3111F3

SNOHOMISH SCHOOL DISTRICT 201NEW STUDENT REGISTRATION FORM

SCHOOL: DATE:

Please complete additional registration information on back…

01/2017

IS THERE A JOINT‐CUSTODY OR PARENTING PLAN IN EFFECT?   Yes    No     (If yes, plan must be on file with the school)    Copy Attached 

 IS THERE A RESTRAINING ORDER IN EFFECT?    Yes      No      (If yes, legal papers must be on file with the school)      Copy Attached 

Restraining order is against:   Mother    Father     Other  

SCHOOL PREVIOUSLY ATTENDED  SCHOOL DISTRICT PREVIOUSLY ATTENDED  PREVIOUS SCHOOL LOCATION (City and State) 

HAS STUDENT EVER ATTENDED SNOHOMISH PUBLIC SCHOOLS?   Yes          No IF YES, NAME OF SCHOOL(S) ATTENDED  DATE ATTENDED (Month/Year) 

SECOND HOUSEHOLD  (Non‐custodial parent/guardian not residing with student) Legal Last Name  Legal First Name  Middle Name 

    RELATIONSHIP TO STUDENT  Father    Mother    Stepfather       Stepmother    Guardian  

Grandfather    Grandmother    Uncle       Aunt    Agency      Friend     Self 

PHONE #1 (include area code)  Home  Work      Cell

  Please check if unlisted

PHONE #2  (include area code)  Home   Work   Cell

  Please check if unlisted

PHONE #1 (include area code)  Home   Work    Cell

  Please check if unlisted

PHONE #2  (include area code)  Home   Work    Cell

  Please check if unlisted

FAMILY EMAIL ADDRESS  RELATIONSHIP TO STUDENT:      Father      Mother        Stepfather       Stepmother

Guardian Grandfather      Grandmother    Uncle        Aunt      Agency

Friend       SelfSECOND HOUSEHOLD MAILING ADDRESS  (Street/PO Box, City, State, ZIP)  ADDITIONAL MAILINGS REQUESTED 

 Yes    No

PRIMARY HOUSEHOLD  (primary parent/guardian where student resides) Legal Last Name (of primary contact)  Legal First Name  Middle Name 

PRIMARY CONTACT # (include area code)   Home    Work     Cell

 Please check if unlisted 

PRIMARY CONTACT PH #2  (area code)  Home    Work     Cell

 Please check if unlisted 

Legal  Last Name  Legal First Name  Middle Name  PHONE #1 (include area code)   Home    Work     Cell

 Please check if unlisted 

PHONE #2  (include area code)   Home       Work     Cell

 Please check if unlisted

FAMILY EMAIL ADDRESS  ADDITIONAL EMAIL ADDRESS 

RESIDENT ADDRESS 

Street  Apt #  City  State  ZIP 

MAILING ADDRESS (If different from above) 

Street  Apt # P O Box City  State  ZIP 

      Has any member of your family ever been enrolled in the Snohomish School District?            Yes No

STUDENT NAME:     Legal Last Name  Legal First Name  Legal Middle Name  Also Known As: 

BIRTHDATE (Month/Day/Year)  GENDER      F         M            

BIRTHPLACE:  City  County  State  Country  Grade Level: 

DISTRICT RESIDENT? Yes         No 

   Resident District: 

Military Family Status (circle)  A – U.S. Armed Forces active duty G – National Guard member M – More than one member of Armed Forces/National Guard 

N – No affiliation R‐ U.S. Armed Forces reserves  Z – Do not wish to state 

PRIMARY LANGUAGE SPOKEN AT HOME 

  English 

 Other

DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY 

STUDENT SCHOOL NUMBER  SCHOOL ENTRY DATE  MEDICAL ALERT  HOMEROOM NUMBER  LOCKER NUMBER  BUS ROUTE 

AM PM

RELATIONSHIP TO STUDENT  Father    Mother    Stepfather       Stepmother    Guardian  

Grandfather    Grandmother    Uncle       Aunt    Agency      Friend     Self

RELATIONSHIP TO STUDENT  Father    Mother    Stepfather       Stepmother    Guardian  

Grandfather    Grandmother    Uncle       Aunt    Agency      Friend     Self 

(Non‐custodial parent/guardian not residing with student) Legal  Last Name  Legal First Name  Middle Name 

RELATIONSHIP TO STUDENT  Father    Mother    Stepfather       Stepmother    Guardian  

Grandfather    Grandmother    Uncle       Aunt    Agency      Friend     Self 

   

    3111F1

STUDENT RELEASE AUTHORIZATION 

When injury, illness or other non‐emergency situations occur involving your child, we want to be able to quickly reach families or otherresponsible adults. In the event we cannot reach a parent/guardian, please list persons you trust who are available during the day to provide care for your child. 

