ADMINISTRATIVE OFFICES
MOON AREA SCHOOL DISTRICT
8353 UNIVERSITY BOULEVARD ● MOON TOWNSHIP PA 15108 ● 412-264-9440 ●
WWW.MOONAREA.NET
● FAX: 412-264-3268
MOON AREA SCHOOL DISTRICT
REGISTRATION FORMS AND PROCEDURES
STUDENT’S NAME:
__________
GRADE LEVEL:
For
-
M
F
School Year
DATE OF REGISTRATION:
Dear Parents/Guardians:
Please check off each item that has been completed as part of the registration process in the column labeled
“Parent.” Office personnel will also check through the packet when you register and check off items completed
under “Office." All components must be complete to register. Thank you!
Forms and documentation to be completed and returned:
Parent
Office
______
______ 1.
Proof of Birth: Original birth certificate or passport must be provided.
The child’s name must match his/her proof of birth. No name can be used without
documentation of legal name change process presented at registration. Documentation
will be photocopied and returned at time of registration.
NON-CITIZENS (Without Birth Certificate) must provide one of the following:
CIRCLE ONE: Passport Visa. (All pages will be copied.)
______
______ 2.
Proof of Residency:
One of the following documents must be provided:
Original lease or deed signed by both parties
Mortgage payment booklet or mortgage statement that includes name, current
address and contact information of the financial institution.
Agreement of Sale, followed by original copy of settlement papers within 45
calendar days of settlement
Plus any two of the following:
Valid driver’s license or change of address card with your current address
Valid vehicle owner’s card with your current address
Utility bill or Utility Activation Statement within 30 days in your name with your
current address (energy, water, sewer, gas, oil, cable)
Pay check stub within 30 days with your current address
Tax bill (most recent) with your current address
Homeowners/renters insurance bill with your current address
FAMILIES BUILDING OR BUYING A HOME who request admittance prior to when
district residency is established must contact the Registrar in the Moon Area Central
Administration Building (412-264-9440 ext. 1132) to secure before submitting this
registration packet. They must move into the district within 45 calendar days of
student’s entry date.
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
FAMILIES WHO RESIDE WITH ANOTHER FAMILY within the school district must
contact the Registrar in the Moon Area Central Administration Building (412-2649440 ext. 1132) in order to secure a Multiple Occupancy Certificate before
submitting this registration packet. Multiple Occupancies will be validated
periodically.
Parent
Office
______
______ 3.
Registration Forms are complete and have been signed by parent or guardian.
FAMILIES AWAITING APPROVAL OF GUARDIANSHIP of a student must contact
the Registrar in the Moon Area Central Administration Building (412-264-9440
ext. 1132) before completing this registration packet in order to secure
information regarding required documentation.
FOSTER CHILDREN need a placement letter from their foster agency.
______
______ 4.
Health records/immunizations are up to date and signed by physician.
All students must have proof of immunizations (list of immunizations and
forms included).
All K, 6th and 11th grade students and any students new to Pennsylvania must
have a complete physical examination by their doctor (physical form included).
All K, 3rd and 7th grade students and any students new to Pennsylvania must
have a complete dental examination by their dentist (form included).
______
______ 5.
Request for Records Form is completed in order to send for your child’s records from
his /her previous school.
______
______ 6.
Record of Divorced, Separated, or Single Parent Form is completed (if applicable).
______
______ 7.
Questionnaire for Parents Moving Into or Out of Moon Area School District.
______
______ 8.
Additional Forms: (if applicable)
Parent Survey of Incoming Kindergarten Students
Parent Survey of Incoming First Grade Students
Multiple Occupancy / Guardianship
______ _______ 9.
Request for Special Education Services Procedures
□
□
My child has an IEP
□
My child has a 504 plan
My child has a GIEP
______
SIGNATURE OF PARENT
DATE
SIGNATURE OF SCHOOL REPRESENTATIVE
DATE
YOU MUST HAVE ALL OF THE REQUIRED ITEMS TO REGISTER.
