you must have the following information before coming into register

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YOU MUST HAVE THE FOLLOWING INFORMATION BEFORE COMING
INTO REGISTER YOUR STUDENT
□ ORIGINAL CERTIFIED BIRTH CERTIFICATE
□ TWO PROOFS OF RESIDENCY
a. If you own your own home: Mortgage statement or Property Tax Statement
b. If you rent or lease: Current Lease Agreement
(If you are not the homeowner, or signer on the lease agreement, you will need a notarized
statement of residency from the taxpayer and the taxpayer’s proof of residency)
ALONG WITH CURRENT UTILITY BILL WITH NAME AND ADDRESS
CURRENT CHARGE STATEMENTS OR CURRENT BILL (i.e. Physician, dentist,
insurance etc.) All must have name and address on bill
□ PROOF OF IMMUNIZATION
□ VISION & HEARING TEST (Kindergarten only)
□ DRIVER’S LICENSE
□ SPECIAL EDUCATION - Speech, IEP Report, etc.
□ PROOF OF CUSTODY (if applicable)
□ MEDICAL ISSUES
□ PROOF OF GRADE PLACEMENT CURRENT REPORT CARD (1-8
MUST HAVE TRANSCRIPTS (9-12
TH
TH
GRD)
GRADE)
ALL ENCLOSED FORMS MUST BE COMPLETELY FILLED OUT IN THEIR
ENTIRETY BEFORE COMING IN TO REGISTER YOUR STUDENT
□ HEALTH APPRAISAL
□ STUDENT REGISTRATION FORM
□ AFFIRMATION OF PRIOR DISCIPLINE RECORD (GRADES 3-12)
□ RESIDENT INFORMATION FORM
□ REQUEST FOR CA-60 FILE FROM PREVIOUS SCHOOL
Warren Consolidated Schools 31300 Anita Warren, Michigan 48093 888‐4WCSKIDS _________________ Student ID # STUDENT REGISTRATION INFORMATION CARD Last Name Address Apt. Birth Date Home Telephone Number First Name City Middle Name Nick Name Place of Birth – City, State or Country Parent email address Grade Cellular Telephone Number Zip Code + 4 digit Gender □Alaskan or American Indian □ Asian □ African American □ Caucasian □ Pacific Islander
□ Multi Racial, specify Is Student Hispanic/Latino? Choose only one: □ No, not Hispanic/Latino □ Yes, Hispanic/Latino – (A person of Cuban, Mexican, Puerto Rican, South or Racial/Ethnic:
School last attended: Central American, or other Spanish culture or origin, regardless of race.) If applicable, fax copy to Curriculum and Instruction Do you have a white card: □ Yes □ No If yes, please give a copy to the school. Alien # _________________________________ What language does your child speak at home? ________________________________________________________________________ What language do the adults speak in your home? ______________________________________________________________________ If the student was born outside the U.S.A., when did the student arrive in the U.S.A? ___________________________________________ If the student was born outside the U.S.A., record the date the student first attended school in the U.S.A. __________________________ Does your child receive special education/504 services? _____ Yes _____ No ________ Parent Initials Please indicate any health problems which you believe school personnel should be aware of: ____________________________________________ PARENT/GUARDIAN INFORMATION: Whom does the child reside with, please check appropriate status: □ Both parents □ Father/Stepmother □ Mother/Stepfather □Father Only □Mother Only □Legal Guardian □ Court Placed □ Relative □ Foster Home □ Divorced, joint custody Male Parent/Guardian: _________________________________________ Area Code & Alternate Number: _____________________ Place of Employment: _________________________________________ Area Code & Business Number: ______________________ Female Parent/Guardian: _________________________________________ Area code & Alternate Number: _____________________ Place of Employment: _________________________________________ Area code & Business Number: ______________________ Parent living elsewhere: ___________________________________________________________________________________________________ Address Apt City/State Zip code + 4 digit Area Code & Home Number Area Code & Business Number Area Code & Alternate Number DA Code: __________ Street Code: __________ ES# __________ MS# __________ HS# __________ Office of Student Affairs Form: 01/2011 Page 1 of 2 Warren Consolidated Schools 31300 Anita Warren, Michigan 48093 888‐4WCSKIDS EMERGENCY CONTACT INFORMATION: The individuals listed below have authorization to pick up my child and can be reached during school hours at the number listed: Name Relationship Area Code & Telephone Number Name Relationship Area Code & Telephone Number Name Relationship Area Code & Telephone Number Warren Consolidated Schools has designated the following as Directory Information: student’s name, address, telephone number, date and place of birth, grade, major field of study, participation in school activities, honors and awards, other similar information (alumni