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WESTCLERMONTCENTRALENROLLMENTPACKET
PREK–12
ContentsofthePacket:Pleasecompleteyourpacketforeachstudentandthencall943‐5042or
emailtoweaver_v@westcler.orgtoscheduleanappointment.Pleasebringwithyou,theentirecontentsofthispacket.
Parent/GuardianchecklistforRegistrationStudentRegistrationFormEmergencyMedicalFormHealthRecord–Thisformisrequiredforallpre‐K&KindergartenstudentsAffidavitI–Residency–ifapplicableAffidavitII–Residency–ifapplicableSchoolRecordsRequestTechnologyUseGuidelinesMedia&PublicityExclusionformFERPAStudentAttendanceAccountingPolicyFree&ReducedLunchProgramInformation
EnglishLanguageLearner/EnglishasaSecondLanguageProgramReferral
Pleasevisitourdistrictwebsiteforadditionalinformationaboutourdistrictandourschools.
www.westcler.k12.oh.us–(513)‐943‐5000
CentralEnrollment
Onceyourstudenthasbeenenrolled,yourchild’sschoolwillcontactyoutomeetthe
principal/teacherand/orcreateascheduleformiddle&highschoolstudents.
WelcometoWestClermontSchools!WeareexcitedtoofferyouanyaidwecaninmakingyourentryintotheWestClermontSchoolDistrictaquickandeasyone.Beforewebegin,thereissomeinformationthatyoumusthavebeforewecanbegintheenrollmentprocess.Pleasereviewthefollowingchecklisttoensurethatyouhaveallthepaperworknecessaryforyourscheduledappointment.Ifduringyourenrollmentappointment,itbecomesclearthatarequireddocumentismissing,anewmeetingforregistrationwillbescheduledtoallowyoutimetoobtainthenecessaryinformation.
DOCUMENTS/FORMSREQUIREDFORREGISTRATION(ThedocumentslistedareMANDATORYforregistration–theyarerequiredtoenroll)
CompletedStudentRegistrationPacketChild’sOriginalBirthCertificate–WewillmakeacopyChild’sImmunizationRecords&Physical(physicalrequiredforPre‐K&KindergartenONLY)PhotoID(oftheparent)CustodyPapers(ifapplicable)ProofofResidency–PleasehaveONEofthefollowing…
OfficialRental/LeaseAgreementPurchaseContractORLandContractDeedORSettlementStatementAffidavitI–withutilitybill‐signedbyanotaryAffidavitII–withutilitybill–signedbyanotary
Additionalinformationyoumayprovide–Ifyouhaveastudenttransferringfromanotherschooldistrict–Pleasebringcurrentreportcardortranscriptswithyoutoyourappointment.Thiswillspeeduptheprocessingettingtherightclassesscheduledforyourchild.Additionalinformationyoumayprovide–AnystudentthatisonanIEP–parent’smustbringtheIEPand
ETRwiththematthetimeoftheappointment.
SchoolContacts:
CentralEnrollment
AmeliaElem:Mrs.Knudsen–513‐943‐3801BrantnerElem:Mrs.Dugan–943‐6401CloughPikeElem:Mrs.Little–943‐6701HollyHillElem:Mrs.Henize–513‐943‐8901MerwinElem:Mrs.Ogden–513‐947‐7801SummersideElem:Mrs.Fields–513‐947‐7901WillowvilleElem:Mrs.Prewitt–513‐943‐6801WithamsvilleElem:Mrs.Ilg–513‐943‐6901AmeliaMiddleSchool:Mrs.Horine–513‐947‐7500GlenEsteMiddleSchool:Mrs.Hater–947‐7711AmeliaHighSchool:Mrs.Wurschmidt–513‐947‐7401GlenEsteHighSchool:Mrs.Denton–947‐7616
AdditionalContacts:CentralEnrollment:513‐943‐5042Transportation:513‐752‐4020VitalStatistics–ClermontCountyHealthDepartment–513‐732‐7499(toorderabirthcertificate)Ifyourchildisridingthebus,pleasecalleitheryourschoolorthebus
garagetoreceiveyourbusnumber&pickuptimes.
PLEASEPRINTCLEARLY
Male FemaleStudent’sLegalLastName LegalFirstName LegalMiddleName GradeDateofBirth(mm/dd/yy) PlaceofBirth(City) (State) (Country)HomeAddress:(Street#) (Apt.#) (City) (Zip)HomePhoneorCell Mother’sMaidenName Child’sNativeLanguageLEGALGUARDIANSHIPAreyouthenatural/adoptiveparent(s)ofthechild? YES NO IfNO,whatisyourrelationshiptothechild?_______________________StatusofNATURALParents: Married Divorced Widowed Separated Single/NeverMarriedIfdivorced,whohaslegalcustody? Mother Father SharedParentingIfFOSTER/GUARDIAN,whatschooldistrictdidthenaturalparent(s)resideinatthetimeyoureceivedcustody?________________________IfFOSTER/GUARDIAN,pleaselistCaseManager/CourtLiaisonname&contactinfo:_______________________________________________________PleasefilloutinformationonFather&Mother,includingcontactnumbers,regardlessofmaritalstatus.(unlessyouarethe
guardianorfosterparent–pleasecompleteinformationforyourself)
CentralEnrollment STUDENTREGISTRATIONFORM
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐OFFICEUSEONLY‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐StudentID#:_________________________School:____________________
Grade:________EnrollmentDate:_____________StartDate:______________
ESL GT SPEC 504 CUST IMM
( )
CircleONE:FATHER/Guardian/FosterParent
Name:
Address:( sameasstudent)
HomePhone:
Cell/Pager:
Email:
NameofEmployer:
Step‐Mother(ifapplicable):
WorkPhone:
Cell/Pager:
CircleONE: MOTHER /Guardian/FosterParent
Name:
Address:( sameasstudent)
HomePhone:
Cell/Pager:
Email:
NameofEmployer:
Step‐Father(ifapplicable):
WorkPhone:
Cell/Pager:
ForSY:_______
CITIZENSHIP/ETHNICSTATUS
USCitizen *Immigrantstudentsarethosewho:
ForeignExchangeStudent 1.Areage3‐21
Non‐USCitizen/Immigrant* 2.WereNOTbornintheUnitedStates& 3.Havenotattendedoneormoreschoolsinanyoneormoreofthestatesformorethanthreeacademicyears.
DateyourchildfirstenteredU.S.schools?___________________HowlonghasyourchildattendedschoolintheUnitedStates?______(yrs.)IsthestudentHispanic/Latino? YES NO
Isthestudentfromoneormoreofthefollowingraces?AmericanIndianorAlaskanNative Asian BlackorAfricanAmerican
NativeHawaiianorOtherPacificIslander WhitePRIORSCHOOLHISTORY
HasyourchildeverbeenenrolledinWestClermontSchools? YES NOIfYes,whatyearwashe/shewithdrawn?___________Isyourchildcurrentlyexpelledorsuspendedfromyourpreviousschooldistrict? YES NO
HasyourchildattendedKindergarten?.................... YES NO
Didyourchildattendfulldayeveryday?…………. YES NO
Didyourchildattendhalfadayeveryday?……… YES NOSPECIALSERVICES
HasyourchildeverattendedSpecialEducationclasses? YES NO
Doesyourchildhavea504Plan? YES NO(Disabilityrequiringonlyreasonableaccommodations?)
Hasyourchildhadanevaluation(*)inthepast3years? YES NO (*M.F.E.;multifactoredevaluationisanassessmentofyourchildinallareasrelatedtothesuspecteddisability)
Ifyes,whatisthedateoftheevaluation?______________________________ DisabilityCategory_________________________________________Ifyes,isthereacurrentIndividualizedEducationPlan? YES NO
Hasyourchildbeenidentifiedgifted? YES NOIfyes,dateofplacementinGiftedProgram._______________________
Ifyes,didyourchildreceiveGiftedServicesatpriorschool? YES NO
DoesyourchildprimarilyspeakalanguageotherthanEnglish? YES NOLanguagespoken?_________________________________Ifyouanswered“YES”toanyquestioninthissection,pleasenoteanyspecialneedsinformationthatmayhelpusplaceyourstudent.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I,theundersigned,doherebystateanddeclareunderpenaltyoffalsification(*)thatIamtheparentorlegalguardianoftheabovenamedstudentandthatthisregistrationinformationistrueandcorrect.Parent/Guardian/FosterParent/CaseWorkerSignature Date(*)FalsificationunderOhioRevisedCodesection2921.13isamisdemeanorofthefirstdegreepunishablebyamaximumof(6)sixmonthsimprisonment
orafineof$1,000.00orboth.
CentralEnrollment
PLEASEPRINTCLEARLY
ThisEmergencyMedicalAuthorization,requiredbyO.R.C3313.712,mustbeonfileforeachstudent.Pleasereturntoschoolwithin7days.Student’sName School GradeStudent’sAddress City ZipDateofBirth StudentCell#(ifapplicable) Studentemailaddress(highschoolONLY) TeacherNote:Listingindividualsbelowallowsyourstudenttobereleasedtothoseindividuals(mustbeage18orolder)
************************************************************************************************************************************************************************************************************************************************************************
ListinorderPerson(s)whomaybenotifiedandtowhomyourchildmaybereleasediftheschoolcannotreachyou:Name Relationship HomePhone CellPhone WorkPhoneCHILD’SMEDICALHISTORYFactsconcerningyourchild’smedicalhistoryincludingallergies,medicationsandanyphysicalimpairmenttowhichaphysicianshouldbealerted.Doctortobecalled:Phone:.Dentisttobecalled:Phone:_____________________________________ PreferredLocalHospital:___.PART1–TOGRANTCONSENTIntheeventreasonableattemptstocontactmehavebeenunsuccessful,Iherebygivemyconsentfor(1)theadministrationofanytreatmentdeemednecessarybytheabovenameddoctororintheeventthedesignatedpreferredphysicianisnotavailable,byanotherlicensedphysicianordentistand(2)thetransferofthechildtoanyhospitalreasonablyaccessible.Thisauthorizationdoesnotcovermajorsurgeryunlessthemedicalopinionsoftwootherlicensedphysiciansordentistsconcurringinthenecessityforsuchsurgeryareobtainedpriortotheperformanceofsuchsurgery.SignatureofParent/Guardian:Date:. .PART2–REFUSALTOCONSENTIdoNOTgivemyconsentforemergencymedicaltreatmentofmychild.Intheeventofillnessorinjuryrequiringemergencytreatment,Iwishtheschoolauthoritiestotakethefollowingaction:.SignatureofParent/Guardian:Date:.
CentralEnrollment
EMERGENCYMEDICALAUTHORIZATIONFORMEnablesparentsandguardianstoauthorizetheprovisionofemergencytreatmentforchildrenwhobecomeillorinjuredwhileunderschool
authority,whenparents/guardianscannotbereached.
Student ID#:
( )
Parent/Guardian’sName: Relationtostudent:
HomePhone:() Cell:() WorkPh:()
Parent/Guardian’sName: Relationtostudent:
HomePhone:() Cell:() WorkPh:()
AffidavitI–examplesofproofofresidencyINSTEADofthisform:
*OfficialRental/LeaseAgreementOR*PurchaseContractORLandContractOR*CopyofDeedORSettlementStatement
I,(parent/guardianname),beingdulycautioned,dosolemnlyswearoraffirmthefollowing:
1. Iamtheparent,guardianorlegalcustodianof.andIliveat.,Ohio.
2. Thishasbeenmyresidencesince.
Myaddressimmediatelypriortothisdatewas:.
3. Iacknowledgeandunderthatiftheaboveinformationisnottrueandcorrect,thatknowinglyswearingoraffirmingthetruththereofconstitutescriminalfalsification,aviolationofOhioRevisedCodeSection2921.13afirstdegreemisdemeanor,punishablebyamaximumfineof$1,000.00and/ormaximumtermofimprisonmentofsixmonths.Further,ifthestudentisfoundtonotbealegalresident,thedistrictwillseekremunerationforeachdaythestudentillegallyattendedschoolinthedistrict.
4. IagreethatWestClermontLocalSchools,iftheydeemnecessary,havetherighttoinvestigatemyresidency.Iagreeto
allowthereleaseofrentalinformationandalsoutilitycustomerinformationtoarepresentativeofWestClermontLocalSchools.
Signature:Date:.TOBECOMPLETEDBYNOTARYSworntooraffirmedandsubscribedbeforemeonthis.dayof,.by.Signature:.
CentralEnrollment
AFFIDAVITIAffadavitIiscompletedbytheParent/LegalGuardianofthechildenteringWestClermontLocalSchools.Ifyouliveinyourownhome/apartment,completethisformasproofofresidency,ONLYifyou
cannotproduceyourleaseagreement,mortgagedeedorotherrequireddocumentasproofofresidency.ThisformMUSTbeaccompaniedbyautilitybilldisplayingthepropertyowner’snameandaddress.
