FINAL CHECKLIST

If you have not uploaded all of the required registration documentation, you must go to your student(s) school
to complete the registration process. All new students must upload or bring to the school the following items:

Student's birth certificate, proof of age, and verification of guardianship-if different from birth certificate
Parent/Guardian Photo ID-Valid drivers, non-drivers, or Military ID
An up-to-date State of Alabama Certificate of immunization
Documentation/proof of grade level (transcript, last report card, etc..)
Two proofs of residence- At least 1 must be from the Primary list below.

All documents submitted as proof of residence must contain the parent or legal guardian's physical address in
order for the school to verify that the residence is in zone. (No Post Office Box addresses will be accepted).

Primary Proof of Residence

Utility bill or deposit receipts for electric, gas, or water service only. Bill must be current within the last
30 days. No disconnect service allowed.
Monthly mortgage statement-must be current
Monthly mortgage statement must be current within 30 days.

Secondary Proof of Residence

Property Tax Records or Deeds-Tax Receipt, Property Deed-(please blacken out any personal financial
information)
Income Tax Records-Copy of check from IRS, correspondence from the IRS
Social Security Checks or other correspondence from Social Security Office
Correspondence from other U. S. Government agencies-(Dept. of Human Resources, Food Stamp
Office)
Employment Records-Paycheck stub issued from employer showing physical address of employee
within the last 30 days.

If you have any questions or need any additional information please contact 334-223-7900 for assistance.

Some forms required by the District are not included in the online registration portal and will be sent home with
the first few days of school
 Student Enrollment Form
Montgomery Public Schools
Student's Name: Gelder Geovani Sales lopez IV
Date of Birth: 10/16/2008
School:
Grade: 07
Student ID:
Today's Date:

Student Information
Student's Name: Gelder Geovani Sales lopez Gender: Male:M
Grade: 07
Social Security Number: 771-76-8588
Date of Birth: 10/16/2008 City of Birth: Fort Myers Lee county
State of Birth: Florida:FL Country of Birth: USA
Date of Entry into State: Date of Entry into USA:

Student resides with: Mother/Stepfather

Academic Session Student is Registering for: Current (2021-2022)

Have you been given permission to attend another school other than your zoned school? No
School you have been given permission to attend:
If student is not attending zoned school, please indicate reason:

Is either parent (guardian) a member of the Military Services (active or reserve)? No

Military Branch:
Is either parent (guardian) a civilian employed on federal property? No

Address Section
Address: 4475 WIMBLEDON RD
City, State, Zip Code: MONTGOMERY Alabama:AL 36116

Previous School Information

Are you currently homeschooled and registering for public schooling? No:0
Home School Umbrella/Organization:
Has the student been previously enrolled in Montgomery Public Schools? No
Which school did student attend?

Last School Attended: Dothan preparatory Acadamy

Phone Number: (334)794-1400
Address: 1236 o Oates st
City: Dothan State: Alabama:AL

Date first attended U.S. school:

Is this student in at least one Special Education class, or does this student have an IEP (Individual
Education Plan)? No
Do you have a current copy of this student's IEP?

Does the student currently have a 504 plan in place? No

Ethnicity and Race Information

Is the student Hispanic or Latino? Yes:1 Black or African American: No
American Indian or Alaska Native: No Native Hawaiian or other Pacific Islander: No
Asian: No White: No

Primary Ethnicity: Hispanic:H

Sibling Information
Does this student have any siblings enrolled in the district? No
If yes, please list siblings' names, schools, and ages below:

Name: School: Age:

Social Restriction(s)
Is there any individual not permitted to have contact with the student? No
Name: Reason:
Expiration Date of Court Order:

Name: Reason:
Expiration Date of Court Order:

Parent/Guardian's Signature:

Parent/Guardian's Electronic Signature: Carmelina lopez Today's Date:

Office Use Only

Enrollment status: FTEID:
Entry code: Entry date:
District date of entry: School date of entry:
Expected graduation year:
 Contact Information
Montgomery Public Schools
Student's Name: Gelder Geovani Sales lopez IV
Date of Birth: 10/16/2008
School:
Grade: 07
Student ID:
Today's Date:

