Berkeley County School District

Returning Student Update Form

Student Demographic Information

School where the student is registering
Cane Bay High School

Student’s Name as it appears on the birth/proof of age

document:

First Name David

Middle Name Louis
Last Name Lopez
Suffix
Preferred Name

Date of Birth 7/14/2009

Gender Male
Enrolling in Grade 10
*If any of the above information is incorrect, please contact your
child's school.*

Student's Physical Address (No PO Box):

Subdivision/Community
Street Address 352 Bo Ln
Apt
City Summerville
State South Carolina
Zip 29486-2302
Do you need to update the student's physical address?
No

Student's Mailing Address

Street 352 Bo Ln
Apt./Suite
City Summerville
State South Carolina
Zip 29486-2302

Do you need to update the student's mailing address?

No

Home Phone 843-296-4183

Secondary Call #

Transportation

AM Transportation POV (Car Rider)

PM Transportation POV (Car Rider)

Special Programs

Does your student have a

No
current IEP?
Enrollment Survey

Right to Translation and Interpretation Services

In what language do you
wish to have Oral
English
Communication from the
school?
In what language do you
wish to have Written
English
Communication from the
school?

Title I, Part C: Education of Migratory Children & Youth

In the last three (3) years,
has anyone in your family
moved from another school No
district, state, city, or
country?
In the past six (6) years,
has anyone in your family
worked in any of the
following occupations? This
includes work related to
logging, timber
planting/growing,
No
harvesting, food processing
plant (such as poultry, pork,
beef, or vegetable),
packing houses (fruits and
vegetables), dairy farms, or
other general farm work not
listed.

McKinney-Vento
What best describes where
Single-family house/apartment/trailer
you live now?

Parent Information
Is a parent Active Duty Military?
No

The State of South Carolina has transitioned to a new system for storing contacts. Because of this, some contact data listed may be
incomplete or duplicated. Please carefully look at each parent/guardian contact listed and update if necessary. Only Parents/Guardians
should be in this section. To remove a contact, click on the “Remove Contact” button. A new Parent/Guardian contact can be added in its
place if needed. Ensure each contact is listed only ONCE.

* Please be advised that, if you are providing a cellular phone number, by listing a cellular phone number you are providing consent to the
Berkeley County School District to contact this number for non-emergency purposes via an automated calling system.

Parent/Guardian 1

First Name Dina

Middle Name
Last Name Lopez
Suffix
Relationship to Student
 Mother
Is this person a legal guardian?
Yes
Student lives with this contact?
Yes

Parent/Guardian 1 Physical/Residential Address

Street 352 Bo Ln
Apt / Unit / Ste
City Summerville
State South Carolina
Zip 29486-8240

Parent/Guardian 1 Contact Information

Phone 1 Number 843-296-4183

Phone 1 Type Mobile
Preferred phone number? Yes
Receives SMS Text
Yes
Messages?
[ ] Add additional phone number

Phone 2 Number 843-296-4183

Phone 2 Type Home
Preferred phone number? No
[ ] Add additional phone number

Phone 3 Number 843-296-4183

Phone 3 Type Daytime
Preferred phone number? Yes

Highest Level of Education High School Diploma

Email Address [email protected]
[ ] Check if this Parent/Guardian has no email
address.
Employer

Parent/Guardian 2

First Name Luis

Middle Name
Last Name Lopez
Suffix
Relationship to Student
Father

Is this person a legal guardian?

Yes
Authorized to pick child up from school?
Yes
Contact receives school communications?
Yes
Student lives with this contact?
Yes

Parent/Guardian 2 Physical/Residential Address

Street 352 Bo Ln
Apt / Unit / Ste
City Summerville
 State South Carolina
Zip 29486

Parent/Guardian 2 Contact Information

Phone 1 Number 843-296-4183

Phone 1 Type Mobile
Preferred phone number? Yes
Receives SMS Text
Yes
Messages?
[ ] Add additional phone number

Highest Level of Education No High School Diploma

Email Address
Employer Lopez Remodeling

Additional Parent/Guardian

Would you like to add

No
another parent/guardian?

Emergency Contacts (other than parents)

The State of South Carolina has transitioned to a new system for storing contacts. Because of this, some contact data listed may be
incomplete or duplicated. Please carefully look at each emergency contact and update if necessary. Only emergency contacts should be in
this section, not parents or guardians. To remove a contact, click on the “Remove Contact” button. A new emergency contact can be added in
its place if needed. Ensure each contact is listed only ONCE.

The individuals below have my permission to sign this student out of school, either for illness or early dismissal. These are the
ONLY individuals besides parent(s)/legal guardian(s) who will be allowed to check my student out of school after providing
appropriate picture ID.

Fill in information for at least one contact other than parent or legal guardian. Emergency contacts should be local contacts
whenever possible, and will only be contacted if parent/guardians are unavailable.
* Please be advised that, if you are providing a cellular phone number, by listing a cellular phone number you are providing consent to the
Berkeley County School District to contact this number for non-emergency purposes via an automated calling system.

Contact #1

First Name Anthony

Middle Name
Last Name Lopez
Suffix

Relationship to Student
Brother
Authorized to pick child up from school?
Yes
Emergency medical contact?
No
Email Address

Emergency Contact 1 Physical/Residential Address

Street
Apt / Unit / Ste
City
State
Zip

Emergency Contact 1 Contact Information

Phone 1 Number 843-442-7804

Phone 1 Type Mobile
Preferred phone number? No
Receives SMS Text
No
Messages?
[ ] Add additional phone number

Contact #2

First Name Daniel

Middle Name
Last Name Lopez
Suffix

Relationship to Student
Brother
Authorized to pick child up from school?
Yes
Emergency medical contact?
No
Email Address

Emergency Contact 2 Physical/Residential Address

Street
Apt / Unit / Ste
City
State
Zip

Emergency Contact 2 Contact Information

Phone 1 Number 843-442-7808

Phone 1 Type Mobile
Preferred phone number? No
Receives SMS Text
No
Messages?
[ ] Add additional phone number

Contact #3

First Name fernanda

Middle Name
Last Name pineda
Suffix

Relationship to Student
Friend
Authorized to pick child up from school?
Yes
Emergency medical contact?
No
Email Address

Emergency Contact 3 Physical/Residential Address

Street
Apt / Unit / Ste
City
State
Zip
Emergency Contact 3 Contact Information

Phone 1 Number 631-435-8630

Phone 1 Type Mobile
Preferred phone number? No
Receives SMS Text
No
Messages?
[ ] Add additional phone number

Additional Emergency Contact

Would you like to add

another emergency No
contact?

Emergency Contact Priority

To adjust the priority in which emergency contacts will be called, please select the appropriate order number next to the name.

Dina Lopez 1
Luis Lopez 2
Anthony Lopez 3
Daniel Lopez 4
fernanda pineda 5

Medical Information
Health care provider/Nurse
Eliza A Varadi
practioner name
Phone 843-795-3344
Last Physical/Visit 07/02/2023

Dental care provider name

Does the student have any medical problems, take medications, have a special diet, etc.?
No

Does the student have any allergies?

No
Does the student have
No
ADD/ADHD?
Does the student have
No
Anemia (Low Blood)?
Does the student have
Asthma? (Inhaler should
be available at school with No
completed medication
forms on file)
Does the student have a
No
Bladder/Urinary condition?
Does the student have a
Bone/Orthopedic No
condition?
Does the student have
No
Diabetes (Sugar)?
Does the student have
No
Epilepsy/Seizures?
Does the student have
No
Fainting Spells (Syncope)?
Does the student have a
No
Genetic Condition?
Does the student have
No
Heart Trouble?
Does the student have a
 Hemophilia/Bleeding No
disorder?
Does the student have
No
High Blood Pressure?
Does the student have
No
Mental Health Illness?
Does the student have
No
Problems with vision?
Does the student have
No
problems with hearing?
Does the student have
No
ReactiveAirwayDisease?
Does the student have
No
Sickle Cell?
Does the student have
No
Sickle Cell Trait Only?
Does the student have a
No
Skin Disorder?
Does the student have
No
Turberculosis (TB)?
Does the student have
No
other conditions?

Does your child take any

No
daily medications?

Primary Health Care Source

Emergency Room
Preferred Hospital Musc

Medicaid No

A Medication Authorization Form is required for medication delivery at school. This form is to be completed and signed by your child’s healthcare
provider and parent/legal guardian. Parents must sign a parental release form if student is to self medicate/carry his or her meds while at school
(i.e. albuterol inhaler). An Over the Counter Medication form is required for over the counter medication delivery at school. This form is completed
by parent/legal guardian

I GIVE THE SCHOOL NURSE PERMISSION TO COMPLETE THE ANNUAL HEALTH SCREENINGS AS RECOMMENDED PER SC DHEC. THESE
SCREENINGS INCLUDE VISION, HEARING, DENTAL, HEIGHT, WEIGHT AND BMI MEASUREMENTS.

I GIVE THE SCHOOL NURSE PERMISSION TO ENTER MY CHILD’S VACCINATION HISTORY INTO THE SC DHEC STATE IMMUNIZATION REGISTRY.

I GIVE THE SCHOOL NURSE PERMISSION TO SHARE THE ABOVE INFORMATION WITH SCHOOL STAFF AS NECESSARY FOR MEETING MY CHILD’S
EDUCATIONAL NEEDS.

Parent's/Guardian's Signature
Dina Lopez
Date 08/05/2024

Consent for Treatment, Release of Information, and Reimbursement

Click here to read the Notification of Use of Public Benefits and Consent for Treatment, Release of Information, and reimbursement for Non-IEP
Nursing Services.

I agree Yes

Student Internet Access

Internet in Residence
Yes – Internet Access in Residence
Options:

Internet Access: 1- Residential Broadband (eg, DSL, Cable, Fiber)

Internet Performance: 1- Yes – No issues
Device Access 2. Personal – Shared (sharing among others in household)

Use of Public Benefits

Click here to read the Notification of Use of Public Benefits/Consent to Bill Private Insurance and Medicaid policy.
 I have read and agree to
the Notification of Use of
Public Benefits/Consent to Yes
Bill Private Insurance and
Medicaid Policy.

Release of Student Information to Media

Click here to read the Release of Student Information to Media form.

The District MAY release publicity information during the 2024-2025 school year.
Yes
The District MAY release recruiter information during the 2024-2025 school year.
Yes
The District MAY release directory information during the 2024-2025 school year.
Yes

1:1 User Agreement

Click here to read the 1:1 User Agreement for participation in the mobile device take-home initiative.

I have received and carefully read the terms of this agreement. By giving my child permission to participate in the mobile device take-
home initiative, I understand and acknowledge that if my child does not honor all the terms in this agreement, take-home access may be
denied or restricted. I understand my child will be subject to disciplinary action at the school level, and he/she may be asked to surrender
his/her BCSD issued device.
Yes

Acceptable Use of Technology

Click here to read the Acceptable Use of Technology policy.

I/We have read Berkeley County School District’s technology acceptable use policy. I give permission for my child to conduct
independent research on the internet under the conditions described in the student handbook. I have explained to him/her the
acceptable ways in which the internet may be used. I understand that any violation of the guidelines may result in loss of Technology
privileges and/or disciplinary action.
Yes

Attendance Policy and Laws

Click here to read the Attendance Policy and Laws.

[X] I have read and agree to the Attendance Policy and Laws.

Document Upload
Please upload all required documents (.doc or .pdf) or images (jpg or .png) to complete your student’s registration. Your student’s registration is
NOT complete until all required documents have been uploaded or provided to the school. If required documents are not uploaded, please contact
the school to schedule an appointment to provide required documentation. Do not upload any documents containing a social security number. If a
social security number is visible, please strike through it prior to uploading the document.

PROOF OF RESIDENCY

Two proofs of residency are required in order for the child to attend Berkeley County School District. Each document must be current (no older than
45 days) and show the parent/legal guardian's correct name and address at the time of enrollment.

Š Proof of Residency Documents:

Š parent/legal guardian's current monthly utility bill (electric, gas, water) showing his/her correct name and address
Š parent/legal guardian's current monthly land line phone statement showing his/her correct name and address
Š parent/legal guardian's rental lease or real estate purchase contract showing his/her correct name and address
Š parent/legal guardian's cable or satellite bill showing his/her correct name and address
Š parent/legal guardian's rent receipt showing the address of the dwelling as well as the landlord/landlady's name, address and telephone
number; statements from apartment complexes or other multiple dwellings need to be on letterhead stationary showing the appropriate
information mentioned above
Š address at which the individual receives local, state and/or federal financial assistance
Š individual with whom the tax assessor's office lists as the owner of the property
 Š existence of a deed identifying the owner of the property
Š children of any parent/legal guardian residing out-of-district but in the process of building or buying a residence in the district may request
enrollment in the attendance zone's school of the new residence, provided the residence will be occupied within 90 days of the date of
enrollment; the parent/legal guardian must present a statement from the builder or seller showing the expected date of occupancy of the
new residence

Upload Proof of Residency

17228934689061435951087005392841.jpg
1 Here
Upload Proof of Residency
NO DOCUMENT UPLOADED
2 Here

PARENT/GUARDIAN IDENTIFICATION

Parent/legal guardian's proof of identification as a means of verifying identity.

Upload Drivers
License/Proof of Identity 17228935754472458707961118923817.jpg
Here

Signature
I understand that my student’s registration is NOT complete until all required documents have been uploaded or provided to the school.

[X] I Agree

Electronic Signature
The electronic signature below and its related fields are treated by Berkeley County School District like a handwritten signature on a paper form.

My signature indicates that the registration information I have provided is complete and accurate to the best of my knowledge.

I / We Agree Yes
Parent's/Guardian's Signature
Dina Lopez
Date 08/05/2024
Relationship to student Mother