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Centreville Elementary Registration Form

Please complete the following registration form to be considered for enrollment at Centreville Public Schools. If you have any questions, please direct your inquiry to Lara Kirby at lakirby@cpschools.org or call the office at 269-467-5200.

Required

GENERAL STUDENT INFORMATION
Student's Legal Name (as it appears on the child's birth certificate)required
First Name
Middle
Last Name
Must contain a date in M/D/YYYY format
Student Genderrequired
PRIMARY RESIDENCE
Street, City, State, Postal Code, Country
Must contain only numbers
Primary Residence (Student Resides With): required
Mother Name
First Name
Last Name
(Must contain only numbers)
Stepmother Name
First Name
Last Name
Must contain only numbers
Father Name
First Name
Last Name
Must contain only numbers
Stepfather Name
First Name
Last Name
Legal Guardian Name
First Name
Last Name
Must contain only numbers

SECONDARY RESIDENCE

Name of Second Residence Parent (If Applicable)
First Name
Last Name
ETHNICITY | RACE | LANGUAGE SURVEY
 
Race and ethnicity questions must be answered. If either part is not answered, the US Dept. of Education requires the district to supply an answer on your behalf.
Ethnicity
Student Race (Select All That Apply)required
Was Your Child Born Outside the US or Puerto Rico? required
Must contain a date in M/D/YYYY format
Is the Primary Language Used in Your Child's Home or Environment a Language Other Than English?required
Is Your Child's Native Tongue a Language Other than English?
(English or list other language)

SPECIAL SERVICES

Did Your Student Receive Any Special Services at Another School? required
If Yes, Please Select All Applicable Services
SUSPENSION | EXPULSION HISTORY
Has the Student Ever Been Expelled from Another School? required
Has the Student Ever Been Suspended from Another School within the Last 2 Years? required
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
HOUSING INFORMATION
Is Your Current Address Temporary?
If Yes, How Would You Describe Your Current Living Location? Please select up to 3 choices
Please select up to 3 choices
HEALTH INFORMATION
Does Your Child Have Any Health Concerns, Medical Conditions, or Medications?
Will Medication Be Taken at School?
If yes, a medical authorization form must be on file on our office for your child to be given any prescribed or over-the-counter medication while at school. All medications must be brought to the office by a parent. 
CONSENT FOR DISCLOSURE OF IMMUNIZATION INFORMATION
Sharing immunization and personally identifiable information, including the student's name, date of birth, gender, and address with local and state health departments will help to keep your child safe from vaccine-preventable diseases. The Family Educational Rights and Privacy Act (FERPA) requires written parental consent before personally identifiable information from your child's education records is disclosed. If your child is 18 or over, he / she is an eligible student and must provide consent for disclosures of information from his / her education records. You may withdraw, in writing, your consent to share this information at any time. 
Authorization required
Student Namerequired
First Name
Last Name
Parent / Guardian Signature Namerequired
First Name
Last Name
TRANSPORTATION

Information listed here is used to schedule transportation for your child. Please be sure to have a consistent plan in place for getting your child to and from school each day. 

How Will Your Child Be Transported to SCHOOL?
How Will Your Child Be Transported to HOME?
AUTHORIZATION TO ENROLL
Terms of Servicerequired
Student Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format
Parent / Guardian Signature Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format

VERIFICATION OF RESIDENCY

This form is to be completed for each child who enrolls in this school district for the first time AND for every change of address.

Residency Verificationrequired
Tuition Verification
Student Namerequired
First Name
Last Name
Select One
Attach up to 1 file with a maximum size of 10MB
No file chosen
This can be a utility bill, driver's license, rental / purchase agreement, tax bill, etc.
Parent / Guardian Signature Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format