associations, height and weight of athletes) and information generally found in a yearbook. Directory Information can be provided to any individual, other than for‐profit organizations, even without the written permission of a parent. If you wish to have Directory Information totally withheld from release, please check the box below. Until further notice, withhold all Directory Information from the student listed on this form. Warren Consolidated Schools and the local media regularly cover school events for news, public relations, cable TV or other not‐for‐profit purposes. This would include photographs, video and audio taping and interviews. If you wish your student to be excluded from video tapes, audio tapes, photographs or interviews in conjunction with school or school district events, performances, or activities, please check the box below. Until further notice, exclude the student shown on this form from all school, school district, or news media video and audio taping, photography or interviews. VERIFICATION OF DATA. I affirm that as the parent/guardian, all information provide in this document is true and accurate, and my child and I reside at the listed address. I understand any false information provided by me may result in the immediate removal of this student from the Warren Consolidated Schools. Signature of Parent/Guardian Date Office of Student Affairs Form :01/2011 Page 2 of 2 _____________________________________
Student’s Last Name, First Name
_____________________________________
School
_____________________________________
Date
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
HEALTH APPRAISAL
Dear Parents or Guardians,
The following information is requested so that the school and parent can work together to meet the physical, intellectual ad emotional needs of the child. Fill in the
information requested in Section I. Section II must be filled in by a doctor or nurse or parent may bring the child’s immunization card to the school to be copied.
Parents are responsible to pay for the cost of medical, hospital, ambulance, and related services as determined by school personnel in the event of illness or injury of
their child at school.
Child’s Last Name
First Name
Middle
Address
City
Zip Code
Telephone Number
Parent/Guardian’s Last Name
First Name
Middle
Cellular Telephone Number
Address
City
Zip Code
Work Telephone Number
Section I – HEALTH HISTORY (to be filled in by parent)
Is your child having any of the following problems:
1. Allergies or reactions e.g., food, medication, or
other?
2. Hay fever, asthma, or wheezing?
3. Eczema or frequent skin rashes?
4. Convulsions/Seizures?
5. Heart trouble?
6. Diabetes?
7. Frequent colds, sore throats, earaches (4 or more
per year)?
8. Trouble with passing urine or bowel movements?
9. Shortness of breath?
10. Speech problems?
11. Menstrual problems?
12. Dental problems?
13. Other
14.
Please explain any problem area identified above:
YES
NO
Does your child take any medication regularly? ( ) Yes ( ) No
If yes, what medication:
Reason for medication:
Vision Tested? ( ) Yes ( ) No
If yes, copy of report must be attached. Date:
Hearing Tested? ( ) Yes ( ) No
If yes, copy of report must be attached. Date:
Parent’s Signature:
According to Act 368, Public Acts of 1978, any child enrolling in a Michigan
school for the first time must be adequately immunized, vision tested, and
hearing tested. Exemptions to these requirements are granted for medical,
religious, and other objections provided that waiver forms are properly
prepared, signed, and delivered to school administrators. Forms for these
exemptions are available at your school or local health department.
Gender
Birth Date
Section II – IMMUNIZATION (to be filled in by physician or nurse only or
parents may bring the student’s immunization card to be copied)
Statements such as “UP TO DATE” or “COMPLETE” will not be accepted.
Admission to school may be denied on the basis of this information.
DATE ADMINISTERED
Vaccine
Mo/Day/Yr
Mo/Day/Yr
1.
2.
POLIO (IPV/OPV)
(Specify Type)
3.
4.
1.
5.
2.
6.
DTaP/DTP/DT/Td/Tdap
(Specify type)
3.
7.
4.
8.
Measles, Mumps, Rubella (MMR)
1.
2.
1
3.
Haemophilus Influenzae
Type b (HIB)
2.
1.
3.
Hepatitis B (Hep B)
2.
Varicella (Chickenpox)
1.
2.
Chickenpox History of Disease. ( ) Yes ( ) No; Date:
1.
3.
Pneumococcal Conjugate (PCV7)
2.
4.
Hepatitis A (Hep A)
1.
2.
1.
3.
Influenza (TIV/LAIV)
2.
4.
Meningococcal MCV4/MPSV4
1.
2.
(Specify Type)
1.
3.
Rotavirus (Rota)
2.
Human Papillomavirus (HPV)
1.
3.
2.
4.
Other Vaccines
(Specify Date and Type)
Indicate physician diagnosis of
disease or laboratory evidence of
immunity as applicable
I certify that the immunization dates are true to the best of my knowledge.
Validating Signature
Title
Date
Office of Curriculum Instruction Form: 02/09
Page 1 of 1
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
STATEMENT OF VARICELLA DISEASE
(CHICKEN POX)
Macomb County Immunization Regulations require all children admitted to any public,
private, or parochial elementary or secondary school, day care center, camp, or any
other organized care or educational facility operating in Macomb County to present a
certificate indicating dates of all required immunizations.
Complete the portion below only if your child has had varicella (chickenpox) disease.
This must be signed and witnessed at your child’s school/child care program.
I certify my child:
Last Name
Birth Date
First Name
Grade
Middle Initial
Date of School Enrollment
has had varicella disease
(When did varicella occur: age or date)
Parent/Guardian’s Signature
Date
Name of Witness from School or Child Care Program
Date
School District:
School/Child Care Program:
PLACE IN CHILD’S PERMANENT RECORD
Office of Curriculum Instruction Form: 02/09
Page 1 of 1
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date Warren Consolidated Schools 31300 Anita Warren, Michigan 48093 888‐4WCSKIDS RESIDENT INFORMATION FORM Student Last Name First Name Street # Initial Apt # Gender Birth Date School / / Street Name Zip Code Grade Telephone LIST ALL ADULTS LIVING AT ABOVE ADDRESS 19 YEARS OF AGE OR OLDER. Last Name First Name Initial Gender Birth Date / / / / / / / / LIST ALL CHILDREN FROM BIRTH TO 18 YEARS OF AGE. Last Name First Name Initial Gender Birth Date School / / Grade Male Parent/Guardian Last Name First Name Female Parent/Guardian Last Name First Name Last Name First Name Initial Gender Birth Date School / / Grade Male Parent/Guardian Last Name First Name Female Parent/Guardian Last Name First Name Last Name First Name Initial Gender Birth Date School / / Grade Male Parent/Guardian Last Name First Name Female Parent/Guardian Last Name First Name Last Name First Name Initial Gender Birth Date School / / Grade Male Parent/Guardian Last Name First Name Female Parent/Guardian Last Name First Name Office of Curriculum Instruction Form: 02/09 Page 1 of 1 WARREN CONSOLIDATED SCHOOLS
REQUEST TO RELEASE CUMULATIVE SCHOOL RECORDS
DATE:
STUDENT INFORMATION
STUDENT’S LAST NAME:
FIRST NAME:
ADDRESS:_________________ CITY:_____________ MI ZIP:_______
PHONE: ___________________ BIRTH DATE:
PREVIOUS SCHOOL INFORMATION
SCHOOL DISTRICT: ____________________________________________
SCHOOL NAME:
ADDRESS:
________________
CITY, STATE, ZIP:
PHONE:______________________ FAX: ________________________
CURRENT GRADE:_________
NEW SCHOOL INFORMATION
STUDENT HAS ENROLLED AT: ________________________________
GRADE ENROLLED FOR: ________
SEND FILE TO (School Stamp with address):
___________________________________________________________
Please send the complete school records of the above named student showing
subjects, marks, test scores, grade placement, health records and UIC number.
Please include current transcript and record of prior discipline.
Thank You
PARENT/GUARDIAN SIGNATURE
DATE
WARREN CONSOLIDATED SCHOOLS
31300 Anita Warren, MI 48093 586-825-2400 FAX 586-698-4114
AFFIRMATION OF PRIOR DISCIPLINE RECORD
A willful false statement on this affirmation will result in a report to the appropriate authorities.
DIRECTIONS: Read the paragraphs below and choose the appropriate paragraph for your student. Provide all appropriate
information, and sign this document.
Paragraph 1:
The undersigned affirms that
, has NOT been suspended or expelled from any public
or private school in Michigan or any other state for an offense involving weapons, alcohol or drugs, or for the willful infliction of injury to
another person or for any act of threats or violence against persons and/or property committed on school premises, at any schoolsponsored activity, or on a public or private conveyance providing transportation to and from a school or school-sponsored activity.
Paragraph 2:
The undersigned affirms that
_ , has been suspended or expelled from a public or private
school in Michigan or any other state for one or more offenses involving weapons, alcohol or drugs, or for the willful infliction of injury to
another person or for any act of threats or violence against persons and/or property committed on school premises, at any schoolsponsored activity, or on a public or private conveyance providing transportation to and from a school or school-sponsored activity.
