2024 -2025 School Registration Online Packet- fillable form

PICKENS COUNTY SCHOOLS

ALABAMA APPLICATION FOR STUDENT ENROLLMENT

(MUST BE COMPLETED BY PARENT/LEGAL GUARDIAN)
Date

MonthDayYear
Date
SCHOOL*
GRADE*
STUDENT LAST NAME*
STUDENT FIRST NAME*
STUDENT MIDDLE NAME
DATE OF BIRTH*

MonthDayYear
Date
GENDER*

MALEFEMALE
HOME PHONE
PHYSICAL ADDRESS*
CITY*
ZIP CODE*
MAILING ADDRESS*
CITY
ZIP CODE
STUDENT LIVES WITH:*

PARENTSMOTHERFATHERCOURT APPOINTED GUARDIAN
IF COURT APPOINTED GUARDIAN (RELATION)
*SOCIAL SECURITY NUMBER (VOLUNTARY)
ARE THERE ANY ADDITIONAL CHILDREN IN YOUR HOME? IF SO, PLEASE LIST THEIR AGE AND NAMES.
AGE age NAME Name
AGE age NAME Name
AGE age NAME Name
PARENT(S)/GUARDIAN NAME: ** Verification shall be in accordance with local school board policy**
MOTHER / GUARDIAN*
ADDRESS
EMAIL ADDRESS
CELL PHONE
EMPLOYER
WORK PHONE
FATHER / GUARDIAN*
ADDRESS
EMAIL ADDRESS
CELL PHONE
EMPLOYER
WORK PHONE
SPECIAL INFORMATION ABOUT CUSTODY
EMERGENCY CONTACTS: (PLEASE LIST NUMBERS OTHER THAN YOUR OWN... VERY IMPORTANT!!!)
EMERGENCY CONTACT NAME #1 Name
RELATION Relation to student
PHONE (Area Code) + Phone Number
EMERGENCY CONTACT NAME #2 Name
RELATION Relation to student
PHONE (Area Code) + Phone Number
THESE PEOPLE HAVE PERMISSION TO CHECK MY CHILD OUT OF SCHOOL:
NAME #1 Name
RELATION Relation to student
PHONE (Area Code) + Phone Number
NAME #2 Name
RELATION Relation to student
PHONE (Area Code) + Phone Number
NAME #3 Name
RELATION Relation to student
PHONE (Area Code) + Phone Number
NAME #4 Name
RELATION Relation to student
PHONE (Area Code) + Phone Number
NAME AND ADDRESS OF LAST SCHOOL ATTENDED:
PARENT SIGNATURE*

Clear
*Disclosure of your child's social security number (SSN) is voluntary. If you elect not to provide a SSN, a temporary identification number will be generated and utilized instead. Your child's SSN is being requested for use in conjunction with enrollment in school as provided in Ala. Admin. Code 290-3-1-02(2)(b)(2. It will be used as a means of identification in the statewide student management system.

NOTARIZED CHECK OUT FORM
STUDENT'S NAME (LAST, FIRST, MIDDLE)*
SCHOOL:*
GRADE*
HOMEROOM TEACHER:
MODE OF TRANSPORTATION TO SCHOOL (MORNING)*

BUSWALKERCAR RIDER
IF BUS RIDER, ENTER BUS NUMBER
MODE OF TRANSPORTATION TO SCHOOL (AFTERNOON)*

BUSWALKERCAR RIDER
IF BUS RIDER, ENTER BUS NUMBER
MOTHER / GUARDIAN*

First NameLast Name
CELL PHONE NUMBER
Please enter a valid phone number.
HOME PHONE NUMBER
Please enter a valid phone number.
WORK PHONE NUMBER
Please enter a valid phone number.
FATHER / GUARDIAN*

First NameLast Name
CELL PHONE NUMBER
Please enter a valid phone number.
HOME PHONE NUMBER
Please enter a valid phone number.
WORK PHONE NUMBER
Please enter a valid phone number.
The persons listed below have my permission to check my child out of school (PLEASE PRIORTIZE):
Name of Person #1

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #2

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #3

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #4

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #5

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #6

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #7

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #8

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #9

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Name of Person #10

First & Last NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
** A VALID PHOTO ID MUST BE PRESENTED EACH TIME A STUDENT IS CHECKED OUT**

NO ONE will be allowed to check out a student if his or her name does not appear on this list.

THIS FORM REQUIRES A NOTARY. PLEASE BE SURE TO PRESENT YOUR IDENTIFICATION FOR NOTARY TO COMPLETE FORM.

PHOTO AND VIDEO RELEASE FORM
Dear Parent/Guardian,

On occasion ___________ or representative/employees of the Alabama State Department of Education wish to photograph, videotape, and/or interview individuals in connection with a school activity or project.

One of the primary purposes of this photograph, videotape, and/or interview is to enhance student learning, encourage excellence in teaching or recognize students that are excelling. Although the videotapes involve both the teacher and various students, the primary focus is on the instruction of or recognition of students.

In order to relese photographs, video footage and/or comments that are posted on district school websites, we need written permission.

To give your consist, please complete the form below.
Name of School and Board of Education
PCHS & PCBOE
I, parent/guardian full name)* , parent/guardian of (student's name) student full name* , (student) give permission for my child to be photographed, videotaped and/or interviewed by our school or representatives/employees of the Alabama State Department of Education for educational or public relation purposes. I authorize the use and reproduction of any and all photographs and/or videotapes of my child, without compensation to me or my child.

All of these photographs or video recordings shall be the property, solely and completely of the said school above. I waive any rights to inspect or approve the finished photographs/videotapes, the soundtrack, script or printed matter that nay be used in conjunction with them.
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date

INTERNET ACCEPTABLE USE POLICY
Dear Parents and Students:

The PICKENS COUNTY SCHOOLS Internet Acceptable Use Policy is designed to provide guidelines for using Internet in the classroos, school media center, and computer labs of the school. Please take the time to read this policy. If you have any questions about it, please be sure to contact your child's school principal.

This policy must be read and signed by the student and a parent/guardian at the time of registration. Please return the signed form as soon as possible, since your child will no be given access to the Internet until you agree to this policy.

Please note that uf you violate the terms of polcy, you may lise privileges or receive punishment as defined in the Pickens County Board of Education Student Code of Conduct. It is your responsibility to read and ask questions about this policy.

Your teacher is planning an in-class discussion of this policy after you have had a chance to become familiar with it.

Thank you,

Jamie Chapman, Superintendent

*********************************************

PLEASE RETURN THIS FORM AS SOON AS POSSIBLE
I acknowledge that I have read, understand and agree to all terms as outlined in the Internet Accepatable Use Policy. I further understand that this agreement will be kept on file at the school.
Date*

MonthDayYear
Date
STUDENT'S NAME (PRINTED)*
STUDENT'S NAME (SIGNATURE)*

Clear
PARENT/GUARDIAN NAME (PRINTED)*
PARENT/GUARDIAN (SIGNATURE)*

Clear

CELL PHONE PROCEDURES
Cell Phone Procedures

Student will be allowed to bring cell phones to school.
- Phones may be used only with the permissions of school personnel.
- Phones nust be out of sight and powered off unless directed by school personnel to do otherwise.
- cameras, Videons, and Text Messaging, or anu other function availabe on a cell phone that invades the privacy of another individual is expressly prohibited on school grounds at any time.
Consequences for cell phone usage:
- 1st offense: Phone will be confiscated. Student wil be written up and parents will be allowed to pick up phone after 3:11 PM.
- 2nd offense: Phone will be confiscated. Student will be written up and parents will be allowed to pick up phone after 3:11 PM. Student may also receive detention or ISS.
- 3rd offense: Phone will be confiscated. Student will be written up and parents will be allowed to pick up phone after 3:11 PM. Student will be subject to suspension (in and/or out of school).
*School personnel will not be responsible for replacing lost or stoeln cell phones.
Parent Printed Name*
Parent Signature*

Clear
Student Printed Name*
Student Signature*

Clear

VEHICLE REGISTRATION FORM

(complete only if your child will have their own transportation for this school year.)
STUDENT'S FULL NAME
GRADE
AGE
STUDENT'S DATE OF BIRTH
STUDENT'S CONTACT NUMBER:
PARENT/GUARDIAN'S NAME
PARENT/GUARDIAN'S CONTACT NUMBER
VEHICLE #1
VEHICLE MAKE:
VEHICLE MODEL
YEAR:
TAG NUMBER:
VEHICLE #2
VEHICLE MAKE:
VEHICLE MODEL:
YEAR
TAG NUMBER

HANDBOOK ACKNOWLEDGEMENT
MY CHILD, STUDENT FIRST & LAST NAME , A STUDENT ENROLLED IN PICKENS COUNTY SCHOOLS AT NAME OF SCHOOL , AND I, FIRST & LAST NAME .
SIGNATURE OF STUDENT

Clear
SIGNATURE OF PARENT, GUARDIAN, CUSTODIAN, OTHER PERSON HAVING CONTROL

Clear
DATE

MonthDayYear
Date
THIS SHEET IS TO BE RETURNED TO THE STUDENT/S FIRST BLOCK TEACHER. CONTAINED IN THIS HANDBOOK ARE POLICIES APPROVED BY THE PICKENS COUNTY BOARD OF EDUCATION.

