Dunseith Indian Day School Student Name: ______________________ Grade: ____________________

You will need the following documents turned in before your child/children can start.

o Enrollment Form o Birth certificate o Certification of Indian Blood ( If your child is not

enrolled we can take the parents enrollment) o Immunizations o Student Contact Information Form o Emergency Medical Authorization Form o Media Release Form o IHS Dental Form o Parent Portal Form o Authorization to Administer Meds o Nurse Medication / Permission List

If your child/children are in foster care we will also need: o Placement papers

Is your child on an IEP Yes or No

[2020-2021] Returning

[STUDENT ENROLLMENT APPLICATION]

OMB Control No. 1076-0122 Expires: 00/00/0000

Page 1

STUDENT ENROLLMENT APPLICATION

FOR STUDENTS ENROLLED IN BUREAU-FUNDED SCHOOLS

Name of School: Dunseith Indian Day School Type: Day School ( X ) Boarding School ( ) Peripheral Dormitory ( )

Funding: Pub. Law 100-297 Grant ( ) Pub. Law 93-638 Contract ( ) BIA Operated ( X )

1.IDENTIFICATION Name of Student:________________________________________________________

(Last) (First) (Middle) Address:_______________________________ Street:___________________________________

City:_____________________________ State:_______________ Zip Code:_____________

Miles from home to school: Date of Birth:_________________________ Place of Birth:_____________________________

Month Day Year Sex: Male ( )Female ( ) Verified by:_______________________________ Tribal Affiliation:___________________________ Degree Indian:______________________

Enrollment Number:_________________________ Home Agency:______________________

Dominant language spoken in the home: (1) (2) 2. FAMILY INFORMATION Father: _______________________________________ Address: _______________________________________ Tribal Affiliation: _______________________________________ Home Agency: _______________________________________ Enrollment Number: _______________________________________ Living: ( ) Dead: ( ) Occupation (Optional): _______________________________________ Employer: _______________________________________ Telephone Home: ______________________________________ Work: ______________________________________ Emergency:

Mother: _______________________________________

Address: _______________________________________ Tribal Affiliation: _______________________________________ Home Agency: _______________________________________ Enrollment Number: _______________________________________ Living: ( ) Dead: ( ) Occupation (Optional): _______________________________________ Employer: _______________________________________ Telephone Home: _______________________________________ Work: _______________________________________ Emergency:

SY- 20-21

OMB Control No. 1076-0122 Expires: 00/00/0000

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Legal Guardian: _____________________________________ Address: _____________________________________ Tribal Affiliation: _____________________________________ Home Agency: _____________________________________ Enrollment Number: _____________________________________ Occupation (Optional): _____________________________________ Employer:

Other (group home, etc): _____________________________________ Address: _____________________________________ Telephone: _____________________________________ Student Lives With: _____________________________________ Telephone Home: _____________________________________ Work: _____________________________________ Emergency:

3. SCHOOL(S) PREVIOUSLY ATTENDED:

School Name:________________________ Dates:__________________Grades:__________

Attended:________________Completed:______ Address:_____________________________Reasons for Leaving:______________________ City / State: School Name:_________________________ Dates:______________Grades:____________

Attended:_______________ Completed:______ Address:____________________________ Reasons for Leaving:______________________ City / State: School Name:__________________________Dates:________________Grades:___________

Attended:________________ Completed:______ Address:____________________________ Reasons for Leaving:______________________ City / State: I am legally responsible for this student and hereby apply for his/her admission to this school. I understand that additional information may be requested by the school before the student is enrolled. Signature of Parent/Legal Guardian/Adult Student: Date: Day School Enrollment: Approved: _____ Not Approved:_____ _________________________ _________ Principal Date

OMB Control No. 1076-0122 Expires: 00/00/0000

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STUDENT CONTACT INFORMATION  

Student NAME________________________________________GRADE________ 

DATE OF BIRTH_______________ 

Address___________________________________________________________ 

Mothers Name_____________________ Fathers Name____________________ 

Home Phone #_____________________ 

Mothers Work #____________________ Fathers Work #___________________ 

Mothers Cell #______________________ Fathers Cell #____________________ 

Emergency Name____________________ Emergency #____________________ 

Emergency Name____________________ Emergency #____________________ 

List anyone who Can and Cannot pick up your child/children: 

1.____________________ 2.____________________ 3.____________________ 

4.____________________ 5.____________________ 6.____________________ 

 

Addi onal Comments, requests or personal informa on: 

