Shepherd Public Schools Enrollment Request
THIS FORM IS FOR STUDENTS ENROLLING AT SHEPHERD SCHOOLS FOR THE FIRST TIME OR TRANSFERING FROM ANOTHER SCHOOL.

Please carefully complete this form in its entirety. This form is the BEGINNING of the process to enroll your child at Shepherd Schools.  Building Administration must approve all requests before enrollment is complete.
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Building which student is enrolling *
Grade level in which student is enrolling *
Student Residency - Proof of Residency is required.  In which district does the student reside? *
Student's LAST Name (legal name from birth certificate) *
Student's FIRST Name (legal name from birth certificate) *
Student's MIDDLE Name (legal name from birth certificate) *
Student's Gender *
Student's Date of Birth *
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Birth Place (City - State - Country) *
If born outside the U.S., WHEN did the student enter the country?  If born in U.S., put DOB. *
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Student's (HOME) STREET address *
Student's (HOME) City *
Student's (HOME) Zip Code *
Student's (HOME) County *
Student's (MAILING) STREET or PO BOX *
Student's (MAILING) CITY *
Student's (MAILING) STATE *
Student's (MAILING) ZIP *
PRIMARY contact phone number (format = 999-999-9999) *
Is this student Hispanic or Latino? *
What is the student's race? *
Do you have any tribal affiliation? *
Is your child's native (first) tongue a language other than English? *
Is the primary language used in your child's home or environment a language other than English? *
Has a Parent/Guardian or an immediate household family member worked in agriculture, poultry, dairy in the past 3 years? *
Is the student currently in Foster Care? *
Is the Parent/Guardian an active member of the Armed Forces or National Guard? *
Is there a current court issued No Contact Order or other safety factors which concerns this student? *
Are parents divorced or separated? *
Is there custodial paperwork for this student that the school needs to be aware of? *
Please supply a copy to the office for the student's file.
Parent or Guardian #1 - LAST name *
Parent or Guardian #1 - FIRST name *
Parent or Guardian #1 - RELATIONSHIP to student *
Parent or Guardian #1 - Do you reside with this student? *
Parent or Guardian #1  - Are you legally responsible for this student? *
Parent or Guardian #1 - Street Address *
Parent or Guardian #1 - City *
Parent or Guardian #1 - Zip *
Parent or Guardian #1 - CELL/PRIMARY phone number (format = 999-999-9999) *
Parent or Guardian #1 - Email *
Parent or Guardian #1 - Place of Employment *
Parent or Guardian #1 - WORK/SECONDARY Phone Number (format = 999-999-9999)
Parent or Guardian #2 - LAST name
Parent or Guardian #2 - FIRST name
Parent or Guardian #2 - RELATIONSHIP to student
Parent or Guardian #2 - Do you reside with this student?
Clear selection
Parent or Guardian #2  - Are you legally responsible for this student?
Clear selection
Parent or Guardian #2 - Street Address
Parent or Guardian #2 - City
Clear selection
Parent or Guardian #2 - Zip
Parent or Guardian #2 - CELL/PRIMARY phone number (format = 999-999-9999)
Parent or Guardian #2 - Email
Parent or Guardian #2 - Place of Employment
Parent or Guardian #2 - WORK/SECONDARY Phone Number (format = 999-999-9999)
Does this student currently have an IEP? (Special education services including; speech, resource room, social worker, etc...)? 

If YES, documentation must be provided to the school before enrollment is finalized.
*
Does this student currently have a 504-Plan?  
If YES, documentation must be provided to the school before enrollment is finalized.
 *
Is there any medical condition(s) that the school nurse should be informed about in relation to this student? *
Emergency Contact Person #1  - LAST name *
If we are unable to reach you, who could we call or release student to other than parent/guardian listed above.
Emergency Contact Person #1 - FIRST name *
Emergency Contact Person #1 - RELATIONSHIP TO STUDENT *
Emergency Contact Person #1  - CELL/PRIMARY NUMBER - (format = 999-999-9999) *
Emergency Contact Person #1 - WORK NUMBER
Emergency Contact Person #2  - LAST name
If we are unable to reach you, who could we call or release student to
Emergency Contact Person #2 - FIRST name
Emergency Contact Person #2 - RELATIONSHIP TO STUDENT
Emergency Contact Person #2 CELL/PRIMARY NUMBER - (format = 999-999-9999)
Emergency Contact Person #2 - WORK NUMBER
Emergency Contact Person #3  - LAST name
If we are unable to reach you, who could we call or release student to
Emergency Contact Person #3 - FIRST name
Emergency Contact Person #3 - RELATIONSHIP TO STUDENT
Emergency Contact Person #3 - CELL/PRIMARY NUMBER - (format = 999-999-9999)
Emergency Contact Person #3 - WORK NUMBER
I consent to Shepherd Public School’s collection, use, and/or disclosure of information about my children through video conferencing, online classes and recording applications and other procedures used with course instruction. I understand that my student may be participating in a virtual academic setting. My child’s name, image, speech, typed content, and segments of video may be transmitted during remote learning and online instruction.The information shared with the teacher and/or Shepherd School is meant solely for educational / class use. *
If your family lives in any of the following, your child might be able to receive help through a federal law called the McKinney-Vento Act:

» Living in a shelter
» Living in a motel or campground due to the lack of an alternative adequate accommodation
» Living in a car, park, abandoned building, or bus or train station
» Living in substandard housing (not up to code, unsafe, etc.)
» Doubled-up with other people due to loss of housing or economic hardship 
 *
Directory Information? *
The Board designates as student "directory information" a student's name, address, telephone number, date and place of birth, major field of study, participation in officially-recognized activities and sports, height & weight, if a member of an athletic team, dates of attendance, date of graduation awards received, honor rolls, scholarships, telephone numbers only for inclusion in school or PTO directories, school-assigned email addresses, only to register for online educational service providers, including mobile apps, as utilized by the student for educational purposes. If you have any objections regarding the release of this information please notify the school where your student will attend in writing.
Required
Photo Consent? *
Do you give the school permission to include this student's photo in yearbook, external media, school programs, possibly TV?
PARENT SIGNATURE (electronic) *
By typing your name you are verifying that you are the person completing this form and verify that it has been completed to the best of your knowledge.
REQUIRED REGISTRATION DOCUMENTATION:      Birth Certificate - Proof of Residency - Immunization Record - MCIR Consent - Concussion Awareness Form *
Required
Today's Date *
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