Waco ISD Enrollment Sheet
Transcription
Waco ISD Enrollment Sheet
Waco ISD Enrollment Sheet For Office Use Only: Entry Date: ________ Withdrawal Date: ________ Withdrawal Code: ________ Registrar Signature:______________ Student Information Student name: ____________________ ___________________ ______________________ Date of Birth: _______ First Student ID #:______________________ Gender: Male Last Middle SSN:___________________________ Female Grade: __________ Home Language: _______________________ Preferred spoken Language: _____________________ Correspondence Language: ________________________ Birthplace City: Birth State: _________________ Birth Country ____________________ Address: City: ________Zip:_________ Home Phone #: __________ Last School Attended: What city if not in Waco: _________________ Parent/Guardian Information Does child live with both natural parents? Yes No If “Yes,” are parents married? If child does not live with both natural parents who has legal custody? Are there any legal custodial issues we need to be aware of? Yes No ____________________________ Yes No (if yes, please contact principal) Who does child live with if not living with one or both natural parents? (Please check the boxes that apply.) Parent Guardian Is the guardian a relative? Yes No Parent/Guardian: __________________ __________________ ___________________ Foster Parent? Yes No First Parent/Guardian birthdate: ________________ Address: Middle Last Relationship to child: ____________________________ City: ____________Zip:_________ Place of Employment: ______________________________________________ Home Phone:____________________ Cell Phone: ________________________ Work Phone: ____________________ Parent/Guardian: __________________ __________________ ___________________ Foster Parent? Yes No First Parent/Guardian birthdate: ________________ Address: Middle Last Relationship to child: ____________________________ City: ____________Zip:_________ Place of Employment: ______________________________________________ Home Phone:____________________ Cell Phone: ________________________ Work Phone: ____________________ Emergency Contacts In case of emergency or illness, my child may leave with: (You must list at least 2 persons for emergency/discipline reasons. Student may not leave with anyone not listed below. Your emergency contacts must have identification when picking up your children. Name: ________________________________________________ Relationship: __________________________ Home Phone: _________________ Work Phone: _____________ Cell Phone:____________________________ Address: _____________________________________________________________________________________ Name: ________________________________________________ Relationship: __________________________ Home Phone: _________________ Work Phone: _____________ Cell phone:____________________________ Address: _____________________________________________________________________________________ Name: ________________________________________________ Relationship: __________________________ Home Phone: _________________ Work Phone: _____________ Cell Phone:____________________________ Address: _____________________________________________________________________________________ Name: ________________________________________________ Relationship: __________________________ Home Phone: _________________ Work Phone: _____________ Cell Phone:____________________________ Address: _____________________________________________________________________________________ List brothers/sisters in Waco Public Schools: Name: _________________________________ Grade: ____________ School: _______________________________ Name: _________________________________ Grade: ____________ School: _______________________________ Name: _________________________________ Grade: ____________ School: _______________________________ Name: _________________________________ Grade: ____________ School: _______________________________ After school Information: How does your son/daughter get home? Walk Bus Car Campus Afterschool program Other/Name of Day Care __________________________________________________________________________ Parent signature Date Medical Information Student Name: ________________________________________________ Insurance Information: What type of health insurance does your child have? (Please check one.) Employer-provided insurance Hospital of choice: Hillcrest CHIP or Medicaid Private insurance No insurance Providence Medical History: Is there ANY illness the school needs to be aware of? Yes No If yes what is the illness? __________________________________________________________________________ Will this illness cause excessive absences or interfere with your child's ability to learn? Yes No If yes, please have your child’s doctor complete a WISD Chronic Illness Form (obtained from school office) and return it immediately to the school. Medications taken regularly: _______________________________________________________________________ Drugs to which the student has had allergic or adverse reaction are:________________________________________ Physician’s Name: I agree I do not agree Phone Number: My child is prescribed an Epi-Pen for a history of an anaphylactic reaction Yes No TREATMENTS & MEDICATIONS AT SCHOOL Medications to be given during school hours must be provided and brought to the school by the parents/guardian. Students are not allowed to carry medication. All medication is kept in the school clinic. Administration of prescription and non-prescription medication requires written parent consent. All prescription medication must be current and have the proper labeling intact from the pharmacy. This policy does NOT give the school permission to dispense prescription or over-the-counter medications. The parent/guardian must complete a Medication Permission Form (see school nurse) for properly labeled, original container (NOT EXPIRED). Medication will be reviewed periodically for expiration and will be discarded if necessary. Any medications left at the end of the last instructional day will be destroyed. I understand that the health information will be shared at the nurse’s discretion with school staff directly involved with my child and that it is in the best interest of my child to provide current health information and emergency telephone numbers to the school nurse. I also understand that any pertinent health documentation written by a physician that is shared by the parent will be entered as a Medical Alert in the WISD Student Information System. Copies of this documentation including Chronic Illness Forms will be stored in the student’s file but will not be shared with other agencies or organizations outside WISD. I agree I do not agree I have completed this sheet to the best of my knowledge. I understand I must notify the school anytime the above information changes. I also understand that presenting a false document or false records for identification is a criminal offense under Penal Code 37.10. Students who are found to be ineligible for enrollment in WISD, will be withdrawn and the parent, guardian or person in legal control of the student will be liable for the maximum tuition fee the District may charge (see FDA (Legal) or the amount the District has budgeted per student as maintenance and operating expense, whichever is greater. Texas Education Code 25.001 (h) Parent Signature: _________________________________________________________________ Date: _____________________ Student Name: ________________________________________________ Permissions I understand that my student will participate in the District’s Electronic Communication System. In consideration for the privilege of using the District’s Electronic Communication System, I hereby release the District, its operators, and any institutions with which they are affiliated from any and all claims and damages arising from my student’s use of, or inability to use, the system including, without limitation, the type of damage identified in the District’s policy and administrative regulations. Email I give permission for my student’s information to be sent to me electronically by the staff of the Waco ISD. I understand that the transmittal of this information may not be available by completely secure methods and may be capable of observation, interception, or monitoring by others. Further, I understand the District cannot guarantee the records will be received only by the requester at the email address provided. Yes No My student has permission to participate and appear in: Yes No WISD-TV video productions of school events and activities Yes No Photographs and articles published on Waco ISD internet and social media sites for promotional purposes. Photographs and video taken for instructional and promotional purposes by Baylor University, Tarleton State University, and other institutions of higher learning who partner with Waco ISD. Promotional purposes may include internet and social media sites, television channels and radio stations operated by the universities. All forms of newspaper, broadcast television, and radio station coverage of school events and activities. May we email you important news and information about our schools? Email address: _____________________________________ Yes No Yes No Yes No Federal law allows public schools to release "directory" information such as a student's name, address, telephone number, date of birth, honors and awards received, and dates of attendance. Such information is often provided to colleges, universities, supplemental education service providers and branches of the armed services. Parents may request that the school not release directory information about their child. Yes No The school may release my child's directory information? Waco ISD has the ability to send text messages to your cellular telephones. Such notifications may include school closings and early release days caused by inclement weather, reminders about important meetings, and information about possible emergency situations. Yes No If yes, to which cell phone number should we send texts?_______________________ For High School Students Only Parent’s Response Regarding Release of Student Information to Military Recruiters and Institutions of Higher Education Federal law requires that the district release to military recruiters and institutions of higher education, upon request, the name, address, and phone number of secondary school students enrolled in the district, unless the parent or eligible student directs the district not to release information to these types of requestors without prior written consent. Do you authorize Waco ISD to release information, if requested, to both the military and institutions of higher Education? Parent Signature Date: Yes No Student Residency Questionnaire This questionnaire is given to ALL students to ensure our district remains in compliance with the McKinney‐Vento Homeless Education Act 42 U.S.C. 11434a(2), which is also known as Title X, Part C, of the No Child Left Behind Act. Your answers will help school staff determine if the student is eligible for certain rights under federal law and supportive services. All questions contained in this questionnaire are strictly confidential and will become part of your academic record. Student Name: ______________________________________ ID #: ____________________ Parent/Guardian Name: ____________________________ Phone: ______________________ 1. Does the student live with a parent or legal guardian? Do you have court papers? Yes No Yes No 2. Does the student live within any of the following situations? Owner-occupied home Rental unit Military housing Long-term, agreed-upon living arrangement with a family member or friend Emergency shelter or transitional housing* Motel/hotel* Campground* Non-traditional housing space including cars, parks, public spaces, abandoned buildings, substandard housing, and bus or train station that is a public/private place not designed for, or ordinarily used as regular accommodation for people*. Foster care placement. Temporary, shared housing with friends, family or others due to: Loss of personal housing* (due to reasons such as eviction, inability to pay rent, destruction or damage to home, abuse or neglect, unhealthy conditions, parental abandonment or incarceration); Economic hardship*; Other, similar reason: If temporary housing, please state reason: If the student is living in a transitional living situation and/or is an “Unaccompanied Youth”, the school counselor will review more information with the student and family to determine appropriate services. For Office Staff: Scan and email this document to the Homeless Liaison (Cheryl Pooler) I certify the above named student qualifies for Child Nutrition Services under the provisions of the McKinney-Vento Act. McKinney-Vento Liaison Signature Date For more information call: ESC Region 12 Contact Person Polo Vielma : (254) 297-1214 Waco ISD 2015-2016 Family Survey Please print Please return form to school office Campus: Student Name: Date:_____________ Grade:________ Father/Guardian:_______________________________ Mother/Guardian:________________________________ Father’s Place of Employment:___________________ Mother’s Place of Employment:__________________ Home Address City Home Phone: Zip Cell Phone: Work Phone: In order to better serve your child/children, the school district would like to identify students who may qualify to receive additional educational services. The information provided will be kept confidential. Please answer the following questions. 1. Within the past 3 years have you moved from one city ,state or school district to another ? ☐YES or ☐NO 2. If yes, did you or your child move/leave in order to work (temporary or seasonal) in agriculture or fishing? (by checking yes, you are stating that you have worked in agricultural or fishing work within the last 36 months.) ☐YES or ☐NO If you answered YES to question 2, please check all that apply. Working with fruits , vegetables, cotton, wheat, grain, agricultural farms, fields or vineyards ☐ Working in a cannery ☐ Working on a dairy farm. Working on a ranchfeeding livestock, clearing fields, building fences ☐ Working in a slaughter House-packaging and cutting meat ☐ Working on a poultry farm ☐ Working in a plant, nursery or orchard, growing or harvesting trees or picking pecans Other similar work, please explain: Working in a fishery ☐ ☐ SCHOOL DISTRICT PERSONNEL: THIS FORM SHOULD NOT BE ALTERED IN ANY MANNER 01-15/FP/1 ☐ Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data Questionnaire The United State Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). School district staff and parents or guardians of students enrolling in school are requested to provide this 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. Please answer both parts of the following questions on the student's or staff member's ethnicity and race. United States Federal Register (71 FR 44866) Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino — A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. Not Hispanic/Latino Part 2. Race: What is the person's race? (Choose one or more) American Indian or Alaska Native — A person having origins in any of the original peoples of North and South American (including Central America), and who maintains a tribal affiliation or community attachment. 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 Island, Thailand, and Vietnam. Black or African American - A person having origins in any of the black racial groups of Africa. 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. Student/Staff Name (please print) Parent/Guardian or Staff Signature Student/Staff ID number Date THIS FORM MUST BE COMPLETED FOR ALL STUDENTS BORN OUTSIDE THE U.S. ESTA FORMA TIENE QUE SER COMPLETADA POR TODOS LOS ESTUDIANTES NACIDOS FUERA DE EE. UU. Immigrant Form Inverview for Grades PK-12 Entrevista para Estudiantes Nuevos de los Grados PK al 12 Name: I.D. # School: Grade: 1. Was your child born in the U.S.? ¿Nació su hijo(a) en los EE.UU.? 2. What city or state are you coming from? ¿De cuál ciudad o estado viene Ud.? 3. Has your child always lived outside the U.S.? ¿Siempre ha vivido su hijo(a) fuera de EE.UU.? 4. How long have you been in the U.S.? ¿Cuánto tiempo tiene su hijo(a). aquí en los Estados Unidos? 5. Has your child ever lived in the U.S. before? ¿Ha vivido su hijo(a) alguna vez en los Estados Unidos? 6. Has your child been in school in the U.S. for 3 academic years? ¿Ha estado su hijo(a) en alguna escuela por tres años en los Estados Unidos? 7. How many days of school did your child miss last year? ¿Cuántos días faltó a la escuela su hijo (a) el año pasado? 8. What were your child's grades in school last year? ¿Qué calificaciones sacaba su hijo(a) el año pasado? 9. Has your child ever been enrolled in Waco ISD? ¿Ha estado su hijo(a) alguna vez inscrito en alguna escuela del distrito de Waco? Receiving Campus: Please send this completed form, along with a copy of the student's birth certificate, to the Bilingual/ESL office which will have the responsibility of determining if the student meets the definition of "immigrant" for PEIMS purpose Nondiscrimination Policy The Waco Independent School District, as an equal opportunity educational provider and employer, does not discriminate on the basis of race, color, national origin, sex, religion, age, disability, or genetic information in educational programs or activities that it operates or in employment matters. The District is required by Title VI and Title VII of the Civil Rights Act of 1964, as amended, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, as amended, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act, as well as Board policy not to discriminate in such a manner. For information or complaints regarding compliance with the nondiscrimination requirements of Title IX, contact Waco ISD Executive Director of Human Resources at 254-755-9473 and/or Waco ISD Director of Athletics, at 254-7452250. For information or complaints regarding compliance with the nondiscrimination requirements of Title VI and Title VII, as amended, contact Waco ISD Executive Director of Human Resources at 254-755-9473. For information or complaints regarding compliance with the nondiscrimination requirements of Section 504 or the Rehabilitation Act of 1973, as amended, contact Waco ISD Section 504 Coordinator at 254-755-9473 or; P.O. Box 27, Waco, TX, 76703. Declaración de No Discriminar El Distrito Escolar Independiente de Waco como un proveedor de igualdad de oportunidades educativas y como el empleador no discrimina en base de la raza, color, origen nacional, género, religión, edad, incapacidad, o por la información genética en los programas educativos o en las actividades que dirige o en los asuntos de empleo. El Distrito es requerido por el Título VI y el Título VII de la Ley de Derechos Civiles de 1964, según enmendada, el Título IX de las Enmiendas de Educación de 1972, la Ley de Discriminación por Edad de 1975, según enmendada, la Sección 504 de la Ley de Rehabilitación de 1973, la Ley de Estadounidenses con Discapacidades, así como la Política del Consejo Escolar de no discriminar de tal manera. Para obtener información o para quejarse respecto al cumplimiento de los requisitos de no discriminar del Título IX, póngase en contacto con el/la Director(a) Ejecutivo(a) de Recursos Humanos del Distrito Escolar Independiente de Waco al 254-755-9473 y/o con el/la Director(a) de Atletismo del Distrito Escolar Independiente de Waco al 254745-2250. Para obtener información o para quejarse respecto al cumplimiento de los requisitos de no discriminar del Título VI y del Título VII, según enmendada, póngase en contacto con el/la Director(a) Ejecutivo(a) de Recursos Humanos del Distrito Escolar Independiente de Waco al 254-755-9473. Para obtener información o para quejarse respecto al cumplimiento de los requisitos de no discriminar de la Sección 504 o de la Ley de Rehabilitación de 1973, según emendada, póngase en contacto con el/la Coordinador(a) de la Sección 504 del Distrito Escolar Independiente de Waco al 254-755-9473 o; P.O. Box 27, Waco, TX, 76703. WACO INDEPENDENT SCHOOL DISTRICT HOME LANGUAGE SURVEY-19TAC Chapter 89, Subchapter BB §89.1215 TO BE COMPLETED BY PARENT OR GUARDIAN (OR STUDENT IF GRADES 9-12): The state of Texas requires that the following information be completed for each student that enrolls for the first time in Texas public schools. This survey shall be kept in each student’s permanent record folder. NAME OF STUDENT____________________________________STUDENT ID#___________________________ ADDRESS________________________________________TELEPHONE #_______________________________ CAMPUS____________________________________________________________________________________ 1. What language is spoken in your home most of the time? ________________________ 2. What language does your child speak most of the time? _________________ 3. Has your child lived outside the U.S. for two or more consecutive years? ______ Yes ____ No If yes, indicate when ___________________________________ (From month/year to month/year) 4. When your child lived outside the U.S. did he/she attend school regularly? (Check one) ___ Yes, my child attended school regularly in all previous grades outside the U.S. ___ No, my child missed significant portion of one or more school years, as specified: Specify grade and time period, including month and year (example: Grade 2 from March 2000 to May 2000) Do not include periods of absence that lasted less than 1 month. Do not include regularly scheduled school holidays or vacations. 5. Has your child participated in a Bilingual/ESL program in the state of Texas? YES NO 6. What school years did your child participate in the Bilingual/ESL program in the State of Texas? ___________________________________________________________________________________ ______________________________________ Signature of Parent/Guardian _______________________________ Date ______________________________________ Signature of Student if Grades 9-12 _______________________________ Date Nondiscrimination Statement The Waco Independent School District (District) as an equal opportunity educational provider and employer does not discriminate on the basis of race, color, national origin, sex, religion, age, disability, or genetic information in educational programs or activities that it operates or in employment matters. The District is required by Title VI and Title VII of the Civil Rights Act of 1964, as amended, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, as amended, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act, as well as Board policy not to discriminate in such a manner. For information or complaints regarding compliance with the nondiscrimination requirements of Title IX, contact Waco ISD Executive Director of Human Resources at 254-755-9473 and/or Waco ISD Director of Athletics, at 254-745-2250. For information or complaints regarding compliance with the nondiscrimination requirements of Title VI and Title VII, as amended, contact Waco ISD Executive Director of Human Resources at 254-755-9473. For information or complaints regarding compliance with the nondiscrimination requirements of Section 504 or the Rehabilitation Act of 1973, as amended, contact Waco ISD Section 504 Coordinator at 254-755-9473 or; P.O. Box 27, Waco, TX, 76703. WACO ISD ANNUAL STUDENT HEALTH HISTORY WISD Health Services Department requires the following information to complete your enrollment. Health information you provide about your child is confidential and will be used to provide safe, informed care at school, and will only be communicated to WISD personnel who require it to better serve your child. If your child has a medical condition, or medical changes occur during the school year, it is the parent/guardian's responsibility to notify the school nurse and update this information. Name of Student Sex. _ M _F Date of birth Phone number Mother / Stepmother / Guardian's name Home phone number Cell / Pager number Place of employment Work phone number E-mail Father / Stepfather / Guardian's name Home phone number Cell / Pager number Place of employment Work phone number E-mail Grade IN CASE OF AN EMERGENCY AND THE PARENTS CANNOT BE REACHED, THE FOLLOWING MAY BE CONTACTED: Name Home phone number Work phone number Cell / Pager number Name Home phone number Work phone number Cell / Pager number Preferred Hospital Primary Care Doctor Doctor’s Number Type of Insurance , EXPLAIN MEDICAL PROBLEM Abdominal conditions Crohn's Disease Gastric Reflux Irritable Bowel Syndrome Constipation Gastrostomy tube or feedings Allergic to Insect stings Latex Environmental Food Medicine , - , . . MEDICATIONS/TREATMENTS . EpiPen? Yes No (If yes, see school nurse) Other medication: Symptoms/Reaction: See School Nurse for food, insect, latex or other serious allergic reactions and provide Anaphylaxis Action Plan. Please provide doctor’s documentation for all allergies. Age diagnosed: Asthma Please provide current Asthma Action Plan if you child requires medications or treatments for asthma at school—See School Nurse. Medications taken for asthma: At home: At school: Under medical care now? Yes No Texas Law requires special permission form to carry inhaler at school—see school nurse. Behavioral, Emotional, Psych Blood disease /disorder Diabetes Type 1 Type 2 Additional information: Hearing loss Vision loss not corrected with glasses/contacts Other: Ears, Eyes, Nose A Diabetes Management & Treatment Plan is required for care at school—See School Nurse Hearing aid(s) R L Implant or previous surgery: Heart condition/Heart surgery Neurological disorder Migraines Cerebral Palsy Spina Bifida Muscle, Bone, Joint condition Arthritis Muscular Dystrophy Scoliosis Other: Cystic Fibrosis Tuberculosis Tracheostomy Other: Other: Respiratory other than asthma: Skin condition See School Nurse for an emergency seizure plan if your child has a history or diagnosis of seizures. Seizures Diastat Anti-Seizure Meds Other health conditions/Surgeries MEDICATIONS NOT LISTED ABOVE CURRENTLY TAKEN: All meds taken during school hours and school related activities must be brought to the clinic by a parent or guardian. A permission form is required for ALL medications—see the school nurse. Medication Dose/Time (s) given Reason Need at school? Yes No Yes No Parent/Guardian Signature: ___________________________________________________ Date: ___________________ 2015-2016 Waco Independent School District To: Parents/Guardians of Waco ISD Students From: Heather Branch, RN, Coordinator of Health Services Subject: Food Allergy It is important for the school district to know about any food allergy or severe food allergy that a student may have. A “severe food allergy” means that a student has an allergic response that is dangerous or is a life-threatening reaction of the human body to a foodborne allergen introduced by inhalation, ingestion, or skin contact and requires immediate medical attention. Please complete this form if your child has had a food allergy or a severe food allergy. Student safety is very important. If your child has had a severe food allergy, please provide a doctor’s note and speak with the school nurse as soon as possible. Does the student have a food allergy? Yes or No The student has a food allergy to: The nature of the allergic reaction is: Is there any necessary precaution that the school needs to be aware of to ensure the student’s safety in regards to this food allergy? Student Name: Teacher: Parent Signature: Date: Waco Independent School District Enrollment Information 2015-2016 Grade: Name of Student: Birthdate: Información de Inscripción Grado Fecha de Nacimiento Nombre del Estudiante Does your child receive the following services? ¿Recibe su hijo(a) los siguientes servicios? Special Education/ARD Meetings Yes/Sí No 504 Services Servicios 504 Yes/Sí No Dyslexia Services Yes/Sí No Educación Especial/Juntas ARD Servicios de Dislexia Other Services Otros Servicios Parent Signature/Firma del Padre Date/Fecha For Internal Use Only If YES to Special Education – Counselor complete transfer meeting/Temporary Transfer Meeting Form and then forward to appropriate assessment personnel. If NO to Special Education, but YES to 504 and/or Dyslexia – Enroll student in General Education then forward to appropriate campus program personnel to enter into TEAMS and Esped. If No – Enroll student in general Education. Immunization Information – Ask your Nurse. Military/Foster Form - question is now included on Media Permissions Page. Free/Reduced Lunch forms