Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Studentregistrationformsareveryimportant—foryourfamilyandfortheschooldistrict.Theinformationyouprovideallowsusto:*Distributeimportantschoolorschooldistrictinformationtoyou,includingyourstudent’sacademicprogress(reportcards)andattendanceinformation.*Respondappropriatelyintheeventofamedicalsituationinvolvingyourstudent.*Contactyouorothersifthereisaschoolemergency.Informationfromregistrationformsalsosupportsstudents’academicsuccessbyallowingtheschooldistrictto:*Helpyourstudentreceivesupportsuchaslanguageservices.*Seekgrantstostrengthenclassroominstruction.*Evaluateourworkonbehalfofstudentgroups(racial/ethnic,socioeconomic,etc.).*Ensurethatweareincompliancewithcivilrightslawsregardingstudentsandstaff.
Your student’s registration form: Important for you and our school district
STUDENTREGISTRATIONFORMGRESHAM-BARLOWSCHOOLDISTRICT
Rev23,March2018
INSTRUCTIONS:Theregistrationformisarequiredofficialrecord.Thequestionsonthisformaskforimportantinformationthatwillhelpprovideservicesforyourchild.Ifyouneedhelpfillingoutthisform,pleasecontactyourschool.Pleaseprintusingablackpen,completeallpagesandsignthelastpage.Ifanyinformationshouldchangeduringtheschoolyear,notifyyourschoolimmediately.
STUDENTINFORMATION
1.LEGALLASTNAME__________________________________________2.LEGALFIRSTNAME___________________________________________
3.LEGALMIDDLE______________4.FIRSTNAME“GOESBY”______________________5.LASTNAME“GOESBY”__________________________
6.GRADE_____ 7.GENDERqFemaleqMaleqNon-Binary 8.HOMELANGUAGE__________________________________________
9.BIRTHDATE(mm/dd/yyyy)________________10.BIRTHSTATE_____________________11.BIRTHCOUNTRY____________________________
FederalandStateRegulationsrequireschoolstogathertheinformationin12aand12bforstatisticalreports.Formoreinformation,yourschoolcanhelp.12a.ETHNICITY-HISPANIC/LATINO? Yesq Noq (Note:bothEthnicity&Racemustbeselected)
12b.RACEselectatleastone qAmericanIndian/AlaskaNativeqAsianqBlackqNativeHawaiianorOtherPacificIslanderqWhite
13.HOMEADDRESS_________________________________________14.CITY________________________15.STATE______16.ZIP___________
17.MAILINGADDRESS(ifdifferent)______________________________________18.CITY______________________19.STATE______20.ZIP__________
21.FAMILYPRIMARYPHONE(cell?Yesq Noq)_________________________22.STUDENTCELLPHONE______________________________________
Note:Familyprimaryphonenumberwillbeusedforattendanceandemergencynotifications
PREVIOUSSCHOOLINFORMATION
23. School(mostrecentfirst) 24. CityandState 25. YearsAttended(ex2007-09)
1.
2.
3.
SHADEDAREAFOROFFICEUSEONLY:ENTRYDATE_____________________SCHOOL________________________________STUDENTID#_____________________
STUDENTNAME____________________________________________GRADE____________HOMEROOM_____________________________________________
BUS#_____________BUSSTOP________________________________________________________PICKUPTIME____________________FTE__________
PROOFOFAGE________________________PROOFOFRESIDENCE_____________________________IMMUNIZATION______________________________
PARENT/GUARDIANINFORMATION—Contactphonenumbersandemailaddresseswillbeusedtodistributeimportantinformation.
PARENT/RESPONSIBLEADULT#1:26.LIVINGWITHSTUDENT:YqNq(Ifno,providemailingaddresson#33;checkifyouwantcopyofcorrespondenceq)
27.qMOTHERqFATHERqGUARDIAN qOTHER:___________________________________
28.LASTNAME_________________________________________29.FIRSTNAME_________________________________________________
30.PRIMARYLANGUAGE___________________________31.E-MAILADDRESS___________________________________________________
32.MILITARYSTATUS:Active?YesqNoqReserve?YesqNoqVeteran?YesqNoq
33.MAILINGADDRESS_____________________________________34.CITY_______________________35.STATE_____36.ZIP___________
37.PRIMARYPHONE_______________________Cell?YesqNoq38.SECONDARYPHONE_______________________Cell?YesqNoq
39.WORKPHONE___________________________ 40.EMPLOYER_________________________________________
41.Contactallowedwithstudent?YesqNoq 42.HasCustodyofstudent?YesqNoq 43.Permissiontopickup?YesqNoq
44.INTERESTEDINVOLUNTEERING?YesqNoq 45.Interpreterneededforschoolmeetings?YesqNoq
PARENT/RESPONSIBLEADULT#2:46.LIVINGWITHSTUDENT:YqNq(Ifno,providemailingaddresson#53;checkifyouwantcopyofcorrespondenceq)
47.qMOTHERqFATHERqGUARDIAN qOTHER:___________________________________
48.LASTNAME_________________________________________49.FIRSTNAME_________________________________________________
50.PRIMARYLANGUAGE___________________________51.E-MAILADDRESS___________________________________________________
52.MILITARYSTATUS:Active?YesqNoqReserve?YesqNoqVeteran?YesqNoq
53.MAILINGADDRESS_____________________________________54.CITY_______________________55.STATE_____56.ZIP___________
57.PRIMARYPHONE_______________________Cell?YesqNoq58.SECONDARYPHONE_______________________Cell?YesqNoq
59.WORKPHONE___________________________ 60.EMPLOYER_________________________________________
61.Contactallowedwithstudent?YesqNoq 62.HasCustodyofstudent?YesqNoq 63.Permissiontopickup?YesqNoq
64.INTERESTEDINVOLUNTEERING?YesqNoq 65.Interpreterneededforschoolmeetings?YesqNoq
ADDITIONALEMERGENCYCONTACTS—Inanemergency,parent/guardian(s)inthepriorsectionwillbecalledfirst.Bylistingnamesinthissectionasemergencycontacts,youareauthorizingthesepeopletopickupyourchildatschoolifyoucannotbereached.
66.RELATIONSHIPTOSTUDENT___________________67.FIRSTANDLASTNAME________________________________________________
68.HOMEPHONE________________69.WORKPHONE_____________________70.CELLPHONE_______________________
71.RELATIONSHIPTOSTUDENT___________________72.FIRSTANDLASTNAME________________________________________________
73.HOMEPHONE________________74.WORKPHONE_____________________75.CELLPHONE_______________________
76.RELATIONSHIPTOSTUDENT___________________77.FIRSTANDLASTNAME_______________________________________________
78.HOMEPHONE________________79.WORKPHONE_____________________80.CELLPHONE_______________________
SIBLINGS—Pleaseliststudent’ssibling(s)currentlyattendingadistrictschool.
81.SIBLINGLASTNAME__________________________________________82.SIBLINGFIRSTNAME_________________________________
83.RELATIONSHIPTOSTUDENT______________________84.SCHOOL_____________________________________85.GRADE_________
86.SIBLINGLASTNAME__________________________________________87.SIBLINGFIRSTNAME_________________________________
88.RELATIONSHIPTOSTUDENT______________________89.SCHOOL_____________________________________90.GRADE_________
91.SIBLINGLASTNAME__________________________________________92.SIBLINGFIRSTNAME_________________________________
93.RELATIONSHIPTOSTUDENT______________________94.SCHOOL_____________________________________95.GRADE_________
PARENTS
EMERG
ENCY
SIBLINGS
STUDENTMEDICALINFORMATION—Schoolstaffneedtoknowifyourstudenthasamedicalconditionforwhichhe/shemayrequireassistanceduringtheschoolday.Remembertoadvisetheschoolofanychangesininformation.
96.PHYSICIAN’SNAME(optional)____________________________________97.PHONE(optional)___________________________________
98.PREFERREDHOSPITAL____________________________________EMS(EmergencyMedicalSystem)makesthefinaldecisionforsiteofbestavailablecarewhenseriousillness,accident,orotheremergencyeventdirectsneedfortransportingtoahospital.Ifpossible,theschoolwilladviseEMSofyourhospitalpreference.
99.CHECKANYCURRENTMEDICALCONDITIONS:
q ASTHMA q HEARTDISEASE q SEIZUREDISORDER q DIABETES-TYPEIq DIABETES-TYPEII
q SERIOUSALLERGIES:____________________________________________________________________LIFETHREATENING?Yq Nq
100.OTHERSPECIALHEALTHNEEDSATSCHOOL:
101.MEDICATIONSTOBETAKENATSCHOOL(pleaselistandalsocompletetheAuthorizationforMedicationform):
PERMISSIONS/AUTHORIZATIONS—ForannualnoticesonDirectoryInformation,StudentRecords,MilitaryRecruitingandProtectionofStudentRights,pleaseseetheDistrictParentandStudentHandbook.*Underfederallawandschoolpolicy,theschooldistrictmayreleasethefollowinginformationwithoutpriorparentalconsent:Studentname,participationinofficiallyrecognizedactivitiesandsports,weightandheightofmembersofathleticteams,degrees,honors,andawardsreceived,majorfieldofstudy,datesofattendance,andthemostrecentschoolattended.Ifyoudonotwantthisinformationreleased,pleasecontactyourschooltosubmitawrittenrequest.Thisrequestmustbecompletedeachyear.
*Studentphotographsarecommonlyusedinyearbooks,newsletters,websites,andotherschool-relatedpublications.Ifyoudonotwantyourstudent’sphotographusedorreleasedforthesepurposesorfornewsmedia,pleasecontactyourschooltosubmitawrittenrequest.
*Studentsoccasionallyhavetheopportunitytoparticipateinschoolfieldtripsandhealthscreenings.Wewillsendoutdetailedinformationabouttheseeventswhentheyarise.Ifyoudonotwantyourstudenttoautomaticallyhavepermissionfortheseevents,pleasecontactyourschooltosubmitawrittenrequest.
*Allstudentshaveaccesstousedistrict-providedemail.Ifyoudonotwantyourstudenttohaveaccesstodistrict-providedemail,pleasecontactyourschooltosubmitawrittendenial.
IhavereadandunderstandthePermissions/Authorizationsinformationabove___________________(InitialsofParentorResponsibleAdult)
HIGHSCHOOLSTUDENTSONLY106.Idonotwantmychild’sname,addressandphonenumberreleasedto: q MilitaryRecruiters q CollegeRecruitersFederallawrequiresschooldistrictstoprovide,uponrequest,thenames,addressesandphonenumbersofhighschooljuniorsandseniorstomilitaryrecruiters,collegesanduniversities.Ifyoudonotwanttheschooldistricttoprovideinformationaboutyourstudenttoeitherthemilitaryorcollegesanduniversities,youhavetheopportunityto“optout.”Inordertodoso,youmustcheckoneorbothofthecategoriesabove.
KINDERGARTENSTUDENTSONLY
102.IntheyearbeforeKindergarten,didyourchildusuallyspend5hoursormoreperweekinapreschoolorpreschool
classroom(suchasinaschool,HeadStart,orchildcarecenter)?qYesqNo
103.Nameofpreschool________________________________________________
STUDENTSAGE7ANDUNDERONLY
104.Didthisstudentreceiveadentalscreeningorexambyaproviderotherthanatschool?qYesqNo
105.IfyouansweredNo,whatisthereasonfornodentalscreening?(selectonlyone)
q Burdentostudentorparent/guardianq Religiousreasonsq Submittedtoprioreducationprovider
HEALTH
EM
ERGEN
CYEN
ROLLM
ENT
ADDITIO
NAL
PROGRAMINFORMATION
107.DoesyourstudenthaveacurrentIndividualizedEducationPlan(IEP)? YesqNoq108.DoesyourstudenthaveacurrentSection504Plan? Yesq Noq 109.IsyourstudentinaTalentedandGifted(TAG)program?Yesq Noq
BYSIGNINGTHISFORM,IAGREETHATALLTHEINFORMATIONISTRUE.IFITISDETERMINEDTHATTHEADDRESSIHAVEPROVIDEDISFALSE,IACKNOWLEDGETHATMYSTUDENTCOULDBEIMMEDIATELYREMOVEDFROMTHESCHOOL.
123.SIGNATUREOFPARENT/RESPONSIBLEADULT(required)_____________________________________________________DATE____________________
124.SIGNATUREOFPARENT/RESPONSIBLEADULT______________________________________________________DATE____________________
OFFICEUSEONLY:STUDENTID#_________________SCHOOL:____________________STUDENTNAME:________________________________________________
WEWISHYOUANDYOURSTUDENTASUCCESSFULACADEMICSCHOOLYEAR!
FEDERALTITLEPROGRAMQUESTIONS(notetoschoolstaff:ifafamilychecks‘yes’foranyofthesequestions,pleasescanthispagetoFederalPrograms)
IndianEducationProgram—Thisinformationestablishesthedistrict’seligibilityforafederalgrant.Youmayreceivemoreinformationifyoumark“Yes.”119.Isthestudent,aparent,oragrandparent,amemberofaU.S.federallyrecognizedAmericanIndianTribe? Yesq Noq
120.IfYES,pleasefillintribename:________________________________________________________________
MigrantEducationProgram—Thisprogramhelpschildrenandyoungadultsages3-21whomovefrequently(ontheirownorwiththeirparents)inordertoseekorobtaintemporaryorseasonalworkinagriculture,forestryand/orfishingactivities.121.Apersoninmyfamilyhasworkedin,orhasplannedtoworkin,agriculture,forestryand/orfishing.Thiscanincludeworkonfarms,ranches,canneries,nurseries,treesorfishing. Yesq Noq
McKinney-VentoProgram—Thisprogramguaranteesthatstudents,nomattertheirlivingsituation,haveaccesstopubliceducation,includingtransportationtoandfromschool.Aschooldistrictrepresentativemaybeintouchifyoucheckabox.122.Pleaseplaceacheckintheappropriateboxifitapplies:qYouarestayinginamotel,carorcampsiteuntilyoucanfindaffordablehousing qYouaresharinghousingwithanotherfamilyduetoeconomichardshipqYourchildislivingwitharelative/friend/oranyoneotherthanhis/hercustodialparents qYouarelivinginashelter,temporaryhousingormovingfromplacetoplacewithoutpermanenthousing
LANGUAGEINFORMATION
110.Whatlanguage(s)doesyourchildhearoruseregularlyinyourhousehold(i.e.spoken,media,music,literature,etc.)?Hear:__________________________________________Use:(i.e.,AmericanSignLanguage(ASL))____________________
111.Checktheboxthatdescribesyourchild’sunderstandingoflanguage.NOEnglishq MostlyanotherlanguageandalittleEnglishq
EnglishandanotherlanguageequallyqMostlyEnglishandalittleofanotherlanguageq ONLYEnglishq
Tribal/Heritage/NativeLanguage(i.e.languagesspokenbyAmericanIndian/Alaskan,NativeHawaiians,orU.S.Territories)q
112.Whatlanguage(s)doadultsmostfrequentlyusewhenspeaking/conversingtoyourchild?_______________________________
113.Whatlanguage(s)doesyourchildCURRENTLYspeak/expressmostfrequentlyoutsideofschool?________________________________________________________________________________________________________________________
114.DoesyourchildparticipateinculturalactivitiesthatareinalanguageotherthanEnglish,2ormoretimesamonth?YesqNoq
115.Isthereanythingelseyouwouldliketheschooltoknowaboutyourchild’slanguageuse?(i.e.,whatlanguagedidyourchildspeak/expressfromages0-4;didyourchildhavespeechclasses;didyourchildattendabilingualschool,etc.)?
_____________________________________________________________________________________________________________
116.Isthestudentin,orhasthestudentbeenin,anEnglishasaSecondLanguageProgram?YesqNoq
117.IfYesto116,whatwasthestudent’sfirstdayinaU.S.school?________________________________________
118.Doesyourfamilyneedaninterpreterforschoolmeetings?Yesq Noq
PROGRAM
SLAN
GUAG
E