Whitehouse ISD - d2ct263enury6r.cloudfront.net · Whitehouse ISD Proof of Residency and Educational Guardianship Information Parent/Guardian should bring the following information:

Whitehouse ISD Proof of Residency and Educational Guardianship Information

Parent/Guardian should bring the following information:

Driver’s license or photo I.D.

Year, Make, and Model vehicle information Resident of the District should bring the following information:

Driver’s license or photo I.D.

Utility Bill: Water, electric or gas. (Current month)

A disconnect notice will not be accepted.

Do you own? Provide a current tax statement

Do you lease? Provide the district with a current lease agreement

FYI: The lease must list all occupants, including any new occupants living on your property.

Educational Guardianship Information Educational Guardianship documents are required when a student will be staying with another family in the district without the parent/guardian.

Both parent/guardian and resident of the district are required to complete Educational Guardianship forms at the Administration office.

The resident of the district will provide current proof of residency (as listed above).

The student is required to live full time with the resident of the district.

Please Print

Student Name: Gender:

Student Social Security #: Student Cell Phone:

Birthdate: Birth City: Birth Country:

Student's Language: Grade Level:

Check Ethnicity: Hispanic/Latino: __ Yes, __ No Definition on Second Page

STUDENT LIVES WITH: ~~~Print Last, First, Middle name for each Parent/Guardian.~~~

Parent/Guardian Name #1: Relationship to Student:

#1 Birth Date: Primary Phone: 2nd Phone:

Physical Address: 3rd Phone:

Mailing Address:

Email Address:

Occupation: Employer:




Mailing Address:

Email Address:





Mailing Address:

Email Address:


Emergency Contact #1: Relationship to Student:

Local Phone: Phone #2: Phone #3:

Emergency Contact #2: Relationship to Student:

Local Phone: Phone #2: Phone #3:

Medical Alert Information:

For additional information, please use the back of the form.

Entry Date: ____________ Homeroom ____________ Bus # ________ Office Use only

Language spoken at home:

Whitehouse ISD Registration Form

Check if legal guardian of this child.

Years in US Schools:



Parents or guardians of students enrolling in school are required to provide race/ethnicity information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Check both Race and Ethnicity.

Please list below individuals to contact other than Parents/Guardians listed above.

Severe Food Allergy:

Check Race: __ American Indian or Alaska Native, __ Asian, __ Black or African American, __ Native Hawaiian or Other Pacific Islander, __ White

Please complete the back portion. Then read and sign the Proof of Residency Statement.

Restricted Pickup: No Yes Can NOT be picked up by:

Will the student ride the bus? Yes No

Previous Campus (Most Recent):

Previous School District (Most Recent):

Previous City and State of Residence (Most Recent): Military Connection: Check the appropriate box.

Not a military-connected student Student is a dependent of a member of the Army, Navy, Air Force, Marine Corps, or Coast Guard on Active Duty Student is a dependent of a member of the Texas National Guard (Army, Air Guard, or State Guard) Student is a dependent of a member of a reserve force in the United States military (Army, Navy, Air Force, Marine Corps, or Coast Guard)

Sibling Name: WISD School:Sibling Name: WISD School:Sibling Name: WISD School:

_________________________________________ _____________________________________Parent/Guardian (Print)

_________________________________________ _____________________________________

_________________________________________ _____________________________________

Race/Ethnicity Definition:

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Anyone falsifying any document or documents for the purpose of school enrollment is a violation of 25.001 of the Texas Education Code and Article 37.10 of the Texas Penal Code.

For prosecution purposes, the proper authorities will be given a copy of this document in the event documents are falsified.

Additional Information

Signature

Whitehouse ISD Employee

Signature

Date

Black or African American - A person having origins in any of the black racial groups of Africa

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam

Date

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment

Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race

Other Children in the Family:

7-2012

New Enrollees

Counselor’s Program Verification Form

Name of Student: ________________________ Date of Birth __________________ Date: __________________

Name and city of any previous school: _______________________________ Current grade: ______

READ CAREFULLY and CIRCLE the correct response.

1. This child speaks another language, MOST of the time, at home. YES NO

If yes, what language? ______________

IF YES, ASK TO SEE THE COUNSELOR BEFORE YOU LEAVE

2. This child has been tested and identified as eligible for Special Education services. YES NO

IF YES, ASK TO SEE COUNSELOR BEFORE YOU LEAVE

3. This child is currently receiving Speech Therapy. YES NO

4. This child has repeated a grade. If yes, what grade? _________ YES NO

5. This child has taken the TAKS/STAAR tests and did not pass. YES NO

If yes, what grade level and subject did they fail? ______________

6. This child is in the custody/care of the Department of Protective Services or is a foster child. YES NO

7. This child has been reported to CPS in the last 12 months. YES NO

8. This child might be eligible for Free and Reduced Lunch Program. YES NO

9. This child is designated as homeless. YES NO

10. This child has been placed in an alternative school in the past 12 months. YES NO

11. This child has been expelled from school in the past 12 months. YES NO

12. This child is currently on parole or probation. YES NO

13. This child resides now or resided last school year in a residential placement facility such as: group foster home,

detention facility, substance abuse treatment facility, emergency shelter, psychiatric hospital, or halfway house.

YES NO

14. This child is the child of an active duty member of the armed forces of the United States, including the state

military forces or a reserved component of the armed forces, who is ordered to active duty by proper authority.

YES NO

15. This child is the child of a member of the armed forces of the United States, including the state military forces or a

reserve component of the armed forces, injured or killed while serving on active duty. YES NO

16. This child has been identified as Dyslexic. YES NO

17. This child has been identified as Gifted. YES NO

18. How many years has the student been enrolled in US school? _________________

Signature: ____________________________________________

Your signature verifies that you have read the above and answered to the best of your knowledge. Thank you.

Teacher assigned: ____________

Scheduled in Skyward: _______

Previous school’s grades: _____

__________________________

Whitehouse ISD

Student Residency Questionnaire

Please check the campus where the student is enrolled or attempting to enroll: 2015-2016

Campus: __Brown __Higgins __Cain __Stanton-Smith__ Holloway __Whitehouse Jr. High __WHS

The information on this form is required to meet the law known as 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. The answers you give will help the school determine

the services the student may be eligible to receive.

Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under

false documents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3)(d).

Name of 1st Student: ___________ ______/_____/______

Last First Middle Date of Birth

Current Grade: ____ Gender: � Male � Female

PEIMS Coding: __1 Sheltered __2 Doubled Up __3 Unsheltered __ 4 Hotel/Motel AND __Not UY __1 UY __2UY

The questions below should be completed regarding the student’s place of residency. In some instances, the

parent may be living at another location. Check the box that best describes with whom the student resides. ____Parent(s)

____Legal Guardian(s)

____Caregiver(s) who are not legal guardian(s) (i.e. grandparent(s), friend or relative – with or without parent)

____Other_________________________________________________________________________________

Name of person who leases or owns the residence where the student resides:_______________________________

Address:________________________________City:_________________________ZIP:___________

Home Phone #:______________Cell Phone #:_____________Other Emergency #:___________

Last District Attended:_____________________ Last School Attended:_____________________

Please answer Yes or No regarding the location where the student currently resides: 1. Yes___ No____ Is your current residence a temporary living arrangement?

2. Yes___ No____ Is this temporary living arrangement due to loss of housing, economic hardship,

or other contributing factors (i.e. loss of job, family violence, divorce, natural disaster, fire, etc.)

3. ____Not Applicable ___ In my own home, apartment or military housing with parent(s), legal guardian(s)

or caregiver(s) (Code N)

Please check the place that most closely describes where the student slept last night:

___Living in a motel (CODE HM)

___Living in a shelter or transitional housing (i.e. housing provided for a specific length of time & is

partially or completely paid for by a church or organization) (CODE S)

___Living with another family in a house or apartment (CODE D)

___Living in a place not designed for ordinary sleeping accommodations such as a car, park, or campsite (CODE U)

___Living in a place that has no electricity and/or water (CODE U)

List other school-age siblings: OFFICE USE Name Date of Birth Grade Campus Name District PEIMS HL PEIMS UY

Signature of Parent/Legal Guardian/Caregiver/Unaccompanied Student Date

________________________________________________________________ _______________

Betty Lough, WISD McKinney-Vento Liaison – (903) 839-5500 ext. 6762 Date

I certify that the above named student(s) qualify for the Child Nutrition Program

Whitehouse ISD

Cuestionario de Residencia para Estudiantes

Please check the campus where the student is enrolled or attempting to enroll: 2015-2016

Campus: __Brown __Higgins __Cain __Stanton-Smith__ Holloway __Whitehouse Jr. High __WHS

El propósito de este cuestionario es presentar los objetivos del Acta McKinney-Vento (42 U.S.C.11435). Las respuestas a

estas preguntas ayudarán determinar los servicios que el estudiante debe recibir.

Nombre de la Escuela _________________________________________________________

Nombre del Estudiante _______________________________________ Sexo: o Masculino o Femenino

Apellido Nombre Segundo Nombre

Fecha de Nacimiento _____/_____/______ Edad: ______ # de Seguro Social: _________________________

Mes Día Año (o número de indentificación escolar)

Liste a otros ninos que assistan a WISD:______________________________________________________

1. ¿Es su domicilio actual un arreglo de vivienda temporal (de poca duración)? _____Si _____ No

2. ¿Es este arreglo de vivienda temporal debido a la pérdida de su casa, vivienda o habitación,

o debido a algún problema económico (ejemplo: desempleo)? _____Si _____ No

Si usted contestó SI a estas preguntas, por favor complete el resto de este formulario.

Si usted contestó NO a estas preguntas, no siga.

¿Dónde se encuentra viviendo el estudiante actualmente? (Marque una opción.)

o En un motel

o En un albergue o lugar de refugio

o Con más de una familia en una casa o apartamento

o Moviéndose de lugar en lugar

o En un lugar generalmente no designado para dormir (ejemplo: carro, parque, o campamento)

Nombre del Padre/Madre/Guardián_____________________________________________________________

Dirección ______________________________________ Zona Postal _________ Teléfono ______________

Presentar información falsa o la falsificación de documentos para uso escolar son ofensas bajo la Sección 37.10 del Código

Penal, y la inscripción del estudiante usando documentos falsos traerá como consecuencia que los responsables estarán

sujetos a pagar los gastos de instrucción u otros cargos. TEC Sec. 25.002(3)(d).

Firma del Padre/Madre/Guardián _________________________________________ Fecha _____________

Por favor envíe una copia de este documento a Betty Lough en el Departamento de Whitehouse ISD.

Betty Lough, WISD McKinney-Vento Liaison – (903) 839-5500 ext. 6762 Fax: 903-839-5515

Yo certifico que el estudiante nombrado en este formulario califica para los programas de nutrición escolares bajo las

provisiones del Acta McKinney-Vento.

___________________________ ______________________________________________________ Fecha Firma del oficial autorizado

WISD 2012

HOME LANGUAGE SURVEY Grades PreK-12 (Must be kept in Student’s Permanent File)

□Brown Elem. □Cain Elem. □Higgins Elem. □Stanton-Smith Elem. □Holloway □Jr. High □High School

TO BE COMPLETED BY PARENT OR GUARDIAN (OR STUDENT, IF GRADES 9-12): GRADE: _____________ NAME OF STUDENT_________________________________STUDENT ID#_________________ ADDRESS__________________________________________TELEPHONE#__________________ 1. What language is spoken in your home most of the time?_________________________________

2. What language does your child speak most of the time?__________________________________

3. Year (or grade) your child was first enrolled in a U.S. school: Year__________ Grade ___________

_____________________________________________ ___________________________ Signature of Parent/Guardian Date

_____________________________________________ ___________________________ Signature of Student (Grades 9-12) Date

CUESTIONARIO del idioma que se habla en el hogar DEBE DE COMPLETARSE POR EL PADRE/MADRE/O REPRESENTANTE LEGAL (O POR EL ESTUDIANTE SI ESTÁ EN LOS GRADOS 9-12): NOMBRE DEL ESTUDIANTE___________________________________ID#_________________ DIRECCIÓN_________________________________________TELÉFONO___________________ ESCUELA_______________________________________________________________________ 1. ¿Qué idioma se habla en su hogar la mayorίa del tiempo?__________________________________

2. ¿Qué idioma habla su hijo/a (o usted) la mayorίa del tiempo?_______________________________

3 Año o grado su estudiante fué matriculado por primera vez en una escuela en los Estados Unidos:

Año?_______________________________________ Grado?__________________________________

_____________________________________________ ___________________________ Firma del Padre/Madre/o Representante Legal Fecha

_____________________________________________ ___________________________ Firma del estudiante si está en los grados 9-12 Fecha

Whitehouse Independent School District

2015-2016 Family Survey / Encuesta de la Familia

Betty Lough, District Migrant Contact

Your child may be eligible for educational services through the Migrant Education Program. Contact the Office of Migrant Education at (903) 839-5500 ext. 6162 if you need additional information.

1. During the last three years has your family moved from one school district to another? ____Yes ____ No

2. Do you or does anyone from your family do the following temporary or seasonal work? ____ Yes ____ No

What type of work? _Farming _Ranching _Fencing _Dairying

_Fishing

_Baling Hay _Picking Fruit or Vegetables _Cotton Farming/Ginning _Combining/Harvesting Grain _Driving Tractors/Machinery

_Tree Growing or Harvesting

_Food Processing in Plants _Plant Nursery _Poultry Production _Clearing Land _Picking Nuts, Pecans, etc.

_Other Similar Work

Su nino/a puede ser elegible para recibir servicios escolares proporcionado por el programa

educacional migrante. Entre el contacto con la Oficina de Educaci6n Migrante si necesitas

informaci6n adicional Betty Lough (903) 839-5500.

1. Durante los ultimos tres afios ha viajado su familia de un distrito escolar a otro?

___Si ___No

2. Trabaja usted 0 alguien en su familia en una de las siguientes actividades temporalmente? ___Si ___ No

Que tipo de trabajo?

_Cultivando

_ En ranchos/granjas

_ Cercando

_En lecherias

_Pescando

_ Juntando paja

_ Cosecha de frutas/verduras

_ Cultivando algod6n _ Mezclando/cosechando granos _ Manejando tractores/maquinaria

_ Procesando comida en fabricas

_Cultivando arboles

_ En viveros _ En producci6n de aves _ Limpiando terrenos _ Recogiendo nueces, etc.

_ Otro trabajo similar

_________________________ ______________________ _________

Student Name/Estudiante

Parent Name/Padre ______

Created: 12/07/2005

Birthdate/Fecha de Nacimiento Telephone/Telefono __________________

Reviewed: 01/30/2015

Grade/Grado

Revised: 01/30/2015

State law requires the district to give you the following information:

Certain information about district students is considered directory

information and will be released to anyone who follows the procedures for

requesting the information unless the parent or guardian objects to the

release of the directory information about the student. If you do not want

Whitehouse ISD to disclose information directory information from your

child’s education records without your prior written consent, you must notify

the district in writing by returning this form within ten school days of your

child’s first day of instruction for this school year no later than Sept. 15,

2015.

This means that the district must give certain personal information (called

“directory information”) about your child to any person who requests it,

unless you have told the district in writing not to do so. In addition, you have

the right to tell the district that it may, or may not, use certain personal

information about your child for specific school–sponsored purposes. [See

Directory Information in the Student Handbook for more information.]

Whitehouse ISD has designated the following information as directory

information for both school-sponsored purposes, and purposes other than

school-sponsored purposes:

• Student’s name

• Photograph

• Degrees, honors and awards received

• Dates of attendance

• Grade level

• Participation in officially recognized activities and sports

• Weight and height, if a member of an athletic team

Parent: Please circle one of the choices below:

For the use of school-sponsored / related purposes, such as, but not limited to,

Athletic programs, Field Day rosters, Student Clubs, etc. I, parent of

________________________________, (do give) or (do not give) the district

permission to release/publish this information.

For the use of non-school related requests for information, such as, but not limited to

the local newspaper, civic organizations or special interest groups, I, parent of

_______________________, (do give) or (do not give) the district permission to

release information as requested.

Parent Signature: _________________________________Date: _________

Whitehouse ISD

Notice Regarding Directory Information and

Parent’s Response to Release of Student Information

Whitehouse Independent School DistrictWhitehouse Independent School DistrictWhitehouse Independent School DistrictWhitehouse Independent School District

Corporal Punishment 2015-2016

I understand that according to WISD Student Code of Conduct for the

2015-2016 school year, corporal punishment is one discipline

management technique that may be used.

Please check the box that indicates your decision regarding corporal

punishment, sign and return to your child’s campus.

□ Yes - May use corporal punishment according to district policy

□ No - May NOT use corporal punishment


Student Name ________________________________ Grade__________

Parent Name__________________________________ Date __________

(Print)

Parent Signature _______________________________

WISD Title I Updated 2011-2012


District Wide Parent-School Compact

The School’s Responsibility

Whitehouse Independent School District will:

• communicate with parents and notify them of school events in a timely, efficient manner

• communicate learning expectations for students at each grade level

• provide an environment that promotes positive communication between the teacher, parent and student

• provide homework assignments that will reinforce classroom instruction

• provide opportunities for parent conferences and school functions to maximize parent participation

The Parent’s Responsibility

As a parent, I will try to:

• see that my child is on time and attends school regularly

• establish a time for homework and review it regularly

• encourage my child’s efforts and be available for questions

• read aloud to my child and let my child see me read

• be an interested listener as my child reads to me

• help my child establish a routine for school days

• attend parent/teacher conferences

• support the school in its effort to maintain proper discipline

• help my child learn to resolve differences in positive ways

• stay aware of what my child is learning

• respect school staff and the cultural differences of others

The Student’s Responsibility

As a student, I will try to:

• attend school regularly

• work hard to do my best in class and schoolwork

• help to keep my school safe

• ask for help when I need it

• respect and cooperate with other students and adults

______________________________________ ___________________________________

Student Signature Date Parent Signature Date

______________________________________ ___________________________________

Print Student’s Name Principal Signature Date

The purpose of the parent-school compact is to communicate a common

understanding of home and school responsibilities to assure that every

child attains high standards and a quality education.


Student Code of Conduct / Campus Student Handbook Electronic Distribution Acknowledgment

2015-2016 School Year

Dear Student and Parent:

As required by state law, the board of trustees has officially adopted the Student Code of

Conduct and Campus Student Handbook in order to promote a safe and orderly learning

environment for every student.

We urge you to read this publication thoroughly and to discuss it with your family. If you have

any questions about the required conduct and consequences for misconduct, we encourage you to

ask for an explanation from the student’s teacher or campus administrator.

The student and parent/guardian should each sign this page in the space provided below, and

return the page to the student’s school.

Thank you,

Richard Peacock, Assistant Superintendent

Parents and Students: Read and Sign Below

We acknowledge that we have been offered the option to receive a paper copy of the Whitehouse

ISD Student Code of Conduct Student Handbook/Campus Student Handbook for the 2015-2016

school year, or to electronically access it on the Whitehouse ISD web site at

www.whitehouseisd.org. We understand that the student will be held accountable for their

behavior and will be subject to the disciplinary consequences outlined in the Student Code of

Conduct.


