MCCSC Student Registration 22-23

MCCSC Student Registration 22-23

Little Cadets Preschool
Legal Name of Child:
Grade Level
Child's Birthdate

Month Day Year
Date
Gender
Race/Ethnicity: Check all that apply

White: A person having origins in any of the original peoples of Europe, theMiddle East, or North Africa. Black or African American: A person having origins in any of the black racialgroups of Africa. Hispanic: A person of Cuban, Mexican, Puerto Rican, Cuban,South or Central American, or other Spanish culture or origin, regardless ofrace. American Indian: A person having origins in any of theoriginal peoples of North America and maintaining cultural identificationthrough tribal affiliation or community recognition. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander: A person having origins in any ofthe original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Other
Parent/Guardian Name:
Relationship to Child:
Legal Residence Address:
Contact Phone Number
Please enter a valid phone number.
Guardian Email
example@example.com
Mother's Name:
Mother's Home Phone
Please enter a valid phone number.
Mother's Cell Phone
Please enter a valid phone number.
Father's Name
Father's Home Phone (if separate homes)
Father's Cell Phone
Please enter a valid phone number.
Mother Employer:
Phone:
Address:
Father Employer:
Phone:
Address:
Emergency Contact: Primary
Name:
Relationship:
Phone:
Emergency Contact: Secondary
Name:
Relationship:
Phone: Phone Number
Doctor Name & Phone Number
Dentist Name & Phone Number
Hospital-Preference
Medical Conditions & Medication
The U.S Department of Education requires all states to collect information on the race and ethnicity of public school students and staff. The federal government has developed a new way to report ethnicity and race that includes these new categories. The changes are intended to provide a more accurate picture of the nation’s ethnic and racial diversity.
Grade
Date

Month Day Year
Date
Part 1: Ethnicity
Is this individual Hispanic/Latino? (Choose only one)

No, not Hispanic/Latino Yes, Hispanic/Latino A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of
Part 2: Race

This has already been answered in the previous section. Please refer to the top portion.
MCCSC Residency Verification
The Board of Education recognizes that a child must be a legal resident of our community to attend our school system.

In accordance with Board Policy, we are requiring verification of legal residency to complete the registration process. Please read and sign the verification statement below. No student will he fully registered until this statement is signed and information verified. Questions of legal residency will be resolved through the Administration Services Center by calling 539-9212.
Address of legal residence: (student resides here with parent or legal guardian)
If moving or building, note date of occupancy: (must fall with current school year)

Month Day Year
Date
Home phone or parent's work
Parent Or Guardian's name
Parent or guardian must sign statement below:

By checking this box I am verifying the address I have provided is accurate for my child. By checking this box I am verifying that my child is a Transfer student and is in compliance with
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Student Health Record

Please complete the following medical information for your child so that we may provide the best care during school hours.
Student Name
Medical Condition(s)

Asthma Diabetes Epilepsy Heart Condition Allergies Other
Daily Medication(s) (List name, dose, frequency, and reason for each listed medication)
Please list any other special needs for your child
Authorization To Release Medical Information
In order that my child may receive the best possible care during the school hours, I give permission for my child’s medical information to be shared with necessary school employees on a need to know basis while my child is under their supervision.
Parent/Guardian Signature

Clear
*****Please read very carefully before signing*****

**Cascade High School, Cascade Middle School, Mill Creek East and Mill Creek West will no longer be providing Tylenol, Ibuprofen, Tums or Cough Drops.**

Should your student require the use of Tylenol, Ibuprofen, Tums or cough drops, it will be up to you as the parent to provide this for your student. Also, you will need to complete a Permission to medicate form. Antibiotic ointment, hydrocortisone cream and calamine will be provided on a need to basis and will be maintained in the clinic.
Can your child have antibiotic ointment, hydrocortisone cream or calamine if it is needed?
Parent/Guardian Signature

Clear
Medical History
Neurological Disorders

Chicken Pox Whooping Cough Scarlet Fever Rheumatic Fever Stomach / Intestinal Kidney / Urinary Diabetes Seizure Hepatitis Heart / Circulatory Orthopedic Emotional / Behavior Major Accidents Operations Skin Conditions Other
For all checked answers, Please give dates and / or explanation
Respiratory Illness (check all that apply)

Asthma Bronchitis Pneumonia Sinus Problems Tuberculosis Ear / Nose / Throat Frequent Colds
For all checked answers, Please give dates and / or explanation
Please list and explain any regularly prescribed Treatments or Health Services
Does your child require Special Needs or Restrictions in the following areas?
Dietary / Foods
Bathroom Privileges
Vision / Hearing
Physical Activity / Mobility
Allergies
Does your child suffer from allergies?
If Yes, please list all allergies and the Typical Reaction your child exhibits: i.e. rash, hives, sneezing, tearing, nasal congestion, coughing, wheezing, itching, swelling of tongue, difficult breathing.
Have you noticed a recent increase in the severity of your child's reaction?
How do you treat the above reactions? (Medication, Dose, Frequency)
Have you ever used an Epi-Pen to treat any of the above reactions?
Do you wish to provide an Epi-Pen to be kept in the school clinic for use if your child has a severe life threatening reaction while at school?
I hereby give permission to the Mill Creek Schools to administer the above medication in the event my
Parent/Guardian Signature

Clear
Home Language Survey
The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district. The HLS is administered once, upon initial enrollment in Indiana, and remains in the student’s cumulative file. Please note that the answers to the survey below are student specific.

Please answer the following questions regarding the language spoken by the student:
1. What is the native language of the student?
2. What language(s) is spoken most often by the student?
3. What language(s) is spoken by the student in the home?
Student Name
Parent/Guardian Name
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
IDOE Work Survey

The Migrant Education Program (MEP) provides supplemental education and support services to eligible children through national funding. The purpose of the program is to ensure that all migrant students reach the academic standards and graduate with a high school diploma (or complete GED/HSE).
Date

Month Day Year
Date
Parent/Guardian Signature

Clear
1. Within the last 3 years, have your children moved for any reason?

Yes No
2. Has anyone in your household moved from one school district to another within the United States to look for seasonal or temporary work in agriculture?

Yes No
If you answered NO to either of these questions, please STOP and continue to the next section: Parent Permission From for World WIde Web Publishing.

If you answered YES to both of these questions, please continue to numbers 3, 4, & 5.
3. When was the last time you or anyone in your household has moved to look for, or work in an agricultural activity within the United States? (Please list month & year)
4. Please check any of the agricultural activities listed below that you have looked for or worked in:

Plant/Harvest vegetables or fruits Detassel Corn Tobacco Farm Poultry and/or Egg Farm Duck, turkey, chicken, pork, or beef processing plant Aquacultural/Fish Hatcheries Canning vegetables/fruits Sod Farm Planting, pruning, & cutting trees Dairy Farm Flora culture/gladiola farm Green house or plant nursery

Please list the names of all of the children in the household under 22 years of age

	Child Name	Date of Birth
1
2
3
4
5

Parent Permission Form For World Wide Web Publishing of student work and/or photo
Name of Student
Date

Month Day Year
Date
Dear Parent/Guardian,

As Mill Creek Community School Corporation integrates Internet Technology into our classrooms there could be projects that might involve publishing your child's photo or work on our Web Page, www.mccsc.kl2.in.us. We want to assure you that your child will not be involved in any of these projects without the direct supervision of a teacher or staff member.

In order to ensure your child's privacy and safety, Mill Creek Community School Corporation requires that:
- Publishing any student's image, full nam e , photograph or original work on our website requires written permission from the parent and the student.
- Pictures published on the websi t e will b e of at least three students.
- No personal information pertaining to the student, s uch as full name, address, phone number, etc. will be published with a photograph.
- If names are published w i th the pictures, it will only be the students' first names and they will not be listed in the order of the students in the picture.
- All work published will be with the permission of the student.
Please check all that apply and return to your student's teacher or school office.

I grant permission for the publishing of my child's photograph on the website. I grant permission for the publishing of my child’s work on the website. I do not grant permission for the publishing of the above-described material on the website.
Parent/Guardian Signature

Clear
Parent/Guardian Printed
Parent/Guardian Active Duty Military Form
School Name:
Does the above named student have a parent/guardian who are currently active duty in the Armed Forces?

Yes No
Beginning with the 2015-2016 school year, each school corporation and charter school shall annually:
- (1) Determine whether a student’s parent is a member of:
  - (A) The armed forces of the United States who is on active duty;
  - (B) The reserve component of a branch of the armed forces of the Unites States; or
  - (C) The national guard; and
- (2) Pro vide a list to the department of the students who have been identified under subdivision
Should be Empty:

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MCCSC Student Registration 22-23

Part 1: Ethnicity

Part 2: Race

MCCSC Residency Verification

Student Health Record

Authorization To Release Medical Information

Medical History

Allergies

Home Language Survey

IDOE Work Survey

Parent Permission Form For World Wide Web Publishing of student work and/or photo

Parent/Guardian Active Duty Military Form