1. Healthcare

Chickasha Public Schools Enrollment Form
Student Information
Social Security Number: ________________________________ Grade: _________
Gender: ____M ____F
Student’s Full Legal Name: ______________________________________________________________________
(First)
Birthdate: _________________
(Month/Day/Year)
(Middle)
(Last)
Birthplace: __________________________
(City/State)
Birth Certificate: ___Y ___N
Physical Address: _______________________________________________________________________________
(Address)
(City)
Mailing Address SAME as Physical Address? ____Yes
(Zip)
(If not, please complete mailing address information)
Mailing Address:_________________________________________________________________________________
(Address)
Home Phone: (
(City)
)
Cell Phone: (
(Zip)
)
Last School Attended: ___________________________________________________________________________
(Name of School)
(City/State)
Special Education:
Is your child on an IEP? ____Yes ____No
Race: (choose all that apply)
What is the student’s race?
____American Indian or Alaskan Native
____Asian
____Black or African American
____Pacific Islander or Native Hawaiian
____White
Ethnicity: (choose only one)
Is the student Hispanic/Latino?
____No, not Hispanic/Latino
____Yes, Hispanic/Latino
Transportation
How will your child get home daily? _____Bus Rider _____Car Rider _____Walker
My child can go on school sponsored field trips: ____Yes ____No
Parent/Guardian Information
Is address the same as students? ___Yes ___No (If not, please complete address information)
Father/Guardian: ____________________________
Phone Number: (
)
Address: _____________________________________
City/St/Zip:___________________________________
Place of Employment: ________________________
Work Phone: _________________________________
Mother/Guardian: ____________________________
Phone Number: ( )__________________________
Address:_______________________________________
City/St/Zip: ____________________________________
Place of Employment: _________________________
Work Phone:___________________________________
Step Father’s Name:___________________________ Step Mother’s Name:__________________________
Phone Number: (
)
Phone Number: ( )__________________________
Place of Employment: ________________________ Place of Employment: _________________________
Work Phone: _________________________________ Work Phone:___________________________________
Please indicate with whom the student lives: ___Parents ___Single Mother ___Single Father ___Grandparents
___Mother & Step Father ___Father & Step Mother ___Foster Parents ___Other _____________________________
Emergency Contacts
In case of an emergency, we will attempt to contact parent/guardian first. In the event we cannot do this,
please provide the name of a relative or close friend that we may contact. These contacts are also able to
pick student up from school.
Name: ___________________________________________ Phone #: _______________________________ Relation:____________________
Name: ___________________________________________ Phone #: _______________________________ Relation:____________________
Name: ___________________________________________ Phone #: _______________________________ Relation:____________________
Health Information
Does the student have any major health problems or take medication on a regular basis? ____Yes ____No
If so, please explain:_______________________________________________________________________________
___________________________________________________________________________________________________
Doctor’s Name:___________________________ Phone Number:________________ Hospital:________________________
K-12 Student Accident Insurance
Although the school system assumes NO financial responsibility for medical costs of any accident occurring to a
student while participating in a sport or other school activities, a special accident insurance policy underwritten
by Nationwide Life Insurance Company is available should you wish to purchase it. If you have other insurance,
student accident insurance can help with deductibles and copays.
If you feel you have adequate insurance and do not wish to participate, please initial here:___________________
Acceptable Use & Internet Safety Policy
I have received a copy of the Acceptable Use & Internet Safety Policy. I have read the policy and agree to
abide by the rules in the policy. I understand that any violation could result in loss of networking privileges,
school disciplinary action, and/or appropriate legal action.
User/Student Signature:__________________________________________________________
Parent/Guardian Section
I have read and understand the Acceptable Use and Internet Safety Policy. I understand that Chickasha Public
Schools will take reasonable precautions to limit access to offensive material. I realize, however, that it is not
possible to completely prevent access to such material. I understand that loss of networking privileges,
disciplinary action, and/or appropriate legal action may result if this policy is violated. I accept responsibility for
providing guidance to the above student on the computer network including the Internet. I grant permission for
the above student to access Chickasha Public Schools computer network including the Internet. I hereby
release Chickasha Public Schools from liability in the event that my child acquires offensive material through use
of the computer network including the Internet.
Parent/Guardian Signature:__________________________________________________
Permission for Photo & Videoing Students
During the course of the school year, there are newspaper articles, school website articles and videos,
celebrations, and other promotions that include students’ pictures. Do you, the parent/guardian, give
permission for your child to have his/her pictures published in the newspaper, school website, or other
publications used by the school?
Please check one:
_____Yes, I agree that my child may have their picture published in a newspaper, website, video or other
publications used by the school
_____No, I do not want my child’s picture published
Parental Refusal of Authorization to Release Student Directory Information
The Chickasha Public School District has a policy designated to assure parents and students the
full implementation, protection and enjoyment of their rights under the Family Educational Rights
and Privacy Act of 1974. A copy of the school district’s policy is available for review in the office
of the principal of all of our schools. You have the right to refuse the designation of any or all of
the categories of personally identifiable information as directory information with respect to your
student provided that you notify the school district in writing. If you have no objection to the use
of student information, you do not need to take any action.
If you direct Chickasha Public Schools to withhold student directory information for the 2014-2015
school year, please check the items you would like withheld:
____Student’s name, address, phone number
____Names of the student’s parents
____Student’s major field of study & class designation
____Student’s date & place of birth
____Student’s extracurricular participation
____Student’s photograph
____Student’s achievement awards or honors
____Student’s dates of attendance
____Student’s electronic email address
____Student’s weight & height if a member of an athletic team
____Most recent education institution the student attended prior to enrolling in this school district
Other
Your child may be eligible for additional educational services through Title X, Part C McKinneyVento Assistance Act. Eligibility can be determined by completing the following questions.
Where are you and your family currently living? (Please check one)
____Rent/Own my own home or apartment
____Temporarily with another family member or friend until we can locate affordable housing
____In an emergency or transitional shelter
____In a vehicle, park, campground, or on the streets
____In a house, building, or trailer WITHOUT running water or electricity
____In a hotel or motel
____With an adult that is not a parent or legal guardian
____Alone or in different locations, without an adult serving as a caregiver
____Wherever I can find a place to stay at night
____Other, Please explain:___________________________________________________
Please list all children in the household:
Name
Birthdate
School
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I, the undersigned, do hereby authorize officials of the Chickasha Public Schools to contact the persons named on the
enrollment information and do authorize physicians to render such treatment as may be deemed necessary in an
emergency, for the health of the above named child. In the event that persons named on this form or parents cannot
be contracted, the school officials are hereby authorized to take whatever action is deemed necessary in their
judgment, for the health of said child. I will not hold the school district financially responsible for the emergency care
and/or transportation for said child.
_____________________________________________________________________________________
Legal Parent/Guardian Signature
Date
*************************************************************************************
For office use only: ____Birth Certificate ____Shot Record ____SS Card ____Proof of residency ____Release of records
request ____Transfer student (from:____________________) ____CDIB ____Homeless
Entry Date:________________________
Janet Barresi
State Superintendent of Public Instruction
Oklahoma State Department of Education
20___ - 20___ HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS
Name of Student:
Last Name
First Name
Student ID #:
Gender:
Middle Name
Male
Female
School Site:
Grade:
Date of Birth:
Place of Birth (City/State/Country):
Is the student of Hispanic or Latino culture or origin?
Select one or more of the following races:
Yes
No
African American/Black
American Indian/Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
White
Parent’s/Guardian’s Name:
Parent’s/Guardian’s Address:
Street
Parent’s/Guardian’s Telephone Number:
(
City
)
Cell Phone:
1. Is a language other than English used in your home?
If NO, go to numbers 6 and 7.
2. Is that language spoken in the home
Zip Code
Yes
No
If YES, what is that language?
MORE OFTEN than English?
LESS OFTEN than English?
3. What language is spoken by adults in the home?
4. What was the first (1st) language your child learned to speak?
5. What was the date (month and year) your child first enrolled in a school in the United States?
6. Parent/Guardian Signature:
7. Date:
FOR SCHOOL USE ONLY
THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION.
If a language other than English is spoken MORE OFTEN (see question #2), the student automatically qualifies as bilingual on application for accreditation.
OR
1.
2.
3.
If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation if he or she meets ONE OF THE FOLLOWING:
Scores 35% or below on norm-referenced test (NRT) on the composite reading score.
Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs).
Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs)
Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL), or the Oklahoma Pre-K Language Screening Tool.
Documentation of a test result for students who marked LESS OFTEN:
1. NRT Test Date:
Name of the NRT:
2. Reading OCCT Date:
Score on Reading OCC T:
Reading Total Composite Score:
Limited Knowledge
3. ACCESS for ELLs Test Date:
Unsatisfactory
Satisfactory
1
2
WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date:
Score on K W-APT, W-APT, or MODEL: 1
2
Oklahoma Pre-K Language Screening Tool Date:
Score on Pre-K Language Screening Tool:
Note: Have test score documentation available for regional accreditation officer review.
Score on ACCESS for ELLs:
Advanced
1
Composite Score
2
Literacy Score
Janet Barresi
State Superintendent of Public Instruction
Oklahoma State Department of Education
20___ - 20___ ENCUESTA DEL IDIOMA HABLADO EN CASA PARA LOS DISTRITOS ESCOLARES GRADOS PRE-K-12
Nombre del Estudiante:
Apellido(s)
Primer Nombre
Número de Identificación:
Sexo:
Segundo Nombre
Femenino
Masculino
Grado:
Escuela:
Fecha de Nacimiento:
Lugar de Nacimiento:
Ciudad
Es el o la estudiante de la cultura u origen Hispano o Latino?
Seleccione una o más de las siguientes razas:
Sí
Estado
País
No
Africano-Americano/Negro
Indio Americano o de Alaska
Hawai /Isleño del Pacífico
Caucásico/Blanco
Asiático
Nombres de los padres/tutores:
Domicilio de los padres/tutores:
Número y Calle
Numero de teléfono de los padres/tutores (
1.
Ciudad
)
Código postal
Cell:
¿En su hogar se habla otro idioma aparte del inglés?
Si contestó NO, vaya directamente a números 6 y 7.
Sí
No
Si contestó Sí, ¿cuál es el otro idioma?
2.
¿Hablan el otro idioma en el hogar?
3.
¿Cuál es el idioma que hablan los adultos en el hogar?
4.
¿Cuál fue el primer idioma que aprendió a hablar su niño?
5.
¿En que fecha (mes y año) fue matriculado su niño por primera vez en una escuela en los Estados Unidos?
6.
7.
¿Con MAYOR FRECUENCIA que el inglés?
¿Con MENOR FRECUENCIA que el inglés?
Firma del padre/tutor:
Fecha:
FOR SCHOOL USE ONLY/ SOLO PARA USO EN LA ESCUELA
THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION.
If a language other than English is spoken MORE OFTEN (see question #2), the student automatically qualifies as bilingual on application for accreditation.
OR
1.
2.
3.
If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation IF he or she meets ONE OF THE FOLLOWING:
Scores 35% or below on norm-referenced test (NRT) on the composite reading score.
Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs).
Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs)
Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL) or the Oklahoma Pre-K Language Screening Tool.
Documentation of a test result for students who marked LESS OFTEN:
1. NRT Test Date:
Name of the NRT:
Reading Total Composite Score:
2. Reading OCCT Date:
Score on Reading OCCT:
Limited Knowledge
Unsatisfactory
Satisfactory
3. ACCESS for ELLs Test Date:
Score on ACCESS for ELLs:
1
WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date:
Score on K W-APT, W-APT, or MODEL:
1
Pre-K Language Screening Tool Date:
Score on Pre-K Language Screening Tool:
Note: Have test score documentation available for regional accreditation officer review.
1
Composite Score
Advanced
2
2
2
Literacy Score