NEW STUDENT ENROLLMENT FORM
Student ID Number
Student Information
(School Assigns-Office use Only.)
Student’s Full Legal Name: _________________________________________________________________
(according to birth certificate)
Last
First
Middle
Grade: ________
Gender
Male
Female
Date of Birth: ___________
List Preschool, if attended: (Kindergarten Registration Only)__________________________________________
Student’s Country of Birth
Student’s Home Language
Student’s Home Address: ___________________________________________________________________
Street
City
State
Zip
Mailing Address (if different from Home address):________________________________________________________________
Street
City
State
Zip
Home Phone:__________________________
Answer both questions:
1. Is this Student Hispanic or Latino? (choose yes or no)
Yes (a person of Cuban, Mexican, Puerto Rico, South or
Central American or other Spanish culture or origin,
regardless of race.)
No (not Hispanic or Latino)
2. What is this student’s race? (Choose one or more)
Student Classification (see sheet)
Foster Home
Refugee Student
Neglected Student
Immigrant Student
Homeless Student (circle one)
(I) American Indian or Alaskan Native
(A) Asian
(B) Black or African American
(P) Native Hawaiian or Other Pacific Islander
(W) White
(1)
(2)
(3)
(4)
Unsheltered
Shelters
Doubled-Up
Hotel/Motel
Has student ever attended a Virginia Public School? Yes
No
n
If yes, please list the school’s name and the last year attended: ____________________________________
Has the student ever attended Shenandoah County Public Schools? Yes
No
If yes, please name the school and list the years of attendance_____________________________________
Is your child receiving Special Education or 504 services? Yes
No
Military Information: Please indicate below if the student is a dependent of a member of the military.
___ Student is not military connected (1)
___ Active duty; student is a dependent of a member of the Active Duty Forces (Army, Navy, Air Force, Marine Corps, Coast Guard, the
Commissioned Corps of the National Oceanic and Atmospheric Administration, or the Commissioned Corps of the U.S. Public Health Services) (2)
___ Reserve; student is a dependent of a member of the Reserve Forces (Army, Navy, Air Force, Marine Corps, or Coast Guard) (3)
___National Guard, active or reserve; student is a dependent of a member of the National Guard (and not a dependent of a member of the US Armed
Services) (4)
PARENT INFORMATION-Complete information for each parent separately. Please provide
information and legal documentation regarding any custody arrangements for each parent.
Please Note: Unless parental rights of one of the parents have been legally severed and the paperwork has been filed
with the school, both biological parents must be listed on this form.
Mother: ____________________________Mother’s Mailing Address: ________________________________
Last
First
Street
City
State
Zip
Cell Phone: _______________Home Phone: _______________Work Phone: _____________________
Employer: __________________________________________________Occupation _____________________
Work Address: ____________________________________ Mother’s Email: ___________________________
Does the student reside with this parent? YES
(Continued on page 2)
NO
Is this person the Legal Guardian: YES
NO
Rev. 10.28.2016
Continued from page 1- Student’s Name:_______________________________________________
Page 2 of 3
Father: ____________________________Father’s Mailing Address: ___________________________________
Last
First
Street
City
State
Zip
Cell Phone: _______________Home Phone: _______________Work Phone: ____________________
Employer: __________________________________________________Occupation ____________________
Work Address: ____________________________________ Father’s Email: ___________________________
Does the student reside with this parent? YES
NO
Is this person the Legal Guardian: YES
NO
GUARDIAN INFORMATION – Use this section for step-parents, legal guardians, foster parents, etc.
Please provide information and legal documentation, if applicable.