Continue to next page for Ethnicity & Race Information

01/2017

EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child. 

Legal Parent/Guardian Signature  Date 

PRIMARY EMERGENCY  CONTACT (after parent/guardian contact) Legal Last Name  Legal First Name 

   RELATIONSHIP TO CHILD  PHONE #1 (include area code)  Home        Work         Cell

PHONE #2   (include area code)  Home                   Work       Cell 

PRIMARY CONTACT ADDRESS  Street  City  State  ZIP 

SECONDARY EMERGENCY CONTACT (after parent/guardian contact) Legal Last Name  Legal First Name 

RELATIONSHIP TO CHILD  PHONE #1  (include area code)  Home         Work         Cell

PHONE #2   (include area code)  Home  Work       Cell 

SECONDARY CONTACT ADDRESS  Street  City  State  ZIP 

STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above. 

Legal Parent/Guardian Signature  Date 

SPECIAL INSTRUCTIONS REGARDING RELIGIOUS BELIEFS (Please provide information to school in writing) 

PLEASE LIST OTHER SIBLINGS ATTENDING SNOHOMISH PUBLIC SCHOOLS 

Last Name  First Name  School Grade 

DOES STUDENT ATTEND CHILD CARE? 

Before school     After school    Before and after school

CHILD CARE PROVIDER  Name  Address  Phone Number 

ADDITIONAL CHILD CARE ARRANGEMENTS (Please provide information to school in writing) 

HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL EDUCATION 

PROGRAM?    Yes    No 

HAS YOUR CHILD EVER BEEN ON AN IEP? (Individualized Education Program)      Yes       No 

HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN?    Yes      No 

HAS YOUR CHILD EVER PARTICPATED IN:    Title  –  Title 1 Services 

LAP – Learning Assistance Program

Gifted – Accelerated Learning Program

ELL – English Language Learner

HAS YOUR CHILD EVER BEEN RETAINED? 

 Yes    No 

If yes, at what grade level(s)  

HAS THE STUDENT EVER BEEN SUSPENDED FOR A WEAPONS VIOLATION?   Yes   No  Date:  

 

   

   

         

    3111F1

SNOHOMISH SCHOOL DISTRICT NO. 201Ethnicity and Race Collection Form – State and Federally Required Information 

QUESTION 1. Is your child of Hispanic or Latino origin? (Check all that apply) 

QUESTION 2. What race(s) do you consider your child? (Check all that apply) 

QUESTION 3. What local race do you consider your child? (Choose one only, please) 

ASIAN BLACK, NON‐HISPANIC HISPANIC AMERICAN INDIAN/ALASKAN NATIVE

MULTIRACIAL PACIFIC ISLANDER  WHITE, NON HISPANIC NOT PROVIDED

REQUIRED INFORMATION:   If born in a country other than the United States, please answer these questions: 

How many months have you been in US?  How many years?  Has your child had any formal education outside the US? 

Where and how long?   

Legal Parent/Guardian Signature of Verification:    Date  

02/2018

 

MEXICAN/ MEXICAN AMERICAN/ CHICANO CENTRAL AMERICAN

SOUTH AMERICAN

LATIN AMERICAN 

OTHER HISPANIC/LATINO 

NOT HISPANIC/LATINO

  CUBAN

DOMINICAN

SPANIARD

ALASKA NATIVE

CHEHALIS COLVILLE

COWLITZ

HOH JAMESTOWN

KALISPEL LOWER

ELWHA LUMMI

MAKAH

MUCKLESHOOT

NISQUALLY

NOOKSACK

PORT GAMBLE KLALLAM

PUYALLUP

QUILEUTE

SAMISH

SAUK‐SUIATTLE

SHOALWATER

SKOKOMISH

SNOQUALMIE

SPOKANE SQUAXIN

ISLAND

STILLAGUAMISH

SUQUAMISH

SWINOMISH TULALIP

YAKIMA 

OTHER WASHINGTON INDIAN

OTHER AMERICAN INDIAN

AFRICAN AMERICAN/BLACK

WHITE

NATIVE HAWAIIAN 

FIJIAN

GUAMANIAN or CHAMORRO

MARIANA ISLANDER

MALANESIAN

MICRONESIAN

SAMOAN

TONGAN

OTHER PACIFIC ISLANDER

ASIAN INDIAN

CAMBODIAN

CHINESE FILIPINO

HMONG

INDONESIAN

JAPANESE

KOREAN

LAOTIAN

MALAYSIAN

PAKISTANI

SINGAPOREAN

TAIWANESE

THAI

VIETNAMESE

OTHER ASIAN

EMERGENCY INFORMATION

Snohomish School District No. 201, Snohomish, WA 98290

3431F1

Please print student’s last name

Bus #

In order to provide immediate and safe care for your child and carry out your wishes in case of injury or illness at school, we require the following information. Please fill out completely. Please Print. 

