2021-2022 Student Registration K-4

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Welcome to Hillsdale Community Schools! Please complete each question listed. If your child is new to our district, you will be contacted by a HCS staff member regarding the enrollment process. Please call Gier Elementary School (517-437-7347) if you have any questions or concerns.

Date *

YYYY

Student Legal Name, (last, first, middle) *

Student Nick Name

Grade Entering 2021-2022 (Please note that if your student is new to the district the school office will need to see the Birth Certificate, Shot Records and Proof of Residency documents upon enrollment) *

D-Kdg

Kdg

1st

2nd

3rd

4th

Learning Option *

Option 1: In-person (traditional) learning at school.

Option 2: Online/distance learning at home.

Date of Birth *

YYYY

Place of Birth (City, State, County) *

Gender

Female

Male

Clear selection

Student Street Address *

City *

Zip *

Last School Attended *

Does the student live in HCS District? *

Yes

No - please indicate district of residence below

District of residence.

Does your student have an IEP or 504 plan *

Yes

Student lives with: *

Both Parents

Mother Only

Father Only

Mother and Step Father

Father and Step Mother

Legal Guardian (documentation required)

Other:

Father's Name: *

Father's Phone Number:

Father's email address:

Father's employer (include employer's phone number)

Mother's Name: *

Mother's Phone Number:

Mother's email address:

Mother's employer (include work phone number)

Student's cell phone number:

List other siblings attending HCS (Name & Grade) *

Emergency Contact Name (and relationship to student): *

Emergency Contact Phone: *

Emergency Contact Name 2 (and relationship to student): *

Emergency contact phone 2:

IN CASE OF EMERGENCY: In case my child becomes ill or injured at school and needs emergency medical care, please take him/her to the family doctor, any other doctor who is available, or to the nearest hospital. I agree to assume responsibility for the expenses incurred by the handling of this emergency care. *

Yes

Parent/Guardian: The No Child Left Behind legislation requires the tracking of Limited English Proficient students (students or other family members in the household who speak another language other than English) and the McKinney-Vento Act (students who have temporary arrangements for residency and/or housing). Your assistance filling out the two-part questionnaire below will assist Hillsdale Community Schools with updating enrollment documentation. LIMITED ENGLISH PROFICIENCY SURVEY: Is there a second language other than English spoken in the home? *

Yes - if yes, please indicate the language below

Second language spoken in the home?

Student Ethnic Origin:

American Indian

Alaska Native

Black

Hispanic/Latin

White

Other

Clear selection

McKinney-Vento Homeless Education Assistance Program (Students/Families in Transition) Where is the student currently living? *

In a shelter

With more than one family in a house or apartment

With friends or family members (other than parent/guardian)

Choices listed above do not apply

I give the school permission to use pictures/videos that my child appears in to recognize their accomplishments and activities or to share highlights of the school. *

Yes

I have, or will read the contents of the Student Handbook then review with my student. *

Yes

I give permission for my student to take online course(s) if needed. *

Yes

By clicking agree, I am agreeing that the above information is accurate and was provided by the parent or legal guardian of the student. *

Agree

Disagree

Name (and relationship) of the person completing this form. *

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