All Students:

  • Mortgage, Lease or Deed with current address (We accept tax notice, Mortgage Payment Book, monthly statement or deed)
  • 2 Current Utilities with current address (Water, Gas or Power) (Cannot say disconnect notice without receipt)
  • Parent or Guardian’s Driver’s License with current address
  • Updated Alabama Blue Immunization Form if expired or if you are new to our school
  • Custody Papers if applicable


New Students:

  • The Above Items
  • Social Security Card (Voluntary)
  • Alabama Blue Immunization Form
  • Custody Papers if applicable


2nd Party Residency (This means that the guardian lives with someone else and does not own the home)

  1. Mortgage, Lease or Deed and two utilities of the owner of the house
  2. Two significant items with the address where you are living, we will only accept the following:
  • A bank statement with three month’s activity at current address
  • A check stub at current address
  • Anything from the government at current address



If you are registering from another school, we will need a copy of your child’s last report card.


**Please note:  If your child is coming from a home school or private school setting, we reserved the right to place the child in the grade level that we feel is appropriate after a thorough evaluation of their academic skills.






Date of Request: _________________       Date Request Received: ___________________


The Jefferson County Board of Education and Clay Elementary School request that you transmit the following student records as soon as possible.  If the student is currently receiving special education and related services, the records must be transferred to the requesting school. (Alabama Administrative Code 290-8-9-.8 [2])


Student Name: _____________________________              Grade: ______

Student Name: _____________________________              Grade: ______

Student Name: _____________________________              Grade: ______

Student Name: _____________________________              Grade: ______


Prior School Name: _________________________________________

Mailing Address: __________________________________________

City, State and Zip ________________________________________


Please ship records to:


6745 Old Springville Road

P.O. Box 127

Clay, AL 35048

205-379-3000 Fax: 205-379-3045



Please include the following items:


Permanent Cumulative Records


Test Scores




Exceptional Education Records






Principal’s (or designee) Signature:



Classroom _____________




2017-2018 Registration Form


Student’s Legal Name: _____________________________________________ Called: __________________

                                             Last                                  First                                    Middle

Social Security # : _______________________________  DOB: ______________________


Permanent Home Address: ___________________________________________________________________

                                                Street Address                                                          City                                          Zip


Main Contact Phone: (205) ______________________  Alternate phone: ___________________


Race:  White   Black   Hispanic   Asian   Other _______________  Gender:    Male      Female

                (Please Circle One)                                                                                                                         (Please Circle One)


Child goes home by:   Car  _______   Bus #:____________   Daycare Name: ____________________


E-mail address: _________________________  Student lives with: _______________________________


Legal Guardian: ________________________________     Phone:________________  Cell: _________________


Circle One:  Mother                Father              Grandparent                Other________________________(Explain)


Address if different from student: ________________________________________________________________

                                                            Street Address                                                          City                                          Zip


Employer’s Name: ___________________________________Work Phone:  ___________________________



Legal Guardian: ________________________________     Phone:________________  Cell: _________________


Circle One:  Mother                Father              Grandparent                Other________________________(Explain)


Address if different from student: ________________________________________________________________

                                                            Street Address                                                          City                                          Zip


Employer’s Name: ___________________________________Work Phone:  ___________________________




The people listed below will be notified in the event of an emergency and we are unable to contact you. 

They will also be able to pick up or check out your child.


1.  _____________________________________     ____________________            ____________________________

       Name                                                                    Relation                                   Phone


2.  _____________________________________     ____________________            ____________________________

     Name                                                                      Relation                                   Phone


3.  _____________________________________     ____________________            ____________________________

     Name                                                                      Relation                                   Phone


4.  _____________________________________     ____________________            ____________________________

     Name                                                                      Relation                                   Phone


Student Medical Information



Student Name: _____________________________             Grade:  ______________


Student’s Physician: __________________________________      Phone: _________________________


Name/Type of Insurance: ______________________________      Policy #_________________________


List any physical conditions that the student has such as asthma, diabetes, epilepsy, etc. which may affect the student’s ability to participate in any event or may need to be considered in the event of a medical event with your child.