Primary Contact Information

Name: Carmelina Lopez gabriel I Relationship to Student: Mother:7 Gender: Female:F
Does this contact have full or partial custody of this student? Yes:1
Is this contact an emergency contact? Yes:1
Does this contact have permission to pick up this student? Yes:1
Should this contact receive mailings? Yes:1
Primary Phone: (334)435-3794 Alternate Phone: (318)608-9764 Additional Alternate Phone:
Phone type: Mobile Phone type: Mobile Phone type:
Email: [email protected]

Does this contact live with the student? Yes:1

Address: 4475 WIMBLEDON RD ,
City, State, Zip Code: MONTGOMERY , Alabama:AL 36116

Secondary Contact Information

Name: Jose Pacheco Relationship to Student: Stepfather:10
Does this contact have full or partial custody of this student? Yes:1
Is this contact an emergency contact? Yes:1
Does this contact have permission to pick up this student? Yes:1
Should this contact receive mailings? Yes:1
Primary Phone: (318)608-9764 Alternate Phone: Additional alternate phone number:
Phone type: Mobile Phone type: Phone type:
Email: [email protected]

Does this contact live with the student? Yes:1

Address: ,
City, State, Zip Code: ,

Other Contact Information

Contact 3 Information
Name: Yolanda Salinas Relationship to Student: Friend
Does this contact have full or partial custody of this student? No:0
Is this contact an emergency contact? Yes:1
Does this contact have permission to pick up the student? No:0
Should this contact receive mailings? Yes:1
Primary Phone: (334)676-9265 Alternate Phone: Additional alternate phone number:
Phone type: Mobile Phone type: Phone type:
Email:

Does this contact live with the student? No:0

Address: ,
City, State, Zip Code: ,

Contact 4 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Contact 5 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Contact 6 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Contact 7 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Contact 8 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Contact 9 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Contact 10 Information
Name: Relationship to Student:
Does this contact have full or partial custody of this student?
Is this contact an emergency contact?
Does this contact have permission to pick up the student?
Should this contact receive mailings?
Primary Phone: Alternate Phone: Additional alternate phone number:
Phone type: Phone type: Phone type:
Email:

Does this contact live with the student?

Address: ,
City, State, Zip Code: ,

Parent/Guardian's Signature:

Parent/Guardian's Electronic Signature: Carmelina lopez Today's Date:

 Home Language Survey
Montgomery Public Schools
Student's Name: Gelder Geovani Sales lopez IV
Date of Birth: 10/16/2008
School:
Grade: 07
Student ID:
Today's Date:

Today's Date: Grade: 07

Student's Name: Gelder Geovani Sales lopez IV
Guardian's Name: Carmelina Lopez gabriel
Address: 4475 WIMBLEDON RD
City, State, Zip Code: MONTGOMERY , Alabama:AL 36116
Primary Phone: (334)435-3794
Date of Birth: 10/16/2008

Country of Birth: USA Date of Entry into USA:

City of Birth: Fort Myers Lee county Date of Entry into State:
State of Birth: Florida:FL

Has this student previously attended any US Schools? No

How many years?

What is the language most frequently spoken at home? Spanish

If available, in what language would you prefer to receive communication from the school? Spanish
Please choose your student's race: Guatemala:GTM
Is your student's first-learned or home language anything other than English? Yes
In what country did your student most recently reside? U.S.A
Which language did your student learn when he/she first began to talk? Spanish
What language does your student most frequently speak at home? Spanish
What language do you most frequently speak to your student? Spanish
Please describe the language understood by your student: Understands the home language and
English equally
Parent/Guardian's Signature:

Parent/Guardian's Electronic Signature: Carmelina lopez Today's Date:

 Health Assessment Record
Montgomery Public Schools
Student's Name: Gelder Geovani Sales lopez IV
Date of Birth: 10/16/2008
School:
Grade: 07
Student ID:
Today's Date:

Student's Name: Gelder Geovani Sales lopez IV

Is the student Hispanic or Latino? Yes:1
Date of Birth: 10/16/2008 American Indian or Alaska Native: No
Gender: Male:M Asian: No
Grade: 07 Black or African American: No
Native Hawaiian or other Pacific Islander:
Address: 4475 WIMBLEDON RD No
City, State, Zip Code: MONTGOMERY , Alabama:AL , White: No
36116

Guardian's Name: Carmelina Lopez gabriel I

Primary Phone: (334)435-3794
Alternate Phone: (318)608-9764 Phone type: Mobile
Additional Alternate Phone: Phone type: Mobile
Phone type:

Health Information
Place where your student receives Place where this student receives Type of insurance your
regular health care: regular dental care: student has:
No regular place No regular place Medicaid

Doctor's Name: Dentist's Name:

Telephone: Telephone:
Does the student currently have a 504 plan in place? No

Authorizations
In case of an emergency, I allow school officials to:
Seek medical help for the student: Yes
Give treatment that a doctor says is needed: No

If hospitalization is required, where should we send the student? Baptist East Hospital

I authorize for my student to participate in all school health screenings, such as vision, hearing and
scoliosis Yes

I authorize the yearly review of my student's Certificate of Immunization (Blue Slip) by the local
Public Health Department. Yes

I allow this student's contagious disease history (such as chicken pox) to be given to the Public
Health Department. Yes
Parent/Guardian's Signature:

Parent/Guardian's Electronic Signature: Carmelina lopez Today's Date:

 Attestments
Montgomery Public Schools
Student's Name: Gelder Geovani Sales lopez IV
Date of Birth: 10/16/2008
School:
Grade: 07
Student ID:
Today's Date:
I have read and understand the Medicine Administration Policy. I attest.
Parent/Guardian's Signature:

Parent/Guardian's Electronic Signature: Carmelina lopez Today's Date:

 Consent Form for Digital Media

In the case of a minor, please provide the name of the minor:

Student's Name: Gelder Geovani Sales lopez

Provide the name of the minor’s parent or legal guardian:

Name: Carmelina Lopez gabriel

I hereby give Montgomery Public Schools the right and permission to publish, use photographs or
video, and/or audio recordings of my child, a student enrolled in Montgomery Public Schools.

I understand that such reproductions could be used to publicize or promote the school system, and/or
my child's school through its own media productions (district Website, social media, printed and/or
online brochures, reports, promotional videos, etc.) or through the commercial media (television,
radio, Internet or print).

I waive any right to inspect and/or approve the finished product and do release Montgomery Public
Schools from any liability by virtue of distortion by processing. I further agree that these items may be
used for publication, broadcast or reproduction without limitation or reservation or any fee.

I agree

I/We hereby acknowledge by our initials that we have received, read and understand, and/or had read
to us and understand, the Media Release Form. G.g.s.l.

Today's Date:

Parent/Guardian's Electronic Signature: Carmelina lopez

Address: 4475 WIMBLEDON RD

City, State, Zip Code: MONTGOMERY , Alabama:AL 36116

Primary Phone: (334)435-3794

 Notice of Receipt Form
Montgomery Public Schools
Student's Name: Gelder Geovani Sales lopez IV
Date of Birth: 10/16/2008
School:
Grade: 07
Student ID:
Today's Date:
I, the above mentioned student, along with my parent/guardian hereby acknowledge by our signatures that
we have received, read, and understand, and/or had read to us and understand, the Student Conduct
Manual.

We understand that these policies and laws apply to all parents and students enrolled in Montgomery Public
Schools, and at all activities and events, including school buses, sponsored or supervised by MPS school
officials.

Student Signature: Gelder lopez Date: 12/13/2021

NOTE: If the student lives with both parents/guardians, both are to sign the statement. If the student
only lives with one parent, only one signature is required. Failure to return this form does not
absolve the student or parent from the requirements stated in this Student Conduct Manual.

Parent/Guardian Signature Carmelina lopez Date: 12/13/2021

Parent/Guardian 2 Signature (if applicable): Carmelina lopez Date: 12/13/2021

Parent/Guardian's Signature:

Parent/Guardian's Electronic Signature: Carmelina lopez Today's Date: