30 Day Temporary Form

30 Day Temporary Form
(MUST BE COMPLETED IF A STATE ISSUED CERTIFICATE OF LIVE BIRTH IS NOT AVAILABLE AT SCHOOL REGISTRATION)
To local Law Enforcement Agency: This affidavit and any accompanying documentation is being submitted pursuant to WV Code $18-2-5c solely to determine whether the named student has been reported as a missing or abducted child. This information will not be disclosed to any other party except as provided under state law without the prior written consent of the parent or guardian of the student.
Name of person enrolling student
Relationship to student
Full name of student
I would like the school to use the following accurate information
Student's name appearing on birth certificate
Date of Birth
Current Age
Sex
City of Birth
County of Birth
State of Birth

Street Address

Street Address Line 2

City

Zip Code
Name of mother appearing on birth certificate
Country (If Not United States)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Race
Height
Weight
Height / Weight
Name of father appearing on birth certificate
Explanation of inability to produce a certified copy of birth record
By signing this Affidavit of Birth Record - Thirty Day Temporary, I understand that I have 30 days during which to place an order for a Certificate of Live Birth with the Vital Registration Office in the state in which my child was born and provide a copy to my child's school.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

I would like the school to use the following accurate information