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Española Public Schools714 Calle Don Diego Española, NM 87532

505-753-2254 phone 505-747-3514 faxWebsite: www.k12espanola.org

2016/2017RETURNING STUDENT

REGISTRATION

Legal Student Name (As it appears on birth certificate)

First Name Middle Initial Last Name

Date of Birth:

Grade:

Age:

Welcome to the Española Public Schools where our mission is to provide and continuously improve a quality education for all students in a safe environment by implementing an educational program that insures students are prepared to meet educational and life-long challenges.

Attached are the required forms and list of required documentation. Please complete all forms and return to your child’s school. We look forward to registering and educating your child.

Required Forms Student Information Form

(VERIFIED IN SIS/PAW) Medical Authorization, Consent & History Form

Release Form Bus Transportation Information Form and Bus Contract

Code of Conduct School Meal Application (EVHS STUDENTS ONLY)

Student Computer Use and Internet Access Form

Title 1 School Compacts (individual per school site)

Special Education / 504 / SAT Disclosure My Child Currently has an IEP Qualifying Condition: My Child Currently has a 504 Plan Qualifying Condition: My Child Currently has a SAT Plan Area(s) of Concern: I believe that my child may have a disability or qualifying condition that qualifies my child for IEP, 504, or SAT accommodations,

and I request a review of his/her case. Suspected Disability:

Area(s) of Concern:

Special Programing Considerations My child is a migrant student. A migratory child is a child who is, or whose parent, spouse, or guardian is, a migratory agricultural worker or

migratory fisher, and who, in the preceding 36 months, has moved from one school district to another, to obtain or accompany such parent, spouse, or guardian, in order to obtain temporary or seasonal employment in agricultural or fishing work as a principal means of livelihood. Please consider my child for Migrant Education Program Services (Title I, Part C).

My child is homeless. The McKinney-Vento Act defines homeless children as "individuals who lack a fixed, regular, and adequate nighttime residence." This may include: Children and youth sharing housing due to loss of housing, economic hardship or a similar reason; Children and youth living in motels, hotels, trailer parks, or camp grounds due to lack of alternative accommodations; Children and youth living in emergency or transitional shelters; Children and youth abandoned in hospitals; Children and youth awaiting foster care placement; Children and youth whose primary nighttime residence is not ordinarily used as a regular sleeping accommodation (e.g. park benches, etc); Children and youth living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations; and Migratory children and youth living in any of the above situations. Please consider my child for assistance and services offered via the McKinney-Vento Homeless Education Assistance Act

Parent/Guardian Signature Date:

http://www.k12espanola.org/

Española Public Schools Returning Student Registration 2016/2017

STUDENT INFORMATION FORM



Date of Birth:

Grade:

Age:

Homeroom Teacher Room # Student ID Number Special Programs/Needs:

Ethnicity /étnico:AsianAfrican AmericanCaucasian (check if Hispanic / Latino)

Native American /Alaskan Native Tribe Affiliation

CIB#

TransportationWill the student be picked up daily? ¿Normalmente recogió? Yes / NoWill the student ride the school bus? ¿Va montar el bus? Yes / No

Physical Address for Bus Service: Bus Number:

(Note: bus service is provided in school zone only. Out of zone students will not be provided bus service)

Last School Attended

School Address:

Phone: Fax:

Dates Attended: Grade(s) Attended:

Mother’s (Guardian 1) Contact Information Father’s (Guardian 2) Contact InformationName/nombre:

Name/nombre:

Cell Phone/Celular:

Home Phone/Casa:

Work/Msg / Trabajo:

Cell Phone/Celular:

Home Phone/Casa:

Work/Msg / Trabajo:

Mailing Address/Dirección postal:


Physical Address/Dirección física:


EMAIL Address/Dirección de ‘email’:


In addition to parents, who is authorized to pick up your child? Please provide a complete list with contact information. ¿Además de los padres, quien está autorizado para recoger a su hijo? Proporcione un lista complete con información de contacto. Name/Nombre:

Relationship to child/ Relación:

Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Completed by/Completado por: ____________________________________________ Date/Fecha:


RELEASE FORM



Date of Birth:

Grade:

Age:

In order to comply with FERPA (Family Educational Rights and Privacy Act) and the No Child Left Behind Act of 2001, it will be necessary to obtain parental permission in order to publish or release your child’s name and/or address.

Photo Release (Check One)

I give my permission for my child to be interviewed, photographed, or videotaped by media representatives.

I DO NOT give my permission for my child to be interviewed, photographed, or videotaped by media

representatives.

Student Art Work Permission Slip

I give my permission for my child’s artwork to be displayed and/or published in EPS publications.

I DO NOT give my permission for my child’s artwork to be displayed and/or published in EPS

publications.

School Web Sites

I give my permission to allow my child’s photo to be published on the EPS District websites.

I DO NOT give my permission to allow my child’s photo to be published on the EPS District websites. Directory

Information (Check One) HIGH SCHOOL ONLY

I want my child’s education records to be disclosed.

I DO NOT want my child’s education records to be disclosed.

Military Recruiter 11th and 12th Grade ONLY

I give my permission for my child to be contacted by a military recruiter.

I DO NOT give my permission for my child to be contacted by a military recruiter.

Signature of Parent/Guardian ______________________________________________________ Date _____

This form will remain on file in the Main Office for the current school year.

Date

Code of Conduct - Prohibited Behavior Infractions



Date of Birth:

Grade:

Age:

DIRECTIONS: Parents please review with your child and sign and return immediately. Thank you. Level 1

Behavior InfractionsLevel 2




Behavior Infractions Inappropriate display of

affection Regulated use of electronic

devices (cell phone prohibited at elementary level)

Students’ dress and personal appearance

Inappropriate language, displays, or images

Dishonesty

Refusal to cooperate with school personnel

Tobacco use Disruptive conduct Criminal damage to

property and vandalism (under $250)

Trespassing

Sexual Harassment Knowledge of alcohol,

drugs, or weapons* Instigation (of disruptive

misconduct) Disorderly Conduct False Fire Alerts Academic Dishonesty Gang Related Activity*

Larceny/Theft over $100* Criminal damage to

property and vandalism over $250*

Sexual battery (includes attempts)*

Alcohol violation* Fighting (mutual) Assault, battery, and

bullying* Possession or use of fake

weapon* Other delinquent acts (per

NM statutes as determined by law enforcement)*

Extortion/Coercion* Robbery* Battery* Possession of weapon* Arson* Drug Violation*

Behaviors marked with an * indicate behaviors for which referral to law enforcement is either (1) required by law; (2) based on the totality of the circumstances, severe enough to merit referral to law enforcement upon the first occurrence; or (3) merit referral to law enforcement if the behavior is repeated. Referral to law enforcement may result in a secondary referral by law enforcement to Juvenile Probation, the District Attorney, or Children’s Court.

Behavior Interventions & ConsequencesLevel 1

Interventions/ConsequencesLevel 2




Interventions/Consequences Student Warning Student conference Parental contact Parental Conference Student Accountability/

Behavior Contract

Referral to LEVEL 2

Referral to school support services (Counselor / SAT)

Exclusion from extra-curricular activity (must be within 2 weeks of infraction)

Restitution for damages Detention In School Suspension (ISS)

Referral to LEVEL 3

Referral to a community-based agency

Temporary Suspension (1-3 days, invokes due process)

Referral to Level 4

Referral to law enforcement Mid-term out of school

suspension (5-10 days, invokes due process)

Referral to Level 5

Referral to Law Enforcement Long-term out of school

suspension (specified time, exceeding 10 days, invokes time specific due process)

Expulsion (permanent or indefinite time exceeding 10 days, invokes time specific due process)

We have reviewed the behavior infractions and consequences.

Parent’s Signature Date Student’s Signature Date


Student Computer Use and Internet Access Release Form



Date of Birth:

Grade:

Age:

As a condition to use of the School District’s computer system, including access to and use of the Internet, I understand and agree to the following:

1. To abide by the School Board’s Policy on Acceptable Use and its Computer and Internet Code of Conduct.

2. School Site and district level administrators have the right to review any materialscreated or stored in any files I may create and to edit or remove any material which they, in their sole discretion, believe may be unlawful, obscene, abusive, or otherwise objectionable and I hereby waive any right of privacy which I may otherwise have to such material.

3. That the Espanola Public School District will not be liable for any direct or indirect, incidental or consequential damage due to information gained and/or obtained via use of the School District’s computer system including, without limitation, access to public networks.

4. That the Espanola Public School District does not warrant that the functions of the School District computer system or any of the networks accessible through the system will meet any specific requirements you may have, or that the School District computer system will be error-free or uninterrupted.

5. That the Espanola Public School District shall not be liable for any direct or indirect,incidental, or consequential damages (including lost data or information) sustained or incurred in connection with the use, operation, or inability to use the School District computer system.

6. That the use of the School District computer system, including use to access publiccomputer networks, is a privilege which may be revoked by School District administrators at any time for violation of the district's Acceptable Use Procedures and Code of Conduct. School District administrators will be the sole arbiter(s) of what constitutes a violation of the policy or Code of Conduct.

7. In consideration for the privilege of using the School District computer system and in consideration for having access to the public networks, I hereby release Espanola Public School District, the School Board, its members, administrators and employees, including its computer operators, and any institutions with which they are affiliated from any and all claims and damages of any nature arising from my use, or inability to use, the School District computer system.

I hereby certify that we have reviewed the policy and my child will abide by the conditions set forth in this document, the School District's Acceptable Use Procedures and Computer and Internet Code of Conduct.

Parent’s Signature Date Student’s Signature Date

A copy of this signed form shall be maintained in the Students file.


Bilingual Education Program Parent Notification



Date of Birth:

Grade:

Age:

To the Parents or Guardians EPS Students:

The State of New Mexico provides financial support so that the students can receive bilingual education in the public school. The Espanola Public Schools applies and receives these funds in order to include bilingual education in their curriculum. The students receive instruction in English, Spanish, or Tewa.

As part of our regular program of instruction, you son/daughter m a y participate in a bilingual program, which gives them the opportunity to learn and develop the English language fluently and also maintain, develop and enrich their native language, which may be Spanish or Tewa.

You are cordially invited to visit the school, observe the program meet, and converse with your son/daughters teacher.

------------------------------------------------------------------------------------------------------------------------

Para los padres o tutores de estudiantes de EPS:

El Estado de Nuevo Mexico provee fondos para que los alumnos reciban una educación bilingüe en las escuelas públicas. Las escuelas Públicas de Española solicitan y reciben estos fondos estatales para proveer instrucción bilingüe en su currículo. Los alumnos reciben instrucción en Inglés, español o Tewa.

Su hijo-hija participa en el programa de educación bilingüe para darle la oportunidad de hablar y desarrollar en Ingles con fluidez, para mantener, desarrollar y enriquecer su idioma nativo, el Español o Tewa.

Ustedes están cordialmente invitados a visitar la escuela y el programa bilingüe, para que conozcan y conversen con el/la maestro(a).

Note: This form is due: Upon registration and at the beginning of each school year.

Signature of Parent/Guardian ________________________________________________ Date ___


EMERGENCY MEDICAL AUTHORIZATION FORMPURPOSE: To enable parents or guardians to AUTHORIZE emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached. Upon completion, parents must return this form to the school. The original form and any copies thereof may be used to identify the medical options of the undersigned parent.



Date of Birth:

Grade:

Age:

Mother’s (Guardian 1) Contact Information Father’s (Guardian 2) Contact InformationName/nombre:

Name/nombre:

Cell Phone/Celular:

Home Phone/Casa:

Work/Msg / Trabajo:

Cell Phone/Celular:

Home Phone/Casa:

Work/Msg / Trabajo:







ALTERNATE EMERGENCY CONTACTS (Local people to contact if parents cannot be reached)

In addition to parents, who is authorized to be an Emergency Contact and pick up your child? Please provide a complete list. ¿Además de los padres, en un emergencia quien está autorizado para recoger a su hijo? Proporcione un lista complete. Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

Name/Nombre:


Phone/Numero 1:

Phone/Numero 2:

Phone/Numero 3:

INSURANCE INFORMATION

Please check one:

Private/Personal Insurance Medicaid Uninsured

Insurance Company:

Subscriber’s Name:

ID Number:


EMERGENCY CONSENT



Date of Birth:

Grade:

Age:

In case of an emergency involving my child and I cannot be reached, I hereby give consent to transport my child to the following medical care providers and hospital, and authorize these providers and hospital to give any reasonable and customary medical and health care deemed necessary:

Doctor Phone

Dentist Phone

Nurse Practitioner/Physician Assistant: Phone

Hospital Phone

If, for any reason, the listed medical care providers or hospital cannot be reached, I authorize appropriate transport and medical care of my child to any appropriate medical care provider, hospital or medical facility. This authorization does not cover major surgery unless one other doctor/dentist concur to the need.

Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts to comply with this section. It is understood that I will be financially responsible for all emergency care.

Signature of Parent/Guardian ______________________________________________________ Date ____________________

ADMINISTRATION OF MEDICATION

I give permission for my child to take the following over-the-counter medication at school, (students may not carry medication at school), with the supervision of the nurse. Dosages will be administered in accordance with Age/weight per the dosing directions.

Acetaminophen (Tylenol) Regular Strength (325 mg) Yes No Acetaminophen (Tylenol) Extra Strength (500 mg) Yes No Ibuprofen (Motrin/Advil) Regular Strength Yes No Pepto-Bismol/Tums Yes No Midol/Pamprin Yes No Allergy Medication (Claritin, Zyrtec, Generic Brand) Yes No Cough Syrup/Cough Drops/Throat Spray Yes No Saline Eye Drops Yes No Triple Antibiotic Cream Yes No Hydrocortisone Cream Yes No

Notes:___________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Signature of Parent/Guardian ______________________________________________________ Date


MEDICAL HISTORY & INFORMATION



Date of Birth:

Grade:

Age:

Please indicate if student has had or is currently under treatment for any of the following conditions:

Give year or age when problem occurred.

Please indicate if student has had or is currently under treatment for any of the following conditions:

YES / NO Asthma. Current Inhaler? YES / NO YES / NO Diabetes. On insulin? YES / NO YES / NO Ear/Hearing Problem. Type: YES / NO Emotional Problem. Type: YES / NO Seizures Type: YES / NO High Blood Pressure YES / NO Heart Problems. Type: YES / NO Hepatitis. Type: YES / NO Seasonal Allergies. YES / NO Food Allergies. Type: Epi-Pen? YES / NO YES / NO Medication Allergies. Type: Epi-Pen? YES / NO YES / NO Reactions to medicine/injections Type: YES / NO Meningitis YES / NO Migraine Headaches YES / NO Muscular Weakness or Paralysis YES / NO Bleeding Disorders. Type: YES / NO Infectious Disease. Type: YES / NO Hospitalized or serious illness, surgery or accidents? When/For what? YES / NO Vision? Corrected Wears glasses Wears contact lenses YES / NO Long Term Medications? Name:

What/dose/time? YES / NO Immunizations Current?

Name/Number of Doctor’s Office/Clinic where last immunizations were received? __________________________________________________________________

Have you ever been informed of the need to be on antibiotic therapy prior to dental treatment? Yes No If yes, identify therapy:

Please list any additional problems/concerns/conditions not listed above.


School Bus Information FormTransportation

Department505-753-2293 – Main Line

753-3925 – Fax



Date of Birth:

Grade:

Age:

All students should have this form on file with the Transportation Department. Even if your child does not plan on riding a bus, please fill out this form and list the bus they may ride. There may be an instance that they may have to use the bus transportation and without this form on file we will not know if your child is a registered student in our district.

My child will ride the bus on a regular basis. Bus Number:

My child will ride the bus on an as needed/Emergency basis ONLY. Bus Number:

An adult is required to be at the stop to pick up Kindergarten students, or the student will be returned to their school. All other students, grades 1-6 may be dropped off at their assigned stops without an adult present. If a parent of a student in grades 1-6 does not want their child to be left at the stop without an adult present, they must below and sign the acknowledgement.

I DO NOT want my grade 1-6 student left at the bus stop without an adult present. I understand it is my responsibility to ensure an adult is present at the bus stop to release my child. I understand my child will be returned to the school building if an adult is not present to meet my child at the bus stop.

Parent/Guardian Signature & Date:

Along with filling out this form, you are being informed and giving the Espanola Public Schools, Transportation Department, permission to videotape your child on the bus. Videotaping is done automatically on each bus to help deter incidents that may occur. Videotapes are randomly viewed by District Personnel, unless an incident occurs where the videotape will be used as documentation on that incident. If parents/guardians wish to view a video, you must submit your written request to the Transportation Department within 24 hours of an occurrence; otherwise the video will be erased. You may contact the Transportation Office at 505-753-2293 should you have any questions.

Mother’s / Guardian 1 Contact Information Father’s /Guardian 2 Contact InformationName/nombre:

Name/nombre:

Cell Phone/Celular:

Home Phone/Casa:

Work/Msg / Trabajo:

Cell Phone/Celular:

Home Phone/Casa:

Work/Msg / Trabajo:



Bus Stop / Physical Address/Dirección física:

Parent/Guardian Signature_____________________________________________ Date


School Bus Transportation ContractTransportation

Department505-753-2293 – Main Line

753-3925 – Fax



Date of Birth:

Grade:

Age:

This contract made and entered into by and between the Espanola Public School District, the parent/guardian, and the student, properly signed, acknowledges the agreement of the Espanola Public School District to provide transportation for (student name) to and from school during the school year.

Student Conduct: It is understood by all parties that the student will abide by the following rules and regulations regarding bus transportation, privileges and responsibilities:

1. Students will adhere to the rules and regulations set forth by the bus driver. The bus driver has the same authority as the classroom teacher when students are riding the bus.

2. The use of profanity will not be allowed in the bus. 3. The bus driver is authorized to assign seats; all passengers are expected to abide by such and will be responsible

for their assigned seat. 4. Students must stay in their seats when the bus is in motion; students must not extend their hands, arms, or

bodies out of the bus at any time. 5. Students must cooperate in keeping the bus clean. Eating and drinking on the bus will only be allowed at the

discretion of the bus driver. 6. The use of tobacco, narcotics, or alcoholic beverages shall not be permitted in the bus or students under the

influence of any of the above substances. 7. Students will not be permitted to leave the bus on the way to and from school except at the regularly assigned

stops. In case of any emergency, a school issued bus pass that has been signed by a school administrator is needed.

8. The following are not permitted in the bus; animals, firearms, explosives, breakable glass items or knives. 9. Students whose presence poses a threat to other passengers on the bus will lose his/her riding privileges

immediately. 10. Students who do not obey the above rules and regulations will have their transportation privileges suspended

for a maximum of not less than three school days for the first offense. On the second offense, a parental meeting may be required before privileges are restored. During this time, the student will not be allowed to ride any other school bus to and from school.

The School Bus Driver or School Principal will notify parents/guardian in writing of violations by their child in the school bus rules.

I/We, the below have carefully read and fully understand the bus rules and regulations and will abide by these rules.

Students Signature______________________________________ Date

Parent/Guardian Signature_______________________________ Date

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