4/8/2016

Metropolitan Nashville Public Schools Registration Packet Cover Sheet

Only a custodial parent or legal guardian may register a student. ***A legal guardian must show proof of guardianship by presenting a copy of a Birth Certificate, custody papers, a court order or DCS Educational Passport.***. LegalGuardian’sLastName______________________________________________________LegalGuardianAddress______________________________________________________________

StudentstransferringfromanotherMetroNashvillePublicSchool:YouMustHaveWithYouToday:

____ProofofResidenceCurrentUtilityBillorLease/MortgageDocumentintheParent/Guardian’sname

____Parent/GuardianPhotoID

StudentsenrollinginfromanotherpublicSchoolwithintheStateofTennessee:YouMustHaveWithYouToday:

____ProofofResidenceCurrentUtilityBillorLease/MortgageDocumentintheParent/Guardian’sname

____Parent/GuardianPhotoID____StudentBirthCertificate/Verification

TransferringfromaTennesseeCounty:StudentstransferringfromanotherTNschoolwillbegiven30daystoshowproofofimmunizationsontheTNform

Ifyourstudent(s)isenrollingfromoutsidetheStateofTennesseeorfromoutsidetheUnitedStates,inadditiontotheinformationabove,youwillalsoneedthefollowing:____CurrentImmunizationsonaTNstateform

a. Transferring from outside the State of Tennessee: Parents must take their child's immunization records to a Davidson County Health Department location or contact a local physician to have the immunization record transferred to the Tennessee Certificate of Immunization.

b. Transferring from outside the United States:mustprovidebeforeenrolling____PhysicalExamRecord

a. StudentstransferringfromanotherUSschoolwillbegiven30daystocompleteandprovidedocumentationoftheirphysicalexamination.Examhastobewithin12monthsofthedateofenrollment.

b. StudenttransferringfromoutsidetheUnitesStatesmustprovideproofofaphysicaltoenroll.

*OFFICEUSEONLY*_____HERO/emailed _____RecordsRequest_____/_____/___________POA/emailed_____Approved_____Alert _____EmailedSchools_____SearchSMS _____ScanPacket_____SearchEIS|SSNY/N|Pin________________________ _____ReadytoMailPacket

ApprovedSchoolAssignment__________________________ Completedby_________________

1. Name____________________________________________________School__________________________________

2. Name____________________________________________________School__________________________________

1. (name) ______________________________________________2. (name) ___________________________________________________

Name______________________________________________________________________________________________ Last Name First MI

Home Address:_________________________________________APT#______ City ___________ ST ____ Zip _________

Mailing Address if different from Home address _________________________________________________________

Home Ph: (landline) ________________ Cell : ____________________ Parent / Guardian DOB________________

Email Address:______________________________________________________________

Allow this person access to: portal / attendance / behavior / mailings / teacher / message circle all that apply

EMERGENCY CONTACT Sequence 1 2 3

Name______________________________________________________________________________________________ Last Name First MI

Home Address:_________________________________________APT#______ City ___________ ST ____ Zip _________

Mailing Address if different from Home address _________________________________________________________

Home Ph: (landline) ________________ Cell : ____________________ Parent / Guardian DOB________________

Email Address:______________________________________________________________

Allow this person access to: portal / attendance / behavior / mailings / teacher / message circle all that apply

EMERGENCY CONTACT Sequence 1 2 3

Name____________________________________________________________________________________________ Last Name First MI

HOME Address:_______________________________________________________________APT#______

City ________________ St ______ Zip _________ Email Address:_____________________________________

Home Ph: (landline only) _____________________Cell : ___________________________ DOB__________________

If so what name were they enrolled under? _________________________________________________________

Allow this person access to: portal / attendance / behavior / mailings / teacher / message circle all that apply

EMERGENCY CONTACT Sequence 1 2 3

Emergency Contact ______________________________________ (M / F) phone_______________________________Last First MI

Emergency Contact ______________________________________ (M / F) phone_______________________________

Last First MI

Did this Parent/Guardian ever attend an MNPS school? Y / N

Metro Nashville Public Schools Student Registration Current MNPS students living with you. (name and school attending)

Parents/Guardians Living in the Household With Student

Did the Parent/Guardian ever attend an MNPS school? Y / N If so, what name were they enrolled under?

Relationship to Student (circle one) Mother / Father / Legal Guardian / POA **approval required**

Parents/Guardians Living in the Household With Student

Parents/Guardians Living at a Different Address Other Than The One Listed Above

Does this parent/guardian have joint custody? Y / N

Relationship to Student (circle one) Mother / Father / Legal Guardian / POA ***approval required***

Relationship to Student (circle one) Mother/ Father/ Legal Guardian/ POA **approval required**

If School Personnel cannot reach the parent/guardian with the phone numbers listed above who do they

call next?

PRIOR SCHOOL What school did this student last attend? _________________________City______________ST_______

Last Name__________________________________First name ___________________________________

Middle Name__________________DOB____/____/________ Sex _____ Social Security #________________

Birth City ____________ Birth County___________ Birth Country _______________ Birth State _________________

Has this student ever received services for: EL 504 IEP Has this student ever been expelled? Y / N

Legal Alert: ______________________________________________________________________

My child has no health problems which would affect his/her school day. Y / N

Allergies to (Nuts, Bees, Food, Other please list)_____________________________________________________

Asthma, is inhaler prescribed? Yes _____ No _____ Home only? _____ Need at school?

Diabetes Type 1 _____ Type 2 _____ What medication taken? __________________________________________

Seizures - what type? ___________________________________________ Date of last seizure? ______________Behavior/Emotional (ADHD, Depression) Catheterization Cancer/Leukemia Sickle Cell Anemia

Heart Problems _______________________________________________ Date diagnosed? ___________________

Any other condition you would like to tell us about___________________________________________________

1. What is the first language this child learned to speak? _______________________

2. What language does this child speak most often outside of school? _______________________

3. What language do people usually speak in your child’s home? _______________________

___Home/Apartment owned or rented by the student's parent/legal guardian

___a campsite ___in an automobile_____With a relative or friend (family does not have a residence)

___Shelter ___in a motel ___Other housing (please explain) ____________________________________________

__________________________________________________________________

Student ID_______________________ Student PIN ___________________

Start Date ________________________ Enrolled at___________________

ES_____ Center_____________ Zoned School________________________

6/1/2016 jw

MNPS use only

NEW SCHOOL What school is this student registering for? ____________________________________Grade_________

Student Health Information

Date ________________________________________________

TENNESSEE STATE BOARD OF EDUCATION ESL PROGRAM POLICY 3.207, states that: "Each School District must administer

the Home Language Survey to all students entering the District for the first time."

The information is used to identify the need for English language support services for the student.

Please note : If the answer to question(s) 1, 2, or 3 is not English, The Office of EL will assess the student's English language

proficiency and additional forms will need to be completed.

Home Language Survey

Does your child have a health problem? (circle all that apply)

Statement of Residence: Where does the student stay at night? (Please check ONE)

I certify that the above information is true, accurate, and subject to verification. If any information is found to be fraudulent the student may be subject

to withdrawal and the parent/legal guardian subject to tuition reimbursement (TCA 49-6-3003).

Race (circle all that apply) Black/African American American Indian/Alaskan Native

Pacific Islander / Native Hawaiian Asian White

(If yes, a copy of the court order MUST be provided)

Ethnicity ( circle one ) : Hispanic or Non Hispanic

Parent/Legal Guardian signature required for enrollment

STUDENT ENROLLMENT INFORMATION

Optional

What is this student's Mother's maiden name__________________________________________________________

Medical Alert:____________________________________________________________________

Enrollment stamp here

June 2015 TN form #ED-5438

Tennessee Department of Education (TDOE) Title I, Part C of the Elementary and Secondary Education Act (ESEA)

Migrant Education Program

Occupational Survey Student Information: ______________________________________________________________ DATE: ____________ Last Name First Name Gender Race District: ______________________School: ________________________________Grade: ______ School Year: _______ Migrant students may be eligible for additional services and assistance. Please answer the following questions and return the survey to the school so that we can determine if your child qualifies for migrant services. 1. Did you or someone in your family come to Tennessee looking for temporary or seasonal work in a factory

processing foods or working in agriculture, fishing, or dairy (examples: working with tobacco, tomatoes, cotton, strawberries, nurseries, trees, pork, chickens, vegetables, etc.)?

YES _____ NO _____ If yes, please mark which member of the family does or did this kind of work: Mother ____ Father ____ Children ____ Other _____

2. Do you or someone in your family currently work in a factory processing foods or in agriculture, fishing, or dairy?

(examples: working with tobacco, tomatoes, cotton, strawberries, nurseries, trees, pork, chicken, vegetables, etc).

YES _____ NO _____ If yes, please mark which member of the family does or did this kind of work:

Mother ____ Father ____ Children ____ Other _____ 3. If your current job is not temporary work in agriculture or fishing, did you or someone in your family work in a

temporary or seasonal agriculture or fishing in the last 3 years?

YES ________ NO_____

If yes, where? _________________________________ _____________ ______________________ City State Country If you answered “yes” to any of the questions above, please answer questions 4, 5, and 6. 4. How long have you been in this county in Tennessee? _______________________________________

months years

5. What is your current address? _________________________________________________________________ Street Address City State Zip Code

6. What is your current telephone number with the area code? (____)____________________________________

NOTE TO THE SCHOOL: Please send all surveys with at least one “yes” response to your district migrant liaison. Please make sure the form is filled out completely. NOTE TO DISTRICT MIGRANT LIAISON: All surveys with at least one “yes” answer should be uploaded to the TNMEP site upon receipt. Please email migranted@blomand.net to inform Jessica Castañeda that new surveys have been uploaded.

June 2015 TN form #ED-5438

Tennessee Department of Education (TDOE) Title I, Part C of the Elementary and Secondary Education Act (ESEA)

Programa de Educación para Estudiantes Migrantes Encuesta Ocupacional

Nombre del Estudiante: ___________________________________________________________ FECHA: __________ Nombre Apellido Sexo Raza Distrito:_________________Escuela:_______________________________ Grado:__________ Año Escolar:________ El programa de educación para los estudiantes migrantes [MEP] es parte del Departamento de Educación Pública del Estado de Tennessee [TDOE] provee servicios a los niños y familias que se han mudado a Tennessee en los últimos 3 años. Para calificar por el programa, las familias deben de haberse mudado de un lugar a otro buscando trabajo temporal en agricultura, ganadería, o pesca. El programa registra a niños y jóvenes entre las edades de 3 a 21 años. Agradecemos que nos ayuden a determinar si su niño o pariente califica para recibir servicios de este programa. Por favor, conteste las siguientes preguntas y entregue este documento a la escuela. 1. ¿Vino Usted o alguien en su familia en busca de trabajo temporal en agricultura, el campo, una finca (ejemplo:

sembrando/cultivando/cosechando tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc.), o de pesca (empacadora de pescado o mariscos) o alguna fábrica que procesa alimentos como cerdos, pollos, vegetales, etc.?

SÍ ________ NO___________

Si su respuesta es “sí,” por favor, indique que miembro de su familia hizo este tipo de trabajo.

Madre_______ Padre_________ Hijos_______ Otros___________ 2. Trabaja ahora Ud. o alguien en su familia en agricultura (ejemplos: tabaco, papas, algodón, fresas, viveros, trabajo

con árboles, etc. ), en una lechería o en una fábrica procesando comida (puerco, pollo, vegetales, etc.)?

SÍ ________ NO___________

Si su respuesta es “sí,” por favor, indique que miembro de su familia hace este tipo de trabajo. Madre_______ Padre_________ Hijos_______ Otros___________ 3. Si su trabajo actual no se relaciona a la agricultura ni pesca, ¿Ha trabajado Usted o algún miembro de su familia en

este tipo de actividades en los últimos 3 años?

SÍ ________ NO___________

¿Dónde? ___________________ _________________ ________________ Ciudad Estado País Si usted contestó "sí" a alguna de las preguntas anteriores, por favor, conteste las preguntas abajo (#4, 5 y 6). 4. ¿Hace cuánto tiempo que se mudó a este condado? ______________________________________ Mes Año 5. ¿Cuál es su dirección actual? ___________________________________________________________ Dirección Ciudad Estado Código Postal 6. ¿Cuál es su número de teléfono actual (con el código de área)? (___)_______________________ NOTE TO THE SCHOOL: Please send all surveys with at least one “yes” response to your district migrant liaison. Please make sure the form is filled out completely. NOTE TO DISTRICT MIGRANT LIAISON: All surveys with at least one “yes” answer should be uploaded to the TNMEP site upon receipt. Please email migranted@blomand.net to inform Jessica Castañeda that new surveys have been uploaded.

Preschool Experiences

Child's Name

Date of Birth

District you are registering your child to attend in 2016-17

Name of preschool program(s) your child attended in 2015-16, if applicable

City and state where 2015-16 preschool program is located

Tell us how often your child attended preschool.

Attended half

day

(1-4 hours)

Attended full day

(5 or more hours)

Number of days

attended per week

Number of months

attended between

August 2015 and

August 2016

Public school pre-Kindergarten

(Pre-K classroom in a K-4 or K-12 public school, including elementary, middle, and/or high schools

and charter schools )

Private school pre-Kindergarten

(Pre-K classroom in a K-4, K-6, K-8 or K-12 non-public, tuition-based school )

Head Start

Child Care Center or Preschool

(Pre-K, K, 4s, 5s, or 3-5 yr old classroom at a public, private, or religious based preschool program )

Stayed home with parent/guardian

Home-based child care

(child care provided in an individual’s home that is not the parent/guardian )

Don’t know/chose not to answer

Tell us where your child attended preschool.

Check ALL options that apply

Thank you for your responses. This information will help us meet the needs of your child by understanding more about their preschool experiences.

If your child attended more than one preschool program between August 2015 and August 2016, please list the name of the program(s) and how many months he/she attended each

program.

1)

2)

3)

Metropolitan Nashville Public Schools 2016-2017 McKinney-Vento Eligibility Assessment FORM A The information on this form is required to meet the McKinney-Vento Act 42 U.S.C. 11434a(2), which is also known as Title X, Part C, of the No Child Left Behind Act. Under federal law a student may qualify for services under the McKinney-Vento Act if he/she is living in certain situations. The answers you give will help the school determine the services the student may be eligible to receive. The student will not be discriminated against based upon the information provided, and the information you provide is confidential. School____________________________________________________________________Date______________________________ Student Name______________________________________________________________Date of Birth________________________

(Last) (First) (Middle) Parent/Guardian Name_______________________________________________________Phone Number______________________ Student’s current address:_______________________________________________________________________________________ Street number and name Zip code 1. Where is the student currently living?

♣ In a hotel/motel - name of hotel/motel: ____________________________________________________________________ ♣ In a shelter/transitional housing program – name of program:___________________________________________________ ♣ With a relative or friend (family does not have housing) ♣ In a location not designed for sleeping such as a car, park or campsite ♣ In housing that is inadequate (i.e. no electricity, running water, etc.) ♣ Other situation – please explain:__________________________________________________________________________

2. Why is the student living in the above situation? ♣ Loss of housing due to eviction/foreclosure ♣ Asked to leave by parent/guardian ♣ Domestic violence ♣ Natural disaster (fire, flood, tornado, etc.) ♣ Financial hardship (lost job, rent too high, behind on bills, unable to pay deposits for own housing, etc.) ♣ Other – please explain:_________________________________________________________________________________

3. With whom does the student currently live?

♣ Parent/parents ♣ A friend or relative who is a legal guardian – name and number:_________________________________________________ ♣ A friend or relative who is not a legal guardian – name and number:______________________________________________

4. How long has the student lived at this residence?________________________________________________________________

5. What was the last address where the student or family had housing?_________________________________________________

6. What is the student’s or family’s mailing address?_______________________________________________________________

My signature below affirms that the information provided on this form is true and accurate to the best of my knowledge or belief. I understand that enrolling a child in a Tennessee public school under false pretense is punishable by law.

_________________________________________________ _____________________ _______________ Signature of Parent/Guardian or Person Enrolling the Student Relationship to student Date MNPS STAFF USE ONLY: MCKINNEY-VENTO ELIGIBILITY DETERMINATION ___Student MEETS the McKinney-Vento requirements and QUALIFIES as a student in transition ___Student DOES NOT MEET the McKinney-Vento requirements and DOES NOT QUALIFY as a student in transition ____________________________________________ ____________________________________ ______________ Signature of School District Employee School/Enrollment Center Date SCHOOL DISTRICT STAFF—Email form to HeroProgramReferrals@mnps.org or fax to 615-259-8664. File the original in the

student’s school record. Metropolitan Nashville Public Schools

2016-2017 McKinney-Vento Eligible Student, School Selection and Needs Assessment FORM B Student Name______________________________________________________________ SCHOOL SELECTION Students who qualify for services under the McKinney-Vento Act have two choices for school selection. Students may enroll in the zoned school for their temporary address or they may remain in the last school they attended or were attending at the time they lost housing. Please select one option below for this student.

♣ I would like to enroll this student in the zoned school for our temporary address.

♣ I would like for this student to remain in his/her current school even though we are now living in another school zone. School name:________________________________ ____Last date attended:______________________________________ **The McKinney-Vento Student School Placement and Transportation Assistance Form (Form D) must be completed for all students who select the option to remain in their current school.**

CURRENT NEEDS AND CONCERNS The HERO Program can provide assistance with the items listed below. Information on housing programs and other community resources will be provided in the Parent Pack Folder you receive from the enrollment center or from the student’s school. Please select the services below that would be helpful to you and we will make referrals to school resources.

♣ Academic/school performance concerns ♣ Attendance issues ♣ Backpack and school supplies ♣ Counseling needs ♣ Food assistance (weekend food packs to be sent home once a month) ♣ Standard school attire, size information must be provided. Circle one: Boys Girls Juniors Mens Womens

Pants/shorts size:_____ Shirt size:_____

SIBLING INFORMATION If the student has siblings who live in the same situation, please list their information below. You will need to complete separate HERO Forms for all school-age children in order for them to receive services. Please include school-age children as well as infants, toddlers and preschool age children. Name: __________________________________Birth date: ____________________School:_______________________ Name: __________________________________Birth date: ____________________School:_______________________ Name: __________________________________Birth date: ____________________School:_______________________ Name: __________________________________Birth date: ____________________School:______________________ SIGNATURES My signature below indicates that I have provided this family/student with a Parent Pack Folder detailing the rights of students under the McKinney-Vento law and I have reviewed this material with them. ____________________________________________________ _____________________ _______________ Signature of School District Employee School/Enrollment Center Date My signature below indicates that I have received a copy of my rights under the McKinney-Vento law and the information has been explained to me. ____________________________________________________ _____________________ _______________ Signature of Parent/Guardian or Person Enrolling the Student Phone Number Date

SCHOOL DISTRICT STAFF—Email form to HEROProgramReferrals@mnps.org or fax to 615-259-8664. File the original in the student’s school record.