Please sign and return this page to the student’s school. Thank you.

Date: _______________ Student’s Current Grade: _____________

Student Name (print): ________________________ Student Signature: ________________________

Parent/Guardian (print): ______________________ Parent/Guardian Signature: __________________

WISD 4/5/2012

Occasionally, Whitehouse ISD wishes to display or publish student artwork or

special projects on the district’s Web site and in district publications. In

addition, this may include publication of student work in area newspaper or

organizational journals/Web sites. When a student’s work is published, the

publication may include the student’s name and grade level.

Please check one of the choices below:

I, parent of ___________________________________, a student at: Print Student’s Name


□ Yes – DO

□ No – DO NOT

Give the district permission to use my child’s artwork or special project on

the district’s Web site, in district publications, and for publication in area

newspapers or organizational journals/Web sites.

Printed Name of Parent: ________________________________________

Signature of Parent: _______________________________ Date: ________

Whitehouse ISD

Public Display and Use of Student Work

in District Publications

AUTHORIZATION OF EMERGENCY MEDICAL TREATMENT/STUDENT HEALTH INFORMATION

WHITEHOUSE INDEPENDENT SCHOOL DISTRICT In an effort to provide safe, informed care for your child at school, the following information is required to complete your child’s enrollment. Medical information you provide about your

child is a confidential education record. WISD keeps all medical information about your child confidential as required by the Family Educational Rights and Privacy Act and other

applicable laws. However, health information about your child will be communicated to WISD school personnel who require the information to better serve your child.

If your child has an acute or chronic medical condition, or any medical changes occur during the school year, it is your responsibility as the parent/guardian to notify the school nurse and update this information.

Student Name ___________________________________________________ Date of Birth ___________________ Gender: ______ Grade: ______ ID# ________________

Last First MI

Parent Name ____________________________ Home # ________________ Cell # ________________ Work # ________________ Email ___________________________N/A

Health Conditions: Please answer ALL questions below that are associated with your child’s condition(s). If your child has a significant health condition, requires medication or any special procedures, please contact your school nurse. All medication brought to the school must be brought and signed in by the parent, must be in the original container, and prescribed by a physician/dentist.

Abdominal Issues: �Colitis �Constipation �Crohn’s Disease

�Gastric Reflux �G-Tube �Irritable Bowel Syndrome

�Kidney/Bladder �Other__________________________________

Emotional Issues: �Bipolar �Depression �OCD �School Phobia

�Other________________________________________________________

Is your child under medical care at this time for this condition? YES NO

Medications taken for this condition:__________________________________

ADD/ADHD: When was your child diagnosed?______________________________


Medication taken for this condition:_______________________________________

Medication needed during the school day? YES NO

Heart:�High Blood Pressure �Irregular Heart Rate �Long Q/T Syndrome

�Defibilator �Pacemaker �Other__________________________________

�Heart defect, type:_____________________________ Repaired? YES NO

Medications taken for this condition:______________________________________

___________________________________________________________________

Allergy(s): �Animal �Food �Insect �Latex �Medicine �Seasonal

Allergic to:__________________________________________________________

Symptoms of reaction:________________________________________________

Medications taken for this condition at home and/or at school:_________________

__________________________________________________________________

Severe enough to have an Epi-Pen/Twinject at home or school? YES NO

Muscle, Bone, Joint Disorders: �Arthritis �Scoliosis

�Other___________________________________________________________

Is your child currently under medical care for this condition? YES NO

Medications taken for this condition:_____________________________________

Neurological: �Autism �Cerebral Palsy �Headaches �Migraines �Spina

Bifida �VNS �Other______________________________________

�Seizures (Type):___________________ Date of last seizure:_______________

Medications taken for this condition:_______________________________________ Asthma: When was your child diagnosed?________________________________


Medication taken for this condition:______________________________________

Medication needed during the school day? YES NO

Does your child use a nebulizer? YES NO Respiratory other than asthma: �Cystic Fibrosis