Thisformmustbe signedbyanotary!
I,,beingdulycautioned,dosolemnlyswearoraffirmthefollowing:
1. Iamtheowneroftheresidenceat.,Ohio,(zip),locatedinthedistrictofWestClermontLocalSchools.HomePhone#:.Work/CellNumber:.
2. Listedbelowarealltheotheroccupantsattheaboveaddressandtheirrelationshiptothetenant:(thisaffidavitmustlistall
theresidentswithinthedwellingtoinsurecompliancewithcityhousingandzoningcodes,ordinancenumbers1351.03and1478.03,astheyrelatetothenumberofpersonsallowableonthepremisesitself.)
Name Age RelationshiptoTenant___________________________________________________________________ _______ ________________________________________________________________________________________________________________ _______ ________________________________________________________________________________________________________________ _______ ________________________________________________________________________________________________________________ _______ _____________________________________________
3. Theabovelistedtenant(s)arelivingatmyabovestateresidenceandhavebeensincethe_______________dayof__________________________________________________________,_______________________.Theexpectedperiodofthistenancyis(monthly,yearly,etc.):____________________________________________________________________
Iacknowledgeandunderstandthatiftheaboveinformationisnottrueandcorrect,thatinformationhasnotbeenwithheld,concealedormisrepresented,andthatknowinglyswearingoraffirmingthetruththereofconstitutescriminalfalsification,aviolationofOhioRevisedcodeSection2921.13(D),and2921.21afirstdegreemisdemeanor,punishablebyamaximumfineof$1,000.00and/ormaximumtermofimprisonmentofsixmonths.Further,ifthestudentisfoundtonotbealegalresident,thedistrictwillseekremunerationforeachdaythestudentillegallyattendedschoolinthedistrict.IagreethatWestClermontLocalSchools,iftheydeemnecessary,havetherighttoinvestigatemyresidency.IagreetoallowthereleaseofrentalinformationandalsoutilitycustomerinformationtoarepresentativeofWestClermontLocalSchools.PropertyOwner’sName(pleaseprint):__________________________________________________________________________________________________________PropertyOwner’sSignature:______________________________________________________________________________________________________________________TOBECOMPLETEDBYNOTARYSworntooraffirmedandsubscribedbeforemeonthis.dayof,.by.NotaryPublic:.
CentralEnrollment
AFFIDAVITII‐RESIDENTAffadavitIIisusedwhentheParent/LegalGuardianandchildislivinginadomicilebelongingtoanotherperson.(Example:acoupledivorcesandthemotherandchildmoveinwiththemother’sparentswhoareresidentsof
WestClermontLocalSchools.)TheOwner/LessorwouldcompleteAffidavitIIandprovideacopyofautilitybillorotherdocument.ThisformMUSTbeaccompaniedbyautilitybilldisplayingthepropertyowner’sname
andaddress.
Thisformmustbe signedbyanotary!
Student’sName BirthDate GradeSignatureofParent/Guardian(neededtoreleaserecords) Relationship DateNameofSchoolReleasingRecords StudentCounselor/TeacherAddressofschoolreleasingrecords (Street) (City) (State) (Zip) PhoneNumberofschoolreleasingrecords FaxnumberofschoolreleasingrecordsPleasesendrecordstothefollowingWestClermontSchoolformychild(checkone):
ElementarySchools:Amelia–5EastMainStreet,Amelia,OH45102‐0175‐ph:513‐943‐3800 email:[email protected]–609BrantnerLn.,Cincinnati,OH45245‐1592–ph:513‐943‐6400 email:[email protected]–808CloughPike,Cincinnati,OH45245‐1715–ph:513‐943‐6700 email:[email protected]–3520StateRoute132,Amelia,OH45102‐0185–ph:513‐943‐8900 email:[email protected]–1040GaskinsRd.,Cincinnati,OH45245‐2745–ph:513‐947‐7800 email:[email protected]–4639VermonaDr.,Cincinnati,OH45245‐1021–ph:513‐947‐7900 email:[email protected]–4529SchoolhouseRd.,Batavia,OH45103‐1099–ph:513‐943‐6800 email:[email protected]‐Tobasco–3950BrittonBlvd.,Cinti,OH45245‐2199–ph:513‐943‐6900 email:[email protected]
MiddleSchools:Amelia–1341CloughPike,Batavia,OH45103‐2545–ph:513‐947‐7500 email:[email protected]–4342GlenEsteWithamsvilleRd.,Cinti,OH45245‐1599‐ph:513‐947‐7703 email:[email protected]
