Proof Of Student Identity And Age Form (Page 2 of 2) in pdf

Proof Of Student Identity And Age Form Page 2

Who are the parents, parents by legal adoption, or person serving in loco parentis and

responsible for the care of the pupil desired to be enrolled?

________________________________________________________________________

Where do you reside? _____________________________________________________

_______________________________________________________________________

Child’s Name:____________________________________________________________

Social Security Number: (if available)_________________________________________

If the Social Security Number is not available, please check one of the following:

STATUS (Check one)

_____

Student /family will file an application for a social security number.

_____

Application for a social security is in process (receipt presented).

_____

In accordance with the Code of Virginia, Section 22.1-260, a social security number waiver has

been granted for the student because the student is ineligible to obtain a social security number, or

the parent is unwilling to provide that social security number.

_____

Social Security Number included in Registration

Race:__________________________Sex: M F Height:_________Weight:________

Date of Birth:__________________________

Color Hair: _________________________ Color Eyes:__________________________

Birth Parents:

____________________________________________________________

___________________________________________________________

State & County of Child’s Birth:_____________________________________________

Statement as to why a certified copy of the birth certificate is not available:

________________________________________________________________________

Signed:_______________________

Affidavit

Subscribed and sworn to before me this ______day of ___________________, ________

(year)

Witness my hand and official seal.

My commission expired:_______________________

Seal

__________________________

Notary Public

Ref. VA Code 22.1-3.1

SCR SY 2015-16 REG PKT: Affidavit form (page 2)

Proof Of Student Identity And Age Form Page 2