I (we), the undersigned, being duly sworn, depose and say that the student named below is currently residing with me/us on a full-time basis and that the information provided herein is true and complete to the best of my (our) knowledge:
1)1/We reside at………………………………………………………………………………………………
2) Student’s Name: …………………………………………….Grade (20..-....) ………….Age……….
3) What is your.relationship to this student?
4) Have you assumed financial support of this student in addition to providing a home? Yes No
If NOT, what portion of financial support have you assumed? …………..%
Who provides the remaining financial support? ………………………………………………..
5) Has this student lived with you before ? Yes No
If YES, when & why ? ……………………………………………………
6) How long will the student be living with you ? ………………………………
7) In case of medical or other emergency, who will be responsible for decisions affecting this student?
NAME(s) ADDRESS
………………………………………………. …………………………………………………
………………………………………………. …………………………………………………
PHONE: (Home)…………………………. (Work) ……………………………………………..
8) What school has this student most recently attended?
NAME(s) ADDRESS
………………………………………………. …………………………………………………
ADOPTED: 4-12-00 WAYNE CENTRAL SCHOOL DISTRICT
(continued....)
Exhibit 5151 E-2
Page 2 of2
14) Will this student reside in the home of anyone else at any time during the following periods:
During the Week On Weekends During School Recess Periods
IF YES, When & why:
15) Please indicate as fully as possible the reasons why this student will no longer reside with his or her parents:
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CERTIFICATION
I (we) hereby certify that: I (we) have assumed full responsibility for and custody and control over the student named in item 2, above, including the right to make decisions pertaining to the health, welfare and education of the student If the student is permitted to attend Wayne Central School District. I (we) agree to promptly notify the Superintendent of Schools in the event that there is any change in the information provided herein.
Signature …………………………………………………………………Date …………………………………..
Signature …………………………………………………………………Date …………………………………..
Subscribed and sworn before me on this ….. day of ……………………………20………
Notary Public………………………………….
(Please Affix Stamp)
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