List any medication that the student is currently taking including the dosage and possible side effects: (This includes medicines that are administered at home.)






Please Note:  If your child is required to take any medication at school, the nurse must have specific doctor orders and a Medication Form signed by the doctor on file in order to administer those medications.  This includes rescue inhalers and epi-pens.  An adult must always drop off medicine in the office or with the nurse and verify pill counts.



List any known allergies that the student has:







Does your child require an epi-pen to be on hand at the school?  Yes or No  (Circle One)




Medical Release

I, __________________________________, being the parent/guardian of _____________________________

Give permission for Clay Elementary personnel to administer medication (as directed above) at school or on field trips, and to contact a physician if additional information is needed.  If the parents cannot be reached in case of a medical emergency, the school will take the following procedures:

  1. Call paramedics
  2. Upon recommendation of paramedics have them transport your child to the hospital
  3. If you have any other desired procedure, please state here: _____________________________________


Parent/Guardian signature: ___________________________________________  Date: ___________________







The Jefferson County Board of Education requires that every student attending a Jefferson County School reside in the designated zone for the school he or she attends.  In order to meet this requirement, students must live in a dwelling (defined as house, apartment, or secured mobile home) in the designated zone with a custodial parent or a court appointed legal guardian who resides in that zone. At the time of registration, the

Custodial parent or court appointed legal guardian must provide proof of residence and agree to inform the school by completing a CHANGE OF ADDRESS FORM for the current school year school district within fourteen (14) days of the date of the move if he or she moved from the address given at registration.


Registration of any student whose custodial parent or court appointed legal guardian is not a bona fide resident of the zone for the school he or she attends is a fraudulent act. Any student found to be fraudulently enrolled in a Jefferson County School must withdraw and enroll in his or her zoned school.


Parents are responsible for giving accurate and up to date information regarding legal addresses and contact information to school officials. Giving false information to public officials in the performance of his or her duty is a violation of the Criminal Code of Alabama §13A-1 0-109(a) and punishable by a fine of $500.00·and up to 90 days in jail.




I certify that have read, understand and agree to comply with the residency requirements for enrollment in Jefferson County Schools and understand that providing false residence information is a violation of the laws of the State of Alabama.


I further certify that I am the custodial parent or court appointed legal guardian of _____________________

My legal residence is ____________________________________________________________________ and this residence is located in the Clay Elementary school zone.



_________________________________________________                      ____________________

Signature of Custodial Parent/Court Appointed Legal Guardian                     Date




6745 Old Springville Road · P.O. Box 127 · Clay, Alabama 35048

205-379-3000 · Fax:  205-379-3045





Car riders MUST have a Clay Elementary Security Card hanging from the rear view mirror. (Use a pant/skirt hangar)  Please use this every day as the person who calls the car riders to your car may not always be the same person.  If you do not have the Clay Elementary Security Card with you, you will be asked to park your car and come into the office to show your identification before picking up your child.  Remember this is a Safety precaution put in place to protect all of our students at Clay Elementary.


Your child must be picked up from school by 3:30 each day.  Students are dismissed at 2:50 p.m.  This allows 40 minutes for you to get your child picked up while we have someone to supervise them.  If your child is picked up later than 3:30, there will be a $5.00 charge per child for each 15 minutes late.




Student Name



Parent Signature


Jefferson County Board of Education

2100 18th Street South

Birmingham, AL 35209-1891







Date:  _______________________                                                   School:  Clay Elementary


Schools are required to determine the home language(s) of each student.  This information is essential in order for schools to provide appropriate instruction for all students.


Student’s Name:  ______________________________________________________________________

                                    Last                                         First                                         Middle


Grade:  ______________                                                                   Age: ___________



  1. What was the first language the student learned? _____________________________


  1. What is the language most often spoken in your home? ____________________________



  1. What is the language the student uses with his friends? ____________________________


  1. What language has the student been using at school? _____________________________




                                                                                                            Signature of parent or guardian






Jefferson County Staff:  If the answer to any question above is other than English, copy this form and notify Karen L. Smith

by calling 379-2101.  File this Home Language Survey in the student’s permanent file.