Student Name     

Last  First  Initial 

Birth date  Grad Year_    

Home Address  City  Zip    Home Phone         

Mailing Address if different from home address:      City                                             Zip    

Lives with:       Parents             Mother only             Mother/Stepfather                Guardian                   Father only                 Father/Stepmother     Other_          Parent/Guardian Name 1.    ____________________________             E‐mail Address       _____________________  Employer  _____________________Work Phone    ____________Cell Phone___ _____________________ 

       

  Parent/Guardian Name 2.    ____E‐mail Address    

Employer  Work Phone    Cell Phone

Primary language spoken at home:            English                                  Spanish  Other    

Day Care Provider (if applicable)    Phone       

Please complete the following if student has a non‐custodial parent who can make emergency decisions for the student and receive copies of records involving this student, including newsletters, grade reports, correspondence, etc. 

Home Address    City    Zip    Home Phone       

Parent/Guardian Name 1.      E‐mail Address      _ 

Place of business  Work Phone      Cell Phone   

Parent/Guardian Name 2.    E‐mail Address       

Place of business  Work Phone    Cell Phone   

In addition to the parent/guardian, if you cannot be reached, the school may call and release your child to any of the following:  

Name  1.  Relationship  Phone     

Work Phone      Cell Phone      

2.    Relationship  Phone      

Work Phone      

Cell Phone      

3.    Relationship  Phone      

Work Phone      

Cell Phone  ___  

Please list all children in Snohomish School District this year. (Please list students in this school first.) 

Last Name  First Name  School  Grade 

 

 

Signature of Parent or Legal Guardian  Date      Please check here if any information on this form is new.   ***THIS FORM MUST BE RETURNED AT REGISTRATION                                                1/2017 

Health History 3431 F3

MEDICAL HISTORY (check all that apply) OR no health concerns at this time (please sign form).

State law requires written permission from parent and/or a health care provider before any medications, prescription or over-the-counter medication may be taken at school. Forms are available from the school health rooms or school office. * Law requires that life threatening conditions such as anaphylaxis, asthma, or diabetes have a care plan completed prior to the first day of school. Please contact the building nurse as soon as possible to insure the paper work is complete.

If parent/guardian or authorized emergency contact cannot be reached at the time of a medical emergency, and if immediate care is urgent in the judgment of school authorities. I authorize and direct the school authorities to send the student to the hospital or doctor most accessible. I understand that I will assume full responsibility for the payment of any services rendered. I understand that the information given above will be shared with appropriate school staff that needs to know in order to provide for the health and safety of my student.

I understand that SSD staff may obtain immunization info from Washington State Immunization Information System to update my student’s immunization status. If I do NOT want SSD staff to obtain info from Washington State Immunization Information System I will check here.

Date Signature Relationship Phone

1/2018

Is medication needed at home? ☐NO ☐YES Please List ____________________________________________________________________________________________________________________________________

Is medication needed at school? ☐NO ☐YES Please List ____________________________________________________________________________________________________________________________________

To be completed by parent/guardian

(Last, First): ____________________________________________DOB: ______________ M F Grade: ____________ ID #: _______________

Student Name This information is needed to plan an appropriate program for your student and to prepare for an emergency, should one arise. Your building nurse will contact you if there are any

additional questions.

Hospital preference ___________________________________________________

Health insurance ☐NO ☐YES Name of Company ___________________________

Dental insurance ☐NO ☐YES Name of Company ___________________________

Family doctor ______________________________ Phone ____________________ Date of last physical exam____________ Date of last vision exam _______

Specialist __________________________________ Phone ____________________ Date of last exam ________________________________________________

Dentist ____________________________________ Phone ____________________ Date of last dental exam ___________________________________________

Orthodontist _______________________________ Phone ____________________ Date of last exam ________________________________________________

Congenital Conditions

A_ Please List ___________________________________

Hematology (Blood)

