enrollment packet new london-spicer schools€¦ · [if yes, go to question 1a.] o. no [if no, go...

Enrollment Documents included in this packet:

____ Birth Verification in the form of a Birth Certificate or Passport ____ Enrollment Form ____ Ethnic and Racial Demographic Designation Form ____ Minnesota Language Survey ____ McKinney-Vento Questionnaire ____ Student Health Information ____ Records Request ____ Enrollment Options (If primary address is outside of the district) ____ Application for Educational Benefits ____ Parent Portal Request ____ Kindergarten Questionnaire

** Please return the completed forms to Rachel Ree in the District Office

District Office Superintendent Bill Adams

(P) 320-354-2252; Option 0

High School Principal Jamie Boelter

(P) 320-354-2252; Option 1

High School Alternative Learning Program Principal Jamie Boelter

(P) 320-354-2252; Option 2

Middle School Principal Dr. Trish Perry

(P) 320-354-2252; Option 3

Prairie Woods Elementary Principal Randall Juhl

(P) 320-354-2252; Option 4

Prairie Meadows Learning Center

Director John Vraa (P) 320-354-2252; Option 9

Community Education Director John Vraa

(P) 320-354-2252; Option 6

www.nls.k12.mn.us

Welcome to New London-Spicer Schools! Go Wildcats!

We are excited you have chosen to enroll your student into our school

district. If you have any questions regarding the attached enrollment packet or about New London-Spicer Schools, please reach out to me as I am

happy to help! Thank you for this opportunity to work with your family!

- Rachel Ree District Administrative Assistant

(P) 320-354-1402 [email protected]

Tours of the District: Megan Swanson to set up an appointment 320-354-2252 ext. 2422 [email protected] Busing/Transportation: Palmer Bus Service to coordinate busing/transportation

320-354-2414

New London-Spicer Schools Independent School District# 0345

101 4th Ave SW - New London, MN 56273

Enrollment Packet Kindergarten

New London-Spicer School District #0345 Enrollment Documents

School Year 2019-2020

Students LEGAL Name

___________________________________________________________ _____________ __________ __________ Last Name First Name Middle Name Birthdate Gender Grade Social Security Number: ______-__ _-______ Birth Verification: ___ Birth Certificate ___Passport ___ Other ( ) Students Primary Physical Address: _________________________________________________________________ Mailing Address (If different than above) __________________________________________________________ Cell Phone: _________________________________ Student lives with: _____ Mother _____Father _____Guardian ____Other (If shared time, indicate percentage) Custody agreement (if applicable, please describe): ____________________________________________________ *Please provide legal documents/Indicate percentage if shared custody________________________________________

Parent/Guardian #1 ______________________________________________________________________________ Last Name First Name Middle Name Birthdate Gender

Relationship: Physical Address: Contact Info: Notifications*: ___ Biological Mother ___ Same as Student Cell Phone:________________________ ___ Text

___ Biological Father ___ Other Physical/Mailing: Home Phone: ______________________ ___Call/Voicemail

___ Legal Guardian** _________________________________ Work Phone: _______________________ ___ E‐mail

(**Attach Documents) _________________________________ E‐mail: ____________________________

Parent/Guardian #2 ______________________________________________________________________________ Last Name First Name Middle Name Birthdate Gender





Parent/Guardian #3 _______________________________________________________________________________________ Last Name First Name Middle Name Birthdate Gender





*Notifications will be automatically set up for cell phones, home phones and e-mail; Please log on to Parent Portal to change notification preferences.

Other Members of Primary Household: **All Adults and Children**

Name: Gender: Birthdate: Relationship: ___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

Office Use Only:

Received: _________ Start Date: _________

____ Transportation ____ E-mail

____ SSID ____ HS Cohort Date ____ PW ____ MS ____HS

____ SpEd Coor. ____ Nurse ____ ( )

Emergency Contacts: (List two people who will assume temporary care and/or transportation of your child in case you cannot be reached)

Name__________________________________ Relationship _________________Phone: _____________ Name__________________________________ Relationship _________________Phone: _____________

If Applicable: Day Care Provider _______________________________ Phone: _______________ Bus#: _________

About the Student: Has the student:

Previously been Preschool Screened? ____ No ____ Yes (If yes, please list where _______________________________)

Previously Attended New London-Spicer? ____ No ____ Yes (If yes, please list last grade attended at NL-S ______________)

Previously Attended a school outside of MN? ____ No ____ Yes (If yes, please list where and when student was enrolled below)

Previously Attended a school in MN? ____ No ____ Yes (If yes, please list where and when student was enrolled below)

Name of school(s) previously attended: City & State Dates Enrolled _________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________

Reason for leaving last school: _____ Moved _____ Expulsion _____ Suspension _____ Exclusion ____Other

If Other, Please specify:______________________________________________________________________

Does the student receive Special Services: ____ No ____ Yes (Ex. Title I, Speech, ECSE, Counseling, Special Education, ESL)

If Yes, Please describe: ____________________________________________________________________________ Does the Student have an IEP? ____ No ____ Yes

Is the student a Military Connected Youth? ____No ____ Yes (If yes, please indicate relationship _________________) (Immediate family who are in the military or recently retired from the military.) Is the Student a Teen Parent? ____No ____ Yes (A teen parent is a student who has a minor child or children for which the parent has either custody or joint custody; or is pregnant.) Is the Student a Displaced Homemaker? ____No ____ Yes ( This is a parent whose youngest dependent child will become ineligible to receive assistance under Part A of Title IV of the Social Security Act, Not later than 2 years after the date on which the parent applies for assistance under this title; and is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment.) Does the student have access to the Internet at home? ____No ____ Yes

Permissions *Note: If you select NO to picture consent in the following permissions, this excludes your child from being publicly recognized for special achievements including honors and awards.

Picture in Media (Local Newspaper, School Newspaper) ____ No ____ Yes Initial _______ Picture in Yearbook (NL-S Yearbook, Lifetouch Pictures) ____ No ____ Yes Initial _______ Picture in Web Page (NL-S School Webpage & Social Media Pages) ____ No ____ Yes Initial _______ Field Trips (Course Related) ____ No ____ Yes Initial _______ Internet Use ____ No ____ Yes Initial _______ The Information I have provided in this registration document is correct. ___________________________________________________________ _________________ Parent/Guardian Signature Date

2019-20 Ethnic and Racial Demographic Designation Form Student’s First Name: Middle Name/Initial: _____ Last Name: Date of Birth: _______________ District: ___________________________ School:

Schools are required to report ethnicity and race to the state and to the U.S. Department of Education. Because of recent changes to Minnesota state law, Minnesota disaggregates each category into detailed groups to further represent our student populations. Parents or guardians are not required to answer the federal questions (in bold) for their children. If you choose not to answer the federal questions (in bold), federal law requires schools to choose for you. This is a last resort—we prefer if parents or guardians complete the form. State questions are labeled as “Optional” and schools will not fill in this information for you.

This information helps improve teaching and learning for everyone and helps us accurately identify and advocate for students currently underserved. The information this form collects is considered private information. You can review the privacy notice to learn more about the purpose of collecting this information, how it will be used and not used, and how the detailed groups were identified. The privacy notice can be found in our Frequently Asked Questions: Ethnic and Racial Designation Form.

Is the student Hispanic/Latino as defined by the federal government? The federal definition includes persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.1

[You must select “yes” or “no” to this question.]

o Yes [If yes, go to Question A.] o No [If no, go to Question 1.]

Optional Question A: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

□ Decline to indicate □ Colombian □ Ecuadorian

□ Guatemalan □ Mexican □ Puerto Rican

□ Salvadoran □ Spaniard/Spanish/

Spanish-American

□ Other Hispanic/Latino □ Unknown

Go to Question 1.

[Select “yes” to at least one of the Questions (1-6) below.]

Question 1: Does the student identify as American Indian or Alaska Native as defined by the state of Minnesota? The state of Minnesota definition includes persons having origins in any of the original peoples of North America who maintain cultural identification through tribal affiliation or community recognition. [This question is needed to calculate state aid/funding.]

o Yes [If yes, go to Question 1a.] o No [If no, go to Question 2.]

Optional Question 1a: If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff): □ Decline to indicate □ Anishinaabe/Ojibwe

□ Cherokee □ Dakota/Lakota

□ Other North American Indian Tribal Affiliation □ Unknown

Go to Question 2.

1Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274

https://education.mn.gov/MDE/fam/count/

Question 2. Is the student American Indian from South or Central America?

o Yes [Go to Question 3.] o No [Go to Question 3.]

Question 3. Is the student Asian as defined by the federal government? The federal definition includes persons having origins in 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 Philippine Islands, Thailand, and Vietnam.1


Optional Question 3a. If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

□ Decline to indicate□ Asian Indian□ Burmese

□ Chinese□ Filipino□ Hmong

□ Karen□ Korean□ Vietnamese

□ Other Asian□ Unknown

Go to Question 4.

Question 4. Is the student black or African American as defined by the federal government? The federal definition includes persons having origins in any of the black racial groups of Africa.1


Optional Question 4a. If yes was chosen above, select all that apply from the list below (this question will not be answered by school staff):

□ Decline to indicate□ African-American□ Ethiopian-Oromo

□ Ethiopian-Other□ Liberian□ Nigerian

□ Somali□ Other black□ Unknown

Go to Question 5.

Question 5. Is the student Native Hawaiian or Other Pacific Islander as defined by the federal government? The federal definition includes persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.1

o Yes [Go to Question 6.] o No [Go to Question 6.]

Question 6. Is the student white as defined by the federal government? The federal definition includes persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.1

o Yes o No

Parent(s)/Guardian Name Date __________________

Parent(s)/Guardian Signature

Minnesota Language Survey

Minnesota is home to speakers of more than 100 different languages. The ability to speak and understand multiple languages is valued. The information you provide will be used by the school district to see if your student is multilingual. In Minnesota, students who are multilingual may qualify for a Multilingual Seal upon further assessment. Additionally, the information you provide will determine if your student should take an English proficiency test. Based upon the results of the test, your student may be entitled to English language development instruction. Access to instruction is required by federal and state law. As a parent or guardian, you have the right to decline English Learner instruction at any time. Every enrolling student must be provided with the Minnesota Language Survey during enrollment. Information requested on this form is important to us to be able to serve your student. Your assistance in completing the Minnesota Language Survey is greatly appreciated.

