Form Ccf-705 - Clark County School District Registration Form

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clARK coUnTy School DISTRIcT ReGISTRATIon FoRM – Please Print clearly

9998-500705

CCF-705

Rev. 02/11

nRS 392.165: STATe lAw ReqUIReS enRollMenT oF STUDenT By leGAl nAMe

Homeroom Teacher:

Room No.:

STUDenT MUST Be enRolleD

Student’s Last Name

First Name

Middle Name

Apndg

Grade

Gender

School USe only

By leGAl nAMe. (As per birth

Student ID ___________

certificate or other legal document)

Home Address

Zip Code

Status Date __________

Status Code _________

hoMe lAnGUAGe SURVey:

Parent or Guardian Must Complete.

Residence Phone Number

Student Cell Number

Mailing Address/P.O. Box

Zip Code

English Prof. _________

(If Different Than Residence)

1. First language learned by student?

Attend. Permit

English

ASL/Deaf

Birth Date

Birth Place (City/State/Country)

SSN # (Last four digits only)

Code ____________

Other ____________________

000-00- ___ ___ ___ ___

Date _____________

2. Language spoken by student

PARenT/GUARDIAn InFoRMATIon – MUST Be coMPleTeD By leGAl PARenT/GUARDIAn

with friends?

Relationship

Parent Last Name

Parent First Name, Middle Initial

English

ASL/Deaf

Other ____________________

3. Language used in home?

Resides With

Cell Phone Number

Parent Employer

Occupation

Employer Phone

Work Ext.

Work Hours

English

ASL/Deaf

Yes

_____ To _____

Other ____________________

Relationship

Parent Last Name

Parent First Name, Middle Initial

Is student ¼ (25%) AMERICAN

INDIAN or enrolled in a tribe?

Resides With

Cell Phone Number

Parent Employer

Occupation

Employer Phone

Work Ext.

Work Hours

Yes

_____ To _____

School InFoRMATIon

Mother /Guardian E-mail address:

Father/Guardian E-mail address:

Has student ever received Special

Education Services?

Yes

PARenT/GUARDIAn InFoRMATIon

non-custodial

Joint custody

Relationship

Parent Last Name

Parent First Name

Parent M.I.

Telephone Number

Does student have a current

Accommodation Plan (Section 504)

in school?

Yes

Home Address

Zip Code

Extra Mailing

Yes

Has student ever been expelled?

School InFoRMATIon

Yes

Last School Attended – Name/Address/City/State Please Check One:

CCSD

Public

Private

Charter

Has the student ever been enrolled in a

School USe only

CCSD SCHOOL?

Yes

new Students:

SIBlInG InFoRMATIon

Birth Certificate

Yes

Sibling At This School

Grade

Sibling At This School

Grade

Sibling At This School

Grade

Immunizations

Yes

Records Requested

Yes

locAl eMeRGency conTAcT:

A person who may be contacted if the parent/guardian is unavailable and who is authorized to pick up the student in an emergency.

Military Compact

Yes

1. Emergency Contact Person

Telephone Number

Relationship to Student

3. Emergency Contact Person

Telephone Number

Relationship to Student

30-day Provisional Enrollment

Yes

Homeless (SASI code) __________

2. Emergency Contact Person

Telephone Number

Relationship to Student

4. Emergency Contact Person

Telephone Number

Relationship to Student

All Students:

1 Proof of Address

Yes

TRAnSPoRTATIon ReqUeSTeD FoR:

Zone Variance

Yes

____ MAG (Magnet)

____ 2M (Lives 2 miles away or greater)

____ MD (Medical, Non SpEd)

___ SE (SpEd Related)

Residential Affidavit

Yes

Custodial Papers/Legal Docs

____ CHOICE (NCLB) ____ M2M (Approved Zone Option)

____ Hazard

Note: Please contact Special Education to arrange

Yes

Pending

transportation for self-contained students.

PARENT/GUARDIAN SIGNATURE: ______________________________________ DATE: _______________ COMMENTS: _____________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________

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