ENROLLMENT CHECKLIST Please complete and sign ALL of the ... · referenced / HUD Verification with owner's name and address Closing escrow papers or warranty deed - Purchase dated

ENROLLMENT CHECKLIST

ENROLLMENT FORM (4 page form) MINNESOTA LANGUAGE SURVEY (1 page form) TRANSPORTATION FLYER - Online Student Transportation Special Request Form (1 page form) REQUEST FOR RECORDS FORM (1 page form) TITLEVIISTUDENTELIGIBILITYCERTIFICATION-OfficeofIndianEducation(1pageform) STUDENT INFORMATION FORM (1 page form) EMERGENCY CONTACT AND HEALTH HISTORY FORM (1 page form) STUDENT IMMUNIZATION FORM (2 page form)

FORM

SBI

OLOG

ICAL

PAR

ENT/

LEGA

L GU

ARDI

AN D

OCUM

ENTS

STUD

ENT

DOCU

MENT

S

PHOTOID(IncludeONEofthefollowingidentificationdocuments) Driver’sLicense Passport

StateID Military ID

PROOFOFRESIDENCY(BringTWO ofthefollowing) CurrentDriver’sLicensewithcurrentaddress CurrentUtilityBill-datedwithin60days LetterfromGovernmentAgency-datedwithin60days LeaseAgreement-signedbylesseeandlessorandshowtheleaseperiod(startdateandenddate) PurchaseAgreement-signedagreement(bybothbuyerandseller)withpurchasedateandaddress

referenced / HUDVerificationwithowner'snameandaddress Closing escrow papers or warranty deed - Purchase dated within 60 days Property Tax Statement -must show principal residential address and current year. Homeowners or Renters Insurance Policy - must be active and issued within 60 days (proof of insurance car

unacceptable) U.S Postal Service change of address confirmation letter -dated within 60 days (cannot be a PO Box)

IMMUNIZATION RECORDS BIRTH CERTIFICATE or PASSPORT (Early Childhood Special Education, Pre-Kindergarten, and Kindergarten)

EARLY CHILDHOOD SCREENING DOCUMENT (Early Childhood Special Education & Kindergarten only)(only if not screened in Osseo Area Schools )

TRANSCRIPT FROM PREVIOUS SCHOOL (6th through 12th grade only) SPECIAL EDUCATION RECORDS (If applicable) ANY COURT (LEGAL) DOCUMENTS RELATED TO THE STUDENT (If applicable)

Fordataprivacyinformation,seeschoolboardpolicy#515atdistrict279.org

2020-2021 School Year

Bring PHOTO ID and TWO PROOF OF RESIDENCY of biological parent/legal guardian. Approved documentation listed below:

Please complete and sign ALL of the attached forms listed below.

ALTERNATE

College ID Tribal ID

ENROLLMENT FORM SCHOOL ________________________________________ PROGRAM ______________ GRAD INCENTIVE ___________STUDENT ID

OFFICEUSE

ONLY

BEGIN DATE (mm/dd/yyyy) LAST LOCATIONCODE

NEW RE-ENTRY TRANSFER ADDRESS CHANGEMove date:

WARD OF THE STATE

HOMELESS

SHARED-TIME 504 IEP

PRIMARY LIVES WITH ADDRESS CHANGE

PRIMARY LIVES WITH ADDRESS CHANGE

DWELLING # FAMILY # CCARESIDENT DISTRICT RESIDENT SCHLEGAL 1 3 5 2 4 6

SAC

DWELLING # FAMILY # LEGAL 1 3 5 2 4 6

ACTION CODE NW EO SP OS RO

HOME LANGUAGE COMPLETED BY

1. STUDENT INFORMATION (LEGAL NAME AS IT APPEARS ON THE BIRTH CERTIFICATE)

LEGALNAME

LAST FIRST MIDDLE GENDER Male Female

BIRTH DATE (mm/dd/yyyy) ENR GRADE

ADDRESSMAIN STREET NAME & HOUSE NUMBER (Apt/Unit #) CITY STATE ZIP CODE

HOME PHONE WHO DOES THE STUDENTLIVE WITH?

CHECK ALL THAT APPLY STEPFATHER FATHER STEPMOTHER MOTHER OTHER - Relationship:

SAME AS MAIN ADDRESS



2. BIOLOGICAL OR ADOPTIVE PARENT #1 INFORMATION

LEGALNAME


RELATIONSHIP Father Mother

INCLUDE FOR MAILINGS? Yes No

ADDRESS(If different than MAIN)

STREET NAME & HOUSE NUMBER (Apt/Unit #) CITY STATE ZIP CODE

HOME PHONE CELL PHONE WORK PHONE EMAIL

3. BIOLOGICAL OR ADOPTIVE PARENT #2 INFORMATION

4. LEGAL GUARDIAN (LEGAL DOCUMENTATION IS REQUIRED TO USE THIS ADDRESS FOR SCHOOL ASSIGNMENT)

5. OTHER ADULT #1 (OTHER ADULT IN HOME WITH LEGAL RESPONSIBILITY FOR THE STUDENT)

LEGALNAME


RELATIONSHIP INCLUDE FOR MAILINGS? Yes No


6. OTHER ADULT #2 (OTHER ADULT IN HOME WITH LEGAL RESPONSIBILITY FOR THE STUDENT)LEGALNAME




LEGALNAME


INCLUDE FOR MAILINGS? Yes No




LEGALNAME






2020-2021 School Year1 of 4 ALTERNATE

RELATIONSHIP Father Mother

Military:A“Military-connectedyouth”meanshavingabiologicalparentorlegalguardianwhoiscurrentlyinthearmedforces(eitherasareservistoronactiveduty)orhasrecentlyretiredfromthearmedforces.

Expelled: Hasyourstudenteverbeenexpelledfromapreviousschool?ThisinformationisusedindeterminingifanOpenEnrollmentrequestwillbegranted.Determinationisbasedonthereasonfortheexpulsion.

Arrested: Hasyourstudenteverbeenarrestedresultinginacharge?Ifyes,theschooldistrictcontactstheprobationofficertoexchangeinformationregardingtheenrollment(suchasattendance,grades,etc.).Thisinformationisusedtodetermineifyourstudentiscurrentlyonprobation.

Title I–PartA(TitleI)oftheElementaryandSecondaryEducationAct,asamended(ESEA)providesfinancialassistancetoLocalEducationAgencies(LEAs)andschoolswithhighnumbersorhighpercentagesofchildrenfromlow-incomefamiliestohelpensurethatallchildrenmeetchallengingstateacademicstandards.Federalfundsarecurrentlyallocatedthroughfourstatutoryformulasthatarebasedprimarilyoncensuspovertyestimatesandthecostofeducationineachstate.

Section 504–Section504oftheRehabilitationActof1973(34C.F.R.Part104)isafederalcivilrightsstatutethatassuresindividualswillnotbediscriminatedagainstbasedontheirdisability.Allschooldistrictsthatreceivefederalfundingareresponsiblefortheimplementationofthislaw.IndividualswhohavebeendeterminedtohaveadisabilityunderSection504mayormaynotbedisabledunderspecialeducation(IDEA).Section504protectsastudentwithanimpairmentthatsubstantiallylimitsoneormoremajorlifeactivities,whetherthestudentreceivesspecialeducationservicesornot.ParentswhohaveconcernsorquestionsregardingSection504shouldcontacttheirbuildingprincipal.

Is this your student’s first school enrollment in the United States? Providingtheinformationisnotrequiredandtherequestedinformationwillonlybeusedtodeterminewhetherthechildmaybeeligibleforprogramsofferedinthedistrictthatprovideenhancedinstructionalopportunitiesforimmigrantchildrenandyouth.

Why do we ask these questions?

7. GENERAL ENROLLMENT QUESTIONS

2020-2021 School Year2 of 4

9. RACIAL/ETHNIC INFORMATIONThisinformationisforfederalandstatecivilrightsandstatisticalreports.Thisisanonscientificracial/ethnicdesignationasdefinedbytheU.S.DepartmentofEducation.ThemannerofcollectionisdescribedinRule3535.0120,DutiesoftheDistrict.

American Indian or Alaskan Native–ApersonhavingoriginsinanyoftheoriginalpeoplesofNorthandSouthAmerica,includingCentralAmerica,andwhomaintainsatribalaffiliationorcommunityattachment.

Asian–ApersonhavingoriginsinanyoftheoriginalpeoplesoftheFarEast,SoutheastAsiaortheIndianSubcontinentincluding,forexample,Cambodia,China,India,Japan,Korea,Malaysia,Pakistan,thePhilippineIslands,ThailandandVietnam.

Black or African American–ApersonhavingoriginsinanyoftheblackracialgroupsofAfrica.

Native Hawaiian/Other Pacific Islanders–ApersonhavingoriginsinanyoftheoriginalpeoplesofHawaii,Guam,SamoaorotherPacificIslands.

White–ApersonhavingoriginsinanyotheroriginalpeoplesofEurope,theMiddleEastorNorthAfrica.

Thisinformationisusedtoensuretheeducationalrightsandprotectionforstudentsexperiencinghomelessness.Ahomelessindividualisonewho:(1)lacksafixed,regularandadequatenighttimeresidenceand(2)includes:(a)childrenandyouthswhoaresharingthehousingofotherpersonsduetolossofhousing,economichardship,orasimilarreason;arelivinginmotels,hotels,orcampinggroundsduetothelackofalternativeadequateaccommodations;arelivinginanemergencyortransitionalshelter;areabandonedinhospitals;orareawaitingfostercareplacement;(b)childrenandyouthswhohaveaprimarynighttimeresidencethatisapublicorprivateplacenotdesignatedfororordinarilyusedasaregularsleepingaccommodationforhumanbeings:and(c)childrenandyouthswhoarelivingincars,parks,publicspaces,abandonedbuildings,substandardhousing,busortrainstations,orsimilarsettings.Youarenotrequiredtocompletetheinformationinthissectionoftheform.Ifyouchoosenottocompletethissectiontheremaybeadelayintheprovisionofservices.Theschoolteacher,schoolanddistrictadministratorsandtheMinnesotaDepartmentofEducation(MDE)haveaccesstothisinformation.

10. RESIDENCY INFORMATION

ALTERNATE

OFFICEUSE ONLY

STUDENT ID

ENROLLMENT FORM (continued)

7. GENERAL ENROLLMENT QUESTIONSHaveyourecentlymovedtotheschooldistrictinthelast36monthsfortemporaryorseasonal qYes qNoagricultureorfishingwork?

Isthestudentamemberofamilitaryfamily?(See definition on page 2) qYes qNo

IfYes,isthemilitarymemberactivelydeployedorexpectstobeactivelydeployedthisyear? qYes qNo

HasyourstudenteverenrolledinaMinnesotapublicschoolbefore? qYes qNo

HasyourstudenteverenrolledinISD279-OsseoAreaSchoolsbefore? qYes qNo

Isyourstudentcurrentlyenrolledinatalentedandgiftedprogram? qYes qNo

HasyourstudenteverreceivedhelplearningAmericanEnglish?(ESL,ELL,EL,etc.) qYes qNo

IsyourstudentcurrentlyreceivingTitleIservices?(See definition on page 2) qYes qNo

Doesyourstudenthaveasocialworker? qYes qNo

Nameandphonenumberofsocialworker:_______________________________________________________

Hasyourstudenteverbeenexpelledfromaschool? qYes qNo

IfYes,where?andwhen?____________________________________________________________________

Hasyourstudenteverbeenarrestedresultinginacharge? qYes qNo

Nameandphonenumberofprobationofficer:_____________________________________________________

IfenrollingforKindergarten,hasyourstudentcompletedEarlyChildhoodScreening? qYes qNo

IfYes,where?______________________________________________________________________________

DoesyourstudenthaveaSection504AccommodationPlanasdefinedbytheAmericanswith

DisabilitiesAct(ADA)?(See definition on page 2) qYes qNo

DoesyourstudenthaveaSpecialEducationIEP(IndividualEducationPlan)? qYes qNo

IfYes,whatisyourstudent’sdisability? (Check all that apply)

AutismSpectrumDisorders Emotional/BehaviorDisorders qSpeech/LanguageImpairments

DevelopmentalCognitiveDisability OtherHealthDisabilities qSeverelyMultipleImpaired

DevelopmentalDelay PhysicallyImpaired qTraumaticBrainInjury

Deaf–HardofHearing SpecificLearningDisabilities qVisuallyImpaired


ENROLLMENT FORM (continued)

7. GENERAL ENROLLMENT QUESTIONS - continuedThe district is sometimes able to offer translated documents and messages. How would you like to receive communications? English Hmong (Hmoob Dawb) Spanish (Español) Vietnamese (Tiêńg Viêt) Somali

Do you, as biological parent/legal guardian, need an interpreter? No Yes If yes, which language ____________________________________

What is your student’s country of birth? ____________________________________

Date your child first attended school in the USA? ____________________________ (mm/dd/yyyy)

Is this your student’s first school enrollment in the United States? qYes qNo

8. SIBLINGS OF THE STUDENT UNDER THE AGE OF 21 LIVING IN THE SAME HOUSEHOLDLAST NAME FIRST NAME MIDDLE

NAMEGENDER BIRTH DATE

(mm/dd/yyyy)GRADE SCHOOL

MaleFemale

MaleFemale

MaleFemale

MaleFemale

9. RACIAL/ETHNIC REPORTING INFORMATION (check ALL 3 columns)

10. RESIDENCY INFORMATION (McKINNEY - VENTO)Are you temporarily staying with another person or family due to loss of housing, economic hardship or similar reason? Yes qNoAre you living in a hotel, motel, or camping grounds due to lack of alternative, adequate housing? Yes qNoAre you living in emergency or transitional shelters, cars, parks, public spaces or similar places? Yes qNo

11. PREVIOUS SCHOOL ENROLLMENT INFORMATION. LIST ALL PREVIOUS ENROLLMENTS (Most recent first):DISTRICT NAME SCHOOL NAME STATE GRADE(S) WITHDRAW DATE

12. BIOLOGICAL PARENT/LEGAL GUARDIAN/OTHER PRIMARY CARE PROVIDER/EMANCIPATED STUDENT CERTIFICATIONI certify the information given above is true and complete to the best of my knowledge and belief.

Print Name ____________________________________________ Signature _______________________________________ Date _____________

Primary Racial Ethnic Backgroundfor STATE - Check ONE response Not Northern American Indian Northern American Indian

FEDERAL Reporting - Part ACheck ONE response Hispanic or Latino NOT Hispanic or Latino

FEDERAL Reporting - Part BCheck ALL responses that apply American Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Islander Hispanic or Latino Black, not of Hispanic origin White, not of Hispanic origin


OFFICEUSE ONLY

STUDENT ID

Will your child need bus transportationto/from childcare in 2020-21?

If your child will need to be picked up from (before school) and/or dropped off (after school) at a childcare location in 2020-2021, please let us know by completing an online Student Transportation Special Request form. Having this information by August 1 will help transportation staff plan efficient and effective bus routes.

Please complete the form online here:

http://bit.ly/studenttransrequest

Or you can request a hard copy from your child’s school or Enrollment Center.

Completing the form by August 1 will also help ensure that you receive a postcard during the last week of August with your student’s confirmed busing information.

You can also access your child’s busing information through ParentVUE throughout the school year.

As always, please call/email if you have any transportation questions:

E-mail: [email protected] Phone: 763-391-7244

Thank you for choosing Osseo Area Schools.

We wish you a great 2020-2021 school year!

2020-21

mailto:[email protected]

Ph: (763) 585-7350 Fx: (763) 585-7368

7051 Brooklyn Blvd. Brooklyn Center MN 55429

[email protected]

REQUEST FOR RECORDS FORM

DATE:____________________

Please send the official school records for:

STUDENT LEGALNAME________________________________________________________________________________(Last) (First) (Middle)

GRADE_______________DATEOFBIRTH________________________________GENDER M F(Mostrecentgrade) (Month/Day/Year)

Records are requested from:

PREVIOUS SCHOOL __________________________________________________________________________________

ADDRESS___________________________________________________________________________________________(City) (State) (Zip)

PHONENUMBER___________________________________FAXNUMBER_____________________________________

Please include:• Transcriptorcumulativefolder(dateofbirth,nameofbiologicalparents/legalguardians,address,datesofattendance,

daysabsent,coursestaken,gradesobtained,rankinclass,over-allgradeaverage,andstandardizedtestscores).• MINNESOTASCHOOLS-pleaseincludeACCESS,MCA-II,GRADandBSTscores,ifapplicable.

• Gradesatthetimeofwithdrawal• IMMUNIZATIONSandotherhealthrecords• SpecialEducationrecords,includingcurrentIEP,assessmentreports,andverificationofhandicap• Disciplinerecords-InaccordancewithFederalandStateStatutes,adistrictthattransmitsastudent’seducational

recordstoanotherschooldistricttowhichthestudentistransferringmustincludeinthetransmittedrecordsinformationaboutdisciplinaryactiontakenintheformofsuspensionandexpulsionandanydispositionorderwhichadjudicatesthestudentasdelinquentforcommittinganillegalactonschoolpropertyandcertainotherillegalacts.

Please forward these records to:

ISD279-OsseoAreaSchoolsEnrollmentCenter7051BrooklynBlvd.BrooklynCenter,MN55429-1371Phone:(763)585-7350Fax: (763) [email protected]

*Records request is authorized by:

Records are requested by the Enrollment Center:

_____________________________________________________(PrintedNameofBiologicalParent/LegalGuardian)

_____________________________________________________(SignatureofBiologicalParent/LegalGuardian)

* In accordance with revised Federal and State Statutes, written permission of the biological parent/legal guardian is notnecessary in the transfer of records to a school in which the student intends to enroll.


OMB Number: 1810-0021 Expiration Date: 07/31/2019

U.S. Department of Education Office of Indian Education

Washington, DC 20202 TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

Name of the Child __________________________________________________ Date of Birth ______________ Grade ______ (As shown on school enrollment records)

Name of School ____________________________________________________________________________________________

TRIBAL ENROLLMENT

Name of the individual with tribal enrollment: ___________________________________________________________________ (Individual named must be a descendent in the first or second generation)

The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent

Name of tribe or band for which individual above claims membership: _______________________________________________

The Tribe or Band is (select only one): _____ Federally Recognized _____ State Recognized _____ Terminated Tribe (Documentation required. Must attach to form) _____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988

as it was in effect October 19, 1994. (Documentation required. Must attach to form)

Proof of enrollment in tribe or band listed above, as defined by tribe or band is:

A. Membership or enrollment number (if readily available) _____________________________________________________ OR

B. Other Evidence of Membership in the tribe listed above (describe and attach) _______________________________________

Name and address of tribe or band maintaining enrollment data for the individual listed above:

Name ____________________________________________ Address ________________________________________________

City _______________________________State ______Zip Code ____________

ATTESTATION STATEMENT

I verify that the information provided above is accurate.

Name Parent/Guardian ______________________________________ Signature _______________________________________

Address ______________________________________ City ____________________________State ______Zip Code __________

Email Address ________________________________________ Date _______________

OMB Number: 1810-0021 Expiration Date: 07/31/2019

INSTRUCTIONS FOR THE ED 506 FORM

FOR APPLICANTS:

PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under this subpart, and that otherwise meets the requirements of subsection (b)”.

MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year, which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.

FOR PARENTS/GUARDIANS:

DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band, including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.

STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level.

TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can provide membership information.

Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to this form.

Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department ofInterior maintains a list of federally-recognized tribes, which OIE can provide you upon request.

State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department ofEducation does not maintain a master list. It is recommended that you use official state websites only.

Terminated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interiorand had that designation terminated.

Organized Indian Group- Member of an organized Indian group that received a grant under the Indian Education Act of 1988as it was in effect October 19, 1994.

Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent, or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate. Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians.

ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.

The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act.

PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of

information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021.

The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian

student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete

and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this

form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your

individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W.,

LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 07/31/2019.

STUDENT INFORMATION

STUDENT NAME ________________________________________________________________

Please read the following list and check/circle all that apply.

This information will be shared with staff at the school to help your student.