Student Information

Student’s Full Name: (Last, First, Middle)

Birthdate AND Student ID:

Check the phrase that best describes your student:

Indicate the language(s) other than English in space provided:

1. My student first learned: ___ language(s) other than English.

___ English and language(s) other than English.

___ only English.

2. My student speaks: ___ language(s) other than English.


___ only English.

3. My student understands: ___ language(s) other than English.


___ only English.

4. My student has consistentinteraction in:

___ language(s) other than English.


___ only English.

Language use alone does not identify your student as an English learner. If a language other than English is indicated, your student will be screened for English language proficiency.

Parent/ Guardian Information

Parent/Guardian Name (printed):

Parent/Guardian Signature: Date:

* All data on this form is private. It will only be shared with district staff who need the information to best serve your student and for legally required reporting

about home language and service eligibility to the Minnesota Department of Education. At the district and at the Minnesota Department of Education, this

information will not be shared with other individuals or entities, except if they are authorized by state or federal law to access the information. Compliance with

this request for information is voluntary.

Encuesta sobre los Idiomas de Minnesota Minnesota es el hogar de hablantes de más de 100 idiomas diferentes. La capacidad de hablar y entender varios idiomas es valorada. La información que usted proporcione será utilizada por el distrito escolar para ver si su estudiante es multilingüe. En Minnesota, los estudiantes que son multilingües pueden calificar para un sello multilingüe tras una previa evaluación. Además, la información que usted provea determinará si su estudiante debe tomar una prueba de habilidad del idioma inglés. Basado en los resultados de la prueba, su estudiante puede tener derecho a instrucción de desarrollo del idioma inglés. El acceso a la instrucción es requerido por la ley federal y estatal. Como padre o tutor, usted tiene el derecho de rechazar la instrucción de clases de Aprendiz de Inglés (English Learner) en cualquier momento. Cada estudiante que se matricula debe recibir la Encuesta sobre los Idiomas de Minnesota durante la inscripción. La información solicitada en este formulario es importante para poder servir a su estudiante. Su ayuda para completar la Encuesta sobre los Idiomas de Minnesota es muy apreciada.

Información del estudiante

Nombre completo del estudiante:

(Apellido, Nombre, Segundo Nombre)

Fecha de nacimiento o identificación del estudiante:

Marque la frase que mejor describe a su estudiante:

Indique el (los) idioma (s) aparte del inglés en el espacio provisto:

1. Mi estudiante primeroaprendió:

___ idioma(s) aparte del inglés. ___ inglés e idioma(s) aparte del inglés. ___ solo inglés.

2. Mi estudiante habla: ___ idioma(s) aparte del inglés. ___ inglés e idioma(s) aparte del inglés. ___ solo inglés.

3. Mi estudiante entiende: ___ idioma(s) aparte del inglés. ___ inglés e idioma(s) aparte del inglés. ___ solo inglés.

4. Mi estudiante tiene unainteracción consistente con:

___ idioma(s) aparte del inglés. ___ inglés e idioma(s) aparte del inglés. ___ solo inglés.

El uso del lenguaje por sí solo no identifica a su estudiante como aprendiz de inglés. Si se indica un idioma que no sea el inglés, se evaluará a su hijo para determinar el dominio del idioma inglés.

Información del padre/tutor

Nombre del padre/tutor (en letra de imprenta):

Firma del padre/tutor Fecha:

* Todos los datos en este formulario son privados. Solo se compartirán con el personal del distrito que necesite dicha información para atender mejora su estudiante y para los informes requeridos legalmente sobre el idioma del hogar y elegibilidad del servicio al Departamento de Educación deMinnesota. En el distrito y en el Departamento de Educación de Minnesota, esta información no se compartirá con otras personas o entidades,excepto si están autorizadas por ley estatal o federal para acceder a la información. El cumplimiento de esta solicitud de información es voluntario.

Minnesota Language Survey Spanish

New London-Spicer School District #0345 McKinney-Vento Questionnaire

Your child may be eligible for additional educational services through Title 1 Part A, Title 1 Part C-Migrant, and or Federal McKinney-Vento Assistance. Your answers will help the administrator determine residency

documents necessary for enrollment of this student and the student’s eligibility for services.

Is your current address a temporary living arrangement? ______ Yes ______ No Is this living arrangement due to economic hardship? ______ Yes ______ No

If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here.

Presently where are the Student(s) living:

___Doubled up with relatives or friends

___In a motel/hotel

___In a shelter

___Moving from place to place

___In a place not considered traditional ‘housing’ (campground, car, public place, etc.)

The Student(s) live with: ___Parent or Parents

___Relative(s), friend(s) or other adult(s)

___Alone with no adults

___An adult that is not the parent or the legal guardian

Are you a high school student who is currently living on your own? ___ Yes ___No Legal Name of Student(s)/Child(ren): Birthdate: Age: Grade: Male/Female

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Parent/Guardian(s) Name: ______________________________________________ Phone:____________ Mailing Address, City and State: ____________________________________________________________

I certify the information given above is true and complete to the best of my knowledge. Signature of Parent/Legal Guardian: ______________________________________Date:______________

District Use Only:

Based on the above information and a brief interview/inquiry with and/or of this family, I attest to the best of my knowledge they are eligible for benefits under the McKinney-Vento Act.

________________________________________ _______________ ____________________________ Signature of District McKinney-Vento Liaison Date Start Date:

New London-Spicer School District #0345 Student Health Information

Student________________________________ Grade______ Birth Date_____________

Health information is collected to provide for student’s health and safety at school. This confidential data will be recorded in the student’s health record. It will be shared with school and emergency personnel on a “need

to know” basis. You are not legally required to supply this information, but lack of data may impact planning for your student.

1. Parent: please mark if your student has any of the following and describe:

☐ No Health Concerns (go to question 2)

Please Describe Condition/Medications and/or Treatment ☐ ADHD/ADD ________________________________________________________________________

☐ Asthma ___________________________________________________________________________

☐ Allergies __________________________________________________________________________

☐ Diabetes __________________________________________________________________________

☐ Headaches ________________________________________________________________________

☐ Hearing Impairment _________________________________________________________________

☐ Mental Health Concerns ______________________________________________________________

☐ Seizure ___________________________________________________________________________

☐ Vision Impairment ________________________________________________________________

☐ Other: ____________________________________________________________________________ __________________________________________________________________________________

2. Other Health Questions (Please answer all questions)

No Yes If yes, please describe Hospitalization/Surgery/Injury past 12 months?

Any health problems that could result in an emergency?

Does the student use an inhaler?

Does the student have an Epi-Pen?

Will your student take medication at school? Please see School Nurse for required paperwork.

Is physical activity limited in any way?

Are there any classroom accommodations needed at school?

Does the student need special nutritional consideration?

Doctor/Clinic/Signature_____________________________________ Phone:________________ Examiner’s Signature NOT required, please note Physician and Clinic for student file-

PRINTED Name of Parent/Legal Guardian: ___________________________ Phone:_____________

Signature of Parent/Legal Guardian: _________________________________ Date: _____________

New London-Spicer School District #0345 Request for Student Records

Former School Information: Date: ______________

__________________________________ School District Name and District Number

__________________________________ School Mailing Address

__________________________________ City, State and Zip

__________________________________ Phone Number and Fax Number

Please send any and all information on:

Educational GRAD/MCAIII Test Results Psychological Medical Early Childhood Screening

And other pertinent information (If applicable, MARSS Request Enclosed)

REGARDING:

_______________________________________________________________ __________ __________________

Last Name First Name Middle Name Birthdate Current Grade Level

Please forward this information to:

Grades ECSE and K-4: Helen Gronli Prairie Woods Elementary 101 4th Ave SW New London, MN 56273 [email protected] Fax: 320-354-2093

Grades 5-8 Connie Lee

New London-Spicer Middle School 101 4th Ave SW

New London, MN 56273 [email protected] Fax: 320-354-4244

Grades 9-12 & ALP Sharon Pierce

New London-Spicer High School 101 4th Ave SW

New London, MN 56273 [email protected]

Fax: 320-354-9001

It is understood that this information will be used in a confidential and professional manner in the best interest of the student. Thank you for your attention and anticipated cooperation. Students and/or parental

signatures are no longer required when authorized school personnel request records.

(Section 1232g of the Family Education Rights and Privacy Act of 1974, 20 U.S.C. 1232g.)

If you have any questions regarding this request, please contact Rachel Ree at 320-354-1402 or [email protected]

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General Statewide Enrollment Options Application for K-12 and Early Childhood Special EducationThe General Statewide Enrollment Options Application for K-12 and Early Childhood Special Education is the required application for all Minnesota school districts. Please use this application for inter-district K-12 open enrollment and inter-district enrollment in Early Childhood Special Education (ECSE). Please use the Statewide Enrollment Options Application for State-funded Voluntary Pre-Kindergarten and School Readiness Plus for voluntary pre-kindergarten or school readiness plus open enrollment.

IMPORTANT NOTE: Do not disclose other information to the non-resident district until a seat is offered in writing. At that point, the district will request information such as special needs, birth date, race, ethnicity, academic and other records.

Section 1: To be Completed by One or Both of the Student’s Parents or Guardians

Student Information

Student Last Name:

First:

Full Middle:

Will the student be at least age 5 and under age 21 by September 1 of the enrollment year or be applying for ECSE?

Yes No*

*If No, please read information in the Statewide Enrollment Options Instructions before proceeding.

Student’s current grade level (If applying for ECSE, write EC):

Grade Level Desired:

Updated 10/16/2018

1

Student Resident District Information

Resident District Name:

District Number:

City:

District of Choice Name:

District Number:

City:

Identify the reason for the request to enroll in a nonresident district:

District of Choice (non-resident school district)

Site or Program Preferences

If the non-resident school district has multiple sites/programs that serve your child’s needs, you mayrank sites/programs in order of preference (add more preferences if desired).

1.

2.

3.

Enrollment Timeline

When are you seeking to enroll your child?

Immediately

Not immediately, but sometime during the current school year

Next school year.

Special Situations

Please check all that apply. Sibling preference: student has a sibling currently open-enrolled in this non-resident district. Employee child preference: Student has parent or legal guardian who is a Minnesota resident who is

an employee of the non-resident district.

Updated 10/16/2018

2

Family move: The student’s resident district changed after December 1 prior to the school year requested, waiving deadlines.

Student is a resident of City of Edina but the resident school district for the student’s Edina home is not Edina Public Schools. Student seeks enrollment in Edina Public Schools.

Student is requesting a move into and/or a move out of a district that receives Achievement and Integration Revenue, waiving deadlines. You can check here if you do not know the answer to this:

Student is currently expelled under Minnesota Statutes, section 121A.45 for a reason listed in Minnesota Statutes, section 124D.03, Subdivision 1, which allows but does not require the non-resident district to deny the application.

Parent/Legal Guardian Information The student must live with at least one parent/guardian who lives in Minnesota.

Minnesota Parent/Guardian 1

Last Name:

First Name:

MI:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Street Address:

City:

State:

ZIP:

Parent/Guardian 2:

Last Name:

First Name:

MI:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

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3

Street Address:

City:

State:

ZIP:

Physical Signature of at Least One Parent/Guardian is Required I hereby verify that the above information is true and correct to the best of my knowledge.

Signature of parent/legal guardian 1:

Date:

Date:

Signature of parent/legal guardian 2 (optional):

Submission Information

For priority consideration, please complete this application and send it to the Superintendent’s Office in the non-resident District by January 15 before the first fall enrollment. Please do not send this application to the Minnesota Department of Education. Use one application per student per requested district.

Applications received by the non-resident district after the January 15 deadline may qualify for exceptions to deadline or, if not, districts may voluntarily agree to allow enrollment through a voluntary School District Non-resident Agreement for Inter-district Enrollment.

Section 2: To be Completed by the Non-resident District

Non-resident District: Notify parents/guardians of application approval or disapproval in writing by February 15 or no more than 90 days after receiving applications that come later through an Achievement and Integration School Choice Program If rejected, you must let families know legal reason for denial. Reminder: ECSE open enrollment applications cannot be denied solely due to lack of capacity to provide special education services. (See Minn. Stat. § 124D.03, subd. 6).

Please expedite any requests for open enrollment into Early Childhood Special Education Services.

Families must accept or decline the offer by March 1 or 45 days after notification that their application has been approved. After receiving the commitment to attend, the non-resident district must notify the resident district by March 15 (or 30 days after initial receipt if form filed after January 15) of the student’s intent to enroll. Districts must report all counts of rejected applications and reasons to the Minnesota Department of Education by July 15 or each year.

Updated 10/16/2018

4

Date Application Received:

District Name: New London- Spicer Schools

District Number: #0345

District Contact Name: Rachel Ree

Title: MARSS Coordinator/Administrative Assistant to the Superintendent

Phone: (320) 354-1402

Email Address: ____________________________________________________________

Does the January 15 deadline apply?

Yes, the deadline applies and it was met. ☐ Yes, but it was not met. If this is the case, contact the superintendent’s office in the resident districtimmediately regarding Section 3 of this form to determine whether the resident district and yourdistrict will agree to a Non-resident Agreement to serve the student prior to open enrollment becomingavailable.

No, one or both districts receive Achievement and Integration funding from MDE.No, family moved to resident district on December 1 or later.

No, the commissioner of education and commissioner of human rights have determined the resident district’s policies, procedures or practices are in violation of Title IV of the Civil Rights Act (Minn. Stat. §124D.03, subd.7).

Will the student have priority in a lottery? No Yes, based on: Sibling of currently open-enrolled student in this district.

☐MDE-approved Achievement and Integration with specific school choice plan involving the districts.☐ Child of Minnesota resident who is a district employee.☐ City of Edina resident whose resident school district is not Edina Public Schools, seeking entry to thedistrict.

Approval/Disapproval of Open Enrollment Application

☐☐ APPROVED☐ APPROVED BUT WITH A NON-RESIDENT AGREEMENT for upcoming year that is mutually agreedupon by both districts. Enrollment will continue in subsequent years as open enrollment provided that alottery is not needed for the student’s grade level in the first fall enrollment or the grade level has notbeen closed by board action. Students will be entered into lottery if one is held. (Non-resident district:keep documentation of the agreement. Districts may document agreement using Section 3 or anotherformat of their choosing.)

STUDENT ASSIGNMENT SITE/PROGRAM: On the basis of information provided in the above application, and with respect to district policies and procedures, the above student will be assigned to:

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5

[email protected]

School Building Name:

Starting Date:

Grade Level:

☐☐

The

Statutory Grade District

NOT APPROVED The non-resident district has denied the request for open enrollment because of the following reason(s) allowed in Minnesota Statutes, section 124D.03. Reminder: ECSE open enrollment applications cannot be denied based on special education program capacity. Check all that apply:

January 15 deadline applies and was not met; situations that would have waived the deadline are not present. See Statewide Enrollment Options Instructions or Minnesota Statutes, section 124D.03, subdivision 3.

enrollment cap has been reached for open enrollment. (Minn. Stat. § 124D.03, subd.2) is closed district-wide by board action. (Minn. Stat. § 124D.03, subd. 2 and subd.6) has denied the application because of specific expulsion reasons allowed in law. (Minn. Stat. §

124D.03, subd.1)

NOTIFICATION TO RESIDENT DISTRICT Non-resident district must notify resident district or last district of attendance by March 15 or 30 days later of the pupil's intent to enroll in the non-resident district. The same procedures apply to a pupil who applies to transfer from one participating non-resident district to another participating non-resident district.

Name of Superintendent/Responsible Authority: _____________ Signature: Date:

Please Note: districts may not modify this form, add data fields or create alternative formats.

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6

Bill Adams, Superintendent

New London‐Spicer Schools 101 4th Ave SW New London, MN 56273

Dear Parent/Guardian:

Our school provides healthy meals each day. Breakfast costs: Kindergarten‐Free, Grades 1‐4 ‐ $1.25, Grades 5‐12 ‐ $1.35, Adults $1.80: Lunch costs: Grades K‐4 ‐ $2.25, Grades 5‐12 ‐ $2.50, Adults $3.75.

Your children may qualify for free or reduced‐price school meals. To apply, complete the enclosed Application for Educational Benefits following the instructions. A new application must be submitted each year. At public schools, your application also helps the school qualify for education funds and discounts.

State funds help to pay for reduced‐price school meals, so all students who are approved for either free or reduced‐price school meals will receive school meals at no charge. State funds also help to pay for breakfasts for kindergarten students, so all participating kindergarten students receive breakfasts at no charge.

Return your completed Application for Educational Benefits to: Vicki Mickelson New London‐Spicer Schools 101 4th Ave SW New London, MN 56273

Who can get free school meals? Children in households participating in the Supplemental Nutrition Assistance Program (SNAP), Minnesota Family Investment Program (MFIP) or Food Distribution Program on Indian Reservations (FDPIR), and foster, homeless, migrant and runaway children can get free school meals without reporting household income. Alternatively, children can get free school meals if their household income is within the maximum income shown for their household size on the instructions. To apply for free school meals, please complete the Application for Educational Benefits form.

COMMON QUESTIONS:

I get WIC or Medical Assistance. Can my children get free school meals? Children in households participating in WIC or Medical Assistance do not automatically qualify for free meals. Children may be eligible for free or reduced‐price school meals depending on other household financial information. Please fill out an application.

Who should I include as household members? Include yourself and all other people living in the household, related or not (such as grandparents, other relatives, or friends).

May I apply if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens for your children to qualify for free or reduced‐price school meals.

What if my income is not always the same? List the amount that you normally get. If you normally get overtime, include it, but not if you get overtime only sometimes. For seasonal work, write in the total annual income.

Will the income information or case number I give be checked? It may be. We may also ask you to send written proof.

How will the information be kept? Information you provide on the form, and your child’s approval for meal benefits, will be protected as private data. For more information see the back page of the Application for Educational Benefits.

If I don’t qualify now, may I apply later? Yes. Please complete an application at any time if your income goes down, your household size goes up, or you start getting SNAP, MFIP or FDPIR benefits.

Please provide the information requested about children’s racial identity and ethnicity, which helps to make sure we are fully serving our community. This information is not required for approval of school meal benefits.

If you have other questions or need help, call (320) 354‐2252 x2607.

Sincerely,

Superintendent Bill Adams

How to Complete the Application for Educational Benefits

Complete the Application for Educational Benefits form for school year 2019‐20 if any of the following applies to your household:

Any household member currently participates in the Minnesota Family Investment Program (MFIP), or the Supplemental

Nutrition Assistance Program (SNAP), or the Food Distribution Program on Indian Reservations (FDPIR) or

The household includes one or more foster children (a welfare agency or court has legal responsibility for the child) or

The total income of household members is within the guidelines shown below (gross earnings before deductions, not take‐

home pay). Do not include as income: foster care payments, federal education benefits, MFIP payments, or value of assistance

received from SNAP, WIC, or FDPIR. Military: Do not include combat pay or assistance from the Military Privatized Housing

Initiative. The income guidelines are effective from July 1, 2019 through June 30, 2020.

Maximum Total Income

Household size $ Per Year $ Per Month $ Twice Per Month

$ Per 2 Weeks $ Per Week

1 23,107 1,926 963 889 445

2 31,284 2,607 1,304 1,204 602

3 39,461 3,289 1,645 1,518 759

4 47,638 3,970 1,985 1,833 917

5 55,815 4,652 2,326 2,147 1,074

6 63,992 5,333 2,667 2,462 1,231

7 72,169 6,015 3,008 2,776 1,388

8 80,346 6,696 3,348 3,091 1,546

Add for each additional person

8,177 682 341 315 158

Step 1: Children

List all infants and children in the household, their school and grade if applicable, and birthdate. Attach an additional page if needed

to list all children. Check the box if a child is in foster care (a welfare agency or court has legal responsibility for the child).

Step 2: Case Number

If any household member currently participates in SNAP, MFIP or FDPIR, write in the case number and then go to Step 4. If you do

not participate in any of these programs, leave Step 2 blank and continue on to Step 3.