HighSchools:Amelia‐1341CloughPike,Batavia,OH45103‐2546‐ph:513‐947‐7401 email:[email protected]‐4342GlenEsteWithamsvilleRd.,Cinti,OH45245‐1599‐ph:513‐947‐7616 email:[email protected]
*****Thissectionistobecompletedbythepriorschool,ifapplicable******Ifthestudenthasbeenexpelled,pleaseincludedetailsofexpulsion(reasonanddates):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________TherecordsfortheabovelistedstudentCANNOTbereleasedbecause(checkallthatapply):
FeesDue(Amountowed:_______________________) GradesIncomplete NoRecordsAvailable
Booksnotreturned(Titles):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SignatureofPersonCompletingthisSection Title Date
CentralEnrollment
SCHOOLRECORDSRELEASEPleasereleaseallappropriatepastandpresentacademic,testing,
discipline,medical,confidentialandspecialeducationrecords(includingpsychologicalinformation,diagnosticsummaries,IEP’s,etc.)onthestudentnamedbelow.Recordsshouldbesenttotheschoolindicatedbelow,
thefutureschoolofthechild.–WestClermontLocalSchoolDistrictI.R.N.#‐046359
( ) ( )
LAST DATE OF ATTENDANCE AT PREVIOUS SCHOOL:
OPEN ENROLLMENT FROM: START DATE:
West Clermont Local School District Health Record
Child’s Legal Name Date of Birth Parent/Guardian’s Name Sex: Male Female Age Address Home Phone
Work Phone Elementary School Cell Phone / Pager
******** DOCTOR TO COMPLETE FROM HERE DOWN ******** Medicine / Food Allergies EpiPen Needed? Yes No Chronic Medical Problems / Past Surgeries Medications Taken
PHYSICAL EXAM Height in. ( %) Weight lbs. ( %) B/P (No shoes, nearest 1/4 in.) (Light clothing, nearest 1/4 lb.)
General Appearance Nose Neck Lungs Skeletal System Eyes Throat Lymph Nodes Abdomen Neuro Muscular Ears Teeth Heart Genitalia Skin
Abnormal exam findings
LABORATORY TESTSIMMUNIZATIONSTYPE DATE (MO/DA/YR)
DTaPTdapPOLIOHIBHEPATITIS B MMRVARICELLA OTHER
(optional) Hb. / Hct. ________________ Lead Level _______________
Urine glucose _____________ Urine protein _____________ Urine blood ______________ TB Mantoux______________ Other ___________________
SPEECH AND LANGUAGE Speech Assessment: Child has no discernable speech problem Speech screen not done Child has possible problem with: None Articulation Rhythm Voice Language Formal speech evaluation recommended? No Yes
HEARINGDATE
MO/DA/YRAUDIOMETRY
RESULTS (Pass/Fail) OTHER TESTS
(Specify) REFERRED TO / MANAGED BY
R L R L Pass Fail Pass Fail
VISIONDATE
MO/DA/YRDISTANCE ACUITY
Circle one: corrected uncorrected STRABISMUS REFERRED TO / MANAGED BY
R L R L 20/ 20/
This child is able to participate in the following: Classroom and academic activities Competitive athletics Physical education classes Contact and collision sports
Describe any concerns, limitations, or recommendations to the school:
Physician’s Signature: _______________________________________________ (Office / Doctor’s Address Stamp Here)
Date: _________________________________
_____________________ Exam Date
WEST CLERMONT LOCAL SCHOOL DISTRICT Our mission is to ensure all students achieveacademic excellence in a safe environment supported by parents and the community.
Revised 8/13/2012
DR. KEITH KLINE ALANA CROPPER, CPA SUPERINTENDENT TREASURER
Student’s Name _______________________________________________ School ___________________________
ACCEPTABLE USE GUIDELINES FOR COMPUTER TECHNOLOGY AND NETWORKSGUIDELINES FOR WIRELESS COMMUNICATION DEVICES
All students must read (or have read to them) the summary of the ACCEPTABLE USE GUIDELINES FOR COMPUTER TECHNOLOGY ANDNETWORKS and the GUIDELINES FOR WIRELESS COMMUNICATION DEVICES of the West Clermont Local School District as outlinedon the District’s homepage located at www.westcler.org. or by going to http://bit.ly/TechUseGuidelines. Parent(s) of any studentunder the age of eighteen (18), must also read and sign below acknowledging that their student understands and agrees to follow allrules and policies as detailed on the District’s website. Parents are also strongly encouraged to discuss the safe use of the Internetwith their student(s).
