Douglas County School District Student Census

Registration Form Use Dropdown to Select School

Teacher/Counselor: ______________________ Track/Team: __________ AM

* * * P L E AS E

PM

First

Permit Code: ________

Middle (full)

Bus #: __________

2016-2017

P RINT***

Legal Name from Birth Certificate ___________________________________________________________ Last

Start Date: _______________

Student ID #: __________________ Grade: _______ Room: __________ Session:

School: Student Information

For Office use Only Date of Enrollment: __________________

Nickname _________________ Phone

Grade _______ Gender M F Date of Birth _____________ Cell ____________________ Residence Address ________________________________________________________________________ City ____________________________ State _____ Zip _________ Email _______________________ Notice to Parents and Students - Parents and students should be aware that if they choose not to answer the two-

part question, school districts are required to identify an ethnicity and race on behalf of the student, based on several factors, including observation, in accordance with U.S. Department of Education and Colorado Department of Education Guidelines.

Race/Ethnicity

Part A. Is this student Hispanic / Latino? (choose only one) No. NOT Hispanic Yes. Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

The above part of the question is about ethnicity, not race. No matter what you selected in Part A above, please provide an answer to Part B by marking one or more boxes below to indicate what you consider your child's race to be. Part B. Which of the following groups describe the student's race? (choose one or more) American Indian or Alaskan Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Black or African American - A person having origins in any of the black racial groups of Africa. Asian - A person having origins of any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for

example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand, and Vietnam.

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

ESL

Previous School

White - A person having origins in any of the original peoples of Europe, the Middle East or North Africa Has the student attended another Douglas County School District school? If Yes, School ____________________________________ Grade ______ Last school attended outside the Douglas County School District: School _________________________________ City ________________ Is your child presently under an expulsion order from any other school district? Is your child presently under consideration for expulsion? Is your child presently involved in the Juvenile Justice system?

Y N School Year ___________ State _____ Grade _____ Y N Y N Y N

What language did the student use when he/she first began to talk? _________________________________ What language(s) does the student speak / understand? __________________________________________ Is a language other than English regularly used by the student's parents/guardians? Y N If Yes, please specify language: __________________________________________________________ What language is primarily spoken in the home by the parent/guardian? ______________________________ Date most recently enrolled in US? ___________________ (This question is used only to determine if your child may

Special Services

be exempt from one administration of the reading/language arts State assessment and is not used for any other purpose.)

Is your child currently on an Individual Educational Plan for Special Services? Y N Has your child received any previous testing, evaluations or services in any of the following areas? Learning Disabilities Speech/Language Physical Therapy Occupational Therapy

Counseling Psychological Behavioral Difficulties Hearing/Visual Impaired

Gifted & Talented Remedial Reading (Title 1) 504 Services Other

Page 1 of 4

Parent/Guardian Signature ________________________________

READ Plan

1617 DCSD Reg Form 112415

Date __________________

Douglas County School District Household Information

Student Name: ___________________________________________________ Last First Middle School: ___________________ Grade: _______ Student ID #: ____________

Registration Form

Household Info

* * * P L E AS E

For Office use Only

Teacher/Counselor: ______________________________ Room: __________

P RINT***

2016-2017

Residence Address ________________________________________________ _______________________ City ________________________________________________

State ______

Household Telephone _________________________________________ Name ______________________________________________

Zip _________________

Unlisted?

Y

N

Relationship to Student _______________

Residence Address ___________________________ City __________________

State ___

Zip ______

Mailing Address ______________________________ City __________________

State ___

Zip ______

(if different from above)

Phones: Home _____________________ Work _____________________ Cell ____________________ Pager _________________

Email ___________________________

Parent / Guardian Info

Does Student reside with? Parent Y

N

Legal Guardian Y (Court Document)

Name ______________________________________________

Receive Mailings N

Y

N

**Step-Parent Y

N

Relationship to Student _______________

Residence Address ___________________________ City __________________

State ___

Zip ______

Mailing Address ______________________________ City __________________

State ___

Zip ______

(if different from above)

Phones: Home _____________________ Work _____________________ Cell ____________________ Pager _________________

Email ___________________________

Does Student reside with? Parent Y

N

Legal Guardian Y (Court Document)

Name ______________________________________________

Receive Mailings N

Y

N

**Step-Parent Y

N

Relationship to Student _______________

Residence Address ___________________________ City __________________

State ___

Zip ______

Mailing Address ______________________________ City __________________

State ___

Zip ______

(if different from above)

Phones: Home _____________________ Work _____________________ Cell ____________________ Pager _________________

Email ___________________________

Does Student reside with? Parent Y

N

Legal Guardian Y (Court Document)

Receive Mailings N

Y

**Step-Parent Y

N N

Note: When a student does not reside with both parents, additional information must be on file so that the school can determine who is responsible for the student. If there are applicable legal documents, such as custody papers, a copy should be provided to the school. Note: **Step-parents are not considered legal guardians unless they have legal guardianship paperwork which must be provided to the school. Other Children Under Age 18 in the Home - Names MUST be from Birth Certificate First Name

Middle Name (full)

Last Name

Date of Birth

Gender

Page 2 of 4

Parent/Guardian Signature ________________________________

Relation to Student

School Attending

County

1617 DCSD Reg Form 112415

Date __________________

Douglas County School District Emergency Information

Registration Form * * * P L E AS E

For Office use Only Student Name: ___________________________________________________ Last First Middle School: ___________________ Grade: _______ Student ID #: ____________ Teacher/Counselor: ______________________________ Room: __________

2016-2017

P RINT***

Emergency Contacts are not the Parent/Guardian and should be a Colorado Resident Please provide at least one (1) local emergency contact. Name _________________________________________

Relationship to Student ___________________

Additional Information _____________________________________________________________________ ______________________________________________________________________________________

Emergency Contact Info

Phones

Home ____________________ Work ____________________

Name _________________________________________

Cell _____________________

Relationship to Student ___________________

Additional Information _____________________________________________________________________ ______________________________________________________________________________________ Phones

Home ____________________ Work ____________________

Name _________________________________________

Cell _____________________

Relationship to Student ___________________

Additional Information _____________________________________________________________________ ______________________________________________________________________________________ Phones

Home ____________________ Work ____________________

Doctor's (full) Name ______________________________________________

Cell _____________________

Gender _______________

Doctor

Name of Practice / Group ___________________________________________________________________ Phone ________________________________

Extension _________

Address _________________________________________________________________________________________ City ________________________________

State ______________________

Page 3 of 4

Parent/Guardian Signature ________________________________

Zip Code _________________

1617 DCSD Reg Form 112415

Date __________________

Douglas County School District Health Information

Registration Form * * * P L E AS E

P RINT***

For Office use Only Student Name: ___________________________________________________ Last First Middle School: ___________________ Grade: _______ Student ID #: ____________ Teacher/Counselor: ______________________________ Room: __________

2016-2017

Is your student taking any medications at home or at school?

Y

N

List: __________________________________

If your student needs to take medication at school, the "Student Medication Request Release Agreement" or "Permission to Carry" form is available at the school office. These forms must be completed for any medication a student will need to take during school hours. They are also available at www.dcsdk12.org - search "medication form." (Contained in the Health Services web page.)

Health Info

Does your student have any known allergies? Seasonal Reaction: __________________________

Food ___________________

Reaction: __________________________

Insect Sting Reaction: ________________________

Other _____________________

Reaction: __________________________

Latex Reaction: ______________________________

Other _____________________

Reaction: __________________________

Does your student (please check applicable boxes): Wear glasses/contacts?

Have heart problems?

Hearing impaired?

Have asthma/respiratory ailments?

Have convulsions/seizures?

Have diabetes?

Had a head injury/significant bump to the head?

Have physical activity limitations?

Please explain any conditions marked above: ______________________________________________________________________ Other medical conditions the school needs to be aware of: ________________________________________________________ Please note: Health information will be shared with school personnel to provide for the health and safety of your student By signing below, you indicate your agreement with sharing this information.

Parent/Guardian Signature _______________________________

Date __________________

Tylenol Release

*** Tylenol Release for ELEMENTARY SCHOOLS ONLY *** I request and give permission to Douglas County School District Re. 1 to provide acetaminophen (Tylenol) to my student for the following health problems: headache, toothache, dysmenorrhea (cramps), musculoskeletal pain, and fever over 100F). I acknowledge that the provision of this medication by school personnel is an accommodation performed solely upon my request. In consideration of the acceptance of this request, I release and waive any and all claims which I now have or may hereafter have against Douglas County School District Re. 1 and its employees arising out of the provision or failure to provide the medication to the student or any adverse reaction by the student to the medication.

Y

N

Medicaid

Parent/Guardian Signature _______________________________

I give consent and authorize the Douglas County School District Re. 1 to release to Health Care Policy and Financing (HCPF), information related to Medicaid services delivered to my child, if/when my child is enrolled in the Medicaid program. I understand that the school district is entitled to receive partial reimbursement from Medicaid for services provided to my child, including but not limited to: audiology; counseling; nursing; occupational/physical therapy; orientation and mobility; psychological; social work; speech; and targeted case management.

Acknowledgemet

Parent/Guardian Signature _______________________________

Notice

Date __________________

Date __________________

The information contained on this Student Registration form is true and correct. In accordance with Colorado Revised Statutes Sections 22-33-104 and 22-33-107, I acknowledge my obligation to ensure that every child between the ages of 6-17 under my care and supervision shall attend school. The only exceptions shall be illness and other absences excused by the Principal. Notice to Parents and Students - All students new to the district shall be enrolled conditionally until records, including discipline

records, from the schools previously attended by the student are received by the district. In the event the student's records indicate a reason to deny admission, the student's conditional enrollment status shall be revoked. State law requires immunization records be submitted at the time of registration. THIS PAGE MUST BE SIGNED EVERY SCHOOL YEAR.

Page 4 of 4

Parent/Guardian Signature ________________________________

1617 DCSD Reg Form 112415

Date __________________

Registration Form 2016-2017 - Douglas County School District

State _____ Grade _____. Is your child presently under an expulsion order from any other school district? Y. N. Is your child presently under consideration for ...

NAN Sizes 0 Downloads 226 Views

Recommend Documents

Registration Form 2016-2017 - Douglas County School District
be exempt from one administration of the reading/language arts State assessment and is not used for any other purpose.) Douglas County ... 2016-2017. Legal Name from Birth Certificate ... including observation, in accordance with U.S. Department of E

Registration Form 2016-2017 - Douglas County School District
Asian - A person having origins of any of the original peoples of the Far East, ... Mexican, Puerto Rican, South or Central American, or other Spanish culture or.

Clark County School District - Fortinet
Dec 22, 2017 - SECURING ONE OF AMERICA'S. LARGEST SCHOOL DISTRICTS. As the fifth-largest school district in the U.S., Clark County School District (CCSD) encompasses 8,000 square miles of southern Nevada, including the greater Las Vegas area. It educ

Manatee County School District - Fortinet
Jan 22, 2018 - In 2006, to accelerate pervasive Internet use, Manatee implemented a district- wide fiber network that ... Fortinet reserves the right to change, modify, transfer, or otherwise revise this publication without notice, and the most curre

Registration Form - Ending Homelessness in Oakland County
2100 Pontiac Lake Road, Building 41 West. Waterford, Michigan 48328-0403. Mission: To support housing solutions by promoting community partnerships.

field_trip_medical.pdf - Elko County School District
... of Guardian Date. Page 2 of 2. field_trip_medical.pdf. field_trip_medical.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying field_trip_medical.pdf.

Pre-School Registration Form Updated.pdf
Retrying... Whoops! There was a problem loading this page. Retrying... Pre-School Registration Form Updated.pdf. Pre-School Registration Form Updated.pdf.

Sunflower County School District Kindergarten ...
K.6 With prompting and support, name the author and illustrator of a story and define the role of ... ideas, or pieces of information in a text. DOK 3. Rl.K.9 With ...

SAMPLE BALLOT - School Bond Election - Douglas County West ...
There was a problem loading this page. Retrying... SAMPLE BALLOT - School Bond Election - Douglas County West Community Schools.pdf. SAMPLE BALLOT - School Bond Election - Douglas County West Community Schools.pdf. Open. Extract. Open with. Sign In.

School Board Niles Township District 219, Cook County, Illinois ...
Jun 30, 2013 - Approved the Minutes of the January 14, 2013 Board of Education ... with the NICE Conference and learning how technology is embedded into a ... meeting was held and it was good to share ideas with staff and learning what.

School Board Niles Township District 219, Cook County, Illinois ...
Apr 7, 2004 - Applied Technology - West ... Assistant Superintendent for Human Resources at an annual salary of ..... There was no new business discussed.

School Board Niles Township District 219, Cook County, Illinois ...
S3 / Step 1, 188 days. 1.0. 11/1/2011. - Approved the employment of the following ... Wasserstrom, Sam. Battaglia, Irma. - Approved the minutes of the October 3, ...

School Board Niles Township District 219, Cook County, Illinois ...
Board members present at Roll Call: Sheri Doniger, Jeffrey Greenspan, Ruth Klint,. Robert Silverman, Lynda ... Dimaano, Jennifer Textbook Center Assistant – West. $7.50/Hr. .... when the cost per student exceeds $1,500. He said it may be a ...

School Board Niles Township District 219, Cook County, Illinois ...
Board members present at Roll Call: Michael ... A roll call vote was taken. ... Cyndi Cohen, Business Manager of District 73.5, stated that Districts 70, 71, 73, 73.5,.

registration form - IndiaCorpLaw
Jul 4, 2016 - REGISTRATION FORM. 2N D GNLU MOOT ON SECURITIES & INVESTMENT LA W. Page 4 of 4. A3. Team Member 3. Full Name: ...

registration form -
Hypenica. Concrete.TV. Reputable third parties. Terms and conditions* ... It may be necessary for reasons beyond the control of Hypenica to change the content.

Registration Form -
Venue: Dhanmondi Club Limited, Metro Shopping Mall (Level-6), Dhanmondi. Date: 26th October 2015. Time: 7.00 PM. Deadline Date: 22th October 2015.

Registration Form
501 A Avenue N.E., Cedar Rapids, IA 52401 • Tel.: (319) 804-8501 • Fax: (319) 364-1546. E-mail: [email protected] • www.stjohncr.org. 2017 Parish Family ...

Registration Form - IIHMR Bangalore
Registration Form – International Conference - Adwitya 2016. 1. ... If more than one person from an organisation or institution wishes to register, ... Family Name.

registration form -
Applications of Microwave Antennae 2016”. Savitribai Phule Pune University,. IEEE ComSoc Pune Chapter & IETE Pune Centre Technically Sponsored st th.

BIG HORN COUNTY SCHOOL DISTRICT-WELLNESS PLAN 2016 ...
Page 4 of 8. BIG HORN COUNTY SCHOOL DISTRICT-WELLNESS PLAN 2016 Reviewed.pdf. BIG HORN COUNTY SCHOOL DISTRICT-WELLNESS PLAN ...

School Board Niles Township District 219, Cook County, Illinois ...
Aug 14, 2006 - Donation of a 1996 green Plymouth Voyager minivan to Auto Program ... qualified for a Certificate of Achievement for Excellence in Financial ...

School Board Niles Township District 219, Cook County, Illinois ...
Mar 10, 2014 - Trades for the Niles Building Maintenance – Summer 2014 to the contractors .... Pacemaker award, for best in the country online high school ...

BIG HORN COUNTY SCHOOL DISTRICT-WELLNESS PLAN 2016 ...
*Lesson plan template. *Performance Plus program. Weekly. Page 4 of 8. BIG HORN COUNTY SCHOOL DISTRICT-WELLNESS PLAN 2016 Reviewed.pdf.