FOR OFFICE USE

School:

Start Date: Key Pad #:

WASHOUGAL SCHOOL DISTRICT STUDENT REGISTRATION FORM

STUDENT LEGAL NAME: (Last First Middle)

Preferred Name: Grade Level

BIRTHDATE (Month/Day/Year) BIRTHPLACE (City/State/Country) GENDER Male Female

PRIMARY LANGUAGE STUDENT SPEAKS AT HOME: English Spanish Russian Other:

PRIMARY HOUSEHOLD WHERE STUDENT RESIDES PARENT/GUARDIAN First Name Last Name

PRIMARY PHONE FOR NOTIFICATIONS – Used for automated call system (include area code)

Home Cell ( ) Additional phones ( ) Home Cell Work ( ) Home Cell Work

STUDENT RESIDES WITH

Both parents Father only Mother only Joint Custody Grandparent(s) Father/Stepmother Mother/Stepfather Other Family Member Legal Guardian Self Agency Foster Home Other (specify)

Email Address

First Name Last Name Additional phones ( ) Home Cell Work ( ) Home Cell Work

Email Address

PHYSICAL ADDRESS WHERE FAMILY RESIDES – Required City State Zip MAILING ADDRESS – If different from physical address City State Zip

USE THIS SECTION TO PROVIDE INFORMATION FOR STUDENTS WITH A SECOND HOUSEHOLD

SECONDARY HOUSEHOLD PARENT/GUARDIAN First Name Last Name

PRIMARY PHONE FOR NOTIFICATIONS – Used for automated call system (include area code)

Home Cell ( ) Additional phones ( ) Home Cell Work ( ) Home Cell Work

Relationship to student

Emergency Contact

Email Address

First Name Last Name Additional phones ( ) Home Cell Work ( ) Home Cell Work

Relationship to student

Emergency Contact Email Address PHYSICAL ADDRESS WHERE FAMILY RESIDES City State Zip

MAILING ADDRESS – If different from physical address City State Zip

IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? Yes No (provide copy to school) IS THERE A RESTRAINING ORDER IN EFFECT? Yes No (provide copy to school) RESTRAINING ORDER AGAINST: Father Mother Other:_____________________________ IS THERE A LEGAL RESTRICTION PREVENTING THE NON-CUSTODIAL PARENT FROM VISITING THE SCHOOL OR REMOVING THE STUDENT FROM THE SCHOOL: Yes No (provide copy to school) IS THERE A LEGAL RESTRICTION PREVENTING THE SCHOOL FROM SENDING COPIES OF REPORT CARDS TO 2nd HOUSEHOLD? Yes No (provide copy to school)

2

SCHOOL PREVIOUSLY ATTENDED

SCHOOL DISTRICT PREVIOUSLY ATTENDED PREVIOUS SCHOOL LOCATION (City & State)

DID STUDENT FORMALLY WITHDRAW: Yes No If yes, date of withdrawal:

HAS STUDENT EVER ATTENDED WASHOUGAL PUBLIC SCHOOLS? Yes No If yes, name of school attended:

If enrolling from out of state, has student ever attended Washington State Public Schools? If yes, name of school & district:

ETHNICITY AND RACE - PLEASE ANSWER BOTH QUESTIONS 1 AND 2

BOTH RESPONSES ARE PER WASHINGTON STATE AND FEDERAL REQUIREMENTS Question 1: Is your child of Hispanic or Latino origin? à (Check all that apply)

Answer: NOT HISPANIC-10

CENTRAL AMERICAN-75 CUBAN-55

DOMINICAN -60 LATIN AMERICAN-85 MEXICAN / CHICANO /

MEXICAN AMERICAN-30

PUERTO RICAN-70 SOUTH AMERICAN-80 SPANIARD-65 OTHER HISPAN./LATIN-90

Question 2: What race do you consider your child? à (Check all that apply)

Answer: AFRICAN AMER./BLACK-200

WHITE / CAUCASIAN-300

ASIAN INDIAN-505 CAMBODIAN-507 CHINESE-510 FILIPINO-520 HMONG-525 INDONESIAN-530 JAPANESE-535 KOREAN-540 LAOTIAN-545 MALAYSIAN-550 PAKISTANI-555 SINGAPOREAN-560 TAIWANESE-565 THAI-570 VIETNAMESE-575 OTHER ASIAN-599

NATIVE HAWAIIAN-605 FIJIAN-615 GUAMANIAN/CHAMORRO-620 MARIANA ISLANDER-625 MELANESIAN-630 MICRONESIAN-632 SAMOAN-635 TONGAN-640 OTHER PACIFIC ISLAND-699 ALASKAN NATIVE-405 CHEHALIS-410 COLVILLE-416 COWLITZ-416 HOH-418 JAMESTOWN-421 KALISPEL-424 LOWER ELWHA-427 LUMMI-430 MAKAH-433 MUCKLESHOOT-436

NISQUALLY-439 NOOKSACK-442 PORT GAMBLE

CLALLAM-445 PUYALLUP-448 QUILEUTE-451 QUINAULT-454 SAMISH-457 SAUK-SUIATTLE-460 SHOALWATER-463 SKOKOMISH-466 SNOQUALMIE-469 SPOKANE-472 SQUAXIN ISLAND-475 STILLAGUAMISH-478 SUQUAMISH-484 TULALIP-487 YAKAMA-490 OTHER WA INDIAN-495 OTHER AMER. IND.-499

STUDENT PROGRAMS/ADDITIONAL INFORMATION Are there any school activities in which

your student should not participate? Yes No If yes, please provide

information to school in writing on a separate sheet. Does student have a Boundary Exception? Yes No If yes, from what district: _________________________________ Has student ever been retained?

Yes No Grade? ______________

Indicate if student has ever been enrolled in the following programs: Special Education 504 Plan Title/Lap ELL Gifted/HiCap Other

Yes No If yes: Current IEP Exited Program

Yes No If yes: Current Plan Exited Program

Yes No If yes: Current Plan Exited Program Yes No If yes: Current Plan Exited Program Yes No If yes: Current Plan Exited Program Yes No Specify: ___________________________

Has student ever been suspended for a weapons violation? Yes No Date: _________________________________ Has student ever been long-term suspended or expelled? Yes No Date: _________________________________ Has student ever had a drug violation? Yes No Date: _________________________________ Has student ever had an alcohol violation? Yes No Date: _________________________________ Has student ever been adjudicated or had diversion agreements? Yes No Date: _______________________________ Does student have a probation officer or caseworker? Yes No Name: ______________________________________

3

PLEASE LIST OTHER SIBLINGS ATTENDING WASHOUGAL PUBLIC SCHOOLS Student Name School Grade

IS STUDENT BUSED TO/FROM CHILD CARE?

Before school After school Before & after school

CHILD CARE PROVIDER: Address: Phone:

DOES THE STUDENT HAVE ANY LIFE-THREATENING HEALTH CONDITIONS? If yes, please list: _____________________________________________________________________________________________________________________ (More detailed information will be requested on Student Health Inventory Form)

VERIFICATION OF ENROLLMENT: The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Washougal School District. _______________________________________________________________________ Student Name _______________________________________________________________________ __________________________

Parent/Legal Guardian/Adult Student Signature Date 1/2018

EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of an 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. Parent/Guardian Signature __________________________________________________________________ Date _________________________ *If health exemptions exist based on religious beliefs, please list those here: ______________________________________________________ ____________________________________________________________________________________________________________________ If injury, illness or other nonemergency situations occur involving your child, the District needs to be able to quickly reach families or other responsible adults. In the event you cannot be reached, please list persons you trust who are available during the day to provide care for your child (local area only please). If you wish to add more than 4 emergency contacts, please list on an additional page. 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 below. Parent/Guardian Signature __________________________________________________________________ Date _________________________ EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

                                             

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WASHOUGALSCHOOLDISTRICT

REQUESTFORSENDINGPERSONALLYIDENTIFIABLERECORDS

StudentName______________________________________________________________________Grade:____________Birthdate_________________________________NewSchoolStartDate:___________________________

CapeHorn-SkyeElementary ColumbiaRiverGorgeElementary GauseElementary9731WashougalRiverRd 35300SEEvergreenHwy110034thStWashougal,WA98671 Washougal,WA98671 Washougal,WA98671

Ph360-954-3600 Ph360-954-3900Ph360-954-3702 Fax360-954-3699Fax360-954-3999Fax360-954-3799

HathawayElementary CanyonCreekMiddleSchool 63024thSt 9731WashougalRiverRdWashougal,WA98671 Washougal,WA98671Ph360-954-3802 Ph360-954-3500Fax360-954-3899 Fax360-954-3599

JemtegaardMiddleSchool WashougalHighSchool WSDSpecialServicesDept.35300SEEvergreenHwy 120139thSt 4855EvergreenWayWashougal,WA98671 Washougal,WA98671 Washougal,WA98671Ph360-954-3406 Ph360-954-3105 Ph360-954-3020Fax360-954-3499 Fax360-954-3198 Fax360-954-3082 Pleaseforwardthefollowingpertinentrecords:____PermanentRecords ____HealthRecords ____SpecialEducation/ESL/ELL ____StateHistoryRequirement____Attendance ____Discipline ____LegalDocs(courtorders) ____Other:____504Plan ____OfficialTranscript ____BirthCertificate(copy)PREVIOUSSCHOOLATTENDED:

_________________________________________________________ ____________________________________________________________NameofSchool Parent/GuardianName–PLEASEPRINT_________________________________________________________ ___________________________________________________________AddressofSchool Parent/GuardianSignature _________________________________________________________ ___________________________________________________________City/State/ZipCode RelationshiptoStudent_________________________________________________________ DateRecordsRequested:______________________________SchoolPhone#________________________________________________________ SecondRequestSent:__________________________________SchoolFax#

AsprovidedundertheFamilyRightsandPrivacyActof1974,IunderstandthatImayobtainacopyofmychild’spersonallyidentifiablerecords.IamawarethatImaychallengethecontentoftheserecords.Ialsounderstandthattheschoolwilltreattheserecordswithconfidentiality.Finally,noonewillsendtheserecordstoanon-publicschoolagencywithoutmywrittenconsent.Parentalpermissionisnolongerrequiredwhenachildenrollsinaschoolandrecordsarerequestedbyauthorizedschoolpersonnel.[FamilyEducationalRightsandPrivacyActof1974(FERPA)20USC&232g;34CFR&99.31] FormRevised8/24/2017

                                             

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Certificate of Immunization Status (CIS) For Kindergarten-12th 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 Immunization Information System to help the school maintain my child’s school record. ______________________________________________________________ Parent/Guardian Signature Required Date

I certify that the information provided on this form is correct and verifiable.

______________________________________________________________ Parent/Guardian Signature Required Date

♦ Required for School and Child Care/Preschool Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Documentation of Disease Immunity Healthcare provider use only

If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider I certify that the child named on this CIS has: a verified history of Varicella (Chickenpox). laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. Diphtheria Mumps Other: Hepatitis A Polio __________ Hepatitis B Rubella __________ Hib Tetanus Measles Varicella

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name

● Required Only for Child Care/Preschool

Required Vaccines for School or Child Care Entry

♦ DTaP / DT (Diphtheria, Tetanus, Pertussis)

♦ Tdap (Tetanus, Diphtheria, Pertussis)

♦ Td (Tetanus, Diphtheria)

♦ Hepatitis B 2-dose schedule used between ages 11-15

● Hib (Haemophilus influenzae type b)

♦ IPV / OPV (Polio)

♦ MMR (Measles, Mumps, Rubella)

● PCV / PPSV (Pneumococcal)

♦ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV / MPSV (Meningococcal)

MenB (Meningococcal)

Rotavirus

Office Use Only:

Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

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: waiisrecords@doh.wa.gov 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 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)

Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® DTaP + Hep B + IPV RotaTeq® Rotavirus (RV5)

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

Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 Meningococcal Conjugate Vaccine OPV Oral Poliovirus

Vaccine Tdap Tetanus, Diphtheria, acellular Pertussis

DTaP Diphtheria, Tetanus, acellular Pertussis

Hep B Hepatitis B MenB Meningococcal B PCV / PCV7 / PCV13

Pneumococcal Conjugate Vaccine VAR / VZV Varicella

DTP Diphtheria, Tetanus, Pertussis Hib Haemophilus

influenzae type b MPSV / MPSV4 Meningococcal Polysaccharide Vaccine

PPSV / PPV23 Pneumococcal Polysaccharide Vaccine

Flu (IIV) Influenza HPV (2vHPV / 4vHPV / 9vHPV)

Human Papillomavirus MMR Measles, Mumps,

Rubella Rota (RV1 / RV5) Rotavirus

HBIG Hepatitis B Immune Globulin IPV Inactivated

Poliovirus Vaccine MMRV Measles, Mumps, Rubella with Varicella

Td Tetanus, Diphtheria

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

IMMUNIZATIONRECORDSREQUIRED*–FIRSTNOTICEStudentName:Toparentorguardian,Thisletterisyourfirstnotificationthatweneedacopyofyourstudent’simmunizationrecord.WashingtonStateImmunizationLaw(RCW210.080)requiresthatallstudentsbeproperlyimmunizedinordertoattendorcontinueattendingschool.AllstudentsmustalsosubmitasignedCertificateofImmunizationStatusformattimeofregistration.Pleaseturnindocumentationofimmunizationtotheschoolofficeassoonaspossible.WashougalSchoolDistrictwillexcludeyourstudent30daysafterhe/shestartsschoolwithoutdocumentationforcomplianceasstatedintheStateImmunizationLawlistedabove.Thankyouforyourhelpinthismatter.WashougalSchoolDistrict_______________________________________________________Parent/GuardiansignatureacknowledgingreceiptofthisnotificationDatereceived:__________________

*Ifyoudonothavetheserecords,pleasecontactourMcKinney-VentoLiaison,TraceyMacLachlanat360-954-3901.

2/2018

                                             

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Washougal School District Student Health History & Emergency Medical Treatment Consent Form

Information on this form is required to be filled out (updated) each school year. School Year

Rev. 5/2019 Reviewed by School Nurse_______________________________

Student Name School Grade

Teacher Birth Date Gender

HEALTH INFORMATION Yes No Explanation if “Yes” Allergies/Anaphylaxis Triggers/Allergens: ________________________________________________

Epi-Pen required at school YES NO

Asthma Triggers: _________________________________________________________ Rescue inhaler used in the past year: YES NO Date inhaler last used: _____________ Has your student ever needed to go to the emergency room for Asthma: YES NO

Diabetes My student has: Insulin Pump Insulin Pen Insulin injection

Seizure Disorder Emergency medication required at school YES NO Name of medication: ___________________________________________

Other life-threatening condition

If yes, please explain: _________________________________________________________

IMPORTANT – Any box checked above will require a meeting with the school nurse to ensure we have physician orders, medications at school, and health care plan in place prior to starting school. Per state law RCW 28A.210.320 and district policy, your student may be excluded from school without this info and medication on file.

My student has NONE of the health conditions listed above Other health care needs: ___________________________________________________________________ Wears glasses/contacts. Please specify: Glasses Contacts Hearing loss. Please specify: Right Ear Left Ear Hearing Aids MEDICATION

Does your student take any medication? YES NO Will medication be needed at school? YES NO Meds taken at: Name of medication: _______________________________ Reason for medication: _______________________________ Home School Name of medication: _______________________________ Reason for medication: _______________________________ Home School Name of medication: _______________________________ Reason for medication: _______________________________ Home School *Please note: Students requiring medication during the school day (herbal, over the counter or prescription) MUST have a written physician order and parent signature on file at school. PLEASE SEE MEDICATION AUTHORIZATION FOR FURTHER INSTRUCTIONS. CONTACT INFORMATION

Parent/Guardian/Emergency Contacts Relationship ☎Phone Call 1st: Cell: Home:

Work: Call 2nd: Cell: Home:

Work:

Call 3rd: Cell: Home:

Work:

Student’s doctor/healthcare provider: Phone: _____ _

Insurance Provider: _

The information on this form may be shared confidentially with school staff and emergency responders as needed. In the event of a medical emergency with my child, I understand every effort will be made to inform me. If emergency care is needed, I authorize qualified professionals to provide assessment, diagnosis and any necessary emergency treatment. I understand that the school district assumes no financial liability for expenses incurred due to accident, injury and/or unforeseen circumstance.

____________________________________ _____________________________________ _________________ Parent/Guardian Signature Printed Name Date

                                             

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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

Interpretation Services

Indicate your language preference so

we can provide an interpreter or

translated documents, free of

charge, when you need them.

All parents have the right to information about their child’s

education in a language they understand.

1. In what language(s) would your family prefer to communicate

with the school?

__________________________________

Eligibility for Language

Development Support

Information about the student’s

language helps us identify students

who qualify for support to develop

the language skills necessary for

success in school. Testing may be

necessary to determine if language

supports are needed.

2. What language did your child learn first?

__________________________________

3. What language does your child use the most at home?

__________________________________

4. What is the primary language used in the home, regardless of

the language spoken by your child?

__________________________________

5. Has your child received English language development support

in a previous school? Yes___ No___ Don’t Know___

Prior Education

Your responses about your child’s

birth country and previous

education:

Give us information about the

knowledge and skills your child is

bringing to school.

May enable the school district to

receive additional federal funding

to provide support to your child.

This form is not used to identify

students’ immigration status.

6. In what country was your child born? ___________________

7. Has your child ever received formal education outside of the

United States? (Kindergarten – 12th grade) ____Yes ____No

If yes: Number of months: ______________

Language of instruction: ______________

8. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________

Month Day Year

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.

(Native Language)

(Home Language)

(Language)

                                             

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WASHOUGAL SCHOOL DISTRICT

4855 Evergreen Way, Washougal, WA 98671

Student Housing Questionnaire The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. (Please see reverse side for more information) If you own/rent your own home, you do not need to complete this form. If you do not own/rent your own home, please check all that apply below. (Submit to District Homeless Liaison. Contact information can be found at the bottom of the page).

In a motel A car, park, campsite, or similar location

In a shelter Transitional Housing

Moving from place to place/couch surfing Other________________________________

In someone else’s house or apartment with another family

In a residence with inadequate facilities (no water, heat, electricity, etc.)

Name of Student: First Middle Last Name of School: Grade: Birthdate: Age: Month/Day/Year Gender: Student is unaccompanied (not living with a parent or legal guardian) Student is living with a parent or legal guardian ADDRESS OF CURRENT RESIDENCE:

PHONE NUMBER OR CONTACT NUMBER: NAME OF CONTACT: Print name of parent(s)/legal guardian(s): (Or unaccompanied youth) *Signature of parent/legal guardian: Date: (Or unaccompanied youth) *I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct.

Please return completed form to: Tracey MacLachlan 360-954-3901 Columbia River Gorge Elementary School District Liaison Phone Number Location For School Personnel Only: For data collection purposes and student information system coding

(N) Not Homeless (A) Shelters (B) Doubled-Up (C) Unsheltered (D) Hotels/Motels

McKinney-Vento Act 42 U.S.C. 11435

SEC. 725. DEFINITIONS.

For purposes of this subtitle:

(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities.

(2) The term homeless children and youths' —

(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1)); and

(B) includes —

(i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals;

(ii) children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C));

(iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and

(iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).

(6) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian.

Additional Resources Parent information and resources can be found at the following: http://center.serve.org/nche/ibt/parent_res.php http://naehcy.org/educational-resources/naehcy-publications http://www.schoolhouseconnection.org/

Washougal School District Internet Use and FERPA Annual Collection

Student Name: __________________________________School:_______________ Please complete this form and submit it to the school office only if you wish to restrict the following items for your students. Otherwise, there is no need to return it. STUDENT INTERNET ACCESS To support academic achievement and enhance curriculum, Washougal School District provides students with Internet access. The school staff provides guidance and direction to students about the appropriate use of the Internet. The school district has created filters to minimize web sites that are inappropriate under district policy. The district’s policy #2022 Instructional Technology and Electronic Resources can be found on the district website at: http://www.washougal.k12.wa.us/schoolboard/board-policy-table-of-contents.htm or you may request a hard copy from your school. Students are allowed filtered Internet access unless the parent directs otherwise. Please check the box below if you do not want your child to have Internet access at school. I do not want my child to have Internet access at school. DIRECTORY INFORMATION (FERPA) The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that school districts, with certain exceptions, obtain written consent prior to the disclosure of personally identifiable information from a child’s education records. (www.ed.gov) However, school districts may disclose appropriately designated “directory information” without written consent, unless you have advised the district to the contrary. To request withholding of information pursuant to FERPA, please complete this form and return it to your child’s school office. If this form is not completed and filed with the district, it will be assumed that the directory information listed below may be disclosed for the remainder of the current academic year. A nondisclosure form must be completed each academic year. You may revoke this nondisclosure in writing by filing consent with the school office.

DO NOT DISCLOSE TO MILITARY. (Applicable to high school students only) DO NOT DISCLOSE TO HIGHER EDUCATION. (Applicable to high school students only) DO NOT DISCLOSE FOR PUBLIC USE.

Exclude student information from being sent outside the district such as newsletters, traditional media (newspaper, TV, radio, web site). For example, if this is checked and your student makes honor roll, their name will not be printed in the newspaper listing. Also, if events are photographed at school, your child will not be included in published photographs.

DO NOT DISCLOSE FOR DISTRICT USE (which could become public). Exclude student information from within the district like yearbooks, photographs, sports information such as rosters and programs and/or articles where student’s information is identified. If you check this box, your child/children will NOT appear in the school yearbook.

DO NOT DISCLOSE TO SOCIAL MEDIA USE.

Exclude student information from being distributed via Facebook, Twitter, or other social media.

Parent Name (Please Print) __________________________________________________ Parent Signature______________________________________ Date: _______________ At the beginning of each school year, the district will provide parents and adult or emancipated minor students written notice of the district’s continued use of Policy 3232 and this procedure. The notice will include the specific or approximate dates of any student survey, analysis, or evaluation scheduled during the school year.

Washougal School District Connect FVRL Parent Opt-Out form

Complete this form and return it to your student’s school only if you do NOT want your child to have access to Connect FVRL digital resources. (Your child will automatically be enrolled in the Connect FVRL unless you opt out using this form.

Washougal Public Schools, the Fort Vancouver Regional Library and the Washougal Public Library are partnering to support your child’s ongoing education. We know that a love of books and learning is a strong foundation for student success. That is why we are working together on a program to ensure that WSD students will have access to eBooks on their school-issued device and information at their public library.

Here are some important things for parents to know:

• Connect FVRL allows students access to library e-resources and databases just like any other Fort Vancouver Regional Library cardholder.

• There are no overdue fines for Connect FVRL accounts.

________________________________________________ Student Name _____________________________ School _______ Grade ________________________________________________ Parent/Guardian Name (Please Print) By signing this form, I understand my child will not have a FVRL library account. I also understand that by signing this form, my child will not be able to participate in classroom use of public library resources unless they have a Fort Vancouver Regional Library card AND know the full card number and PIN. ___________________________________________ _______________ Parent/Guardian Signature Date

Revised 8/22/18

Washougal School District

Military Parent or Guardian Affiliation Annual Collection

Student Full Name:

School attending: Grade

Parent/Guardian(s) Name(s):

Date

Beginning in the 2016-17 school year, the state legislature passed a law requiring Washington State public schools to collect information annually on military affiliation. http://app.leg.wa.gov/billinfo/summary.aspx?bill=5163&year=2015 Please circle all that apply:

N – No parent or guardian of the above child is currently serving as a member of the active duty U.S. Armed Forces, Reserves of the U.S. Armed Forces or National Guard of Washington or other state. A – A parent or guardian of the above child is a current member of the active duty U.S. Armed Forces. R – A parent or guardian of the above child is a current member of the reserves of the U.S. Armed Forces. G – A Parent or guardian of the above child is a current member of the National Guard of Washington or other state. M – More than one parent or guardian of the above child is currently either a member of the active duty U.S. Armed Forces, Reserves of the U.S. Armed Forces, or National Guard of Washington or other state.

1/2018