BB *Hemophilia_________________________________

BC Sickle Cell Anemia_____________________________

BD Other Blood Condition_________________________

Cardiovascular/Heart Conditions

C_ Please List___________________________________

Endocrine, Allergy, Immune System, Metabolic, and Nutritional

ED Allergy-Food___________________________________

EE Allergy–Insect__________________________________

E- Other Allergy___________________________________

EG*Anaphylactic Condition (Epi-Pen)_________________

EJ Cystic Fibrosis__________________________________

EK/L*Diabetes Type 1 *Diabetes Type 2

ENEating Disorder________________________________

EU Thyroid Disorder_______________________________

E_ Other Endocrine, Immune, or Metabolic Disorder_____

Gastrointestinal, Dental, and Oral Conditions

GA/J/K Celiac Disease Crohn’s Irritable Bowel

GH/LGastroesophageal Reflux Lactose Intolerance

GI Other________________________________________

GMLiver Disease __________________________________

GD Dental Condition _______________________________

GNOral Condition _________________________________

Musculoskeletal and Connective Tissue

MC Juvenile Idiopathic Arthritis_______________________

MD Muscular Dystrophy_____________________________

MFOsgood-Schlatter_______________________________

MH Scoliosis______________________________________

M_ Other________________________________________

Nervous System

NA Autism Spectrum Disorder

ADHD-Inattentive ADHD-Hyperactive/Impulsive

NB ADHD-Combined Diagnosed by: __________________

NE Cerebral Palsy___________________________________

NF Developmental Delay_____________________________

NH/I/J Migraines Headaches Shunt

NL Intellectually Disabled____________________________

NN Paralysis_______________________________________

NP Seizure Disorder_________________________________

NQ Sensory Condition_______________________________

NS Spina Bifida_____________________________________

NT Spinal Cord Injury________________________________

NU Traumatic Brain Injury____________________________

Behavioral Health Conditions

PH Sleep Disorder__________________________________

PI Tourette Syndrome______________________________

P_ Other_________________________________________

Respiratory

RA Exercise-Induced Bronchospasm *Inhaler

RB/C/DAsthma Mild *Moderate *Severe *Inhaler

RE Reactive Airway Disease__________________________

RF Other_________________________________________

Skin and Subcutaneous Tissue

SB Contact Dermatitis (Eczema)_______________________ S_ Other_________________________________________

Neoplasms (Cancer/Tumors)

T_ Please List______________________________________

Renal and Genitourinary

UB/U- Chronic Urinary Tract Infection Urinary Reflux

UC Dysmenorrhea (painful periods)____________________

U_ Other_________________________________________

Eye and Ear

YB Hearing Impaired________________________________

YA/YC Chronic Ear Infections________ Ear Condition______

YD Visually Impaired________________________________

YE Eye Condition______________ Wears Glasses____

2018-2019 Student Transportation Input Form Will your student ride the school bus during the 2018-2019 school year? Yes ______ No ______ Student's name (first and last) _______________________________________________________________ Student's ID number (please provide if known) _________________________________________________ Student address (home address and city) ______________________________________________________ School student will attend during the 2018-2019 school year

Cathcart Elementary ______ Centennial Middle School ______ Central Primary Center ______ Valley View Middle School ______ Cascade View Elementary ______ Glacier Peak High School ______ Dutch Hill Elementary ______ Snohomish High School ______ Emerson Elementary ______ Aim High School _______ Little Cedars Elementary ______ Machias Elementary ______ Riverview Elementary ______ Seattle Hill Elementary ______ Totem Falls Elementary ______

Grade student will be in during the 2018-2019 school year

Kindergarten ______ 7th grade ______ 1st grade ______ 8th grade ______ 2nd grade ______ 9th grade ______ 3rd grade ______ 10th grade ______ 4th grade ______ 11th grade ______ 5th grade ______ 12th grade ______ 6th grade ______

A.M pick-up location Home ______ Student does not plan to ride the bus ______ Other ______ P.M. drop-off location Home ______ Student does not plan to ride the bus ______ Other ______ Will student be making a request for a permanent bus pass at the beginning of the year for alternative pick-up or drop-off location? If so, to where? _________________________________________________ Parent's name (printed) ___________________________________________________________________ Parent's signature ________________________________________________________________________ E-mail address ___________________________________________________________________________ Contact phone number ____________________________________________________________________ The form will need to be completed for every student in your household who will attend a Snohomish School District School in the 2018-2019 school year. Please return this completed form to your student’s school. Please contact the Transportation Dept. at (360) 563-3525 if you have any questions or

concerns.

School Attendanceform1601 Avenue D, Snohomish, WA 98290-1799

360-563-7300 Fax 360-563-7279

School attendance is required by state law.• State law requires children from age 8 to 17 to attend

school.

• Children that are 6- or 7-years-old, who are enrolled in school, must also attend school.

• Youth who are 16 or older may be excused from attending school if they meet certain requirements per state law (RCW 28A.225.010).

• If your child is going to be absent, please contact the school office.

School’s duties upon a student’s absences:• If your child has two unexcused absences in one

month, state law (RCW 28A.225.020) requires we schedule a conference with you and your child.

• In elementary school after five excused absences in any month, or ten or more excused absences in the school year, the school district is required to contact you to schedule a conference. A conference is not required if your child has provided a doctor’s note, or pre-arranged the absence in writing, and plans are in place so your child does not fall behind academically.

• If your child has seven unexcused absences in any month or ten unexcused absences within the school year, we are required to file a petition with the juvenile court, alleging a violation of RCW 28A.225.010, the mandatory attendance laws. You and your child may need to appear in juvenile court.

Did you know? • Attending school on-time, all day, every day will give

your child the best chance of graduating from high school.

• Starting in kindergarten, missing on average just two days a month, whether excused or unexcused, makes it more likely that your child will not meet academic standards in math and reading by third grade.

• By 6th grade, absenteeism is one of three signs that a student may drop out of high school.

• Absences can be a sign that a student is losing interest in school, struggling with school work, dealing with a bully or facing some other potentially serious difficulty.

• By 9th grade, regular attendance is a better predictor of high school graduation rates than 8th grade test scores.

What you can do:• Don’t let your child stay home unless they are truly

sick, such as fever, vomiting, diarrhea, or a contagious rash.

• Avoid appointments and travel when school is in session.

• Keep track of your child’s attendance. Missing more than nine days, excused or unexcused, could put your child at risk of falling behind.

• Set a regular bedtime and morning routine as well as finishing homework and packing backpacks the night before.

• Have a back-up plan in place with family members, neighbors, or other parents for getting your child to school in case something comes up.

If you are struggling to get your child to school for any reason, we are here to support you and work with you towards possible solutions. Please do not hesitate to contact the school office to schedule an appointment to discuss your child’s attendance.

I acknowledge that I have read (or I have had someone read this to me) and I understand this document.

Student Name: ____________________________________________________________________________________________ First Middle Last

Date of Birth: __________________ Age: ______ Grade: ______ Name of School: ___________________________________

Current address:___________________________________________________________________________________________ Street City Zip

Phone/Contact Number: ___________________________________________________________________________________

Do you have other children that attend a school in the Snohomish School District?

Name: _________________________Date of Birth: _________Age: _______ Grade:_______ School: ___________________

Name: _________________________Date of Birth: _________Age: _______ Grade:_______ School: ___________________

Name: _________________________Date of Birth: _________Age: _______ Grade:_______ School: ___________________

I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate.

Print name of person completing form: ___________________________________________________________________

Signature: _____________________________________________________________Date: ___________________________

Relationship to student(s): Parent Guardian Self Other ––––––––––––––––––––––––––––––––––––––

Please read and complete this form and return to your child's school office by the end of September.

Student Housingquestionnaire

The answers to the following questions help determine educational services your child(ren) may be eligible to receive through the McKinney-Vento Homeless Assistance Act.

Are you ‘doubled up’ with another family due to a loss of housing or economic hardship? Yes No

Are you living in a motel/hotel due to lack of housing? Yes No

Are you living in transitional housing? Yes No

Are you living in a shelter? Yes No

Are you living in a car, park, campsite or location not usually used for sleeping accommodations? Yes No

Are you moving from place to place/couch surfing? Yes No

As a student, are you living with someone other than your parent? Yes No

Student Name: __________________________________________________________________________________________________________First Middle Last

Date of Birth: _____________________ Age: _______ Grade: ________ Name of School: _________________________________________

Current address: ________________________________________________________________________________________________________Street City Zip

Phone/Contact Number: _________________________________________________________________________________________________

Gender: _______________________________________________________________________________________________________________

Student is unaccompanied (not living with a parent or legal guardian)

Student is living with a parent or legal guardian

Do you have other children that attend a school in the Snohomish School District?

Name:______________________________ Date of Birth: ___________ Age: _________ Grade: _________School: ______________________

Name:______________________________ Date of Birth: ___________ Age: _________ Grade: _________School: ______________________

Name:______________________________ Date of Birth: ___________ Age: _________ Grade: _________School: ______________________

I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate.

Print name of person completing form: _________________________________________________________________________________

Signature: ______________________________________________________________________ Date: _______________________________

Relationship to student(s): Parent Guardian Self Other –––––––––––––––––––––––––––––––––––––––––––

1601 Avenue D, Snohomish, WA 98290-1799360-563-7300 Fax 360-563-7279

For School Staff Only: If “Yes” is checked for any question above, please give this form to the School Counselor or Administrator

    01/2017 

Photos/Recordings Opt‐Out Form

There are times during the year when photographs or audio‐visual recordings of studentsmay be taken for school or district use. When possible, we will alert parents in advance, but this is not always possible. 

It is important that you know that student family members, community members, and attendees at school events may take and publish photos and other recordings of students without coordinating such with school district personnel, and it is possible that your student could appear in a third party's photos and other recordings. Snohomish School District is not responsible for the use of any of your student’s likeness (photo, voice, etc.) that appears in those photos and recordings. 

You  may  choose  to  opt  out  of  allowing  your  student  to  appear  in  photos  or  otherrecordings taken by or on behalf of the Snohomish School District by checking and signing below. 

I do NOT want my student to appear in photos or audio‐visual recordings taken by or on behalf of the Snohomish School District. (By checking this box your student will NOT appear inANY  photos  and  recordings  taken  for  yearbook,  classroom/school/district  presentations,parent club/classroom/school/district newsletters, media, etc.) 

Please note – Opt‐out restrictions must be renewed at the beginning of each school year.

Student     _______________________________                _____________________________                                        Last Name            First Name 

Parent       _______________________________  _____________________________                                        Last Name          First Name 

3600F3

   

F o r  O f f i c e  U s e O n l y 1. Enter opt‐out date in Skyward student record – custom forms/internet opt out. 2. From WS/ST/TB/CF – web student/student tabs/custom forms 3. Check photo opt‐out box and enter date of opt out. 4. Retain this signed form at the school for the duration of school year. 

 

 

  

Parent Signature ___________________________________________________________________ 

Contact Phone __________________________              Date________________________________ 

If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). DOH 348-295 November 2017

Parents - Are Your Kids Ready for School?

Required Immunizations for School Year 2018-2019

Hepatitis B

DTaP/Tdap (Diphtheria, Tetanus,

Pertussis) Vaccine doses required may

be fewer than listed

Polio Vaccine doses required

may be fewer than listed

MMR (Measles, Mumps,

Rubella)

Varicella (Chickenpox)

Kindergarten – 5th Grade

3 doses within the correct timeframes

5 doses within the correct timeframes

4 doses within the correct timeframes

2 doses within the correct timeframes

2 doses within the correct timeframes

OR Healthcare provider verified

child had disease

6th – 12th Grade 3 doses within the correct timeframes

5 doses DTaP

AND

1 dose Tdap, all within the correct timeframes

4 doses within the correct timeframes

2 doses within the correct timeframes

2 doses within the correct timeframes

OR Healthcare provider verified

child had disease (Exceptions are allowed for

certain students)

Students must get vaccine doses at correct timeframes to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements.

Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/

Parent/Guardian Instructions: To see which vaccines are required for school, find your child’s grade and look only at that row going across to find the vaccines and number of doses required.

Certificate of Immunization Status (CIS) For Kindergarten-12th Grade / Child Care Entry

Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex: ____________________________________________________________________________________________________________________________________________________

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record. ______________________________________________________________ Parent/Guardian Signature Required Date

I certify that the information provided on this form is correct and verifiable.

______________________________________________________________ Parent/Guardian Signature Required Date

♦ Required for School and Child Care/Preschool Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Documentation of Disease Immunity Healthcare provider use only

If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider I certify that the child named on this CIS has: a verified history of Varicella (Chickenpox). laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. Diphtheria Mumps Other: Hepatitis A Polio __________ Hepatitis B Rubella __________ Hib Tetanus Measles Varicella

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name

● Required Only for Child Care/Preschool

Required Vaccines for School or Child Care Entry

♦ DTaP / DT (Diphtheria, Tetanus, Pertussis)

♦ Tdap (Tetanus, Diphtheria, Pertussis)

♦ Td (Tetanus, Diphtheria)

♦ Hepatitis B 2-dose schedule used between ages 11-15

● Hib (Haemophilus influenzae type b)

♦ IPV / OPV (Polio)

♦ MMR (Measles, Mumps, Rubella)

● PCV / PPSV (Pneumococcal)

♦ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV / MPSV (Meningococcal)

MenB (Meningococcal)

Rotavirus

Office Use Only:

Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide

database). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: waiisrecords@doh.wa.gov or 1-866-397-0337.

To fill out the form by hand: #1 Print your child’s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against

several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.

If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.

#4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.

Reference guide for vaccine trade names in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB® Hib Fluarix® Flu Havrix® Hep A Menveo® Meningococcal Rotarix® Rotavirus (RV1)

Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® DTaP + Hep B + IPV RotaTeq® Rotavirus (RV5)

Afluria® Flu FluLaval® Flu HibTITER® Hib PedvaxHIB® Hib Tenivac® Td

Bexsero® MenB FluMist® Flu Ipol® IPV Pentacel® DTaP + Hib + IPV Trumenba® MenB

Boostrix® Tdap Fluvirin® Flu Infanrix® DTaP Pneumovax® PPSV Twinrix® Hep A + Hep B

Cervarix® 2vHPV Fluzone® Flu Kinrix® DTaP + IPV Prevnar® PCV Vaqta® Hep A

Daptacel® DTaP Gardasil® 4vHPV Menactra® MCV or MCV4 ProQuad® MMR + Varicella Varivax® Varicella

Engerix-B® Hep B Gardasil® 9 9vHPV Menomune® MPSV4 Recombivax HB® Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 December 2016

Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 Meningococcal Conjugate Vaccine OPV Oral Poliovirus

Vaccine Tdap Tetanus, Diphtheria, acellular Pertussis

DTaP Diphtheria, Tetanus, acellular Pertussis

Hep B Hepatitis B MenB Meningococcal B PCV / PCV7 / PCV13

Pneumococcal Conjugate Vaccine VAR / VZV Varicella

DTP Diphtheria, Tetanus, Pertussis Hib Haemophilus

influenzae type b MPSV / MPSV4 Meningococcal Polysaccharide Vaccine

PPSV / PPV23 Pneumococcal Polysaccharide Vaccine

Flu (IIV) Influenza HPV (2vHPV / 4vHPV / 9vHPV)

Human Papillomavirus MMR Measles, Mumps,

Rubella Rota (RV1 / RV5) Rotavirus

HBIG Hepatitis B Immune Globulin IPV Inactivated

Poliovirus Vaccine MMRV Measles, Mumps, Rubella with Varicella

Td Tetanus, Diphtheria

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

Certificate of Exemption - Personal/Religious From School, Childcare, and Preschool Immunization Requirements Complete the box for the desired exemption type

If you have a disability and need this form in a different format please call 1-800-525-0127 (TDD/TTY Call 711) DOH-348-106 January 2018

Religious Membership Exemption Complete this section ONLY if you belong to a church or religion that objects to the use of medical treatment. Use the section above if you have a religious objection to vaccinations but the beliefs or teachings of your church or religion allow for your child to be treated by medical professionals such as doctors and nurses. Parent/Guardian Declaration I am the parent or legal guardian of the above named child. I affirm that I am a member of a church or religion whose teaching preclude health care practitioners from providing medical treatment to my child. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature Date Name of Church or Religion of which you are a member:

Personal/Philosophical or Religious Exemption Exemption Type: ☐Personal/Philosophical ☐Religious I am exempting my child from the requirement that my child be vaccinated against the following diseases to attend school or child care: Diphtheria Hepatitis B Hib Measles Mumps Pertussis (whooping cough) Pneumococcal Polio Rubella Tetanus Varicella (chickenpox)

Parent/Guardian Declaration One or more of the required vaccines are in conflict with my personal, philosophical or religious beliefs. I have discussed the benefits and risks of immunizations with the health care practitioner below. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature Date Health Care Practitioner Declaration I have discussed the benefits and risks of immunizations with the parent/legal guardian as a condition for exempting their child. I am a qualified MD, ND, DO, ARNP or PA licensed under Title 18 RCW, and the information provided on this form is complete and correct.

☐MD ☐ND ☐DO ☐ARNP ☐PA Licensed Health Care Practitioner Name (print) Licensed Health Care Practitioner Signature Date

Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Gender:

NOTICE: A parent or guardian may exempt their child from some or all vaccinations listed below by submitting this completed form to the child’s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. Exempted children/students may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. The diseases vaccines can protect against still exist, and can spread quickly in school and child care settings. Immunizations are one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death.

Certificate of Exemption - Medical From School, Childcare, and Preschool Immunization Requirements Complete the box for the desired exemption type

If you have a disability and need this form in a different format please call 1-800-525-0127 (TDD/TTY Call 711) DOH-348-106 January 2018

NOTICE: A parent or guardian may exempt their child from some or all vaccinations listed below by submitting this completed form to the child’s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. Exempted children/students may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. The diseases that vaccines can protect against still exist, and can spread quickly in school and child care settings. Immunizations are one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death.

Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Gender:

Medical Exemption Licensed Health Care Practitioner (MD, ND, DO, ARNP, PA) completes this section. A health care practitioner may grant a medical exemption to a vaccine antigen required by rule of the state board of health only if in his or her medical judgment, the vaccine antigen is not advisable for the child. When it is determined that this particular vaccine antigen is no longer contraindicated, the child will be required to have the vaccine (RCW 28A.210.090). Guidance for medical exemptions for vaccination can be obtained from the contraindications, indications, and precautions described in the vaccine manufacturer’s package insert and by the most recent recommendations of the Advisory Committee on Immunization Practices (ACIP) available in the Centers for Disease Control and Prevention publication, Guide to Vaccine Contraindications and Precautions. This guide can be found at the following website: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html

Please indicate which vaccine antigen(s) the medical exemption is referring to:

Disease Permanent Temporary Expiration Date for Temporary Medical

Diphtheria

Hepatitis B

Hib

Measles Mumps

Pertussis

Pneumococcal

Polio Rubella

Tetanus

Varicella I declare that vaccination for the disease/s checked above is not advisable for this child. I have discussed the benefits and risks of immunizations with the parent/legal guardian as a condition for exempting their child. I am a qualified MD, ND, DO, ARNP or PA licensed under Title 18 RCW, and the information provided on this form is complete and correct.

☐MD ☐ND ☐DO ☐ARNP ☐PA Licensed Health Care Practitioner Name (print) Licensed Health Care Practitioner Signature Date

Parent/Guardian Declaration I have discussed the benefits and risks of immunizations with the health care practitioner granting this medical exemption. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct.

Parent/Guardian Name (print) Parent/Guardian Signature Date

English/November 2016

Office of Superintendent of Public Instruction (OSPI)

Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools.

Student Name: Grade: Date:

Parent/Guardian Name Parent/Guardian Signature

Right to Translation and

Interpretation Services

Indicate your language preference so

we can provide an interpreter or

translated documents, free of

charge, when you need them.

All parents have the right to information about their child’s

education in a language they understand.

1. In what language(s) would your family prefer to communicate

with the school?

__________________________________

Eligibility for Language

Development Support

Information about the student’s

language helps us identify students

who qualify for support to develop

the language skills necessary for

success in school. Testing may be

necessary to determine if language

supports are needed.

2. What language did your child learn first?

__________________________________

3. What language does your child use the most at home?

__________________________________

4. What is the primary language used in the home, regardless of

the language spoken by your child?

__________________________________

5. Has your child received English language development support

in a previous school? Yes___ No___ Don’t Know___

Prior Education

Your responses about your child’s

birth country and previous

education:

Give us information about the

knowledge and skills your child is

bringing to school.

May enable the school district to

receive additional federal funding

to provide support to your child.

This form is not used to identify

students’ immigration status.

6. In what country was your child born? ___________________

7. Has your child ever received formal education outside of the

United States? (Kindergarten – 12th grade) ____Yes ____No

If yes: Number of months: ______________

Language of instruction: ______________

8. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________

Month Day Year

Thank you for providing the information needed on the Home Language Survey. Contact your school

district if you have further questions about this form or about services available at your child’s school.

Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.

Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative

Commons Attribution 4.0 International License.

SNOHOMISH SCHOOL DISTRICT NO. 201 

Snohomish, Washington  98290 

CONSENT TO RELEASE EDUCATIONAL RECORDS    

Student_________________________________________________________ Birth date__________________  Last         First     Middle 

School_________________________________________________________________________________________________________________

For  the purpose of gathering data  relevant  to educational  programming,  I  authorize  the  release of  information regarding the above‐named student between the Snohomish School District and: 

Name/Agency___________________________________________________________ Phone_____________________ 

Address________________________________City/State_______________________ Zip________________________ 

Name/Agency___________________________________________________________ Phone_____________________ 

Address________________________________City/State________________________Zip________________________ 

I acknowledge notification of this transfer of records as required by the Family Educational Rights and Privacy Act of  1974  and  understand  that  I 

have  a  right  to  receive  a  copy at my own  expense,  if  requested,  and  have  an opportunity for a hearing to challenge the content of the records. 

I understand that the information transferred will be  treated  in  a  confidential  manner  and  will  not  be  transmitted  to  a  third  party without 

my consent,  except  as allowed by WAC 392‐171‐631. 

Signature_________________________________________________________________________Date______________________Parent, guardian or adult student 

Address________________________________________City/State__________________________Zip___________________ 

Phone__________________________________________ 

Responding agency please address information regarding this student to: 

Snohomish School District No. 201 

Attention__________________________________________________________________________________________ 

School/Department__________________________________________________________________________________ 

Phone____________________________________________________________________________________________ 

Email address_______________________________________________Fax Number______________________________ 

Address________________________________________ City/State___________________________ Zip_____________ 

3600F11/2017