Durham Public Schools High School Student Enrollment Packet

Checklist of requirements

q Check DPS Street Listing for correct school assignment.

q Proof of Residency (current lease; deed; property tax record; mortgage statement or three current consecutive months of receipts). If the residence is in someone else’s name, the parent and the lease holder or home owner must present their picture ID’s, proof of residency and completed Shared Housing Affidavits. The Office of Student Assignment or ESL Department will review, nota- rize, and approve.

q Withdrawal form from previous school.

q Report card/Transcripts.

q Immunizations (may be in Power School). The parent or guardian has 30 days from the first day of the child’s attendance in school to obtain the required immunizations and additional days if need- ed upon certification of a physician. Upon termination of the 30 days or the extended period, the principal shall not permit the child to attend the school unless the child has been immunized or has obtained the necessary exemption. N.C. Gen. Stat. §§130A-155, 156, 157.

q Custody Papers (if the person registering the student is not the parent, he/she must present a copy of the appropriate court order to establish legal guardianship). A notarized statement from the parent permitting temporary custody is not acceptable. A foster parent does not have the legal authority to enroll/withdrawl a student unless he or she has a court order granting them the au- thority to make educational decisions. Students placed in foster care through any agency can only be enrolled and/or withdrawn by an authoritative representative of that agency (DSS social worker/ case manager, etc).

q Completed Ebrollment Packet.

q SS card (not required, but important for tracking student records).

q Health Assessment Form (Required for all K-12 students coming to from another state, country, and those enrolling for the first time coming from a home-school, religious or pri- vate/independent school).

Learn more about : www.dpsnc.net Facebook: DurhamPublicSchools • Twitter: @durhampublicsch page 1

Admission Information (Office Use Only) Student Data Sheet - 320 Enrollment Date ______Grade _____ Date ______Homeroom ______Student Information Legal Last Name ______Previous School Information including Pre-K & Daycare Legal First Name ______Previous School ______Middle Name ______City ______Birth Date __ / __ / ____ Gender M / F State ______Zip ______Student # ______Enrolling Grade ___ Phone (___) ____ - ____ Fax (___) ____ - _____ SS# (optional) ___ / ____ / ______Previous DPS schools? ______Home Ph (primary) (___) ____ - ____Unlisted? Y / N Home Language (Required) Student’s Country of Birth ______Proof of Age (circle one) When did student first enter a U.S. school? ______Birth Cert. Baptismal Cert. Birth Regis. Form What is student’s first language? ______Driver’s Lic Passport Other What language is spoken at home? ______Ethnicity (circle one) Not Hispanic Hispanic What language is most used by student? ______Race (circle one or more) Miscellaneous Forms: After reading & signing the cor- Amer. Indian/Alaskan Native Asian responding documents, please indicate your preference. /Afr. Amer. Native Hawaiian/Pac. Islander Release of Media Information: Y / N Address ______College Recruitment: Y / N {No Form} Apt or PO Box ______(Grades 6-12) Military Recruitment: Y / N City ______Zip ______Is Student Military Connected? Y / N (If yes, fill out form)

Parent/Guardian Information Custody ______Lives with ______Court Access ______Relationship ______Relationship ______Last name ______Last name ______First name ______First name ______Living with Student? Y / N Living with Student? Y / N Address ______Address ______Apt or PO Box ______Apt or PO Box ______City ______Zip ______City ______Zip ______Correspondence in qEnglish qSpanish Other ______Correspondence in qEnglish qSpanish Other ______Employer ______Employer ______Home Phone (___) ____ - ______Home Phone (___) ____ - ______Day Phone (___) ____ - ______Day Phone (___) ____ - ______Cell Phone (___) ____ - ______Cell Phone (___) ____ - ______Text messages Y / N Text messages Y / N Email address ______Email address ______Email addressSTUDENT DATA ______Email address ______GO TO PAGE 2 Ü page 2 Student Data Sheet - 320 - Continued

Emergency Contacts Last Name ______Last Name ______First Name ______First Name ______Relationship ______Relationship ______Home Ph (___) ____ - ______Home Ph (___) ____ - ______Work (___) ____ - ______Cell (___) ____ - ______Work (___) ____ - ______Cell (___) ____ - ______Permission to pick up? Y / N Permission to pick up? Y / N Speaks English? Y / N Speaks English? Y / N Medical Doctor’s Name ______Phone: (____) ____ - ______Dentist Name ______Phone: (____) ____ - ______Preferred Hospital ______Allergies______Life-threatening? Y / N Other Health Factors ______