                                                                                                                                                            Jefcoed 08/01-1









I, the parent of ______________________, have read and fully understand the rules as defined in the Clay Elementary Rules for Specific Areas.  By signing and initialing each area below, I am acknowledging that I have received a copy of these rules and certify that I have read and understand them fully.  I further agree that my child will agree to comply with these rules while he/she is a student at Clay Elementary.  This agreement will remain effective through my child’s completion of 5th grade at Clay Elementary.


These rules are in addition to the rules defined in the Jefferson County Student Code of Conduct.



Rules Received


Rules for Checking out Library Books


Textbooks Rules


School Bus Rules


Rules for Internet Use


Rules for Non Sufficiently Funded Checks


Rules for Medication


Drop Off and Pick Up Procedures




Parent Signature: __________________________________      Date: ______





Checking Out Library Books:


Students are responsible for the care and conditions of items that are checked out of the library.


  • If a book is lost or damaged beyond repair, the student will pay full, replacement price.
  • If a book can be repaired, the student will pay a $3.00 repair fee.
  • There is a $1.00 charge to replace bar codes and a $10.00 charge to replace magazine holders.
  • We cannot give refunds for items that are found after they have been paid for by the student.
  • Students will pay a fine of .05 per day for overdue books.
  • Students may not check out books when they have outstanding fines or charges.


Textbooks Rules


Textbooks are the property of the State of Alabama and shall not be damaged in any way including but not limited to:

  • Loss of pages, water damage, marked with pencil, pen, crayon, etc. Defaced, Marred, Broken, Cut or Bent.
  • Penalty for a lost or damaged book is as follows:
  • Full price, if issued new.
  • Half price, if issued used.
  • No refunds will be given if the book is found after payment has been made.
  • No replacement textbook will be given to a student with outstanding books or charges.
  • All textbooks must be returned to the teacher by the student when they are promoted or transferred.


School Bus Discipline


When a student is traveling on a bus going to and from home or traveling to and from a scheduled school event (field trip, special events & performances, etc.), they are considered to be on Jefferson County property.  The same rules for behavior are enforced as listed in the Jefferson County Student Code of Conduct Book.  The students will also be asked to comply with the following bus rules:

  • No changing seats or standing while bus is in motion.
  • Seat belts must remain secured for all handicapped students at all times.
  • No eating or drinking on the bus.
  • No throwing objects on the bus or out of the windows.
  • Arms, legs and heads are to be kept inside the bus at all times.
  • Students will not leave the bus without the driver’s consent.
  • Loud talking and yelling will not be tolerated.
  • You must be at your stop on time and load the bus from the school and special events on time.
  • The driver has disciplinary powers which students must respect.  All unacceptable conduct will be reported to the school administrators.


Internet Use


Use of the internet must be for support of education or research or consistent with educational objectives.  Student users must have permission from their instructor before using the computers and must sign in on the appropriate log to use the network.  Users may not use the computers for non-academic purposes when another user needs them for academic purposes.  Users may not waster or take without permission supplies provided by the board.


The following will not be permitted and will result in disciplinary action:

  • Transmission or receipt of any material in violation of any state or federal law is prohibited.
  • Sending, displaying or downloading offensive, profane or prurient messages or pictures.
  • Using obscene language.
  • Harassing, insulting or attacking others
  • Violating copyright laws
  • Damage to computers, computer systems or networks.
  • Using another person’s password or trespassing in their files, folders or work
  • Intentionally wasting limited resources
  • Using network for commercial or political purposes
  • Revealing person information (photos, addresses, phone numbers, etc.)
  • Disrupting the use of the network by other users.
  • Uploading or creating computer viruses.
  • Logging in as an administrator


Non-Sufficiently Funded Checks


The Jefferson County Board of Education has elected to use an outside company to recover returned checks.  No longer will the district or school staff arrange for the repayment of checks returned for non-sufficient funds.  Federal Automated Recovery Systems will be responsible for the electronic collection of NSF checks turned in to any school or district account.


