Special Education Information
School of Choice Information
Female Head of Household Contact Information
Male Head of Household Contact Information
Certification of Truthfulness - I certify that all statements on this student registration form are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false, will be sufficient reason for possible removal of this student from enrollment in the Jackson Public School District and may result in legal action.
SECTION ONE: Please read below and complete
According to State Attorney General Opinion No. 5925,
school districts have the right to request proof of pupil residency. By signing this affidavit, you are affirming that the address given on all enrollment forms is the legal residence of the parent or guardian enrolling the student and is the residence of the student. If you are living in the home of another person without a rental or lease agreement, that person must sign this document and prove their residency.
SECTION TWO: Please provide (2) of the following: (check which is used)
SECTION THREE: Please read and complete if applicable
If you are NOT a resident of the JACKSON PUBLIC SCHOOL DISTRICT please complete the School of Choice form on the next page (otherwise, you may skip to the page after that.)
Please upload any documents needed for the previous sections of this form.
It is the policy of the Jackson Public Schools District that no discriminatory practices based on sex, race, color, national origin, religion, height, weight, marital status, handicap, age, political affiliation, sexual orientation, or disability or any other status covered by federal, state, or local law be allowed in providing instructional opportunities, programs, services, job placement assistance, employment, or in policies governing student conduct and attendance. Any person suspecting a discriminatory practice should contact the Human Resources Office at Jackson Public Schools, 522 Wildwood Avenue, Jackson, Michigan 49201 or call (517)841-2153.
The Jackson Public Schools, as required by Federal and State Laws, is collecting information regarding the language background of each of its students. This information will used by the district to determine the number of children who should be provided bilingual/second language instruction according to Sections 380.1152-380.1157 of the School Code of 1995, Michigan's Bilingual Education Law.
Please provide the following information.
Thank you for your cooperation.
NOTE: Translation of this survey form in Spanish, Japanese, Chinese (Mandarin), Polish, and Vietnamese is available at Jackson Public School's Reynolds Hall, 522 Wildwood Ave., Jackson, MI 49201. If completing a printed form, please return form to your school office.
SCHOOL OFFICE USE ONLY: If the parent/guardian has checked YES for Question 1, this completed form must be faxed immediately to the attention of the ELL Coordinator at 768-5918. The original form is to be kept at the school in the student's CA-60 for audit purposes during the school year.
This section is intended to address the McKinney-Vento Homeless Assistance Act under the guidelines of the Every Student Succeeds Act (ESSA), 2015. Your answers will help the administrator determine the supplemental needs of the student. (Complete one form per student.)
For any choices selected in the first question of this section, this form must be completed and faxed (517-990-0556) to JPS Homeless Liaison (Mrs. Willye Pigott) immediately after completion. Original forms are kept (in the school) separate from the student's CA 60 for audit purposes during the school year.
Name and phone number of a school contact person who may know of the family's situation:
South Central Michigan Virtual is dedicated to making your education a fulfilling and pleasurable experience. We will continue to provide you with enhanced technology throughout your educational path while enrolled at SCMV.
By signing below, we understand that:
We acknowledge that we have reviewed this agreement together and understand our responsbilities.
If you have any questions or concerns regarding SCMV technology please contact Amy Barton. firstname.lastname@example.org or 517-841-2822.
Under the provisions of the Federal Educational Rights and Privacy Act, Federal Register, Volume 41. NO. 118, June 17, 1976, it is no longer necessary to have written consent of the parents to release records. School officials, including teachers within the educational institution and officials of other school systems in which the student intends to enroll, may request student records.
Please Fax Transcript ASAP to: 517-990-0002
Please include cumulative school records, health records, test scores, psychological reports, special education records, etc. Any additional information you can give us to help in proper placement will be appreciated. Send all confidential and cumulative student records (CA60) to:
South Central Michigan Virtual
ATTN: Amy Barton, SCMV Secretary
1060 Jackson Crossing
Jackson, MI 49202
South Central Michigan Virtual