I have read (or have had read to me) the agreement and understand and agree to abide by the terms of the ACCEPTABLE USEGUIDELINES FOR COMPUTER TECHNOLOGY AND NETWORKS and the GUIDELINES FOR WIRELESS COMMUNICATION DEVICES of theWest Clermont Local School District as outlined on the District’s website. Should I break any of the rules or in any way misuse myaccess to the School District’s computers, network and/or the Internet or other technology or technology services, I understand andagree that school disciplinary action may be taken against me and that my access privilege to technology equipment and/or servicesmay be revoked.
Parent’s Signature _____________________________________________ Date _____________________________
Student’s Signature ____________________________________________ Date _____________________________
NOTE: This agreement remains in effect while the student is enrolled in the same school building. It must be resubmitted ifparent(s) do not wish their child to have internet access at school or the student changes buildings.
MEDIA AND PUBLICITY EXCLUSION FORMOccasionally, student involvement in school related activities may create news and/or photo opportunities for local media andDistrict and School communications. We encourage these positive opportunities for your child to display their talents within ourcommunity. Parents, however, have the right to exclude their child from such opportunities.
IF YOUDO NOT WANT YOUR CHILD TO PARTICIPATE IN THE FOLLOWING ACTIVITIES, PLEASE SIGN THE BOTTOM OF THISAGREEMENT AND RETURN IT TO YOUR SCHOOL’S OFFICE.
IDO NOT give permission:
for my child to be interviewed for news media stories, district publications or other news andelectronic media. (This includes advertising of Honor Roll lists, performing arts programs, athletic team lists/rosters,student awards, etc.)to have my child’s picture used in news stories, district publications, on the web/internet, or in othernews, electronic media or publicity.to have my child’s name be posted on the District or School website.
Please sign only if you DO NOT give permission for your child to participate in the above activities.
Parent’s Signature _____________________________________________ Date _____________________________NOTE: This agreement remains in effect while the student is enrolled in the same school building. It must be resubmitted ifparent(s) do not wish their child to have internet access at school or the student changes buildings.
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT
The Family Educational Rights and Privacy Act (FERPA) gives parents and students over 18 (“eligible students”) the following rights to the student’s educational records.
(1) The right to inspect and review the student’s education records within 45 days of their initial request to the district. After parents or eligible students submit a written request to the principal identifying the record(s) they wish to inspect, the principal will arrange for access and tell the parent or eligible student when and where the records may be inspected. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies of records.
(2) The right to request an amendment to the student’s educational records that the parent or eligible student believes are inaccurate or misleading. Parents or eligible students may ask for amendment of a record believed to be inaccurate or misleading by writing to the school principal and clearly identifying the record to be changed and specifying why it is inaccurate or misleading. If the District decides not to amend the record, the District will notify the parent or eligible student of the decision and advise them of the right to a hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information.
(3) The right to fi le a complaint with the U.S. Department of Education. The Offi ce administering FERPA is the Family Policy Compliance Offi ce, 600 Independence Avenue, SW, Washington D.C. 20202-4605.
FERPA also allows West Clermont Local Schools to share portions of educational records without parental con-sent with school offi cials with legitimate educational interests. A school offi cial is an employee of West Clermont Local Schools or a person/entity designated to perform tasks; or a person serving on an offi cial committee, such as a disciplinary committee. A legitimate educational interest exists if the offi cial needs to review an education record in order to fulfi ll a professional responsibility. For example, if a student plans to enroll in another school district, West Clermont will disclose education records to the receiving district upon the receiving district’s request.
Unless we hear from you otherwise, West Clermont Local Schools will assume your child’s name, address, tele-phone number, gender, birth date, participation in activities or sports, weight and height of athletic team mem-bers, awards, dates of enrollment, grade level and intended fi eld of study may be disclosed in district directo-ries. Parents who DO NOT want any or all of the above portions of educational records to be disclosed in district directories should sign below and return it to their school’s main offi ce. THIS WILL EXCLUDE YOUR CHILD FROM INCLUSION IN YEARBOOKS, GROUP PHOTOS, PLAY AND CONCERT PROGRAMS, SPORTS ROSTERS, HONOR ROLL LISTS, INFORMATION RELEASED TO SCHOOL VENDORS (SUCH AS CLASS RING VENDORS), COLLEGES AND POST-SECONDARY TRAINING INSTITUTIONS (EX: SCHOLARSHIPS FOR COLLEGES,) etc. A copy of this request will remain on fi le at the school for one year.