Siblings currently enrolled in Durham Public Schools Last Name ______Last Name ______First Name ______First Name ______Relationship ______Grade ______Relationship ______Grade ______Gender Male / Female Gender Male / Female Last Name ______Last Name ______First Name ______First Name ______Relationship ______Grade ______Relationship ______Grade ______Gender Male / Female Gender Male / Female

Transportation Morning Afternoon Bus? Y / N Car? Y / N Bus? Y / N Car? Y / N

Parent Enrollment Declaration Is the student currently suspended or expelled from any school? Y / N Has the student been convicted of a felony? Y / N I, ______, hereby swear and affirm that the above information is true and accurate. Parent/Guardian Signature ______Date ______

ID Checked ? Y / N Date ______STUDENT DATA School Official ______page 3

Durham Public Schools Military Connection Form Is the student military connected? If you answered “yes” on the data sheet, complete the form below.

Which immediate family member? Circle all that apply. Father Mother Guardian Sibling Stepfather Stepmother Other

Branch of service: Air Force Army Coast Guard Marine Corps Navy

What is the status? Active Duty Reserves National Guard Disabled Veteran Retired Military Veteran Foreign Military Active Reserve/Guard Deceased Deceased - Killed in Action Federal Civil Service Employee

Grade: E1 E2 E3 E4 E5 E6 E7 E8 E9 01 02 03 04 05 06 07 08 09 W-1 W-2 W-3 W-4 W-5 Federal Civil Service Employee

Installation: Camp Lejeune Ft. Bragg MCAS Cherry Point Pope Army/AFMILITARY MCAS New River Seymour Johnson Air Force

Coast Guard: Elizabeth City Ft. Macon Wilmington Special Mission Training Center Other

Unit Squadron: ______page 4

Notification of Possible Media Visits / Photo Release Form Durham Public Schools uses photographs, slides, videos, or illustrations of students for many purposes related to DPS business. This form allows you to grant or deny permission to DPS to release your child’s image for display or publication. This form also allows a parent or guardian to choose whether or not their child may be identified by name on the school or district’s websites. Student names may be released unless a parent or guardian has expressly contacted the school and requested their child’s “directory information” not be shared. However, as a safeguard, the district does not directly publish student names to the Internet unless given permission by a parent or guardian.

Parents have two options for granting or denying consent: • Parents may deny permission for any display or publication of their child’s image. You should select this option if you do not want your child’s photograph to be used on the DPS or individual school websites, in DPS or school publications, or in release to external organizations (such as PTA) or the media. • Parents also may grant permission for their child’s image to be published or displayed in print, video, and/or digital media. Selecting this option means that your child’s photograph and name may appear in DPS or school publications, on the DPS or individual school websites, and may be released to external organizations (such as PTA) or the media.

Please complete this form and have your child return it to his or her school. This consent form remains valid throughout your child’s K-12 experience with the Durham County Public School System or until a new form is completed and signed by a parent / guardian or eligible student. MEDIA □ I deny permission to use my child’s image for display, publication or release to external organizations. □ I grant permission for use of my child’s image in print, video and/or digital media. I understand that my child’s image may be used or released by DPS without additional notification and that my child’s name may appear along with his or her photograph.

Student’s Name: ______

Student’s grade and school: ______

Parent/Guardian Name ______

Parent/Guardian Signature ______Phone number: ______Date: ______page 5

Military Recruiter Opt-Out Form for School Year ______

The No Child Left Behind federal law requires that names, addresses and telephone listings of secondary school students shall be released to military recruiters upon request.

Parents or guardians may opt out of this request by signing this form and returning it to your school office.

IF YOU DO NOT want your child’s directory information released to military recruiters, please complete the following:

Student’s Full Name

______

Student’s Birthdate (dd/mm/yyyy)

_____ / ______/ ______

Student’s School

______

Parent/Guardian Name

______

Parent/Guardian Signature

______

Please return this form to school if you do not want your student’s information released to military recruiters. This form must be completed each year. RECRUITER OPT-OUT RECRUITER page 6

College, Universities, or Institutions of Higher Learning Opt-Out Form

Our district receives funds from the federal government under the No Child Left Behind Act of 2001. These funds are used in a variety of ways to provide additional help to students in greatest academic need. The law also requires that districts receiving these funds must, upon request, provide to colleges, universities and institutions of higher learning, access to the names, addresses and telephone listings of secondary students.

It is important for you to know that a secondary school student or his/her parent or guardian may request that the student’s name, address, and telephone number not be released by the district without prior written parental consent. If you would like to make such a request, please complete the following and return it to your child’s school.

______

Parent or Guardian: If you DO NOT want your child’s directory information released to colleges, universities and institutes of higher learning complete this section and return the entire form to your child’s school.

Use a separate form for each child.

School Year ______

Student’s Full Name ______

Student’s Birthdate (dd/mm/yyyy) ______

Student’s School ______

Parent/Guardian Name ______

Parent/Guardian Signature ______

This form must be completed each year. COLLEGE OPT-OUT page 7

Special Education Placement or Other Formal Education Plans

Student’s Full Name ______

___Yes ___No Student has received Special Education (Exceptional Children) services in the past student has had an IEP (Individualized Education Plan) ___Yes ___No Student has been identified as Academically/Intellectually Gifted ___Yes ___No Student has a Section 504 Plan ___Yes ___No Student has a PEP (Personalized Education Plan) ___Yes ___No Student has received ESL (English as Second Language) services

If yes, complete the following information:

Student’s Birthdate (dd/mm/yyyy) _____ / ______/ ______

Address ______

Parent/Guardian Name ______

Parent/Guardian Phone Home: ______Work: ______Cell: ______

School last attended ______School address ______Contact person ______Phone ______

Student has (check all that apply): _____ IEP (Individualized Education Program—Special Education) _____ AIG Plan (Academically/Intellectually Gifted) _____ Section 504 Plan _____ PEP (Personalized Education Plan)

_____SPECIAL PLACEMENT LEP (Limited English proficiency Plan) page 8

January 2016 NORTH CAROLINA HEALTH ASSESSMENT TRANSMITTAL FORM This form and the information on this form will be maintained on file in the school attended by the student named herein and is confidential and not a public record. (Approved by North Carolina Department of Public Instruction and Department of Health and Human Services)

PARENT to COMPLETE THIS SECTION

Student Name: M F (Last) (First) (Middle) Birthdate (M/D/YYYY): School Name:

1 Other Non-White 2 White 3 Black 4 American Indian 5 Chinese Hispanic of Latino Origin: 1 Yes 2 No Race: 6 Japanese 7 Hawaiian 8 Filipino 9 Other Asian 10 Unknown Home Address: City: State: County:

Parent Information: Name of Parent, Guardian, or person standing in Telephone(s) loco parentis: Home:

Work:

Cell Phone:

Health Concerns to be shared with authorized persons (school administrators, teachers, and other school personnel who require such information to perform their assigned duties):

HEALTH CARE PROVIDER TO COMPLETE THIS SECTION Medications prescribed for student:

Student’s allergies, type, and response required:

Special diet instructions:

Health-related recommendations to enhance the student’s school performance:

Vision screening information: Passed vision screening: Yes No Concerns related to student’s vision: HEALTH ASSESSMENT HEALTH

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January 2016 Hearing screening information: Passed hearing screening: Yes No Concerns related to student’s hearing:

Recommendations, concerns, or needs related to student’s health and required school follow-up:

School follow-up needed: Yes No

Medical Provider Comments:

Please attach other applicable school health forms:

Immunization record attached: School medication authorization form attached: Diabetes care plan attached: Asthma action plan attached: Health care plans for other conditions attached:

Health Care Professional’s Certification I certify that I performed, on the student named above, a health assessment in accordance with G.S. 130A-440(b) that included a medical history and physical examination with screening for vision and hearing, and if appropriate, testing for anemia and tuberculosis. I certify that the information on this form is accurate and complete to the best of my knowledge.

Name: Title:

Signature: ______Date (m/d/yyyy):

Practice/Clinic Name: Practice/Clinic Address:

Practice/Clinic City: State: Zip: Phone: Fax:

Provider Stamp Here:

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