Mannsdale - Madison County School District
Mannsdale Upper Elementary Registration Information for?2016-2017 School YearStudents New to MUES?Dear Parent or Guardian,Thank you for registering your child this school year. We are so glad that your child will be joining us in the fall. In order to complete the registration process, we will need to have the items checked below sent to school as soon as possible. Thank you so much for your cooperation.?A child must live in the Mannsdale Attendance Zone in order to attend Mannsdale Upper Elementary.? This includes but is not limited to:? Red Oak Plantation, Hathaway Lake, Providence, Devlin Springs, Johnstone, Livingston,?Ashbrooke, Hartfield, Grayhawk, Stillhouse Creek, Wellington, Arrington, Camden Lake, Cedar Hill Plantation, Chestnut Hill, Church Road, Fieldstone, Germantown, Lake Mannsdale, Lake Trails, Trails End, Meadowview, Oakdale, Ridgefield, Stonebridge, and portions of Lake Caroline.? If you are unsure of the attendance zone in which you live, please call our front office or access the Madison County Schools homepage.What to Bring:?? A completed registration form? Certified birth certificate (no copies)? Social security card (no copies)? Certificate of health compliance (Mississippi Immunization form 121) issued by the Mississippi Department of Health or a local physician? Affidavit (owner of property)? Warranty Deed, Mortgage document, filed homestead exemption. If leasing, original home or apartment lease;?if buying and copy of the contract complete with closing date.? Two (2) current utility bills (electric, water, gas, land phone).?Bills addressed to a PO Box will not be accepted. Cell phone bills will not be accepted? Withdrawal information from the previous school attended with current grades.? Address of previous school attended?? A copy of last report card? Child Service Survey? Language Survey? Divorce Papers if applicable? Guardianship papers if applicableRegistration forms should be completed and brought with you.?Mannsdale Upper Elementary School Registration InformationStudent Name_________________________________________________________________________________ LastFirstMiddlePreferred Name:______________________________ Social Security Number______-______-______Race(circle): B W A H Native American Other__________________Gender (circle) M F Hispanic/Latino Ethnicity: ___Yes ___No Date of Birth: __________________________ Grade: ______________Street Address_______________________________________ City_________________ Zip_______________Subdivision__________________________________________ Own/Lease:______________ Lease expires:_________Student lives with (check all that apply): ____ Mother ____Father ____Stepfather ____Stepmother ____OtherMother/Guardian Name_______________________________________________________________________________Address if different from child __________________________________________________________________________Please check primary number to be used for automated calling!!! ___Home Phone ___________________________ ____ Work Phone________________________ ___Cell Phone___________________________________Place of Employment ________________________________________ Occupation______________________________E-Mail Address_______________________________________________________________________________________Father/Guardian Name_________________________________________________________________________________Address if different from child ____________________________________________________________________________Home Phone ____________________ Work Phone____________________ Cell Phone___________________Place of Employment ________________________________________ Occupation________________________E-Mail Address_________________________________________________________________________________Siblings, grade, DOB, and school: ________________________________ _____ __/__/__ _____________________ ___________________________ _____ __/__/__ __________________________ ___________________________ _____ __/__/__ __________________________Previous School Name attended: ____________________________________________________________________Special Services (circle): GiftedSPED – IEPSpeech – IEPELLEmergency numbers and individuals authorized to check out:__________________________________Relationship _________________ Phone #___________________________________________________Relationship _________________ Phone # __________________________________________________Relationship _________________ Phone # ________________***DO NOT RELEASE CHILD TO:______________ (Please provide legal documentation)___________________________ Yes, my child’s name, address & phone number may appear in the school directory. _____ No, my child’s name, address and phone number may not appear in the school directory.Affidavit of ResidenceMadison County School DistrictState of Mississippi County of Madison I, _________________________________________________, of lawful age, being first duly sworn on oath state that: (Print name of Affiant) I presently and permanently reside at ___________________________________________________________________________ ___________________________________________________________________________(Physical street address and street name is required. Post office box address is not acceptable.) which is my legal residence and is located within the boundaries of the Madison County School District. 2. As verification of my residence, I attach to this affidavit and include by reference the following: A. Copies of two utility bills (water, electricity, gas, land phone or cable, NOT a cell phone) and B. One of the following documents that contains my current physical street address, not a post office box: 1. Deed, deed of trust, mortgage, or filed homestead exemption 2. Current original, not copy, of apartment or house lease, showing names of occupants. 3. I am the _____________________of ________________________________________________, (Parent /Guardian) (Full Name of Child or Ward) who permanently resides with me at my residence at the address given in paragraph 1 above. 4. If I move or change my residence, I will notify my child’s school within 30 days. 5.I understand that the District may refuse to enroll or dismiss from school the child named in paragraph 3 above if the child does not reside with me within the Madison County School District at the address stated above. 6. By signing this affidavit, I understand that I am making a sworn statement that the information given in this affidavit is true and correct. I understand that lying or giving false information in the affidavit is a felony and is a violation of Miss. Code Ann. Sections 97-7-35 and 97-9-19., which may subject me to criminal penalties, including a fine of up to $1,000.00 and/or up to five years in the county jail. This the __________day of _________________________, 20_____. __________________________________________________ Signature of Affiant Personally came and appeared before me, the undersigned authority in and for the county and state aforesaid, the Affiant listed above, who on oath states that the matters and facts contained in the above foregoing Affidavit of Residence are true and correct. SWORN TO AND SUBSCRIBED BEFORE ME, this _________ day of ____________________, 20__________. _________________________________________________________Notary Public My Commission Expires:____________________________________Mannsdale Upper Elementary SchoolChild Services SurveyChild’s Name________________________________________ Grade_______________________Address _________________________________________________________________________Phone Number__________________________________*****Please check all that apply:__________My child has not received special services__________My child received special services from our previous school__________My child currently has an IEP from our previous school(Please attach a copy of the IEP to this page)The ruling for my child is in the following area(s):__________Hearing Impaired__________Speech__________Resource Specific Learning Disability (SLD) ____________________________Other (please specify) _____________________________________________________________________________________________________________________________________Parent’s Signature Date*If you do not have a copy of the IEP please fill out the information below.Previous School Name___________________________________________________________________School Address____________________________________________________________________________________________________________________________________________________________City ________________________________State ___________________________Zip Code__________School Phone Number ( )____________________Fax ( )________________________Contact person at school __________________________________________________________ ................
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