To decline inclusion in district publicity and media stories, please sign the Media and Publicity Exclusion Form.
West Clermont Local Schools cannot decline to provide recruiters this information under the No Child Left Behind Act unless the Military Service and Institutions of Higher Education Opt-Out Form is completed and on fi le. (high school only)
(Only complete this form if you DO NOT WANT YOUR CHILD to be included in directories such as YEAR-
BOOKS, PLAY PROGRAMS, HONOR ROLL LISTS, ETC. Return even if left blank.)
Student Name: ______________________________________ Grade/School: ______________________________
Parent/Guardian Signature: ____________________________ Date: _____________________________________
(Only complete this form if you DO NOT WANT YOUR CHILD
to be included in directories such as YEARBOOKS, PLAY PRO-
GRAMS, HONOR ROLL LISTS, ETC. Return even if left blank.)
STUDENT ATTENDANCE ACCOUNTING POLICY FORM
The Ohio Revised Code 3313.205 states that Board of Education of each school district must adopt a policy of notifi -cation of parent, custodial parent, guardian, legal guardian, or other person having care or charge of a student who is absent from school.
The parent, custodial parent, guardian, legal guardian, or other person having care or charge of a student shall report by telephone or otherwise to the appropriate school administrator that his or her child will be absent for a specifi ed number of days or part of the day from school. Notifi cation must occur as early as possible the same day that the student is absent from school, but no later than 10:00 a.m.
If the building principal does not receive a call from the “parent” by 10:00 a.m., he/she will be responsible for con-tacting the “parent” to determine why the child is not in school. To comply with the Ohio Revised Code 3313.205, “parents” must provide the school with the following information:
1. Student Name: ____________________________________________________
2. Name of Parent, Custodial Parent, Guardian or Legal Guardian or person having charge or
care of the student: ______________________________________________
Daytime phone #: __________________________________
Signature __________________________________ Relationship _______________________
PLEASE PRINT
Free and Reduced Lunch ProgramIf you are interested in the free and reduced lunch program, please request an application at
the time of enrollment. To complete the application process, a student must give the completed
application to their school principal. The school principal will then forward that application to
the Food Service Department.
The entire process can take several days to complete, so plan accordingly. If your student
qualifi es for the program, you will be notifi ed by the school distict. Students are qualifi ed for
the duration of the school year. Applications need to be re-submitted each school year.
If you are enrolling from a diff erent school district, the qualifi cation for free and reduced lunch
WILL NOT transfer. A new application needs to be submitted. Likewise, if you leave the West
Clermont Local School District, you will need to apply for the free and reduced lunch program
at your new school.
If you have any questions about the program, please call the Food Service Department at 943-
5038.
Guidelines for the Identification and Assessment of Limited English Proficient Students/English Language Learners Ohio Department of Education, March 2012
WEST CLERMONT LOCAL SCHOOL DISTRICT 4350 Aicholtz Road, Suite 220
Cincinnati, OH 45245 (513) 943-5000
www.westcler.org Dr. Keith Kline – Superintendent
Mrs. Alana Cropper, CPA - Treasurer
English Language Learner / Limited English /
Home Language Survey
Name of Student: ___________________________________________________________________
Date of Birth: _____________________ Grade Level: ________ WC School: __________________
Name of Parent/Guardian: ____________________________________________________________
Home Address: _______________________________ City: ___________ State: _____ Zip:_______
For Parents/Guardians:
Please answer the following questions.
1. What language did your son/daughter speak when they first learned to talk? _______________ 2. What language does your son/daughter use most frequently at home? _____________________ 3. What language do you use most frequently to your son/daughter? ________________________ 4. What language do the adults at home most often speak? ________________________________ 5. How long has your son/daughter attended school in the United States? ____________________ 6. Do you have access to someone who can interpret and translate school notices and or documents?
Yes No
If the answer to any of the first 4 questions above is a language other than English, indicate the studen’ts native/home language in EMIS Student Data Element (GI270), and proceed to assess the student’s English language proficiency.
CC: ESL Coordinator, Student Permanent File (Cum Folder)
