i/¡11 Public Schools NEW STUDENT REOPEN ENROLLMENT FORM · Public Schools NEW STUDENT REOPEN...
Transcript of i/¡11 Public Schools NEW STUDENT REOPEN ENROLLMENT FORM · Public Schools NEW STUDENT REOPEN...
School Name: __________ _
STUDENT HEAL TH APPRAISAL: (Th1s information wi/1 be used by O1strict Health staffto help ourstudent
Student Legal Name:
Does yourstudenthave a physical disability? □ No □Yes---------------------------------
2 Doesyourstudentwearglassesorcontacts? □l'ilo □Yes--------------------------------
3 lsyourstudenttaking anymedication? □ No □Yes _______________________________ _
il Will yourstudenttake medicine atschool? □ No □Yes (list medicine and condition) ______________________ _
5 Is your student a ble to participate fully in activities al school? □Yes □ No (if no, please explain) ____________________ _
6 Check ifyourstudent hasanyof thefollowing?
□ Allergies-food: ____________ _
□ Allergies-insects: ___________ _
□ Allergies-seasonal: ___________ _
O Allergies-misc: ____________ _
□Asthma
O Check if Life Threatening
O Check if Life Threatening
O Check if Life Threatening
O Check if Life Threatening
□ Check if Life Threatening
□Diabetes
□ Heart Problem
□ Seizure Disorder
O Hearing Loss
O Speech Disorder
O Check if Life Threatening
O Check if Life Threatening
O Check if Life Threatening
Explain health conditions: (attach additional sheet if needed) _________________________________ _
Other: -------------------------------------------------
SIGNA TU RE: I declare that the abo ve information is true to the best of my knowledge and belief. I understand I commit the e rime of false swearing if J
make a false statement, knowing it to be false. (ORS 162.075). Further, I understand that my student could be returned to their neighborhood school
upan determination of a falseaddress.
Parent/Guardian Signature: __________________________________ Date: _______ _
School Name:
� Springfield i/¡11 Public Schools NEW STUDENT REOPEN ENROLLMENT FORM
2020-21 New Student Reopening Enrollment Form
/ School Use Only
School Year: ___ _ School: ___________________ _ Student ID# _______ 1'
This enroflment form is a legal document. The information you provide must be accurate and complete.
This information is protected by the Family Educational Rights and Privacy Act (FERPA).
SPECIAL SERVICES: (Please check al/ serv1ces needed by th1s student)
O Speech Se rvices □ Section 504 Plan
□Talented & Gifted Program
□ Special Ed IEP
□ELL/LEP Services □TitleVll lndianEd:Tribe __________ _
STUDENT'S LEGAL NAME:
Legal Last Name First Middle Suffix
Grade: (startingatthisschool) _______ _ Birthdate: __ / __ / __ Gender: □Female □ Male □ Non-Binary
Home Language Preferred First Name Last Name Goes By
First Language Spoken Student Cell Phone Number
Birth City Birth State Birth Country
ETHNICITY & RACE:
Federal Regulations require this information. Jf ethnicity and race fields are not entered, school staff must select for you.
ETHNICITY: O Hispanic □ Non-Hispanic
RACE: (Mark al/ that apply) □ White □ Asian
□Black/African American
O Non-US Native American
□ American lndian or Alaska Native
O Native Hawaiian or Pacific lslander
STUDENT'S HOME ADDRESS: MAILING ADDRESS:
Home Address Apt# Mailing Address (if different than home address)
City State Zip City
CountyofResidence: __________________ _
State
Apt#
Zip
Address Verification: (Provide Photo ID and One UtilityBi/1) Mustbe currentcopies-valid in the past 30days. Verifica/ion can be submittedthrough scannedorphoto copy as we/1 as mail-in documentation.
□ Oregon Drivers License □ UtilityBill□ Oregon ID O Cable/Satellite Bill
Primary Phone: !..__
__ .,_\ ________ (U sed for Attendance & Emergency Calling)
200113-0820
Are there custody issues that the school should be made aware of? □Yes □ No
Aretherecustodypapers? □Yes □No
Relationship to Student: □Father □ Mother □ Guardian (mustprovidelegalguardianshipdocumentation) □Other: (specify) _______ _Living with student? □Yes □No
Paren! Legal Las! Name Legal First Name
Mark ali that apply: □ Contact allowed □Ed. Rights □ Has Custody □ Mailings Allowed □ Release To □ Deceased
Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _
Employer: _____________________ _ Job Tille: ______________________ _
Home Address (if differentfrom student's) City State Zip
HomePhone: ( __ ) ________ Work: ('-___________ Cell: '-----' ________ _ Primary Phone (preferred contact): □ Home □Work □ Cell Active Military? □ Yes □ No
Relationship to Student: □Father □ Mother □Guardian (mustprovidelega/guardianship documentation) □Other: (specify) _______ _Living with student? □Yes □No
ParentLegalLastName Legal First Name
Mark ali that apply: □ Contact allowed □Ed. Rights □ Has Custody □ Mailings Allowed □ Release To □ Deceased
Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _
Employer: _____________________ _ Job Tille: _____________________ _
Home Address (if different from student's) City State Zip
Home Phone: ( __ ) ________ Work: ! _____________ Cell: ( __________ _
Primary Phone (preferred contact): □ Home □Work □Cell Active Military? □ Yes □ No
Relationship to Student: □Father □ Mother □Guardian (mustprovidelegalguardianshipdocumentation) □Other: (specify) _______ _Living with student? □Yes □No
ParentLegal Las!Name Legal First Name
Mark ali that apply: □ Contact allowed □Ed. Rights □ Has Custody □ Mailings Allowed □ Release To □ Deceased
Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _
Employer: _____________________ _ Job Tille: ______________________ _
Home Address (if differentfrom student's) City State Zip
HomePhone: ( __ ) ________ Work: '--- ________ Cell: �--� ________ _ Primary Phone (preferred contact): □ Home □Work □Cell Active Military? □ Yes □ No
Relationship to Student: □Father □ Mother □Guardian (mustprovidelegalguardianshipdocumentation) □Other: (specify) _______ _Living with student? □Yes □No
Paren! Legal Last Name Legal First Name
Mark ali !ha! apply: □ Contact allowed □Ed. Rights □ Has Custody □Mailings Allowed □ Release To □ Deceased
Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _
Employer: _____________________ _ Job Tille: ______________________ _
Home Address (if different from student's) City State Zip
Home Phone: ( __ ) ________ Work: '--- ________ Cell: '--- _______ _ Primary Phone (preferred contact): □ Home □Work □Cell Active Military? □ Yes □ No
In an emergency, Parents/Guardians Jisted on page 2 with "Contact Allowed" checked, will be called befare Other Emergency Contacts listed below. Líst on/y !hose authorized to pickup your student. lndividua/s listed below wi/1 be contacted to pickup your student in the event of an emergency e/asure.
1st (__ ) □ Home
Name Relationship to Student Phone
Address City State Zip
2nd (__ ) □ Home
Name Relationship to Student Phone
Address City State Zip
3rd (__
) □ Home
Name Relationship to Student Phone
Address City State Zip
4th (__
) □ HomeName Relationship to Student Phone
Address City State Zip
EMERGENCYSCHOOLCLOSURE
To prepare for an unexpected early school dismissal, please assist us by establishing a plan with your child and indicating your choice below:
□ My child will ride !he bus and has been instructed by me about what to do.□ 1 will make arrangements for my child to be picked up al school within an hour of emergency closure.□ My child may be released towalk and has been instructed by me aboutwhat todo.
