Student Services 

School District of Clay County 

Checklist for Enrollment of K­12 Students 

 

NOTE:    Students whose parents are found, after appropriate investigation, to have submitted fraudulent information in an effort to enroll a student in a school to which the student is not assigned shall be immediately withdrawn and referred for enrollment in the appropriate zoned school. For further information, please contact the Records Secretary at your zoned school. 

 

Evidence of Proper Age  

 

_____ Official birth certificate.  If such certificate is not available, the following forms of evidence are acceptable: 

 

_____ A duly attested transcript of a certificate of a religious document showing date of  birth accompanied by an affidavit sworn to by the parent. 

_____ Insurance policy on the child’s life which has been in force at least two years.  _____ A passport or certificate of arrival in the U.S. showing the age of the child. _____ Official school records that provide evidence that the child has attended school for  

four years.  Evidence of Immunization and Physical Exam 

 

_____ Florida Certificate of Immunization (Form HD680). _____ Religious exemption (Form 681), a temporary exemption (Form DH680, Part B) or  

a medical exemption (Form DH680, Part C). _____ Within 30 days students grades K­12 and entering Florida school for the first time,  

must present evidence of a physical examination performed within twelve months  prior to their initial enrollment, or the day student was brought to school to fill out  necessary forms for the purpose of becoming a Clay County Public School student. 

Evidence of Medical Condition (If Applicable) 

 

_____ Parents must provide a written notification of any health/medical condition that  requires staff awareness and/or supervision for the child. 

_____ Medical Treatment Form, if applicable, will be provided at the school.   Evidence of Custody/Guardianship   If the student is residing with someone other than the parent or legal guardian, the following provisions shall apply:   _____ The individual registering the child must provide documentation of custody by an  

appropriate state agency such as the Department of Children and Families or the Court.  

_____ If the student lives in a residence licensed by the Department of Children and  Families, the student may be enrolled in the school that serves that licensed residence.  

_____ A bona fide In‐Loco‐Parentis relationship must be established.  School Board Policy  4.08.  

 Emergency Information   _____ Registration emergency card (Note: Only parents/guardians signing registration  

form can change registration/emergency information).   School Records (If Any)  

 

_____ Latest report card and/or transcript needed for appropriate grade placement.  A records request form will be provided at the school. 

STUDENT NUMBER

SCHOOL DISTRICT OF CLAY COUNTY NEW STUDENT REGISTRATION

EMERGENCY & MEDICAL INFORMATION

School Year 2016-2017

THIS AREA FOR OFFICE USE ONLY Entry Date Homeroom

Grade IEP EP 504

Records requested

Yes No Birth Verification (1 – 9) ______

Health Exam Yes No

Form 680 Yes No

Medical Alert Condition: Code 99 Yes No

Out-of-Zone Yes No

Residence Verification Yes No

Military Family Yes No

DIRECTIONS: Parent/Guardian please complete all areas and check appropriate boxes, sign & date Student’s Legal Name:

First Middle Last DOB: GRADE:

SSN ( - - ) * Required to request by FS. 1008.386, but is not required as a condition for enrollment or graduation Previous School Name: _______________________________________________ Phone/Fax __________________________________ District:_____________________State:_______________________Country:_______________________City:______________________

Primary Address of Student City State Zip Primary Phone Number ( ) Mailing Address (if different than above) City State Zip

PARENT CONTACT and EMAIL INFORMATION Mother/Legal Guardian Name E-Mail Legal Custody Resides with Student Phone # by order of preference (H W C) Yes No Yes No 1: _________________________ ______ 2: _________________________ ______

Father/Legal Guardian Name E-Mail Legal Custody Resides with Student Phone # by order of preference (H W C) Yes No Yes No 1: ________________________ ______ 2: ________________________ ______

Primary Parent/Guardian E-Mail: _____________________________________________________________________

By signing this release, consent is given to the use of email to transmit factual information about my student and releasing the School District of Clay County from liability should such emails be received by unauthorized parties and/or cause a libelous incident. It is understood that the email address listed above will be used until parent appears at the school with a written notice to discontinue use of the email address. It is understood further that email is not a private medium and that email can be edited and redistributed without the knowledge or permission of the originator, and that at no time, can a staff member email medical or subjective information such as behavior. Student Lives with: Both Parents Mother Father Guardian Other ________________________________________

Court ordered custody/restraint documentation provided Yes No - If Yes, describe here ________________________________

List alternate contacts & phone numbers who can pick up student in case of an emergency. Indicate the relationship of each contact to the student. Resides with

Student? Primary Phone #

Alternate Phone #

First Contact (Name) (Relationship) Yes No

Home Work Cell

( ) Home Work Cell

( )

Second Contact (Name) (Relationship) Yes No

Home Work Cell

( )

Home Work Cell

( )

Third Contact (Name) (Relationship) Yes No

Home Work Cell

( )

Home Work Cell

( )

********PLEASE COMPLETE BOTH SIDES********

Female Male City of Birth ___________________________________ State of Birth___________ Country of Birth__________________

Immigrant Student Yes No Race: White Black Asian American Indian Pacific Islander Multiracial

Ethnicity: Is student of Hispanic/Latino/Spanish Origin Yes No

____________________________________________________________________________________________________________________________

Resident Status: In County Out of County: Residence County:____________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Home Language Survey Date (Date of Registration): ________________ Date Entered United States School(DEUSS)________________________ Is a language other than English used in the home? Yes No If yes, what language_______________________ If ‘yes’ is checked, your child will be screened for ELL.

Did the student have a first language other than English? Yes No If yes, what language_______________________

Does the student most frequently speak a language other than English? Yes No If yes, what language_______________________

INSURANCE COVERAGE: No Coverage Group or Private Insurance Healthy Kids Medicaid Other

Provider: _____________________________________________ Group Number: ________________________________________

Doctor: _____________________________________________ Phone # _____________________________________________

I understand that if emergency medical services of any kind or nature what so ever are provided to my child I will bear full responsibility for payment of all charges resulting from rendition of said services. I give my consent to the school to provide medical information on this emergency card with emergency medical personnel should the need arise for emergency medical services. I hereby give permission to release pertinent health information to official school personnel. I also authorize the School District of Clay County to release my child’s name, date of birth, and social security number to agencies of the State of Florida for the purpose of determining possible Medicaid eligibility. If applicable, I further authorize the School District to receive Medicaid payments for any exceptional student services/medical services provided to my child. I understand that I may withdraw consent at any time. This consent will not impact my child’s Medicaid coverage or my child’s entitlement to a free and appropriate public education. Upon request, I may receive copies of records disclosed pursuant to this authorization.

HEALTH INFORMATION: List any health problems or conditions such as heart disease, diabetes, epilepsy, or severe allergies and related medications. Please be specific i.e., asthma, allergies to bee stings. etc. ____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

CURRENT MEDICATIONS: Parents/guardians of children requiring medication during school hours must contact school for specific procedures

and forms. _______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Registering for Grade _______________ Has this student been retained? Yes No If so what grade? ____________

Military Family Student Yes No

Does either parent work on Federal Property? Yes No If ‘yes’, Name of Property _______________________________ Uniform Service Branch __________________Civil Service_________________

Does your child have a 504 plan? Yes No

Was your child in the MTSS/RTI Process? Yes No

Was your child enrolled in a Dropout Prevention Program? Yes No

Does your child have an IEP or an EP? Yes No

If ‘yes’, which program: Gifted SLD EBD ID Speech/Language ASD Other ______________

232.0205 Disclosure at school registration.—According to procedures established by the district school board, each student at the time of initial registration for school in a school district shall note previous school expulsions, arrests resulting in a charge, and Juvenile Justice actions the student has had. If any, please list including dates: ________________________________________

Transportation: Bus Day Care Name/Phone___________________________________________ Drives Self Parent Pick-Up Walker

OTHER CHILDREN IN THE FAMILY:

______________________________________________ DOB: ______________ Gender: _______ Grade in School ____________

______________________________________________ DOB: ______________ Gender: _______ Grade in School ____________

I understand it is my responsibility as the Parent/Guardian to notify the school of any changes in the information provided as they occur. I certify that the above enrollment information is true and accurate to the best of my knowledge. Parent/Guardian signature: _______________________________________________ Date: ___________________

STD 2-2443 E 04/12/2018

2/1/2016

Proof of Residency Clay County School District requires detailed proof of residency provided by a parent/guardian or adult student. Follow the requirements below that best describe your living situation. \

If you are HOMEOWNER, you MUST provide the following three documents: ☐ Current mortgage/HUD statement (dated within 30 days) or deed, with all required signatures ☐ One current utility bill dated within 30 days (For new services an activation notice may be accepted.) ☐ Driver’s license/Florida ID with current address AND You MUST provide one additional document showing current address from the list below: ☐ Homeowners insurance policy ☐ Vehicle registration ☐ Medical insurance statement ☐ Paycheck stub ☐ Property tax record ☐ Credit card statement ☐ Termite bond If you are a RENTER, you MUST provide the following three documents: ☐ Current lease with the names of everyone living in the household listed on the lease. Lease must have both tenant and landlord/property manager’s signature and contact information. If the lease is month to month, a letter from the landlord/owner/property manager is required. ☐ One current utility bill dated within 30 days (For new services an activation notice may be accepted.) ☐ Driver’s license/Florida ID with current address AND You MUST provide one additional document showing current address from the list below: ☐ Renters insurance policy ☐ Paycheck stub ☐ Medical insurance statement ☐ Credit card statement ☐ Vehicle registration

If you are living with a person who owns their home, the homeowner MUST provide the following four documents: ☐ Current mortgage/HUD statement (dated within 30 days) or deed, with all required signatures ☐ One current utility bill dated within 30 days (For new services an activation notice may be accepted.) ☐ Homeowner’s Acknowledgement form ☐ Driver’s license/Florida ID with current address AND You MUST provide: ☐ Declaration of Domicile ☐ Driver’s license/Florida ID showing the address of the homeowner You MUST provide one additional document showing current address from the list below: ☐ Bank statement ☐ Vehicle registration ☐ Cell phone statement ☐ Paycheck stub

2/1/2016

Verifying Residence for the District: All addresses and changes of address are subject to verification. All student residence addresses and all documents submitted for verification are subject to validation by district staff. Students who are suspected of residing outside of Clay County or in an attendance zone not designated for that student– unless having an approved SPR – will be reported to the district for residency verification. The district has the authority to verify enrollment information provided by the parent and to reassign a student based upon the investigative determination. A student who is found to be attending an out-of-zone school as the result of giving false or misleading information at registration, shall immediately be transferred to the appropriate school OR withdrawn and referred to the county of legal residence. Any disagreement regarding the investigative finding(s) will be reviewed by the Superintendent or his/her designee. Parent(s) residing in Clay County or in another district requesting their child live with someone other than the parent/guardian must show documented evidence of physical, mental, or financial infirmity which, by ordinary and reasonable standards, precludes the parent from actually caring for the student. If not, that person must have guardianship of the student(s).

If you are living with a person who is a renter, the renter MUST complete: ☐ Notarized Homeowner’s Acknowledgement form AND The renter MUST provide the following three documents: ☐ Current lease ☐ One current utility bill dated within 30 days (For new services an activation notice may be accepted.) ☐ Driver’s license/Florida ID with current address AND You MUST provide: ☐ Declaration of Domicile ☐ Driver’s license/Florida ID showing the address of the renter You MUST provide one additional document showing current address from the list below: ☐ Bank statement ☐ Paycheck stub ☐ Cell phone statement ☐ Credit card statement ☐ Vehicle registration

SCHOOL DISTRICT OF CLAY COUNTY STUDENT RESIDENCY INFORMATION

This survey is intended to address the requirements of the Every Student Succeeds Act of 2015. The answers to questions below will assist us in determining if your student may qualify for additional educational support services.

*IF YOU ANSWERED “NO” TO ALL QUESTIONS ABOVE, PLEASE ! IF YOU MARKED “YES” TO ANY QUESTIONS ABOVE, PLEASE COMPLETE THE REMAINDER OF THIS FORM. INDICATE THE CAUSE OF YOUR CURRENT LIVING ARRANGEMENT BY PLACING AN “X” IN THE APPROPRIATE BOX.