Jefferson County Board of Education will gladly accept your checks.  When you provide a check as payment, you authorize us either to use information from the check to make a one-time electronic funds transfer from your account or to process the payment as a check transaction.  In addition, you authorize us to collect a fee (currently $30.00) through an electronic funds transfer from your account if your payment is returned unpaid.


Please include the following on your check:     Full Name, Street Address, and Phone Number & Driver’s License Number.





The Alabama Board of Nursing, Alabama State Department of Education and Jefferson County Board of Education have implemented guidelines related to medications in the school setting.  These important guidelines are:


  • If your child has prescription medication that needs to be taken at school, your doctor must complete an authorization before any medication can be given.  A new authorization is required for changes in dosage or time.
  • All medication that is administered at school must be in the original container. (No Ziplocs, envelopes, etc.)
  • Children are not permitted to transport medications from home to school.  Parents/Guardians must be responsible for bringing all medications to the school.  This includes cough drops, cough medicine, vitamins, supplements, etc.
  • A form must also be completed by the parent for over the counter medicines such as Tylenol, Motrin, Benadryl, etc. in the original container.  A two week limit is set for such medications.
  • Please do not send Extra-Strength Tylenol, Adult Strength Motrin or Advil (Ibuprofen), Aspirin or products containing Aspirin, or Aleve (Naproxin) without signed authorization from a doctor.
  • Liquid medications must be precisely measured.  Parents must provide a calibrated medicine cup, spoon or syringe.  Silverware or plastic spoons cannot be used.  If your child takes ½ of a pill, you should cut the pill(s) in half before bringing them to school.  School personnel are not responsible for cutting or crushing pills.
  • School personnel can treat cuts, scraped, bug bites, bumps, etc. with soap, water, band-aids, and ice bags only.
  • All medication should be picked up on the last day of school for students.  Medication that is not picked up by a parent/guardian within two weeks of the last day of school will be destroyed in the presence of a witness.


Drop Off and Pick Up procedures:


Clay Elementary requires that each child be dropped off at the front door of the school and enter only through the front door.  If you, the parent, must come into the school, please park your car in the appropriate parking spaces and enter through the front door only.  No child is to be dropped off in the parking lot and allowed to walk by themselves into the building.  If you are walking your child into the building, you must walk them all the way up the sidewalk to the flagpole and wait with them until it is clear for them to walk across to the front of the school.  Carline remains the safest way to drop off and pick up your child.  You may drop your child off as early as 7:30 but not before as there are not staff members to supervise them before this time.  All students should be here in their seats and ready to work by 7:55.  The tardy bell rings at 8:00.  Any student walking in the door at 8:00 or after is considered tardy.  This means that if you are in the carline at 8:00, even if there are multiple cars in line, your child will still be considered tardy.


(Pick Up Procedures on the next page)


Pick Up Procedures


When you pick up your child in the afternoon, we ask that you pick them up through the carline.  You must have the Clay Elementary Security Card hanging from your rear view mirror with each student’s name clearly printed on the card.  If you do not have the Security Card with you, you will be asked to park your car and come into the office to pick up your child by showing your identification.  Please remember these security measures are in place to protect the students at our school.





SCHOOL SYSTEM: _____________________________ SCHOOL YEAR: _______


SCHOOL: _____________________________________GRADE: _____________


Dear Parents or Guardians;


Please, complete the following survey. The results of this survey will be used to determine if you are possibly eligible for the Migrant Education Program.


Student Name: _____________________________________________________


Name of Parent or Guardian: __________________________________________


Address: __________________________________________________________


Telephone Number: _________________________________________________


1.       Have you moved during the last 3 years to work or to seek work even

         if it  was for a short period of time?                      YES ____     NO ____


2.      Are you or your spouse working or have you worked in an activity

        directly related to some of the following? Please, check () all applicable:


             The production or process of harvests, milk products, poultry farms,

               poultry plants, cattle farms

             Fruit farms

             The cultivation or cutting of trees

             Work in nurseries or sod farms

              Fish or shrimp farms

              Worm farms

              Catching or processing sea food (shrimp, oysters, crabs, fish, etc……)


3.       From what city, state or country did you come from? _________________




4.       What type of work did you or your spouse do before coming here? _____






Revised: 6/1/08 V.2










Clay Elementary

Authorization to record and use student image/voice for instructional purposes and/or other school related purposes.



I hereby give the Jefferson County Board of Education and person acting on its behalf (Clay Elementary) permission:



  • To record my child’s voice and photographic or video graphic image in the classroom and in other educational, instructional, or school settings, and to use such recordings for the purposes of internal staff training and instructional improvement.


  • To record, reproduce and distribute or make my child’s photographic or video graphic image available to newspapers, television and radio stations, and to other print electronic media organizations and outlets in order to portray Jefferson County programs, activities and students in an appropriate favorable light and for other uses as may be designed to promote public interest in and support of Jefferson County schools.


  • To publish my child’s photographic or video graphic image in school publications and media (yearbook, school and school support organization newsletters, athletic programs, school newspaper, school or school system website) for such reasonable and generally accepted purposes as are appropriate to the nature of the publication.


_____ I DO give permission for any photo/image, voice, video, work and/or first name of this student

to be utilized by Clay Elementary in any of the above for mentioned capacities.


_____ I DO NOT give permission for any photo/image, voice, video work and/or first name of this

student to be utilized by Clay Elementary in any of the above mentioned capacities.



Student Name: ___________________________________________________________


Teacher: ________________________        Date: ______________________________


Parent/Guardian Signature: _________________________________________________



Student Special Services Form


Student Name: ______________________________________


Does your child have an IEP (Individual Education Plan) in place:     Yes    or    No


If yes, what is your child’s exceptionality or diagnosis: __________________________


Has the student ever been TESTED for Learning disabilities?       Yes     or     No


If yes, what were the results: __________________________________________________________


Circle any of the following that the student has RECEIVED SERVICES for at any time:


Gifted             Learning Disabilities              Speech             Hearing           Vision


Emotional Disorder                Educable Mentally Retarded              Other Health Impairment    


List any services received that are not listed:______________________________________________


Has the student been part of the PST program (Problem Solving Team):   Yes or No


If yes, what accommodations were made for the student: _____________________________________________


Are there any areas academically where the student struggles or needs extra help: ___________________________


***Any NEW students with an IEP must present a copy at the time of registration.







Parent Signature: _________________________________________  Date: _________________





(Please circle the appropriate answer or fill in the blank)


Is student currently receiving services from the local school system?                 Yes    or          No

If Yes, which services? _______________________________________________________

Does child have a current Individualized Education Plan (IEP)?                       Yes    or          No

Has the student attended Early Head Start or Head Start?                                Yes    or          No

Has your child attended a State Funded Preschool (First Class Pre-K) program?

                                                                                                                             Yes    or          No

If Yes,         More than one year                  1 Year                  Less than 1 Year


Has the student attended a center based childcare program?                            Yes    or          No

If Yes,         More than one year                  1 Year                  Less than 1 Year


Has the student attended a home based childcare program?                              Yes    or          No

If Yes,         More than one year                  1 Year                  Less than 1 Year


Has the student participated in a home visiting program?                                 Yes    or          No

If Yes,         More than one year                  1 Year                  Less than 1 Year


Has student attended another preschool program?                                           Yes    or          No

If Yes,         More than one year                  1 Year                  Less than 1 Year


No Preschool:  My child was primarily taken care of at home by a relative prior to Kindergarten entry:                                                                                                                         Yes    or      No






Parent/Guardian Signature _______________________________       Date ____