THE STUDENT WILL NOT BE OFFICIALLY ENROLLED UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED WITHIN FIVE (5) DAYS OF RECEIPT.

PARENT NOTICE

THE PARENTAL RESPONSIBILITY ACT OF 1994 (CODE IF ALABAMA, 16-28-12) REQUIRES THE FOLLOWING:
1. STUDENTS AND PARENTS, OR GUARDIANS OR OTHER PERSONS HAVING CONTROL OF CUSTODY OF A CHILD MUST SIGN THAT THEY HAVE RECEIVED A COPY OF THE SCHOOL BOARD'S POLICY ON BEHAVIOR STANDARDS.
2. PRINCIPALS MUST REPORT TO THE SUPERINTENDENT ANY PARENT, GUARDIAN, OR OTHER PERSON HAVING CONTROL OR CUSTODY OF A CHILD WHO FAILS TO ATTEND SCHOOL OR WHO FAILS TO HAVE THE CHILD PROPERLY CONDUCT HIM/HERSELF AT SCHOOL. THE SUPERINTENDENT MUST REPORT THE VIOLATORS TO THE DISTRICT ATTORNEY WITHIN TEN (10) DAYS.
3. THE PARENT, GUARDIAN, CUSTODIAN, OR OTHER PERSON RESPONSIBLE FOR THE CARE OR CONTROL OF THE CHILD IS FINANCIALLY RESPONSIBLE FOR THE CHILD'S DESTRUCTIVE ACTS AGAINST SCHOOL PROPERTY OR PERSONS.

OPT-IN FOR MENTAL HEALTH SERVICES
**PLEASE NOTE THIS IS AN OPT - IN FORM, YOU WILL ONLY NEED TO COMPLETE IF YOU WISH TO RECEIVE THESE SERVICES FOR YOUR CHILD.** iF YOU DO NOT WISH TO RECEIVE THIS SERVICE, PLEASE SCROLL DOWN AND CLICK ON "NEXT".
AS OF THE DATE OF MY SIGNATURE BELOW, MY CHILD, (ENTER CHILDS FULL NAME)
IS UNDER THE AGE OF 14 YEARS OLD

YESNO
IF NO, STOP HERE. IF YES, CONTINUE BELOW.
I HEREBY GIVE MY PERMISSION FOR MY CHILD TO PARTICIPATE IN THE FOLLOWING MENTAL HEALTH SERVICES: (CHECK THE BOX FOR EACH MENTAL HEALTH SERVICE YOU WANT TO BE AVAILABLE TO YOUR CHILD)

ASSESSMENTS/SURVEYS - INCLUDES QUESTIONAIRES PROVIDED TO STUDENTS RELATED TO SOCIAL BEHAVIORS, FEELINGS, ETC.CRISIS INTERVENTION - SHORT-TERM, IMMEDIATE ASSISTANCE BY SCHOOL COUNSELOR OR PROFESSIONAL FOR A SPECIFIC SITUATION.SCHOOL-BASED MENTAL HEALTH ON-GOING COUNSELING SERVICES BY SCHOOL PROFESSIONALS OR PRIVATE PRACTITIONERS IN THE SCHOOL SETTING. PARENT OR LEGAL QUARDIAN'S PERMISSION WILL BE OBTAINED DURING AN INTAKE MEETING BEFORE SERVICES ARE PROVIDED.
YOU MAY RESCIND PERMISSION FOR A STUDENT TO PARTICIPATE IN MENTAL HEALTH SERVICES AT ANY TIME BY PROVIDING WRITTEN NOTICE TO SCHOOL ADMINISTRATION OR SCHOOL COUNSELOR.
PARENT / GUARDIAN NAME (PRINTED)
DATE

MonthDayYear
Date
PARENT/GUARDIAN NAME (SIGNATURE)

Clear

ALABAMA STATE DEPARTMENT OF EDUCATION

PART I - HEALTH INFORMATION

PLACE YOUR CHILD RECEIVES HEALTH CARE:

PART II - MEDICAL HISTORY MEDICAL EQUIPMENT / PROCEDURES REQUIRED AT SCHOOL

PART III - MEDICAL HISTORY

NOTARIZED CHECK OUT FORM

PHOTO AND VIDEO RELEASE FORM

INTERNET ACCEPTABLE USE POLICY

CELL PHONE PROCEDURES

VEHICLE REGISTRATION FORM

PICKENS COUNTY SCHOOLS

PICKENS COUNTY SCHOOLS

ALABAMA STATE DEPARTMENT OF EDUCATION

HANDBOOK ACKNOWLEDGEMENT

OPT-IN FOR MENTAL HEALTH SERVICES

PICKENS COUNTY PRIMARY CARE, A CERTIFIED SMART STUDENT HEALTH AND WELLNESS CENTER: