Snohomish High School 1316 Fifth Street Snohomish, WA 98290
Welcome to Snohomish High School!
Please return the arrowed items to Jennifer Harris via email, fax, or personal delivery. Items with asterisks * will be requested from student’s previous school. We will contact you to set an enrollment appointment with your student’s counselor when all enrollment materials have been received.
1. Proof of Residence (must be one of the following): o Deed of trust o Mortgage Payment Receipt (dated within past month) o Rental/Lease Agreement (listing names of occupants w/name, address, and phone number of the landlord/management company o Escrow/closing papers o Current utility bill or cable bill (PSE, PUD, cable, water, garbage, etc.)
2. Verification of Student Birth Date (choose one of the documents below): o Birth Certificate o Hospital Certificate o Passport
3. Parent/Guardian State or Government Photo Identification
4. Attached Snohomish School District forms o All forms in this registration packet must be complete, with signature where requested
5. * Student Immunization Information (choose one of the documents below): o School records o Doctor records o WA State Immunization
6. * Student’s current transcript or last report card (beginning 9th graders) - OR- if enrolling after start of current school year, withdrawal form and withdrawal grades from previous school.
7. *Does your student has an IEP? We must have a copy of the IEP and the most recent evaluation prior to your enrollment appointment. Please call for further details.
Contact Jennifer Harris, Administrative Assistant, at (360) 563-4050 or [email protected] Fax (360) 563-4194
SHS Counseling Office Staff Sheri Adams A-Dav Tiffany Coleman Me-Sa Kelly Lago Daw-Hoi Ken Hansen Sc-Z Joelle Ediger Hoj-Mc Heidi Gauthier, Registrar Jennifer Harris, Admin Assistant Courtney Brown, Records Office Hours 7 a.m. – 3 p.m. Monday – Friday 3111F1 SNOHOMISH SCHOOL DISTRICT 201 NEW STUDENT REGISTRATION FORM SCHOOL: DATE :
DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY STUDENT SCHOOL NUMBER SCHOOL ENTRY DATE MEDICAL ALERT HOMEROOM NUMBER LOCKER NUMBER BUS ROUTE
AM PM
Has any member of your family ever been enrolled in the Snohomish School District? Yes No
STUDENT NAME: Legal Last Name Legal First Name Legal Middle Name Also Known As:
BIRTHDATE (Month/Day/Year) GENDER BIRTHPLACE: City County State Country Grade Level: F M DISTRICT RESIDENT? Military Family Status (circle) PRIMARY LANGUAGE SPOKEN AT HOME A – U.S. Armed Forces active duty G – National Guard member Yes No M – More than one member of Armed Forces/National Guard English N – No affiliation R‐ U.S. Armed Forces reserves Resident District: Z – Do not wish to state Other
PRIMARY HOUSEHOLD (primary parent/guardian where student resides) PRIMARY CONTACT # (include area code) PRIMARY CONTACT PH #2 (area code) Legal Last Name (of primary contact) Legal First Name Middle Name Home Work Cell Home Work Cell
Please check if unlisted RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Please check if unlisted Grandfather Grandmother Uncle Aunt Agency Friend Self Legal Last Name Legal First Name Middle Name PHONE #1 (include area code) PHONE #2 (include area code) Home Work Cell Home Work Cell
RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Please check if unlisted Please check if unlisted Grandfather Grandmother Uncle Aunt Agency Friend Self FAMILY EMAIL ADDRESS ADDITIONAL EMAIL ADDRESS
RESIDENT Street Apt # City State ZIP ADDRESS
MAILING Street Apt # P O Box City State ZIP ADDRESS (If different from above) SECOND HOUSEHOLD (Non‐custodial parent/guardian not residing with student) PHONE #1 (include area code) PHONE #2 (include area code) Legal Last Name Legal First Name Middle Name Home Work Cell Home Work Cell
RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Please check if unlisted Please check if unlisted Grandfather Grandmother Uncle Aunt Agency Friend Self
(Non‐custodial parent/guardian not residing with student) PHONE #1 (include area code) PHONE #2 (include area code) Legal Last Name Legal First Name Middle Name Home Work Cell Home Work Cell
Please check if unlisted Please check if unlisted RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self FAMILY EMAIL ADDRESS RELATIONSHIP TO STUDENT: Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self SECOND HOUSEHOLD MAILING ADDRESS (Street/PO Box, City, State, ZIP) ADDITIONAL MAILINGS REQUESTED Yes No
SCHOOL PREVIOUSLY ATTENDED SCHOOL DISTRICT PREVIOUSLY ATTENDED PREVIOUS SCHOOL LOCATION (City and State)
HAS STUDENT EVER ATTENDED SNOHOMISH PUBLIC SCHOOLS? Yes No IFME YES, NA OF SCHOOL(S) ATTENDED DATE ATTENDED (Month/Year)
IS THERE A JOINT‐CUSTODY OR PARENTING PLAN IN EFFECT? Yes No (If yes, plan must be on file with the school) Copy Attached
IS THERE A RESTRAINING ORDER IN EFFECT? Yes No (If yes, legal papers must be on file with the school) Copy Attached Restraining order is against: Mother Father Other Please complete additional registration information on back…
01/2017 3111F1 HAS THE STUDENT EVER BEEN SUSPENDED FOR A WEAPONS VIOLATION? Yes No Date:
HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL EDUCATION HAS YOUR CHILD EVER BEEN PROGRAM? Yes No RETAINED?
