GEAR UP Cover-sheet Form | Edstar Analytics

Student Name:
First Middle Last
Student Date of Birth:
Date Format: MM slash DD slash YYYY
Gender
Home Phone
Address of student:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Which category best describes the student’s race? (This information is used for U.S. Census data).
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic
- White
- Native Hawaiian or other Pacific Islander
- Multi-racial
- Prefer not to say
Current Grade:
Student ID Number if known:
Name of parent or legal custodian:
First Last
Relationship to student:
- Mother
- Father
- Legal Custodian
Is students adress the same as your own?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day Phone Number:
Evening Phone:
Email:
Place of Employment:
Would you like to list an additional parent or legal custodian:
- Yes
- No
Name of parent or legal custodian:
First Last
Relationship to student:
- Mother
- Father
- Legal Custodian
Is students address the same as your own?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day Phone Number:
Evening Phone:
Email:
Place of Employment:
Emergancy Contact:
First Last
Phone Number:
Relationship to student:
Has your child ever been enrolled in a Wake County school?
- Yes
- No
School Name:
Has your child ever been enrolled in a North Carolina school?
- Yes
- No
School Name:
Last school attended:
Withdrawal Date (mm/dd/yyyy):
Date Format: MM slash DD slash YYYY
Type of school last attended:
- Public
- Private
- Charter
- Home
Address of last school attended:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does the student have an IEP?
- Yes
- No
Does the student have a 504 plan?
- Yes
- No
Does the student receive services through Title 1?
- Yes
- No
What language is spoken at home?
Do you need translation services to understand WCPSS school records?
- Yes
- No
Which language:
Do you need an interpreter for school system meetings involving your child’s education?
- Yes
- No
Which language:
Will your student need bus transportation?
- AM/PM (round-trip)
- AM only (morning rider)
- PM only (afternoon rider)
Where is the student sleeping at night? (You may choose more than one option.)
- The student lives with a parent or legal custodian in a residence owned or leased by the parent or legal custodian
- In a motel or hotel
- In a shelter
- Moving from place to place
- In a church
- A friend, relative or other person(s) is letting the student and/or family stay at their place temporarily
- In a car, park, campsite, abandoned building or home
- In a residence where a church or other organization pays for all or part of the current rent (ex. The Carying Place, Families Together, Passage Home, Support Circle)
List all siblings including age 0-4 and children under age 21 who are not in school. Additional services and/or resources may be available.
Please mark next to the item(s) listed below if you would like to receive information on these additional resources:
- Housing or Shelter
- Birth Certificate
- Preschool Program
- Mental Health Services
- Food
- Clothing
- School Supplies
- Immunizations
- Address Confidentiality Program
- School Based Medical Plan
- Preschool Program
- Address Confidentiality Program
- School Based Medical Plan
- Preschool Program
- Before/After School Program
- Special Education Services
- 504 Accommodation
Photo/Video Release:
- I deny permission to use my child’s image for display, publication or release to external organizations.
- I grant permission for use of my child’s image in print, video and/or digital media. I understand that my child’s image may be used or released by the WCPSS without additional notification and that my child’s name may appear along with his or her photograph.
Name Release:
- I grant permission for my child to be identified by name on the school or district’s Internet websites.
- I deny permission for my child to be identified by name on the school or district’s Internet websites.
Check appropriate box:
- The student is NOT currently suspended or expelled from any school or does not have a pending suspension or expulsion
- The student is/has been recommended for a long-term suspension of more than ten days or expulsion
- The student is/has been long-term suspended for more than ten days or expelled and is currently serving the term of suspension or expulsion
Describe the offense for which the recommendation is being made and the proposed beginning and ending dates of the suspension/expulsion:
Describe the offense for which the student was suspended/expelled and the beginning and ending date of the suspension/expulsion:
Are there any custody issues involving this student of which the school needs to be aware?
- Yes
- No
Have custody papers been presented to the school for this student?
- Yes
- No
Are there any legal restraints prohibiting a parent/guardian from having access to this student’s data?
- Yes
- No
Check all boxes in which you have records you have on this student including the following so that enrollment may be completed.
- Student Cumulative Folder
- Attendance Reports
- Report Cards
- Student Health Information
- Student Confidential Information (Special Educations Services)
- Student Related Services Information (Speech, PT, OT)
Records should be sent to:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Technology and Digital Resource Permission
- I GRANT permission for my student to use all technology and digital resources, both devices and web based applications. We have read and agree to the terms of the WCPSS Student Responsible Use Policy.
- I DENY permission for my student to use any technology and digital resources, both devices and web based applications. We have read the WCPSS Student Responsible Use Policy.
Is an immediate family member of your child connected to the U.S. Military, including Active Duty, National Guard or Reserves, Retired Military, Disabled Veteran or a Federal Civil Service Employee?
- Yes
- No
Branch (required):
- Air Force
- Army
- Coast Guard
- Marine Corps
- Navy
Status:
- Active Duty
- National Guard
- Reserves
- Retired Military
- Disabled Veteran
- Federal Civil Service
Relationship to Student:
Does the student have any medical conditions that school officials should know about?
- Yes
- No
Including medical, diet, vision, ect.
Medications prescribed for student:
Student’s allergies, type, and response required:
Special diet instructions: