HOWARD SCHOOL DISTRICT 48-3 ENROLLMENT FORM

HOWARD SCHOOL DISTRICT 48-3 ENROLLMENT FORM

Section I: Student Information

Student Name (Last)*

Answer required for "Student Name (Last)"

Student Name (First)*

Answer required for "Student Name (First)"

Student Name (Middle)*

Answer required for "Student Name (Middle)"

Student Gender*

Answer required for "Student Gender"

Male

Female

Student Birthday (MM/DD/YYYY)*

Answer required for "Student Birthday (MM/DD/YYYY)"

United States Citizen*

Answer required for "United States Citizen"

Yes

Birthplace (City, State, Country)*

Answer required for "Birthplace (City, State, Country)"

Ethnicity (Required Answer)*

Answer required for "Ethnicity (Required Answer)"

Hispanic/Latino

Not Hispanic/Latino

Race (Required Answer)*

Answer required for "Race (Required Answer)"

White

American Indian/Alaska Native

Black/African American

Asian

Native Hawaiian/Pacific Islander

Other:

Current Grade Level*

Answer required for "Current Grade Level"

Previous School Attended (Name of School, City, State)

Number Required

Special Services: Does your child currently receive Special Education Services?*

Answer required for "Special Services: Does your child currently receive Special Education Services?"

Yes

Special Services: Does your child currently have a 504 Plan?*

Answer required for "Special Services: Does your child currently have a 504 Plan?"

Yes

Has your child ever participated in the following services: Check all that apply.

Answer required for "Has your child ever participated in the following services: Check all that apply."

Title I

Speech

Occupational Therapy (OT)

Physical Therapy (PT)

Other:

General Health: Does your child have any allergies, medical conditions, dietary restrictions, vision or hearing, cardiac, diabetes, etc. Please list all:*

Answer required for "General Health: Does your child have any allergies, medical conditions, dietary restrictions, vision or hearing, cardiac, diabetes, etc. Please list all:"

Medications: Does your child take any scheduled medications? If yes, please complete the Request and Authorization for Medication/Treatment Form.

Answer required for "Medications: Does your child take any scheduled medications? If yes, please complete the Request and Authorization for Medication/Treatment Form."

Section II: Family Information/Contact Information (Primary Household)

Parent Name/Guardian 1 (Last, First, Middle)*

Answer required for "Parent Name/Guardian 1 (Last, First, Middle)"

Parent Name/Guardian 2 (Last, First, Middle)*

Answer required for "Parent Name/Guardian 2 (Last, First, Middle)"

Street Address (Street, PO BOX, City, State, Zip Code)*

Answer required for "Street Address (Street, PO BOX, City, State, Zip Code)"

Student Cell Phone (In the need of school emergency to reach your child)*

Number Required

Home Phone

Number Required

Cell Phone*

Number Required

Email Address*

Answer required for "Email Address"

Work Phone

Number Required

Place of Employment (Name of Business, City, State)

Answer required for "Place of Employment (Name of Business, City, State)"

Are there any school age siblings? Please list name and date of birth.

Answer required for "Are there any school age siblings? Please list name and date of birth."

Secondary Household (In the event of dual households). Please only complete if necessary.

Parent Name/Guardian 1 (Last, First, Middle)

Answer required for "Parent Name/Guardian 1 (Last, First, Middle)"

Parent Name/Guardian 2 (Last, First, Middle)

Answer required for "Parent Name/Guardian 2 (Last, First, Middle)"

Street Address (Street, PO BOX, City, State, Zip Code)

Answer required for "Street Address (Street, PO BOX, City, State, Zip Code)"

Home Phone

Number Required

Cell Phone

Number Required

Email Address

Answer required for "Email Address"

Work Phone

Number Required

Place of Employment (Name of Business, City, State)

Answer required for "Place of Employment (Name of Business, City, State)"

Is there a joint custody or parenting plan in effect?

Answer required for "Is there a joint custody or parenting plan in effect?"

Yes

If Yes, is there a restraining order or other court order (other than custody/visitation) in effect?

Answer required for "If Yes, is there a restraining order or other court order (other than custody/visitation) in effect?"

Yes

Section III: Emergency Contact Information

In the event of emergency when no parent or guardian is able to be contact, please list an emergency contact for your child.

Emergency Contact Name (Last Name, First Name)*

Answer required for "Emergency Contact Name (Last Name, First Name)"

Home Phone*

Number Required

Cell Phone*

Number Required

Work Phone*

Number Required

Email Address*

Answer required for "Email Address"

Place of Employment (Name of Business, City, State)*

Answer required for "Place of Employment (Name of Business, City, State)"

Section IV: Home Language Survey

A local school district may administer a home language survey to students enrolled in the district as the first screening process to identify students with limited English proficiency.

What is the language most frequently spoken at home?*

Answer required for "What is the language most frequently spoken at home?"

English

Other:

Which language did your child learn when he/she first began to talk?*

Answer required for "Which language did your child learn when he/she first began to talk?"

English

Other:

What language does your child most frequently speak at home?*

Answer required for "What language does your child most frequently speak at home?"

English

Other:

What language do you most frequently speak to your child?*

Answer required for "What language do you most frequently speak to your child?"

English

Other:

Section V: McKinney-Vento Act

The McKinney-Vento Homeless Assistance Act defines homeless children and youths in the effort to insure they receive a seamless education. If you answer yes to either question below, you will be contacted to determine eligibility for services under this act.

Is your current living arrangement a result of loss of housing or economic hardship?*

Answer required for "Is your current living arrangement a result of loss of housing or economic hardship?"

Yes

Do school aged children lack a fixed, regular and adequate nighttime residence?*

Answer required for "Do school aged children lack a fixed, regular and adequate nighttime residence?"

Yes

Section VI: Active Military Parent

Does this child have a parent currently on active duty in the military?*

Answer required for "Does this child have a parent currently on active duty in the military?"

Yes

By signing below, I verify that the above information to be true and accurate. (Parent/Guardian Signature)*

Signature Required

Please fix the highlighted areas below before submitting.

HOWARD SCHOOL DISTRICT 48-3 ENROLLMENT FORM