Mortgage Foreclosure (M) Natural Disaster-Flooding (F) Natural Disaster-Hurricane (H) Natural Disaster-Tropical Storm (S) Natural Disaster-Tornado (T) Natural Disaster-Wildfire or Fire (W) Man-made Disaster (Major) (D) Other – i.e., lack of affordable housing, long-term poverty, unemployment or underemployment, lack of affordable health care, mental illness, domestic violence, forced eviction, etc. (O)

PLEASE PRINT VERY CLEARLY, COMPLETE ONE PER FAMILY, and return the survey to your School Records Secretary.

¿Habla Ud. Español? Por favor doble este papel al otro lado para llenar este estudio.

Names of Students Enrolled in School (PK – grade 12) or Adult School (If needed, use an additional sheet of paper.)

First Name MI Last Name Birth Date Grade School

First Name MI Last Name Birth Date Grade School

First Name MI Last Name Birth Date Grade School

First Name MI Last Name Birth Date Grade School

How many other children/youth are in your household (even if not enrolled in school)? ____________

Parent or Guardian Name (Print): _______________________________________________________________________________

Street Address (Location of House): _____________________________________________________________________________

Mailing Address: ____________________________________________________________________________________________

Telephone: ________________________ Cell phone: ________________________ Work phone: ___________________________

Length of time at this address: __________ Former Address: _________________________________________________________

Parent or Guardian Signature: _________________________________________________ Date: __________________________

Directions for school staff: Please fax copy of Survey to (904) 278-5777 for students with positive responses to questions 1-6.

PLEASE PLACE AN “X” IN THE APPROPRIATE BOX TO ANSWER “YES” OR “NO”. YES NO CODE

1. My family lives in an emergency or transitional shelter or FEMA trailer. A

2. My family is sharing the housing of other persons due to loss of housing, economic hardship or a similar reason; doubled-up. B

3. My family is living in a car, park, temporary trailer park or campground due to lack of alternative adequate accommodations, public space, abandoned building, substandard housing, bus or train station, public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings or similar settings.

D

4. My family lives in a hotel or motel. E

5. A child/youth in my home is waiting for foster care placement. F

6. A child/youth in my home is an unaccompanied youth (youth not in the physical custody of a parent or guardian). Y or N

SCHOOL DISTRICT OF CLAY COUNTY - DISTRICT OCCUPATIONAL SURVEY DISTRITO ESCOLAR DEL CONDADO DE CLAY – ENCUESTA LABORAL DEL DISTRITO

CHILD’S NAME:________________________________________ SCHOOL:______________________________ NOMBRE DEL ALUMNO ESCUELA PARENT NAME:________________________________________________________________________________ NOMBRE DEL PADRE/LA MADRE PRESENT OCCUPATION:_______________________________________________________________________

The school system is interested in providing help to children whose family have had to move from one school district to another so a member of the family could work/seek work in certain jobs. Please assist us in finding out which children we will be able to serve in this special project by completing one of these forms.

Este sistema escolar está interesado en brindar ayuda a los alumnos cuyas familias han tenido que mudarse de un distrito escolar a otro para que uno de sus miembros puede trabajar / buscar algún tipo de empleo. Por favor llene uno de estos formularios para que nos ayude a averiguar a qué niños les prestaremos servicios mediante este proyecto especial.

Have you or anyone in your family crossed state or county lines to work, or seek work, in one of the following occupations, either full-time or part-time during the last three years?

¿Usted o alguien en su familia de las fronteras estatales o del condado para trabajar o buscar trabajo, en una de las siguientes ocupaciones, ya sea a tiempo completo oa tiempo parcial durante los últimos tres años cruzó?

YES NO SÍ NO FARMING (plowing, planting, cultivation,

harvesting and/or processing of farm crops) AGRICULTURA (labrado, plantación, cultivo,

cosecha y procesamiento de cultivos agrícolas)

DAIRY WORK LECHERÍA LIVESTOCK WORK (hoofing, cutting,

banding, feeding and/or rounding up) GANADERÍA (herrado, faenado, identifiación,

alimentación y acorralamien)

POULTRY OR EGG WORK PRODUCCIÓN AVÍCOLA O TRABAJO CON HUEVOS

PLANTING, GROWING OR HARVESTING OF TREES

PLANTACIÓN, CULTIVO O COSECHA DE ÁRBOLES

COMMERCIAL FISHING (fresh/saltwater, crabbing and/or shrimping)

PESCA COMERCIAL (agua dulce/salada, pesca de cangrejos y camarónes)

WORKING ON FISH FARM TRABAJO EN CRIADEROS DE PECES PROCESSING OR HAULING OF

FARM/FISH PRODUCTS PROCESAMIENTO O TRANSPORTE DE

PRODUCTOS DE CRIADEROS DE PECES O PESCA

If you checked NO to all items, you may stop at this point, sign and date. If you checked YES in any category above, please continue with next question.

Si marcó NO en todos los puntos, puede dejar de responder. Si marcó en SÍ alguna categoría antedicha, continúe y responda

Did your child(ren) move with you ? ___YES ___NO ¿Se trasladó su hijo o hijos con usted? ____SÍ ____NO _____________________________________________________________Date_________________________________ Parent’s Signature/ Firma del Padre/la madre Fecha __________________________________________________________________________________________________ Address & Phone Number/ Dirección y Número de Teléfono

TTL-2-2519 E Send original to Title 1 Office. No copy required at school.

ClayCountyDistrictSchools

AUTHORIZATIONFORRELEASEAND/OREXCHANGEOFINFORMATION

Pleasereleaseand/orexchangerecordstotheschoolmarkedbelow:To: _______________________________________________________________________ PreviousSchoolName

_______________________________________________________________________PreviousSchoolAddress

_______________________________________________________________________ PreviousSchoolCity/State/ZipPhone/Fax

Subject:RecordsRequest

Iherebyrequestandauthorizethatthefollowinginformation:

()Attendance ()BirthCertificate()Discipline()Gifted/IEP/504/ELL/MTSS()Immunization/HealthRecords/Physical ()Legal(custody,guardianship)()PsychologicalEvaluations ()ReportCards()StandardizedTestScores

Bereleasedon:

_________________________________________________________StudentName(First,Middle,Last)_________________________________________________________StudentDateofBirth_________________________________________________________DateofRequest_________________________________________________________AuthorizedSignature*/ParentSignature

*ParentalPermissionisnotrequiredwhenauthorizedschoolpersonnelrequestrecords.(FamilyEducationalRightsandPrivacyAct,FinalRuleonEducationRecords,FederalRegister,June17,1976,Vol.41,No.118,Page24673.)

*ELEMENTARY* ArgyleElementary

2625SpencerPlantationBlvd.OrangePark,32073

(904)573-2357;Fax:573-2368

MiddleburgElementary3958MainStreetMiddleburg,32068

(904)291-5485;Fax:291-5491 C.E.BennettElementary

1SouthOakridgeAvenueGreenCoveSprings,32043

(904)529-2126;Fax:529-2133

MontclairElementary2398MoodyAvenueOrangePark,32073

(904)278-2030;Fax:278-2090 W.E.CherryElementary

420EdsonDriveOrangePark,32073

(904)278-2050;Fax:339-3928

OakleafVillageElementary410OakleafVillageParkway

OrangePark,32065(904)291-5458;Fax:291-5471

ClayHillElementary6345CountyRoad218Jacksonville,32234

(904)289-7193;Fax:289-9667

OrangeParkElementary1401PlainfieldAvenueOrangePark,32073

(904)278-2040;Fax:278-2045 CoppergateElementary

3460CopperColtsCourtMiddleburg,32068

(904)291-5594;Fax:291-5597

PatersonElementary5400PineAvenue

FlemingIsland,32003(904)336-2575;Fax:336-2576

DoctorsInletElementary2634CountyRoad220Middleburg,32068

(904)213-3000;Fax:213-3011

PlantationOaksElementary4150PlantationOaksBlvd.

