high school student enrollment form - english · high school student enrollment ... please provide...

Legal Name: _________________________________________________________________________________________ Last Name First Name Full Middle Suffix

Gender: M F Birth Date: _______________________ Primary Language: _________________________ Grade: ______

Birth Country: ______________________ Date Entered U.S _______________ Date entered U.S. Schools _____________

Name of Last School Attended __________________________________________________________________________

Address _______________________________________ ________________________________ ________ ___________

Address City State Zip

Phone Number: ______________________________________ Fax Number: ____________________________________

Special Programs

Does this student currently receive Special Education Services

(IEP)

Does this student have a 504 Plan

Did this student receive ELL services at their previous school

Was this student expelled from the previous school

Military Status

Are any of the student’s parents/guardians on active military duty

Y N

Y N

Y N

Y N

Y N (this does not include full-time National Guard

Duty)

Home Phone Number: _____________________________

Primary Student Address: _______________________________ _______ ____________________ _______ ___________

Address Apt. # City State Zip

Mailing Address: ☐ Same as household address ___________________________ _______________ _______ __________

Mailing Address/PO Box City State Zip

Is student in foster care placement? ____ Yes ____ No

Parent/Guardian Residing with Student:

Legal Last Name: _____________________________ Legal First Name: ____________________________ Gender: M F

Relationship to Student: __________________ Cell Phone: ____________________ Work Phone: ___________________

Email: _______________________________

Spouse of Parent/Guardian Residing with Student:



Email: _______________________________

High School Student Enrollment Form 2018-2019

Student Information

Previous School Information

Primary Household Information


Address: _________________________________________ _______ ________________________ _______ ___________ Address Apt. # City State Zip


Email: _______________________________



Email: _______________________________

Secondary Household (additional legal guardians)

If there are any legal restrictions regarding the non-custodial parent, please provide a copy of legal documentation to be sent to the school.

List the name(s) of other siblings who attended the Waterloo Community Schools

Name (First/Last) School Grade Name (First/Last) School Grade

Emergency Contacts List other designated adults who are authorized to pick up your student (Local contacts only)

Name Relationship Home Phone Cell Phone & Work Phone

Doctor N/A N/A

Dentist N/A N/A

Connect Ed Contact System Parent/Guardian Participation Refusal

All phone numbers listed in the Primary Household will be utilized by the Connect Ed Emergency notification system

which includes weather related announcements

☐ I as parent/guardian request that NO phone calls, emails, or text messages be sent to me using the Connect-Ed system

Parent signature ____________________________________________________________________________________

Residency Documentation

In accordance with the Waterloo Community Schools policies and practices, proof of residency will be required for

ALL students.

- I affirm that the address provided on the student enrollment form is the legal residence of the parent or

guardian enrolling the student and that is the residence of the student.

- I acknowledge that residency is defined as living and sleeping under the same roof with parent/guardian.

Note: Falsifying this document will results in transfer of the student to his/her school of residency and may result in a

tuition charge

Signed ______________________________________________________________ Date ______________________

(Parent/Guardian)

Documentation provided to verify residency includes:

Current letter from Department of Human Services

Utility bill, cable bill, or water bill Current letter from employer on company letterhead

Rent receipt or current lease agreement Mortgage document or purchase agreement that shows ownership

Waterloo School District Anti-Bully Pledge

I agree to work to stop bullying in our school community.

The definition of harassment and bullying in the law is: Any electronic, written, verbal or physical act or conduct toward a student which

is based on any actual or perceived trait or characteristic of the student which is based on any actual or perceived trait or characteristic

and which creates an objectively hostile school environment that meets one or more of the following conditions: Places the student in

reasonable fear or harm to the student’s person or property. Has a substantially detrimental effect on the student’s physical or mental;

has the effect of substantially interfering with the student’s academic performance; and/or has the effect of substantially interfering with

student’s ability to participate in or benefit from the services, activities, or privileges provided by a school.

“Bullying behavior can consist of child to another, a group of children ganging up against one lone child, or one group of kids targeting

another group. Common behaviors attributed to bullying include put downs, name calling, rumors, gossip, threats, menacing,

harassments, intimidation, social isolation/exclusion, and physical assaults “(www.stopbullying.gov).

No student deserves to be bullied and that every regardless of age color, creed, national, origin, race, religion, marital status, sex, sexual

orientation, gender identity, physical attributes, physical or mental ability ancestry, political party reference, political belief,

socioeconomic status, or familial status has the right to feel safe, secure, and respected.

I agree to:

Treat other students and staff with kindness and respect.

Be aware of and abide by my school’s anti-bullying policies (Policy 103.1)

Support students who have been victimized by bully behavior.

Speak out against verbal, physical and cyber bullying (being an up-stander)

Notify a parent, teacher, or school administrator if/when I see bullying behavior occur.

Be a good role model for other students.

Be responsible for my choices, actions and words.

Student’s Signature ________________________________________________ Date ________________

Parent’s Signature _________________________________________________ Date ________________

Physical Activity Agreement, Grades 6-12 2018-2019

In 2008, the Iowa Legislature enacted “The Healthy Kids Act,” requiring that all students in grades 6-12 engage in physical activity for a

minimum of 120 minutes per week in which there are at least five days of school. Due to student scheduling, there will be weeks that

your student may not meet this requirement through physical education class alone. Therefore, each student shall complete this

agreement. The law also requires that we monitor how students fulfill this requirement.

Name of Student _____________________________________________________________ Grade________

School activities that students will be involved in during the 2018-2019 school year

Cross Country _____ Football _____ Volleyball _____ Golf _____ Bowling _____ Wrestling _____

Basketball _____ Track and Field _____ Swimming _____ Tennis _____ Soccer ____ Baseball _____

Softball _____ Marching Band _____ Show Choir _____ Cheerleading _____ Dance Team _____

Non-School activities that the student will be involved in during the 2018-2019 school year

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Student’s signature_______________________________________________ Date_________________________

Parent’s signature________________________________________________ Date_________________________

Attendance Procedures

One of the most important things you can do to help your children succeed is to make sure that they are in school, on time and ready to learn.

Tardy Procedure:

Children who arrive late must report to the office for a tardy slip. Tardiness is recorded and monitored for all students. Students who are on Voluntary

Transfer status may have the transfer revoked if tardiness becomes a concern.

Absence Procedure:

For the safety of your child, it is important that you call or notify the school before 9:15 when an absence occurs (messages can be left on the school’s

answering machine during non-school hours). By notifying the school, you are verifying that you know your child’s whereabouts. Examples of valid

reasons for which a child’s absence from school will not count toward their total absences for the year include:

• A medical or dental excuse is brought to the office, verifying the reason for absence. Please schedule routine medical and dental appointments

after school hours, when possible.

• Death or serious illness in the immediate family or household.

• Suspension from school.

• Religious holidays requiring absence from school.

• Prior approval or notification of court appearances or other legal proceedings beyond the control of the family.

• Other verified emergency, as approved by the building administrator.

• Other reasons which can be justified from an educational standpoint and which are approved in advance by the building administrator.

If your child accumulates four (4) and eight (8) unexcused absences, you will receive a computer-generated letter notifying you of the absences. If the

absences continue to accumulate, you and your child may be referred for review to address attendance issues. In accordance with Iowa Law, it is the

parents’ responsibility to ensure their child attends school (Code of Iowa, Chapter 299). Parent/Guardian failure to see to it that their child attends school

on a regular basis is a criminal offense.

Chronic Absenteeism has been defined by Attendance Works as missing 10% (17+ days) or more of a school year for any reason. Excused, unexcused

absences and suspension, can translate into third-graders unable to master reading, sixth-graders failing subjects, and ninth-graders dropping out of high

school.

The Waterloo Community School District believes the primary purpose of education is to provide an opportunity for students to fully develop the basic

skills needed to function as responsible citizens in a changing world. Students can make academic progress only if they attend school regularly and take

advantage of the educational experiences offered.

I have read, understand and agree to abide by the attendance rules and procedures.

Student Name ________________________________________________________

Parent/Guardian Signature: ________________________________________________ Date: ____________________________

Field Trips/Network and Email account/Student Information/Media Release 2018-2019

YOU ONLY NEED TO FILL THIS OUT TO DENY PARTICIPATION*

The Waterloo Community School District had adopted a policy designed to assure parents and students the full implementation, protection and

enjoyment of their rights under the Family Educational Rights and Privacy Act of 1974 (FERPA)

This law requires the school district to designate as “directory information” any personally identifiable information taken from a student’s educational

record prior to making it available to the public. This includes information released to branches of military upon request.

*The school district has designated the following information as directory information: Student name, Address and Telephone number, Grade level,

Activities and Sports, Weight and Height for athletic teams, Degrees and Awards received and Photographs and other likeness in still pictures or

videotape.

The school district had created Google Apps for Education accounts that include email for all students in grades 2-12. Additionally, teachers periodically

use other online tools with students as needed to achieve their curricular objectives. The district has adopted a policy which governs the appropriate use

of technology resources. This policy is viewable on our website at www.waterloo.k12.ia.us/TechPolicy/policy.pdf. Paper copies may also be requested

by contacting your child’s school.

Please check each box if you DO NOT give permission:

□ I DO NOT give permission for my student to go on field trips.

□ I DO NOT give permission for directory information to be released. (This includes media, photos, social media, honor roll, etc.)

□ I DO NOT give permission for directory information to be released to military branches.

□ I DO NOT give permission for my student to have a network and email account and access technology resources.

Permission will automatically be granted unless designated above and received within two weeks of enrollment or the second Friday in September

of the current school year.

Student Name______________________________________________ School_________________________________ Date_______________

Parent/Guardian Signature: ________________________________________________ Date: ____________________________

http://www.waterloo.k12.ia.us/TechPolicy/policy.pdf

FAMILY RESIDENTIAL STATUS

Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento

Act. This information will remain confidential.

Student ____________________________ Parent/Guardian __________________________

School _________________________ Phone _____________________________

Age _____ Grade _____ D.O.B. __________

Address __________________________________________________________ City _______________

Zip Code _______________ Is this address Temporary or Permanent? (circle one)

Please choose which of the following situations the student currently resides 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)

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)

_____ None of this applies to me or my family

Are you a student under the age of 18 and living apart from your parents or guardians? Yes No

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 (Cora Turner) or designee

(Jayme Dunn) at 319-433-1801 or the State Coordinator (Carolyn Paulaitis) at 515-281-6131.

By signing below, I acknowledge that I have received and understand the above rights.

______________________________________________________________________________

Signature of Parent/Guardian/Unaccompanied Youth Date

______________________________________________________________________________

Signature of McKinney-Vento Liaison Date

Waterloo Community School District

ANNUAL STUDENT HEALTH UPDATE

Parent/Guardian: Address: Zipcode:

Father’s Name: Phone #: Cell #:

Workplace: Work #:

Mother’s Name: Phone #: Cell #:

Workplace: Work #:

Emergency Contacts:

1. Relationship: Phone #:

2. Relationship Phone #:

Has your child traveled outside the United States in the last 30 days? Yes No

Indicate if your child has any of these health conditions or diseases.

Allergies* Arthritis Dental Problems Heart Problems Surgery/Hospitalization

Environmental Asthma Developmental Delays Mental Illness Vision Concerns

Food Bed Wetting Diabetes Migraines Weight Gain

Medicine Broken Bones Ear Problems Speech Problems Weight Loss

Other Cerebral Palsy Emotional Concerns Seizures Other

ADHD Constipation Hearing Loss Serious Head Injury

*Allergic to: If allergies are food related, complete the Diet Medication Form.

Does your child have an EPI-Pen? Yes No

Does your child use an inhaler? Yes No

Please share any additional information that will help us meet your child’s needs.

List any assistive devices, crutches, listening devices, etc.:

Surgery: Date: Surgery: Date:

Date of most recent physical: By whom?

Date of most recent vision exam: By whom?

Date of most recent dental exam: By whom?

Has your child had any immunizations in the past year? If yes, please list immunization(s) and date(s).

Immunization Date: Immunization Date:

Is your child currently on regular medication? If yes, please list what medication(s) and what condition(s). Indicate Y or N if medication will be taken during the school day and complete Medication Authorization Form.

Medication Yes ____ No ____ Medication Yes ____ No ____

Condition Condition

Medication Yes ____ No ____ Medication Yes ____ No ____

Condition Condition

Health Insurance Information

Private Medicaid Hawk-I None Other

Policy # Policy # Policy # Policy #

I give specific permission to the school nurse and dental hygienist to conduct health screening and to share information as deemed appropriate with school staff and staff from Black Hawk County’s I-Smile Program. This information sharing would be deemed appropriate if it directly affects my student’s learning, well-being, and/or safety at school (this may include referrals for health services as needed). I give permission to the school nurse and/or dental hygienist to exchange information with the above listed health professionals for the purpose of referral, diagnosis, and treatment.

PARENT/GUARDIAN SIGNATURE: Date: Rv. 1.17

Student Last Name: First: Birthdate: Gender:

Grade: Building:

high school student enrollment form - english · high school student enrollment ... please provide...

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