preschool enrollment guide - jordan.k12.mn.us · 1/28/2020 · filipino hmong karen korean...

Updated: 01/28/2020 (kp)

Preschool ONLY

Preschool Enrollment Guide In order to expedite the registration process please have the following items with you when registering: ____ Original birth certificate OR passport to enroll in Early Learning Services through Grade 12 if is not

included in previous school records. This is to verify the student's date of birth, legal name, and legal gender. To obtain a certified copy of your child’s Birth Certificate, visit the CDC website at: www.cdc.gov/nchs/w2w.htm or contact your local County Recorder.

____ Legal guardianship paperwork or Delegation of Parental Rights if registration is done by a

noncustodial parent/guardian. Registration Checklist ( * required upon registration)

� FORM A * Registration Form (required) � FORM B * Ethnic and Racial Demographic Designation Form (required) � FORM B-1 * Minnesota Language Survey Form (required) � FORM C * Child/Parent Status (required) � FORM D * Parent Authorization Form (required) � FORM E * Emergency Contact Form (required) � FORM F * Health Care Summary Form (required) � FORM G * Immunization Record Form (required only needed if not sent from previous school) � FORM H * Family Education Rights and Privacy Act (FERPA) Form (required) � FORM I * Registering Adult Form (required) � FORM J-1 Preschool Transportation Registration/Change Form � FORM K Educational Benefits Form (if you qualified in the current school year in a different district, please notify the District Office at 952-492-4221)

� FORM K-1 Waiver of Confidentiality (if qualifies for Form K - Educational Benefits) � FORM N * Preschool Screening (required)

Updated: 01/28/2020 (kp)

INTENTIONAL BLANK PAGE

Complete both sides Page 1 of 2 Updated: 01/28/2020 (kp)

Student’s PRIMARY Household – all information will be sent to the primary household

Student’s SECONDARY Household (if applicable) – all information will be sent to the secondary household

FORM A(ELS) JORDAN PUBLIC SCHOOLS DISTRICT 717 EARLY LEARNING SERVICES – ENROLLMENT FORM

** Please provide a copy of the student’s birth certificate Student LAST Name (Legal): Student FIRST Name (Legal): Student MIDDLE Name (Full):

_______________________________ _______________________________ _________________________________

Legal Gender: Male Female Birth Date (mm/dd/yyyy): _______________

Note: Please notify the school office and provide legal documentation if there is a custodial concern.

________________________________________________________________________________ Primary Street Address

_______________________________ ________________________ _____________ City State Zip Code

Primary Parent/Guardian Primary Parent/Guardian

Name (include maiden)

Birth Date

Home Phone

Cell Phone

Work Phone

Email Address

Preferred Language

Note: Please notify the school office and provide legal documentation if there is a custodial issue.

________________________________________________________________________________ Primary Street Address

_______________________________ ________________________ _____________ City State Zip Code

Primary Parent/Guardian Primary Parent/Guardian

Name (include maiden)

Birth Date

Home Phone

Cell Phone

Work Phone

Email Address

Preferred Language

Student lives with:

Mother

Father

Step-Parent

Foster-Parent

Family Relative

Other (please list):

_________________

Student lives with:

Mother

Father

Step-Parent

Foster-Parent

Family Relative

Other (please list):

_________________

Complete both sides Page 2 of 2 Updated: 01/28/2020 (kp)

MILITARY CONNECTIONS

CENSUS – please list all other children in student’s household

SPECIAL EDUCATION SERVICES INFORMATION – please check all that apply

TRANSLATION SERVICES

RESIDENCE STATUS

Student LAST Name (Legal): Student FIRST Name (Legal): Student MIDDLE Name (Full):

_______________________________ _______________________________ _______________________________

Was your student born in the United States? Yes No

If not, when did the student enter the United States? Date: ____________________

Birth Country: ______________________________

1. Are any of the student’s parents or legal guardians a member of the Army, Navy, Air Force, Marine Corp, or Coast Guard (excluding National Guard)? Yes No

2. Relationship to student: Father Mother Other: _________________________________

3. Approximate enlistment date (mm/yyyy): ___________________________

4. Status of military personnel (choose one):

Active Duty – Deployed Injured Student Military Identifier Active Duty – Not Deployed Killed in Action Transitioning Out of the Military Discharged Inactive Retired

Do you require translator services? Yes No

If yes, what language is needed for translation? _____________________________________________

Which Special Service(s) has the student received or is currently receiving? Vision Impaired Emotional/Behavioral Gifted & Talented Hearing Impaired Learning Disabled Student has an IEP Speech/Language English Language Learner (ELL) Student has a 504 Plan Title One Reading Other: ________________________

Full Legal Name Birth Date (mm/dd/yyyy) Legal Gender (male or female) Grade Level

Data provided on this registration form will be used by personnel in the Jordan School District 717 to identify the student and family for school placement, open enrollment, and transportation. You are not required to respond to all requests for information on this form; however, be advised that incomplete information may limit the ability of the Jordan Schools to fully provide educational services. I certify the information given above is true and complete to the best of my knowledge.

