Exhibit 5151 -E-1

WAYNE CENTRAL SCHOOL DISTRICT ● Ontario Center, New York 14520
1. Exhibit 5151-E-1

Exhibit 5151 E-1
Page 1 of 2

WAYNE CENTRAL SCHOOL DISTRICT ● Ontario Center, New York 14520

RESIDENCY AFFIDAVIT OF EMANCIPATED STUDENT

STATE NEW YORK (
COUNTY OF WAYNE (
TOWN OF…………… (

I, the undersigned being duly sworn, depose and say that the information provided herein is true and complete to the best of my knowledge:
1) Name………………………………………………………………………………………

2) Date & Place of Birth……………………………………………………………………..

3) Grade (20 …-….) …………………….. Age ……………………………………..

4) Present Full-Time Address: …………………………………………………………..

………………………………………………………………………………

5) Name(s) & Address(es) of Parent(s):
………………………………………………………………………………………………
………………………………………………………………………………………………

5) Date on which you no longer resided with your parent(s): …………………………..

7) Please indicate as fully as possible the reasons why you are no longer residing with your parents:

8) Will you be staying in the home of your parents at any time:

During the school year? Yes No During school vacation periods ? Yes No 0

If YES, indicate when & why:

(9) Indicate as fully as possible the means by which you are supporting yourself financially:

(10) Are you receiving any financial assistance or support from your parents? Yes No

If so. what portion of your total financial support are your parents providing and what is the nature of that support?

ADOPTED: 4/1 2/00 (continued)

Exhibit 5151-E-1

Exhibit 5151-E-1
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11) Please describe your current relationship with your parents ( example: the date of your last contact with them and the nature and degree of future contact you expect to have with them):

12) In case of medical or other emergency, who should be contacted for decisions affecting you?
NAME: ……………………………………………TELEPHONE: (Home)……………………….
ADDRESS:…………………………………………………………………………………………..
13) Where did you reside last year ?
14) What school have you been attending?
District Name…………………………………….Building:………………………………….
Address (Street & Post Office)………………………………………………………………
15) Have you previously attended Wayne Central SchoolDistrict? Yes No
If Yes, please list latest date & school:

CERTIFICATION BY STUDENT

I hereby certify that I am an emancipated minor living beyond the custody and control of my parents and that I am full’ responsible for all decisions pertaining to my health, welfare and education.

In the event that I am permitted to enroll in the Wayne Central School district, I agree to promptly notify the superintendent of schools in the event there are any change in the information provided in this affidavit.

SIGNED ……………………………………………………………DATE:……………………………..

STREET ADDRESS…………………………………….Post Office ……………….Zip……………..
(Do not use a PO. Box)

Subscribed and sworn before me on the

~~—~day of…………………….., 20…..

…………………………………………
Notary Public

(Please affix stamp)