EXCEPTIONS WILL NOT BE MADE.
THANK YOU
“The Moon Area School District is an equal opportunity education institution.”
Page 2
MOON AREA SCHOOL DISTRICT
REGISTRATION FORMS
Student's ID Number:
Date:
Grade Entering:
Sex:
Male
Female
Student's
Legal Name:
Last
First
Middle
Address:
Street
Bldg/Apt.#; Box #
City
State
Student's Ethnicity:
Zip Code
Hispanic / Latino / Spanish Origin
Select one or more races:
American Indian or Alaska Native
Yes
No
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Phone Number:
Listed
Student's Date of Birth:
Verification for date of birth:
Living
Birth Certificate
Passport
First
Married
Single
Widowed
Separated
Divorced
Remarried
Occupation:
Business Phone:
Mother's Name:
or Guardian
Last
First
Middle
Circle title:
Mrs. Ms.
Miss Dr.
Deceased
Married
Educational Background:
Place of Business:
Middle
Deceased
Place of Business:
Marital Status:
Other
Circle title:
Dr. Mr.
Educational Background:
Living
Unlisted
Place of Birth (City, State):
Father's Name:
or Guardian
Last
Marital Status:
White
Single
Widowed
Separated
Divorced
Remarried
Occupation:
Business Phone:
If you speak another language, do you have English proficiency? (Circle one):
YES
“The Moon Area School District is an equal opportunity education institution.”
NO
Page 3
Children living in student's home:
NAME
DATE OF BIRTH
RELATIONSHIP
DATE OF BIRTH
RELATIONSHIP
Others living in the home:
NAME
Are there any other circumstances related to this student's academic history or family life which you want school personnel
to know? Please list below
Signature:
Date:
“The Moon Area School District is an equal opportunity education institution.”
Page 4
MOON AREA STUDENT EMERGENCY INFORMATION
Please print using black or blue ink. If using web form, sign in ink. Complete all information on both pages for each child.
1 – Student Information
Student Name:
M
Sex:
Date of Birth:
F
Grade:
Homeroom Teacher:
Custodial Parent #1:
Your child resides with (check)
HR. No.(if known):
Custodial Parent #2:
Both:
Other:
2 - Custodial Parent/Guardian #1 (Custodial=First parent or guardian who is given physical or legal custody by court order.)
Name:
Relation to Student:
Physical address is required and will be used for student transportation purposes.
House # and Street:
P1
Rapid Alert Notification System Information
PLEASE NOTE: THIS IS THE FIRST PERSON THAT WILL BE CONTACTED REGARDING HEALTH ISSUES
Apt. No.:
PO Box:
City:
Zip:
Employer:
Phone numbers–Checking a box indicates that phone will NOT be used for rapid alert broadcasts. Must have at least one box
unchecked for attendance purposes.
Cell:
Home:
Other:
Email:
3 - Custodial Parent/Guardian #2 (Custodial=Second parent or guardian who is given physical or legal custody by court order.)
Name:
Relation to Student:
Physical address is required and will be used for student transportation purposes.
House # and Street:
Apt. No.:
P2
PO Box:
City:
Zip:
Employer:
Phone numbers–Checking a box indicates that phone will NOT be used for rapid alert broadcasts. Must have at least one box in P1 or
P2 unchecked for attendance purposes
Cell:
Home:
Other:
Email:
E1
4 - Since the care and treatment of the student is primarily the responsibility of the parent, every effort will be made to contact the parent
first. Please list Other Contacts who can be contacted regarding student’s care in the event a parent cannot be located. Only those
listed below will be permitted to pick up your child in case of illness or emergency (unless otherwise specified by parent.
Name:
Phone #:
Relationship:
Name:
Phone #:
Relationship:
Name:
Phone #:
Relationship:
5 - List anyone who is NOT PERMITTED to visit/pick up your child from school. Note: You must file papers with the District.
