Chippewa Hills School District

1) Please enter your email address

2) Which building are you enrolling your student?

*Please note: Elementary student buildings are based on residency. You will be notified if it is different than the building you choose.

Barryton Elementary

Mecosta Elementary

Weidman Elementary

Middle School

Mosaic School

High School

4) Has your student ever been enrolled at Chippewa Hills School District?

Yes

No

5) If yes, which building? (optional)

6) What is the name and address of student's previous district? (optional)

Student Information

7) Student Legal First Name

8) Middle Name

9) Legal Last Name

10) Preferred Name (optional)

11) Physical Street Address

12) City

13) Student Cell Phone Number (optional)

14) Mailing Address (if different from physical address) (optional)

15) Please provide proof of residency (optional)

This could be a copy of your driver's license, a utility bill showing your address, rental agreement, etc.) If you cannot upload, please be prepared to bring a copy with you to school.

Max 10 files | 200 MB limit

16) Student's date of birth

Month, day, year

17) Gender

Male

Female

18) What is your student's race? (Please check all that apply)

American Indian/Alaska Native

Hawaiian or Pacific Islander

Asian

White

Black/African American

Hispanic or Latino

Two or more races

19) Birth City

20) Birth State

21) Birth Country

22) Please provide a copy of student's birth certificate (optional)

If you cannot upload, please be prepared to bring a copy with you to the school.

Max 10 files | 200 MB limit

23) Have the courts placed this student in the present home? (optional)

Yes

No

24) Is your family currently experiencing transition with regards to permanent stable housing?

Yes

No

Student Home Language

26) Is the student's native tongue a language other than English?

Yes

No

27) If yes, what language(s) does your student speak? (optional)

28) Is a language other than English spoken in the student's home environment?

Yes

No

29) If yes, what language(s) are spoken at home? (optional)

Medical Information

31) Does your student have any allergies? (optional)

32) Does your student have any physical restrictions? (optional)

33) Does your student require medication during school hours? (optional)

Parent Contact Information

Contact Priority 1

34) Relationship to student

Mom

Dad

Guardian

Other

35) Last Name

36) First Name

37) Physical Address (if different than student's address) (optional)

38) Mailing Address (if different than physical address) (optional)

39) Home Phone Number (optional)

40) Cell Phone Number (optional)

41) Work Phone Number (optional)

42) Email Address (optional)

Parent Contact Information

Contact Priority 2

43) Relationship to student

Mom

Dad

Guardian

Other

44) Last Name

45) First Name

46) Physical Address (if different than student's address) (optional)

47) Mailing Address (if different than physical address) (optional)

48) Home Phone Number (optional)

49) Cell Phone Number (optional)

50) Work Phone Number (optional)

51) Email Address (optional)

Other Children in the Family

52) Please list siblings (optional)

Please include name, date of birth and name of school attending

Emergency Contact Information

If a parent cannot be contacted, please list AT LEAST TWO contacts who can be reached and who are authorized to pickup or give permission for the student to leave in the event of illness or emergency.

53) Emergency Contact #1 Full Name

54) Relationship to Student

55) Cell Phone Number (optional)

56) Home Phone Number (optional)

57) Work Phone Number (optional)

58) Emergency Contact #2 Full Name (optional)

59) Relationship to Student (optional)

60) Cell Phone Number (optional)

61) Home Phone Number (optional)

62) Work Phone Number (optional)

63) Emergency Contact #3 Full Name (optional)

64) Relationship to Student (optional)

65) Home Phone Number (optional)

66) Cell Phone Number (optional)

67) Work Phone Number (optional)

Discipline Information

68) Has student been expelled from another school or has an expulsion pending? (optional)

Yes

No

69) Is the student currently under suspension from another school? (optional)

Yes

No

70) If yes to either of the above, which district (please include city and state of district) (optional)

71) If suspended or expelled, please explain the reason and when. (optional)

Special Education and 504 Information

72) Does your student currently receive special education and/or services or attend special education classes?

Yes

No

73) Has this student ever had Special Education and/or Speech services?

Yes

No

74) Does your student currently have a Section 504 plan?

Yes

No

Residency

75) Is this student a current resident of the Chippewa Hills School District?

Yes

No

76) County of residence?

77) Is this student participating in the MOISD Schools of Choice Program? (optional)

Do you live outside of Chippewa Hills School District?

Yes

No

78) What is the student's resident district? (optional)

If you do not live in the Chippewa Hills School District, please fill out the School of Choice Application.

Transportation

79) Will your student require CHSD Transportation?

Yes

No

80) In case of an EMERGENCY school closing, my student is to: (optional)

Follow their normal routine

Go to an alternative location

81) If an alternative location, please provide the name, address and phone number. (optional)

82) Please describe additional transportation issues (riding the bus, sitter, alternate drop off or pick up...) (optional)

Consent Information

83) I give permission for my student's name and/or picture to be released for directory information. (optional)

Examples of Directory Information may include listing in the honor roll, scholarships, awards received, participation in officially recognized production, annual yearbook, graduation programs, music programs, photographs and videos of students participating in school events.

Yes

No

84) I give my permission for my student to be photographed or videoed for use/or broadcast for public media. (optional)

Yes

No

85) I give my student permission to attend school field trips. (optional)

Yes

No

86) In case of emergency, I authorize the school to seek medical attention for my student. (optional)

Yes

No

Concussion Awareness Acknowledgement

Click for the Understanding Concussion Fact Sheet https://docs.google.com/document/d/1Ryd0VpPZuL6bp8LpGPU9UOE5_6vk4iC9ZwgKeOFMCHk/edit

87) I acknowledge that I have reviewed the Understanding Concussion Fact Sheet (linked) in accordance with Public Acts 342 and 343 of 2012.

Yes

No

Student Acceptable Use Policy Acknowledgement

Click for the CHSD Acceptable Use Policy for Elementary https://bit.ly/2TgtFL7 and Middle School/High School https://bit.ly/3rcOIe6

88) I acknowledge that I have received and reviewed the CHSD Acceptable Use Policy.

This policy describes student responsibilities related to the use of computer hardware/software and computer network. I understand that computer usage is a privilege, not a right, and my student and I agree to comply with this policy.

Yes

No

Directory Information Acknowledgement

Click here for the CHSD Directory Information notice: http://bit.ly/3bnyirz

89) I acknowledge that I have received and reviewed the CHSD Directory Information notice.

Yes

No

Chippewa Hills Wellness Center

Click here for the CHSD Wellness Center consent form.

Consent for Disclosure of Immunization Records

Please review the following document before completing this form: http://bit.ly/3s9TU1r

90) I confirm that I have reviewed the Consent for Disclosure of Immunization Records.

Yes

No

91) Please upload a photo of your student's immunization record. (optional)

If you are unable to upload, you may bring a copy to the school

Max 10 files | 200 MB limit

92) Student Immunization Record Release

By stating my name below, I release my student’s immunization record to the Michigan Department of Health and Human Services and the local Health Department. I understand this information will be used to improve the quality and timeliness of immunization services and to help schools comply with Michigan Law. This includes any immunization information and limited personally identifiable information from the school. If you do NOT consent to release, type I DO NOT CONSENT instead of your name.

School Autonomy and Parent/Guardian Consent Signature

Although the above recommendation of the parent will be respected as far as possible, I understand that in the final disposition of and emergency case, the judgement of school authorities will prevail. Anytime the above information must be changed, I will notify the principal in writing.

93) Consent Signature

I acknowledge that the information submitted on this form is true to the best of my knowledge. I agree to provide the required immunization documentation, proof of Student identity, and proof of residency in accordance with requirements established on this Enrollment Form, Board Policy, and State Law. By typing my name below, I am electronically signing this enrollment form.

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