Bradley County Schools Registration Form

Bradley County Schools Registration Form - Website Version

"*" indicates required fields

Welcome to the Bradley County Schools Technology website. NEW Students (grades K-12), Returning Students, or Students wishing to Transfer within Bradley County Schools should complete this form. Please complete the form below. Required fields marked with an asterisk * If a question is not applicable, please leave the section blank or use N/A. You can change the language of the form at the bottom of the page.

School Year*

School Name*
Please select the school you wish to attend. Note for Preschool applicants: Please select Preschool as the School.

Grade*

Student Name (as it appears on the Birth Certificate):

First*

Middle*

Last*

Preferred Name

Is this student a single parent?*

Gender*

Date of Birth*
MM slash DD slash YYYY

Country of Birth*

State of Birth*

County of Birth*

City of Birth*

Ethnicity - Please select Hispanic or Non-Hispanic*
Hispanic
Non-Hispanic

Race (Check all that apply)*
Asian
American Indian/Alaskan Native
Black/African American
Pacific Islander/Native Hawaiian
White

Student Information:

Student's Address*

Student's City*

Student's State*

Student's Zip*

Student's Home Phone Number*

List other Children in Family

When a call is made about your child, what number should we call? Call #1*

Call #2*

Call #3

Call #4

Special Services he/she receives: [Pick all that apply]

Special Service Received:
RTI Reading
RTI Math
Speech
English Learner

Does he/she have an IEP?
Yes

or 504 plan?
Yes

or ILP-D?
Yes

Emergency Contact Information [other than parent]:

Emergency Contact Name

Emergency Contact Phone

Emergency Relationship

Check Out Information: Names listed below may check out my child. (Use NONE if no one else will check out your child.)*

Custody:*
Both Parents
Mother
Father
State Custody
Other Legal Guardian

Custody Issue?
No
Yes

What, if any, custody issues do we need to be aware of?

Mother's Information:

Mother's Full Name*

Maiden name*

Mother's Address (include City, State, Zip)*

Mother's Home Phone*

Mother's Cell Number

Employed By: Mother

Mother's Work Number

Mother's Email Address*
(email address for parents can be the same email address)

Father's Information:

Father's Name*

Father's Address (include City, State, Zip)*

Father's Home Phone*

Father's Cell Number

Employed by: Father

Father's Work Number

Father's Email Address*
(email address for parents can be the same email address)

Does the parent/legal guardian presently serve in the:
Active Military
National Guard Military
Reserve Military

Custody Other - Legal Guardian Information. If you do not need this section, please leave blank.

Custody/Legal Guardian's Name

Custody/Legal Guardian's Address (include City, State, Zip)

Custody/Legal Guardian's Number

Custody/Legal Guardian's Cell Number

Employed by: Custody/Legal Guardian

Custody/Legal Guardian's Work Number

Custody/Legal Guardian's Email Address

Custody/Legal Guardian's Relationship to Student

Last School Attended Information. If this is your child's first time in school, please leave blank.

School Last Attended by Student

Is your child EXPELLED or SUSPENDED?*

School Last Attended Address

School Last Attended City

School Last Attended State

School Last Attended Zip

School Last Attended Phone Number

School Last Attended Fax Number

For children entering Kindergarten or First Grade check if attended - Pre-School
Yes

For children entering Kindergarten or First Grade check if attended - Day Care
Yes

For children entering Kindergarten or First Grade check if attended - Kindergarten
Yes

Do you plan to enter another school next year?
Yes
No

If Yes, where?

Parent or Legal Guardian's Signature*

Date*
MM slash DD slash YYYY

Student Name*

Parent Guardian Name*

School*

Student Phone Number*

STUDENT MEDICAL INFORMATION - My student has the following health conditions that may require special care during school hours:

MY CHILD HAS NO SPECIAL HEALTH NEEDS - If NO, please check box and skip to Primary Care Physician.*
MY CHILD HAS NO SPECIAL HEALTH NEEDS
MY CHILD HAS SPECIAL HEALTH NEEDS

Please complete ONLY those that apply:

Asthma:
Yes

Asthma Triggers:

Asthma Treatment at home:
Yes

an inhaler will be needed and provided for use during school:
Yes

Diabetes:
Yes

Diabetes - treated with Diet:
Yes

Diabetes - treated with insulin injections or pump:
Yes

Food Allergy:
Yes

Food Allergy to:

Describe Reaction Food Allergy:

Current Required Treatment Food Allergy:

Other Allergy:
Yes

Other Severe Allergy to:

Describe Reaction Other Allergy:

Current Required Treatment Other Allergy:

Vision Impairment:
Yes

Glasses:
Yes

Contacts:
Yes

Hearing Impairment:
Yes

Left:
Yes

Right:
Yes

Physical Impairment:
Yes

Describe Physical Impairment:

Seizure Disorder:
Yes

Seizure Type:

Seizure Treatment at home:
Yes

Seizure Treatment: emergency medication is ordered and will be provided for use at school
Yes

Seizure Medication:

ADD/ADHD:
Yes

ADD/ADHD: medicated at home
Yes

ADD/ADHD: will require medication during school hours (as prescribed by MD)
Yes

Other Medical Issues Not Listed Above:

Primary Care Physician

Doctor Office Phone Number

Consent:

The information provided above is true and accurate to the best of my knowledge.*
Yes

I acknowledge that students cannot transport medication of any kinds. The parent must bring medication into school and sign appropriate paperwork.*
Yes

It is my responsibility to notify the school if my child's medical condition changes and/or they have developed any medical needs that may require attention during school hours.*
Yes

The school may use over-the-counter first aid products such as Neosporin, Benadryl spray/cream, wound cleanser, etc (Topical First Aide) as needed for my student as they have no known sensitivity to these items. This does not include medication taken by mouth.
Yes

Topical First Aide?*
Yes
No

The school may use over-the-counter Tylenol, Ibuprofen, cough drops, or TUMS as needed for my student as they have no known sensitivity to these items.
Yes

Medicine by mouth Tylenol, Ibuprofen, cough drops, or TUMS?*
Yes
No

** IF NO INFORMATION IS GIVEN, IT WILL BE ASSUMED THAT YOUR CHILD HAS NO SPECIAL HEALTH NEEDS **

Health screenings including hearing, vision, height, weight, and blood pressure take place yearly in K, 2nd, 4th, 6th, 8th, and 9th grade. This information is used for overall data collection only and no identifying information will be released. These screenings do not substitute for having regular check-ups with a healthcare provider. If you DO NOT want your child to receive these screenings, a written request to excuse the student from these screenings must be provided to the school nurse by September 1st.

STUDENT RESIDENCY INFORMATION - As part of the ESSA requirements, each school registrant should complete the following information. WHERE DOES THE STUDENT STAY AT NIGHT?

in His/Her home owned or rented by parent?
Yes

in a shelter?
Yes

with a relative or friend?
Yes

in a motel/hotel?
Yes

in housing that is inadequate?
Yes

unsheltered?
Yes

other?
Yes

If other, please explained:

Thank you for registering your student with Bradley County Schools. The principal or designee of the school you are applying to attend will contact you soon.
Requirements for all new students:

Immunization Record on a TN Certificate of Immunization

Updated Physical for Kindergarten – Physical must be completed during the current year.

Student Medical Form

Custody Paperwork – if needed

Proof of Address – must show parent name and service connection address

Proof of Birth, one of the following forms:

Birth Certificate – issued by a government

Passport issued by any nation (translated)

Immigration documentation

Decree of adoption issued by a court

Other official documentation showing date of birth and parent’s name (refer to board policy 6.203)

Parent or Legal Guardian's Signature*

Date*
MM slash DD slash YYYY

Tennessee Parent Occupational Survey (to be completed annually)

STUDENT FIRST NAME*

STUDENT LAST NAME*

Date*
MM slash DD slash YYYY

Grade*

School*

Parent/Guardian Name*

1. Have you or an immediate family member performed any agriculture or fishing jobs temporarily or seasonally, in any part of the United States, in the past 3 years?*
NO
YES. Check all that apply:

Processing & Packing (fruit, vegetables, chicken, eggs, pork, beef, etc.)
Yes

Agriculture/Field Work (planting, picking, and sorting crops; soil preparation; irrigation; fumigation; etc.)
Yes

Dairy/Cattle Raising (feeding, milking, rounding up, etc.)
Yes

Nursery/Greenhouse (planting, potting, pruning, watering, etc.)
Yes

Forestry (soil preparation, planting, growing, cutting trees, etc.)
Yes

Other: Any other agriculture or fishing work, please list here:

2. In the past 3 years, has your family moved to another state, city, school district, and/or county?*
No
YES. My family has moved within the past 3 years. Indicate how long ago below.

Indicate how long ago below.

YEARS:

MONTHS:

WEEKS:

If you answered “Yes” to question 1 above, please complete the information below. A staff from the Migrant Education Program will follow up with your family to verify if you qualify for free services.

HOME ADDRESS

Apt. #

CITY

STATE

ZIP

Language

Email

TELEPHONE WITH AREA CODE

Best Day of Week and Time to Call:

Bradley County Schools Student Release Form (to be completed annually):

Student First Name*

Student Last Name*

Grade*

Parent/Guardian Printed Name*

I authorize Bradley County Schools to publish the indicated information of the undersigned minor child for use in the schools’ publications, advertisements, and websites. I release Bradley County Schools from any expectation of confidentiality regarding the indicated information for my child. I understand that my failure to permit the release of this information will result in my child's elimination from end-of-year videos, video yearbooks, and other video publications.

I attest that I am the parent or legal guardian of the child listed on this form and that I have the authority to permit the use of his/her videos. I acknowledge that participation in publications, advertisements, and websites produced by Bradley County Schools is voluntary, and neither the minor child nor I will receive financial compensation.

Check all that apply:*
Yes, videos of my child may be released.
No, videos of my child may not be released.
No, I do not give permission for my child to complete student surveys and evaluations, such as school climate surveys. Visit http://www.bradleyschools.org for samples of surveys.

Parent/Guardian Signature*

Date*
MM slash DD slash YYYY

Student Records and Directory Information:

Parents have the right to review and inspect their child’s educational record and to seek correction of items believed to be inaccurate. Parents may limit others’ access to their child’s records, except when prior written consent is given, when required by law or regulation, or when information is designated as “directory information.” In accordance with Bradley County Board of Education policy, directory information includes the following: name, address, telephone listing, date and place of birth, major field of study, photo, participation in officially recognized activities and sports, weight and height of members of athletic teams, dates of attendance, degrees and awards received and the most recent or previous educational agency or institution attended by the student. Student directory information for 11th and 12th graders shall be made available upon request to persons or groups that make students aware of occupational and educational options, including official recruiting representatives of the military forces of the State and the United States. Parents have two weeks from the first day of school (or the first date of enrollment if beginning mid-year) to advise the school system in writing of any items they designate not to be used as directory information.

Bradley County Schools Truancy/Attendance Letter:

Students and Parents, It is with great excitement that I welcome you back. The beginning of a new school year is an exciting time, full of endless possibilities and potential for all. A special welcome to the families who are new to the Bradley County School District. We are happy to serve you and our child(ren). Thank you all for giving us the opportunity to be part of the educational experience.

The Bradley County Schools Student/Parent Handbook outlines expectations and procedures for the school district. Processes and procedures are established to eliminate questions or uncertainties around different topics. I ask that you all familiarize yourselves with the contents of our student handbook as it covers many pertinent topics.

Tier 1 of the plan applies to all enrolled students. This means that each student will begin the school year in Tier 1 and at five (5) unexcused absence will move to Tier 2. Please find more information about the Progressive Truancy Plan in the District Student Handbook. Also, check the Student Handbook of the school your child or children attend. Individual schools will provide more information specific to the expectations for their schools.

Because absences dramatically impact learning, we are also concerned about chronic absenteeism. According to the Tennessee Department of Education, students are defined as chronically absent when they miss 10% of school calendar days, regardless of whether the absences are excused or unexcused. Please make every effort to have your child at school. If a health issue interferes with your child’s attendance, please discuss this concern with your school’s administration.

Education is one of the most important keys to a student's future success. The Bradley County School District is blessed with outstanding administrators, teachers, and staff that have a passion for education. The goals for student success are limitless if we all work together.

I would like to encourage you to be the best you can be and make the most out of every day in this upcoming school year.

Best Regards, Dr. Linda Cash, Director of Schools

Please confirm you have read the previous statement regarding Truancy/Attendance:*
I have read the following statement.

Parent Name:*

Please select a SCHOOL at the top of the form.