BCS Registration Form - New Student Form

Registration Form for NEW students to Bradley County Schools. Please complete the form below. Required fields marked with an asterisk * If a question is not applicable, please put NONE or the first item in a drop-down list.

Grade:*

Answer Required

When a call is made about your child, what number should we call?

Call Phone Number #1*

Number Required

Call Phone Number #2*

Number Required

Student Name (as it appears on the Birth Certificate):

First Name*

Answer Required

Middle Name*

Answer Required

Last Name*

Answer Required

Preferred Name:

Answer Required

Gender/Sex:*

Answer Required

Date of Birth:*

Answer Required

Country of Birth*

Answer Required

State of Birth*

Answer Required

County of Birth:*

Answer Required

City of Birth:*

Answer Required

Ethnicity*

Answer Required

Hispanic

Non-Hispanic

Race (Check all that apply):*

Answer Required

Asian

American Indian/Alaskan Native

Black/African American

Pacific Islander / Native Hawaiian

White

Student's Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

List other childern in Family:

Answer Required

Special Services he/she receives: [Pick all that apply]*

Answer Required

Resource

Title I Reading

Title 1 Math

Speech

My child has an IEP

My child has a 504 plan

Not Applicable

Emergency Contact Information [other than parent]

First Name

Answer Required

Last Name

Answer Required

Phone Number:

Number Required

Relationship:

Answer Required

Check out information: Names listed below may check out my child

Answer Required

Custody:*

Answer Required

Both Parents

Mother

Father

State Custody

Other-Legal Guardian

Are there Legal/Custody issues we should be aware of?*

Answer Required

Yes

Please explain the custody issues?

Answer Required

Father's Information

Student lives with*

Answer Required

Yes

Father's First Name*

Answer Required

Father's Last Name*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Phone Number*

Number Required

Work Phone Number

Number Required

Cell Phone Number

Number Required

Email Address

Answer Required

Employed by:

Answer Required

Does the parent/legal guardian presently serve in the *

Answer Required

Active Military

National Guard Military

Reserve Military

None

Mother's Information

Student lives with*

Answer Required

Yes

Mother's First Name*

Answer Required

Mother's Last Name*

Answer Required

Mother's Maiden Name*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Phone Number*

Number Required

Work Phone Number

Number Required

Cell Phone Number

Number Required

Email Address

Answer Required

Employed by:

Answer Required

Does the parent/legal guardian presently serve in the *

Answer Required

Active Military

National Guard Military

Reserve Military

None

Custody Other - Legal Guardian Information

If you do not need to this section, please place NONE in each box since these fields are required.

Student lives with?*

Answer Required

Yes

Custody Other - Legal Guardian's First Name:*

Answer Required

Custody Other - Legal Guardian's Last Name:*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Phone Number*

Number Required

Work Phone Number

Number Required

Cell Phone Number

Number Required

Email Address

Answer Required

Employed by:

Answer Required

Does the parent/legal guardian presently serve in the *

Answer Required

Active Military

National Guard Military

Reserve Military

None

Relationship to Student:

Answer Required

Last School Child Attended:

If you do not need to this section, please place NONE in each box since these fields are required.

School Name*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

School Phone Number*

Number Required

School Fax Number*

Number Required

For children entering Kindergarten or First Grade (Check if attended):*

Answer Required

Pre-School

Day Care

Kindergarten

Does your child have special health needs that may require special care during school hours?*

Answer Required

Yes

Explain briefly:

Answer Required

HOME LANGUAGE SURVEY - In an effort to comply with Title VI of the Civil Rights Acts, we have been asked to survey parents to see if we are meeting the needs of students who may speak English as their second language.

1. What is the first language that your child learned to speak?*

Answer Required

2. What language does your child speak most often outside of school?*

Answer Required

3. What language do people usually speak in your child’s home?*

Answer Required

Date first enrolled in U. S. Schools: *

Answer Required

STUDENT RESIDENCY INFORMATION - As part of the ESSA requirements, each school registrant should complete the following information.

WHERE DOES THE STUDENT STAY AT NIGHT?*

Answer Required

his/her home owned/rented by parent

a shelter

with a relative or friend (family does not have a residence)

a motel/hotel

in housing that is inadequate (i.e. no electricity, running water, etc.)

unsheltered (cars, parks, campgrounds, temporary trailer, abandoned building)

Other:

If other please explain;

Answer Required

There MUST be a complete medical examination for every student entering school. The required TN Child Health Record must be on the Certificate of Immunization developed and authorized by the TN Department of Health. The immunization and physical exam will be recorded on the Certificate and placed in the student’s school record. Children entering Kindergarten must be five years of age on or before August 15 (MUST have proof of birth). Children entering First Grade must have attended a State Approved Kindergarten.

Thank you for registering your student with Bradley County Schools. The principal or designee of the school you are applying to attend will contact you soon.

Requirements for all new students:

Proof of Birth, one of the following forms:

Birth Certificate - issued by a government
Passport issued by any nation (translated)
Immigration documentation
Decree of adoption of other records issued by a court
Other official documentation showing date of birth and parent's names (refer to board policy 6.203)

Requested if available:

Social Security Card

Parent or Legal Guardian's Signature: (Typing name and completing date will verify information)*

Answer Required

Today's Date:*

Answer Required

Please fix the highlighted areas below before submitting.

BCS Registration Form - New Student Form