If you checked paragraph 2, explain the circumstances in detail. Include the school name, dates of suspension or expulsion, and a
description of the incident giving rise to the suspension or expulsion.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________
Date
Signature of Student (Grades 3-12)
__________________
Date
__________________________________________________
Signature of Parent
FOR OFFICE USE ONLY – DO NOT WRITE BELOW THIS LINE
Date copy sent for verification: _________
____
Name of WCS School: ____________________________________
Verification sent by: __________________________________________________
Name of Sending (former) School District: __________________________________________________________
Sending School - Please Check One:
According to our records, we can verify that the information provided above by
the parent/student is correct.
According to our records, the information provided above by the parent/student
is not correct.
If the student has been involved in offenses involving weapons, alcohol, drugs, or willful infliction of injury to persons or an act of
threats or violence against persons and/or property committed on school premises, at a school-sponsored activity, or on a public or
private conveyance providing transportation to or from school or a school-sponsored activity, please forward appropriate disciplinary
documentation.
Date
____________________________________________
Signature of Sending District Administrator
____________________________________________
Title
H:\School of Choice\Affirmation of Prior Discipline.doc
Warren Consolidated Schools
31300 Anita
Warren, MI 48093
Angus Elementary
3180 Hein
Sterling Heights, MI 48310
Contact: Clerk
586-825-2780
Green Acres Elementary
4655 Holmes
Warren, MI 48092
Contact: Clerk
P: 586-825-2890
Jefferson Elementary
37555 Carol
Sterling Heights, MI 48310
Contact: Clerk
P: 586-825-2680
Wilde Elementary
32343 Bunert
Warren, MI 48088
Contact: Clerk
P: 586-294-8490
Black Elementary
14100 Heritage
Sterling Heights, MI 48312
Contact: Clerk
P: 586-825-2840
Harwood Elementary
4900 Southlawn
Sterling Heights, MI 48310
Contact: Clerk
P: 586-825-2650
Lean Elementary
2825 Girard
Warren, MI 48092
Contact: Clerk
P: 586-574-3230
Wilkerson Elementary
12100 Masonic
Warren, MI 48093
Contact: Clerk
P: 586-825-2550
Cromie Elementary
29797 Gilbert
Warren, MI 48093
Contact: Clerk
P: 586-574-3160
Hatherly Elementary
35201 Davison
Sterling Heights, MI 48310
Contact: Clerk
P: 586-825-2880
Siersma Elementary
3100 Donna
Warren, MI 48091
Contact: Clerk
P: 586-574-3174
Willow Woods Elementary
11001 Daniel
Sterling Heights, MI 48312
Contact: Clerk
P: 586-825-2850
Fillmore Elementary
8655 Irving
Sterling Heights, MI 48312
Contact: Clerk
586-825-2860
Holden Elementary
37565 Calka
Sterling Heights, MI 48310
Contact: Clerk
P: 586-825-2670
Susick Elementary
2200 Castleton
Troy, MI 48083
Contact: Clerk
P: 586-825-2665
Middle School Information
Beer Middle School
3200 Martin Rd.
Warren, MI 48092
Contact: Clerk
P: 586-698-4278
Carleton Middle School
8900 Fifteen Mile
Sterling Hts., MI 48312
Contact: Clerk
P: 586-698-4498
Carter Middle School
12000 Masonic
Warren, MI 48093
Contact: Clerk
P: 586-698-4296
Flynn Middle School
2899 Fox Hill
Sterling Hts., MI 48310
Contact: Clerk
P: 586-698-4305
Grissom Middle School
35701 Ryan
Sterling Hts., MI 48310
Contact: Clerk
P: 586-698-4314
High School Information
Cousino High School
30333 Hoover
Warren, MI 48093
Contact: Clerk
P: 586-698-4200
Sterling Heights High School
12901 Fifteen Mile
Sterling Heights, MI 48312
Contact: Clerk
P: 586-698-4617
Warren Mott High School
3131 Twelve Mile
Warren, MI 48092
Contact: Clerk
P: 586-698-4571
Butcher Educational Center
Community High/MMSTC
27500 Cosgrove
Warren, MI 48092
Contact: Clerk
P: 586-698-4423
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
KINDERGARTEN QUESTIONNAIRE
CONFIDENTIAL INFORMATION
FAMILY BACKGROUND
Child’s Name:
Name to be
Used in School:
Birth Date:
Telephone:
Address:
City:
Mother’s Name:
Mother’s Occupation:
Mother’s Education:
Business Telephone:
Father’s Name:
Father’s Occupation:
Father’s Education:
Business Telephone:
Current Marital Status of Child’s Parents:
With Whom Does the Child Reside:
Language Spoken by the Child:
Language Spoken in the Home:
Other Children in Family
Birth Date
/
/
/
/
/
/
/
/
/
/
Zip Code:
Grade Level
School
Has there been a divorce, death, or illness in the family which might affect your child?
