Re-Enrollment Form - South Central Michigan Virtual

Semester*

Fall
Spring

Student Information

Student Name*

As it appears on the birth certificate.

First Middle Last

Student Home Address*

Street Address City State Zip

Gender*

Male
Female

Date of Birth*

Grade*

Ethnicity*

If more than one, check all that apply

Hispanic / Latino
American Indian / Alaskan
Native Hawaiian / Pacific Islander
Asian
White
Black or African American

Responsible Party*

Name of Parent or Guardian Student Lives With

First Last

Relationship of Responsible Party to Student*

Student Home Phone*

Student Cell Phone

Best # to receive text messages at

Student Email Address

Preferred method of communication*

Text
Phone
Email

Prior School Name*

Prior School Address*

Street Address City State Zip

Does your child currently receive special education services?*

Yes
No

Does your child have an active IEP?*

Yes
No

What is your child's certification?*

Residency Information*

Resident of JPS District
Non-Resident

District of Residency*

County of Residency*

Is student a School of Choice student?*

Yes
No

Has student attended JPS in the past?*

Yes
No

When did they attend JPS? (mm/yr)*

Head of Household Contact Information

Female Head of Household

Male Head of Household

Name / Relationship

Home Phone

Cell Phone

Email

Address

Street Address City State Zip

Address

Street Address City State Zip

Certification of Truthfulness - By signing this document 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.

Signature of Parent/Guardian

Re-enrollment

Student Information

Head of Household Contact Information

Female Head of Household

Male Head of Household