Initial at the bottom of the page if you have NO concerns

STUDENT HAD THE FOLLOWING AT PREVIOUS SCHOOL:

____ Advanced Placement Classes

____ English Language Support (EL, ELL, ESL)

____ 504 Accommodation Plan

____ Special Education Services (IEP) Primary Disability: _____________________________________

STUDENT MAY NEED SUPPORT IN THE FOLLOWING AREAS: (Check all that apply)

Reading Math Writing Behavior Attendance Mental Health

Family Change Social Skills English Language Credit Recovery

Other Concern(s) please list: ____________________________________________________________

STUDENT HAS HAD OR CURRENTLY HAS:

_____ Expulsion

_____ Suspension

_____ Chemical Use Concern

_____ Probation Officer

_____ Social worker

_____ Mental Health Concern

Therapist’s name & phone # _______________________________________________________

_____ Health/Medical Concerns- briefly describe ____________________________________________

_________ INITIAL HERE IF YOU HAVE NO CONCERNS FOR YOUR STUDENT


1. STUDENT INFORMATIONLEGALNAME

LAST FIRST MIDDLE GENDER

OFFICEUSE ONLY

STUDENT ID

EMERGENCY CONTACT AND HEALTH HISTORY FORMNOTES

BIRTHDATE(mm/dd/yyyy) ENR GRADE

2. EMERGENCY CONTACT INFORMATIONThisinformationisbeingcollectedtoprovideforthestudent’shealthandsafetyatschool.Refusaltosupplyemergencyinformationcouldresultintheschool’sinabilitytocontactyouincaseofanemergency.Intheeventofanemergencyandtheschoolisunabletoreachtheparent,theschoolwillsecureemergencyservices(medical,dental,paramedic,ambulance)formychild,atparentexpense.DistrictPolicyauthorizesschoolstafftoreleaseprivatedatatoappropriatepartiesinconnectionwithanemergencyiftheknowledgeoftheinformationisnecessarytoprotectthehealthandsafetyofthestudent.Icertifythatallinformationbelowisaccurateandthatitismyresponsibilitytoapprisetheschoolofanychangesinresidency,phonenumbers,andemergencyreleasecontacts.BIOLOGICAL PARENT/LEGAL GUARDIAN/OTHER ADULT that lives with the studentLEGALNAME

LAST FIRST MIDDLE GENDER RELATIONSHIP

HOME PHONE CELL PHONE WORK PHONE

LEGALNAME



PRIMARYEMAILADDRESS-Pleaselistonlyone DOCTOR/CLINIC NAME DOCTOR/CLINIC PHONE NUMBER

3. HEALTH HISTORY INFORMATIONThisinformationisrequiredinordertoprovideappropriatehealthservicesforyourstudent.Thisdatawillbetreatedasprivatedataandwillberecordedinthestudenthealthrecord.Itwillbesharedwiththoseworkingwithyourchildonlyona“needtoknow”basisandwithemergencypersonnelintheeventofanemergency.DOES YOUR CHILD HAVEANY OF THE FOLLOWINGCHRONIC HEALTHCONDITIONS?(Check all that apply)

ADD/ADHD HearingLoss SickleCellDisease/Trait Cancer HeartDisease Tuberculosis Diabetes Hepatitis VisionLoss Epilepsy/Seizures KidneyProblems WheelChairType:

Other(Explain)

DOESYOURCHILDHAVEALLERGIES?LIST:qYes No

DOES YOUR CHILD HAVE AN EPI-PEN? qEpi-Pen(Prescribed)-willbekeptinthenurse’sofficeqYes No qEpi-Pen(Prescribed)-studentwillself-carrytheirEpi-penDOES YOUR CHILD HAVE ASTHMA? qInhaler/Neb(Prescribed)-willbekeptinthenurse’sofficeqYes No qInhaler-studentwillself-carrytheirinhalerHASYOURCHILDBEENHOSPITALIZEDFORILLNESS,SURGERY,ORINJURY?IFYES,EXPLAIN:qYes No

DOESYOURCHILDTAKEANYMEDICATIONS?IFYES,LISTMEDICATIONS:qYes No

4. BIOLOGICAL PARENT/LEGAL GUARDIAN/OTHER PRIMARY CARE PROVIDER/EMANCIPATED STUDENT CERTIFICATIONIcertifytheinformationgivenaboveistrueandcompletetothebestofmyknowledgeandbelief.PrintedName__________________________________________________Signature___________________________________________________Date_________________


OTHER EMERGENCY CONTACT(S) - If possible please list at least two contactsLEGALNAME



LEGALNAME



LEGALNAME



Documents

ENROLLMENT CHECKLIST Please complete and sign ALL of the ... · referenced / HUD Verification with owner's name and address Closing escrow papers or warranty deed - Purchase dated