STUDENT REGISTRATION FORM - MIAMI PALMETTO SENIOR HIGH

Additional Emergency Contact Information:
The legal responsibility of medical and transportation expense incurred on behalf of your child is a parental one. If parent can’t be reached, whom should we try to contact?
1st Emergency Contact

First NameLast Name
1st Emergency Contact (Relation to Student)
1st Emergency Contact (Home Address)
1st Emergency Contact Phone Number
Please enter a valid phone number.
2nd Emergency Contact

First NameLast Name
2nd Emergency Contact (Relation to Student)
2nd Emergency Contact (Home Address)
2nd Emergency Contact Phone Number
Please enter a valid phone number.
Doctor's Information

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.
Hospital Preference
Hospital Phone Number
Please enter a valid phone number.
Student health data which should be known in an emergency:

Previous School History:
Please provide information for ALL previous grades as state funding for your child may be impacted. List most recent grades/schools first.
1. Previous School Attend*
1.Previous School Address*
1.Previous School City*
1.Previous School State*
1.Year Attended Previous School State*
1.Previous School Grade*
Previous School Attend1
Previous School Address1
Previous School City1
Previous School State1
Previous School Grade1
2.Additional School Attend
2.Additional School Address
2.Additional School City
2.Additional School State
2.Additional School-Year Attended
2.Additional School-Grade Attended
3.Additional School Attend
3.Additional School Address
3.Additional School City
3.Additional School State
3.Additional School Year Attended
3.Additional School Grade
Additional School Attend
Additional School Address
Additional School City
Additional School State
Additional School Grade

Miami-Dade County Public Schools

Directory Information Opt-Out Form
Miami-Dade County Public Schools (M-DCPS) generally protects a student’s personally identifiable information¹ from disclosure without prior consent from parents or eligible students. However, unless the parent or eligible student specifically states in writing that they do not want this information provided, M-DCPS is required to provide senior high school students’ names, addresses, and telephone listings to military recruiters or institutions of higher education upon their request. 2

Additionally, in a joint effort to increase the number of students applying for higher education financial aid, Miami-Dade County Public Schools and the United States Department of Education (USDOE) are participating in a Free Application for Federal Student Aid (FAFSA) Completion Project. Unless the parent or eligible student specifically states in writing that they do not want student information provided, M-DCPS may provide student information to the USDOE for this purpose. If you do not want your child’s information disclosed to any or all of these entities, check the space next to each entity listed below to which you do not want your child’s information disclosed.

I understand that by checking the spaces below and submitting this form, M-DCPS will restrict the disclosure of personally identifiable student information from my child's educational records to the entities that I have selected. I further understand that if I do not complete and return this form, M-DCPS will release the information to the beelow mentioned entities upon request by the entity and has no further obligation to contact me on a case-by-case basis to request my consent for the disclosure of directory information to these entities.
I DO NOT CONSENT TO DISCLOSURE of my child’s name, address, telephone listing, or birth date to the following (check all that apply or this section may be left unanswered):

United States Military (Army, Navy, Air Force, Marines, Coast Guard, etc.)Institutions of Higher EducationUSDOE for FAFSA Completion Project

Disclosure at Time of Registration

Miami- Dade County Public Schools
Chapter 1006.07 (l)(b), requires that any student seeking admission to a public school in the State of Florida will provide the following information at the time of initial registration:
1. Has the student ever been expelled from any school, in or out of the State of Florida?

YESNO
If your answer to question l is "YES", please list each and every instance for which the student was expelled.
2. Please state whether the student has ever been arrested where the arrest resulted in the student being formally charged. If your answer is "YES", please list each and every arrest which resulted in a formal charge.
3. Please state whether the student has ever been involved as a party in a case before the Juvenile Justice System? If so, state each action taken by the Juvenile Justice System which involved the student.
4. Please state whether the student has any corresponding referrals to mental health services related to your answers to Questions 1, 2 and 3. If yes, please list them.

HOME LANGUAGE SURVEY
What Language is spoken by the parent?
What Language is spoken by the student?
If the answer is "YES" to any of these questions, the student must be tested for English Proficiency.
1. Is a language other than English used in the home?

YESNO
2. Did the student have a first language other than English?

YESNO
3. Does the student most frequently speak a language other than English?

YESNO
Date

MonthDayYear
Date
School Name

I, {registeringParent} {registeringParent239}, understand and accept all the following terms and conditions listed below.
- As the parent of {studentsFirst311} {studentsLast} ({studentsId}), I understand that my son/daughter has been placed in the {futureGrade} grade temporarily pending the arrival and/or evaluation of school records from his/her previous school(s).
- Upon reciept of the school records, I agree that my son/daughter will be placed in the propert grade, and or change schools if necessary, should the record(s) prove to be other than what I have indicated. Parent/Guardian will have 40 days to submit any required documents.
- By signing below, I authorize the release of all records for the above mentioned student to Miami Palmetto Senior High School.
- In accordance with School Board Rule (Policy 5112) students in the regular school program (K-12) are assigned to attend school based on the actual residence of the parent and the attendance area of the school as approved by the School Board. It is the responsibility of the parent(s) to provide proper documentation to verify their residence. Parents may choose a different school through a variety of choice programs or through the transfer process. Additional information on Schools of Choice may be found at
  http://choice.dadeschools.net.
Florida Statute §837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree. Florida Statute §92.525 provides that whoever knowingly makes a false verified declaration is guilty of the crime of perjury, a felony of the third degree.
Under penalties of perjury, I declare that I have read the foregoing agreement and that the facts stated in it are true. I agree to notify the School District within 10 days in writing of any future changes in residence or living arrangements of this (these) child(ren). I certify that the above information is true and correct, and I understand that this information may be verified.
Student Signature*
Parent Signature*

Final Documents Needed for Registration

You may use your phones camera to take pictures of the documents.
Picture of the Students Birth Certificate*

Cancelof
Health Record Form 1 (DHL680)*

Cancelof
Health Record Form 2 (3040)*

Cancelof
Address Verification (Image of most recent FPL Bill)*

Cancelof
Address Verification (Image of Lease or Deed)*

Cancelof
Identification Verification (Image of Drivers License)*

Cancelof
If you have any transcript or grades from a private school or an out of state school (Image of transcripts and or grades)

Cancelof
Email1
example@example.com
Email2
example@example.com
Email3
example@example.com
Should be Empty:

STUDENT REGISTRATION FORM - MIAMI PALMETTO SENIOR HIGH

Miami-Dade County Public Schools

Disclosure at Time of Registration

Final Documents Needed for Registration