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________ 

 

Dunseith Day School  

DUNSEITH INDIAN DAY SCHOOL STUDENT INFORMATION SYSTEM

PARENT/ GUARDIAN USER AGREEMENT

Dunseith Indian Day School is providing parent access to NASIS/ Infinite Campus to further promote educational excellence and enhance communication with parents. NASIS/ Infinite Campus will allow parents to view their child’s attendance/grades. In receiving the privilege of accessing NASIS/Infinite Campus, every parent/guardian of a Dunseith Day School student is expected to act in a responsible ethical and legal manner. Users of NASIS/Infinite Campus are required to adhere to the following guidelines:

1. Parents will not share their passwords with anyone, including their children.

2. Parents will not attempt to harm or destroy data of their children or of another user, school or district network or the internet.

3. Parents will not use NASIS/Infinite Campus for any illegal activity, including violation of data privacy laws. Anyone found to be violating laws will be subject to civil and / or criminal prosecution.

4. Parents will not access data or any account owned by another parent.

5. Parents who identify a security problem with NASIS/Infinite campus must notify Dunseith Day School immediately, without demonstrating the problem to anyone else.

6. Parents who are identified as a security risk to the NASIS/Infinite Campus program or Dunseith Day School computers or networks will be denied access to NASIS/Infinite Campus.

Only by signing and returning the agreement will you receive access to NASIS/Infinite Campus for your children at Dunseith Day School. Please Sign, date, and return Parent Signature__________________________________________________Date__________

Parent Name___________________________________________________________________

Student Name____________________________________________________Grade_________

Address__________________________________________Phone________________________

Please have a form filled out for each child.

Once we get this form back we will send home the activation link along with directions on how to make an account.

Family And Child Educa on

Media Release Form

I hereby grant to the Bureau of Indian Educa on (BIE), Dunseith Indian Day School, or anyone authorized

by them, including without limita on any of their partners or affiliates, the right to copyright and use my

name, likeness, image, voice, story, appearance , performance, and artwork to record or transfer to video

tape, film, slides, photographs, audio tape, print, on‐line courses, or other media now known or later

developed.

I hereby waive any right I may have to inspect and approve the finished product, or the adver sing or other

copy that may be used in connec on therewith or the use to which it may be applied.

I hereby release and discharge the BIE, Dunseith Day School School and all person ac ng under their per‐

mission or authority, from any liability by virtue of any blurring, distor on, altera on, op cal illusion, or use

in composite form, whether inten onal or otherwise, that may occur or be produced in any process tending

toward the comple on of the finished product.

I understand that this product will be used for broadcast, exhibit, marker, sale or other distribu on and the

BIE Dunseith Day School have no financial commitment or obliga on as a result of this agreement.

I have read this agreement and I understand what I am signing.

Name of Parent/Guardian ( Please Print) _______________________________ Date__________________

Name of Child ( Please Print) _________________________________________ Grade ________________

Address _________________________________________________________________________________

Email Address____________________________________________________________________________

In the case of a minor, the signature and date of the parent or guardian is required.

Signature __________________________________________________________Date__________________

Dunseith Indian Day School

Po Box 759 Dunseith ND 58329

2994 99th ST NE Dunseith ND 568329

701‐263‐4636 Fax 701‐263‐4200

                           Dunseith Day School  

                          S‐Y 2020‐2021 

                           Nurse Medica on/ Permission List  

                 

Students Name: _____________________________ Garde:_________ DOB: __________________

Parent/Guardian _______________________________ Phone Number__________________________

Purpose : To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

The Dunseith Indian Day School would like permission to give emergency care and / or over the counter

Medicines ( such as: Tylenol, Pepto-Bismol, Ibuprofen, Cough drop, Benadryl, Cough Syrup, Tums) If he/she feels it is needed to help your child be as comfortable as possible in school.

Please Answer the following questions as completely as possible since we need as many phone numbers and con-tact people to be able to get a hold of you in the case of an emergency or illness.

Does your child currently or will he /s he be starting on medication?

If so, What is the name of the mediation? ___________________________________

What amount or dosage is taken each time?__________________________________

How often is it taken: ( Once on day, twice etc…_______________________________

List any allergic reactions he/she has had with over the counter medication:

________________________________________________________________________________________________________________________________________________________________________________________________

Emergency Contact

Name:________________________ Relationship: __________________

Phone # ________________________ Address: _________________________________________

TO GRANT CONSENT

I herby give consent In the event reasonable attempts to contact me have been unsuccessful, the Dunseith Day School can take my child to a local hospital.