OrangePark,32065(904)214-7474;Fax:214-7477

FlemingIslandElementary4425LakeShoreDriveFlemingIsland,32003

(904)278-2020;Fax:278-2026

RideOutElementary3065ApalachicolaBlvd.Middleburg,32068

(904)291-5430;Fax:291-5434 GroveParkElementary

1643MillerStreetOrangePark,32073

(904)278-2010;Fax:287-2015

RidgeviewElementary421JeffersonAvenueOrangePark,32065

(904)213-5800;Fax:213-2960 S.BryanJenningsElementary

215CoronaDriveOrangePark,32073

(904)213-3021;Fax:213-3014

ShadowlawnElementary2945CountyRoad218

GreenCoveSprings,32043(904)529-1007;Fax:529-1011

KeystoneHeightsElementary335SWPecanStreet

KeystoneHeights,32656(352)473-4844;Fax:473-4110

SwimmingPenCreekElementary1630WoodpeckerLaneMiddleburg,32068

(904)278-5707;Fax:278-5720 LakeAsburyElementary

2901SandridgeRoadGreenCoveSprings,32043

(904)291-5440;Fax:291-5452

ThunderboltElementary2020ThunderboltRoadFlemingIsland,32003

(904)278-5630;Fax:278-5633 LakesideElementary

2752MoodyAvenueOrangePark,32073

(904)213-2966;Fax:213-2965

TynesElementary1550TynesBlvd.Middleburg,32068

(904)336-3850;Fax:291-5403 McRaeElementary

6770CountyRoad315-CKeystoneHeights,32656

(904)336-2125;Fax:336-2139

WilkinsonElementary4965CountyRoad218,West

Middleburg,32068(904)291-5420;Fax:291-5425

*JUNIORANDSENIORHIGHS* GreenCoveJuniorHigh

1220BonaventureAvenueGreenCoveSprings,32043

(904)529-2140;Fax:529-2114

ClayHigh2025Highway16,WestGreenCoveSprings

(904)529-3000;Fax:529-3131 LakeAsburyJuniorHigh

2851SandridgeRoadGreenCoveSprings,32043

(904)291-5582;Fax:214-7481

FlemingIslandHigh2233VillageSquareParkway

FlemingIsland,32003(904)336-7500;Fax:336-7476

LakesideJuniorHigh2750MoodyAvenueOrangePark,32073

(904)213-2980;Fax:213-2987

KeystoneHeightsJr.-Sr.High900S.W.OrchidAvenueKeystoneHeights,32656

(352)473-2761;Fax:473-7747 OakleafJuniorHigh(6-8)

4095PlantationOaksBlvd.OrangePark,32065

(904)213-5500;Fax:213-5654

MiddleburgHigh3750StateRoad220Middleburg,32068

(904)213-2100;Fax:336-8079 OrangeParkJuniorHigh

1500GanoAvenueOrangePark,32073

(904)278-2000;Fax:278-2074

OakleafHighSchool4035PlantationOaksBlvd.

OrangePark,32065(904)213-1900;Fax:272-8596

WilkinsonJuniorHigh5025CountyRoad218,West

Middleburg,32068(904)291-5500;Fax:336-6178

OrangeParkHigh2300KingsleyAvenueOrangePark,32073

(904)272-8110;Fax:272-8174 BannermanLearningCenter

608MillStreetGreenCoveSprings,32043

(904)529-2100;Fax:529-1025

RidgeviewHighSchool466MadisonAve

OrangePark,FL32065(904)213-5203;Fax:336-8978

*ADULTEDUCATION/VIRTUALSCHOOL* Adult/CommunityEducation

2306KingsleyAve.,Bldg.17OrangePark,32073

(904)336-4450;Fax:336-4465

ClayVirtualAcademy,2306KingsleyAve.,Bldg.20

OrangePark,32073(904)336-9875;Fax:336-9881

*CHARTERSCHOOLS* ClayCharterAcademy

1417RedAppleRoadMiddleburg,32068

(904)-406-1607;Fax:406-1608

OrangeParkPerformingArts1324KingsleyAvenueOrangePark,32073

(904)269-0039;Fax:269-0487