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2724150-13398500Bartlett Yancey High School466 Main Street EastYanceyville, NC 27379(336) 694-4212New Student Enrollment FormWelcome to Bartlett Yancey High School. We look forward to building a positive relationship with you and your family. We are eager to help you enroll your child in our school and register them for the appropriate courses. Attached, you will find forms that you will need to complete before you meet with a counselor. In addition to these forms, you will need to provide the following documents at the time of your registration appointment:Copy of Birth CertificateCopy of Social Security CardImmunization DocumentationTranscripts of courses completedIEP (Individualized Education Plan), 504 Accommodation Plan, LEP documentation (If Applicable)Withdrawal form from other school8th grade report card showing promotion if new 9th grade studentProof of Residency in Caswell County in Parent/Guardian’s Name with Caswell County Address (Signed Lease, Signed Purchase Agreement, Current Electric Bill, Vehicle Registration) Legal Guardianship Documents if other than the parent. When all documents are ready, please call the Counseling Department to schedule an appointment to complete the registration process. Please note – A notarized note from a parent giving another person temporary guardianship is not legally recognized as Legal Guardianship. Legal Guardianship can only be granted in a court proceeding. A Legal Guardian can only enroll a student with court documents and must live in Caswell CountyPlease contact the Counseling Department with questions/concerns regarding guardianship. 2286004254500Bartlett Yancey High SchoolStudent Enrollment Information Form School Year:___________________ Student Grade Level: 9 10 11 12Student’s Legal Name: (as it appears on the birth certificate)(Circle One)__________________________________________________________________________________________________ (First) (Middle) (Last) Gender: M / F Date of Birth: _____/_____/_____ Age: __________Race: (Circle One) Black White Hawaiian/Pacific Islander Asian American IndianEthnicity: (Circle One) Hispanic Non-HispanicSocial Security Number: __________-__________-__________ Home Phone #: _______________________________Address: (Street) __________________________________________________________________________________ (City) ___________________________________________________________(Zip)____________________Parent /Guardian Information:Living With: (Check One)____Both Parents____Mother Only____Father Only____Father and StepMother ____Mother and Step-Father____Guardian/Other:____________________________________Mother/Stepmother/Guardian/Other:(Name)___________________________________________________________Place of Employment:_________________________________________Work Phone #:__________________________Father/Stepfather/Guardian/Other(Name): _____________________________________________________________Place of Employment: _________________________________________Work Phone #:__________________________Mother/Stepmother/Guardian/Other Cell Phone #: ______________________________________________________Father/Stepfather/Guardian/Other Cell Phone # :_________________________________________________________Email Address (Optional): ____________________________________________________________________________Emergency Contact Information:Name:______________________________________________________Relationship:____________________________ Home Phone: ________________________________________________Cell Phone #:___________________________Name:______________________________________________________Relationship:____________________________Home Phone: _______________________________________________Cell Phone #:____________________________Previous School Information:Has your child ever attended school in Caswell County before? (Check one) _____ Yes _____NoIf “Yes”, Where and When: ____________________________________________________________________________Student attend 8th Grade At _____________________________________in __________________/_________________ (Name of School) (City) (State)Does your student have a current Individualized Education Plan (IEP)? (Check One) _____Yes _____ NoDoes your student have a curremt 504 Accommodation Plan? (Check One) _____ Yes _____ NoHas you student attend school in North Carolina before? (Check One) _____ Yes _____ NoIf “Yes”, Where and When: ____________________________________________________________________________Did your student take Math 1 in Middle School? (Check One) _____ Yes _____ NoIf “Yes”, Where and When: ____________________________________________________________________________Student’s Last School Attended: _____________________________________________Years Attended_____________School Address: ________________________________________________ School Phone #:_______________________ (Street)____________________________________________________________ Zip Code: _____________________________ (City) (State)Please list other schools where High School Credits were attempted: ___________________________________________________________________________________________________________________________________________Parent/Guardian Signature: _____________________________________________________Date: _________________Counselor Signature: __________________________________________________________ Date: _________________2857590170For Counselor Use Only: Enrollment Date: ________________________________Date Given to Data Manager:________________ ________9th Grade Entry Date:_____________________________For Counselor Use Only: Enrollment Date: ________________________________Date Given to Data Manager:________________ ________9th Grade Entry Date:_____________________________25920702794000Date: _____________________Fax TO: Guidance Department/RegistrarFROM: Bartlett Yancey High School Counseling DepartmentReceiving Organization/Person:PAGES: 1FAX: FAX: 336-694-7473PHONE: PHONE: 336-694-4212RE: Records requested for : First: ____________________Middle: _____________________Last: __________________Grade: _________ Date of Birth: ____________________Social Security #:_____________________________________Name of School Attended: ____________________________________________________________________________Address: _______________________________________City:________________________State: _______Zip:________I Hereby Grant Premission For The Release of the Records Below:Signature of Parent/Guardian: ______________________________________________Date: _____________________COMMENTS:Requested Information:TranscriptsTest ScoresPsychologicalHealth/MedicalGrading ScaleAttendance InfoWithdrawal GradesImmunizationsBirth CertificateSocial Security #8th Grade Report Card showing PromotionIEP/504 Accommodation Plan (If going to 9th Grade)AIG PlanDiscipline RecordsThis information may be faxed to 336-694-7473.Thank you in advance for your prompt attention to this request. Counselor Signature: ______________________________Title:_____________________Date:___________________2819400-4572000Discipline Status Enrollment FormSTUDENT'S LEGAL NAME: (As it appears on birth certificate)__________________________________________________________________________________________ (First) (Middle) (Last)Gender: M / F Date of Birth: _____/_____/_____ Age: __________Race: (Circle One) Black White Hawaiian/Pacific Islander Asian American IndianEthnicity: (Circle One) Hispanic Non-HispanicName of School Attended: ____________________________________________________________________________Address: _______________________________________City:________________________State: _______Zip:________School's Telephone Number: __________________________________________________________________________Current Discipline Status of Student Seeking EnrollmentPlease check the applicable box as related to ____________________________________________________________(Student Name)_____Is not currently suspended or expelled from any school and does not have pending suspension orexpulsion._____Has been recommended for long-term suspension (more than ten (10) days) or expulsion (permanentremoval from school) from ___________________________________________________________________________(Name of School)and that recommendation is currently pending. Describe the offense for which the recommendation is beingmade and the proposed beginning and ending dates of the suspension/expulsion. (Documentation)_____Has been long-term suspended (more than ten (10) days) or expelled from and is currently serving theterm of suspension or expulsion _______________________________________________________________________(Name of School)Describe the offense for which the student was suspended/expelled and the beginning and ending date of thesuspension/expulsion. (Documentation)I give consent to the Caswell County Schools to share this document with student's prior school and to obtaininformation or records from that to verify the information on this form.Signature of Parent/Guardian: ___________________________________________Date: ____________________ 19050112395***TO BE COMPLETED BY THE TRANSFERRING SCHOOL***Transferring School Name: _____________________________________________________________________I certify, to the best of my knowledge, the information above is correct. Documentation of the offense(s), if any, has been provided, if applicable.Signature of Principal or Designee: _______________________________________Date: ________________________0***TO BE COMPLETED BY THE TRANSFERRING SCHOOL***Transferring School Name: _____________________________________________________________________I certify, to the best of my knowledge, the information above is correct. Documentation of the offense(s), if any, has been provided, if applicable.Signature of Principal or Designee: _______________________________________Date: ________________________ ................
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