Northwest Area School District

Online Student Registration System

Student First Name *

Student Middle Name

Student Last Name *

Student Photo (HEADSHOT ONLY) *

Student Ethnicity- Please check all that apply *

If Multi-Racial is Selected, Please Select all that apply:

Sex *

Male

Female

Student Date of Birth (MM/DD/YYYY) * +

Student Anticipated Grade Level *

Student Cell Phone Number 🛈

Student Place of Birth

City *

State *

Country *

Has the student been a resident of Pennsylvania since birth? *

Yes

No

If not, please enter the date the student entered Pennsylvania (MM/DD/YYYY) +

Has the student been a U.S. citizen since birth? *

Yes

No

If not, Please enter the date the student became a U.S. citizen (MM/DD/YYYY) +

Primary Physical Address

Street *

City *

State *

Zip Code *

Primary Phone Number * 🛈

Secondary Phone Number 🛈

Mailing Address if different than Primary Physical Address

Primary Guardianship Information
Student lives with:
*

What mode of learning would you request for your child? *

Enrollment Year *

Primary Guardianship Information

First Name *

Last Name *

Relationship to Student *

Street Address (If different from Primary Address)

Address Line 2

City

State

Zip Code

Email Address *

Primary Phone Number * 🛈

Secondary Phone Number 🛈

Employer *

Occupation *

Primary Guardianship Information (2)

First Name

Last Name

Relationship to Student

Street Address (If different from Primary Address)

Address Line 2

City

State

Zip Code

Email Address

Primary Phone Number 🛈

Secondary Phone Number 🛈

Employer

Occupation

Are there any custody documents on file regarding the guardianship of this student? *

Yes

No

Attach custody documents if available

Siblings

Name of other siblings living in the home

+-

Age of Sibling

+-

Please list the schools that the siblings are enrolled in

Emergency Contact Information

Family Doctor Name *

Phone * 🛈

Student Medical or Physical Concerns

Emergency Contacts

Name

+-

Relationship to Student

+-

Phone 🛈

+-

Are emergency contacts allowed to pickup child from school? *

Student Enrollment Information

Previous School Attended

Street Address

Address Line 2

City

State

Zip Code

Phone Number 🛈

Has your child ever been enrolled in The Northwest Area School District? *

Yes

No

If Yes, which School did she/he attend?

Has the student attended school in the United States for at least 3 years during his/her lifetime? *

Yes

No

School Name / Information

+-

Special Services: Is your child currently enrolled in one of the following special programs? check all that apply

I hereby swear or affirm that my child was not previously suspended or expelled and is not presently suspended or 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 of 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. *

Agree

Disagree

If this student has been or is presently suspended or expelled from another school, please complete the following:

Name of School

+-

Reason for Suspension/Expulsion

+-

Home Language Survey

The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS 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 this identification.

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.

What is the student's first language? *

English

Spanish

Other Other

Does the student speak any language other than English? *

Yes

No

If Yes, Please specify

If Yes, please provide the following information:

Name of School

+-

State

+-

Dates Attended

+-

Media and Internet

Students participate in classroom and school sponsored activities during the course of a school year. Certain classes and activities may be photographed, taped, videotaped, or posted to the school district website by the news media, district personnel, or other students. Likewise, live images may be relayed via cable or satellite connections to other districts or to other classrooms within our district to allow for live interactions between students and teachers at separate locations. Distance learning videotapes may be used to educate others about distance learning at seminars and other public places. Any media interaction with students must be approved in advance by the administration. Photographs, tapes, or videotapes created for commercial use are not permitted by the NASD. This involvement by students, and the sharing of educational techniques and experiences, is intended to enhance and enrich the educational opportunities of all students and staff. The school’s experiences and involvement in these areas has been positive. I/we acknowledge that the student is a minor, and certify that I/we have given consent to the Northwest Area School District permission to properly use the aforementioned media format(s). *

Agree

Disagree

As the parent/guardian of this student I have read the NASD Acceptable User Policy #815. I understand that this access is designed for educational purposes and the district has taken available precautions to eliminate controversial material, however, I also recognize it is impossible for the district to restrict access to all controversial materials and I will not hold them responsible for materials these students may acquire on the district network. I herby give my permission to issue an account for the student being enrolled in this form and certify that the information contained on this form is correct. *

Agree

Disagree

Parent/ Guardian Signature *

clear

Both Parents	Mother	Father
Shared Custody- Mother/Father	Grandparent(s)	Foster Parent
Guardian	Self	Other Other

Learning Support	Emotional Support	Gifted Support
Autistic Support	Speech Therapy	English As A Second Language (ESL)
Title I	Life Skills	504 Plan