HAS YOUR CHILD EVER BEEN ON AN IEP? (Individualized Education Program) Yes No Yes No
HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN? Yes No If yes, at what grade level(s)
HAS YOUR CHILD EVER PARTICPATED IN: Title – Title 1 Services
LAP – Learning Assistance Program
Gifted – Accelerated Learning Program
ELL – English Language Learner
DOES STUDENT ATTEND CHILD CARE? CHILD CARE PROVIDER Name Address Phone Number Before school After school Before and after school
ADDITIONAL CHILD CARE ARRANGEMENTS (Please provide information to school in writing)
PLEASE LIST OTHER SIBLINGS ATTENDING SNOHOMISH PUBLIC SCHOOLS Last Name First Name School Grade
SPECIAL INSTRUCTIONS REGARDING RELIGIOUS BELIEFS (Please provide information to school in writing)
STUDENT RELEASE AUTHORIZATION
When injury, illness or other non‐emergency situations occur involving your child, we want to be able to quickly reach families or other 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.
PRIMARY EMERGENCY CONTACT (after parent/guardian contact) RELATIONSHIP TO CHILD PHONE #1 (include area code) PHONE #2 (include area code) Legal Last Name Legal First Name Home Work Cell Home Work Cell
PRIMARY CONTACT ADDRESS Street City State ZIP
SECONDARY EMERGENCY CONTACT (after parent/guardian contact) RELATIONSHIP TO CHILD PHONE #1 (include area code) PHONE #2 (include area code) Legal Last Name Legal First Name Home Work Cell Home Work Cell
SECONDARY CONTACT ADDRESS Street City State ZIP
STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above.
Legal Parent/Guardian Signature Date
EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child.
Legal Parent/Guardian Signature Date
Continue to next page for Ethnicity & Race Information
01/2017 3111F1 SNOHOMISH SCHOOL DISTRICT NO. 201 Ethnicity and Race Collection Form – State and Federally Required Information
QUESTION 1. Is your child of Hispanic or Latino origin? (Check all that apply)
NOT HISPANIC/LATINO MEXICAN/ MEXICAN AMERICAN/ CHICANO CENTRAL AMERICAN CUBAN SOUTH AMERICAN DOMINICAN LATIN AMERICAN SPANIARD OTHER HISPANIC/LATINO
QUESTION 2. What race(s) do you consider your child? (Check all that apply)
AFRICAN AMERICAN/BLACK ALASKA NATIVE WHITE CHEHALIS COLVILLE COWLITZ HOH JAMESTOWN KALISPEL LOWER ASIAN INDIAN ELWHA LUMMI CAMBODIAN MAKAH CHINESE FILIPINO MUCKLESHOOT HMONG NISQUALLY INDONESIAN NOOKSACK JAPANESE PORT GAMBLE KLALLAM KOREAN LAOTIAN PUYALLUP MALAYSIAN QUILEUTE PAKISTANI SAMISH SINGAPOREAN SAUK‐SUIATTLE TAIWANESE SHOALWATER THAI SKOKOMISH VIETNAMESE SNOQUALMIE OTHER ASIAN SPOKANE SQUAXIN ISLAND STILLAGUAMISH NATIVE HAWAIIAN SUQUAMISH FIJIAN SWINOMISH TULALIP GUAMANIAN or CHAMORRO YAKIMA MARIANA ISLANDER MALANESIAN OTHER WASHINGTON INDIAN MICRONESIAN OTHER AMERICAN INDIAN SAMOAN TONGAN OTHER PACIFIC ISLANDER
QUESTION 3. What local race do you consider your child? (Choose one only, please)
ASIAN MULTIRACIAL PACIFIC ISLANDER BLACK, NON‐HISPANIC HISPANIC WHITE, NON HISPANIC AMERICAN INDIAN/ALASKAN NATIVE NOT PROVIDED
REQUIRED INFORMATION: If born in a country other than the United States, please answer these questions:
How many months have you been in US? How many years? Has your child had any formal education outside the US? Yes No Where and how long?
Legal Parent/Guardian Signature of Verification: Date
01/2017
3431F1 EMERGENCY INFORMATION Snohomish School District No. 201, Snohomish, WA 98290
Please print student’s last name
Bus # In order to provide immediate and safe care for your child and carry out your wishes in case of injury or illness at school, we require the following information. Please fill out completely. Please Print.
Student Name Birth date Grad Year_ Last First Initial Home Address City Zip Home Phone Mailing Address if different from home address: City Zip Lives with: Parents Mother only Mother/Stepfather Guardian Father only Father/Stepmother Other_
Parent/Guardian Name 1. ______E‐mail Address ______
Employer ______Work Phone ______Cell Phone______
Parent/Guardian Name 2. ____E‐mail Address
Employer Work Phone Cell Phone
Primary language spoken at home: English Spanish Other Day Care Provider (if applicable) Phone Please complete the following if student has a non‐custodial parent who can make emergency decisions for the student and receive copies of records involving this student, including newsletters, grade reports, correspondence, etc.
Home Address City Zip Home Phone Parent/Guardian Name 1. E‐mail Address _ Place of business Work Phone Cell Phone Parent/Guardian Name 2. E‐mail Address Place of business Work Phone Cell Phone
In addition to the parent/guardian, if you cannot be reached, the school may call and release your child to any of the following:
Name 1. Relationship Phone Work Phone Cell Phone
2. Relationship Phone
Work Phone Cell Phone
3. Relationship Phone
Work Phone Cell Phone ___
Please list all children in Snohomish School District this year. (Please list students in this school first.) Last Name First Name School Grade
Signature of Parent or Legal Guardian Date
Please check here if any information on this form is new. ***THIS FORM MUST BE RETURNED AT REGISTRATION 1/2017
To be completed by parent/guardian HEALTH HISTORY 3431F3
(Last, First): ______DOB: ______ M F Grade: ______ID #: ______Student Name This information is needed to plan an appropriate program for your student and to prepare for any emergency situation if one should arise. Your building nurse will contact you if there are any additional questions.
MEDICAL HISTORY (check all that apply) OR no health concerns at this time (please sign form).
Congenital Conditions Nervous System
A_ Please List ______NA Autism Spectrum Disorder ADHD‐Inattentive ADHD‐Hyperactive/Impulsive Hematology (Blood) NB ADHD‐Combined Diagnosed by: ______
BB *Hemophilia______NE Cerebral Palsy______NF Developmental Delay______BC Sickle Cell Anemia______BD Other Blood Condition______NH/I/J Migraines Headaches Shunt NL Intellectually Disabled______NN Paralysis______Cardiovascular/Heart Conditions NP Seizure Disorder______C_ Please List______NQ Sensory Condition______
NS Spina Bifida______
Endocrine, Allergy, Immune System, Metabolic, and NT Spinal Cord Injury______Nutritional NU Traumatic Brain Injury______EDAllergy‐Food______Behavioral Health Conditions EE Allergy–Insect______PH Sleep Disorder______E‐ Other Allergy______PI Tourette Syndrome______EG*Anaphylactic Condition (Epi‐pen)______P_ Other______EJ Cystic Fibrosis______
EK/L*Diabetes Type 1 *Diabetes Type 2 Respiratory ENEating Disorder______RA Exercise‐Induced Bronchospasm *Inhaler EU Thyroid Disorder______RB/C/DAsthma Mild *Moderate *Severe *Inhaler E_ Other Endocrine, Immune, or RE Reactive Airway Disease______Metabolic Disorder______RF Other______
Gastrointestinal, Dental, and Oral Conditions Skin and Subcutaneous Tissue GA/J/KCeliac Disease Crohn’s Irritable Bowel SB Contact Dermatitis (Eczema)______GH/LGastroesophageal Reflux Lactose Intolerance S_ Other______
GIOther______Neoplasms (Cancer/Tumors) GMLiver Disease T_ Please List______GD Dental Condition
GNOral Condition Renal and Genitourinary
Musculoskeletal and Connective Tissue UB/U‐ Chronic Urinary Tract Infection Urinary Reflux UC Dysmenorrhea (painful periods)______MC Juvenile Idiopathic Arthritis______U_ Other______MD Muscular Dystrophy______
MF Osgood‐Schlatter______Eye and Ear MH Scoliosis______YB Hearing Impaired______M_ Other______YA/YC Chronic Ear Infections______Ear Condition______
YD Visually Impaired______YE Eye Condition______Wears Glasses______1/2 OVER
Is medication needed at home? No Yes Please list.
______
Is medication needed at school? No Yes Please list.
______
*Law requires that life‐threatening conditions such as anaphylaxis, hemophilia, asthma, or diabetes have a care plan completed prior to the first day of school. Please contact the building nurse as soon as possible to ensure the paperwork is complete.
3431F3
Hospital Preference ______
Health Insurance: No Yes
Name of Company ______
Dental Insurance: No Yes
Name of Company ______
Family Doctor ______Phone______Date of last physical exam______
Specialist______Phone______Date of last exam______
Dentist ______Phone ______Date of last exam ______
State law requires written permission from parent and/or a health care provider before any medications, prescription or over‐the‐counter, may be taken at school. Forms are available from the school health rooms or the school office.
If parent/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 accessible. I understand that I will assume full responsibility for the payment of any services rendered. I understand that the information given above will be shared with appropriate school staff that needs to know in order to provide for the health and safety of my student. I understand that SSD staff may obtain immunization info from Washington State Immunization Information System to update my student’s immunization status. If I do NOT want SSD staff to obtain info from Washington State Immunization Information System I will check here.
Parent/guardian signature______
Relationship ______Phone______
2/2 Student Housing questionnaire 1601 Avenue D, Snohomish, WA 98290-1799 360-563-7300 Fax 360-563-7279
The answers to the following questions help determine educational services your child(ren) may be eligible to receive through the McKinney-Vento Homeless Assistance Act. Are you ‘doubled up’ with another family due to a loss of housing or economic hardship? Yes No Are you living in a motel/hotel due to lack of housing? Yes No Are you living in a shelter? Yes No Are you living in a car, park, campsite or location not usually used for sleeping accommodations? Yes No As a student, are you living with someone other than your parent? Yes No
If you answered YES to any of the above questions, please complete the remainder of this form and return it to your child’s school.
If you answered NO to all of the above questions, you may stop here.
Student Name:______First Middle Last
Date of Birth:______Age:______Grade:______Name of School:______
Current address:______Street City Zip
Phone/Contact Number:______
Do you have other children that attend a school in the Snohomish School District?
Name:______Date of Birth:______Age:______Grade:______School:______
Name:______Date of Birth:______Age:______Grade:______School:______
Name:______Date of Birth:______Age:______Grade:______School:______
I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate.
Print name of person completing form:______
Signature: ______Date:______
Relationship to student(s): Parent Guardian Self Other–––––––––––––––––––––––––––––––––––––––
For School Staff Only: If “Yes” is checked for any question above, please give this form to the School Counselor or Administrator School Attendance 1601 Avenue D, Snohomish, WA 98290-1799 form 360-563-7300 Fax 360-563-7279
• By 6th grade, absenteeism is one of three signs that a School attendance is required student may drop out of high school. by state law. • Absences can be a sign that a student is losing interest • State law requires children from age 8 to 17 to attend in school, struggling with school work, dealing with a school. bully or facing some other potentially serious difficulty. • Children that are 6- or 7-years-old, who are enrolled in • By 9th grade, regular attendance is a better predictor school, must also attend school. of high school graduation rates than 8th grade test • Youth who are 16 or older may be excused from scores. attending school if they meet certain requirements per state law (RCW 28A.225.010). What you can do: • If your child is going to be absent, please contact the • Don’t let your child stay home unless they are truly school office. sick, such as fever, vomiting, diarrhea, or a contagious rash. School’s duties upon a • Avoid appointments and travel when school is in student’s absences: session. • If your child has two unexcused absences in one • Keep track of your child’s attendance. Missing more month, state law (RCW 28A.225.020) requires we than nine days, excused or unexcused, could put your schedule a conference with you and your child. child at risk of falling behind. • In elementary school after five excused absences in • Set a regular bedtime and morning routine as well as any month, or ten or more excused absences in the finishing homework and packing backpacks the night school year, the school district is required to contact before. you to schedule a conference. A conference is not • Have a back-up plan in place with family members, required if your child has provided a doctor’s note, or neighbors, or other parents for getting your child to pre-arranged the absence in writing, and plans are in school in case something comes up. place so your child does not fall behind academically. • If your child has seven unexcused absences in any If you are struggling to get your child to school for any month or ten unexcused absences within the school reason, we are here to support you and work with you year, we are required to file a petition with the juvenile towards possible solutions. Please do not hesitate to court, alleging a violation of RCW 28A.225.010, the contact the school office to schedule an appointment to mandatory attendance laws. You and your child may discuss your child’s attendance. need to appear in juvenile court. Did you know? • Attending school on-time, all day, every day will give your child the best chance of graduating from high school. • Starting in kindergarten, missing on average just two days a month, whether excused or unexcused, makes it more likely that your child will not meet academic standards in math and reading by third grade. I acknowledge that I have read (or I have had someone read this to me) and I understand this document.
Student Name:______First Middle Last
Date of Birth:______Age:______Grade:______Name of School:______
Current address:______Street City Zip
Phone/Contact Number:______
Do you have other children that attend a school in the Snohomish School District?
Name:______Date of Birth:______Age:______Grade:______School:______
Name:______Date of Birth:______Age:______Grade:______School:______
Name:______Date of Birth:______Age:______Grade:______School:______
I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate.
Print name of person completing form:______
Signature: ______Date:______
Relationship to student(s): Parent Guardian Self Other–––––––––––––––––––––––––––––––––––––––
Please read and complete this form and return to your child's school office by the end of September.
English/November 2016
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___
6. In what country was your child born? ______Prior Education
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.
Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative Commons Attribution 4.0 International License.
2017‐2018 Student Transportation Input Form
Will your student ride the school bus during the 2017‐2018 school year? Yes No
Student's Name (first and last) ______
Student's ID Number (please provide if known) ______
Student Address (home address and city) ______
School student will attend during the 2017‐2018 school year:
AIM High School Little Cedars Elementary Cascade View Elementary Machias Elementary Cathcart Elementary Riverview Elementary Centennial Middle School Seattle Hill Elementary Central Primary Center Snohomish High School Dutch Hill Elementary Totem Falls Elementary Emerson Elementary Valley View Middle School Glacier Peak High School
Grade student will be in during the 2017‐2018 school year:
Kindergarten 7th grade 1st grade 8th grade 2nd grade 9th grade 3rd grade 10th grade 4th grade 11th grade 5th grade 12th grade 6th grade
A.M pick‐up location: Home Student does not plan to ride the bus Other
P.M. drop‐off location: Home Student does not plan to ride the bus Other
Will student be making a request for a permanent bus pass at the beginning of the year for alternative
pick‐up or drop‐off location? If so, to where? ______
Parent's name (printed) ______
Parent's signature ______
E‐mail address ______
Contact phone number ______
The form will need to be completed for every student in your household who will attend a Snohomish School District School in the 2017‐2018 school year. Please return this completed form to your student’s school. Please contact the Transportation Dept. at (360) 563‐3525 if you have any questions or concerns. 3600F3
Photos/Recordings Opt‐Out Form
There are times during the year when photographs or audio‐visual recordings of students may be taken for school or district use. When possible, we will alert parents in advance, but this is not always possible.
It is important that you know that student family members, community members, and attendees at school events may take and publish photos and other recordings of students without coordinating such with school district personnel, and it is possible that your student could appear in a third party's photos and other recordings. Snohomish School District is not responsible for the use of any of your student’s likeness (photo, voice, etc.) that appears in those photos and recordings.
You may choose to opt out of allowing your student to appear in photos or other recordings taken by or on behalf of the Snohomish School District by checking and signing below.
I do NOT want my student to appear in photos or audio‐visual recordings taken by or on behalf of the Snohomish School District. (By checking this box your student will NOT appear in ANY photos and recordings taken for yearbook, classroom/school/district presentations, parent club/classroom/school/district newsletters, media, etc.)
Please note – Opt‐out restrictions must be renewed at the beginning of each school year.
Student ______Last Name First Name
Parent ______Last Name First Name
Parent Signature ______
Contact Phone ______Date______
F o r O f f i c e U s e O n l y 1. Enter opt‐out date in Skyward student record – custom forms/internet opt out. 2. From WS/ST/TB/CF – web student/student tabs/custom forms 3. Check photo opt‐out box and enter date of opt out. 4. Retain this signed form at the school for the duration of school year.
01/2017 3600F1
Purpose: As a parent, guardian or student, you have the right to give permission for the release of your child’s records with other persons or agencies. This request provides you with the opportunity to approve or not approve such a request unless release of records is allowed under one of the exceptions under the rules implementing the Family Education Rights and Privacy Act (FERPA) - for example, transfer of records from one school district to another.
Authorization for Release/Exchange of Records
Student Name: Date: Parent(s) Student DOB: Names: I hereby authorize the release of records: From: To: (Name of agency/person) (Name of agency/person)
(Street Address) (Address)
(City, State, Zip) (City, State, Zip) Phone: Phone: Person making request: Describe the records to be disclosed: Health Records Psychological and Counseling Records Special Education Records Transcripts Communication/exchange of information between an agency and school Educational Records Other ‐ Specify ______
Release Requiring Specific Consent: Specific consent is required for release of the following information. Minor signature is also required at the ages specified below. Mental health records are protected under RCW 71.05.370; Drug and alcohol abuse and treatment record are protected under 42 C.F.R § 2; Information related to HIV/AIDS or sexually transmitted diseases is protected under RCW 70.24.105. I specifically authorize the release of records relating to: Reproductive Care (age 14 and older) Mental Health/Illness (age 13 and older) Drug / Alcohol Abuse Sexually Transmitted Diseases or HIV/AIDS (age 14 and older) The reason for disclosing the record(s) is: An Evaluation or Reevaluation Process A Program Review An IEP is being developed Support Therapeutic Goals Other ‐ Specify: I understand and acknowledge the following: Released information will be treated in a confidential manner by the school district under the provisions of the Family Education Rights and Privacy Act (FERPA). FERPA prohibits disclosure of personally identifiable information without consent except in limited circumstances. If the request is for health or medical information, the medical information received by the district is protected under FERPA privacy standards by a school district and not the Health Insurance Portability and Accountability Act (HIPAA). The information released in response to this authorization may be re‐disclosed to other parties. I do not need to sign this form to assure treatment or payment. My treatment, payment, enrollment in any health plan, or eligibility for benefits is not conditions on signing this authorization form. My consent for the release of records is voluntary and I can withdraw my consent at any time, except to the extent that information has already been released in reliance upon this authorization. Revocation must be in writing. This authorization is valid from to NOTE: For release of medical records, the authorization can be no longer than 90 days after this authorization is signed.
Parent / Guardian Signature Date
Student Signature Date
1/2017 VACCINES REQUIRED FOR SCHOOL ATTENDANCE, GRADES K-12 July 1, 2017 – June 30, 2018
VACCINE Kindergarten - 6th Grade 7th - 10th Grade 11th - 12th Grade
3 doses Dose 3 must be given on or after 4 Hepatitis B Dose 3 must be given on or after 24 weeks of age months of age
5 doses (4 doses only IF 4th dose given on or after 4th birthday)
Diphtheria, Tetanus, and Plus Pertussis (DTaP/DT/Td/Tdap) th th 1 dose Tdap required for 6 -12 grade AND on or after 11 years of age (see page 2 for more details)
4 doses (3 doses only IF 3rd dose given on or after 4th birthday) Polio (IPV or OPV) The final dose given on or after August 7, 2009, 4 doses (3 doses only IF 3rd dose given on or after 4th birthday) must be given on or after 4 years of age AND a minimum interval of 6 months from the previous dose.
Measles, Mumps, and 2 doses Rubella
2 doses
Varicella OR
Healthcare provider verified disease
Look at the Minimum Age and Interval Table on page 2 for recommended minimum age and spacing information. Review the Individual Vaccine Requirements Summary for more detailed information: www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/VaccineRequirements.aspx
Page 1 of 2 Minimum Age & Interval for Valid Vaccine Doses
Minimum Interval Vaccine Dose # Minimum Age Notes Between Doses 4 weeks between Dose 1 & 2 Dose 1 Birth (K-12th) 8 weeks between Dose 2 & 3 Dose 2 4 weeks Hepatitis B (K-12th) . 2 doses valid if adult Recombivax HB® given between ages 11 and 15 and doses separated by HepB 16 weeks between Dose 1 & 3 at least 4 months. 24 weeks (K-10th) Dose 3 4 months 12 weeks between Dose 1 & 3 (11th-12th) Dose 1 6 weeks 4 weeks between Dose 1 & 2 . DTaP: for children through age 6. Dose 2 10 weeks 4 weeks between Dose 2 & 3 . 6 month interval is recommended between Dose 3 and Dose 4, but minimum interval of 4 Diphtheria, Tetanus, months is acceptable. and Pertussis Dose 3 14 weeks 6 months between Dose 3 & 4 . Students 7-10 years of age not fully immunized with DTaP should get one Tdap followed by DTaP/DT Dose 4 12 months 6 months between Dose 4 & 5 additional doses of Td if needed. Dose 5 4 years – . DTaP given after age 7 counts for the Tdap dose; no Tdap required at 11-12 years of age. . Tdap: for children 7 years of age or older. Tetanus, Diphtheria, 10 years . If no DTaP doses given before age 7, students must get Tdap followed by 2 doses of Td. and Pertussis Dose 1 recommended. See – . Tdap given between 7-10 years of age is valid and meets the requirement. Tdap notes for exceptions . Can be given regardless of the interval between DTaP or Td.
Tetanus and Diphtheria Dose 1 7 years 5 years . Td: for children 7 years of age or older. Td Dose 1 6 weeks 4 weeks between Dose 1 & 2 . Not required for students 18 years and older. . If 4 doses of OPV received, and all doses given before 4 years of age, one dose of IPV is Dose 2 10 weeks 4 weeks between Dose 2 & 3 Polio required at 4 years and older. IPV or OPV Dose 3 14 weeks 6 months between Dose 3 & 4 . Please see Individual Vaccine Requirements Summary for more details: www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/VaccineRequirements.a Dose 4 4 years – spx
Dose 1 12 months 4 weeks between Dose 1 & 2 . MMRV (MMR + varicella) may be used instead of separate MMR and varicella vaccines. Measles, Mumps, . Must get the same day as VAR OR at least 28 days apart. and Rubella . 4-day grace DOES apply between doses of the same live vaccine such as MMR and MMR. The 4 MMR day grace period DOES NOT apply between Dose 1 and Dose 2 of different live vaccines, such Dose 2 13 months – as between MMR and Varicella or between MMR and live flu vaccine.
3 months between Dose 1 & 2
(12 months through 12 years) Dose 1 12 months . Recommended: 3 months between varicella doses, but minimum interval of 28 days 4 weeks between Dose 1 & 2 Varicella acceptable. Minimum age of 13 months also acceptable. (chickenpox) (13 years and older) . Must get the same day as MMR OR at least 28 days apart. VAR . 4-day grace DOES apply between doses of the same live vaccine; DOES NOT apply between Dose 2 15 months – doses of different live vaccines.
If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711) DOH 348‐051 December 2016 Page 2 of 2 Parents - Are Your Kids Ready for School? Required Immunizations for School Year 2017-2018
Parent/Guardian Instructions: To see which vaccines are required for school, find your child’s grade and look only at that row going across to find the vaccines and number of doses required.
DTaP/Td/Tdap (Diphtheria, Tetanus, Polio MMR Varicella Hepatitis B Vaccine doses required (Measles, Mumps, Pertussis) (Chickenpox) Vaccine doses required may may be fewer than listed Rubella) be fewer than listed
2 doses within the correct timeframes Kindergarten – 3 doses within the 5 doses within the 4 doses within the 2 doses within the OR th 5 Grade correct timeframes correct timeframes correct timeframes correct timeframes Healthcare provider verified child had disease
2 doses within the correct 5 doses DTaP timeframes OR 3 doses within the 4 doses within the 2 doses within the th th AND Healthcare provider verified 6 – 12 Grade correct timeframes correct timeframes correct timeframes child had disease 1 dose Tdap, all within (Exceptions are allowed for the correct timeframes certain students)
Students must get vaccine doses at correct timeframes to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements. Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/
If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). DOH 348-295 December 2016
Office Use Only:
Reviewed by: Date:
Certificate of Immunization Status (CIS) th Signed Cert. of Exemption on file? Yes No For Kindergarten-12 Grade / Child Care Entry
Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.
Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex:
______
I give permission to my child’s school to share immunization information with the I certify that the information provided on this form is correct and verifiable. Immunization Information System to help the school maintain my child’s school record.
______Parent/Guardian Signature Required Date Parent/Guardian Signature Required Date
♦ Required for School and Child Care/Preschool Date Date Date Date Date Date Documentation of Disease Immunity ● Required Only for Child Care/Preschool MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY Healthcare provider use only Required Vaccines for School or Child Care Entry If the child named in this CIS has a history of
♦ DTaP / DT (Diphtheria, Tetanus, Pertussis) Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a
♦ Tdap (Tetanus, Diphtheria, Pertussis) healthcare provider
♦ Td (Tetanus, Diphtheria) I certify that the child named on this CIS has:
♦ Hepatitis B a verified history of Varicella (Chickenpox). 2-dose schedule used between ages 11-15
● Hib (Haemophilus influenzae type b) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s)
♦ IPV / OPV (Polio) for titers MUST also be attached.
♦ MMR (Measles, Mumps, Rubella) Diphtheria Mumps Other: ● PCV / PPSV (Pneumococcal) Hepatitis A Polio ______ Hepatitis B Rubella ______(Chickenpox) ♦ Varicella History of disease verified by IIS Hib Tetanus Recommended Vaccines (Not Required for School or Child Care Entry) Measles Varicella
Flu (Influenza)
Hepatitis A Licensed healthcare provider signature Date
HPV (Human Papillomavirus) (MD, DO, ND, PA, ARNP)
MCV / MPSV (Meningococcal)
MenB (Meningococcal) Printed Name
Rotavirus Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.
To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide database). 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, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: 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 Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #3 History of Varicella Disease: 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 healthcare 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 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.
Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Full Vaccine Full Vaccine Full Vaccine Full Vaccine Abbreviations Abbreviations Abbreviations Abbreviations Abbreviations Full Vaccine Name Name Name Name Name Tetanus, Meningococcal Oral Poliovirus DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 OPV Tdap Diphtheria, acellular Conjugate Vaccine Vaccine Pertussis Diphtheria, PCV / PCV7 / Pneumococcal DTaP Tetanus, acellular Hep B Hepatitis B MenB Meningococcal B VAR / VZV Varicella PCV13 Conjugate Vaccine Pertussis Meningococcal Pneumococcal Diphtheria, Haemophilus DTP Hib MPSV / MPSV4 Polysaccharide PPSV / PPV23 Polysaccharide Tetanus, Pertussis influenzae type b Vaccine Vaccine HPV (2vHPV / Human Measles, Mumps, Flu (IIV) Influenza MMR Rota (RV1 / RV5) Rotavirus 4vHPV / 9vHPV) Papillomavirus Rubella Measles, Mumps, Hepatitis B Immune Inactivated Tetanus, HBIG IPV MMRV Rubella with Td Globulin Poliovirus Vaccine Diphtheria Varicella
Reference guide for vaccine trade names in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf 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) DTaP + Hep B + Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® RotaTeq® Rotavirus (RV5) IPV 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 December 2016 FOR OFFICE USE ONLY FORUSE OFFICE SIDE A: For Religious, Personal, Certificate of Exemption Philosophical, and Medical DOH 348-106 Jan 2015 Exemptions1
PART 1: PARENT OR GUARDIAN INSTRUCTIONS PART 2: HEALTHCARE PROVIDER INSTRUCTIONS
In order for this form to be valid for religious, In order for this form to be valid, please: ______M.I. ______NAME FIRST ______NAME LAST CHILD’S personal, philosophical, or medical reasons, Step 1: Mark which disease(s) and what type of please: exemption is requested. If medical write a Step 1: Fill in your child’s information in Boxes 1-4 T for Temporary or P for Permanent. Step 2: Read the Parent/Guardian Declaration Step 2: Discuss the benefits and risks of Step 3: Provide your initials where indicated immunizations with the parent or guardian Step 4: Print your name, sign, and date in Boxes 5-6 Step 3: Read the Provider Declaration Step 5: Have a provider complete Part 2 of this Step 4: Print your name, credentials, sign, and date form in Boxes 7-8
Expiration 1. Child’s Last Name Personal/ Medical Date for Vaccine Religious ** Temporary Philosophical (T/P) Medical
Diphtheria 2. Child’s First Name and Middle Initial Hepatitis B Hib Measles 3. Birthdate (mm/dd/yyyy) 4. Gender Mumps Male ______/______/______Pertussis Female I am the parent or legal guardian of the above Pneumococcal named child. One or more required vaccines Polio are in conflict with my personal, philosophical, Rubella
or religious beliefs. Tetanus
Parent/Guardian Declaration Varicella
All I understand that:
My child may not be allowed to attend school or **A provider may grant a medical exemption only if there is a medical contraindication to a vaccine. child care during an outbreak of the disease that my child has not been fully vaccinated against. ______(initial) Provider Declaration
Exempting my child from any or all required I declare that: vaccine(s) may result in serious illness, disability, or death to my child or others. I understand the I have discussed the benefits and risks of risks and possible outcomes of my decision to immunizations with the parent/legal guardian as a condition for exempting their child. exempt my child. ______(initial) I am a qualified MD, ND, DO, ARNP or PA The information provided on this form is licensed under Title 18 RCW. complete and correct. ______(initial) The information provided on this form is complete
and correct.
5. Print Parent/Guardian Name 7. Print Provider Name and Credential (MD, ND, DO, ARNP, PA)
6. Parent/Guardian Signature and Date 8. Provider Signature and Date ____ /____ /______/____ /____
1RCW 28A.210.080-090 “Before or on the first day of every child’s attendance at any public and private school or licensed child care center in Washington State, the parent or guardian must present proof of either: (1) full immunization, (2) the initiation of and compliance with a schedule of immunization, as required by rules of the State Board of Health, or (3) a certificate of exemption signed by a parent or guardian and is either A) signed by a licensed healthcare provider or B) ___ demonstrates membership in a church or religious body that precludes healthcare practitioners from providing medical treatment to children.”
FOR OFFICE USE ONLY FORUSE OFFICE SIDE B: For Religious Membership
Certificate of Exemption Exemption ONLY
NOTICE: Complete this side if you belong to a church or religion that objects to the use of medical treatment.1
______M.I. ______NAME FIRST ______NAME LAST CHILD’S If you have a religious objection to vaccinations, but the beliefs or teachings of your church or religion allow for your child to be treated by medical professionals such as doctors and nurses, then you must use Side A of this Certificate of Exemption.
PARENT OR GUARDIAN INSTRUCTIONS
In order for this form to be legally valid for religious membership reasons, please: Step 1: Fill in your child’s information in Boxes 1-4 Step 2: Read the Parent/Guardian Declaration and provide your initials where indicated Step 3: Provide the name of the church or religion of which you are a member, and print your name, sign, and date in Boxes 5-7
1. Child’s Last Name 2. Child’s First Name and Middle Initial
3. Birthdate (mm/dd/yyyy) 4. Gender M F ______/______/______
I am the parent or legal guardian of the above named child and I am exempting my child from all required vaccinations.
Parent/Guardian Declaration
I understand that:
My child may not be allowed to attend school or child care during an outbreak of the disease that my child has not been fully vaccinated against. ______(initial)
Exempting my child from all required vaccines may result in serious illness, disability, or death to my child or others. I understand the risks and possible outcomes of my decision to exempt my child. ______(initial)
The information provided on this form is complete and correct. ______(initial)
I affirm that I am a member of a church or religion whose teachings preclude healthcare practitioners from providing any medical treatment to my child.
5. Name of Church or Religion of Which You Are a Member 6. Print Parent/Guardian Name
7. Parent/Guardian Signature and Date _____/_____/_____
1RCW 28A.210.090 “The parent of legal guardian demonstrates membership in a religious body or a church in which the religious beliefs or teachings of the church preclude a health care practitioner from providing medical treatment to the child.” ___
If you have a disability and need this form in a different format please call 1-800-525-0127 (TDD/TTY Call 711) OPT OUT FORM
Section 9528 of the No Child Left Behind Act of 2001 requires schools to release our family’s private information to military recruiters unless we “opt out” in writing.
As a parent, I am exercising the right to “opt-out” and request that you do not turn over the name, address and telephone number of the following student to military recruiters.
As a student, I am exercising the right to “opt-out” and request that my own name, address and telephone number not be released to military recruiters.
School
Student Name
Signature of Student
Signature of Parent
Date
Federal public law 107-110, section 9528 of the ESEA, “No Child Left Behind Act” requires school districts to release student names, addresses, and phone numbers to military recruiters upon request. The law also requires the school district to notify students and parents of the right to Opt-Out from this by requesting that the district not release students information to military recruiters. This form is intended to serve as a request to withhold this information. Library Card Registration
Photo identification required for applicants 18 and older One library card per person Please print STAFF USE Barcode ______Last Name Expiration Reg Ltd (1 month) □ □ First Name *Parent/Guardian in notes field □ Staff Initials ______Middle Name/Initial
1. Have you ever had a Sno-Isle library card under a different name? Yes No If YES, what was the name?
2. Mailing address
3. City State______Zip How do you prefer to be In city limits Yes □ No □ notified? □ Email 4. Address □ Phone (If different from mailing address) □ Cell Phone □ Text City State______Zip Carrier Standard text message rates for 5. Phone ______Cell Phone your carrier plan will apply.
6. Email address______
7. Birth date: Month______Day______Year ______
8. I would like to receive information about the Sno-Isle Libraries Foundation. Yes No The Foundation is a non-profit organization dedicated to supporting the Sno-Isle Libraries mission and enhancing library services, resources and activities across 21 community libraries.
I assume financial responsibility for all materials checked out to me or my dependents from Sno-Isle Libraries. I agree to return all items by the due date and will pay full replacement cost for lost materials. I understand that if I allow another person to use my card, that I am financially responsible for any lost or damaged materials; I also understand that that person will have full access to my account records. Please report a lost or stolen card immediately.
Applicant's signature:
*Parent/Guardian Signature: (required if under age 18)
Printed Parent/Guardian Name
Internet Access and Your Library Card A library card is required in order to access the Internet and other online databases in the library. In accordance with the Children’s Internet Protection Act, the library uses a filter to block access to web sites that feature sexuality, nudity, and adult content for all users. Adults who are 17 years of age or older may receive unfiltered Internet access upon request. Computers located in or near a library’s
Children’s Area provide additional Internet filtering which also blocks access to email, chat, and potentially objectionable sites. Parents are cautioned that filters are imperfect tools, and Sno-Isle Libraries cannot guarantee that all sites will be blocked. Sno-Isle Libraries urges parents to supervise their minor children’s Internet sessions, and to discuss appropriate use of the Internet with their children.
October 2012 Date:
Snohomish High School Panther Parent Club Volunteer Information
Name Email Best phone # to reach you Home Mobile Work (circle one) 2nd best phone # to reach you Home Mobile Work (circle one) Is it ok to text you on your mobile phone? Yes No (circle one)
First and last names of SHS Students Grades
Please indicate your preference(s) for Parent Club volunteer support. Please check all that apply. Provide food/beverage for special events (homemade or purchased) Help set-up, take-down or participate in special school events like conference meals or teacher appreciation Sponsor an ink cartridge recycling collection box at work Coordinate e-scrip and other store-based passive fundraisers Volunteer at student RSVP (late August) Serve as a Parent Club Officer Other (please specify)
Financial donations are always welcome! Make checks payable to “Panther Parent Club.” Your donation may be tax deductible; ask your accountant to be sure. Completed forms and/or checks may be put in the Parent Club box in the Main Office or mailed to SHS Parent Club 1316 Fifth Street Snohomish, WA 98290