JEFFERSON R-VII SCHOOL DISTRICT – ENROLLMENT FORM

STUDENT NAME (Legal Name as it appears on birth certificate)

Last Sufix First Nickname___________________ Grade: ___________ Gender: Male

Middle Female Date of Birth _________________

Student Cell Phone Number:_____________________________

Country of Birth: United States Other _______________ If other, date entered the United States: ___________________

RACE / ETHNIC ORIGIN The United States Government requires the schools to make reports using the following categories for Race / Ethnicity: Are you Hispanic or Latino? Yes No Which of the following describes your Race? (choose all that apply): White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

HOME LANGUAGE Is English the primary language spoken in the home? Yes No Is a language other than English spoken in the home? Yes No If Yes, language spoken: ____________________________ Does the student speak a language other than English? Yes No If Yes, language spoken: ____________________________

EMERGENCY CONTACTS Please provide contact information for three individuals, other than parent/guardians, to whom the student may be released from school and who can make emergency decisions if a situation arises and the parent/guardian cannot be reached. List these contacts in the order that you would like them contacted.

1. Name:___________________________________________ Relationship to student:_________________________ Contact Phone: ________________________2. Name:___________________________________________ Relationship to student:_________________________ Contact Phone: ________________________

3. Name:___________________________________________ Relationship to student:_________________________ Contact Phone: ________________________

Complete original copies of any legal documents/court orders pertaining to the student must be presented (divorce decrees, custody/parenting plans, restraining order, etc.)

HOUSEHOLD 2 (Non-Resident Parent/Guardian) Married Separated Divorced Widowed Single Adult #3 Full Name (Include Middle Name) _____________________________________________Date of Birth: _____________ Email __________________________________ Place of employment ______________________________________________ Work Phone ______________________ Mobile Phone ___________________________ Relationship to student: Father Mother Step-Father Step-Mother Guardian Foster Parent Other:_______________________ Military Data for State Reporting: Not Military Connected Active Duty National Guard or Reserve Adult #4 Full Name (Include Middle Name) _____________________________________________Date of Birth: _____________ Email __________________________________ Place of employment ______________________________________________ Work Phone ______________________ Mobile Phone __________________________ Relationship to student: Father Mother Step-Father Step-Mother Guardian Foster Parent Other:______________________ Military Data for State Reporting: Not Military Connected Active Duty National Guard or Reserve Address: ___________________________________________________ City:___________________ State:___________ Zip:___________ Home Phone:__________________ Other Students Living in Household / Grade:_____________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

HOUSEHOLD 1 (Resident Parent/Guardian) Married Separated Divorced Widowed Single Adult #1 Full Name (Include Middle Name) _____________________________________________Date of Birth: _____________ Email __________________________________ Place of employment ______________________________________________ Work Phone ______________________ Mobile Phone ___________________________ Relationship to student: Father Mother Step-Father Step-Mother Guardian Foster Parent Other:_______________________ Military Data for State Reporting: Not Military Connected Active Duty National Guard or Reserve Adult #2 Full Name (Include Middle Name) _____________________________________________Date of Birth: _____________ Email __________________________________ Place of employment ______________________________________________ Work Phone ______________________ Mobile Phone ___________________________ Relationship to student: Father Mother Step-Father Step-Mother Guardian Foster Parent Other:_______________________ Military Data for State Reporting: Not Military Connected Active Duty National Guard or Reserve Address: ___________________________________________________ City:___________________ State:___________ Zip:___________ Home Phone:__________________ Other Students Living in Household / Grade:_____________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________

STUDENT EDUCATIONAL INFORMATION Please list the last school attended: Not applicable—initial enrollment for school

District:___________________________ School:________________ City:______________ State: ________________

Has this student ever been retained? Yes No If Yes, what grade? ____________________________ Has this student ever attended school at Jefferson R-VII? Yes No If Yes, when? ____________________________ Has this student ever received special education services through an Individual Education Plan (IEP)? Yes No Has this student ever received speech or language therapy through a Speech Improvement Plan (SIP)? Yes No Has this student ever received any of the following services? Gifted Program Title I Reading Services Section 504 Plan English Language Learning Other: ______________________________________________

A complete copy of previous educational plan(s) must be received from previous district prior to implementation.

Yes No

Yes No Yes No Yes No

SAFE SCHOOLS ACT The undersigned hereby certify and represent to the Jefferson County R-VII School District, for the purposes of the Missouri Safe Schools Act, that:

If Yes, please indicate which crime(s). ___________________ A. First degree murder under Section 565.020, RSMo B. Second degree murder under Section 565.021, RSMo C. First degree assault under Section 566.050, RSMoD. Forcible rape under Section 566.030, RSMo E. Forcible sodomy under Section 566.060, RSMo F. Statutory rape under Section 566.032, RSMoG. Statutory sodomy under Section 566.062, RSMo H. Robbery in the first degree under Section 569.020, RSMo I. Distribution of drugs to a minor under Section 195.212, RSMoJ. Arson in the first degree under Section 569.040, RSMo K. Kidnapping, when classified as a Class A felony, under Section 565.100, RSMo

The undersigned, being first duly sworn on their oath, states that they provided the above information to the Jefferson County R-VII School District for the purpose of enrolling a student in the Jefferson County R-VII School District and states that such information is true and correct to the best of their information, knowledge and belief.

This student is currently suspended or expelled from any other school district. Yes No

This student has been convicted or indicted of any of the following offenses and no information or petition alleging such offense has been filed: Yes No

ELIGIBILITY In order to comply with Missouri Law regarding the eligibility of children to attend the public schools, the Jefferson County R-VII School District is required to compile certain information. Under penalty of perjury and subject to the laws of the State of Missouri making it a crime under Section 575.050 and Section 575.056 to make a false affidavit or false declaration, the undersigned hereby submits this form, under oath, for the purpose of establishing residency and enrollment in the Jefferson County R -VII School District. At least one (1) signature required.

___________________________________________________________________________________________________________ _____________________________________ Parent/Guardian Signature (Student may sign if 18 years of age and not living with parent) Date

Printed Name:______________________________________________________________________

___________________________________________________________________________________________________________ _____________________________________ Parent/Guardian Signature Date

Printed Name:______________________________________________________________________

McKINNEY-VENTO ACT These questions cover the definition of homeless that is within the No Child Left Behind Law. This enrollment form will meet MSIP Standard 8.3.1 for enrollment identification.

Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason? Yes No Are you currently residing at a motel, hotel, trailer park or camping grounds due to the lack of alternative adequate accommodations? Yes No Are you currently residing in an emergency or transitional shelter? Yes No Has the student been abandoned in a hospital? Yes No Is you primary nighttime residence a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings? Yes No Are you currently living in a car, park, public space, abandoned buildings, substandard housing, bus or train station or similar setting: Yes No If yes on any above questions, please explain: ___________________________________________________________________________________________________

OPTION TO WITHHOLD INFORMATION AND MEDIA RELEASE Family Educational Rights and Privacy Act (FERPA): Parents who wish the school to withhold student directory information are required to submit notice to the building principal each year. The “opt out” only applies to the school year for which it is signed. By “opting out” parents understand that NO information can be released. Detailed information about FERPA can be found at https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html

WITHHOLD my student’s directory information (I realize this is only for the enrollment school year. After this school year, I will have to re “opt out”)

Media Release Form—Student Interviews and Images: I give my permission for my child to be a part of the following media-related situation: Use of photographic image and interviews with local media (yearbook, print, radio, TV, web, social media) *Students will not be interviewed for sensitive subject matter without receiving parental/guardian permission.

Yes, I give permission No, I do not give permission

COPPA, TECHNOLOGY, AND FIELD TRIP AGREEMENT COPPA The Jefferson R-VII School District is committed to providing students with the most effective tools for learning. The Children’s Online Privacy Protection Act (COPPA), a federal law, requires parental notifica-tion and consent for student use of District approved online resources for instructional purposes for students under 13 years of age. The law permits schools to act as the parent’s agent and can consent to the collection of student information on the parent’s behalf. More information about COPPA can be found at http://www.jr7.k12.mo.us/notices/federal_notices/c_o_p_p_a_notice_to_parents Agree Disagree

Technology / Chromebook Insurance Please review the Technology Acceptable Use Policy and the Chromebook Handbook. http://www.jr7.k12.mo.us/UserFiles/Servers/Server_2964082/File/tech/StudentAcceptableUseAgreement2020.pdf

I agree to the Technology Acceptable Use Policy

Voluntary student Chromebook Insurance is available for students in Grades 6-12. Program details can be found at http://www.jr7.k12.mo.us/departments/information_technology/chromebook_insurance_program I wish to purchase Chromebook Insurance I do not wish to purchase Chromebook Insurance

Field Trip Permission I give permission for my student to attend school-related field trips. Yes No

FEDERAL MIGRATORY WORKER SURVEY If you have a child age 3 through 21 and you have moved from one school district to another school district within the past six years, your child may be eligible for a special program of supplemental services. Please answer the following questions to help us determine if your child is eligible.

1. Before the move, was either parent/guardian employed in some form of temporary or seasonal agricultural related work such as:planting or harvesting crops (vegetables, fruits, cotton, etc.); landscaping; transporting farm products to market; feeding poultry,gathering eggs, working in hatcheries, processing poultry, beef, hogs, fruit, vegetables, etc.; working on a dairy farm or a catfish farm; cutting firewood or logs to sell?

2. Was the move from one school district to another made for the purpose of looking for or obtaining any of the above jobs?3. Is either parent/guardian now employed in any of the above kinds of work?4. Have you moved away with your child during only the summer months to engage in crop harvesting or other seasonal agricultural?

JEFFERSON R-VII SCHOOL DISTRICT – CONSENT FOR RELEASE OF INFORMATION

Date of Request:_________________ Student Name:

Last Sufix First Middle

Date of Birth: ____________________ Grade: ______________ Enrollment Date: ______________________ We request the release of the following information to allow for transfer of enrollment into the Jefferson R-VII School District: From:________________________________________ To: Jefferson R-VII School District Previous School District Address:______________________________________ City:_________________ State:_______ Zip:________ Phone:_________________ Fax:___________________ Information to be released: ___ Cumulative permanent school records including Grades up to and at the time of withdrawal Achievement test scores with the name of tests and dates given Attendance records Discipline records ___ Health information, including complete record of immunizations ___ Psychological/Medical reports if needed for educational placement ___ Special Education records (current IEP and current Evaluation Report) ___ 504 records (current 504 Plan and support documents) ___ Last date of attendance at your school:_____________________________________ ___ Other (specify) _________________________________________________________ This information is requested for the following purpose: ___ Transfer of student to this/another district ___ New enrollment/re-enrollment ___ Hospitalization ___ Contractual placement ___ Educational placement consideration ___ Educational evaluation ___ Other (specify) _________________________________________________________ Terms of Authorization: Unless an earlier date is specified, this authorization shall expire 12 months from the date of my signature. This authorization is revocable at anytime. I understand that if I revoke this authorization I must do so in writing to the Jefferson R-VII School District. I further understand that actions already taken based on this authorization, prior to the revocation, will not be affected. At least one (1) signature required.

______________________________________________________________________________ _____________________________________ Parent/Guardian Signature (Student may sign if 18 years of age and not living with parent) Date Printed Name:_______________________________________ _______________________________________________________________________________ _____________________________________ Parent/Guardian Signature Date Printed Name:________________________________________

Jefferson High School (1050) 7 Blue Jay Way Festus, MO 63028 Ph: 636.933.6900 Fax: 636.933.2663 contactjhs@jr7.k12.mo.us Danby-Rush Tower Middle School (3000) 1250 Dooling Hollow Road Festus, MO 63028 Ph: 636.937.9188 Fax: 636.937.9189 contactdanby@jr7.k12.mo.us Telegraph Intermediate School (4060) 1265 Dooling Hollow Road Festus, MO 63028 Ph: 636.937.6530 Fax: 636.937.6835 contacttelegraph@jr7.k12.mo.us Plattin Primary School (4020) 2400 R-7 School Road Festus, MO 63028 Ph: 636.937.7170 Fax: 636.937.7985 contactplattin@jr7.k12.mo.us

Form sent to: For Office Use Only

Form Faxed: Date:

Special Education:

Foster: Homeless: ELL: Documents Received: 504:

JEFFERSON R-VII SCHOOL DISTRICT – PROOF OF RESIDENCY

STUDENT NAME PARENT, COURT-APPOINTED LEGAL GUARDIAN, MILITARY GUARDIAN OR PERSON ENROLLING THE STUDENT:

LAST, FIRST M. LAST, FIRST

THE STUDENT IS A LEGAL RESIDENT OF THE DISTRICT AS ESTABLISHED BY THE FOLLOWING

THE STUDENT IS NOT A LEGAL RESIDENT OF THE DISTRICT, HOWEVER, I HAVE SUBMITTED (OR THE STUDENT HAS SUBMITTED) A REQUEST FOR WAIVER OF RESIDENCY WITHIN FORTY-FIVE (45) DAYS OF THE DATE OF THIS STATEMENT

I AM A LEGAL RESIDENT OF THE JEFFERSON R-VII SCHOOL DISTRICT.

I RESIDE AND AM LEGALLY DOMICILED (HAVE MY PERMANENT HOME) AT THE FOLLOWING ADDRESS:

__________________________________________

__________________________________________

The Student resides with me at the foregoing address, which is also the Student’s permanent home.

I have provided the following document(s) to establish that I am a legal resident of the District: ____ Driver’s License ____ Utility Bill ____ Rental Agreement or Real Estate Contract ____ Custody Agreement

I SUBMITTED THE REQUEST FOR WAIVER ON ____________________________________________

I HAVE ATTACHED A COPY OF THE REQUEST FOR WAIVER TO THIS STATEMENT.

I UNDERSTAND THAT IF THE REQUEST FOR WAIVER IS DENIED AFTER THE STUDENT HAS BEEN REGISTERED, THE

STUDENT WILL NO LONGER BE ELIGIBLE FOR ENROLLMENT IN THE DISTRICT, AND WILL BE REQUIRED TO WITHDRAW FROM SCHOOL IMMEDIATELY FOLLOWING DENIAL OF THE WAIVER.

I attest that all the above information is correct and true. I understand that it is a crime pursuant to §167.023, RSMo., if I do not disclose the information requested or if I provide false information. At least one (1) signature is required.

Parent/Guardian Signature: _____________________________________________ Date: __________________________

Printed Name:__________________________________________

Parent/Guardian Signature: _____________________________________________ Date: __________________________

Printed Name:__________________________________________

In accordance with the Missouri law, any person who knowingly submits false information with respect to the following questions, any sub parts thereto, or the documents provided to support the responses to such questions may be charged with and convicted of a Class A misdemeanor.

FILE ORIGINAL IN STUDENT FOLDER

JEFFERSON R-VII SCHOOL DISTRICT – CONFIDENTIAL MEDICAL HISTORY

Date:_________________ School Year:__________________

Student Name: __________________________________________________________ Birth Date:__________________________ Age:___________

Nickname to be used at school:________________________________________ Grade/Teacher:__________________________________________

Physician Name ________________________________________________ Phone _____________________________________

Specialist MD ________________________________________________ Phone _____________________________________

Dentist Name ________________________________________________ Phone _____________________________________

ALLERGIES:

Does your child have any life threatening allergies? Yes No If yes, list __________________________________________

My child has an EPI-PEN Yes No (If yes, please be sure to inform the school nurse and provide an EPI-PEN to keep at school)

Please describe the type of reaction and triggers your child has to any of the following allergens

Food______________________________________________ Medication_________________________________________ Latex______________________________________________ Bees/Insects________________________________________ Seasonal___________________________________________ Other______________________________________________

MEDICAL HISTORY: Has your child ever been DIAGNOSED with or treated by a doctor for any of the following conditions: Asthma Blood Pressure Problem Seizures (type)___________________________ ADD Diabetes Vision/Eye Problems ADHD Deafness Hearing/Speech Problems Anemia/Sickle Cell Digestion Problems wear glasses Anxiety Depression wear hearing aids Autism/Asperger’s Ear Infections/Tubes Use any adaptive equipment such as Behavior Disorder Heart Disease wheelchair, walker, etc… _______________________ Bladder Problems Headaches/Migraines Please list major surgeries_________________________ Bowel Problems Kidney Disease _______________________________________________

Please explain conditions checked above: ______________________________________________________________________________

MEDICATIONS: A completed medication consent form must be provided for any prescription or over the counter medication to be given at school. See the Health Services letter for more information on state guidelines and the district policies regarding medication.

Please list medications your child takes daily at home _______________________________ ________________________________ _______________________________ ________________________________

Please list medications your child will take at school _______________________________ ________________________________ _______________________________ ________________________________

Does the school have permission to administer the following over-the-counter medications that are kept in the nurse office?

Ibuprofen Tylenol Tums Cough Drops

In a medical emergency, I authorize R-7 School District to arrange for EMS transportation to the nearest medical facility, and for the medical health professionals to treat my child for life threatening emergencies. I understand that school personnel will make every attempt to contact the primary contact on record. Medical costs are my responsibility. The Nurse/Administration may contact my child’s physician(s) directly for updates/information pertaining to my child’s health.

At least one (1) signature required.

______________________________________________________________________________ _____________________________________ Parent/Guardian Signature Date

Printed Name:_____________________________________

______________________________________________________________________________ _____________________________________ Parent/Guardian Signature Date

Printed Name:_____________________________________

R7 Schools are equipped with blood glucose monitors, pre-filled epinephrine syringes, and asthma-related rescue medications to be administered by the school nurse/trained personnel in the event of a life-threatening emergency.