Entered By ______
Date: __________
Water Valley School District
2017-2018 Residency & Registration Form
Student Information:
First Name: ______________________________ Middle: ______________ Last: ________________________
Preferred name: _____________________________________
Date of Birth: _________________ Age: _____ Grade: _____
Race:
White
Black
Hispanic
Native American
Asian
Gender:
Male
Pacific Islander
Multi
Female
Other ________
Student Cell Phone: __________________________ Student Social Security Number: ____________________
Transportation Method:
Car Rider
Bus Rider – Bus # _________
In the event of an emergency early dismissal, how should the student be
dismissed? Please provide name, address, phone, and/or bus #:
____________________________________________________________________________________
____________________________________________________________________________________
Previous School Attended (if other than Davidson Elementary or Water Valley High School):
_____________________________________________________ City ____________________ State ________
Has this student ever been suspended/expelled from school?
Yes
Are there any custody issues regarding this student?
No
Yes
No
If yes, please explain and provide copies of supporting court documents.
__________________________________________________________________________________________
Has this student participated in resource classes? (Gifted, Special Education, Speech, etc.) If so, please list:
__________________________________________________________________________________________
_____ YES _____ NO The student listed above has permission to go on class field trips by bus.
_____ YES _____ NO The student listed above has permission to be included on the WVSD website.
Signature of parent/guardian: ________________________________________________ Date: ________________
Parent/Guardian 1
Parent/Guardian 1 Name: ____________________________________________________________________
Relationship:
Mother
Father
Guardian: Relationship _____________________________
** Legal guardianship papers will need to be provided if you are not the student’s parent.
Parent/Guardian Physical Address:
Street: __________________________________________________________________
City: ________________________________________ State: ______ Zip: ____________
Parent/Guardian Mailing Address:
Same as physical address
Street: __________________________________________________________________
City: ________________________________________ State: ______ Zip: ____________
Parent/Guardian 1 Phone Contacts:
Home: ______________________________________
Use this number for automated calls
Cell: ________________________________________
Use this number for automated calls
Work: ______________________________________
Used only in case of emergency
Parent/Guardian 1 E-Mail: ____________________________________________________________________
Parent/Guardian 1 Employer: _________________________________________________________________
Parent/Guardian 2
Parent/Guardian 2 Name: ____________________________________________________________________
Relationship:
Mother
Father
Guardian: Relationship _____________________________
** Legal guardianship papers will need to be provided if you are not the student’s parent.
Parent/Guardian Physical Address:
Street: __________________________________________________________________
City: ________________________________________ State: ______ Zip: ____________
Parent/Guardian Mailing Address:
Same as physical address
Street: __________________________________________________________________
City: ________________________________________ State: ______ Zip: ____________
Parent/Guardian 2 Phone Contacts:
Home: ______________________________________
Use this number for automated calls
Cell: ________________________________________
Use this number for automated calls
Work: ______________________________________
Used only in case of emergency
Parent/Guardian 2 E-Mail: ____________________________________________________________________
Parent/Guardian 2 Employer: _________________________________________________________________
Water Valley School District
Residency Registration and Documentation Checklist
TO BE COMPLETED BY PARENT, GUARDIAN OR OTHER ADULT
Name of Parent, Guardian or Other Adult: _______________________________________________________
Parent/Guardian/Other Adult PHYSICAL Address: __________________________________________________
__________________________________________________
(A post office box number is NOT acceptable)
List each student attending Water Valley School District and give their grade level:
Student
Grade
I hereby certify the information given above on this form is a true and correct statement of my legal residence. Should any legal
residence change while the above listed students are enrolled in Water Valley School District, I will promptly notify the appropriate
officials of the school district. Further, I understand a pupil is not legally enrolled until this form is completed and signed by the
parent, guardian, or other adult with whom the student may be living. I understand a pupil admitted under false information is not
legally enrolled and is subject to penalty.
_____________________________________________ ___________________ _________________________
Signature of Parent, Guardian or Other Adult
Date
Telephone Number
TO BE COMPLETED BY THE SCHOOL DISTRICT
Documents provided to me by Parent/Guardian/Other Adult: (Minimum of 2 required)
1. ___ Filed Homestead Exemption Application Form/Land Tax Receipt (Must be from current year)
2. ___ Mortgage Documents/Property Deed (mortgage documents must indicate current year, if property deed used,
physical address must appear on the deed)
3. ___ Apartment or Home Lease (cannot be handwritten receipt and must be in current year)
4. ___ Utility Bills (must be within the last three months prior to registration – no cell phone or cable
bills) Acceptable bills: light, gas, water, landline phone
5. ___ Automobile Registration (for current vehicle tag – not car title)
6. ___ Valid Driver’s License or State issued identification
7. ___ Any other documentation that will be objectively and unequivocally establish the parent or legal guardian
resides within the school district as determined by the principal, superintendent or designee.
8. ___ Student is living with legal guardian – (LEGAL CUSTODY DOCUMENT) a copy of the court order appointing the
guardian must be provided to the district. If a petition of guardianship has been filed and the decree is pending, the
student or guardian must provide a certified copy of the filed petition for guardianship.
Date: ___________________ Representative – School District: ______________________________________
Water Valley School District Home Language Survey
Because the Water Valley School District is unaware of all English Language Learners the Mississippi Department of
Education recommends that schools conduct a survey of language used in the home. Please complete this survey and
return it to the school.
Child’s Name: _____________________________ Parent’s Name: ____________________________________
Does your child speak any language other than English?
Yes
No
If YES, please answer the following questions:
1. What was the first language your child learned to speak? _________________________________________
2. Have you and/or your child ever lived in another country? _______ If yes, what country? _______________
3. Has your child ever attended school in another country? _______ If yes, what country? _________________
What grades? ___________ When did your child enroll in school in the United States? _______________
4. Has your child ever received English Language Learner instruction? ______________
5. What language does your child speak most often? _______________________________________________
6. What language is most often spoken in your home? _____________________________________________
Water Valley School District
Corporal Punishment
Student’s Name (Print): __________________________________________________________ Grade: ______
___________________________________ _______________________________________ _______________
PRINT Parent/Guardian name
SIGNATURE of Parent/Guardian
Date
_____ I AGREE for my child to receive corporal punishment (spanking) while at school.
_____ I DO NOT AGREE for my child to receive corporal punishment (spanking) while at school. I understand it
is the responsibility of my child to remind the teacher/administrator that his/her parent/guardian does not
want him/her to receive corporal punishment (spanking) while at school.
FOR OFFICE USE ONLY
MSIS # ______________ Enrollment Date: ___________ Bus # _________ Homeroom Teacher: ____________
Check when complete/received/verified or if applies:
__ Birth Certificate
__ Verification of Legal Residence (2)
__ Form 121
__ Registration Form
__ Social Security Card
__ ACTIVE PARENT
__ IEP
__ Home-Language Survey
__ Corporal Punishment
__ Homeless
__ Limited English Proficient
__ Migrant/Immigrant
__ SAM Data entry Completed
Water Valley School District
2017-2018 Student Health Information Form
PLEASE PRINT
Student __________________________ Age____ Grade_____ DOB _____
Parent/Legal Guardian __________________________________________
Address ______________________________________________________
Mom-Work # _________________ Cell#___________ Home#___________
Dad-Work# _____________Cell# ________________ Home# ____________
List 2 additional emergency contacts in the event the parent/guardian can’t be reached. These contacts will assume responsibility for your child.
Name____________________________ Phone#(s) ____________________
Name____________________________Phone#(s) ____________________
Important Reminder: In the event your contact information should change, or the health status of your child should change, it is the responsibility of the parent or guardian to contact the school
nurse.
I give permission for the school nurse to contact my child’s physician concerning medications or health problems pertaining to my child.
Physician’s Name___________________ Office # _______________
Parent/Guardian __________________________________________
Permission to Administer Over-the-Counter Medications
I give permission for the administration of the following medications to my son/daughter in the event of headache, fever, minor cuts, stomachache, or any minor medical problem.
__Tylenol
__Cough drops
__Calamine lotion
__Hydrocortisone Cream
__Ibuprofen
__Tums
__Children’s Pepto
__Burn Cream
__Benadryl
__Oral-gel
__Visine Eye drops
__Chloraseptic spray
__Neosporin
Medical History
Please check those that apply to your son/daughter:
__Diabetes
____Seizures
____Asthma
___ADD/ADHD
__Fainting
__Head injury
___Stomach problems ___High blood pressure
__Hearing Loss
__Takes breathing treatments
__Shortness of breath
__Blood disorders (Specify) __Wears glasses/contacts
__Heart problems
__Headaches/migraines
__Cancer (Specify)
__Other health problem (Specify) ________________________________________________
ALLERGIES- If your child has an allergy or a history of anaphylaxis, have your doctor fill out an Allergy Action Plan. This includes an allergy to foods, insects, grass, unknown, etc. Please see the
school nurse to set up a plan of care for your child.
ASTHMA- If your child has a diagnosis of asthma, have your doctor fill out an Asthma Action Plan. This is a State Law and must be updated each school year.
Surgeries/Bone Fracture- Has your child had any surgeries or broken bones? If so, explain.
________________________________________________________________________________________________________________________________________________________
MEDICATIONS- Does your child take any medications on a regular basis?
__ Yes __No
Please list names of medications, amount taken, time taken, and physician’s name:
________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________
Please list sibling name and grade below:
________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________
PARENT SIGNATURE/DATE ________________________________________________
Water Valley School District
DES: Hope Shaw, RN WVHS: Debra Beckwith, RN
Water Valley School District requires all students who need medication during school hours must do the
following in order to receive prescribed medications at school:
1. You must present a written consent form that is signed by a parent/guardian and is filled out by your
child’s doctor. These are the regulations set by the MS Department of Education and the MS School
Nurse Association. No prescribed medications will be given without a consent form signed and on file
in the nurse’s office.
2. ALL medications must be brought to the school by the parent/guardian in the original prescription
bottle. Tell your pharmacist you need a labeled bottle for school use. Do not send medications with
the student in a baggie, paper towel, Etc. They will not be given! Students are not allowed to
transport any medications. Parents must bring all medications to the school. These are the
regulations set by MDE and the MS School Nurse Association. It is the Law. This is to ensure the safety
of your child and other students.
3. Medications that can be taken at home before or after school hours must be taken at home. Only
medications that are required during school hours will be given at school. Most ADD/ADHD
medications can be taken at home before school begins unless otherwise instructed by your doctor.
I give the school nurse, Hope Shaw, RN, or Debra Beckwith, RN, permission to give prescribed medications to
my child as prescribed by his/her doctor. In the event the school nurse is out or the student is on a field trip, I
give permission for trained office staff or a trained teacher to give the prescribed medication.
____YES
__NO
I understand if I mark NO, the medication will not be given. The parent/guardian will need to come to the
school to give the medication, and make arrangements of how & when the medication will be given on a field
trip.
Name of Student _________________________________________ Grade _____________
Parent/Guardian Signature _________________________________ Date ______________
Water Valley School District
Active Parent Online Registration Form
NEW USERS/LOST or FORGOTTEN ACCOUNT/ADD NEW STUDENT
_____ I am a NEW USER and request to be an ACTIVE PARENT and view the information made available to
me for the following student(s).
Parent/Guardian Name: ______________________________________________________________________
E-Mail Address: _____________________________________________________________________________
Identification: ___________________
(LAST 4 DIGITS OF PARENT’S SOCIAL SECURITY NUMBER)
_____ I already have an ACTIVE PARENT account and would like to add another child to my account.
List all students you have in the Water Valley School District on one form. You DO NOT have to fill out a form
at each school.
Student(s) Name (PRINT)
Grade
School (DES or WVHS)
Parents – you MUST provide the Username and the Password!
Parent/Guardian Username Information
Your USERNAME will be your last name and the last 4 digits of your Social Security Number.
Your PASSWORD has to be at least 4 letters and 2 numbers.
USERNAME:
PASSWORD:
Parent/Guardian Signature: ______________________________________________ Date: ________________
-------------------------------------------------------------------------------------------------------------------------------------------------(FOR OFFICE USE ONLY)
Yes
No
I authorize the release of the child’s record. I have verified the child’s parent/guardian has been approved
to view his/her records and be registered as an ACTIVE PARENT.
School Official: ________________________________________________________ Date: ________________
Water Valley School District
Transportation Department
Bus Privilege Application
2017-2018
One form per student, filled out completely – multiple students on one form IS NOT acceptable.
Student Name (PRINT): _______________________________________ Nickname: ______________________
Age: ______ Grade (2016-2017 year): ______ Homeroom Teacher (DES): _____________________________
Parent/Guardian Name (PRINT): _______________________________________________________________
Parent/Guardian Emergency Number(s):
Cell ____________________________ Home ________________________ Work _______________________
(Contact anytime)
(Contact anytime)
Contact time? ________________
Parent/Guardian E-Mail Address: _______________________________________________________________
Preferred method of contact from a transportation team member: __ phone call __ text message __ email Does this child have any special needs? _____ yes _____ no (example: wheelchair, seizures, etc.)
If yes, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
Morning Pick – Up Address: ___________________________________________________________________
Afternoon Drop – Off Address: _________________________________________________________________
I agree to abide by the rules set forth in the Water Valley School District Handbook and by the rules and laws set
forth by the Mississippi Department of Education. I understand failure to obey the rules will result in a write up
and consequences set forth by the Water Valley School District, which are listed in the Student Handbook and
Code of Conduct. I understand riding a school bus is a privilege, not a right, and that privilege can and will be
taken away if a student cannot or will not obey the rules.
**Students will ONLY be transported to and from the addresses listed above. Any changes must be made
through the office of your child’s school**
Parent/Guardian Signature: ________________________________________________ Date: ______________
Student’s Signature: ______________________________________________________ Date: ______________
(BOTH signatures required)
-------------------------------------------------------------------------------------------------------------------------------------------------(OFFICE USE ONLY)
Assigned bus morning _______________________________________________ stop number______________
Assigned bus afternoon ______________________________________________ stop number _____________
Approved by ___________________________________________________