�Other_________________________________________________________

Medications taken for this condition:____________________________________

Blood Disorders: �Clotting disorder (such as hemophilia) �Sickle

Cell Anemia �Sickle Cell Trait

�Other _____________________________________________________________

Other health conditions:_____________________________________________

_________________________________________________________________

_________________________________________________________________

Diabetes: When was your child diagnosed?_______________________

Insulin Dependent? YES NO Special procedures: (tube feeding, catheterization, etc.)___________________

_________________________________________________________________

_________________________________________________________________ Ears, Eyes, Nose: �Frequent ear infections �Hearing Loss: R / L

Does your child wear a hearing aid? YES NO Does your child wear �

glasses or �contacts?

Does you child have a vision loss that cannot be correct? YES NO

�Frequent Nosebleeds caused by:_____________________________________

Does your child require any P.E. restrictions ? YES NO

If yes, please explain: ______________________________________________

My child has: �Medicaid �CHIP �Private insurance �No insurance

� My child has NO KNOWN HEALTH CONDITIONS and does not require any medications or special procedures at home or school.

My child's physician is _______________________________________________ Phone Number:_____________________________________

I hereby authorize the Superintendent of the Whitehouse Independent School District or a designated representative to secure any and all emergency medical care and treatment for

_______________________________________________(student’s name) for acute illness suffered or injury sustained while at school or participating in school-related activities. My

hospital preference is ________________________________. I understand that the cost of services provided by ambulance and the medical facility remains the responsibility of the

parent/guardian and will not be assumed by the District.

Parent/Guardian Signature:______________________________________________________________________ Date:________________________________

AUTORIZACIÓN PARA TRATAMIENTO MÉDICO DE EMERGENCIA INFORMACIÓN DEL ESTADO DE LA SALUD DEL ALUMNO

WHITEHOUSE INDEPENDENT SCHOOL DISTRICT

En un esfuerzo para ofrecer un cuidado seguro y a sabiendas de su niño en la escuela, la siguiente información es requerida para completar la matrícula. La información médica que

usted dé del niño es un récord escolar confidencial. WISD guarda toda la información médica del niño como es requerido por el Acta de los Derechos Escolares de la Familia y de

Privacidad y otras leyes aplicables. Sin embargo, la información sobre la salud del niño será dada al personal de las escuelas de WISD que necesite la información para poder servir al

niño.

Si su niño tiene una condición médica aguda o crónica, o algún cambio en el estado de la salud ocurre durante el año académico, es su responsabilidad como padre/guardián de avisarle a la enfermera de la escuela y actualizar esta información.

Nombre del Alumno _____________________________________________ Fecha de Nacimiento ________________ Sexo: ______ Grado: ______ ID# _________________

Apellido Primero Segundo

Nombre del Padre ___________________ Domicilio # ____________ Celular # ____________ Trabajo # ____________ Correo Electrónicol____________________________N/A

Estado de Salud: Por favor conteste TODAS las preguntas debajo que estén asociadas con el estado de salud de su niño. Si su niño tiene un problema de salud importante,

requiere medicinas o procedimientos especiales, por favor haga contacto con la enfermera de la escuela. Todas las medicinas que sean traídas a la escuela tienen que ser

traídas y firmadas por el padre, tienen que estar en los envases originales y recetados por un médico o dentista.

Problemas abdominales: �Colitis �Estreñimiento �Enfermedad de Crohn

�Reflujo Gástrico �G-Tube �Síndrome de Irritación del Intestino

�Kidney/Bladder �Other__________________________________

Problemas emocionales: �Bipolar �Depresión �OCD �Fobia a la escuela

�Otra_____________________________________________________________

¿Está recibiendo tratamiento médico en este momento? SÍ NO

Medicinas tomadas para esta condición: ____________________________________

ADD/ADHD: ¿Cuándo se hizo el diagnóstico? ________________________

¿Está recibiendo tratamiento médico en este momento? SÍ NO

Medicinas tomadas para esta condición : ___________________________________

¿Necesita medicina durante el día escolar? SÍ NO

Problemas Cardiacos: �Síndrome Long Q/T �Ritmo Cardiaco Irregular

�Marcapasos �Presión Alta �Desfibilador �Otro____________________

�Defecto Cardiaco, clase:__________________________ ¿Reparado? SÍ NO

Medicinas tomadas para esta condición: __________________________________

_____________________________________________________________________

Alergias:�Animal �Comida �Insecto �Látex �Medicina �Estacionales

Alérgico a: _________________________________________________________

Síntomas de la reacción: ______________________________________________

Medicinas tomadas para esta condición en la casa y/o en la escuela: ___________

__________________________________________________________________

¿Suficientemente seria para que tenga un Epi-Pen/Twinject en la casa o en la

escuelal? SÍ NO

Enfermedades de los Músculos, Huesos, Articulaciones: �Artritis �Escoliosis

�Otra_____________________________________________________________

¿Está bajo cuidado médico por esta condición? SÍ NO

Medicinas tomadas para esta condición: ____________________________________

Neurológico: �Autismo �Parálisis Cerebral �Dolor de Cabeza �Jaquecas

�Espina Bífida �VNS �Otra____________________________________

�Convulsiones, clase:______________ Fecha de la última convulsión:___________

Medicinas tomadas para esta condición: ____________________________________ Asma: ¿Cuándo se hizo el diagnóstico? __________________________________

¿Está bajo cuidado médico por esta condición? SÍ NO

Medicinas tomadas para esta condición:__________________________________

¿Necesita medicina durante el día escolar? SÍ NO

¿Usa un nebulizador? SÍ NO

Respiratorio que no sea asma: �Fibrosis Quística

�Otra_____________________________________________________________

Medicinas tomadas para esta condición:____________________________________

Desórdenes de la Sangre: �Desórden de la coagulación (como hemofilia) �Anemia

de Sickle Cell �Razgo de Sickle Cell

�Otra______________________________________________________________

Otros problemas de salud:______________________________________________

____________________________________________________________________

____________________________________________________________________

Diabetes: ¿Cuándo se hizo el diagnóstico? _______________________

¿Depende de insulina? SÍ NO Procedimientos especiales: (tubo alimienticio, catéter, etc.) ___________________

____________________________________________________________________

____________________________________________________________________ Oídos, ojos, nariz: �Infecciones de oídos frecuentes �Pérdida

de audición: D / I ¿Usa un aparato para oir? SÍ NO ¿Usa �

espejuelos o �lentes de contacto?

¿Tiene problemas visuals que no pueden ser corregidos? SÍ NO

�Sangra frecuentemente por la nariz a causa de:___________________________

¿Necesita limitaciones en P.E.? SÍ NO

Si sí, por favor explique: _______________________________________________

Mi niño tiene: �Medicaid �CHIP �Seguro privado �No tiene seguro

� Mi niño no tiene NINGÚN PROBLEMA DE SALUD CONOCIDO y no necesita ninguna medicina o intervención especial en la casa o en la escuela.

El médico de mi niño es _______________________________________________ Teléfono:_____________________________________

Autorizo al Superintendente del Distrito Escolar Independiente de Whitehouse o a su representante designado para que asegure cualquier y todo cuidado médico y tratamiento para

_______________________________________________(nombre del niño) para una enfemedad aguda o lesión que tenga mientras esté en la escuela o participando en una actividad

relacionada con la escuela. Mi preferencia de hospital es ________________________________. Entiendo que los costos de los servicios rendidos por servicios de ambulancia y

servicios médicos son mi responsabilidad como padre/guardián y no serán asumidas por el Distrito.

Firma del Padre/Guardián:_____________________________________________________________________ Fecha:____________________________________

Documents

Whitehouse ISD - d2ct263enury6r.cloudfront.net · Whitehouse ISD Proof of Residency and Educational Guardianship Information Parent/Guardian should bring the following information: