2020-2021 Enrollment Packet Grades 1-12 Instructions for Completing Enrollment Forms **Please Note – Google Chrome will not work to complete the forms** Use Internet Explorer, Microsoft Edge or Firefox browser to complete the forms 1. Download and SAVE AS the documents to your device a. Name your document: First Name.Last Name.Enrollment b. Example- Jane.smith.enrollment 2. Open the saved document 3. Complete all the enrollment forms 4. Sign forms using adobe digital signature. You will be prompted to save the document after each signature. 5. Review forms to make sure you did not miss anything 6. Once you have completed the packet, click the submit button below this will create an email with the form attached to our enrollment specialist for processing. 7. Include the following in the email- a. Subject line: New Enrollment 2020-21 School Year b. Body of the email: Include student name, grade & address
Enrollment Forms Checklist: Student Information and Enrollment Form Parent Questionnaire Ethnicity and Race Data Collection Form Home Language Survey Health History Immunization Records Military Affiliation Form Emergency Early Dismissal Plan Student Housing Questionnaire Indian Student Eligibility Form (optional) Student Information and Enrollment Form Kent School District No. 415 Kent, Washington 98030
DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY
Date Registration Received: Date Entered into Student Information System: Student Start/Entry Date: Proof of birth Proof of residence Parent/Guardian ID Student ID: School Resident Area: Bus Route Assigned: Homeroom/Advisor: CIS Legal or custody paperwork
emaN tsaL lageL EMAN TNEDUTS EMAN lageL tsaL emaN ageL l tsriF emaN lageL elddiM emaN Previous Name ( if applicable)
BIRTHDATE (Month/Day/Year) GENDER GRADE LEVEL ___ Male ___ Female
BIRTHPLACE City State yrtnuoC TNEDUTS SEVIL HTIW Both parents Mother only Father/Stepmother Guardian Self Grandparents Father only Mother/Stepfather Foster Parent Agency Other
PRIMARY HOUSEHOLD (parent/guardian where student resides) Relation to Student: PRIMARY HOUSEHOLD (parent/guardian where student resides) Relation to Student: Last Name (LEGAL) First Name M.I. Mom Step-Mother Guardian Last Name (LEGAL) First Name M.I. Mom Step-Mother Guardian Father Step-Father Father Step-Father Other Other RESIDENT teertS tpA # ytiC etatS PIZ ADDRESS
MAILING teertS tpA # OP xoB ytiC etatS PIZ ADDRESS (If different) RESIDENT (HOME) Phone: (Include area code) Please check if unlisted Please check if cell number Guardian #1 Work Phone (include area code) Guardian #2 Work Phone (include area code) Active Military Active Military Yes No Yes No Guardian #1 Cell Phone (include area code) Guardian #2 Cell Phone (include area code)
:SSERDDA LIAME 1# NAIDRAUG 1# LIAME :SSERDDA NAIDRAUG 2# LIAME :SSERDDA
FILL OUT THIS SECTION ONLY IF STUDENT HAS A PARENT/LEGAL GUARDIAN NOT LIVING AT THE ADDRESS ABOVE SECONDARY HOUSEHOLD (non-custodial parent not residing with PHONE #1 (include area code) PHONE #2 (include area code) Relationship to student: student) Home Work Cell Work Cell Father Mother Last Name First Name M.I. Stepmother Stepfather Other
SECONDARY HOUSEHOLD (non-custodial parent not residing with PHONE #1 (include area code) PHONE #2 (include area code) Relationship to student: student) Home Work Cell Work Cell Father Mother Last Name First Name M.I. Stepmother Stepfather Other
SECOND HOUSEHOLD ADDRESS (Street/PO Box, City, State, ZIP) DNOCES DLOHESUOH LIAME Active Military Yes No
IS THERE A PARENTING PLAN IN EFFECT? Yes No If yes, please provide a copy to the office. IS THERE A COURT ORDER IN EFFECT THAT LIMITS EDUCATIONAL DECISION MAKING OR CONTACT WITH THE STUDENT OR SCHOOL (RESTRAINING ORDER, PROTECTION ORDER, NO CONTACT ORDER, ANTI-HARRASSMENT ORDER, ETC.)? Yes No If yes, please provide a copy to the office.
Court order limits Mother Father Other______
Please fill out back of form
Revised 01/2015 DF-101-14 PLEASE LIST SIBLINGS ATTENDING THE KENT SCHOOL DISTRICT Last Name First Name School Grade
DOES STUDENT ATTEND CHILD CARE? CHILD CARE PROVIDER Name Address Phone Number Before school After school Before and after school
Please provide additional childcare arrangements to the school in writing.
HAS YOUR CHILD EVER ATTENDED A PRESCHOOL(S)? Yes No Preschool Name Preschool Address
HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN: HAS YOUR CHILD EVER BEEN RETAINED? Special Education Program (IEP) Yes No 504 plan Yes No Title Yes No Yes No LAP Yes No Highly Capable Yes No English as a Second Language (ELL/ESL) Yes No If yes, at what grade level(s)______Other ______
LAST SCHOOL ATTENDED SCHOOL DISTRICT SCHOOL INFORMATION (Phone, FAX, City and State)
HAS YOUR CHILD EVER ATTENDED A SCHOOL IN WASHINGTON STATE? Yes No IF YES, NAME OF SCHOOL(S) ATTENDED DATE LAST ATTENDED (Month/Year)
HAS YOUR CHILD EVER ATTENDED THE KENT SCHOOL DISTRICT? Yes No IF YES, NAME OF SCHOOL(S) ATTENDED DATE LAST ATTENDED (Month/Year)
HAS YOUR CHILD EVER BEEN SUSPENDED/EXPELLED FOR A WEAPONS VIOLATION? Yes No Date(s)______
When an emergency situation occurs involving your child, we want to be able to quickly reach responsible adults. In the event we cannot reach a parent/guardian, please list persons you trust who are available during the day to provide care for your child.
EMERGENCY CONTACT INFORMATION FIRST CONTACT (other than parent/guardian) Relationship To Child: PHONE #1 (include area code) PHONE #2 (include area code) Last Name First Name M.I. Home Work Cell Home Work Cell
SECOND CONTACT (other than parent/guardian) Relationship To Child: PHONE #1 (include area code) PHONE #2 (include area code) Last Name First Name M.I. Home Work Cell Home Work Cell
THIRD CONTACT (other than parent/guardian) Relationship To Child: PHONE #1 (include area code) PHONE #2 (include area code) Last Name First Name M.I. Home Work Cell Home Work Cell
STUDENT RELEASE AUTHORIZATION: In the event the school is unable to contact the parents or legal guardian, I authorize my child to be released to the person(s) listed above.
Legal Parent/Guardian Signature ______Date ______
EMERGENCY MEDICAL AUTHORIZATION: If the parents or legal guardian on this registration record cannot be reached at the time of an emergency, and if immediate observation or treatment is urgent in the judgment of the school authorities, I authorize and direct the school authorities to send the student (properly accompanied) to the hospital or doctor most easily accessible. I understand I will assume full responsibility for the payment of any services rendered.
Legal Parent/Guardian Signature ______Date ______Kent School District Parent Questionnaire
Student Name: (first, middle, last): Birth date: Likes to be called: Parent/Guardian(s) name: Address where student is living: Family Background Please list the names of the adults the student resides with and the relationship to him/her:
Other children in the family: Name: Age: School: Grade: Name: Age: School: Grade: Name: Age: School: Grade: What language is spoken most often in your home? Has there been an event (divorce, death, illness, etc.) in the family that might affect your child?
Do you celebrate birthdays and/or holidays in your home? Yes No If no, please explain:
School Background How many schools has your child attended in the last year? Name, district and state of the last school attended: Does your child have any unpaid fines or fees at prior schools? Yes No If yes, please explain:
Has your child been in any special programs (special education, ELL etc.)? Yes No If yes, please list:
How does your child like school, previous teachers, other students?
How is your child doing in school (grades, teacher feedback, etc.)?
Are there any past, current or pending disciplinary actions involving your child? Yes No If yes, please explain:
Does your child have any history of violent behavior, sex or criminal offense, or controlled substance or alcohol violation? Yes No If yes, please explain: Briefly describe your child’s strengths and weaknesses: Additional information:
Parent/guardian signature: Date: Ethnicity and Race Data Collection Form
Each year, school districts in Washington are required to report student data by ethnicity and race categories to the State's Office of Superintendent of Public Instruction (OSPI). OSPI is required to report the total number of students in various categories in each school to the federal government, but it does not report individual student data. Recently, the federal government and OSPI changed the reporting categories for student ethnic and race data. As a result of the new reporting categories, we are required to ask you to identify your child as either Hispanic/Latino or not Hispanic/Latino (Question 1) and by one or more racial groups (Question 2). Student’s Legal Name ______
Question 1 Is your child of Hispanic or Latino origin? (Check all that apply)
☐Hispanic (H00) ☐Cuban (H09) ☐Nicaraguan (H19) ☐Not Hispanic/Latino (H01) ☐Dominican (H10) ☐Panamanian (H20) ☐Argentine (H02) ☐Ecuadorian (H11) ☐Paraguayan (H21) ☐Bolivian (H03) ☐Guatemalan (H12) ☐Peruvian (H22) ☐Brazilian (H04) ☐Guyanese (H13) ☐Puerto Rician (H23) ☐Chicano ☐Honduran (H14) ☐Salvadorian (H24) (Mexican/American) (H05) ☐Jamaican (H15) ☐Spaniard (H25) ☐Chilean (H06) ☐Mexican (H16) ☐Surinamese (H26) ☐Colombian (H07) ☐Mestizo (H17) ☐Uruguayan (H27) ☐Costa Rican (H08) ☐Native (H18) ☐Venezuelan (H280 ☐Other Hispanic/Latino (H29)
Question 2 What race(s) do you consider your child? (Check all that apply)
Black/African American ☐Black/African American Central African ☐Cuba Dominican (B10) (B00) ☐ Dominican (Dominican ☐Angolan (B21) African American (B01) Republic) (B11) ☐ ☐Cameroonian (B22) ☐Dutch Antillean ☐ ☐African Canadian (B02) Central African (Central Caribbean (Netherlands Antilles) (B12) African Republic) (B23) Grenadian (B13) ☐Chadian (B24) ☐Anguillan (B03) ☐ Guadeloupian (B14) ☐Congolese (Republic of the ☐Antiguan (B04) ☐ Haitian (B15) Congo) (B25) ☐Bahamian (B05) ☐ Jamaican (B16) ☐Congolese (Democratic ☐Barbadian (B06) ☐ Barthélemois/es (Saint Martiniquais/e (B17) Republic of the Congo) (B26) ☐ ☐ ☐ Barthélemy) (B07) Montserratian (B18) Equatorial Guinean (B27) ☐ ☐ British Virgin Islander (B08) Puerto Rican (B19 Gabonese (B28) ☐ ☐ ☐São Toméan (B29) Caymanian (Cayman Island) Caribbean Other (B20) ☐ ☐ ☐ (B09) Principe (B30)
Ethnicity and Race Data Collection Form DF-101A-13 ☐Central African Other (B31 Latin American South African East African ☐Argentine (B54) ☐Botswanan (B78) ☐ Burundian (B32) ☐Belizean (B55) ☐Mosotho (Lesotho) (B79) ☐Comoran (B33) ☐Bolivian (B56) ☐Namibian (B80) ☐Djiboutian (B34) ☐Brazilian (B57) ☐South African (B81) ☐Eritrean (B35) ☐Chilean (B58) ☐Swazi (B82) ☐Ethiopian (B36) ☐Colombian (B59) ☐South African Other (B83) ☐Kenya (B37) ☐Costa Rican (B60) West African ☐Malagasy (Madagascar ☐Ecuadorian (B61) ☐Beninese (B84) (B38) ☐El Salvadoran (B62) ☐Bissau-Guinean (B85) ☐Malawian (B39) ☐Falkland Islander (B63) ☐Burkinabé (Burkina Faso) ☐Mauritian (Mauritius) (B40) ☐French Guianese (B64) (B86) ☐Mahoran (Mayotte) (B41) ☐Guatemalan (B65) ☐Cabo Verdean (B87) ☐Mozambican (B42) ☐Guyanese (B66) ☐Ivorian (Cote d’lvoire) ☐Reunionese (B43) ☐Honduran (B67) (B88) ☐Rwandan (B44) ☐Mexican (B68) ☐Gambian (B89) ☐Seychellois/Seychelloise ☐Nicaraguan (B69) ☐Ghanaian (B90) (B45) ☐Panamanian (B70) ☐Liberian (B91) ☐Somali (B46) ☐Paraguayan (B71) ☐Malian (B92) ☐South Sudanese (B47) ☐Peruvian (B72) ☐Mauritanian (B93) ☐Ugandan (B49) ☐South Georgia and the ☐Nigerien (Niger) (B94) ☐Tanzanian (United Republic South Sandwich Islands ☐Nigerian (Nigeria) (B95) of Tanzania) (B50) (B73) ☐Saint Helenian (B96) ☐Zambian (B51) ☐Surinamese (B74) ☐Senegalese (B97) ☐Zimbabwean (B52) ☐Uruguayan (B75) ☐Sierra Leonean (B98) ☐East African Other (B53) ☐Venezuelan (B76) ☐Togolese (B99) ☐Latin American Other ☐West African Other (C01) (B77) ☐Black Write in (C02) White ☐White (W00) Middle Eastern and North ☐Jordanian (W22) Eastern European African ☐Kurdish Kuwaiti (W23) ☐Bosnian (W01) ☐ Algerian (W08) ☐Lebanes (W24) ☐Herzegovinian (W02) ☐ Amazigh or Berber (W09) ☐Libyan (W25) ☐Polish (W03) ☐ Arab or Arabic (W10) ☐Moroccan (W26) ☐Romanian (W04) ☐Assyrian (W11) ☐Omani (W27) ☐Russian (W05) ☐Bahraini (W12) ☐Palestinian (W28) ☐Ukrainian (W06) ☐Bedouin (W13) ☐Qatari (W29) ☐Eastern European Other ☐Chaldean (W14) ☐Saudi Arabian (W30) (W07) ☐Copt (W15) ☐Syrian (W31) ☐Druze (W16) ☐Tunisian (W32) ☐Egyptian (W17) ☐Yemeni (W33)
Ethnicity and Race Data Collection Form DF-101A-13 ☐Emirati (W18) ☐Middle Eastern Other ☐Iranian (W19) (W34) ☐Iraqi (W20) ☐North African Other (W35) ☐Israeli (W21) ☐White Other (W36) American Indian/Alaskan Native ☐American Indian/Alaskan ☐Makah Indian Tribe of the ☐Skokomish Indian Tribe Native (N00) Makah Indian Reservation (N25) Washington State Tribe (N13) ☐Snohomish Tribe (N26) ☐Chinook Tribe (N01) ☐Marietta Band of ☐Snoqualmie Indian Tribe ☐Confederated Tribes and Nooksack Tribe (N14) (N27) Bands of the Yakama Nation ☐Muckleshoot Indian Tribe ☐Snoqualmoo Tribe (N28) (N02) (N15) ☐Spokane Tribe of the ☐Confederated Tribes of the ☐Nisqually Indian Tribe Spokane Reservation (N2+) Chehalis Reservation (N03) (N16) ☐Squaxin Island Tribe of the ☐Confederated Tribes of the ☐Nooksack Indian Tribe of Squaxin Island Reservation Colville Reservation (N04) Washington (N17) (N30) ☐Cowlitz Indian Tribe (N05) ☐Port Gamble S’Klallam ☐Steilacoom Tribe (N31) ☐Duwamish Tribe (N06) Tribe (N18) ☐Stillaguamish Tribe of ☐Hoh Indian Tribe (N07) ☐Puyallup Tribe of Puyallup Indians of Washington (N32) ☐Jamestown S’Klallam Tribe Reservation (N19) ☐Suquamish Indian Tribe of (N08) ☐Quileute Tribe of the the Port Madison ☐Kalispel Indian Community Quileute Reservation (N20) Reservation (N33) of the Kalispel Reservation ☐Quinault Indian Nation ☐Swinomish Indian Tribal (N09) (N21) Community (N34) ☐Kikiallus Indian Nation (N10) ☐Samish Indian Nation ☐Tulalip Tribes of ☐Lower Elwha Tribal (N22) Washington (N35) Community (N11) ☐Sauk-Suiattle Indian Tribe Other ☐Lummi Tribe of the Lummi of Washington (N23) ☐Alaska Native Write in Reservation (N12) ☐Shoalwater Bay Indian (N36) Tribe of the Shoalwater Bay ☐American Indian Other Indian Reservation (N24) (N37) Asian ☐Asian (A00) ☐Hmong (A09) ☐Pakistani (A19) ☐Asian Indian (A01) ☐Indonesian (A10) ☐Punjabi (A20) ☐Bangladeshi (A02) ☐Japanese (A11) ☐Singaporean (A21) ☐Bhutanese (A03) ☐Korean (A12) ☐Sri Lankan (A22) ☐Burmese/Myanmar (A04) ☐Lao (A13) ☐Taiwanese (A23) ☐Cambodian/Khmer (A05) ☐Malaysian (A14) ☐Thai (A24) ☐Cham (A06) ☐Mien (A15) ☐Tibetan (A25) ☐Chinese (A07) ☐Mongolian (A16) ☐Vietnamese (A26) ☐Filipino (A08) ☐Nepali (A17) ☐Asian Other (A27) Okinawan (A18)
Ethnicity and Race Data Collection Form DF-101A-13 Native American/Pacific Islander ☐Native Hawaiian/Other ☐Kosraean (P06) ☐Samoan (P14) Pacific Islander (P00) ☐Maori (P07) ☐Solomon Islander (P15) Pacific Islander ☐Marshallese (P08) ☐Tahitian (P16) ☐Carolinian (P01) ☐Native Hawaiian (P08) ☐Tokelauan (P17) ☐Chamorro (P02) ☐Ni-Vanuatu (P10) ☐Tongan (P18) ☐Chuukese (P03) ☐Palauan (P11) ☐Tuvaluan (P19) ☐Fijian (P04) ☐Papuan (P12) ☐Yapese (P20) ☐i-Kiribati/Gilbertese (P05) ☐Pohpeian (P13) ☐Pacific Islander Other (P21)
Guardian Signature ______Date ______
Ethnicity and Race Data Collection Form DF-101A-13 Office of Superintendent of Public Instruction (OSPI) Home Language Survey
The Home Language Survey is given to all students enrolling in Washington schools.
Student Name: Grade: Date:
Parent/Guardian Name Parent/Guardian Signature
Right to Translation and All parents have the right to information about their child’s Interpretation Services education in a language they understand. Indicate your language preference so we can provide an interpreter or 1. In what language(s) would your family prefer to communicate translated documents, free of with the school? charge, when you need them.
Eligibility for Language 2. What language did your child learn first? Development Support ______Information about the student’s language helps us identify students 3. What language does your child use the most at home? who qualify for support to develop the language skills necessary for success in school. Testing may be 4. What is the primary language used in the home, regardless of necessary to determine if language the language spoken by your child? supports are needed. ______
5. Has your child received English language development support in a previous school? Yes No Don’t Know
Prior Education 6. In what country was your child born? ______Your responses about your child’s 7. Has your child ever received formal education outside of the birth country and previous United States? (Kindergarten – 12th grade) Yes No education: • Give us information about the If yes: Number of months: ______knowledge and skills your child is Language of instruction: ______bringing to school. • 8. When did your child first attend a school in the United States? May enable the school district to (Kindergarten – 12th grade) receive additional federal funding ______to provide support to your child. Month Day Year
This form is not used to identify students’ immigration status.
Thank you for providing the information needed on the Home Language Survey. Contact your school district if you have further questions about this form or about services available at your child’s school.
Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children. KENT SCHOOL DISTRICT Kent, Washington
To be completed by parent/guardian HEALTH HISTORY School ______Grade ______Today’s Date______Teacher ______
Name of Student______Birthdate ______Sex: M F
This information is needed to plan an appropriate program for your student and to prepare for any emergency situation if one should arise. Your school nurse will contact you if there are any additional questions.
DOES THE STUDENT HAVE: MEDICAL HISTORY (check all that apply) Please explain any yes answers. Allergies (specify) No ___ Yes ______Life threatening allergy (anaphylaxis)* No ___ Yes ______(*If yes, complete reverse side)______Bee/insect allergy No ___ Yes ______Asthma * No ___ Yes ______(*If yes, complete reverse side)______Concerns/defect present at birth No ___ Yes ______Frequent ear infections No ___ Yes ______Hearing loss No ___ Yes ______Speech difficulties No ___ Yes ______Severe headaches No ___ Yes ______Seizures No ___ Yes ______Neurological condition No ___ Yes ______ADD/ADHD (circle one, diagnosed by whom) No ___ Yes ______Heart condition No ___ Yes ______Diabetes * No ___ Yes ______(*If yes, see reverse side)______Blood disorder No ___ Yes ______Orthopedic condition No ___ Yes ______Chronic condition/disability No ___ Yes ______Vision concerns No ___ Yes ___ Wears: Glasses _____ Contacts _____ Other ______Serious injury/surgery No ___ Yes ______Date: ______Emotional health concerns No ___ Yes ______Other health concerns No ___ Yes ______
MEDICATION Is medication needed at home? No ___ Yes ______Name of medication Is medication needed at school?** No ___ Yes ______Name of medication **State law requires written permission from a licensed health care provider and parent before any medication, prescription or over-the-counter, may be taken at school. A form is available from the school office.
Is there anything you want to tell us about your student which you feel will help school staff to better understand and work with him/her? ______
I understand that the information given above will be shared with appropriate school staff who need to know in order to provide for the heath and safety of my student. If parents/guardian or authorized emergency contact cannot be reached at the time of a medical emergency, and if immediate care is urgent in the judgment of school authorities, I authorize and direct the school authorities to send the student to the hospital or doctor most easily accessible. I understand that I will assume full responsibility for the payment of any services rendered.
Signature ______Relationship ______Phone ______
- Please turn over for more information - HS-33-07 Anaphylaxis If your student has an anaphylactic allergy as indicated on the reverse side of this form, please answer the following questions: 1. What is your student allergicto? 2. What are your student’s symptoms? 3. Has your student been prescribed an Epi-pen? Please contact the school nurse to help implement your student’s individualized healthcare plan.
Diabetes There is a state law, which requires all students with diabetes to have an individualized health care plan implemented in the school setting. If your student is diabetic, please contact the school nurse to help write your student’s plan.
Asthma If your student has asthma as indicated on the reverse side of this form, please answer the following questions: 1. How long has your child had asthma? ______years ______months 2. How many days would you estimate he/she missed school last year due to asthma? 3. How many times in the past year has your child been:
a) Hospitalized overnight or longer for asthma? (check one) _____none _____one _____two-four _____more than four
b) Treated in an emergency room? (check one) _____none _____one _____two-four _____more than four
c) Treated in a Doctor’s office for non-routine asthma? (check one) ____none ____one _____two-four _____more than four 4. What are your child’s early warning signs of an asthma episode? (check all that apply) _____ cough _____ cold symptoms _____ drop in peak flow _____ wheezing _____ decreased exercise _____other______5. If your child’s asthma is monitored with a peak flow meter, write in his/her best peak flow rate. ______6. Does your child have and use a nebulizer machine at home? _____ yes ______no 7. If your child takes medication for their asthma at home please provide the name of any medications: ______
Life Threatening Conditions RCW 28A.210.320-Children with Life-Threatening Conditions, requires a medication or treatment order as a prerequisite for children with life-threatening conditions to attend public schools. The new law defines “life- threatening condition” as a health condition that will put the child in danger of death during the school day, if a medication or treatment order and a nursing care plan are not in place. Potential life-threatening conditions include, but are not limited to, students with seizure disorders, diabetes, life-threatening allergies, and some students with asthma and heart conditions. If this law applies to your student, please contact the nurse at your child’s school.
Signed: ______Date: ______Student Immunization Change
All new students enrolling for 2020-21 school year will be required to provide medically verified immunization records.
If your child is currently enrolled in Kent School District and already meets immunization requirements, you do not need to do anything. If you aren’t sure, or if you have any questions, please contact your child’s school nurse. What are medically verified immunization records? This means immunization records turned in to the school for incoming students must be from a health care provider, or paperwork from a health care provider must be attached to a handwritten form showing your child’s records are accurate.
Examples include:
A Certificate of Immunization Status (CIS) printed from the Immunization Information System.
A physical copy of the CIS form with a healthcare provider signature.
A physical copy of the CIS with accompanying medical immunization records from a healthcare provider verified and signed by school sta .
A CIS printed from MyIR. To register go to: https://wa.myir.net/register
More information can be obtained at the Washington State Department of Health website: https://www.doh.wa.gov/YouandYourFamily/Immunization/SchoolandChildCare/RuleChanges Instructions for completing the Certificate of Immunization Status (CIS): Print the from the Immunization Information System (IIS) or fill it in by hand.
To print with the immunization information filled in: Ask if your health care provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide registry). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: [email protected] or 1-866-397-0337.
To fill out the form by hand: 1. Print your child’s name and birthdate, and sign your name where indicated on page one. 2. Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediatix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. 3. If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your health care provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. 4. If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign and date the form. You must provide lab reports with this CIS. 5. Provide proof of medically verified records, following the guidelines below.
Acceptable Medical Records All vaccination records must be medically verified. Examples include: A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state’s IIS. A completed hardcopy CIS with a health care provider validation signature. A completed hardcopy CIS with attached vaccination records printed from a health care provider’s electronic health record with a health care provider signature or stamp. The school administrator, nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.
Conditional Status Children can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school or child care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care.
Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete.
If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.
Reference guide for vaccine trade names in alphabetical order For updated list, visit https://www.cdc.gov/vaccines/terms/usvaccines.html Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1)
Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix DTaP + Hep B + IPV RotaTeq Rotavirus (PV5)
Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td
Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib +IPV Trumenba MenB
Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B
Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A
Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella
Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 November 2019
Reviewed by: Date:
Certificate of Immunization Status (CIS) Signed COE on File? Yes No
Please print. See back for instructions on how to fill out this form or get it printed from the Washington State Immunization Information System. Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YYYY):
I give permission to my child’s school/child care to add immunization information into the Conditional Status Only: I acknowledge that my child is entering school/child care in Immunization Information System to help the school maintain my child’s record. conditional status. For my child to remain in school, I must provide required documentation of immunization by established deadlines. See back for guidance on conditional status. X X Parent/Guardian Signature Date Parent/Guardian Signature Required if Starting in Conditional Status Date
▲Required for School Date Date Date Date Date Date Documentation of Disease Immunity ● Required Child Care/Preschool MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY (Health care provider use only)
Required Vaccines for School or Child Care Entry If the child named in this CIS has a history of ●▲ DTaP (Diphtheria, Tetanus, Pertussis) varicella (chickenpox) disease or can show immunity by blood test (titer), it must be veri- ▲ Tdap (Tetanus, Diphtheria, Pertussis) (grade 7+) fied by a health care provider.
●▲ DT or Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: ●▲ Hepatitis B A verified history of varicella (chickenpox) disease. ● Hib (Haemophilus influenzae type b) Laboratory evidence of immunity (titer) to ●▲ IPV (Polio) (any combination of IPV/OPV) disease(s) marked below.
●▲ OPV (Polio) Diphtheria Hepatitis A Hepatitis B
●▲ MMR (Measles, Mumps, Rubella) Hib Measles Mumps ● PCV/PPSV (Pneumococcal) Rubella Tetanus Varicella ●▲ Varicella (Chickenpox) Polio (all 3 serotypes must show immunity) History of disease verified by IIS Recommended Vaccines (Not Required for School or Child Care Entry) ► Flu (Influenza) Hepatitis A Licensed Health Care Provider Signature Date HPV (Human Papillomavirus)
MCV/MPSV (Meningococcal Disease types A, C, W, Y) ► MenB (Meningococcal Disease type B) Rotavirus Printed Name
I certify that the information provided Health Care Provider or School Official Name: ______Signature: ______Date:______on this form is correct and verifiable. If verified by school or child care staff the medical immunization records must be attached to this document.
School Year:
Dear Parent or Guardian,
The state legislature has passed a law requiring Washington State public schools to collect information on active military affiliation of legal guardians (Bill 5163).
The purpose of this data collection is to allow educators and policymakers to monitor critical elements of education success, including academic progress and proficiency,
special and advanced program participation. Reliable information about student
performance will assist educators in more effectively transitioning students to a new
school and enable districts to discover and implement best practices.
******************************************************************
Please fill in the following information and return to your student’s school.
Date: BOARD OF DIRECTORS Student Name: School: Leslie Hamada President Please check appropriate affiliation below: Denise Daniels Vice President U.S. Armed Forces active duty Maya Vengadasalam Legislative National Guard member Representative Michele Bettinger More than one member of Armed Forces/National Guard Director No affiliation/other: Leah Bowen Director U.S. Armed Forces reserves
No response/refused to state Dr. Calvin J. Watts Superintendent If you have questions, please contact Student Services at (253) 373-7235.
MISSION Successfully Preparing All Students for Their Futures
Administration Center Sincerely, 12033 SE 256th Street Kent, WA 98030-6503 Phone: (253) 373-7000 www.kent.k12.wa.us Randy Heath Executive Director Student and Family Support Services Kent School District Emergency Early Dismissal Plan/Disaster Plan Dear Parent(s) or Guardians(s): In the event of an unanticipated early dismissal due to inclement weather, power outage or other emergency, it is important that you and your child(ren) have a plan of action. The plan CANNOT include the use of school phones as there may be instances where phone service is not available. PLEASE COMPLETE AND SIGN A SEPARATE EMERGENCY EARLY DISMISSAL FORM FOR EACH CHILD IN YOUR FAMILY AND RETURN IT TO YOUR CHILD’S TEACHER IMMEDIATELY.