Office of Curriculum Instruction Form: 02/09
Page 1 of 4
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
KINDERGARTEN QUESTIONNAIRE
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date
SOCIAL EXPERIENCES
Check the places your child has visited:
( ) grocery store
( ) library
( ) farm
( ) museum
(
(
(
(
) ocean
) factories
) airport
) county fair
(
(
(
(
) zoo
) mountains
) downtown
) other: ____________________
Where has your child traveled?
Has your child attended Preschool/Nursery School?
How Long?
If yes, where?
Does your child play quietly or actively?
With whom does your child play?
Alone?
Does your child play mostly:
Older children?
Younger children?
By him/her self?
With children of same age?
With boys?
With girls?
Would you say your child is a leader or a follower?
What activities does your child enjoy outdoors?
What activities does your child enjoy indoors?
How many hours does your child watch television per day?
Does your child enjoy books?
Do you read to your child?
If so, how often?
Doe she/she enjoy being read to?
Is your child able to remember songs or rhymes?
Has your child had experiences with paints, crayons, and scissors?
Does your child select the clothing he/she wears?
Does your child look forward to holidays?
Do you celebrate birthdays in your home?
If no, please explain.
Office of Curriculum Instruction Form: 02/09
Page 2 of 4
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
KINDERGARTEN QUESTIONNAIRE
DEVELOPMENT
Does your child have any health problems the school should be aware of?
If so, what?
Does your child have any food/other allergies?
At what age did your child:
walk alone?
feed him/her self?
talk in sentences?
Is your child right or left handed?
Does your child dress him/her self?
Birth information:
Premature
Delivery Method:
Full term
Hours in labor
Normal
C-Section
Is your child able to be in a new or strange situation without an undue show of fear?
What kind of problems do you have most often with your child?
For what is your child most often punished?
How do you discipline your child?
How do you expect your child to be disciplined in school?
Can your child take care of his/her own toilet needs?
Does your child wet the bed:
Never?
Occasionally?
Often?
Check the characteristics that apply to your child:
(
) cries easily
(
) dependable
(
) easily angered
(
) happy
(
) temper tantrums
(
) enjoys company
(
) daydreams
(
) independent
(
) jealous
(
) considerate
(
) destructive
(
) sleeping problems
(
) whines
(
) honest
(
) gets along with others
(
) uses good judgment
(
) bites nails
(
) eating problem
(
) sucks thumb
(
) shares
(
) does not like to share
Office of Curriculum Instruction Form: 02/09
Page 3 of 4
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date
KINDERGARTEN QUESTIONNAIRE
SCHOOL ADJUSTMENT
Is your child able to share and take turns?
What do you expect your child to acquire through the kindergarten experience?
Would you be interested in helping in the classroom?
What else would you like your child’s teacher to know about your child?
Please remember: You are encouraged to feel free to contact your child’s teacher regarding anything you feel might
affect your child’s education.
Office of Curriculum Instruction Form: 02/09
Page 4 of 4
_____________________________________
Student Last Name, First Name
_____________________________________
School
_____________________________________
Date
Warren Consolidated Schools
31300 Anita
Warren, Michigan 48093
888-4WCSKIDS
I’M READY FOR KINDERGARTEN
Dear Kindergarten Teacher,
I know I am ready for Kindergarten because:
I can say my first and last name.
I can print my name so it can be recognized.
I know my address and telephone number.
I know my parents’ first and last names (especially important is last names are different from the child’s).
I can recognize my own printed name.
I know how to dress for outdoor play.
I can speak in a voice loud enough so people can hear me when I am in front of a group.
I know how to use a handkerchief or tissue and ask for one.
I have used crayons, paste, and scissors and know what to do and what not to do with them.
I can take responsibility for my own actions. If I spill something, I can clean it up.
I take care of work and play things I have used.
I can listen and sit quietly while others are talking.
I can share, take turns, and play cooperatively with others.
I can put together a simple puzzle.
I can bounce and catch a ball.
I can stand on one foot for five or more seconds.
I can recognize some colors and some shapes.
I can count ten objects.
I can recognize some letters in my name.
I can listen to a story and answer simple questions about it.
Parent/Guardian’s Signature
Child Prints His/Her Name
Office of Curriculum Instruction Form: 02/09
Page 1 of 1