Student Registration Form - Stafford County Public Schools Page 2
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1
2SCPS Student ID
Current Enrolling SCPS
Family ID
Student Registration Form - Part B
To Be Completed by Parent or Guardian
Student Legal Name (as it appears on the birth certificate)
Are you registering your child for
Is your child home
Are you presently approved to provide
full-time instruction?
schooled?
home instruction in Stafford County?
Last
First
Middle
Yes
No
Yes
No
Yes
No
Number of Years Previously in K-12
Number of Full Academic Years Completed in U.S./DOD
Has your child ever received Special Services?
Yes
No (If Yes, select all that apply).
0
1
2
3
4 or more
IEP
Gifted
ESL
504
Other (specify) __________________________________
Is the student a foster child?
Is the student married?
Does your child have
Has your child ever attended Stafford County Public Schools before?
Yes
No
health insurance?
If Yes, Name of Last School Attended in SCPS
Last Year Attended and/or Grade
Yes
No
Yes
No
Yes
No
Last School Attended NOT in SCPS (list previous three)
School Name
City / State
Grade Levels Attended
School Telephone
(_______) _______ - _________
School Name
City / State
Grade Levels Attended
School Telephone
(_______) _______ - _________
School Name
City / State
Grade Levels Attended
School Telephone
(_______) _______ - _________
Country of Birth
Country of Citizenship
Migrant
Non U.S. Citizens Only
First Language
Language Spoken at Home
Original U.S. Entry Date
Refugee
Student Visa Holder
Immigrant
Foreign Exchange Student
Yes
No
______/______/______
Has your child ever been suspended, expelled, or dismissed from another school, public or private, in the Commonwealth of Virginia or in another state for an offense in violation of school
Yes
No
board policies relating to weapons, alcohol, or drugs, or for the willful infliction of injury to another person?
Is your child presently suspended, expelled, or dismissed for any cause from any school?
Yes
No
CHANGE OF ADDRESS: I understand that I must notify the principal of the school and provide proof of residency should the residency of the student change.
I am aware that making a false statement herein constitutes a Class 3 misdemeanor. I am aware that if I move from Stafford County that the above registered student may no longer be eligible to attend
Stafford County Public Schools. I certify that all the information on this student registration form is true and correct to the best of my knowledge and belief.
Parent or Guardian Signature ____________________________________________
Date ______/______/______
Print Name ____________________________________
To Be Completed by SCPS Staff (with input from parent or guardian)
th
Proof of Date of Birth
Date of Entry (current)
Original U.S.
Original Virginia
Original SCPS
Original 9
Grade
Birth Certificate Number: ___________________________________ State __________
School Entry Date
School Entry Date
Entry Date
Entry Date
E _________
____/____/____
Affidavit with Supporting Documentation: ______________________________________
____/____/____
____/____/____
____/____/____
____/____/____
R _________
Student Assigned Base School
Current Special Services
Proof of Address Received
Contact Restriction
Document Type(s):
Yes
No
Enrolling Parent Identification Verified
Type of Identification:
SCPS Staff Signature ________________________________________________
Date _______________________________________
Print Name _____________________________________________________
Current Enrolling SCPS _________________________________________________
Information from the Stafford County Public Schools student education record is released on the condition that the recipient agrees not to permit any other party to have access to such information without
the written consent of the parent or guardian or of the eligible student.
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