_________________________________________ _________________________________________ ________________________ Parent/Guardian Signature Parent/Guardian Printed Name Date

Go to Question 1.

□ Other Hispanic/Latino □ Unknown

Salvadoran Spaniard/Spanish/ Spanish-American

□ □

□ Guatemalan □ Mexican □ Puerto Rican

□ Decline to indicate □ Colombian □ Ecuadorian

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):

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.

[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/KatPassTypewritten TextFORM B

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

o Yes [If yes, go to Question 3a.] o No [If no, go to Question 4.] 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

o Yes [If yes, go to Question 4a.] o No [If no, go to Question 5.] 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

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Updated: 02/12/19 (kp)

FORM B-1 JORDAN PUBLIC SCHOOLS DISTRICT 717 MINNESOTA LANGUAGE SURVEY FORM 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 LAST Name (Legal): Student FIRST Name (Legal): Student MIDDLE Name (Full):

_______________________________ _______________________________ ________________________________

Birth Date or 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:



only English.

3. My student understands:



only English.

4. My student has consistent interaction in:



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.


* 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.

Updated: 01/28/2020 (kp)

FORM C

JORDAN PUBLIC SCHOOLS DISTRICT 717 Child/Parent Status

Child’s LAST Name (Legal): Child’s FIRST Name (Legal): Child’s MIDDLE Name (Full):

_______________________________ _______________________________ _______________________________

Q1: Is the student living with someone OTHER than their biological parent(s)? Yes No Q2: If yes, have the biological parent’s rights been terminated?

Mother Yes No Father Yes No If you checked NO to Q2, please provide the biological parent’s name and address: Name: ___________________________ Address: ____________________________________________________

Name: ___________________________ Address: ____________________________________________________ If there are custodial concerns, do you have documentation by a court that the natural parent(s) may NOT be contacted?

No Yes (If yes, please attach copies) NON-HOUSEHOLD CONTACT As required by State of MN law, both parents must be notified of and receive documentation regarding the assessment procedure. IF NOT LISTED ON FORM A, PLEASE PROVIDE THE ADDRESS OF A NON-HOUSEHOLD PARENT BELOW SO THEY CAN RECEIVE COPIES OF ALL DISTRICT MAILINGS:

Name (Legal): ____________________________________________________________________________________________

Address: _________________________________________________________________________________________________ Street City State Zip Code

Phone: ________________________________________ Email: __________________________________________________


Child lives with:

Both Parents

Mother

Father

Father/Stepmother

Mother/Stepfather

Guardian

Foster Parents

Other Relationship:

__________________

Who has parental/guardian rights? Please check all that apply. Name Name

Both Parents: ______________________ ________________________

Mother: ______________________ ________________________

Father: ______________________ ________________________

Terminated*: ______________________ ________________________

Other*: ______________________ ________________________

* if “Terminated or Other”, please provide legal documentation

Updated: 01/28/2020 (kp)

FORM D(ELS) JORDAN PUBLIC SCHOOLS DISTRICT 717 EARLY LEARNING SERVICES – AUTHORIZATION FORM Student LAST Name (Legal): Student FIRST Name (Legal): Student MIDDLE Name (Full):

_______________________________ _______________________________ ________________________________

1. I will contact the Early Learning Services (ELS) office at 952-492-3233 if I will be late to pick up.

2. I understand that the registration fee is non-refundable. 3. I understand that my child must complete his/her preschool screening within 90 days of starting preschool. This

is mandated by the state. Failure to do so will result in my child losing his/her preschool spot. Please visit www.jordan.k12.mn.us/screening to register.

4. I understand that my child may not start until all the forms are in and complete. I also understand that failure to do this will result in my child losing his/her spot.

5. I understand tuition is due the 15th of the month. Auto pay set up is highly encouraged.

6. I give permission for my child to participate in short field trips (walks to the park, etc.) during preschool class. I

understand that my child will be under the direct supervision of the teachers of this program. I will not hold the teacher, staff, and/or volunteer of Independent School District 717 or the City of Jordan responsible for any injuries or loss of property which may be sustained by my child as a direct or indirect result of participating in this program.

7. I give my permission for staff, in an emergency situation, to administer First Aid and to obtain emergency aid by contacting 911 services. I understand I will be contacted immediately if this happens.


FORM E(ELS) EARLY LEARNING SERVICES – EMERGENCY CONTACT

An emergency contact is needed in case a parent cannot be reached at home or work in the event of student illness or injury. Student Full Name: ________________________________________________________ Birth Date (mm/dd/yyyy): ___________________

Primary Parent/Guardian Primary Parent/Guardian Name

Address

Primary Phone

Email Address

Emergency contact information (other than parents):

#1 Name ____________________________________________ Relationship __________________________ Phone ___________________


Individuals authorized to pick up my child:



Medical and dental information:

Physician______________________________________________________________________________________ Phone ___________________

Dentist________________________________________________________________________________________ Phone ___________________

Hospital_______________________________________________________________________________________ Phone ___________________

Please list any medical problems, food allergies, or heath concerns (e.g. asthma, allergies, diabetes, etc.)