SIBLINGS: (Líst ali brothers, sisters, step and half brothers and sisters of this student attendmg Springfield Pubilc Schools )
Student Name Relationship to Student Grade
Student Name Relationship to Student Grade
Student Name Relationship to Student Grade
Student Name Relationship to Student Grade
Student Name Relationship to Student Grade
OTHER INFORMATION:
School Enrolled
School Enrolled
School Enrolled
School Enrolled
School Enrolled
□ Cell
□ Cell
□ Cell
□ Cell
PreviousSchool: ________________________________ _ Phone: ( __ ) _______ _
Address City State Zip
Special Circumstances:
lsthisstudentcurrentlysuspended? □ No □Yes, from (name ofschool) ____________________________ _ lsthisstudentcurrentlyexpelled? □ No □Yes, from (name ofschool) _____________________________ _
SchoolAddress, City and State: -------------------------------------------
Permissions:
My student may participate in all school field trips. □Yes □No
SERVICES AND PROGRAMS Checklist for New Students
Student’s Name:
If your student had services or was involved in certain programs in the past year, we want to know in order to better serve your child. Please check those that apply.
Home Language:
No English
Both another language and English
Migrant Education
Native Youth. Tribe, Band or Group:
McKinney-Vento Program/Foster Care Student
Talented and Gifted
Title I
Reading
Math
Individualized Education Plan (I.E.P.)
Reading
Math
Written Language
Speech/Language Services
Emotional Disturbed
Physical/Occupational Therapy
Adaptive P.E.
English Language Learner (ELL/ESL)
Behavior Support
Hearing
Vision
Counseling
Head Start/EC Cares/Preschool Promise
Other (please describe):
PERMISSION TO RELEASE STUDENT RECORDS TO SPRINGFIELD SCHOOL DISTRICT,OREGON
Previous School Phone
City/State/Zip Fax
Student Name Grade Enrolling
Date of Birth Phone
Parent Signature
1st Request 2nd Request Fax # Initial
Please FAX the following: Transcript/Immunizatons
Copy of IEP/Eligibility if applicable
Withdraw Grades if applicable
Please forward the following records in their entirety to the school checked below:
•All permanent Records •Current Official Transcript •Health Records
•All Special Education Recofrds (IEP and 504 accommodations)
•Behavioral Records (including attendance, suspensions and expulsions)
Centennial Elementary School 1315 Aspen St., Springfield OR 97477 Attn: Registrar
Douglas Gardens Elementary School 3680 Jasper Rd., Springfield OR 97478 Attn: Registrar
Guy Lee Elementary School 755 Harlow Rd., Springfield OR 97477 Attn: Registrar
Maple Elementary School 2109 J St., Springfield OR 97477 Attn: Registrar
Mt Vernon Elementary School 935 Filbert Ln., Springfield OR 97478 Attn: Registrar
Page Elementary School 1300 Hayden Br Rd., Springfield OR 97477 Attn: Registrar
Ridgeview Elementary School 526 66th St., Springfield OR 97478 Attn: Registrar
Riverbend Elementary School 320 51st St., Springfield OR 97478 Attn: Registrar
Thurston Elementary School 7345 Thurston Rd., Springfield OR 97478 Attn: Registrar
Two Rivers Elementary School 1084 G St., Springfield OR 97477 Attn: Registrar
Walterville Elementary School 40589 McKenzie Hwy., Springfield OR 97478 Attn: Registrar
Yolanda Elementary School 2350 Yolanda Ave., Springfield OR 97477 Attn: Registrar
Agnes Stewart Middle School 900 S 32nd St., Springfield OR 97478 Attn: Registrar
Briggs Middle School 2355 Yolanda Ave., Springfield OR 97477 Attn: Registrar
Hamlin Middle School 326 Centennial Blvd., Springfield OR 97477 Attn: Registrar
Thurston Middle School 6300 Thurston Rd., Springfield OR 97478 Attn: Registrar
Academy of Arts and Academics 615 Main St., Springfield OR 97477 Attn: Records/Counseling
Gateways High School 425 10th St., Springfield OR 97477 Attn: Records/Counseling
Springfield High School 875 7th St., Springfield OR 97477 Attn: Records/Counseling
SPS OnLine (K-12) 425 10th St., Springfield OR 97477 Attn: Records/Counseling
Thurston High School 333 58th St., Springfield OR 97478 Attn: Records/Counseling
Received Records On: Checked In by:
Federal Law 99.31 Requires No Parent Signature for educational records sent to another agency. Permission is required for transfer of Special Education records.