kindergarten registration · legal documentation (custody papers, divorce decree, etc.) should be...
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KINDERGARTEN REGISTRATION
2020-2021
Social Security Number ___________________________________Today’s Date___________________________________
Initial here______, if you wish to have a different number assigned.
Student’s Name______________________________________________________________________________________ First Middle (Legal) Last
Current Grade________ Sex _______ Birth date ________________Language Spoken at Home____________________
IS this student a twin (or a triplet, quadruplet, etc.)? YES NO
Student 911 Address______________________________City___________________________Zip______________________
Student Mailing Address___________________________City___________________________Zip______________________
Home Telephone _________________Mother’s Cell #_______________________Father’s Cell #_______________________
RACE/ETHNICITY (Please answer BOTH questions)
1. Is this student Hispanic or Latino? _____No, not Hispanic or Latino (choose ONE) _____Yes, Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, South or Central America, or other Spanish culture or origin, regardless of race)
2. What is the student’s race? _____ American Indian or Alaska Native – A person having origins in any of the original (Choose ONE or MORE. Peoples of North and South America, including Central America, and who maintains If more than one race applies, tribal affiliation or community attachment. Please rank in order – 1,2,3…. _____ Asian – A person having origins in any of the original peoples of the Far East, with 1 being the primary race) Southeast Asia, or the Indian subcontinent including: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. _____ Black or African American – A person having origins in any of the black racial groups of Africa. _____ Native Hawaiian or other Pacific Islander – A person having origins in an of the original peoples of Hawaii, Guam, Samoa, other Pacific Islands. _____ White – A person having origins in an of the original peoples of Europe, the Middle East, or North Africa ______Hispanic
PARENT/GUARDIAN INFORMATION Student lives with: _______________________________________________________________________________________
(Please be specific about all members living in the home – for example - mother, father, grandfather, aunt, sister, etc.) Does anyone other than this student, his/her siblings, & his/her parents live in your home or does your family live in a household with another family? Y/N If yes, please explain. _______________________________________________________________
(An example would be: the student and parents/guardians are living with grandparents in the grandparent’s home)
Number of individual families living in the household : ____________________________
Other siblings in the Huntsville School District (names/grades) ___________________________________________________
Parents/Guardians living in the home (first/last names) __________________________________________________________
In what language do you prefer to receive written communication from the school in? _________________________
In what language would you prefer to communicate with school staff when speaking? ________________________
Relationship of the guardian(s) to the student__________________________________________________________________ Workplace of Male Guardian _______________________________________________Work Phone #____________________
Workplace of Female Guardian_____________________________________________ Work Phone #____________________
Parent’s e-mail address___________________________ Parent’s e-mail address_____________________________________
HUNTSVILLE SCHOOL DISTRICT
NEW STUDENT REGISTRATION FORM
2nd Parent/Guardian Information (not living in the home, but having legal parental rights to the student/school information)
Name___________________________________________________Relationship to the student_________________________
Mailing Address____________________________________________________________Home Phone#__________________
Workplace of Male Guardian ____________________________Work Phone #_________________Cell #__________________
Workplace of Female Guardian __________________________Work Phone #_________________Cell #__________________
In what language do you prefer to receive written communication from the school in? _________________________
In what language would you prefer to communicate with school staff when speaking? ________________________
Who may pick up your child? (please list)_____________________________________________________________________ _______________________________________________________________________________________________________
Who may NOT pick up your child? (please list)__________________________________________________________________
Legal documentation (custody papers, divorce decree, etc.) should be submitted if biological/non-custodial parent is listed and this parent is also named on birth certificate.
MEDICAL INFORMATION
Should we be unable to reach you by phone, we will attempt to call the ‘contact’ names listed below. Please be aware that these individuals will also be allowed to pick up your child should there be a need (illness, injury, etc). Please be sure they are listed on the above ‘may pick up list’.
Contact Person Other Than Parent (Required) _________________________________Daytime Phone___________________
Daytime Phone___________________ 2nd Contact Person Other Than Parent________________________________________
Name of Family Physician/Pediatrician______________________
Preferred Hospital (in case of emergency) __________________
The school has my permission to treat my child or seek medical treatment for my child if unable to obtain parent/guardian permission.
_______________________________________________________________ (Signature required if permission is given)
TRAVEL INFORMATION
What will student do upon daily dismissal? Select one: Walk Ride Bus #_____ Parent or Other Adult Will Pick Up
Detailed directions to student’s home (even if your child will not ride a bus): __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
DEMOGRAPHIC INFORMATION
Does student live within 2 miles of the school? Select one: Yes No
Resident County________________________________ Distance you live from school (miles) _______________________________
City of Birth_______________________________ State of Birth ____________________Birth Certificate Number_______________
Is this child a dependent of an active or reserve member of a branch of the United States Armed Services? YES NO (select one) If this child resides in a household with an active or reserve member of a branch of the United States Armed Services, please select the branch below.
Active Duty – US Marines Active Duty – US Navy Active Duty – US Air Force Active duty – US Army __ __ __ __
Reserves – US Navy Reserves – US Air Force Reserves – US Army Active Duty – United States Coast Guard __ __ __ __
Parents serve in multiple branches National Guard – US Air Force National Guard – US Army Reserves – US Marines __ __ __ __
PREVIOUS SCHOOL HISTORY (PRESCHOOL AND ABOVE)
Please list ALL previous schools your child has attended in the last 3 years beginning with the most recent: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has your child ever been retained? Y/N _________ If so, what grade were they retained in: ________________________________
Please list all special programs that your child has participated in (special education, speech, migrant, ESOL, GT, etc):____________
___________________________________________________________________________________________________________
Has your child ever attended Huntsville Schools? If so, when? ________________ Which campus? St. Paul Huntsville
Did this child attend a four year old preschool program (at least 20 hours per week for 9 months)? Yes_________ No__________
If you answered YES, please select the preschool program that this child attended – Program Choices are:
Arkansas Better Chance (ABC program)
21st Century Community Learning Center
Early Childhood Special Education
Public School Preschool
Private Preschool
Even Start
Head Start
Other (Name of Program___________________________)
Child attended one of the above, but not for 20 or more hours per week
AFFIDAVIT OF BIRTH
Child’s Full Name (First, Middle Last) ____________________________________________________________________________
Date of Birth______________________ City and State of Birth_______________________________________________________
Biological Mother’s Full Name (present) __________________________________________________________________________
Biological Mother’s Maiden Name___________________ Mother’s Age at Time of Child’s Birth____________________________
Biological Father’s Full Name__________________________________________________________________________________
Father’s Age at Time of Child’s Birth____________________________________________________________________________
I hereby declare the above information to be true and accurate. I understand that the Arkansas Public School System may use this affidavit as legal documentation of the above child’s birth.
_________________________________________________________ _____________________________________________ Signature of Parent or Legal Guardian Date
PURSUANT TO ACT 472 OF 1995:
Has your child ever been expelled from school in any other school district? ___________ Is your child currently under an order of expulsion in their former school district?_________ If so, when may your child return to their former district?_____________
Are expulsions proceedings currently pending against your child or have you been informed that such proceedings will be initiated against your child?____________________
I hereby acknowledge that all registration information provided by me to the Huntsville School District is true and accurate.
Date:____________________________ Parent/Guardian Signature_____________________________________________________
English/October 2017
Arkansas Department of Education (ADE) Home Language Usage Survey
The Home Language Usage Survey is completed by all students initially enrolling in Arkansas schools.
Student Name: Grade: Date:
School: Student State ID #: Gender: Date of Birth:
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. a) In what language do you prefer to receive written communication
from the school? __________________________________ b) In what language would you prefer to communicate with school staff when speaking?
__________________________________
Eligibility for Language Development Support Information about the student’s language usage helps us identify students who may qualify for extended 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(s) is (are) spoken in your home? _______________________________________ 3. What language did your child learn first?
__________________________________ 4. What language does your child use most often at home?
__________________________________ 5. What language does your family speak most often at home? __________________________________ 6. What language do adults speak most often with each other at home? ____________________________________
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. This form is not used to identify students’ immigration status.
7. Where was your child born? ___________________
8. When did your child first attend a school in the United States (this
includes all US territories)? (Kindergarten – 12th grade)
_______________________ Month Day Year
Thank you for providing the information needed on the Home Language Survey. Contact your child’s school 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.arkansased.gov/divisions/learning-services/english-learners A response that includes a language other than English to questions #1-6 indicates English language proficiency screening is needed.
This work, "Arkansas Department of Education (ADE), Home Language Survey", is a derivative of "OSPI Home Language Survey" by OSPI, used under CC BY . "Arkansas Department of Education (ADE), Home Language Survey" is licensed under CC BY by the English Learners Unit of the Arkansas Department of Education.
This form must be turned in with the student registration packet!
In order to satisfy the district’s residency requirements, the student, parent, military guardian, court-appointed
legal guardian or person acting as a parent must provide one (1) or more of the following items as proof of
residency:
Property Tax Statement
Utility Bill/Agreement
Rental Agreement/Receipt
Telephone bill
Other _________________________
NOTICE: According to Arkansas law §6-18-202, any person who knowingly submits false information to
satisfy residency requirements for public school enrollment shall be subject to a fine not to exceed five hundred
($500) dollars. By signing this form, you are certifying to the Huntsville School District that the above
information provided is accurate and that you are a resident of this school district.
SIGNATURE OF PARENT, GUARDIAN, PERSON ACTING AS A PARENT
____________________
DATE
HUNTSVILLE SCHOOL DISTRICT
Residency Verification Form
This form must be turned in
with the student registration
packet!HUNTSVILLE
Green Forest Schools
AGRICULTURAL SURVEY
Title l, Part C
Your child may qualify to receive Extra Services
In the last 3 years (including summer) did
anyone in your family go to another area to work
or try to get work in an agricultural/farming job
or a food processing job? Moving from school
district into another. Yes____ No ____
If YES, where?___________________________________________
If you checked “yes”, please mark any jobs you worked
or tried to get work in:
___ Food Processing--(Chicken, Turkey, ________________
Beef, Hog, Vegetables, Fruits)
___ Chicken Houses, Chicken Catching ________________
Or Vaccinating
___ Farm Work – (Cotton, Rice, Fruits, ________________
Vegetables, Cattle, Dairy, Chicken, Hog)
___ Working at a Cotton Gin, Granary or _______________
Seed Company
___ Tree Farms –(Planting, Marking, _______________
Girdling, Cutting, Skidding)
___ Plant or Tree Nursery _______________
___ Sod Farming _______________
___ Working with Bees ______________
___ Working on a Fish Farm ______________
___ Other Farm Work______________________
Father’s Name:
Mother’s Name:
Evening Phone:
Street Name and House/Apt #
City Zip Code
Where do you work now?
Father:____________________________________________
Mother:____________________________________________
Date you move to Huntsville:
Student Name Birth Date Grade
Please list all children in the home. ↓
Daytime Phone:
Place of Birth:
Student Name Birth Date Grade
Place of Birth:
Student Name Birth Date Grade
Place of Birth:
Student Name Birth Date Grade
Place of Birth:
Name of plant or farm?
Check all that apply: Date
Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act.
List all of your children birth through age 21.
Name of Child School Age Grade Date of Birth
Parent/Guardian ________________________________________________________
Address _____________________________________________________________________
City_________________________________________________________________________
Zip Code _____________________ Phone Number: ________________________________
Is this address Temporary or Permanent?
Please choose which of the following situations the student currently lives in (you can choose more
than one):
_____ House or apartment with parent or guardian
_____ Motel, car, or campsite
_____ Shelter or other temporary housing
_____ With friends or family members (other than or in addition to parent/guardian)
_____Living in inadequate housing (no heat, no water, mold infested, etc.)
If you are living in shared housing, please check all of the following reasons that apply:
_____ Loss of housing
_____ Economic situation
_____ Temporarily waiting for house or apartment
_____ Provide care for a family member
_____ Living with boyfriend/girlfriend
_____ Loss of employment
_____ Parent/Guardian is deployed
_____ Other (Please explain)
Are you a student living apart from your parents or guardians?
Yes No
HUNTSVILLE SCHOOL DISTRICT
Student Residency Questionnaire
Housing and Educational Rights
Students without fixed, regular, and adequate nighttime residences have the following rights:
1) Immediate enrollment in the school they last attended or the local school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations;
2) Transportation to the school of origin for the regular school day;
3) Access to free meals, Title I and other educational programs, and transportation to extra-curricular activities to the same extent that it is offered to other students.
Any questions about these rights can be directed to the local McKinney-Vento liaison at 479-738-6520, or the State Coordinator at 501-683-5428.
Arkansas law provides that anyone who knowingly gives a false residential address for purposes of public
school enrollment is guilty of a violation and subject to a fine of up to $1,000 (Ark. Code Ann. § 6-18-202(f)).
By signing below, I acknowledge that I have received and understand the above rights.
___________________________________________________________________________
Signature of Parent/Guardian/Unattached Youth Date
___________________________________________________________________________
Signature of McKinney-Vento Liaison Date
Services for McKinney-Vento Identified Students
Student: ____________________________
School: _____________________________
Grade ______________________________
Please check the services needed or desired:
______________________________________________________________________ Signature of Parent/Guardian/Unattached Youth Date ______________________________________________________________________ Signature of McKinney-Vento Liaison Date
___ Free Lunch
___ Transportation to the school of origin
___ Clothing/Uniform
___ School supplies
___ Counseling
___ Medical/dental referral
___ Vision referral
___ Medicaid/DSHS services – food stamps
___ Preschool Enrollment records
___ Missing enrollment records
___ Birth certificate
___ Immunization/medical records
___ Tutoring
___ After-school programs
___ Teen Center
___ Mentoring
___ Special Education
___ Gifted/talented
___ Vocational/technical
___ Community resource
___ Prior academic records
___ LEP/Bilingual program
___ Guardianship issues
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