K-12 Online Registration Form

Date *

Zoned School *

assigned school based on physical address

Enrolling Grade *

Child's First Name *

Child's Middle Name *

Child's Last Name *

Date of Birth *

Gender *

Mailing Address *

Enter house number and street or PO Box

City *

State *

Zip Code *

Physical Address *

Enter house number and street

City *

State

Zip Code *

Is your present housing situation temporary? *

Home Phone # *

Cell Phone # *

Is your child Hispanic/Latino? *

Select one

What is your child's race? *

White
Black or African American
Hispanic (Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture)
Alaskan/American Indian
Asian (Far East, Southeast Asia, or for ex., China, India, Japan, Korea, Malaysia, Pakistan, Phillippine Islands, Thailand or Viet Nam)
Native Hawaiian or Pacific Islander

Check all that apply.

Place of Birth *

City/State

Primary language spoken in the home *

For example: English, Spanish, Italian, Chinese, Arabic

Birth Certificate #

Volume/State File Number

Parent 1/Legal Guardian's Name *

First, Middle, Last

Parent 1/Legal Guardian's Relation *

Parrent 1/Legal Guardian's Mailing Address *

Enter house number and street or PO Box

Parent 1/Legal Guardian's City *

State *

Parent 1/Legal Guardian's Zip Code *

Parent 1/Legal Guardian's Home Phone # *

Parent 1/Legal Guardian's Email

Parent 1/Legal Guardian's Place of Birth *

City, State

Parent 1/Legal Guardian's Highest Level of Education Completed *

high school, 2 yr, 4 yr, post grad

Parent 1/Legal Guardian's Place of Employment

Business

Parent 1/Legal Guardian's Occupation

Business Address for Parent 1/Legal Guardian

number, street, city, state, zip

Business Phone Number for Parent 1/Legal Guardian

Parent 2/Legal Guardian's Name

First, Middle, Last

Parent 2/Legal Guardian's Relation

Parent 2/Legal Guardian's Mailing Address

Enter house number and street or PO Box

Parent 2/Legal Guardian's City

State

Parent 2/Legal Guardian's Zip Code

Parent 2/Legal Guardian's Home Phone #

Parent 2/Legal Guardian's Email

Parent 2/Legal Guardian's Place of Birth

City, State

Parent 2/Legal Guardian's Highest Level of Education Completed

high school, 2 yr, 4 yr, post grad

Parent 2/Legal Guardian's Place of Employment

Business

Parent 2/Legal Guardian's Occupation

Business Phone Number for Parent 2/Legal Guardian

Business Address for Parent 2/Legal Guardian

number, street, city, state, zip

If Legal Guardianship has been awarded by a court order, when was it granted?

Enter date

In what city/county, state was the custody granted?

Enter city/county, state

Check all that apply *

US Citizen
Active Military
Civil Service
Migrant
Immigrant
Refugee
Homeless
None apply

A copy of the Custody Order including visitation rights during the school day must be provided.

Foster Parent's Name(s)

first and last

Agency Holding Custody

Child lives with and relation (if any)

If different from above

Phone/cell number

if different from above

Please answer the following questions:

Number of brothers, ages and current school *

Write number, ages, and school, if none state none

Number of sisters, ages and current school *

Write number, ages, and school, if none state none

Others living in the home *

name(s) and relation(s) if any, if not state none

Number of miles child lives from school *

Approximate if not known

1st Person to Contact in Case of Emergency (other than yourself) *

Name and relationship to child

Relationship to child *

Phone/Cell # of 1st Emergency Contact *

Address of 1st Emergency Contact *

street number, city, state, zip code

2nd Person to Contact in Case of Emergency (other than yourself) *

Name and relationship to child

Relationship to child *

Phone/Cell # of 2nd Emergency Contact *

Address of 2nd Emergency Contact *

street number, city, state, zip code

Name of Family Doctor *

Family Doctor's Phone Number *

Family Doctor's Address *

street number, city, state, zip

Has your child ever been enrolled in the Dinwiddie County Public School System? *

If yes, list dates:

Former school system and address: *

Previous school (if applicable) and address; state none if none

Has your child previoulsy received services through any Special Education program (IEP)? For example: Speech, Hearing/Vision, Specific Learning Disability, ect. *

If yes, which program?

Has your child ever been expelled from school (365 days)? *

If yes, from which school division? When? Reason for expulsion.

Has your child every repeated a grade? *

If yes, list grade

Please read and sign the statement below:

I am a resident of Dinwiddie County and live in the district in which I am registering. I realize that any person making a false statement concerning the residency of a child in a particular school division shall be guilty of a Class 4 misdemeanor pursuant to the Code of Virginia: 22.1-264.1. If there are custody issues regarding this child, I will provide a copy of the custody order and visitation rights. I also certify that this child is a student in good standing (not suspended or expelled from any public/private school, nor found guilty of or is an adjudicated delinquent for any offense in subseciton G of the Code of Virginia: 16.1-260)

My name indicates that I have read and certify the statement above. *

enter first and last name

Registration Form K-12

A copy of the Custody Order including visitation rights during the school day must be provided.

Please answer the following questions:

Please read and sign the statement below: