Roff Public S c h o o ls E n roll m e n t P ac k et 2014-2015

This enrollment packet contains important guidelines and policy information. Each form contained in this packet re qu ires yo u r signatur e as well as information only you can supply. It is very important that you complete each form as accurately and completely as possible. It is also important for you to understand that each of these forms are required by the Roff Public School District or by state or federal law and are provided to you primarily for the safety and well-being of your child.

Below you will find a brief description of each form contained in this packet. This is not intended to take the place of your reading and understanding of the information. If you have any questions concerning the guidelines and policy included in the enrollment packet, please don’t hesitate to ask a staff member to explain their use. Plea s e p ri n t a n d s ign each form a n d ret u rn t h e com p leted p a c k et to t h e high s c h ool off i c e .

He al t h I n ven t ory F orm This form is to provide health information about your child so that we can meet the medical needs of your child.

McKinney-Vento Act Enrol l m e nt QuestionnaireThe form will help determine residency necessary for enrollment and ensure that certain needs will be met for this student.

Author i z ation for e m ergency careThis form authorizes Roff Public Schools to obtain medical treatment for your child in the event of injury or sickness when the parent or guardian is unavailable for consent.

Author i z ation to a d m inister m edication This form authorizes Roff Public Schools to administer non-prescription, topical medication in the event of minor injury or sickness.

Stude n t A c cident InsuranceThis form informs you of the availability of student accident insurance which can be purchased by you and absolves Roff Public Schools and its employees of any financial responsibility in the event of a student accident.

H o m e Language SurveyThe Home Language Survey is required by provisions of the No Child Left Behind Act (NCLB). The NCLB Act provides for funds that are dispersed by the state to supplement local educational agency funds.

Stude n t Internet Access, Conduct and Pe r m ission A gre e m e nt and Use of St u dent Pi c t u r es for Internet/Mult i me dia Purpo s es This form requires the signature of both the student and the parent/guardian for the student to be able to access the internet from a school computer. This form also allows the Roff Public Schools District to use your child’s picture or video taken during class time in various internet/multimedia presentations.

Wireless Tel e c o mm un i cations P er m ission Agr ee m e n t The form allows your child to have possession of a wireless telecommunication ( I-Pod, Cell Phone) device while on school premises or attending any school sponsored function.

Roff Public Schools Computer Acceptable Use PolicyThis form outlines guidelines for proper use of computers and internet technology.

Title VII S t ude n t Eligibility Cert i f i c ation Fo r m This form must be completed for all PK students and new students to the Roff Public Schools District.

Enrol l m e n t Fo r m This form is used to provide us the basic information on your child such as birthdate, current address, parents/guardians, those authorized/prohibited from picking up your child.

STUDENT’S HEALTH INVENTORY

Grade

Page 1

STUDENT NAME: Birth date: Male_Female_Last First Middle Initial

Doctor’s Name: Telephone No. Dentist’s Name: Telephone No.

ANSWER THE FOLLOWING QUESTIONS: Your student’s learning depends upon good health. To assist in providing health services at school, please complete all information.

Has the student ever been evaluated, referred for or received special education services and/or related services (i.e. speech/language, occupational therapy, physical therapy)? Yes No If yes, when:

By whom?

Has student had any serious physical injuries? Yes No If yes, explain:

Does the student have any physical limitations or motor impairments? Yes No If yes, explain:

Walker W/C Unstable Gait Crutches Splint

Date of last eye exam or screening By whom Results

Please check any that apply to your child’s eyes:Crossed D Contacts D Difficulty Seeing D Lazy Eye D

Glasses D (reading D distance D) Surgery D Other D

Date of last hearing exam or screening By whom Results

Please check any that apply to your child’s ears:Frequent Infections D Tubes D Hearing Difficulty D

Hearing Aid: Right D Left D Wears at School D

Does the student have allergies to drugs, food, insects or other? Yes D No D

List:_

Has the allergy required emergency action or medication in the past? Yes D No DSymptoms:

How soon occur after contact (length of time): Need e m erg e n c y medication? Yes D No D What kind

Knows symptoms: Yes D No D

Is your child on a doctor prescribed special diet? Yes D No D

Describe:

STUDENT HEALTH INVENTORY CONTINUED GRADE Page 2

Does the student have asthma? Yes D No D Describe reaction:D Mild D Moderate D Severe

Triggered by:_

Does the student have diabetes? Yes D No D

Date Diagnosed: Type I D Type II DDoes the student take insulin? Yes D No D Type: Other: Take oral medication Yes D No D Medicine

Does or has the student had epilepsy/seizures? Yes D No D Type:_

Date of last seizure: Medication:Does student know when a seizure will occur? Yes D No D

Does the student have a heart condition? Yes D No D Please describe:

List any physical restrictions

Does the student have a bone/joint problem? Yes D No D Describe:

List any physical restrictions

Other Health Concerns or Problems. Circle any that apply:

ADD/ADHD Nosebleeds Headaches - Type:

Sleeping Neurological (Brain) Lungs Skin/Rashes Dental

Blood Disorder Bladder Bowel Blood Pressure

Explain any circled:

Does the student take daily medication? Yes D No DWill the student take daily medication at school? Yes D No D

List name of medication and reason for taking?

List any surgeries (operations) your child has had.

Is there any other health information or concerns we should be aware of in caring for your child?

If yes, please explain:

Treatment:

I understand and agree that any health information pertinent to my child’s health needs at school will be shared with school personnel who have the need to know.

Date Parent’s Signature

Roff Public School DistrictEnrollment Questionnaire

This form is intended to address the McKinney-Vento Act. Your answers will help determine residency necessary for enrollment and ensure that certain needs will be met for this student.

Student’s Name Date

Presently, where is this student living? Check one box in either Section A or Section B.

Section A Section B

Child lives at the following permanent addresswith parent(s) or legal guardian(s):

In a shelter

Temporarily with more than one family due to

(permanent address)

STOP: If you checked this section, you do not need to complete the remainder of this form.

ORIf this is no t a permanent address for this child,

PLEASE GO TO SECTION B.

loss of job, loss of housing, etc.

In a motel, car, or campsite

In temporary foster care awaiting placement

Alone without parental support (independent living student)

CONTINUE: If you checked a box in Section B, please complete the remainder of this form.

Student ID#: (Completed by School Staff)

Date of Birth:

School: Grade: Male Female Parent/Guardian: Date:

Present Address:

City: State: Zip: Phone:

Last school attended: City: State:

Oklahoma State Department of Education May, 2008Office of Standards and Curriculum

Roff Public Schools

AUTHORIZATION FOR EMERGENCY CARE FOR MINOR

The undersigned parent or guardian has legal custody of the child named below, and does hereby authorized ROFF PUBLIC SCHOOLS into whose care the child has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care for the child, under the general or special supervision and upon the advice of any physician or surgeon licensed under the laws of the State of Oklahoma, and to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care for the child by a dentist licensed under the laws of the State of Oklahoma.

This consent is given in advance of the occurrence of any specific event and is intended to encourage the person with temporary custody of the child to obtain medical or dental treatment for the child in the event of injury and unavailability of parent or guardian. This consent shall be effective until it is withdrawn in writing.

Date

Name of Child Date of Birth

Family Physician Phone

Family Dentist Phone

Special Medical Information Regarding Child (Allergies, Current Medication, Medical Condition: i.e. asthma, epilepsy, diabetes, braces, contact lenses, etc.)

Parent Signature Witness

Minor children must have parent or legal guardian to consent for medical treatment. Except in a life-threatening situation, treatment could not be administered without it. Persons entrusted with the care of your child cannot give consent for treatment, unless legally authorized by a parent or guardian. This consent form is legal authorization for emergency medical treatment, and ensures that your child will receive treatment without delay.

PARENTAL AUTHORIZATION TO ADMINISTER NON-PRESCRIPTION MEDICATION

Student’s Name: Grade:

School:

It is the policy of Roff Public Schools for the following non-prescription medications to be administered by the school nurse, principal or principal’s designee for treatment of minor illnesses or injuries:

Non-prescription medicines:Neosporin, Tylenol, Motrin, Tums, Pepto-Bismol, Calamine Lotion

Please list any allergies for your child:

Allergies:

I understand that under state law the Roff Board of Education, the Roff School District, and/or any designated employee of the Roff School District shall not be liable to the student or student’s parent or guardian for civil damages for any personal injuries to the student which result from acts or omissions by school employees in administering the topical medicines I have hereby authorized.

□ I AUTHORIZ E the school to provide basic first aid and administer above medication.

(parent/guardian initials)

□ I DO NOT AUTHORIZ E the school to administer above medications, but may provide basic first aid.

(parent/guardian initials)

(Parent/Guardian signature) (Date)

NO MEDICATIONS WILL BE ADMINISTERED WITHOUT WRITTEN PARENT CONSENT

ROFF PUBLIC SCHOOLSOFFICE OF THE SUPERINTENDENT

P.O. Box 157Roff, OK 74865

Dear Parent:

Roff Public Schools District assumes NO financial responsibility for medical cost of an accident occurring to a student while participating in a sport or other school activities. An accident insurance program is offered for your convenience. The Insurance Company compensates neither the school, nor any school official. We have selected an Insurance Company that provides student accident insurance to approximately 400 school districts in Oklahoma. For more information regarding this insurance, please visit www.studentinsurance-kk.co m .

This form is to acknowledge that I have received information regarding the school district’s policy pertaining to accidental injury and student insurance.

Student’s Name Parent’s Signature

D We have adequate accidental insurance and do not wish to participate.

Student’s Name Parent’s Signature

Date

Janet BarresiState Superintendent of Public Instruction Oklahoma State Department of Education

2014-2015 HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

Name of Student: Last Name First Name Middle Name

Student ID #: Gender: Male Female

School Site: Grade:

Date of Birth: Place of Birth (City/State/Country):

Is the student of Hispanic or Latino culture or origin? Yes No

Select one or more of the following races: African American/Black American Indian/Alaskan Native Asian

Native Hawaiian or Other Pacific Islander White

Parent’s/Guardian’s Name:

Parent’s/Guardian’s Address: Street City Zip Code

Parent’s/Guardian’s Telephone Number: ( ) Cell Phone:

1. Is a language other th a n E n gli s h used in your home? Yes No

If NO, go to numbers 6 and 7. If YES, what is that language?

2. Is that language spoken in the home MORE OFTEN than E n glis h ? LESS OFTEN than English?

3. What language is spoken by adults in the home?

4. What was the first (1st) language your child learned to speak?

5. What was the date (month and year) your child first enrolled in a school in the United States?

6. Parent/Guardian Signature:

7. Date:

FOR SCHOOL USE ONLYTHIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION.

If a language other than English is spoken MORE OFTEN (see question #2), the student a utomatic a ll y qualifies as biling u a l on application for accreditation.OR

If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation if he or she meets ONE OF THE FOLLOWING:1. Scores 35% or below on norm-referenced test (NRT) on the composite readin g score.2. Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs).3. Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs)

Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL), or the Oklahoma Pre-K Language Screening Tool.

Documentation of a test result for students who marked LESS OFTEN :1.NRT Test Date: Name of the NRT: Reading Total Composite Score:

2.Reading OCCT Date: Score on Reading OCC T: Limited Knowledge Unsatisfactory Satisfactory Advanced

3. ACCESS for ELLs Test Date: Score on ACCESS for ELLs: 1 2WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date: Score on K W-APT, W-APT, or MODEL: 1 2

Oklahoma Pre-K Language Screening Tool Date: Score on Pre-K Language Screening Tool:

Note: Have test score documentation available for regional accreditation officer review. 1Composite Score

Literacy Score2

Student’s Name

A PARENT OR GUARDIAN MUST SIGN THESE PERMISSIONS WHEN APPLICABLE.

STUDENT INTERNET ACCESS, CONDUCT AND PERMISSION AGREEMENT

As the parent or legal guardian, I have read, understand and agree that I or my child or ward shall comply with the terms of the school district's Acceptab l e Use of the D i strict Network Policy for the student’s access to the school district's computer network and the Internet. I also understand that access is being provided to the students for educational purposes only and hereby give my permission to grant access for my child. I further understand that any violation of these rules is unethical and may constitute a criminal offense. Should a violation be committed, the access privilege may be revoked and school disciplinary and/or appropriate legal action may be taken.

Parent or Guardian Signature:

STUDENT INTERNET PUBLICATION PERMISSIONS AGREEMENT(Please check all that apply)

I hereby give permission to release my child’s name__________ picture________ to the following institutions:

School Yearbook _______ School Web Page________ School Yearbook ________ Educational Institutions________

Scholarship Organizations____________ Legislators (Awards/Certificates) _____________

Photographic Studios (Sr. Pictures)_____ School Calendar________ Military _____

USE OF STUDENT PICTURES, VIDEOS, OR CLASROOM WORK IN MULTIMEDIA/ YEARBOOK/ INTERNET

PRESENTATIONS.

Throughout the school year we have the opportunity to use multimedia/internet/yearbook presentations and visual displays in school assemblies and in class. In these presentations we use pictures and videos of our students in action as well as, pictures of their classroom work. We request your permission to use your child’s picture and/or classroom work in multimedia/internet/yearbook presentations.

Permission Granted: YES NO

Parent or Guardian (please print):

Parent or Guardian Signature: Date:

This agreement is valid until revoked in writing or by adoption of a revised policy

WIRELESS TELECOMMUNICATIONS (CELL PHONE) PERMISSION AGREEMENT

Pursuant to the School Laws of Oklahoma:

The board of education of each school district shall establish and implement rules regarding student possession of a wireless telecommunication device while said student is on school premises or while in transit under the authority of the school, or while attending any function sponsored or authorized by the school. The rules shall provide that a student may possess a wireless telecommunication device upon the prior consent of both a parent or guardian and the school principal or superintendent and shall also specify the disciplinary action a student shall face if found to be in possession of a wireless telecommunication device in violation of the rules. (70 O.S.§24-101.1)

See School Handbook for rules specific to each site.

Student’s Name:

Permission Granted: Yes No

Parent or Guardian (please print):

Parent or Guardian Signature:

Date:

This agreement is valid until revoked in writing or by adoption of a revised policy.

Roff Public Schools Telecommunications/Computer Acceptable Use Policy

The Roff Public School District provides access to various electronic and telecommunications resources. The Internet, networks, computer hardware, and computer software are primarily for providing faculty, staff, and students with the necessary tools to transmit, receive, and share information with their colleagues at other educational institutions and organizations, and to locate and access information for educational and research purposes. Any use of the Internet and/or connecting networks and attendant software for commercial or profit purposes is prohibited.

These are guidelines to follow to prevent the loss of computer and/or telecommunications privileges at Roff Public Schools.

1. Do not use a computer to hurt other people or their work in any way.

2. Do not damage the computer or the network in any way.

3. Do not interfere with the operation of the network in any way. This includes installing software (whether legal or illegal), shareware, or freeware. Students should not download any type of software or materials from the Internet.

4. Do not violate copyright laws.

5. Do not view, send, or display offensive messages or pictures.

6. Do not waste limited resources such as disk space, disks, printing capacity, paper, or ink. All printing should be completed in black ink, with the color cartridges being reserved for specific specialized work.

7. Do not trespass in the folders, work, or files of another person.

8. Do notify the technology coordinator if, by accident, you encounter materials which violate the r u l e s of appropriate use.

9. BE PREPARED to be held accountable for your actions if these Rules of Appropriate Use are violated. This will include the loss of privileges and the use of other discipline deemed appropriate.

I hereby agree to abide by the rules of the Telecommunications/Computer Acceptable Use Policy ofthe Roff Public School District.

Student Signature____________________ Parent Signature _____________________________

Date__________________________

To be completed for all Pre-K and new studentsOMB Number: 1810-0021

Expiration Date: 04/30/2015U.S. DEPARTMENT OF

EDUCATION OFFICE OF INDIAN EDUCATION WASHINGTON, DC

20202TITLE VII STUDENT ELIGIBILITY CERTIFICATION

Elementary and Secondary Education Act, Title VII, Part A, Subpart 1

Parents: Please return t h is comple t e d form to your child's school. In order to apply for a formula grant under the Indian Education Program, your child's school must determine the number of Indian children enrolled. Any child who meets the following definition may be counted for this purpose. You are not required to complete or submit this form to the school. However, if you choose not to submit a form, the school cannot count your child for funding under the program. This form will become part of your child's school record and will not need to be completed every year. This form will be maintained at the school and information on the form will not be released without your written approval.

Definition: Indian means any individual who is (1) a member (as defined by the Indian tribe or band) of an Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized by the State in which the tribe or band reside; or (2) a descendent in the first or second degree (parent or grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

NAME OF CHILD (As shown on school enrollment records)

School Name

Date of Birth

Grade

NAME OF TRIBE, BAND OR GROUP

Tribe, Band or Group is: (check one)Organized Indian Group

Federally Recognized, State Meeting #5 of the Including Alaska Native Recognized

Terminated Definition Above

Name of individual with tribal membership:

Individual named is (check one):

Child Child's Parent

Child's Grandparent

Proof of membership, as defined by tribe, band, or group is:

A. Membership or enrollment number (if readily available) OR

Other (explain)

Name and address of organization maintaining membership data for the tribe, band or group:

I verify that the information provided above is accurate:

PARENT'S SIGNATURE

DATE

Mailing Address

Telephone

For Office Use Only: Date/Time Application Received:LOCKER NUMBER: BUS NO.

Transfer Student (Out of District): Yes No Home School District:

LAST SCHOOL ATTENDED: City: State:

ROFF PUBLIC SCHOOLS ENROLLMENT FORM RED ALERT □(Legal Documentation Required)

Enrollment Date: Grade: Birth date:

Sex: Male or Female

Name of Student: (Please list full name) Last First Middle

Student’s SSN: Place of Birth: ______________________Student Cell _____________________

Race: Are you of Hispanic/Latino culture or origin? Yes No(Circle those that apply): 1 – Black/African American 2 – American Indian/Alaskan Native: Tribe:

4 –Asian 5 – Native Hawaiian or Other Pacific Islander 6 – Caucasian

CDIB NO. SoonerCare NO.

*With Whom Does the Student Live:

Address: Home Phone: Street City ZIP

Father: Mother:E-Mail Address: E-Mail Address:

Place of Employment: Place of Employment:

Work Phone: Cell Phone/Pager: Work Phone: Cell Phone/Pager:

Authorized to pickup: (please circle) Yes No Authorized to pickup: (please circle) Yes No

Stepmother/Guardian: Stepfather/Guardian:

E-Mail Address: E-Mail Address:

Place of Employment: Place of Employment:

Work Phone: Cell Phone/Pager: Work Phone: Cell Phone/Pager:

Authorized to pickup: (please circle) Yes No Authorized to pickup: (please circle) Yes No

Emergency Contact Person: (OTHER THAN PARENTS) Name Phone Relationship

Others Authori z ed to Pick Up Student: S i b li ngs A t te n d i ng Roff Public Sc h oo l s :

Name Phone Name School

Name Phone Name School

Name Phone Name School

Name Phone PEOPLE PROHIBITED FROM PICKI NG UP STU D E N T:

Name Phone

Name Relationship

Name Relationship

(Rev.04/10) Name Relationship

ROFF PUBLIC SCHOOLS IMPACT AIDTHE PURPOSE OF THIS FORM IS TO ENSURE THAT THE SCHOOL DISTRICT IS COMPENSATED FOR LOST LOCAL REVENUE DUE TO TAX-EXEMPT FEDERAL PROPERTY.

This form should be completed by any student whose parent/guardian:• Works on federal property

(Examples: Kerr Lab, Chickasaw Nation, BIA Office, Others may apply)• Lives on federal property

(Examples: Chickasaw Housing, Indian Trust Land, Others may apply)• Is on active military duty in the Uniformed Services of the United States

NAME OF STUDENT(s)

Grade

PARENT/GUARDIAN INFORMATIONNames Address

PHONE NUMBERS:Mother Home Work Father Home Work

EMPLOYER INFORMATIONI F YOU ARE COMPLETI N G TH I S FORM BECAUSE YOU WO R K ON FEDERAL PROPERT Y , PLE A SE CHECK THE CATEGORY T H AT APPLIES .

CHICKASAW NATION‐‐LIST DEPARTMENT __ KERR LAB BUREAU OF INDIAN AFFAIRS ACTIVE MILITARY DUTY OTHER

FEDERAL HOUSING INFORMATIONI F YOU ARE COMPLETI N G TH I S FORM BECAUSE YOU LIVE ON FEDERAL PROPERTY , PLEA S E CHECK THE CATEGORY THAT APPLIES .

CHICKASAW HOUSING INDIAN TRUST LAND

_____ OTHER

Grade