STUDENT INFORMATION - Summerville High School

DORCHESTER SCHOOL DISTRICT TWO
ENROLLMENT FORM GRADES K-12
Enrollment Date ________________________
School ______________________________________
STUDENT INFORMATION Grade Age Now _________ Gender ( ) Male ( ) Female
Last Name First Name Middle Name
(Ethnicity) Is the student Hispanic or Latino ( ) Yes ( ) No
Date of Birth __________________________ Place of Birth ______________________________________________
Student’s Residence Address
Street City State Zip Code
Home Phone: ______________________________ Subdivision/Apartment Complex: _____________________________________
(Race) What is the student’s race ( ) White ( ) Black or African-American
( ) American Indian or Alaska Native ( ) Asian ( ) Native Hawaiian or Other Pacific-Islander
TRANSPORTATION
Student will ride the school bus in the morning ( ) Yes ( ) No Student will ride the school bus in the afternoon ( ) Yes ( ) No
Other (Day Care Bus/Van): ___________________________________
Car Rider ( ) Yes ( ) No
PARENT/GUARDIAN INFORMATION (Please Circle) Mother Step-Mother Legal Guardian
Last Name
Home Address
First Name
Street City State Zip Code
Home Phone _______________________ Education: Last Grade Completed ________ Degree _______________
Employer
Email
Work Phone Ext. Alternate Phone
Last Name
Home Address
(Please Circle) Father Step-Father Legal Guardian
First Name
Street City State Zip Code
Home Phone _______________________ Education: Last Grade Completed ________ Degree _______________
Employer
Email
Work Phone Ext. Alternate Phone
ADDITIONAL PARENT/GUARDIAN
Relationship to the Student ___________________________________
Last Name ____________________________ First Name ________________________ Home Phone ___________________
Home Address
Student Lives With - Relationship to the Student (Please Circle)
Street City State Zip Code
Mother Father Step-Mother Step-Father Foster Mother Foster Father Legal Guardian
Group Home: ___________________________________
Updated
7-12-10
Other (please explain) ____________________________________
Note: If Legal Guardian - legal guardianship papers must be provided and approved by District Two as part of the cumulative
records, and if there is a legal custody agreement, documentation must be provided as part of the cumulative records.
SPECIAL INFORMATION
Has Student repeated a grade ( ) Yes ( ) No If Yes, which grade? _______
Student receives Special Education ( ) Yes ( ) No ( ) Self-Contained ( ) Resource ( ) Speech
Student has a current IEP ( ) Yes ( ) No If Yes, ( ) Reading ( ) Math ( ) Written Expression
( ) Other
Student is on a 504 Plan ( ) Yes ( ) No
Student is currently enrolled in a Gifted and Talented Program ( ) Yes ( ) No
Student wears (circle all that apply): Glasses Contact Lenses Hearing Aid
HOME LANGUAGE SURVEY
Which Language did your son/daughter learn when he/she first began to talk? _____________________________________________
What Language does he/she speak most frequently at home?
_____________________________________________
If your child was not born in the USA, in what country was he/she born? _____________________________________________
Date your child entered school in the United States.
_____________________________________________

EMERGENCY CONTACTS
FAMILY INFORMATION
Please list any other children/siblings at this residence (even if not in school):
Name Age Grade School
Name Age Grade School
Name Age Grade School
Name Age Grade School
EMERGENCY INFORMATION
( ) Medical Alert (i.e. asthma, diabetes, seizures, mental/physical conditions, etc., or allergies (insects, food), etc.)
( ) Medication(s)
Name Relationship Phone Ext.
Address
Street City State Zip Code
Name Relationship Phone Ext.
Address
Street City State Zip Code
Name Relationship Phone Ext.
Address
Physician’s Name
REQUEST FOR RECORDS
School Name: Summerville High School
Street Address: 1101 Boone Hill Rd.
City, State & Zip: Summerville, SC 29483
Phone Number: 843-873-6460
Date
Student’s Full Name
Street City State Zip Code
Phone
Date of Birth
I hereby authorize Dorchester School District Two to receive all school records regarding my child. My signature gives Dorchester
School District Two permission to consider and use this information for appropriate placement.
Previous School Attended
Street City State/Province Zip Code
Signature of Parent/Legal Guardian Relationship to Student Date
All information on both sides of this form is correct to the best of my knowledge. Additionally, I
understand that it is my responsibility to inform the school immediately of any changes.
_________________________________________ _____________________________ _______________
Signature of Parent/Legal Guardian Relationship to Student Date
FOR OFFICE USE ONLY
Proof of Residence Registration Fee Paid Scheduled By
Birth Certificate Records Requested Immunization
Enrollment Date
Approved by Signature
(High Schools) – First Year in 9 th Grade (circle) 2005-06 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14

DORCHESTER SHOOL DISTRICT II / SUMMERVILLE HIGH SCHOOL
POLICY REGARDING “SUSPENSION OF STUDENTS”
1. Students are required to conduct themselves at all times and places in a manner that
will not be contrary to the best interests of the schools. Conduct by a student in any
manner which materially disrupts class work or involves substantial disorder or
invasion of the rights of others is a basis for suspension or expulsion of students.
2. Where the conduct of a student requires such action for the general welfare of the
school system, immediate suspension, without notice, may be made by the principal
or other person in charge of a school, subject to the appeal provisions hereinafter set
forth. In appropriate circumstances notice prior to suspension, as hereinafter
provided, will be given.
3. Where the conduct of a student requires that he be suspended, written notice to the
student, and to the parent or other in loco parentis, will be given setting for the
nature of the conduct leading to the suspension in such manner that the student will
be sufficiently apprised of the charges made against him. A hearing upon such
charges will be provided by the Board of Trustees upon request by the student, parent,
or persons standing in loco parentis if a request for such hearing is made to the Board
of Trustees, in writing, within five days after receipt of the notice of charges.
4. At such hearing the student may be represented by counsel, but no counsel will be
provided for him/her. The hearing will be conducted in an informal manner but with
full opportunity for the student to be heard and to present such matters as he may
wish. Such hearing will be private and not open to the public.
5. Where immediate suspension of a student is not made and charges that may lead
to his suspension or dismissal are to be made by the Trustees, the same procedures
set forth above will be followed.
6. Copies of these rules will be distributed to all students and will be filed in the office
of the Principals of the schools in the District.
________________________ ___________________________________
Date
Signature of parent/ guardian

CONDITIONS OF ENROLLMENT
ENROLLMENT FORM
This is to verify that the undersigned are aware of the conditions of ______________________’s
Enrollment in Summerville High School, and will not hold the school responsible for any discrepancies in his/
her curriculum. He/she is being enrolled without the benefit of a complete transcript or previous school records.
His/ her course selection for the present school term is based on information furnished by what we have been
furnished.
Furthermore, we understand that he/ she will be expected to complete all requirements for a South Carolina
High School diploma by repeating a grade, attending summer school, or both if necessary. We will not hold the
Summerville high School liable for any moral, social, or academic inconveniences or hindrances arising from
this adverse enrollment.
________________________ ___________________________________
Date
Signature of parent/ guardian
NOTIFICATION OF EXIT EXAMINATION REQUIREMENTS
Beginning in 1990, any student who wants to receive a South Carolina High School Diploma must pass all three
subtests of the Exit Examination (reading, math, and writing) in addition to meeting all other requirements for a
diploma.
________________________ ___________________________________
Date
Signature of parent/ guardian
________________________ ___________________________________
Date
Signature of student