__________________________________________________________________________________________________________________________

Is student taking any special medication? * No * Yes Explain: __________________________________________________________

Are this child’s immunizations up to date? * No * Yes


FORM F(ELS)

MUST BE COMPLETED BY YOUR HEALTH CARE SOURCE

JORDAN PUBLIC SCHOOLS DISTRICT 717 EARLY LEARNING SERVICES – HEALTH CARE SUMMARY Child’s LAST Name (Legal): Child’s FIRST Name (Legal): Child’s MIDDLE Name (Full):

_______________________________ _______________________________ _______________________________

Child’s Primary Address: Legal Gender: Male Birth Date (mm/dd/yyyy):

___________________________________________ Female _______________________________ Street

________________________________ __________ _________________ __________________________ City State Zip Code Date of Enrollment

Name of Parent(s)/Guardian: _____________________________________________________________________________ Date of last physical examination ____________ How long have you been seeing this child? __________________ How frequently do you see this child when he/she is not ill? _________________________________________________ Does this child have any allergies (including allergies to medications)? ______________________________________ Is a modified diet necessary? _____________________________________________________________________________ Is any condition present that might result in an emergency? ________________________________________________ What is the status of the child’s… Vision ___________________________________________________ Hearing _________________________________________________ Speech _________________________________________________ Please list below the important health problems:

Followed Followed By Other Requires Special Important Health Problems By You Med Source (Name) Attention at Center ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Other information helpful to the child care program _________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Signature of Health Source: ______________________________________________ Date: ____________________________ Address: ___________________________________________________________ Phone: _______________________________

Immunization Program (2018-2019) www.health.state.mn.us/immunize

Immunizations required for child care, early childhood programs, and school. To be used for 2018-2019 school year.

Name Birthdate

Diphtheria, Tetanus, Pertussis (DTaP, DT, Td)

Haemophilus influenzae type b (Hib)

Pneumococcal (PCV)

Polio

Tetanus, Diphtheria, Pertussis (Tdap)

Meningococcal (MCV4)

Measles, Mumps, Rubella (MMR)

Varicella (chickenpox)

Hepatitis A

Hepatitis B

Birth to 6 months 12 -24 months At Kindergarten At 7th grade At 12th gradeVaccine

Enter the dates for each vaccine your child has received to date. Specify the month, day, and year of each dose such as 01/01/2010.

Minnesota law requires children enrolled in child care, early childhood education, or school to be immunized against certain diseases, unless the child is medically or non-medically exempt.Instructions for parent or guardian:1. Fill out the dates in chronological order even if your child received a vaccine outside of the age/grade category that the box is in. Depending on the age of your child, they may not have received all vaccines; some boxes will be blank.

• If you have a copy of your child’s immunization history, you can attach a copy of it instead of completing the front of this form. • Your doctor or clinic can provide a copy of your child’s immunization history. If you are missing or need information about your child’s immunization history, talk

to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-3980 or 800-657-3970.2. Sign or get the signatures needed for the back of this form.

• Document medical and/or non-medical exemptions in section 1.• Verify history of varicella disease in section 2.• Provide consent to share immunization information (optional) in section 3.

Immunization Record Form

KatPassTypewritten TextFORM G



3. Consent to share immunization information (optional): This school is asking for permission to share your child’s immunization record with Minnesota’s immunization information system. Giving your permission will:• Provide easier access for you and your school to check immunization records, such

as at school entry each year. • Support your school in helping to protect students by knowing who may be

vulnerable to disease based on their immunization record. This can be important during a disease outbreak.

Under Minnesota law, all the information you provide is private and can only be released to those authorized to receive it. Signing this section of the form is optional. If you chose not to sign, it will not affect the health or educational services your child receives.I agree to allow my child’s school to share my child’s immunization documentation with Minnesota’s immunization information system:

Signature: Date:*Health care practitioner is defined as a licensed physician, nurse practitioner, or physician assistant.

2. History of varicella disease. By my signature below, I verify that this child should not receive varicella vaccine for the following reason:

History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in ___________ (year).I am the parent or guardian of the child and state that the child had varicella disease on or before September 1, 2010, in the year ____________.

Signature: Date:(of health care practitioner*, representative of a public clinic, or parent/guardian)

A. Medical exemption: By my signature below, I certify that this child should not receive the vaccines marked with an X in the table because of medical contraindications or the laboratory-confirmed presence of adequate immunity.

1. Document a medical and/or non-medical exemption (A and/or B). Place an X in the box to indicate a medical or non-medical exemption. If there are exemptions to more than one vaccine, mark each vaccine with an X.

Signature: Date:

B. Non-medical exemption: A child is not required to have an immunization that is contrary to their parent or guardian’s conscientiously held beliefs. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, unvaccinated children may be excluded from child care, school, and other activities in order to protect them and others.

By my signature, I certify that this child will not receive the vaccines marked with an X in the table because of my conscientiously held beliefs. I understand that my child may be excluded during a disease outbreak.

Non-medical exemptions must also be signed and stamped by a notary:

This instrument was acknowledged before me on (date)

by

Notary Signature:

(of health care practitioner*)

Vaccine

Diphtheria, Tetanus, and Pertussis

Polio

Measles, Mumps, Rubella

Haemophilus influenzae type b

Varicella

Pneumococcal

Hepatitis A

Hepatitis B

Meningococcal

Medical Exemption

Non-MedicalExemption

(of parent or guardian in presence of notary)Signature: Date:

Notary Stamp

STATE OF MINNESOTA, COUNTY OF

(name of parent or guardian)

NameInstructions: Complete section 1 to document a medical or non-medical exemption, section 2 to verify history of varicella disease, and section 3 to consent to share Immunization Information.

Minnesota Department of Health - Immunization Program (2018-2019 )(of parent/guardian)

of 2 Updated: 07/11/18 (kp)

FORM H JORDAN PUBLIC SCHOOLS DISTRICT 717 FAMILY EDUCATION RIGHTS AND PRIVACY ACT (FERPA) FORM

Dear Parent/s or Guardian/s: The Family Education Rights and Privacy Act (FERPA), a Federal law, requires that Jordan School District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s education records. However, Jordan School District may disclose appropriately “directory information” without written consent, unless you have advised the District to the contrary in accordance with District procedures. The primary purpose of directory information is to allow Jordan School District to include this type of information from your child’s education records in certain school publications. Examples may include, but are not limited to the following:

• The yearbook, honor roll, recognition list, graduation program, school web pages, marketing materials and/or social media, a theatre playbill, and sports activity sheets, showing height and weight of team members.

Directory information, which is information that is generally not considered harmful or an invasion of privacy if released, can also be disclosed to outside organizations without a parent’s prior written consent. Outside organizations include, but are not limited to, companies that manufacture class rings or publish yearbooks. In addition, two federal laws require local educational agencies (LEAs) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon request, with three directory information categories – names, addresses and telephone listings – unless parents have advised the LEA that they do not want their student’s information disclosed without their prior consent. DENIAL OF RELEASE: DIRECTORY INFORMATION

Jordan School District has designated the following information as its directory information. Parents, you need to inform your child of the requests.

! Student's name

! Photographs and other visual and audio representations for school-approved publications, yearbooks, newspapers, public presentations, social media, student ID badges and publication on school-approved Internet pages (important to note: if you check this box your student will not be in the yearbook)

! Degrees, honors, diplomas and awards received

! Participation and performance in officially recognized school activities and sports

! Grade level

! School of attendance

! Date and place of birth

! Weight and height of members of athletic teams (used only for athletics)

! Dates of attendance

! Enrollment status

! Most recent previous educational agency or institution attended

! Major field of study

CONTINUED ON OTHER SIDE

Please check any information you DO NOT WANT USED PUBLICLY by Jordan Public Schools

of 2 Updated: 07/11/18 (kp)

JORDAN PUBLIC SCHOOLS Page 2 DISTRICT 717 FAMILY EDUCATION RIGHTS AND PRIVACY ACT (FERPA) FORM DENIAL OF RELEASE: MILITARY AND INSTITUTIONS OF HIGHER LEARNING

In accordance with the Minnesota Statute 13.01-13.09, Government Data Practices Act and Public Law 107-110 (No Child Left Behind Act of 2001), the district must release to military recruiting officers and institutions of higher learning the names, home addresses and telephone numbers of students in 9th, 10th, 11th and 12th grades within 60 days after the date of the request, unless parents or students refuse to release the information.

! 9th, 10th, 11th or 12th grade student’s home address and telephone number (denial for release to military recruiters only)

! 9th, 10th, 11th or 12th grade student’s home address and telephone number (denial for release to institutions of higher learning only)

STUDENT INFORMATION (REQUIRED) ____________________________________________ _______________ ___________________________________ print LEGAL name of student grade school I understand that, depending upon what information has been denied, my child(ren)/I (for student 18 or older) may be excluded from such published lists as honor rolls, news releases regarding sports achievements, honors received, athletic contest programs, theater and fine arts programs, graduation programs, future class reunion mailings, etc. I understand that this denial of release of directory and yearbook information shall remain in effect until it has been modified or rescinded at my written request or by my child(ren) upon reaching age 18 or older. ____________________________________ ____________________________________ _____________________ Parent/Guardian Signature Parent/Guardian Printed Name Date OR ____________________________________ ____________________________________ _____________________ Student (18 years of age+) Signature Student (18 years of age+) Printed Name Date

– COMPLETE BOTH SIDES OF THIS FORM AND RETURN TO YOUR STUDENT’S SCHOOL –

Please check any information you DO NOT WANT released


FORM I(ELS) JORDAN PUBLIC SCHOOLS DISTRICT 717 EARLY LEARNING SERVICES – REGISTERING ADULT FORM This form is required by Jordan Schools District for Department of Education required reporting.Adult LAST Name (Legal): Adult FIRST Name (Legal): Adult MIDDLE Name (Full):

_______________________________ _______________________________ ________________________________

Adult birth date (mm/dd/yyyy): ______________________

Relation to Child: * Father * Mother * Foster Parent * Guardian * Other Relative

Education Level: * Master’s * Associate’s * High School Diploma * PHD * Some College * 12th Grade; No Diploma * Bachelor’s * GED * 8th Grade Yearly household income: _______________ # of people in the household: _____________

Receiving Interpreter Assistance: * Yes * No Employment Status Classroom Volunteer Type

* Employed over 25 hours per week * Not Volunteering * Employed less than 25 hours per week * Classroom volunteer * Unemployed & seeking employment * Parent Advisory Council Volunteer * Unemployed & not seeking employment * Other _________________________________________ _________________________________________ ________________________ Parent/Guardian Signature Parent/Guardian Printed Name Date

OFFICE USE ONLY Program Type Funding Source * SR * Parent Fee * ECFE * SR * ECFE / ABE * ECFE * SR / ABE * ECSE * Other * Head Start * Scholarship * Pathways I or II Fee Status * Early Head Start * Full Fee * Title 1 * Reduced Fee * Non-DHS Funded Child Care * No Fee * Community Scholarship * Other District Special Ed * Yes * No * Other County

Student Information

Please list all children in preschool program Place an * if FOR OFFICEBirthdate Gender Pick up Drop off student has USE ONLY

(mm/dd/yyyy) M/F Preschool Class Attending (choose one) (choose one) health concerns Student ID#

Home Daycare Home Daycare

Home Daycare Home Daycare

Family Information Physical Home Address (street, city, state, zip code) Mailing Address (PO box, city, state, zip code) Home Phone:

Parent Name: Cell Phone: Work Phone:

Parent Name: Cell Phone: Work Phone:

Alternate Bus Stop Authorization If noted above, the alternate Bus Stop is for parents of students who want to designate a daycare location for bus pick-up and/or drop off.Child Care Provider Name Phone Address

Emergency Contact Emergency Contact Name #1 (other than parent): Cell Phone: Home Phone:

Emergency Contact Name #2 (other than parent): Cell Phone: Home Phone:

"Bus Buddy" Information

Do you have a preference in a bus buddy for your child? (for example: older sibling) Yes No

If yes, please list their name:

c

Parent/Guardian Signature _______________________________________________ Date______________________________________

Please complete the form and return to the Early Learning Services office.

Mon/Wed/Fri 8:30am – 2:30pm Mon/Wed 8:30am – 2:30pm Tues/Thurs 8:30am – 2:30pm Mon - Thurs 12pm – 3pm Mon/Wed/Fri 8:30am – 11am Tues/Thur 8:30am – 11am

Mon/Wed/Fri 8:30am – 2:30pm Mon/Wed 8:30am – 2:30pm Tues/Thurs 8:30am – 2:30pm Mon - Thurs 12pm – 3pm Mon/Wed/Fri 8:30am – 11am Tues/Thur 8:30am – 11am

Last Name, First Name

Jordan Public Schools ISD717 Preschool Bus Registration Form 500 Sunset Drive, Jordan, MN 55352 Phone: 952-492-6200 Fax: 952-492-4445

Rev: 02/15/2020 KP

FORM J-1 (ELS) ONLY COMPLETE IF BUSING IS NEEDED


Rev: 01/28/2020 KP

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 (MA) 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-W

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Gross earnings from Work

Report income before deductions or taxes, for

each source in whole dollars (no cents).

Na

Mon

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Year

ly Net income from

Self-Employment

Na

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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: Jordan Public Schools 500 Sunset Drive, Suite 1 Jordan, MN 55352

“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 Daytime Phone 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 Date 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 & adult income) W

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Annu

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Household Size

Cate

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Elig

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Fost

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Free

Redu

ced

Deni

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$ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Received: _____________

KatPassTypewritten TextFORM K

KatPassTypewritten Text*May also be submitted via the Infinite Campus Parent Portal

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.

http://www.ocio.usda.gov/sites/default/files/docs/2012/Complain_combined_6_8_12.pdfhttp://www.ascr.usda.gov/complaint_filing_cust.htmlmailto:[email protected]


FORM K-1 JORDAN PUBLIC SCHOOLS DISTRICT 717 WAIVER OF CONFIDENTIALITY To save you time and effort, the approval status of your Free and Reduced-Price School Meals Application may be shared with other programs for which your children may qualify such as reduced fees for school activities and supplies. For the following programs, we must have your permission to share your information. Sending in this form will not change whether your children get free or reduced price meals. It is the parent’s/guardian’s responsibility to submit this form in order to receive reduced activity/supply fees.

Yes! I DO want school officials to share the approval status from my Free and Reduced-Price School Meals Application with Jordan Public Schools’ Activities and Business office.

If you checked yes to the box above, please fill out the form below to ensure that your information is shared for the child(ren) listed below. Your information will be shared only with the program you checked.

Child’s Name: School:





For more information, you may contact Hope Mack in the District Office at [email protected] or 952-492-4221.


* 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.

Updated: 01/28/2020 (kp)

FORM N(ELS)

PRESCHOOL SCREENING

JORDAN PUBLIC SCHOOLS DISTRICT 717 EARLY LEARNING SERVICES – PRESCHOOL SCREENING RECORD FORM Student LAST Name (Legal): Student FIRST Name (Legal): Student MIDDLE Name (Full):

_______________________________ _______________________________ ________________________________

Legal Gender: Male Female Birth Date (mm/dd/yyyy): __________________

Has this student been Preschool Screened in the State of Minnesota? Yes No

Was your student screened at Jordan School District 717? Yes No

If your student was NOT screened in Jordan please list where they were screened:

Screening District Name __________________________________________ Phone Number _________________________________

Address ________________________________________ City _____________________ State _______ Zip ____________

I authorize the release of the official school records listed above to Jordan School District 717 _________________________________________ _________________________________________ ________________________ Parent/Guardian Signature Parent/Guardian Printed Name Date

EE_All_Forms.pdfEE_All_FormsCheck List_EE - Jordan Public Schools Enrollment GuideForm A_ELS - Registration - JPS717Form B - Ethnic and Racial Demographic Designation2019-20 Ethnic and Racial Demographic Designation Form

Form B_1 - MN Language Survey - JPS717Form C - Child_Parent Status - JPS717Form D_ELS_Parent Authorization - JPS717Form E_ELS - Emergency Contact - JPS717Form F_ELS_Health care summary - JPS717Form G - Immunization - JPS717Form H - FERPA - JPS717Form I_ELS_Registering Adult - JPS717Form J_1_ELS_Preschool Transportation RegChange - JPS717Form K - Educational_School Meal Benefits 201819 - JPS717_englishForm K_1 - Waiver of Conf - JPS717Form N_ELS_Preschool Screening - JPS717

Form J_1_ELS_Preschool Transportation RegChange - JPS717

Check List_EE - Jordan Public Schools Enrollment GuideForm D_ELS_Parent Authorization - JPS717_FEBForm A_ELS - Registration - JPS717_FEBAll Forms_Gr1_12_Packet_020720All Forms_Gr1_12_Packet.pdfAll Forms_Gr1_12_Packet_new_2Form A - Registration - JPS717_newForm C - Child_Parent Status - JPS717_newForm K - Educational_School Meal Benefits 201920 - JPS717_english2019-20 Application for Educational BenefitsINSTRUCTIONS: Sources of IncomeOPTIONAL: Children’s Racial and Ethnic Identities

All Forms_Gr1_12_Packet_newCheck List - Jordan Public Schools Enrollment Guide_newForm A - Registration - JPS717_newForm B - Ethnic and Racial Demographic Designation2019-20 Ethnic and Racial Demographic Designation Form

Form B_1 - MN Language Survey - JPS717_newForm C - Child_Parent Status - JPS717_newForm D - Release Records - JPS717_newForm E - Emergency Contact - JPS717_newForm F - Health Info - JPS717_newForm G - Immunization - JPS717Form H - FERPA - JPS717Form I - Technology Acceptable Use Policy - JPS717_newForm I_1 - Digital Device Insurance Agreement - JPS717_newForm J - K12_Transportation RegChange - JPS717Form K - Educational_School Meal Benefits 201819 - JPS717_englishForm K_1 - Waiver of Conf - JPS717

Check List - Jordan Public Schools Enrollment Guide_new_1

All Forms_Gr1_12_Packet_newCheck List - Jordan Public Schools Enrollment Guide.pdfForm A - Registration - JPS717_FebForm B - Ethnic and Racial Demographic Designation_febStudent’s First Name: Middle Name/Initial: Last Name:□ Decline to indicateGo to Question 2.

Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.1□ Decline to indicate□ Filipino□ VietnameseGo to Question 4.

□ Decline to indicateGo to Question 5.

Parent(s)/Guardian Name Date

Form C - Child_Parent Status - JPS717_febForm D - Release Records - JPS717_febForm E - Emergency Contact - JPS717_febForm F - Health Info - JPS717_febForm G - Immunization - JPS717Form J - K12_Transportation RegChange - JPS717_febPrint_Area.pdfPrint_Area_2

Form K - Educational_School Meal Benefits 201920 - JPS717_english2019-20 Application for Educational BenefitsINSTRUCTIONS: Sources of IncomeOPTIONAL: Children’s Racial and Ethnic Identities

Form H - FERPA - JPS717_new.pdfAll Forms_Gr1_12_Packet_new_2Form A - Registration - JPS717_newForm C - Child_Parent Status - JPS717_newForm K - Educational_School Meal Benefits 201920 - JPS717_english2019-20 Application for Educational BenefitsINSTRUCTIONS: Sources of IncomeOPTIONAL: Children’s Racial and Ethnic Identities

All Forms_Gr1_12_Packet_newCheck List - Jordan Public Schools Enrollment Guide_newForm A - Registration - JPS717_newForm B - Ethnic and Racial Demographic Designation2019-20 Ethnic and Racial Demographic Designation Form

Form B_1 - MN Language Survey - JPS717_newForm C - Child_Parent Status - JPS717_newForm D - Release Records - JPS717_newForm E - Emergency Contact - JPS717_newForm F - Health Info - JPS717_newForm G - Immunization - JPS717Form H - FERPA - JPS717Form I - Technology Acceptable Use Policy - JPS717_newForm I_1 - Digital Device Insurance Agreement - JPS717_newForm J - K12_Transportation RegChange - JPS717Form K - Educational_School Meal Benefits 201819 - JPS717_englishForm K_1 - Waiver of Conf - JPS717

Check List - Jordan Public Schools Enrollment Guide_new_1

Student Last Name: Student First Name: Student Middle Name: A_Radio Button Translation 1: OffB_Radio Button Translation 1: OffB_Radio Button Translation 2: OffStudent Birth Date: B_Radio Button Translation 3: OffB_Radio Button Translation 4: OffB_Radio Button Translation 5: OffB_Radio Button Translation 6: OffB_Radio Button Translation 7: OffName 2: Name 2a: Address Form E: Address Form E_2: Primary Phone Form E: Primary Phone Form E_2: Email Address 2: Email Address 2a: Emergency Contact Name 1: Relationship to Student 1: Phone 1: Emergency Contact Name 2: Relationship to Student 2: Phone 2: Emergency Contact Name 3: Relationship to Student 3: Phone 3: Emergency Contact Name 4: Relationship to Student 4: Phone 4: Physician: Phone 5: Dentist: Phone 6: Hospital: Phone 7: Concerns: Check Box 1: OffCheck Box 2: OffE_explain: Check Box 3: OffCheck Box 4: OffStudent_Primary_Address: Student_Primary_City 2: Student_Primary_State 2: Student_Primary_Zip Code 2: F_Date of Enrollment: I_Registering Adult Last Name: I_Registering Adult First Name: I_Registering Adult Middle Name: I_Adult Birth Date: ELS_I_Check Box1: OffELS_I_Check Box2: OffELS_I_Check Box3: OffELS_I_Check Box4: OffELS_I_Check Box5: OffELS_I_Check Box6: OffELS_I_Check Box9: OffELS_I_Check Box12: OffELS_I_Check Box7: OffELS_I_Check Box10: OffELS_I_Check Box13: OffYEarly income: ELS_I_Check Box11: OffELS_I_Check Box8: OffELS_I_Check Box14: Offnumber of people in the house: I_Radio Button Interpreter 1: OffELS_I_Check Box15: OffELS_I_Check Box19: OffELS_I_Check Box16: OffELS_I_Check Box20: OffELS_I_Check Box17: OffELS_I_Check Box21: OffELS_I_Check Box18: OffELS_I_Check Box22: OffI_ELS_Signature: I_ELS_Signature_Printed Name: D_ELS_Signature_Date: J-1_Radio Button 1: OffJ-1_Radio Button 2: OffJ-1_Radio Button 3: OffJ-1_Radio Button 4: OffHome Phone 2: Cell Phone 2: Work Phone 2: Cell Phone 2a: Work Phone 2a: K1_School 1: K-1_Signature: K-1_Signature_Printed Name: K-1_Signature_Date: Student Grade: A_Check Box3: OffA_Check Box 7: OffA_Check Box 8: OffA_Check Box 9: OffA_Check Box 10: OffA_Check Box 10_1: OffA_list other 2: Occupation 2: Occupation 2a: Home Phone 2a: A_Check Box 13: OffA_Check Box 14: OffA_Check Box 15: OffA_Check Box 16: OffA_Check Box 17: OffA_Check Box 17_1: OffStudent_Seconday_Address: Student_Secondary_City 2: Student_Secondary_State 2: Student_Secondary_Zip Code 2: A_list other 3: Name 3: Name 3a: Occupation 3: Occupation 3a: Home Phone 3: Home Phone 3a: Cell Phone 3: Cell Phone 3a: Work Phone 3: Work Phone 3a: Email Address 3: Email Address 3a: A_Radio Button Ag 8: OffRadio Button Military 1: OffRadio Button Military 2: OffRadio Button Military 4: Offtranslation language needed: A_Check Box 20: OffA_Check Box 21: OffA_Check Box 22: OffA_Check Box 23: OffA_Check Box 24: OffA_Check Box 25: OffA_Check Box 26: OffA_Check Box 27: OffA_Check Box 28: OffA_Check Box 29: OffA_Check Box 30: OffA_Other 7: A_Name 4: A_Date of Birth 4: A_Male or Female 4: A_Grade Level 4: A_Name 5: A_Date of Birth 5: A_Male or Female 5: A_Grade Level 5: A_Name 6: A_Date of Birth 6: A_Male or Female 6: A_Grade Level 6: A_Name 7: A_Date of Birth 7: A_Male or Female 7: A_Grade