurer Name and Number___________________________

LIST ALL MEDICATION TAKEN BY YOUR CHILD_____________________________________________________________ LIST ANY ALLERGIES YOUR CHILD HAS___________________________________________________________________ NAME OF STUDENT’S DOCTOR_________________________________________________________________________

Please check any of the following care the student has had in the past year: Emergency Room_____ Dentist_____ Public Health Department_____ Specialist(Doctor)_____ Eye Doctor_____ Hospitalization_____ Reason____________________________

STUDENT MEDICAL HISTORY Please check any illnesses this student has now or has had in the past year:

___ADHD ___Depression ___Serious Injury ___Sickle Cell Anemia ___Heart Defects ___Asthma ___Diabetes ___Seizures ___Vision Problems ___Constipation ___Birth Defects ___Headaches ___Stomach Problems ___Physical Handicap ___Ear Infections ___Hearing Problems ___Bone/JointProblems ___High Blood Pressure ___Anemia ___Trouble Urinating ___Rheumatic Fever ___Anxiety ___Surgical History ___Skin Problems ___Leg Pain

Please explain check illnesses or anything more about this child’s health that you think is important for us to know: I, the Parent/Guardian of____________________________give permission for my child to participate in the school health program, mental health program, receive first aid, and health education. In addition, I give the McComb School District staff permission to transport my child for emergencies, medical, mental health, and dental needs, or school issues. I understand that the District will try to locate me in case of emergency at the numbers I have provided. Parent/Guardian Signature___________________________________________________________ Date_________________________________

Name_____________________________________ Address___________________________________ Telephone_________________________________ Relationship to Student______________________

Name_____________________________________ Address___________________________________ Telephone_________________________________ Relationship to Student______________________

of 2 Revised June 2013

McComb School District - Mississippi Medicaid Cool Kids Program

If your child has Mississippi Medicaid, our school nurses can provide your child’s yearly check-up during school hours. Please read and sign the authorization below and fill out the the attached form in order for us to provide this service to your child.

You may call the school nurse’s office if you would like to be present for your child’s check-up. However, if you are unable to be present, the school nurse will send you a written report.

This check-up is important in maintaining the health and well-being of your child. It does not replace the medical services given to your child by your family physician. If you are not interested in your child receiving this check-up at school, please make sure they receive this service with their doctor, nurse practitioner, or the health department.

McComb School District School-Based Health Clinics Authorization for EPSDT Screening

I____________________________________, parent/guardian of___________________________________________,

give McComb School District permission for my child to receive the following health-related services during the annual EPSDT Screening:

head to toe physical examination

immunization evaluation

vision and hearing screening

laboratory tests (appropriate to age according to Medicaid guidelines)

developmental and nutritional assessment

dental screening

urine testing (to screen for diabetes)

I understand that my child’s medical records are strictly confidential.

This authorization is limited to the services described above. I understand that if a health problem is identified, the school nurse will notify me and a referral will be made to the appropriate doctor. This authorization is valid for one year from date of signature.

I retain the right to withdraw permission for services at anytime during the school year.

I hereby authorize payment of insurance benefits to the above named clinic under the term of the child’s policy.

I hereby authorize the clinic to release any information acquired in the course of the examiniation or treatment so that insurance benefits may be promptly and correctly filed.

_________________________________________________ _____________________________ Signature Date


McComb School District - Mississippi Medicaid Cool Kids Program Health Form

Student______________________________________________

Family Medical History (Please check if any member of your child’s family has any of these conditions):

___Heart Disease ___Cancer ___High Blood Pressure ___Stroke ___Tuberculosis ___Sickle Cell/Trait ___Alcohol/Drug Abuse ___Nervous/Mental Problems ___Anemia ___Physical Handicap/Disability ___Asthma ___Kidney Disease

Does anyone smoke in the house/apartment where the student lives? Yes____ No____

Developmental/Behavior:

Please check YES or NO for each question below. If the behavior listed is not a problem this student has,

please check NO. If it is something you have noticed or are concerned about, please check YES.

Student seems to learn as quickly as other children Yes___ No___

Student seems harder to raise than the other children Yes___ No___ Does not apply___

I am concerned about the following:

Problems with sleep Yes___ No___ Potty Training Yes___ No___

Very shy/withdrawn Yes___ No___ Appetite Yes___ No___

STOP! Answer the following questions ONLY IF YOUR CHILD IS UNDER 7 YEARS OF AGE.

1. Does your child live in or or visit a home, daycare, or other building built

before 1950? Yes___ No___ Not Sure___

2. Does your child spend at least six hours a week at home, daycare, or other

building before 1978 with recent, ongoing or planned remodeling? Yes___ No___ Not Sure___

3. Does your child have a family member or friend who has or did have an

elevated blood lead level? Yes___ No___ Not Sure__

4. Does your child frequently come in contact with an adult who works with

lead? (Construction, welding, painting, radiator repair, metal recycling) Yes___ No___ Not Sure__

5. Have you seen your child mouthing or touching painted surfaces

(i.e., window sills, door frames), keys, electrical cords, jewelry, vinyl

(plastic), mini-blinds or bare soil outside or near the home? Yes___ No___ Not Sure___

6. Do you give your child any home or folk remedies which may contain lead? Yes___ No___ Not Sure___

7. Does your child drink well water? Yes___ No___ Not Sure___

8. Does your home have a smoke alarm? Yes___ No___ Not Sure___

9. Does your home have a carbon monoxide detector? Yes___ No___ Not Sure___

10. Are there signs of water leakage in your home (mold or mildew)? Yes___ No___ Not Sure___

11. Has your child been diagnosed with asthma by a primary care provider? Yes___ No___ Not Sure___

Home Language Survey Page 1 of 1 Revised July 2012

McComb School District – Home Language Survey

Student Name______________________________________Age______Date of Birth_____________________________

School________________________________________________Grade_______Date_____________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. What language did your child use when he/she first began to talk?_____________________________________

2. What language does your child usually use at home now?_____________________________________________

3. What language do you usually use when speaking to your child?_______________________________________

4. What language is most often used by the adults at home?____________________________________________

Parent(s) Name (Please print)________________________________and______________________________________

Parent(s) Signatures________________________________________and_____________________________________

Date Signed_____________________


McComb School District – Photograph and/or Video Release Form

I, as the parent/guardian of _______________________________________________________, hereby consent that the photographs and/or videos taken of my child during the school year while enrolled at the McComb School District may be used. When photogrphs and/or videos of students are placed on the website, there will not be any personal identification of any student by name.

___ I give my permission to use my child’s photograph and/or video.

___I DO NOT give my consent to have any photographs and/or videos of my child used by the McComb School District in any way.

Student Name:__________________________________________________

Grade:_________________________________________________________

Street Address___________________________________________________

Telephone Number_______________________________________________

Signature of Parent/Guardian:______________________________________

NOTE: If this form is not returned, we will assume that you do not wish for your child to be interviewed, photographed or video taped. This form will be kept on file at your child’s school. If a situation arises that may change your child’s status regarding publicity, please notify the School and Community Relations Office in writing as soon as possible. New photograph and/or video releases will not be required each school year.

If you do not wish for your chid to be interviewed, photographed or video taped, please instruct your child to let his or her teacher know so that he or she can be removed from the event.