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Elementary School Registration

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Dec. 2017
LA CENTER SCHOOL DISTRICT NO. 101
La Center Elementary School Registration
PO Box 1810 700 East 4
th
Avenue
La Center, WA 98629
Date: __________________________
School Entry Date: _______________ Returning Student? Yes/No Date last attended: _________________
Student's Legal Last Name: ________________ Legal First Name: ______________Middle: ______________
Grade Level: ______Sex: ____ Home Phone: _______________________Birth Date: ___________________
PRIMARY HOUSEHOLD
Guardian #1 Last Name: ___________________ First Name: ________________Relationship: ___________
Cell phone #: ___________________ Work Phone #: _______________________ Ext __________________
Guardian #2 Last Name: ___________________First Name: _________________Relationship: ___________
Cell phone #: ___________________ Work Phone #: _______________________ Ext __________________
Mailing Address: ___________________________City: _________________ Zip Code: ________________
Street Address: ____________________________ City: _________________ Zip Code: ________________
Guardian 1 e-mail address: ________________________ Guardian 2 e-mail address: _________________________________
ALTERNATE HOUSEHOLD (if applicable)
Guardian #1 Last Name: ____________________First Name: _________________Relationship: ___________
Primary phone: _______________________ Cell phone #: ___________________ Work Phone #: __________
Guardian #2 Last Name: ____________________First Name: _________________Relationship: ___________
Cell phone #: ________________________ Work Phone # ____________________ Ext #_________________
Mailing address: ___________________________City: _________________________Zip Code: __________
Home address: ____________________________City: _________________________Zip Code: ___________
Guardian 1 e-mail address: ________________________ Guardian 2 e-mail address: _________________________________
(Office use only) Student # __________________ Teacher: __________________ Bus #: _____________
Legal Restrictions: Are there any current Washington State restraining orders or legal restrictions in effect preventing a
non-custodial person from visiting the school, having access to school reports/records or removing your student from
school? Yes___ No___ If yes, legal papers must be on file with the school.
If yes, who is the order against:_________________________________________ Relationship to student:___________
Dec. 2017
Emergency contacts are contacted in the event that we are unable to reach parent/guardian. Please list individuals that live in the local area if possible.
Emergency Contact #1: __________________ Phone #: ______________ Relationship: ________Pick up any time? Yes/No
Emergency Contact #2: __________________ Phone #: ______________ Relationship: ________Pick up any time? Yes/No
Emergency Contact #3: __________________ Phone #: ______________ Relationship: ________Pick up any time? Yes/No
Will your child ride the bus to an after school daycare provider? Yes/No Daycare Provider: _______________________
Phone #: _____________________Address:______________________________________________________
Other siblings you are enrolling or that are enrolled in La Center School District:
Name Grade
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
For the past five (5) years, the student has attended the following schools:
Date entered Name of School City, State Date withdrawn
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Has student ever been enrolled in a special program? Yes/ No If yes, please indicate which program:
Gifted/TAG ___ Remedial Math (LAP) ___ Remedial Reading (Title 1) ____ Special Ed.___ IEP ___
Section 504 ___ ESL/ELL: ___
Does the student have past, current or pending, disciplinary action? Yes/No
Is student currently suspended or expelled from the previous school district? Yes/No
History of violent behavior: Yes/No If yes, please explain __________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Unpaid fines or fees imposed by other schools: Yes/No
Student Release Authorization: In the event that the school is unable to contact parent/guardian, I authorize that my child may be
released to the emergency contacts listed.
Parent/Legal Guardian signature: ______________________________________________________________
Emergency Medical Authorization: I understand that in the event of accident or illness, every effort will be made to contact the
parent/guardian immediately. If parent/guardian cannot be reached, I authorize the school to obtain emergency care for my child.
Parent/Legal Guardian signature: ______________________________________________________________
Verification of Information: The information on this form is true and accurate as of this date
Parent/Legal Guardian Signature: ___________________________________Relationship to Child _______________
Mexican/Mexican American/Chicano
Central American
South American
Lan American
Other Hispanic/Lano
La Center School District — Ethnicity & Race Data Collecon Form
STUDENT____________________________________________ SCHOOL___________________ GRADE ________
Please ll out both Queson 1 and Queson 2
Queson 1. Is your student of Hispanic or Lano origin? (Check all that apply)
Not Hispanic/Lano
Cuban
Dominican
Spaniard
Puerto Rico
Queson 2. What race(s) do you consider your student? (Check all that apply)
African American/Black
White
Asian/Indian
Cambodian
Chinese
Filipino
Hmong
Indonesian
Japanese
Korean
Laoan
Malaysian
Pakistani
Singaporean
Taiwanese
Thai
Vietnamese
Other Asian
Nave Hawaiian
Fijian
Guamanian or Chamorro
Mariana Islander
Melanesian
Micronesian
Samoan
Tongan
Other Pacic Islander
Alaskan Nave
Chehalis
Colville
Cowlitz
Hoh
Jamestown
Kalilspell
Lower Elwha
Lummi
Makah
Muckleshoot
Nisqually
Nooksack
Port Gamble Klellam
Puyallup
Quilleute
Quinault
Samish
Sauk-Suiale
Shoalwater
Skokomish
Snoqualimie
Spokane
Squaxin Island
Sllaguamish
Suquamish
Swinomish
Tulaup
Yakima
Other Washington Indian
Other American Indian/Alaska
Nave
Dec. 2017
La Center School District
RESIDENCY VERIFICATION DECLARATION FORM
(Please complete one form for each student)
HOME OWNER
RENTER
OTHER (specify) ________________________________________________________________
Washington law requires schools to be open to the admission of all persons between the ages of 5 and 21 residing in that
school district (RCW 28A.225.160). The La Center School District (District) is required to take appropriate steps to ensure that
students attending its schools satisfy applicable laws. This Residency Verification Form must be completed, signed, and
submitted with appropriate documentation demonstrating compliance with Washington residency laws.
DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ARE INCORRECT. Evidence that false information was provided may be cause
for immediate revocation of the student’s school assignment and withdrawal from the District.
Current Current
Student: ____________________________________ School: ____________________ Grade: _______
Last Name First Name
Parent/Guardian: _________________________________ Home Phone: ________________________
Address: ____________________________________________________________________________
Number Street City State Zip Code
Email Address: _________________________________________
NOTE: The District presumes that the person who enrolls a student in school is the residential parent of the student. In circumstances in
which legal and physical custody of the student is shared between two parents, you must provide a certified copy of the court order
identifying each parent’s respective legal and physical custody rights. You also must inform the District of any changes to the court order
within (5) days.
In compliance with WAC 392-137-115, by signing below I acknowledge the following:
My student (listed above) resides with me at least four (4) nights per week at the address listed above which is my primary
residence.
I agree to notify and provide updated proof of residency to the District/School within (5) days of when I change my residence or
that of my student to a new address, either within or outside the District.
The District will investigate all cases where it has reason to believe that residency status has changed and/or false information has
been provided, which may include home visits to verify residency.
Investigations that reveal students have enrolled on the basis of providing false information may result in the revocation of the
student’s school assignment and withdrawal from the District.
I have attached the following two (2) *Proof of Residency documents which include my name and residential address.
Current payroll check stub with name and address Mortgage, rental or lease documents
Government issued check or correspondence Homeowners or Renters Insurance Policy
Public agency documents (DSHS, courts, etc.) Utility bill(s) (water, sewer, gas, electric, cable, etc.)
*Personal correspondence or copies of envelopes are not acceptable Proof of Residency documents.
I swear (or certify) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct, and that any and all copies of
documents submitted to verify my residency are true and correct copies of the original documents, and that any and all documents submitted have not been
altered except for the crossing out of dollar amounts and account numbers (redacted), which is permitted for the purposes of this Residency Verification
Declaration.
____________________________________________________________
Printed Name of Parent/Guardian
____________________________________________________________ ________________________________
Signature of Parent/Guardian Date
English/November 2016
Office of Superintendent of Public Instruction (OSPI)
Home Language Survey
The Home Language Survey is given to all students enrolling in Washington schools.
Student Name:
Grade:
Date:
Right to Translation and
Interpretation Services
Indicate your language preference so
we can provide an interpreter or
translated documents, free of
charge, when you need them.
All parents have the right to information about their child’s
education in a language they understand.
1. In what language(s) would your family prefer to communicate
with the school?
__________________________________
Eligibility for Language
Development Support
Information about the student’s
language helps us identify students
who qualify for support to develop
the language skills necessary for
success in school. Testing may be
necessary to determine if language
supports are needed.
2. What language did your child learn first?
__________________________________
3. What language does your child use the most at home?
__________________________________
4. What is the primary language used in the home, regardless of
the language spoken by your child?
__________________________________
5. Has your child received English language development support
in a previous school? Yes___ No___ Don’t Know___
Prior Education
Your responses about your child’s
birth country and previous
education:
Give us information about the
knowledge and skills your child is
bringing to school.
May enable the school district to
receive additional federal funding
to provide support to your child.
This form is not used to identify
students’ immigration status.
6. In what country was your child born? ___________________
7. Has your child ever received formal education outside of the
United States? (Kindergarten 12
th
grade) ____Yes ____No
If yes: Number of months: ______________
Language of instruction: ______________
8. When did your child first attend a school in the United States?
(Kindergarten 12
th
grade)
_______________________
Month Day Year
Thank you for providing the information needed on the Home Language Survey. Contact your school
district if you have further questions about this form or about services available at your child’s school.
Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that
includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to
questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly
understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.
Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative
Commons Attribution 4.0 International License.
La Center School District #101
725 Highland Road La Center, WA 98629
Student Housing Questionnaire
The answers to the following questions can help determine the services this student may be eligible to receive under the
McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth
experiencing homelessness or housing instability. (Please see reverse side for more information.)
If you own/rent your own home, you do not need to complete this form.
Please check which box reflects your current living situation:
In a motel A car, park, campsite, or similar location
In a shelter Transitional Housing
Moving from place to place/couchsurfing Other ________________________________
In someone else’s house or apartment with another family
In a residence with inadequate facilities (no water, heat, electricity, etc.)
Name of Student: _________________________________________________________________________________
First Middle Last
Name of School: ____________________________Grade:________ Birthdate: ______________ Age: ____
Month/Day/Year
Gender: ________ Student is unaccompanied (not living with a parent or legal guardian)
Student is living with a parent or legal guardian
Address or Current Residence: : _____________________________________________________________________
Phone Number or Contact Number: : _______________________
Name of Contact:: ________________________
Print name of Parent(s)/Legal Guardian(s): _____________________________________________________________
(Or Unaccompanied Youth)
*Signature of Parent/Legal Guardian: ________________________________________ Date: _______________
(Or Unaccompanied Youth)
*I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true
and correct.
McKinney-Vento Building Liaison Signature____________________________________ Date_______________
I hereby certify that the above named student qualifies for rights and services under the McKinney-Vento Act.
McKinney-Vento District Liaison Signature____________________________________ Date_______________
La Center School District 360-263-2136
Rev 10/2016
McKinney-Vento Act 42 U.S.C. 11435
SEC. 725. DEFINITIONS.
For purposes of this subtitle:
(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities.
(2) The term homeless children and youths' —
(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the
meaning of section 103(a)(1)); and
(B) includes —
(i) children and youths who are sharing the housing of other persons due to loss of
housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks,
or camping grounds due to the lack of alternative adequate accommodations; are living in
emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster
care placement;
(ii) children and youths who have a primary nighttime residence that is a public or private
place not designed for or ordinarily used as a regular sleeping accommodation for human
beings (within the meaning of section 103(a)(2)(C));
(iii) children and youths who are living in cars, parks, public spaces, abandoned buildings,
substandard housing, bus or train stations, or similar settings; and
(iv) migratory children (as such term is defined in section 1309 of the Elementary and
Secondary Education Act of 1965) who qualify as homeless for the purposes of this
subtitle because the children are living in circumstances described in clauses (i) through
(iii).
(6) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian.
Additional Resources
Parent information and resources can be found at the following:
http://center.serve.org/nche/ibt/parent_res.php
http://naehcy.org/educational-resources/naehcy-publications
La Center School District
Clark County, Washington
La Center Elementary School
Phone (360) 263-2134 Fax (360) 263-2133
Requested_____________
Received______________
REQUEST FOR SENDING PERSONALLY IDENTIFIABLE RECORDS
STUDENT_______________________________________________DATE_____________
BIRTHDATE_____________________________________________GRADE____________
I request an exchange of records for the following reason:
________________________________________________________________________
Please send:
Permanent records
Health records
Special Education records (Including speech and language records)
Other ________________________________________
This information is to be exchanged between:
the new school and the previous school
As provided under the Family Rights and Privacy Act of 1974, I understand that I may obtain a copy of my child’s
personally identifiable records. I am aware that I may challenge the content of these records. I also understand
that the school will treat these records confidentially. Finally, no one will send these records to a non-public
school agency without my written consent.
Signature:__________________________________
Relationship:________________________________
Address:___________________________________
Phone:____________________________________
La Center Elementary School
PO Box 1810 / 700 E. 4
th
Street
La Center, WA 98629
Parent/guardian signature: ________________________________Date:__________________
La Center School District
Student Health History 2017-18
To be completed by parent/guardian
Student Name: __________________________ Date of Birth: _________Grade: ____ Male Female
Parent Name: _______________________Phone #: ___________________Teacher: __________Bus#____
INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH
ANY OF THE FOLLOWING:
If your child has a life-threatening condition, state law requires a medication and/or treatment orders from a
Licensed Health Professional and an Emergency plan must be in place before your child can attend school.
See office for forms. Please check appropriate boxes below and explain if needed
Health Condition Yes No Explanation if “Yes” checked
Food Allergies
Food(S): peanut tree nut dairy eggs other_________
Rate the reaction: mild moderate life-threatening
Does your child require an EpiPen? yes no
Allergy to Bee Stings
Rate the reaction: mild moderate life-threatening
Does your child require an EpiPen? yes no
Medication Allergies
List:
Allergies (other)
List:
Asthma
Rate the severity: mild moderate life-threatening
Asthma medication taken at home:___________________________
Medication required at school:
Diabetes
Type 1 (insulin Dependent) Type 2
Diabetes medications(s) taken at home:
Seizure Disorder
Type of seizure: Medications:
Heart Condition
Specify:
Cancer
Specify:
Blood Disorder
Specify: Treatment:
ADD/ADHD
Medication for ADD/ADHD:
Mental Health /
Behavioral Issues
Specify:
Treatment/Medication:
Orthopedic Condition
Specify:
Wears glasses
For Distance For Reading
Hearing Loss
Hearing Loss Right Ear Left Ear Hearing Aids
Does your child have any other condition that would affect his/her classroom performance or
P.E. activities?
No Yes if yes, explain: _________________________________________________________
Daily Medication
State law requires written permission from a Licensed Health Professional and parent before any medication
(prescription or over-the-counter) can be given at school. A form is available from the school office.
No Yes Medication needed at school- specify: ___________________________
No Yes Medication needed at home- specify: ____________________________
No Yes For daily medication taken at home, would missing 24 hours of this medication
pose a health risk to your child or others? If yes, a three-day supply of medication would need to
be supplied to the school in case of an emergency (eg. daily asthma, diabetes, seizure, allergy or
ADD/ADHD medication).
This information is considered confidential. It will be shared with school staff and emergency responders as needed during
the time your child is enrolled in La Center School District in order to ensure the health and safety of your child, unless
otherwise requested by you in writing.
LA CENTER ELEMENTARY SCHOOL
______________________________________________________________________________
700 East 4
th
St, La Center, WA 98629 360.263.2134
FAMILY EMERGENCY PLAN
Should an emergency closure of school be necessary, each family needs to have prepared a plan for
supervision of your child (ren). Please discuss with your child (ren) to whom they should report if you
are not home when they arrive. It is especially helpful to children to have at least two alternatives for
safe supervision. Also, in an emergency, they are more assured if the family has actually practiced the
routine of what to do if parents are not home to meet them. Emergency closures of school are extremely
rare. However, we need to prepare our children for a safe experience should the need arise. If we do not
have an alternative plan, we will send your child home according to their regular routine.
Please specify below any specific instructions for the school staff in the event of an unannounced early
dismissal.
PHONE CALLS FROM SCHOOL CANNOT BE A PART OF THIS PLAN
Student Name: ________________________________________________________________
Grade: __________________ Teacher: _____________________________________________
Sibling grade level(s):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Ride the bus home as usual.
Special instructions- please include any alternate bus numbers:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Parent signature: ___________________________________________
Date: _____________________________ Phone: _________________________________
Military Parent or Guardian Aliaon
(Please mark all that apply)
N—No parent or guardian of the above children is currently serving as a member of the acve duty U.S.
Armed Forces, Reserves of the U.S. Armed Forces or Washington Naonal Guard
A—A parent or guardian of the children above is a current member of the acve duty U.S. Armed Forces
R—A parent or guardian of the children above is a current member of the reserves of the U.S. Armed
Forces
G—A parent or guardian of the children above is a current member of the Washington Naonal Guard
Z—No response/Refused to state
Parent/Guardian(s) Name(s): Student Name(s):
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