Level 7: Student Middle Initial: Distict: School_B: B_Check Box 1: OffB_Check Box 4: OffB_Check Box 5: OffA_Check Box 41: OffB_Check Box 9: OffB_Check Box 10: OffB_Check Box 2: OffB_Check Box 3: OffB_Check Box 7: OffB_Check Box 8: OffB_Check Box 11: OffB_Check Box 13: OffB_Check Box 14: OffB_Check Box 12: OffB_Check Box 15: OffB_Check Box 16: OffB_Check Box 17: OffB_Check Box 20: OffB_Check Box 21: OffB_Check Box 22: OffB_Check Box 26: OffB_Check Box 27: OffB_Check Box 18: OffB_Check Box 19: OffB_Check Box 23: OffB_Check Box 24: OffB_Check Box 25: OffB_Check Box 28: OffB_Check Box 31: OffB_Check Box 32: OffB_Check Box 33: OffB_Check Box 29: OffB_Check Box 30: OffB_Check Box 34: OffB_Check Box 35: OffB_Check Box 36: OffB1_Check Box1: OffB1_Check Box2: OffB1_Check Box3: OffB1_Check Box4: OffB1_Check Box5: OffB1_Check Box6: OffB1_Check Box7: OffB1_Check Box8: OffB1_Check Box9: OffB1_Check Box10: OffB1_Check Box11: OffB1_Check Box12: OffB1_language_1: B1_language_2: B1_language_3: B1_language_4: Signature_Printed Name: Signature_Date: C_Check Box1: OffC_Check Box2: OffC_Check Box3: OffC_Check Box4: OffC_Check Box5: OffC_Check Box6: OffC_Check Box7: OffC_Check Box8: OffC_name 1: C_name 1a: C_other rights: C_Check Box 9: OffC_Check Box 10: OffC_Check Box 11: OffC_Check Box 12: OffC_Check Box 13_1: OffC_name 2: C_name 2a: C_name 3: C_name 3a: C_name 4: C_name 4a: C_name 5: C_name 5a: C_Radio Button 1: OffC_Check Box15: OffC_Check Box16: OffC_Check Box17: OffC_Check Box18: OffC_Notterminated_name_1: C_Notterminated_address_1: C_Notterminated_name_2: C_Notterminated_address_2: C_Check Box19: OffC_Check Box20: OffC_Secondary Name: C_Secondary Address: C_Secondary Phone: C_Secondary Email: C_Signature: Student Gender_Check Box 1: OffStudent Gender_Check Box 2: OffMo/Day/Yr 1: Mo/Day/Yr 2: Mo/Day/Yr 3: Mo/Day/Yr 4: Mo/Day/Yr 5: Mo/Day/Yr 6: Mo/Day/Yr 7: Mo/Day/Yr 8: Mo/Day/Yr 9: Mo/Day/Yr 10: Mo/Day/Yr 11: Mo/Day/Yr 12: Mo/Day/Yr 13: Mo/Day/Yr 14: Mo/Day/Yr 15: Mo/Day/Yr 16: Mo/Day/Yr 17: Mo/Day/Yr 18: Mo/Day/Yr 19: Mo/Day/Yr 20: Mo/Day/Yr 21: Mo/Day/Yr 22: Mo/Day/Yr 23: Mo/Day/Yr 24: Mo/Day/Yr 25: Mo/Day/Yr 26: Mo/Day/Yr 27: Mo/Day/Yr 28: Mo/Day/Yr 29: H_Check Box 6: OffH_Check Box 7: OffH_Check Box 8: OffH_Check Box 9: OffH_Check Box 10: OffH_Check Box 11: OffH_Check Box 12: OffH_Check Box 13: OffH_Check Box 14: OffK1_Yes box: OffK1_Name 1: K1_Name 2: K1_School 2: K1_Name 3: K1_School 3: K1_Name 4: K1_School 4: K1_Name 5: EECover_Check Box1: OffEECover_Check Box2: OffEECover_Check Box3: OffEECover_Check Box4: OffEECover_Check Box5: OffEECover_Check Box6: OffEECover_Check Box7: OffEECover_Check Box10: OffEECover_Check Box11: OffEECover_Check Box12: OffEECover_Check Box8: OffEECover_Check Box9: OffEECover_Check Box13: OffEECover_Check Box14: OffPreferred Language 2: Preferred Language 2a: Preferred Language 3: Preferred Language 3a: Year entered: Student Birth county: A Military other: A Military enlistment date: A_Signature: D_ELS_Signature: D_ELS_Signature_Printed Name: Last Name: First Name: Middle Name: Birth Date 1: Radio Button Ethnicity 8: OffRadio Button Ethnicity 9: OffH_Check Box 1: OffH_Check Box 2: OffH_Check Box 3: OffH_Check Box 4: OffH_Check Box 5: OffName of current school: H_Signature: H_Student Signature: Name of District: N_Address Info: N_City: N_State: N_Zip: N_Phone: B1_Signature: N_Signature: J-1_Check Box1: OffJ-1_Check Box2: OffJ-1_Check Box3: OffJ-1_Check Box4: OffJ-1_Check Box5: OffJ-1_Check Box6: OffJ-1_Check Box8: OffJ-1_Check Box9: OffJ-1_Check Box10: OffJ-1_Check Box11: OffJ-1_Check Box12: OffJ-1_Check Box13: Off

preschool enrollment guide - jordan.k12.mn.us · 1/28/2020 · filipino hmong karen korean...

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