Download pdf - Your student’s registration form: Important for you and ... · Student registration forms are very important — for your family and for the school district. The information you

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________________________________________________


76.RELATIONSHIPTOSTUDENT___________________77.FIRSTANDLASTNAME_______________________________________________


SIBLINGS—Pleaseliststudent’ssibling(s)currentlyattendingadistrictschool.

81.SIBLINGLASTNAME__________________________________________82.SIBLINGFIRSTNAME_________________________________

83.RELATIONSHIPTOSTUDENT______________________84.SCHOOL_____________________________________85.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