For Office Use Only

Student ID # __________________

School ______________________

2016-2017 Transportation_________________

Student's Legal Name (as it appears on the Birth Certificate)

First Name ________________________________Middle Name ______________________ Last Name ________________________

Grade __________ Gender __________ Male __________ Female Date of Birth _____________ Age ______

Student's email (if any) ___________________________________ Nickname/Alias _____________________________________

Address ____________________________________________________ City __________________ Zip Code _____________

Apartment/Housing Addition ________________________________________ Home Phone ______________________________

Birth City ____________________________________________________ Birth State _____________________________________

If not born in the US:

Birth Country _____________________________ US Entry Date ________________ First Date in US Schools _____________

Indian Tribe _______________________________________________________________ CDIB Number ______________________

Transportation Parent Pick-Up _____ Bus Rider _____ Driver _____ Walker _____ Daycare (specify) ______________________

Has your child ever attended Mid-Del Schools? Yes _____ No ______ Start Date __________ End Date __________

Has your child ever been homeschooled? Yes _____ No ______ Start Date __________ End Date __________

Name of last school attended __________________________________________ City ________________________ State _____

Name of ALL high schools attended ____________________________________________________________________________________

School Phone _______________________________ School FAX _______________________ Withdrawal Date _____________

Does this student have a current IEP? Yes ____ No ____ Does this student have a current 504? Yes ____ No ____

Has this student ever participated in a Gifted and Talented Program? Yes _____ No ______

Is this student currently under suspension from another school? Yes _____ No _____

Does your student currently participate in the Oklahoma's Promise Program (OHLAP)? Yes ______ No ______

Siblings under the age of 18 living at home:

Name Grade Gender

Name Grade Gender

Name Grade Gender

Is any parent/legal guardian (including non-custodial) an active duty military member? Yes _____ No _____Is any parent/legal guardian (including non-custodial) a military reserve member? Yes _____ No _____Is any parent/legal guardian (including non-custodial) a National Guard member? Yes _____ No _____

School

Pursuant to the School Laws of Oklahoma, Mid-Del Public Schools prohibits the attendance of a student under suspension from another school, until such time as the terms of the suspension have been met or the suspension has expired. The circumstances of an individual's suspension may be reviewed.

Mid-Del Public SchoolsStudent Enrollment Information

School

Birth date

Birth date

Birth date School

Parent/Guardian Contact InformationStudent resides with: Mother/Father Mother Father Mother/Step-Father Father/Step-Mother OtherList contacts in preference order for notification - legal guardians must be listed as first contacts. (Only one person per line)

Parent/Guardian #1Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Work Phone

Employer Address

E-mail Address Relationship to student

Parent/Guardian #2Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Work Phone

Employer Address

E-mail Address Relationship to student

Contact 3:Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Relationship to student

Contact 4:Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Relationship to student

Specify any other individual that is eligible to pick up this student in addition to the contacts listed above:

Name Phone Name Phone

Custody alert Legal Documentation on file? Yes ______ No______

Are you the legal guardian of this student? Yes NoIf no, explain below:

First Name

First Name

First Name

First Name

Student Name_____________________________________ Grade________ School__________________________

Health Information

Has this student been diagnosed with any of these conditions?

Diabetes Yes _____ No _____ Name of medications currently taking ___________________________

Asthma Yes _____ No _____ Name of medications currently taking ___________________________

Seizures Yes _____ No _____ Name of medications currently taking ___________________________

Does this student have a severe allergy that requires Epinephrine? Yes _____ No _____

Does this student have any other chronic health conditions? Yes _____ No _____

If yes, explain below:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Does this student have any medically documented food allergies? Yes _____ No _____

Parent/Guardian Signature_____________________________________ Date___________________

By signing this form I do hereby affirm that the student listed above is not currently under suspension from

another school district. I also affirm that the facts stated herein are true. Any false statement subjects the above

named student to immediate withdrawal.

Medications that are prescribed to be taken during the school day must be brought to the office by an adult.

List medications to be given at school (even if only taken at home): Parental Authority to Administer Medication

form must be on file for each prescribed medication.

If yes, you must provide information from the student's physician explaining each allergy the child has. This

documentation must be provided by October 1 of each school year.

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I-22 R-1

Mid-Del Schools Internet Safety Policy Family Consent Form

Student Section

Student Name __________________________________________ Grade ____________________

School

I have read the Mid-Del District Policy, “Use of the Wide Area Network, The Internet, and

Other Technological Resources”. I agree to follow the rules contained in the Policy and any additional

rules provided by school staff. I understand that if I violate the rules my access privileges may be

revoked and school disciplinary and/or appropriate legal action may be taken.

Student Signature _________________________________________Date___________________

Parent or Guardian Section

I am the parent/guardian of _________________________, the minor student who has signed

the district’s agreement for student use of computerized information resources. I have been provided

with a copy and I have read the district’s Acceptable Use Policy and am aware that additional

guidelines and regulations concerning use of the district computer system are posted for students and

are available at my school for further examination.

I also acknowledge receiving notice that, unlike most traditional or library media materials, the

district computer system will potentially allow my son/daughter student access to external computer

networks not controlled by the school district. I understand that some materials available may be

inappropriate and objectionable; however, I acknowledge that it is impossible for the district to screen

or review all of the available materials. I accept responsibility to set and convey standards for

appropriate and acceptable use to my child when using the district computer system or any other

electronic media or communications.

I also acknowledge that my child will be allowed to post tasks or assignments they have

completed on the Internet. The Board has ensured that the requirements of the Children’s Internet

Protection Act (CIPA) have been addressed.

I hereby release the District, its personnel, and any institutions with which it is affiliated, from

any and all claims and damages of any nature arising from my child’s use of, or inability to use, the

District system, including, but not limited to claims that may arise from the unauthorized use of the

system to purchase products or services.

Please select one and return to the school.

No, I do not give permission for my child to have personal access to electronic communications.

Yes, I agree that my child may have access to electronic communications for educational purposes

only.

________________________________________________ __________________________

Parent or Guardian Signature Date

IF AT ANY TIME, YOU WISH TO CHANGE YOUR ELECTION ABOVE TO THE OTHER

CHOICE, YOU MUST NOTIFY THE PRINCIPAL OF YOUR CHILD’S SCHOOL IN WRITING.

(See Internet Safety Policy on back)

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I-22 R-1

Use of the Wide Area Network, The Internet, and Other Technological Resources

Internet Safety Policy (ISP)

The Board of Education provides the wide area network, local area networks, Internet access, and other technological

resources for the purpose of supporting and enhancing learning and teaching. The Board recognizes that guidelines must

be established to assure that these technologies are used to provide activities that are appropriate to the learning

environment.

Some material accessible via the Internet may contain items that are illegal, defamatory, inaccurate or potentially

offensive. The Board cannot guarantee that a student will not encounter questionable material on the Internet. This policy

addresses the following as required by CIPA:

A. Access by minors to inappropriate matter on the Internet and World Wide Web;

B. The safety and security of minors when using electronic mail, chat rooms, and other forms of direct electronic

communications;

C. Unauthorized access, including so-called “hacking,” and other unlawful activities by minors online;

D. Unauthorized disclosure, use, and dissemination of personal information regarding minors;

E. Measures designed to restrict minors’ access to materials harmful to minors; and

F. Educating minors about appropriate online behavior, including interacting with other individuals on social

networking websites and in chat rooms and cyber bullying awareness and response.

Acceptable uses of the network and Internet are activities resulting from specific tasks and assignments which support

learning and teaching and promote the district’s mission and goals.

Prohibited uses are those which violate the right to privacy or access to materials, information or files of another

individual or organization without permission; violate the copyright laws; spread computer viruses; deliberately attempt to

vandalize, damage, disable or disrupt the property of the District, another individual, organization or the network; or any

effort to locate, receive, transmit, store or print files or messages that are profane, obscene, sexually explicit or use

language that is offensive or degrading to others. Use for commercial activities, product advertisement or political

lobbying is also prohibited. Staff will be provided a school email account to be used for school purposes. Students may be

provided an email account to be used for school purposes. Electronic communications may be used for educational

purposes only. Supervision by an adult is required for students in Kindergarten through grade 12.

The District is responsible for protecting its networks in a reasonable manner against unauthorized access and/or

abuse, while making them accessible for authorized and legitimate users. This responsibility includes informing users of

expected standards of conduct and the punitive measures for violating them.

Before a student may access the Internet, parental permission will be required. In those cases involving adult student

training, business and industry training, or 18 year-old students, a signed statement declaring the participant’s intent to

comply with district policy and guidelines will be required. Students’ directory information may be referenced in the

Student Expectations Policies, Procedures and Safety Guidelines Handbook. (See Policy J-18)

The Superintendent or designee shall be responsible for developing guidelines to govern the use of these technologies

in the District.

For students to remain eligible as users, student use must be in support of and consistent with the educational

objectives of the District. Access requires responsibility. Students and all other users of the district’s networks and other

technological resources are responsible for respecting and adhering to local, state, federal and international laws and

guidelines governing use of information and the available technologies. Any attempt to violate the guidelines, terms and

conditions for use of technology, the network or the Internet may result in revocation of user privileges, other disciplinary

actions consistent with Board of Education policy and existing practice regarding inappropriate language or behavior,

including, but not limited to, suspension from school, termination of employment and/or appropriate legal action.

The District makes no warranties of any kind, either expressed or implied, for the Internet access it is providing. The

District will not be responsible for any damages users suffer, including, but not limited to, loss of data; delays or

interruptions in service; accuracy, nature or quality of information stored on District diskettes, hard drives or servers; and

accuracy, nature or quality of information gathered through district-provided Internet access.

The District will not be responsible for unauthorized financial obligations resulting from district-provided access to

the Internet.

Mid-Del Schools

Child Nutrition Program

2016-2017

It is the goal of the Mid-Del Schools Child Nutrition Program to make available to every

student a nutritious, well-prepared breakfast and/or lunch every day. A computerized

cash register system is used in the school cafeterias and an account has been created for

each child’s use. Students will be issued a personal identification number to access their

account. You may pre-pay into this account with cash, personal checks and/or My School

Bucks online program at www.myschoolbucks.com. We encourage all parents/guardians

to use our free My School Bucks online software to monitor your student’s purchases and

meal account activity.

Check Writing Policy

Personal checks made payable to the school Child Nutrition Program are accepted.

In the event, that a returned check is received on your child’s account, the Child

Nutrition Office will notify you. Payment must be made to the school within ten (10)

days of notification. Payment must be in the form of cash, cashiers check or money order.

If payment is not received within 10 days, Child Nutrition will no longer accept checks

on your child’s account.

Charge Policy

It is the responsibility of each student’s parent/guardian to maintain sufficient funds in

his/her meal account. If a child has a zero balance in his/her account, they will be

expected to pay at the cash register. Elementary students who do not have money to

purchase a lunch can charge no more than three lunch meals, in which time the account

must be made current (including payment of charges).

Secondary students will not receive meals unless money is in their meal account. Parents

are encouraged to have a plan with their child regarding what to do if lunch money is

forgotten, i.e. pay online & call the cafeteria or a relative to call to bring money, etc.

If you have any questions, please feel free to contact the Child Nutrition Department at

739-1611.

I have read, understand and agree to the above Check Writing and Charge Policies.

_________________________________________ Student Name

_________________________________________ ________________________

Parent/Guardian Signature Date

____ - 20____ 20 HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

FOR SCHOOL USE ONLY

Joy Hofmeister

State Superintendent of Public Instruction

Oklahoma State Department of Education

Name of Student: Student ID #: Gender: Male Female School Site: Grade:

Date of Birth: Place of Birth (City/State/Country): Is the student of Hispanic or Latino culture or origin? Yes No Select one or more of the following races: African American/Black American Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander Caucasian/White Parent’s/Guardian’s Name: Parent’s/Guardian’s Address:

Parent’s/Guardian’s Telephone Number: ( ) Cell Phone:

1. Is a language other than English used in your home? Yes No

If NO, go to numbers 6 and 7. If YES, what is that language? 2. Is that language spoken in the home MORE OFTEN than English? LESS OFTEN than English?

3. What language is spoken by adults in the home? 4. What was the first (1st) language your child learned to speak?

5. What was the date (month and year) your child first enrolled in a school in the United States?

6. Parent/Guardian Signature:

7. Date:

Last Name First Name Middle Name

Street City Zip Code

THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION. If a language other than English is spoken MORE OFTEN (see question #2), the student automatically qualifies as bilingual on application for accreditation.

OR If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation if he or she meets ONE OF THE FOLLOWING:

1. Scores 35% or below on norm-referenced test (NRT) on the composite reading score. 2. Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs). 3. Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs)

Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL), or the Oklahoma Pre-K Language Screening Tool.

Documentation of a test result for students who marked LESS OFTEN:

1. NRT Test Date: Name of the NRT: Reading Total Composite Score:

2. Reading OCCT Date: Score on Reading OCCT: Limited Knowledge Unsatisfactory Satisfactory Advanced

3. ACCESS for ELLs Test Date: Score on ACCESS for ELLs: 1 2

WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date: Score on K W-APT, W-APT, or MODEL: 1 2

Oklahoma Pre-K Language Screening Tool Date: Score on Pre-K Language Screening Tool:

Note: Have test score documentation available for regional accreditation officer review. 1 2

Mid-Del Schools

Parent Notification System I  agree  that  Mid-­‐Del  Public  Schools  will  contact  me  by  phone,  email  and  text  through  the  parent  noti=ication  system  unless  I  opt-­‐out  of  this  service,  which  I  may  do  at  any  time.  By  agreeing  to  this  service,  I  will  receive  noti=ications  from  the  school  including  school  closings,  upcoming  events  and  other  important  messages  from  the  school.      

Telephone  Consumer  Protection  Act  (TCPA)    -­‐  http://transition.fcc.gov/cgb/policy/TCPA-­‐Rules.pdf    

By  signing  this  form,  you  agree  to  allow  Mid-­‐Del  to  use  its  parent  noti=ication  system  to  contact  you  throughout  the      2016-­‐2017  school  year.    

______________________________________________________________  

                                                               Print  Student  Name  

______________________________________________________________  

                       Parent/Guardian  Signature    

No,  I  want  to  Opt-­‐Out  of  all  messages.    

�1

Student Directory Information

The  Mid-­‐Del  School  District  proposes  to  designate  the  following  personal  identifiable  information  contained  in  a  student’s  education  records  as  directory  information.    Parents  have  the  right  to  request  this  information  not  be  released.    Such  requests  must  be  made  in  writing  to  the  principal  at  the  school  site.    Unless  such  notice  is  received,  the  following  directory  information  may  be  disclosed:    

A.    The  student's  name;  

B.    The  student's  class  designation  (i.e.,  =irst  grade,  tenth  grade,  etc.);  

C.    The  student's  extracurricular  participation;  

D.    The  student's  achievement  awards  or  honors;  

E.    The  student’s  weight  and  height  if  a  member  of  an  athletic  team;  

F.    The  student’s  photograph  

Within  the  =irst  three  weeks  of  each  school  year,  the  school  district  will  publish  the  above  list,  or  a  revised  list,  of  items  of  directory  information  it  proposes  to  designate  as  directory  information.    For  students  enrolling  after  the  notice  is  published,  the  list  will  be  given  to  the  student's  parent  or  the  eligible  student  at  the  time  and  place  of  enrollment.  

After  the  parent  or  eligible  student  has  been  noti=ied,  he  or  she  will  have  two  weeks  to  advise  the  school  district  in  writing  (a  letter  to  the  school  principal’s  of=ice)  of  any  or  all  of  the  items  they  refuse  to  permit  the  district  to  designate  as  directory  information  about  the  student.  

At  the  end  of  the  two-­‐week  period,  each  student's  record  will  be  appropriately  marked  by  the  record  custodian  to  indicate  the  items  the  District  will  designate  as  directory  information  about  the  student.    This  designation  will  remain  in  effect  until  it  is  modi=ied  by  the  written  direction  of  the  student's  parent  or  the  eligible  student.

STAY CONNECTED Student Directory Information | Parent Notification System