Step 3: Adult and Child Incomes / Last 4 Digits of Social Security Number

Child Income. If any children in the household have regular income, such as SSI or part‐time jobs, list the total amount of

regular incomes received by all children, and check the box for the frequency: weekly, bi‐weekly, twice a month, or monthly. Do

not include occasional earnings like babysitting or lawn mowing.

Adult income. Report the names of adult household members and income earned in this section.

List all adults living in the household not listed in Step 1, whether related or not, such as grandparents, relatives, or friends. Gross Earnings from Work. For each income, check the box to show how often the income is received: weekly, bi‐week,

twice per month, or monthly. List gross incomes before deductions, not take‐home pay. Do not list an hourly wage rate. For adults with no income to

report, enter a ‘0’ or leave the section blank. For seasonal work, write in the total annual income. Self‐employment or Farm Income. List the net income per month or year after business expenses. A loss from farm or self‐

employment must be listed as 0 income and does not reduce other income. All Other Gross Income. List gross incomes before deductions from any other sources, such as SSI, unemployment, child

support, public assistance, social security, rental income or annuities.

Social Security Number/Total Household Members. An adult household member must provide the last four digits of their

Social Security number or check the box if they do not have a Social Security number. The total household members is reported.

Step 4: Signature and Contact Information An adult household member must sign the form. If you do not want your information to be shared with Minnesota Health Care Programs, check the “Don’t share” box in Step 4.

Optional: Please provide the information on ethnicity and race that is requested on the second page of the form. This information is not required and does not affect approval for school meal benefits. The information helps to ensure we are meeting civil rights requirements and fully serving our community.

2019‐20 Application for Educational Benefits Complete one application per household. Please use pen (not a pencil).

STEP 1: List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper).

Definition: A Household Member is “Anyone living with you and shares income and expenses, even if not related.” Children in Foster care are eligible for free meals. Read How to Complete the Application for Educational Benefits for more information.

STEP 2: Do Any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, MFIP or FDPIR? Medical assistance does not qualify. If YES >Enter SNAP, MFIP or FDPIR Case Number _____________________________ then go to STEP 4 (Do not complete STEP 3) If NO > Go to STEP 3. STEP 3: Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2) A. Child Income

Sometimes children in the household earn or receive income. Please include the TOTAL income

received by all children listed in STEP 1.

B. All Adult Household Members (including yourself). For each Household Member listed, if they do receive income, report total gross income only. If they do not receive income from any source, write ‘0’ or leave any fields blank. You are certifying (promising) that there is no income to report. Not sure what income to include here? Flip the page and review “Sources of Income” for information. “Sources of Income” will help you with the Child Income section and All Adult Household Members section.

Name of Adult Household Members (First and Last)

List all Household members not listed in STEP 1 (including yourself) even if they do not receive income. Include children

who are temporarily away at school or in college.

Na

Wee

kly

Bi‐Wee

kly

2x Month

Monthly

Gross earnings from Work

Report income before deductions or taxes, for each source in whole dollars (no cents).

Na

Monthly

Yearly Net income from

Self‐Employment

Na

Wee

kly

Bi‐Wee

kly

2x Month

Monthly

All Other Gross Income such as SSI,

Unemployment, Public Assistance, Child

Support, and others on Page 2

☐ ☐ ☐ ☐ $ ☐ ☐ $ ☐ ☐ ☐ ☐ $

☐ ☐ ☐ ☐ $ ☐ ☐ $ ☐ ☐ ☐ ☐ $

☐ ☐ ☐ ☐ $ ☐ ☐ $ ☐ ☐ ☐ ☐ $

☐ ☐ ☐ ☐ $ ☐ ☐ $ ☐ ☐ ☐ ☐ $

C. Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member XXX‐XX‐_____________ Check if no SSN: ☐ Total Household Members (Children and Adults) _________

STEP 4: Contact information and adult signature. Mail or return completed form to: Vicki Mickelson, New London‐Spicer Schools, 101 4th Ave SW, New London, MN 56273

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is give in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

☐ I have checked this box if I do not want my information shared with

Minnesota Health Care Programs as allowed by state law. Do not fill out: For School Use Only

_________________________ Annual Income Conversion: Printed name of adult signing form Weekly x 52 Bi‐Weekly x 26 Twice a Month x 24 Street Address (if available) Apt# City Zip Monthly x 12

☐ Selected for Verification – attach Verification Tracker

_______________________________________ Signature of Household Adult Daytime Phone Determining Official’s Signature Date Confirming Official’s Signature Date

Child’s First Name MI Child’s Last name School Grade Birthdate Foster Child (√)

☐

☐

☐

☐

☐

Child Income Weekly Bi‐weekly 2x Month Monthly

$ ☐ ☐ ☐ ☐

All Total Income (Include child and adult income) W

eekly

Bi‐wee

kly

2X M

onth

Monthly

Annualize

Household Size

Catego

rical

Eligibility

Free

Red

uced

Den

ied

$ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

INSTRUCTIONS: Sources of Income

Sources of Income for Children Sources of Income for Adults

Sources of Child Income Examples NA

Earnings from Work Public Assistance / Alimony

/ Child Support All Other Income

Earnings from work

Social Security a. Disability Payments b. Survivor’s Benefits

Income from person outside the household

Income from any other source

A child has a regular full or part‐time job where they earn a salary or wages

A child is blind or disabled and receives Social Security

A Parent is disabled, retired, or deceased, and their child receives Social Security benefits

A friend or extended family member regularly gives a child spending money

A child receives regular income from a private pension fund, annuity, or trust

Salary, wages, cash bonuses (before deductions or taxes)

Net income from self‐employment (farm or business)

If you are in the U.S. Military: a. Basic pay and cash bonuses (do

NOT include combat pay, FSSA or privatized housing allowances)

b. Allowances for off‐base housing, food and clothing

Cash Assistance from State or local government

Supplemental Security Income

Unemployment benefits

Worker’s compensation

Alimony payments

Child support payments

Veteran’s benefits

Strike benefits

Social Security

Disability benefits

Regular income from trusts or estates

Annuities

Investment income

Rental income

Regular cash payments from outside household

OPTIONAL: Children’s Racial and Ethnic Identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not

affect your children’s eligibility for free or reduced price meals.

Ethnicity (check one): ☐ Hispanic or Latino ☐ Not Hispanic or Latino

Race (check one or more): ☐ American Indian or Alaskan Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Other Pacific Islander ☐ White

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must

include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or

you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for

your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price

meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine

benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

At public school districts, each student’s school meal status also is recorded on a statewide computer system used to report student data to MDE as required by state law. MDE uses this information to: (1) Administer state and

federal programs, (2) Calculate compensatory revenue for public schools, and (3) Judge the quality of the state’s educational program.

Nondiscrimination statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions

participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity

conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they

applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877‐8339. Additionally, program information may be made available in

languages other than English.

To file a program complaint of discrimination, you have two options: 1. Complete the USDA Program Discrimination Complaint Form, (AD‐3027) found online at Filing a Program Discrimination Complaint as a USDA Customer,

and at any USDA office; or, 2. Write a letter addressed to USDA; provide in the letter all of the information requested in the form. To request a copy of the complaint form, call 866‐632‐9992. Submit your completed form or

letter to USDA by one of the following methods:

(1) Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250‐9410;

(2) Fax: 202‐690‐7442; or (3) Email: [email protected]

This institution is an equal opportunity provider.

Name: _____________________________________

Address: ___________________________________

___________________________________

Phone (H): _________________________________

Phone (C): _________________________________

E-mail: ____________________________________

Are you a parent/legal guardian of student(s) listed? ____ Yes ____ No ____ Other ( )

Name: ____________________________________

Address: __________________________________

__________________________________

Phone (H): ________________________________

Phone (C): ________________________________

E-mail: ___________________________________

Applicant #1 ______Approved ______Denied E-mail Sent __________________________________ Applicant #2 ______Approved ______Denied E-mail Sent __________________________________ File: ________________________________________

New London-Spicer School District #0345 Parent Portal Request

I (Applicant #1) am requesting a login to the New London-Spicer Schools Parent Portal and agree to the terms of Policy 915 Parent Portal. I understand that District #0345 reserves the right to deny access to the Parent Portal due to court orders or any other legal proceedings that limit availability of private educational data.

The Students I am requesting for access via Parent Portal are:

Name: __________________________________________________________________ Grade __________ Name: __________________________________________________________________ Grade __________ Name: __________________________________________________________________ Grade __________ Name: __________________________________________________________________ Grade __________ Name: __________________________________________________________________ Grade __________

Parent Portal Applicant #1 *** Will your spouse be sharing the same login?

____ Yes ____ No (If NO, complete Applicant #2)

Parent Portal Applicant #2

_________________________________________________________ _______________________ Signature of Parent/Legal Guardian / Applicant #1 Date

**Check your e-mail for your Parent Portal approval and activation information. Allow Approximately 1 week to process.

Please return forms to: New London-Spicer Schools Office Use ONLY: Michaelene Frederickson 101 4th Ave SW New London, MN 56273 [email protected] (P) 320-354-2252 ext. 2600 (F) 320-354-9001

New London-Spicer School District #0345 Kindergarten Questionnaire

Student_______________________________________________ Birth Date__________

This information is to assist us in better understanding the needs of your child. You are always welcome to call or visit anytime. We hope your child has a happy and successful Kindergarten experience.

Thank you for completing this questionnaire.

About your incoming Kindergartener:

Has your child:

Previously attended a Preschool Program? ____ No ____ Yes (if Yes, Please share the following)

Name of Current/Previous Preschool: __________________________________________________________

Number of days a week child attended: _________________________________________________________

Has the child and family:

Previously participated in any Early Childhood Family Education Events? ____ No ____ Yes (Please describe)

Previous Events: _________________________________________________________________________

_______________________________________________________________________________________

Does your child currently attend daycare? ____ No ____ Yes (if Yes, Please share the following)

Name and location of current daycare: ________________________________________________________

Please tell us about your child: ______________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Have there been any recent changes in your family which might affect your child? __________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Do you have any concerns about your child’s behavior? ________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Does your child have any health problems we should know about at school? ______________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

PRINTED Name of Parent/Legal Guardian: __________________________________ Phone:___________________ Signature of Parent/Legal Guardian: _______________________________________ Date:____________________