Office
Name:
Relationship:
Court Papers?
Yes:
No:
Court Papers?
Yes:
No:
Name:
Relationship:
Office
6 - Others who may pick-up your student from school. ID will be required at pick-up.
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
7. Because family dynamics change, decline media forms will be collected each year. Full disclosure may be found on www.moonarea.net
under the Public Relations tab. The decline form must be completed and returned to your child’s building.
I hereby grant MASD the right and permission to publish/use photographs, name, video and/or audio recordings of my child, and
schoolwork created by my child, to promote my child, school, and district through its own media productions, yearbook, or thr ough the
external media. I understand a decline form must be completed and returned to the school.
Custodial Parent/Guardian Signature:
Date:
Moon Emergency Card bl.docx Page 1 of 2
MOON AREA STUDENT EMERGENCY INFORMATION
Please print using black or blue ink. If using web form, sign in ink. Complete all information on both pages for each child.
Student Name:
Grade:
Date of Birth:
In case of serious illness/injury, or one which we feel needs immediate attention, children are transported to the emergency room at Sewickley Hospital.
Please note that if an ambulance is called, it is up to emergency personnel in charge to decide where to transport and the parent/guardian will assume
financial responsibility.
Family Medical Personnel
Family Physician:
Phone #:
Family Dentist:
Medical/Hospital Insurance Co. & Policy #:
Allergies
Yes:
Phone #:
Subscriber:
Please list all allergies:
No:
Describe reaction:
Difficulty breathing?
Yes:
No:
Yes:
Emergency medication needed?
No:
PLEASE NOTE: if your child needs epinephrine, it is your responsibility to provide it to the nurse with orders of a
physician and written authorization of a parent or legal guardian. Please provide student’s epinephrine in the original box
provided by the pharmacy.
Asthma
Yes:
Triggered by:
No:
Usual Treatment:
Diagnosis Date:
Doctor name:
Dr. Phone:
PLEASE NOTE: If your child needs an inhaler it is your responsibility to provide it to the nurse along with orders of a
physician and written authorization of a parent or legal guardian. Students in grades 6-12 may carry their own inhaler if
they have a Dr.’s order, the nurse can verify proper self-administration and student and parent have signed the asthma
contract. Please request one from the nurse.
Concussions
Yes:
Describe:
No:
Diabetes
Yes:
Restrictions? (Requires a doctor’s note)
Usual treatment:
No:
Doctor’s Name who Diagnosed:
Date:
Current Doctor’s Name (if different from above):
Seizures
Yes:
Describe Seizure:
No:
Heart Condition
Yes:
Date of last seizure:
Medication:
Describe:
No:
Restrictions? (Requires a doctor’s note)
Other Medical Conditions
or Concerns
Daily Meds at Home
Yes:
No:
Name, dose, time of medication:
Medication at school
Yes:
No:
Name, dose, time of medication:
MEDICATION POLICY
Only medications that are necessary during school hours will be accepted. Medication, including prescription and non-prescription, will be given by the
school nurse in original containers with orders of a physician and written authorization of a parent or legal guardian. Both prescription and over-the-counter
medication including any topical products must be delivered by the parent directly to the school nurse.
Exception for Potentially Harmful Administration: It shall be the policy of this District that the District will not knowingly administer any medication to a
student if the District’s registered professional school nurse believes, in his/her professional judgment, that such administ ration could cause harm to the
student, other students, or the District itself. Such cases may include, but are not necessarily limited to, situation in which the District is being asked to
administer medication in a dosage that exceeds the highest recommended dosage. Please note that the school nurse will share only medical information
deemed by the nurse to be necessary in case of an emergency with appropriate district staff who have a “need to know ” for the wellbeing of the student.
Please notify the nurse if there is something that should not be shared. The above information may be shared with other school personnel on an as need
to know basis.
Custodial Parent/Guardian Signature:
Date:
Moon Emergency Card bl.docx Page 2 of 2
MOON AREA SCHOOL DISTRICT
PARENTAL DISCIPLINE REGISTRATION STATEMENT
Pennsylvania School Code §13-1304-A states in part “Prior to admission to any school
entity, the parent, guardian or other person having control or charge of a student
shall, upon registration, provide a sworn statement or affirmation stating whether
the pupil was previously or is presently suspended or expelled from any public or
private school of this Commonwealth or any other state for an act of offense involving
weapons, alcohol or drugs, or for the willful infliction or injury to another person or
for any act of violence committed on school property.”
Please complete the following:
I hereby swear or affirm that my child
expelled, or
is
is not
was
was not
previously suspended or
presently expelled from any public or private school of this
Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful
infliction or injury to another person or for any act of violence committed on school property. I make this
statement subject to the penalties of 24 P.S. §13-1304-A(b) and 18 Pa. C.S.A. §4904, relating to unsworn
falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge,
information and belief.
Any willful false statement made above shall be a misdemeanor of the third degree.
This form shall be maintained as part of the student’s disciplinary record.
24 P.S. §13-1304-A
Signature of Parent/Guardian________________________________________________ Date_______________
Student Name__________________________________________________ (please print)
Grade___________
The information requested above for basic student identification purposes will be maintained by the district for 100 years as required by the state. Please
notify the school of any changes that occur during your child’s years of attendance. Should the pupil leave Moon Area School District, this information and
the pupil’s grades, attendance record, discipline record and achievement test scores will be transferred to the receiving school. You will be notified of the
transmittal and have the opportunity to receive a copy of the record and challenge its content if desired.
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 7
MOON AREA SCHOOL DISTRICT
HOME LANGUAGE SURVEY*
The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS (Area Vocational Technical
Schools) identify limited English proficient (LEP) students in order to provide appropriate language instructional programs
for them. Pennsylvania has selected the Home Language Survey as the method for the identification.
Student’s Name:
Grade:
School:
Date:
1. What is / was the student’s first Language:
2. Does the student speak a language(s) other than English? Check one:
(Do not include languages learned in school.)
Yes
No
If yes, specify the language(s):
_______
3. What languages(s) is/are spoken in your home?
4. City of Birth:
________ State of Birth:
_______
If your child was not born in this state, what was his/her date of entry into Pennsylvania?
5. Country of birth:
If your child was not born in this country, what was his/her date of entry into the United States?
To assist the school district to comply with Federally Mandated reporting, please complete the following:
Student's Ethnicity:
Hispanic / Latino / Spanish Origin
Yes
No
Select one or more races:
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
6. Has the student attended any United States school in any 3 years during his/her lifetime?
Yes
No
If yes, complete the following:
NAME OF SCHOOL
STATE
DATES ATTENDED
Parent/Guardian signature:
Person completing this form (if other than parent/guardian):
* The school district/charter school/full day AVTS has the responsibility under the federal law to serve students who are limited English
proficient and need English instructional services. Given this responsibility, the school district/charter school/full day AVTS has the right to
ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the
school district/charter school/full day AVTS may conduct screenings or ask for related information about students who are already
enrolled in the school as well as from students who enroll in the school district/charter school/full day AVTS in the future.
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 8
MOON AREA SCHOOL DISTRICT
REQUEST FOR RECORDS FORM
Name of school last attended:
Address of school last attended:
Phone number of last school attended:
The Following Student Has Enrolled In Our School:
Student:
Birthdate:
Grade _______
PLEASE FORWARD TO THE SCHOOL CHECKED BELOW:
1.
2.
3.
4.
5.
6.
Transcript of courses and grades at the time of withdrawal
Testing results (including group and individual tests)
Complete health records
Disciplinary records
PA Secure ID number
Special education or gifted education records
J.A. ALLARD ELEMENTARY
170 Shafer Rd.
Moon Township, PA 15108
Grades K-4
Fax #: 412-262-2581
J.H. BROOKS ELEMENTARY
1720 Hassam Rd. Moon
Township, PA 15108
Grades K-4
Fax #: 412-264-4743
MCCORMICK ELEMENTARY
2801 Beaver Grade Rd. Moon
Township, PA 15108 (
Grades K-4
Fax #: 412-893-0428
MOON AREA HIGH SCHOOL
8353 University Boulevard
Moon Township, PA 15108
Grades 9-12
Fax #: 412-604-1645
BON MEADE ELEMENTARY
1595 Brodhead Rd. Moon
Township, PA 15108
Grades K-4
Fax #: 724-457-0919
HYDE ELEMENTARY
110 Wallridge Drive
Moon Township, PA 15108
Grades K-4
Fax #: 412-262-4617
MOON AREA MIDDLE SCHOOL
904 Beaver Grade Rd. Moon
Township, PA 15108
Grades 5-8
Fax #: 412-604-1600
MOON AREA SPECIAL EDUCATION OFFICE
8353 University Boulevard
Moon Township, PA 15108
Fax #: 412-264-6143
I hereby give my permission for the school checked above to request all school records pertaining to my child.
Parent Printed Name:
Parent Signature
Date:
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 9
MOON AREA SCHOOL DISTRICT
PHYSICAL / IMMUNIZATIONS INFORMATION
Dear Parent/Guardian:
Pennsylvania School Law requires a medical examination by a physician for all students entering
Kindergarten, Grade 6, and Grade 11, plus all new students to Pennsylvania schools regardless of grade
level. The medical examinations must be completed within one year prior to the beginning of the school
year. The PA Physical and Immunizations form is included on the next page.
The following immunizations are currently mandated for all students attending Pennsylvania schools:
4 doses of tetanus toxoid (1 dose must have been given on or after the 4th birthday) Note: If series is
started after 7 years of age, only 3 doses are required.
4 doses of diphtheria vaccine (1 dose must have been given on or after the 4th birthday) Note: If series
is started after 7 years of age, only 3 doses are required.
3 doses of polio vaccine
2 doses of measles vaccine
2 doses of mumps vaccine
1 dose of rubella vaccine
3 doses of hepatitis B vaccine
2 doses of varicella vaccine, or written statement from physician/designee indicating month and year of
disease or serologic proof of immunity
Additional immunizations required for students in grades 7-12
1 dose of tetanus/diphtheria/pertussis vaccine (Tdap)
1 dose of meningitis vaccine (MCV4)
Thank you for your cooperation in these matters.
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 10
MOON AREA SCHOOL DISTRICT
PROCEDURES FOR CHILDREN WITH PARENTS
DIVORCED, SEPARATED OR SINGLE
Children of Divorced Parents with Custody Agreement
At registration time, the parent must present the custody document to the school district. The school district will
follow the terms of the custody agreement specifically. A copy of the document will be maintained in the child's
school file.
Children of Single, Separated or Divorced Parents with No Custody Agreement
Both parents will be allowed access to the child as well as to all data pertaining to the child: report cards,
educational and health records, the right to attend parent conferences and school activities. The parent with
whom the child is living will routinely receive all report cards and other communications regarding his/her child.
The nonresident parent may request, in writing, the same information. This request should be addressed to the
building principal. The district will make reasonable efforts to comply with such requests.
Both parents will be notified and urged to attend meetings pertaining to special education placement, discussions
pertaining to promotion or retention, suspensions, expulsions or other serious disciplinary matters. Therefore, it
will be the parents' responsibility to keep the school informed of their current addresses and phone numbers.
The parent with whom the child is living will be notified in the event of serious accidents. If this parent is not
available, the person(s) listed on the health emergency card will be contacted. If these contact persons are not
available, the non-resident parent will be contacted if possible. The non-resident parent may request, in writing,
that he/she be notified in the event of a serious accident. The district will make reasonable efforts to comply with
such requests.
Registration Details
If a custody agreement exists, a copy must be filed with the school district. If no custody agreement is
provided, the person registering a child will be asked for the name, address and phone number of the
parent with whom the child is not living. A copy of these procedures, with the signature page, will then
be provided to each parent. Parents are then responsible for carrying out their responsibilities regarding
these procedures.
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 11
MOON TOWNSHIP SCHOOL DISTRICT
DENTAL HEALTH REQUIREMENT
To:
Parent/Guardian of Children in Kindergarten, and/or Grades 1, 3 and 7
From:
School Health Services
Re:
Dental Health Requirement
The Pennsylvania Department of Health Guidelines require all children to have a
dental examination upon original entry into school (Kindergarten or Grade 1), as
well as in Grades 3 and 7.
The Dental Examination form on the reverse side of this letter should be
completed by your child's dentist and returned to the school nurse. Examinations
within one year prior to the opening of the school year are accepted as required
proof of dental care.
Submit the completed form to the school nurse with your registration materials
for new students. Students starting 3rd and 7th grades should submit their
completed forms on or before the first day of school.
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 12
Copy: H514.027
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
PRIVATE DENTIST REPORT OF
DENTAL EXAMINATION OF A PUPIL OF
SCHOOL AGE
NAME OF SCHOOL
DATE
AGE
SEX
NAME OF CHILD
GRADE
SECTION/ROOM
M / F
Last
First
Middle
ADDRESS
___
No. and Street
City or Post Office
Borough or Township
County
State
Zip
REPORT OF EXAMINATION
TOOTH CHART
RIGHT
UPPER
LOWER
LEFT
1
2
3
4
A
5
B
6
C
7
D
8
E
9
F
10
G
11
H
12
I
13
J
14
15
16
32
31
30
29
T
28
S
27
R
26
Q
25
P
24
O
23
N
22
M
21
L
20
K
19
18
17
UPPER
LOWER
UPPER
UPPER
LOWER
LOWER
Is the Child Under Treatment?
YES
NO
Treatment Completed?
YES
NO
Date of Dental Examination:
Signature of Dental Examiner
Print Name of Dental Examiner
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 13
MOON AREA SCHOOL DISTRICT
MULTIPLE OCCUPANCY FORMS
Dear Parent/Guardian:
You are currently registered under a Multiple Occupancy Affidavit within the Moon Area School District. We are
asking that you complete the enclosed Multiple Occupancy Affidavit and then contact the registrar’s office (412264-9440 ext. 1132) to schedule a Recertification Appointment. All affidavits must be notarized.
These affidavits and all necessary documents must be submitted and approved in order for the student(s) to
attend the Moon Area School District.
Please be advised that all parties concerned in Multiple Occupancy Affidavits must do the following:
1. Complete the information within the affidavit, and have all three pages signed and notarized.
2. The homeowner/resident of record supply the district with the following pieces of documentation:
One of the following documents must be provided:
Original lease or deed signed by both parties (rental)
Mortgage payment booklet or mortgage statement that includes name, current address
and contact information of the financial institution.
Agreement of Sale, followed by original copy of settlement papers within 45 calendar
days of settlement
Plus any two of the following:
Valid driver’s license or change of address card with your current address
Valid vehicle owner’s card with your current address
Utility bill or Utility Activation Statement within 30 days in your name with your current
address (energy, water, sewer, gas, oil, cable)
Pay check stub within 30 days with your current address
Tax bill (most recent) with your current address
Homeowners/renters insurance bill with your current address
3. In addition to the attached three pages, they must also provide the District with notarized proof from the
owner/lessor of record or his/her agent granting permission for the parties involved to reside at the
residence, under what circumstances, and the expected duration. NOTE: ONLY THE OWNER OF RECORD OR
HIS/HER AGENT CAN GRANT PERMISSION FOR THE PARTIES TO RESIDE IN A PROPERTY, A LESSEE CANNOT.
4. The parents/guardians of the student(s) must also show their Pennsylvania Driver’s License or State ID Card.
This identification must reflect the address listed on the affidavit. This is mandatory and must be in our
possession when the affidavit is filed. They may also be required to submit additional proof of residence such as
a utility bill, bank statement or other qualifying proof.
The burden of proof for establishing current legal residency is yours. Please come to the appointment well
prepared to do so. Please be advised that the submission of support affidavits will be required every year that
your family is residing in the support affidavit situation.
Sincerely,
The Moon Area School District
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 14
MOON AREA SCHOOL DISTRICT
SWORN STATEMENT FOR MULTIPLE OCCUPANCY REGISTRATION
(TO BE COMPLETED BY PARENT)
*Effective for One Year ONLY*
Pennsylvania law states that a child shall be accorded free school privileges by the school district in which
his/her parent(s) resides. Since you are applying for registration of your children within the Moon Area School
District, you are requested to provide the names and birthdates of all individuals who will be moving into the
district to verify that you are a legal resident of the school district:
Name(s)
____________________
____________________
____________________
____________________
____________________
DOB
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Name(s)
____________________
____________________
____________________
____________________
____________________
DOB
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
My children and I reside in the Moon Area School District at the following location:
___________________________________________________________________________________________
This property is owned or leased by:
___________________________________________________________________________________________
I understand the owner/lessee of the above property is required to complete a Multiple Occupancy Certificate
within five days to verify my residence and provide the appropriate proofs of residency. I further understand
that if any information on this application proves to be false, the Moon Area School District has the right to
reject this application or to remove the student(s) from the school district. I understand that I will be liable for
payment of tuition for each child for that portion of time during which my child/children were illegally enrolled.
I assume responsibility for notifying Moon Area School District should any change in my residency status
occur.
_____________________________________
Signature of parent/legal guardian
__________________________________________
Sworn and Subscribed before me – Notary Public
_____________________________________
Home telephone number
__________________________________________
Date
__________________________________________
Registrar
Affective Date
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
PAGE 15
MOON AREA SCHOOL DISTRICT
SWORN STATEMENT FOR MULTIPLE OCCUPANCY REGISTRATION
(TO BE COMPLETED BY THE OWNER/LESSEE)
*EFFECTIVE FOR ONE YEAR ONLY*
I __________________________________________ certify that I am the legal owner or lessee of the
property located at:
______________________________________________________________________________
in the Moon Area School District.
I further certify that the following persons are living on a permanent basis at the above address with me (include
your spouse and children too):
Name
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Relationship to You
_________________
_________________
_________________
_________________
_________________
_________________
Name
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Relationship to You
_________________
_________________
_________________
_________________
_________________
_________________
I assume responsibility for notifying the Moon Area School District should the above information change.
I am aware that the facts as stated above are subject to investigation and, should it be determined that the
above is not a true statement of fact either now or in the future, I am committing a summary offense and shall
upon conviction for such violation be sentenced to pay a fine of no more than $300.00 for the benefit of the
school district or to perform up to 240 hours of community service, or both. In addition, I would then be liable to
pay all court cost and shall reimburse the Moon Area School District for tuition per month for each child for that
portion of time during which there was illegal attendance.
_____________________________________
Signature of owner/lessee
____________________________________________________
Sworn and subscribed before me - Notary Public
__________________________________
Telephone Number
____________________________________________________
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
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AUTHORIZATION AND VERICATION AGREEMENT
(OWNER/LESSEE)
PLEASE NOTE: A PERSON WHO KNOWINGLY PROVIDES FALSE INFORMATION IN THIS SWORN STATEMENT FOR
THE PURPOSE OF ENROLLING IN A SCHOOL DISTRICT FOR WHICH THE CHILD IS NOT ELIGIBLE COMMITS A
SUMMARY OFFENSE AND SHALL UPON CONVICTION FOR SUCH VIOLATION BE SENTENCED TO PAY A FINE OF
NO MORE THAN $300.00 FOR THE BENEFIT OF THE SCHOOL DISTRICT IN WHICH THE PERSON RESIDES OR TO
PERFORM UP TO 240 HOURS OF COMMUNITY SERVICE, OR BOTH. IN ADDITION, THE PERSON SHALL PAY ALL
COURT COSTS AND SHALL BE LIABLE TO THE SCHOOL DISTRICT FOR THE COST OF TUITION DURING THE
PERIOD OF ENROLLMENT.
I, ____________________________________, do hereby give the Moon Area School District authorization to
contact any/all of the following to verify residency dependency, and authenticity of information given on the
“Multiple Occupancy Certificate Affidavit” form bearing my signature.
1. Internal Revenue Service
2. Employer
3. Welfare Agency
4. Previous Landlord or current occupant of former address
5. Bureau of Motor Vehicles
6. U.S. Postal Service
_____________________________
Signature of Homeowner/Lessee
Sworn and subscribed before me
This ____ day of _____________, 20___
_____________________________
Address
__________________________________
Notary Public
_____________________________
Telephone Number
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
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MOON AREA SCHOOL DISTRICT
NON RESIDENT STUDENT AFFIDAVIT
___________________________ 20 _____
I, _______________________________________, being duly sworn, do hereby certify that I am a
resident of the MOON AREA SCHOOL DISTRICT, that I am supporting
________________________________________ gratis, that I will assume all personal obligations for
the child relative to school requirements, and that I intend to so keep and support the said child
__________________________________________ continuously and not merely through the school
term.
I attest to the fact that I have read and AGREE to follow the MOON AREA SCHOOL DISTRICT
RESIDENT/NON-RESIDENT STUDENT POLICY (202/SC1305) and that a copy was supplied to me at the
time of registration.
Parent Signature
Guardian Signature
______________________________
______________________________
Address: ______________________________
_______________________________
Sworn and subscribed to before me by the above named, __________________________
___________________, this __________day of ________________________, 20______
________________________________________ Justice of Peace
Or
_________________________________________Notary Public
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
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MOON AREA SCHOOL DISTRICT
WHEN CAN MY CHILD BEGIN CLASSES?
At all levels K-12, the registration packet will be sent to the building designee responsible for
scheduling. After they have reviewed the packet, it will be sent to the school nurse to be checked to
ensure that all immunizations have been received. You will then be contacted by a building designee
to schedule or determine a start date.
At the elementary school level (grades K-4), a building designee will establish a homeroom
assignment, notify the teachers and gather supplies and materials. You will then be notified by the
school stating the child’s homeroom assignment and date your child can start classes. If you haven’t
heard from the school within three (3) school days of registration, please call the school directly (The
main office numbers are included below).
At the middle school level (grades 5-8), the guidance counselor will establish a homeroom assignment,
notify the teachers and gather supplies and materials. You will be contacted by the guidance counselor
to schedule your child’s courses. If you haven’t heard from the school within three (3) school days of
registration, please call the school directly. MS Guidance Office – (412) 264-9440 ext. 3010
At the high school level (grades 9 –12), you will be contacted by the guidance counselor to schedule
your child’s courses. If you haven’t heard from the school within three (3) school days of registration,
please call the school directly. HS Guidance Office - (412) 264-9440 ext. 2009
The main office phone numbers of the Moon Area Schools are shown below:
Bon Meade Elementary School (Gr. K-2) - (412) 264-9440 ext. 5000
J.H. Brooks Elementary School (Gr. K-2) – (412) 264-9440 ext. 6000
J.A. Allard Elementary School (Gr. 3-4) – (412) 264-9440 ext. 4000
McCormick Elementary School (Gr. 3-4) - (412) 264-9440 ext. 9000
Moon Area Middle School (Gr. 5-8) - (412) 264-9440 ext. 3000
Moon Area High School (Gr. 9-12) - (412) 264-9440 ext. 2004
“THE MOON AREA SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EDUCATIONAL INSTITUTION.”
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