Student last name: First name:
Teacher’s name:
Home address:
Mother/Guardian’s full name:
Cell phone: Work phone: Home phone:
Father/Guardian’s full name:
Cell phone: Work phone: Home phone:
In the event of an unanticipated early dismissal or disaster*:
1. My child is to be picked up by his/her regular daycare transportation Yes No Name of daycare: Daycare phone: In the event that regular daycare transportation is not available, please indicate which of the other options below are acceptable: 2 3 4 5 6 2. My child is to ride home on his/her regular bus. Yes No 3. My child is to walk home. Yes No 4. My child is to walk to ‘s home Yes No Address: 5. My child is to ride home with either of the following people: Yes No Name: Phone: Name: Phone: 6. My child is to stay at school until his/her parent or guardian arrives. Yes No If the options selected above are not possible due to the nature of the situation, your child will be kept at school until you or one of your child’s emergency contacts arrive or until we make contact with you to make other arrangements. I have reviewed this plan with my child. Parent/Guardian Signature: Date: *Please confirm this plan with each person listed above prior to returning this form to the school.
***************TO BE COMPLETED ONLY IN THE EVENT OF AN EMERGENCY BY SCHOOL STAFF*************** The student was released to: (Please print full name) Signature of pickup person: Staff member releasing child: Time/Date:
Student Housing Questionnaire
If you own or pay rent for your home or apartment, you do not need to complete this form.
The answers to the following questions can help determine the services your student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. (Please see reverse side for more information)
If you do not own or pay rent for your home or apartment, please check all that apply below for your current housing situation: (Return completed form to your student’s school).
In a motel A car, park, campsite, or similar location In a shelter Transitional Housing Moving from place to place Other______In someone else’s house or apartment with another family In a residence with inadequate facilities (no water, heat, electricity, etc.)
If you are living in shared housing, please check all the following reasons that apply: Loss of housing Economic situation Provide care for a family member Loss of employment Temporarily waiting for house or apartment Living with boyfriend/girlfriend Parent/guardian is deployed Other, please explain:
List all students living with you: Name Student ID # Grade Age School
Student is unaccompanied (not living with a parent or legal guardian) Student is living with a parent or legal guardian
ADDRESS OF CURRENT RESIDENCE:
PHONE NUMBER: Email:
Print name of parent(s)/legal guardian(s): (Or unaccompanied youth)
*Signature of parent/legal guardian: Date: (Or unaccompanied youth) *I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct. Please return completed form to your student’s school. Revised 1.4.18 McKinney-Vento Act 42 U.S.C. 11435
SEC. 725. DEFINITIONS.
For purposes of this subtitle:
(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities.
(2) The term homeless children and youths' —
(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1)); and
(B) includes —
(i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
(ii) children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C));
(iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and
(iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).
(6) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian.
Additional Resources
Parent information and resources can be found at the following: http://center.serve.org/nche/ibt/parent_res.php http://naehcy.org/educational-resources/naehcy-publications
Lori Madeo, Kent School District McKinney-Vento liaison 253-373-7512 [email protected]
INSTRUCTIONS FOR THE ED 506 FORM FOR APPLICANTS: PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under this subpart, and that otherwise meets the requirements of subsection (b)”.
MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year, which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.
FOR PARENTS/GUARDIANS: DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band, including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, 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 on October 19, 1994.
STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level.
TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can provide membership information.
Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to this form. • Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department of Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request. • State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department of Education does not maintain a master list. It is recommended that you use official state websites only. • Terminated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interior and had that designation terminated. • Organized Indian Group- 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.
Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent, or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate. Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians.
ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.
The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act.
PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020.
OMB Number: 1810-0021
U.S. Department of Education Office of Indian Education Washington, DC 20202 TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM
Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.
STUDENT INFORMATION
Name of the Child ______Date of Birth ______Grade ______(As shown on school enrollment records) Name of School ______
TRIBAL ENROLLMENT
Name of the individual with tribal enrollment: ______(Individual named must be a descendent in the first or second generation)
The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent
Name of tribe or band for which individual above claims membership: ______
The Tribe or Band is (select only one): _____ Federally Recognized _____ State Recognized _____ Terminated Tribe (Documentation required. Must attach to form) _____ 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. (Documentation required. Must attach to form)
Proof of enrollment in tribe or band listed above, as defined by tribe or band is: A. Membership or enrollment number (if readily available) ______OR
B. Other Evidence of Membership in the tribe listed above (describe and attach) ______
Name and address of tribe or band maintaining enrollment data for the individual listed above:
Name ______Address ______
City ______State ______Zip Code ______
ATTESTATION STATEMENT
I verify that the information provided above is accurate.
Name Parent/Guardian ______Signature ______
Address ______City ______State ______Zip Code ______
Email Address ______Date ______