Attachment A - Parental Registration Statement printable pdf download

OLEY VALLEY SCHOOL DISTRICT

OLEY, BERKS COUNTY, PENNSYLVANIA 19547

Student Services

Oley Valley Administration Bldg,

17 Jefferson St., Oley, PA 19547

Phone: 610-987-4100, ext 1187 Fax: 610-987-4138

Attachment A - Parental Registration Statement

Student Name

Date of Birth ___________

Grade

______

Parent or Guardian Name

_______

Address

Telephone Number

Pennsylvania School Code §13-1304-A states in part “Prior to admission to any

school entity, the parent, guardian or other person having control or charge of a

student shall, upon registration provide a sworn statement or affirmation stating

whether the pupil was previously or is presently suspended or expelled from any

public or private school of this Commonwealth or any other state for an action of

offense involving a weapon, alcohol or drugs, or for the willful infliction of injury to

another person or for any act of violence committed on school property.”

Please complete the following:

I hereby swear or affirm that my child was_____ was not ____ previously suspended or

expelled , or is ______ is not _____ presently suspended or expelled from any public or

private school of this Commonwealth or any other state for an act or offense involving

weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any

act of violence committed on school property. I make this statement subject to the penalties

of 24 P.S. §13-1304-A(b) and 18 Pa. C.S.A. §4904, relating to unsworn falsification to

authorities, and the facts contained herein are true and correct to the best of my knowledge,

information and belief.

If this student has been or is presently suspended or expelled from another school, please complete:

Name of the school from which student was suspended or expelled:

_______________________________________________________________________________

Dates of suspension or expulsion:

_______________________________________________________________________________

(Please provide additional schools and dates of expulsion or suspension on back of this sheet.)

12/13/13

The Oley Valley School District is an equal opportunity employer and educator who fully and actively supports equal access for

all people regardless of race, color, religion, gender, age, national origin, veteran status, disability, genetic information or testing,

family and medical leave, sexual orientation, and gender identity or expression. We prohibit retaliation against individuals who

bring forth any complaint, orally or in writing, to the employer or the government, or against any individuals who assist or

participate in the investigation of any complaint, or otherwise oppose discrimination. Compliance issues/questions should be

directed to the Office of the Superintendent.

Attachment A - Parental Registration Statement