Signature of Parent Or Guardian:_______________________________________ DATE: _________________

                           Dunseith Day School  

                          S‐Y 2020‐2021 

                           EMERGENCY MEDICAL AUTHORIZATION FORM 

                 

Students Name: _____________________________ Garde:_________ DOB: _______________

Teacher________________

Students Physical Address :_______________________________________________________________

Phone Number: ________________

Purpose : To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

Parent or Guardian

Mother’ Name: __________________________ Phone # ____________________

Father’s Name: __________________________ Phone # _____________________

Emergency Contact

Name:________________________ Relationship: __________________

Phone # ________________________ Address: _________________________________________

Please List Medical Condition:

Allergies

Asthma

EPI-PEN

Other ( Please Be Specific): ______________________________________________________________

________________________________________________________________________________________

TO GRANT CONSENT

I herby give consent In the event reasonable attempts to contact me have been unsuccessful, the Dunseith Day School can take my child to a local hospital.

Signature of Parent Or Guardian:_______________________________________ DATE: _________________

Release #16-4, Issued: 11/04/15 New

ATTACHMENT A BUREAU OF INDIAN EDUCATION

AUTHORIZATION TO ADMINISTER PRESCRIBED/OVER-THE-COUNTER MEDICATION

PART I TO BE COMPLETED BY THE PARENT/GUARDIAN I hereby request and authorize designated and properly instructed school personnel to administer prescribed medication as directed by the prescribing physician or other duly licensed provider (PART II below). I certify that I have legal authority to consent to the administration of

sary for each medication to be administered, and if the dosage of the medication is changed. If necessary, I authorize the designated school health care

PART II TO BE COMPLETED BY THE PRESCRIBER

PART III TO BE COMPLETED BY School Nurse/Other Duly Licensed Health Care Provider

ATTACHMENT B

STUDENT INFORMATION Student Name _______________________________________________________________Date of Birth ___________Gender M ___ F ___

Last First MI School _________________________________Grade______School Year________Height (inches) _______Weight (lbs) _______

List all medication(s) student is taking, including over-the-counter medication(s): __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________

List any known drug allergies/reactions: ________________________________________________________________________________

Parent/Guardian Signature __________________________________________________ Date ___________________________________

Contact Number(s): ___________________________________ (Day) ___________________________________ (Evening)

PLEASE USE A SEPARATE FORM FOR EACH MEDICATION

Name of Medication: _______________________________________________ Diagnosis: _______________________________________

Dosage: ____________________________________________ Time(s)/Frequency to be given: ___________________________________

Route of Administration: ________________ PRN (as needed) ___Yes ___No If PRN, (signs/symptoms): ________________________

__________________________________________________________________________________________________________________

Side Effects: _______________________________________________________________________________________________________

Begin Medication: _________________________________ Stop Medication: __________________________________ Date Date

Special Instructions: Refrigeration required? ____Yes ___No Is medicine a controlled substance? ____Yes ___No Is this an emergency self carry/self administration medication? ___Yes ___No Has student been instructed in the proper self administration of medicine? ___Yes ___No

-administration of emergency medication: __________________________________________ Signature Date

_____ Phone__________________________ (Type or Print)

Address:____________________________________________________________________________ Fax____________________________

_______________ Date___________________________

Parts I and II above are completed, including signatures. Prescription medication is properly labeled by a pharmacist and within the expiration date. Medication label and prescriber order are consistent. Over-the- intact.

Principal/Authorized School Personnel Signature ____________________________________________Date______________

Dunseith Indian Day School

Student Name _________________________________________________Student Name _________________________________________________ _____________Date of Birth ___________Gender M ___ F ___Date of Birth ___________Gender M ___ F ___

School _________________________________Grade______School Year________Height (inches) _______Weight (lbs) _______School _________________________________Grade______School Year________Height (inches) _______Weight (lbs) _______School _________________________________Grade______School Year________Height (inches) _______Weight (lbs) _______

List all medication(s) student is taking, including over-the-counter medication(s):

List any known drug allergies/reactions: ________________________________________________________________________________

Parent/Guardian Signature __________________________________________________ Date ___________________________________

Contact Number(s): ___________________________________ (Day) ___________________________________ (Evening)Number(s): ___________________________________ (Day) ___________________________________ (Evening)

Parent/Guardian Signature __________________________________________________ Date ___________________________________