If this student has previously attended Mullin ISD, list the two most recent schools. School name(s) Grade(s) School year(s)

Brothers and sisters (aged 4 to 19):

Last name First name Date of birth Grade School

False or misleading information on this form is a misdemeanor offense. I hereby acknowledge that the above information is true.

MULLIN INDEPENDENT SCHOOL DISRTICT

Student Registration Form / Student Entrance Sheet (Please print)

SCHOOL USE ONLYEntry Date:

_____/_____/_____

Campus #:

ID #:

Grade:

Requested Records:

Registrar's Name:

Contact Form Attached

Student Information Student’s name (as legally recorded) First Name: Middle Name: Last Name:

Student’s date of birth: Gender:

o Male o Female

Student’s social security number:

Address (as legally recorded): City: Zip code:

Doctor’s name: Doctor’s phone number:

Country of birth: If not USA, grade and date entered U.S. schools:

Grade: ______ Date: _____/_____/_____

Special Information

This student is currently being served in: o Special Education o 504 o Bilingual/ESL o GT o Dyslexia

This student previously has been served in: o Special Education o 504 o Bilingual/ESL o GT o Dyslexia

Has this student ever been retained? o No o Yes If yes, what grades? _____________________________________________

Last school attended by student: School district:

Date completed: Parent’s / legal guardian’s name (printed):

Parent’s / legal guardian’s signature:

Grade:

State:

MULLIN INDEPENDENT SCHOOL DISTRICT

Student Registration Form / Student Contact Sheet (Please print)

Date completed:Parent / Guardian Signature: _______________________________________________________

Student name Other students registering at this school to which this applies

LIST INDIVIDUALS’ CONTACT INFORMATION IN THE ORDER YOU WISH THEM TO BE CONTACTED FOR SCHOOL COMMUNICATIONS.

1st C

onta

ct

Parent / Guardian Last name Parent / Guardian First name

Parent / Guardian Date of Birth Parent / Guardian Driver License Number

Relationship to studento Lives with student o Has permission to pick student up

Parent / Guardian Primary phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Email (please print clearly)

2nd

Cont

act

Last name First name

Relationship to studento Lives with student o Has permission to pick student up

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Email (please print clearly)

3rd

Cont

act

Last name First name

Relationship to studento Lives with student o Has permission to pick student up

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

4th

Cont

act

Last name First name

Relationship to studento Lives with student o Has permission to pick student up

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Phone numbero Home o Cell o Work o

Include in district’sautomatic call system

Exhibit 1A Ethnicity 2016-17 Texas Education Agency

Texas Public School Student/Staff Ethnicity and Race Data Questionnaire

The United States 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 America (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 Islands, 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)/(Staff) Signature

________________________________

Student/Staff Identification Number

________________________________ Date

This space reserved for Local school observer – upon completion and entering data in student software system, file this form in student’s permanent folder. Ethnicity – choose only one:

_____ Hispanic / Latino

_____ Not Hispanic/Latino

Race – choose one or more: _____ American Indian or Alaska Native _____ Asian _____ Black or African American _____ Native Hawaiian or Other Pacific Islander _____ White

Observer signature: Campus and Date:

Texas Education Agency

Mullin Independent School District

(2016-17) 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 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? __________________________________________

_______________________________________ _______________________________________ Signature of Parent/Guardian Date

________________________________________ _______________________________________ Signature of Student if Grades 9-12 Date

Cuestionario del idioma que se habla en el hogar

DEBE DE COMPLETARSE POR EL PADRE/MADRE/ O REPRESENTANTE LEGAL: (O POR EL ESTUDIANTE SI ESTA EN LOS GRADOS 9-12): El estado de Texas require que la siguiente información se complete para cada estudiante que se matricula por primeravez en una escuela pública de Texas. Este cuestionario se archivará en el expediente del estudiante.NOMBRE DEL ESTUDIANTE____________________________________________________ #ID_____________________

DIRECCION_____________________________________________________________TELEFONO___________________

ESCUELA___________________________________________________________________________________________

1. ¿Qué idioma se habla en su hogar la mayoria del tiempo? _________________________________________

2. ¿ Qué idioma habla su hijo/a la mayoria del tiempo? _____________________________________________

_________________________________________ ________________________________ Firma del Padre/Madre/ o Representante Legal Fecha

_________________________________________ ________________________________ Firma del estudiante se está en los grados 9-12 Fecha

Texas Education Agency Bilingual/ESl Unit Spanish

For more information, please contact Migrant Service Coordinator: _____________________________________

SCHOOL DISTRICT PERSONNEL: THIS FORM CAN NOT BE ALTERED 11-15/FP

Working with fruits, vegetables, cotton, wheat, grain, agricultural farms, fields or vineyards

☐

Working in a fishery

☐

Working in a slaughter House-packaging and cutting meat

☐

Mullin ISD

Family Survey 2016-2017

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 print and return form to school office:

Campus: __________________________________ Date: _________________ Student Name: _____________________________ Grade: ________ Father/Guardian: ___________________________ Mother/Guardian: __________________________ Father’s Place of Employment: ________________ Mother’s Place of Employment: _______________ Home Address: _____________________________ City: ____________________Zip: ______________ Home Phone: ______________________Cell Phone: _____________________Work Phone: ______________

Please answer the following questions:

1. Within the past 3 years have you moved from one city, state, or school district to another?

☐ Yes ☐ 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 ☐ No

If you answered YES to question 2, please check all that apply.

Other similar work, please explain:

__________________________________

__________________________________

Working in a cannery

☐

Working on a dairy farm. Working on a ranch-feeding livestock, clearing fields, building fences

☐

Working in a plant, nursery or orchard, growing or harvesting trees or picking pecans

☐

Working on a poultry farm

☐

Student Emergency Information (2016-17)

Student Name: ____________________________________________ Sex: Male Female

DOB: ________________________________ AGE:_______________________ Grade:_______________

Parent/Guardian Info:

Mother’s Name:____________________________ Father’s Name:__________________________

Mother’s Phone #: __________________________ Father’s Phone #:_________________________

Alternate Phone #:__________________________ Alternate Phone #:________________________

If Medical Care is Necessary, Call:

Doctor:_______________________________________________________________________________ NAME CITY PHONE NUMBER

Hospital:______________________________________________________________________________ NAME CITY PHONE NUMBER

Does your child have insurance coverage? No Yes Medicaid? No Yes Name of Insurance Company: {optional}_______________________

In case of injury of sudden illness, __________________ will be called first. I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for my child’s health and safety. It is understood by me that the expense of this service will be accepted and paid for by me.

In case of emergency, or if I cannot be contacted to pick up my child, I hereby authorize the following person(s) to be contacted to pick up my child:

__________________________________________________________________________________________________ Name Relationship to Child Phone #

__________________________________________________________________________________________________Name Relationship to Child Phone #

__________________________________________________________________________________________________ Name Relationship to Child Phone #

Medical conditions or heath concerns that may affect my child include the following :( please circle or fill in) Diabetes Asthma Nose Bleeds Headaches Menstrual Cramps Seasonal Allergies Other (please list): ___________________________________________________________________________________

I further understand it is my responsibility to provide any necessary medications and instructions for treating my child for the above conditions. All medications and instructions will be listed on the attached medication permission form.

___________________________________________ _______________________________ Parent Signature Date

Mullin Independent School District Military Connected | 16-17 SY

Student Name: _________________________________ School Name: _______________

Student ID: _______ Grade: ________ Date of Birth: _____________

Please return this form to your child’s campus ONLY if your child meets one of the criteria below

In 2009 The Texas Legislature adopted the Interstate Compact on Educational Opportunity for Military Students – Texas Education Code Chapter 162. This legislation requires schools to recognize and extend certain privileges to students who are military dependents and to assist military dependent students in the transition process of changing schools when their military parents are reassigned and forced to relocate.

Please check one box below to indicate if your child is a dependent of a member of:

For all students:

Not a military connected student

Active Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard [This includes Missing in Action (MIA)]

Texas National Guard

Reserve Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard

For Pre-Kindergarten students ONLY:

Pre-kindergarten student is a dependent of: 1) an active duty uniformed member of the Army, Navy, Air Force, Marine Corps, or Coast Guard, 2) activated/mobilized uniformed member of the Texas National Guard (Army, Air Guard, or State Guard), or 3) activated/mobilized members of the Reserve components of the Army, Navy, Marine Corps, Air Force, or Coast Guard; who are currently on active duty or who were injured or killed while serving on active duty.

______________________________ ______________________________ Printed Name of Parent/Guardian Date

______________________________ Parent/Guardian Signature

Please understand that failure to return this release form within ten (10) school days from the

date of distribution will constitute approval of the above requests.

MULLIN INDEPENDENT SCHOOL DISTRICT

Student Media Consent and Directory Release Form

There are two different items that require your signature – photo consent and directory information. For each item, please sign consent or no consent. Please return this form to your child’s School Registrar. Thank you for your assistance.

According to Texas Law a district may video tape students for the following:

(1) Purpose of safety, including the maintenance of order and discipline in common areas of theschool or on school buses;

(2) A purpose related to a co-curricular or extra-curricular activity;(3) A purpose related to regular classroom instruction;or(4) Media coverage of the school.

Mullin ISD will be videotaping students for purposes listed immediately above.

I hereby give Mullin ISD permission for any additional videotaping/photographing for purposes of school related events: i.e. Yearbook, UIL, Ag, etc.

I further release and relieve MISD, its Board of Trustees, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material.

1) Photo Consent: I do consent and allow my child to be filmed, videotaped and/or photographed for use by my school, MISD/its partners andthe media. I also allow my child’s work product to be featured by MISD (this will include the school yearbook).

Child’s Name Parent’s Signature Date

No Photo Consent: I do NOT consent nor allow my child to be filmed, videotaped and/or photographed for use by my school, MISD/its partners and the media (this will include the school yearbook).

Child’s Name Parent’s Signature Date

2) Directory Information Consent:I do consent and allow the district to release directory information on my child. Directory information includes the student’s name, place and dateof birth, major course of study, participation in sports and other official school activities, height and weight if an athletic team member, date ofgraduation, dates of attendance (date of enrollment through date of withdrawal or graduation), degrees and awards.

Child’s Name Parent’s Signature Date

No Directory Information Consent: I do NOT consent nor allow the district to release directory information on my child.

Child’s Name Parent’s Signature Date