Guardian #1: ____________________________________Relationship: ____________________________
Last
First
Address: _______________________________________________________________________________
Street
City
State
Zip
Cell Phone: _______________Home Phone: _______________Work Phone: ___________________
Employer: __________________________________________________Occupation ___________________
Work Address: ____________________________________ Guardian #1 Email: _______________________
Does the student reside with this person? YES
NO
Is this person the Legal Guardian: YES
NO
Guardian #2: ____________________________________Relationship: ____________________________
Last
First
Address: _______________________________________________________________________________
Street
City
State
Zip
Cell Phone: _______________Home Phone: _______________Work Phone: ___________________
Employer: __________________________________________________Occupation ___________________
Work Address: ____________________________________ Guardian #1 Email: _______________________
Does the student reside with this person? YES
NO
Is this person the Legal Guardian: YES
NO
Sibling Information
Siblings or other children
living in home
Gender
Date of birth
Relationship
to student
School attending
(if enrolled)
Parent Signature ___________________________________________ Date ____________________
Date the application process was completed: _____________________________________________
TO BE COMPLETED BY SCHOOL PERSONNEL
Birth Certificate Number ___________________________Country of Birth __________________
Town of Birth_______________ County of Birth ______________State of Birth________________
presented to______________________________________
on ____________________________.
Signature of School Official
(Emergency Contact Information form attached-please complete)
Date
Student’s Name:______________________________
Page 3 of 3
EMERGENCY CONTACT INFORMATION
The individuals below have authorization to pick up my child and can be contacted during school hours at the
number(s) listed. Parents will be called first. Do not list Parent/Guardian below; the enrollment form
information page will be used to contact parents.
Emergency Contact 1: ___________________________________________Relationship: ________________
Last
First
Cell Phone: _________________Home Phone: _________________Work Phone: ______________________
Emergency Contact 2: ___________________________________________Relationship: ________________
Last
First
Cell Phone: _________________Home Phone: _________________Work Phone: ______________________
Emergency Contact 3: ___________________________________________Relationship: ________________
Last
First
Cell Phone: _________________Home Phone: _________________Work Phone: ______________________
Emergency Contact 4: ___________________________________________Relationship: ________________
Last
First
Cell Phone: _________________Home Phone: _________________Work Phone: ______________________
Student Emergency Health Information
Does your child have either of the following conditions as diagnosed by a doctor?
Breathing Problems
Insect Bite Allergy?
Yes
Yes
No Is medication required?
Yes
No Is medication required?  Yes
Is your child on any regular medication?
Yes
No Type __________________
No Type __________________
No
Type of medication _______________________________________________________________
Other medical conditions concerning your child _____________________________________________
____________________________________________________________________________________
Has your child ever been medically diagnosed with a concussion?
If yes, on what date? ______________.
Yes
No
Family Physician__________________________________________ Phone___________________
(If new to area please call us with this information when you have a doctor.)
**School Officials have my permission to transport or secure emergency medical treatment for my child in case
of illness or accident if no one can be contacted. The parent/guardian is responsible for all expenses.
Print Parent/Guardian Name (1): ________________________________________Date: ____________
Parent/Guardian Signature (1): _________________________________________Date: ____________
Print Parent/Guardian Name (2): _______________________________________ Date: ____________
Parent/Guardian Signature (2) _________________________________________Date: ____________
Print Parent/Guardian Name (3): _______________________________________ Date: ____________
Parent/Guardian Signature (3) _________________________________________Date: ____________
(Requires signatures of all parents/guardians with whom the student resides)
Student Classification
Refugee Student
An individual who is outside his/her country and is unable or unwilling to return to
that country because of a well-founded fear that he/she will be persecuted
because of race, religion, nationality, political opinion, or membership in a
particular social group. This does not include persons displaced by natural
disasters or persons who, although displaced, have not crossed an international
border or persons commonly known as “economic migrants,” whose primary
reason for flight has been a desire for personal betterment rather than
persecution.
Homeless Student
a)
b)
c)
d)
e)
f)
g)
Sharing the housing of others due to loss of housing, economic hardship
or similar reason;
Living in motels, hotels, trailer parks or camping grounds due to lack of
alternative adequate accommodations;
Living in emergency or transitional shelters;
Abandoned in hospitals;
Awaiting foster care placement;
Having a primary residence that is a public place or a place not designed
for or ordinarily used as regular accommodation;
Living in cars, parks, public spaces, abandoned buildings, substandard
housing, bus or train stations or similar settings.
Neglected Student
In order to be eligible to be counted as neglected, a child age 5 through 17 must
live in an “Institution for neglected children and youth,” which means a public or
private residential facility, other than a foster home, that is operated primarily for
the care of children and youth who (a) have been committed to the institution or
voluntarily placed in the institution under applicable State law due to
abandonment, neglect, or death of their parents or guardians; and (b) have had
an average length of stay in the institution of at least 30 days;
or
must live in an “Institution for delinquent children and youth,” which means a
public or private residential facility that is operated for the care of children and
youth who (a) have been adjudicated to be delinquent or in need of supervision
and (b) have had an average length of stay in the institution of at least 30 days.
Immigrant Student
The term „immigrant children and youth‟ means individuals who a)
are aged 3 through 21;
b)
were not born in any State; and
c)
have not been attending one or more schools in any one or more
states for more than 3 full academic years.
Rev. 4/14/2016
Shenandoah County Public Schools
Transportation Request
Transportation Department
600 N. Main Street, Suite 200
Woodstock, VA 22664
459-6728 * Fax 459-3851 * [email protected]
PLEASE PRINT CLEARLY
Today’s Date: ________________ Transportation Starting Date:_________________
Circle one:
 New Student
 Change in bus route
 Change in residence
 Change in attendance areas
 Other:
Student (print) __________________________________________________________
Grade_______________
Age__________
Birth Date____/_______/_______
Phone_____________________________________School______________________
Present Address________________________________________________________
New Address (if address change) __________________________________________
Parent(s) Name_________________________________________________________
Work Phone_______________________________ Other Phone_________________
TRANSPORTATION GUIDELINES:
 Only one pickup and one delivery location permitted (may be different).
 Be at designated school bus stop 10 minutes before the scheduled pick up time.
 Students who are not authorized riders are not permitted to ride a bus.
 Follow directions of the school bus driver promptly and courteously.
 Never walk behind the rear of the bus.
TRANSPORTATION INFORMATION (Indicate Daycare Provider’s Name, Address, Phone Number)
To School:  From daycare? _____________ From Home? _________________
Phone_____________________
Name of Daycare___________________________ Address______________________
From School:  To daycare? _______________  To Home?__________________
Phone_______________________
Name of Daycare ____________________________ Address ___________________
Transportation may be delayed until this form is completed and returned.
Additions or changes to student transportation should be made by contacting the Transportation
Department at 459-6728 or [email protected] Additions or changes should be requested 5
school days in advance. Please plan accordingly.
For a quick return, complete this form on the District’s website under the Transportation
Department. This form can also be returned to any Shenandoah County School, faxed, or
mailed to the information above. For more detailed information regarding transportation
and our county go to www.shenandoah.k12.us.va.
Rev 10/2016
Shenandoah County Public Schools
Affidavit of Residency

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


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Proof of residency is required when students are enrolled in school or there is a change in address.
Parents/Guardians must provide a driver’s license or official government identification and at least two (2)
documents which show the parent/guardian name and address. Examples of acceptable documents may include
the following:
Vehicle registration
Utility Bills (cable, electricity, water, gas, phone, internet)
Lease or rental agreement
Bank statement, insurance
Shenandoah County tax statement, medical bills
Current employer verification on company letterhead or payroll stub
Please note: Original documents are required.
Student Name: _____________________________________
Please check one of the following:
New enrollment
School: _________________
Change of address
Residency is defined as the legal domicile where a person lives. This is to verify, under penalty of perjury, that
the above mentioned student currently resides in my primary residence within Shenandoah County at:
______________________________________________________________________________
House Number and Street
Town
*Under penalty of perjury, I declare or affirm that the above information is true and correct.
_________________________________________
_________________________
Signature of Parent/Guardian
Date
The parent/guardian has provided the following documentation as proof of residency:
1. Driver’s license or official government identification
2.
3.
______________________________________
Signature of School Official
____________________
Date
§ 22.1-264.1. Misdemeanor to make false statements as to school division or attendance zone residency; penalty.
Any person who knowingly makes a false statement concerning the residency of a child, as determined by § 22.1-3, in a particular school division or
school attendance zone, for the purposes of (i) avoiding the tuition charges authorized by § 22.1-5 or (ii) enrollment in a school outside the
attendance zone in which the student resides, shall be guilty of a Class 4 misdemeanor and shall be liable to the school division in which the child
was enrolled as a result of such false statements for tuition charges, pursuant to § 22.1-5, for the time the student was enrolled in such school
division.
Rev.SS.5.11.2017
600 North Main Street, Suite 200
Shenandoah County Government Center
Woodstock, Virginia 22664
Phone (540) 459-6222 Fax (540) 459-6707
Student Home Language Survey
Student’s Name:__________________________________________ Date:_________________
Grade:_____ School:____________________________________________________________
Relationship of Person Completing Survey:
Mother___
Father___
Guardian___ Other (specify)___
Please check the best answer to each question:
1. Was the first language your child learned English?
___Yes
___No
2. Can your child speak languages other than English?
___Yes
___No
Which other languages? ______________________________________________
3. Which language does your child use most often when he/she speaks to his/her friends?
English___ Other___
4. Which language does your child use most often when he/she speaks to his/her parents?
English___ Other___
5. Does anyone in your home speak a language other than English?
___Yes
___No
If yes, which other language?__________________________________________

If the answer to Number 2 is “yes” and “Other” languages are given as answers to numbers 3, 4, or 5,
the student’s English language abilities should be tested even if the student’s oral ability is good. In this
case, a copy of this form should be given to the ESL teacher or coordinator in the school or school
district.

One copy of this form should be kept in the student’s permanent record.
From The Identification of Assessment of Language Minority Students: A Handbook for Educators, 1985, Hamayan et al., Illinois Resource Center, Arlington Heights,
IL.
Rcvd________ Source____________
yes____
no____
Shenandoah Valley Migrant Education Program
JMU MSC 9007
Harrisonburg, VA 22807
Phone: 540.568.3666
Fax: 540.568.6374
www.shenandoahvalleymigranted.org
ELIGIBILITY QUESTIONNAIRE
1. In the last 3 years, have you or your spouse worked in (or looked for work in) any of these jobs:
 Poultry processing plant line work (Tyson, Cargill, Perdue, Pilgrims Pride, Georges);
 Growing or harvesting a crop of fruit, vegetables, or trees;
 Work on a dairy or poultry farm or in the fishing industry;
 Or caring for animals on a farm or ranch?
Yes ____
No ____
------------------------------------------------------------------------------------------------------------------------------------------If the answer to number 1 is "yes", Please complete the rest of this form:
2. When did you move to the Shenandoah County area? month_______
year_______
3. Name(s) of Child(ren) enrolling in school today:
Name____________________________________________________ Age________ Grade__________
Name____________________________________________________ Age________ Grade__________
Name____________________________________________________ Age________ Grade__________
4. Parent/Guardian information (if student is a minor):
Name ____________________________________________ Telephone number ____________________________
Address ________________________________________________________________________________________
City ____________________________________________ Zip code ______________________________________
5. School Child(ren) will be attending:________________________________________________________
6. Please fax this form to the SVMEP office at 540.568.6374
name of intake person _________________________
Migrant Education is an ESSA Title One, Part C program that provides supplemental educational services to children of migrant agricultural workers, people who have moved to this area
(or have moved frequently) to find agricultural work. We specialize in addressing the needs of second language learners who have had interrupted educational histories.
Rev.IN.1.17.2017