richmond community schools€¦ · richmond community schools 35276 division * richmond, michigan...

Guaranteed Learning for All Students! Rev 6/2019

Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565 * (586) 727-2098 (FAX) * www.richmond.k12.mi.us

Kindergarten Registration Packet Checklist Welcome to Richmond Community Schools! The following forms must be completed to register your student. Registration only takes a few minutes if the forms are filled out in advance. Please check each line to ensure that you have completed all information. Student Name: _______________________________________________________________________________________ Student Registration Packet (must be completed)

____ Student Registration Form (pages 1-4) Documentation Required for Registration: ☐ Birth Certificate – Original document with the official seal ☐ Parent Identification (Driver’s License or State ID) ☐ Current IEP (Special Education only) ☐ Immunization Record

☐ Custody Papers (if applicable) ☐ Hearing and Vision Testing - REQUIRED ☐ 2 Required Proofs of Residency

One Item listed here: Lease or Mortgage Statement, Purchase Agreement, Property Tax Bill, Deed, Building Permit, Voters Registration

One Item listed here: Utility Bill, Rent Payment Receipts, a copy of money order made for payment of rent, or letter from employer that is written on company letterhead.

☐ Residency Verification Form – Required only if family of student is living with another family already residing in the district (doubled up) **Proof of Residency will be required from both the homeowner/leaser and family residing within the home. ☐ Technology Agreement(K-2nd Form or 3rd-12th Form) ☐ Handbook Acknowledgement Form

Required Health Forms: ______ Statement of Varicella Disease – Only if student has had Chicken Pox (Varicella) Additional Forms to Complete: _____ School of Choice – Required only if you are a non-resident and wish for your child to attend Richmond Schools _____ Kindergarten Waiver Request – Required only if the child will not be age five on September 1 but will be five years of age no

later than December 1. _____ Free and Reduced Lunch Application – Required only if applicable

_____ Indian Education Form – Required only if applicable

_____ Pesticide Notification Advisory to Parents _____ Pay to Participate Information _____ Do Not Photo/Video Form Authorization for:

_____Prescribed Medication Form – Grades K-12th _____Non-prescribed Medication Form– Grades 5th-12th

http://www.richmond.k12.mi.us/


In compliance with Title VI of the Civil Rights Act of 1964, Title IX of the Education amendments of 1972, Section 504 of Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disability Act of 1990, and Elliott-Larsen Civil Rights Act of 1977, it is the policy of the Richmond Community School District that no person shall, on the basis of race, color, religion ,military status, national origin or ancestry, sex (including sexual orientation), disability, age (except as authorized by law,) height, weight, or marital status be excluded from participation in, be denied the benefits of, or be subjected to, discrimination during any program, activity, service or employment. Inquiries related to any nondiscrimination policies should be directed to the Superintendent, 35276 Division Road, Richmond, MI 48062, (586) 727-3565.

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STUDENT REGISTRATION INFORMATION

STUDENT INFORMATION

Last Name First Name Middle Name Gender Grade

□ M □ F Home Street Address (w/ apt. Suite) City Zip Code

Mailing Address (if different than Home) Student Telephone Home Telephone

□ Unlisted

Is your current living arrangement a result of loss of housing or economic hardship? □ Yes □ No □ Unsure

If YES, a Richmond Community Schools’ employee will complete a homeless student referral form in order to determine your eligibility for services under the McKinney-Vento Act.

Resident School District Ethnicity (Please check one from the list below):

(1) American Indian/Alaskan Native (5) White

(2) Asian American (6) Hispanic or Latino

Student’s Date of Birth (3) Black or African American (7) Multi-Racial

(4) Native Hawaiian/Other Pacific Islander

Birth City/State (If Born in US) Student’s Order of Birth Please circle:

01 02 03 04 05 06 07 08

Military Family: □ Yes □ No Relationship to student:

Email Address (REQUIRED)

HOME LANGUAGE SURVEY

Is your child’s native tongue a language other than English?

□ Yes □ No If yes, what is the language?

Is the primary language used in your child’s home environment a language other than English? “Primary Language” means the dominant language used by a person for communication.

□ Yes □ No If yes, what is the language?

What country was your child born in?

US Citizen? □ Yes □ No

Date Entered US _____Month _____ Year

First Attended School in US? _____Month _____ Year

Country of Birth




FORMER SCHOOL

Attended Richmond Community Schools Before? □ Yes □ No If yes, school attended?

Former District

Former School

Former School Address

Former School City, State and Zip Suspended or Expelled from Former School? □ Yes □ No

STUDENT SUPPORT SERVICES AT FORMER SCHOOL

□ Special Education □ Speech & Language □ Social Work □ Title I □ Health Plan □ 504 Plan

□ IEP/MET □ English Learner Services Please describe service or other services received but not listed above.

HEALTH INFORMATION

Preferred Hospital

Name and Schedule for Medications

Emergency Medical Alert, Allergies or Conditions

Physical Limitations (Explain)

□ Asthma □ Diabetes □ Vision Problem □ Hearing Problem □ Heart Conditions

Physician Name

Physician Telephone

Dentist Name

Dentist Telephone

TRANSPORTATION

Do you want transportation for your child? If your child is eligible for transportation, you will be contacted by our transportation department.

□ Yes □ No




COURT DOCUMENTATION

Are there Court documents regarding custody of the child? If YES, please provide a copy of those documents for the school record.

□ Yes □ No

OTHER FAMILY MEMBERS

Are there other students in the same household attending Richmond Community Schools? If YES, please list their names and birthdates below. □ Yes □ No

First and Last Name Birthdate First and Last Name Birthdate

CONCUSSION AWARENESS EDUCATIONAL MATERIAL ACKNOWLEDGEMENT FORM

By my name and signature below, I acknowledge in accordance with Public Act 342 and 343 of 2012 that I have received and reviewed the Concussion Fact Sheet for Parents and/or Concussion Fact Sheet for Students provided by Richmond Community Schools.

Parent or Guardian Name Printed

Parent or Guardian Name Signature

Date

THE CONCUSSION AWARENESS EDUCATIONAL MATERIAL ACKNOWLEDGEMENT FORM shall be kept on file with the student CA60 for the duration of attendance in Richmond Community Schools or age 18. Students and parents should review and keep the educational materials available for future reference.




PARENT/GUARDIAN 1 PARENT/GUARDIAN 2

First Name First Name Last Name Last Name Relationship to Student Relationship to Student Emergency Contact Priority? (Circle one)

01 02 03 04 Emergency Contact Priority? (Circle one)

01 02 03 04 Address Address City & Zip City & Zip Home Telephone Home Telephone Cellular Telephone #1 Cellular Telephone #1 Cellular Telephone #2 Cellular Telephone #2 Employer Employer Work Telephone Work Telephone Email Address Email Address Resides with Student? □ Yes □ No Resides with Student? □ Yes □ No Receives Letter Mailings? □ Yes □ No Receives Letter Mailings? □ Yes □ No

CONTACT 3 CONTACT 4

First Name First Name Last Name Last Name Relationship to Student Relationship to Student Emergency Contact Priority? (Circle one)

01 02 03 04 Emergency Contact Priority? (Circle one)

01 02 03 04 Address Address City & Zip City & Zip Home Telephone Home Telephone Cellular Telephone #1 Cellular Telephone #1 Cellular Telephone #2 Cellular Telephone #2 Employer Employer Work Telephone Work Telephone Email Address Email Address Resides with Student? □ Yes □ No Resides with Student? □ Yes □ No Receives Letter Mailings? □ Yes □ No Receives Letter Mailings? □ Yes □ No

I certify that the information on this registration form is true and correct to the best of my knowledge.

_____________________________ ______________ Parent/Guardian Signature Date



Page 1 | 1 2019-2020 School Year

STATEMENT OF VARICELLA DISEASE

Richmond Community Schools

CONCUSSION FACT SHEET FOR PARENTS

WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury. Concussions are caused by a bump or blow to the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

You can’t see a concussion. Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If your child reports any symptoms of concussion, or if you notice the symptoms yourself, seek medical attention right away.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION? If your child has experienced a bump or blow to the head during a game or practice, look for any of the following signs of a concussion:

SYMPTOMS REPORTED BY ATHLETE:

• Headache or “pressure” in head• Nausea or vomiting• Balance problems or dizziness• Double or blurry vision• Sensitivity to light• Sensitivity to noise• Feeling sluggish, hazy, foggy, or groggy• Concentration or memory problems• Confusion• Just not “feeling right” or is “feeling down”

SIGNS OBSERVED BY PARENTS/ GUARDIANS:

• Appears dazed or stunned• Is confused about assignment or position• Forgets an instruction• Is unsure of game, score, or opponent• Moves clumsily• Answers questions slowly• Loses consciousness (even briefly)• Shows mood, behavior, or personality changes

[ INSERT YOUR LOGO ]

DANGER SIGNS

Be alert for symptoms that worsen over time. Your child or teen should be seen in an emergency department right away if s/he has:

• One pupil (the black part in the middle of the eye)larger than the other

• Drowsiness or cannot be awakened• A headache that gets worse and does not go away• Weakness, numbness, or decreased coordination• Repeated vomiting or nausea• Slurred speech• Convulsions or seizures• Difficulty recognizing people or places• Increasing confusion, restlessness, or agitation• Unusual behavior• Loss of consciousness (even a brief loss of

consciousness should be taken seriously)

WHAT SHOULD YOU DO IF YOU THINK YOUR CHILD HAS A CONCUSSION?

1. SEEK MEDICAL ATTENTION RIGHT AWAYA health care professional will be able to decide howserious the concussion is and when it is safe for yourchild to return to regular activities, including sports.

2. KEEP YOUR CHILD OUT OF PLAY.Concussions take time to heal. Don’t let your childreturn to play the day of the injury and until a healthcare professional says it’s OK. Children who return toplay too soon - while the brain is still healing - risk agreater chance of having a second concussion. Repeator later concussions can be very serious. They cancause permanent brain damage, affecting your child fora lifetime.

3. TELL YOUR CHILD’S COACH ABOUTANY PREVIOUS CONCUSSION.Coaches should know if your child had a previousconcussion. Your child’s coach may not know about aconcussion your child received in another sport oractivity unless you tell the coach.

HOW CAN YOU HELP YOUR CHILD PREVENT A CONCUSSION OR OTHER SERIOUS BRAIN INJURY? • Ensure that they follow their coach’s rules for safety

and the rules of the sport.• Encourage them to practice good sportsmanship at

all times.• Make sure they wear the right protective equipment

for their activity. Protective equipment should fitproperly and be well maintained.

• Wearing a helmet is a must to reduce the risk of aserious brain injury or skull fracture.• However, helmets are not designed to prevent

concussions. There is no “concussion-proof”helmet. So, even with a helmet, it is importantfor kids and teens to avoid hits to the head.

HOW CAN I HELP MY CHILD RETURN TO SCHOOL SAFELY AFTER A CONCUSSION?

Children and teens who return to school after a concussion may need to:

• Take rest breaks as needed• Spend fewer hours at school• Be given more time to take tests or complete

assignments• Receive help with schoolwork• Reduce time spent reading, writing, or on the computer

Talk with your child’s teachers, school nurse, coach, speech-language pathologist, or counselor about your child’s concussion and symptoms. As your child’s symptoms decrease, the extra help or support can be removed gradually.

JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp

TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION

Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).



Page 1 | 1

2019-2020 School Year




RESIDENCY VERIFICATION FORM This form must be completed, in the presence of a Richmond Community Schools staff member enrolling the student, whenever a parent cannot verify that s/he owns or rents a residence in the District.

Student’s Name: ____________________________________________

School: ____________________________________________

Parent’s Name: ____________________________________________ Although I do not own or rent a residence in the District, this is to certify that I am the custodial parent of my child named above and our current permanent residence is:

Address City Zip

Where we are living as guest of:

First and Last Name Telephone

Who (□ owns □ rents) this residence. Should I change this, my permanent residence, I understand that my child may no longer be eligible to attend school in the District. I will notify the school immediately if my residence changes.

Parent/Guardian’s Signature School District Witness Date

I certify that the above information is correct and the above named students(s) currently reside in my home.

Signature of Residence Owner/Renter Date

SWORN TO BEFORE ME and subscribed in my presence this ________ day of _____________, _________.

____________________________________________ ________________________________________

Notary Public Date




KINDERGARTEN AGE WAIVER REQUEST

According to Michigan Law (MCL 380.1147), if a child residing in the Richmond Community School District is not five years of age on September 1st, but will be five years of age not later than December 1st, the parent or legal guardian of that child may enroll the child in kindergarten for the current school year if the parent or legal guardian notifies the school district in writing not later than June 1st that he or she intends to enroll the child in kindergarten. If a child becomes a resident of the Richmond Community School District after June 1st, the child's parent or legal guardian may enroll the child in kindergarten for that school year if the parent or legal guardian submits this written notification not later than August 1st.

A school district that receives this written notification may make a recommendation to the parent or legal guardian as to whether the child is not ready to enroll in kindergarten due to the child's age or other factors. Regardless of the district recommendation, the parent or legal guardian retains the sole discretion to determine whether or not to enroll the child in kindergarten if the student is five years of age not later than December 1st.

Student Name Date of Birth:

Verification of Age (Check one): □ Birth certificate □ Citizenship Paper □ Court Record

□ Government Record □ Hospital Record □ Other

Evidence of School Readiness (provided by parent/guardian):

1.

2.

By signing this document, I am acknowledging that it is my intent to enroll my child into kindergarten for the 2019/2020 school year.

________________________________ ________________________________ _____________________ Parent/Guardian’s Printed Name Parent/Guardian’s Signature Date

RECOMMENDATION OF RICHMOND COMMUNITY SCHOOLS

□ Superintendent or his/her designee agrees with the recommendation of the parents to enroll their child inKindergarten.

□ Superintendent or his/her designee recommends kindergarten begin in September of next year for thefollowing reasons:

Superintendent’s Signature

Tenative List for 2019-2020 SCHOOL YEAR WILL L. LEE ELEMENTARY THESE ITEMS ARE NOT A REQUIREMENT

Kindergarten (Please do not label items with child’s name)

12 #2 yellow Ticonderoga pencils (sharpened; no designs please) 4 boxes of 24 count Crayola crayons** 10 Elmer’s glue sticks 2 large pink erasers One subject wide-ruled notebook 2 containers of Clorox disinfecting wipes Roll of paper towel 2 boxes of tissues to share Backpack large enough for Friday Folder Gym shoes with non-marking soles (for Gym) $15.00 donation for special projects Girls: 1 pkg. gallon size Ziploc bags Boys: 1 pkg. Wet Ones

**CRAYONS, GLUE AND PENCILS WILL NEED TO BE REPLENISHED PERIODICALLY** NO GEL PENS OR TRAPPER KEEPERS IN ANY GRADE

Your child’s teacher may send home a more specific list in August.

Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565

7000 – PROPERTY

7540.03-F1 REVISED 08-15-17

District Contact Person: Brian J. Walmsley, Ed.S., Superintendent [email protected] * (586) 727-3565

Page 1 of 2

K-2ND STUDENT/PARENT EDUCATIONAL TECHNOLOGY ACCEPTABLE USE AND SAFETY AGREEMENT

To access and use the District’s Educational technology, including a school assigned e-mail account and/or the Internet at school, students under the age of eighteen (18) must obtain parent permission and sign and return this form. Students eighteen (18) and over may sign their own forms. Use of the Educational Technology is a privilege, not a right. The District’s Technology, including its internet connection and online educational services, is provided for educational purposes only. Unauthorized and inappropriate use will result in a cancellation of this privilege and possible further disciplinary action. The Board has implemented technology protection measures, which protect against (e.g. block/filter) Internet access to visual displays/depictions/materials that are obscene, constitute child pornography, or are harmful to minors. The Board also monitors online activity of students in an effort to restrict access to child pornography and other material that is obscene, objectionable, inappropriate and/or harmful to minors. Nevertheless, parents/guardians are advised that determined users may be able to gain access to information, communication and/or services on the Internet that the Board has not authorized for educational purposes and/or that they and/or their parents/guardians may find inappropriate, offensive, objectionable or controversial. Students accessing the Internet through the school's computers assume personal responsibility and liability, both civil and criminal, for unauthorized or inappropriate use of the Internet. The Board has the right, that any time, to access, monitor, review and inspect any directories, files and/or messages residing on or sent using the Board's Education Technology. Messages relating to or in support of illegal activities will be reported to the appropriate authorities. Individual users have no expectation of privacy related to their use of the District’s Education Technology. Please complete the following information: First and Last Name of the Student (Please Print) School Grade Parent/Guardian’s Name

Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565

7000 – PROPERTY

7540.03-F1 REVISED 08-15-17


Page 2 of 2

PARENT/GUARDIAN As the parent/guardian of this student, I have read the Student Education Technology Acceptable Use and Safety Policy and Guidelines, and have discussed them with my child. I understand that student access to the Internet is designed for educational purposes and that the Board has taken available precautions to restrict and/or control student access to material on the Internet that is obscene, objectionable, inappropriate and/or harmful to minors. However, I recognize that it is impossible for the Board to restrict access to all objectionable and/or controversial materials that may be found on the Internet. I will not hold the Board (or any of its employees, administrators or officers) responsible for materials my child may acquire or come in contact with while on the Internet. Additionally, I accept responsibility for communicating to my child guidance concerning his/her acceptable use of the Internet - i.e., setting and conveying standards for my daughter/son to follow when selecting, sharing and exploring information and resources on the Internet. I further understand that individuals and families may be liable for violations. To the extent that proprietary rights in the design of a website hosted on the Board's servers would vest in my child upon creation, I agree to assign those rights to the Board. I give:

• Permission for the Board to issue an Internet/e-mail account to my child.

• Permission for my child's image (photograph) to be published online, provided only his/her first name is used.

• Permission for the Board to transmit "live" images of my child (as part of a group) over the Internet via a web cam.

• And authorize and license the Board to post my child's class work on the Internet without infringing

upon any copyright my child may own with respect to such class work. I understand only my child's first name will accompany such class work.

Parent/Guardian’s Signature Date



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Student-Parent Handbook Acknowledgement *Including Student-Athlete Code of Conduct Handbook*

It is understood that our signatures below acknowledge we have been informed that the Student-Parent Handbook and Student-Athlete Code of Conduct Handbook is available on the Richmond Community Schools District website. We also acknowledge that our signatures indicate our willingness to abide by the Student-Parent Handbook and the Student-Athlete Code of Conduct Handbook.

__________________________________ ____________________________________ Student’s Name Printed Parent or Guardian Name Printed

__________________________________ ____________________________________ Student’s Name Signature Parent or Guardian Name Signature __________________________________ ____________________________________ Date Date

**Any changes that are made to above named handbooks will be available online. Hard Copy versions are available in the school offices upon request.

Indian Education Grant Consortium Chippewa Valley Schools

L’Anse Creuse Public Schools

New Haven Community Schools

Richmond Community School District

Dear Parents:

Chippewa Valley Schools has a federal grant called The Indian Education Grant Consortium, which

includes students from Chippewa Valley, L’Anse Creuse, New Haven, and Richmond schools. The grant

offers, free of charge, tutoring and workshops.

Attached you will find the Student Eligibility Certification Form. We would appreciate it if you fill out

all areas, if possible, including membership, and/or enrollment number, if available.

You do not need to have a membership enrollment number, or supply proof of ancestry to participate in

this program but we do need the name of the organization you might belong to.

Please go to http://www.native-languages.org/states.htm and click on the state you think your heritage

may come from. Once you know the state, please go to http://www.ncsl.org/research/state-tribal-

institute/list-of-federal-and-state-recognized-tribes.aspx where you will find federally and state

recognized tribes by state.

To participate in this program the US Department of Education, Office of Indian Education, accepts

federally and state recognized tribes only.

This form needs to be signed by one of the parents and we need one per child.

Please sign and return this form in the attached self-addressed envelope to Chippewa Valley Schools as

soon as possible.

Please feel free to call me, if you have any questions or concerns.

Thank you,

Maria Chisholm

Facilitator of Special Grant Programs

Chippewa Valley Schools

Office: 586-723-2031

Fax: 586-723-2128

Cell: 586-615-1279

Mc/word/Indian Grant/Dear Parents Indian Grant Certification

http://www.native-languages.org/states.htm

http://www.ncsl.org/research/state-tribal-institute/list-of-federal-and-state-recognized-tribes.aspx

http://www.ncsl.org/research/state-tribal-institute/list-of-federal-and-state-recognized-tribes.aspx

OMB Number: 1810-0021 Expiration Date: 02/29/2020

U.S. Department of EducationOffice of Indian Education

Washington, DC 20202TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

Name of the Child _____________________________________________________ Date of Birth ________________ Grade ______ (As shown on school enrollment records)

Name of School _____________________________________________________________________________________________

TRIBAL ENROLLMENT

Name of the individual with tribal enrollment: _______________________________________________________________________ (Individual named must be a descendent in the first or second generation)

The individual with tribal membership is the: ______Child ______Child’s Parent ______Child’s Grandparent

Name of tribe or band for which individual above claims membership: ____________________________________________________

The Tribe or Band is (select only one):

_____ Federally Recognized

_____ State Recognized

_____ Terminated Tribe (Documentation required. Must attach to form)

_____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994. (Documentation required. Must attach to form)

Proof of enrollment in tribe or band listed above, as defined by tribe or band is:

A. Membership or enrollment number (if readily available) __________________________________________________________OR

B. Other Evidence of Membership in the tribe listed above (describe and attach) ___________________________________________

Name and address of tribe or band maintaining enrollment data for the individual listed above:

Name __________________________________________________ Address ____________________________________________

City ________________________________ State _____ Zip Code ____________

ATTESTATION STATEMENT

I verify that the information provided above is accurate.

Name Parent/Guardian ____________________________________ Signature ___________________________________________

Address _______________________________________ City __________________________ State ______ Zip Code ___________

Email Address __________________________________________ Date __________________

OMB Number: 1810-0021 Expiration Date: 02/29/2020

INSTRUCTIONS FOR THE ED 506 FORMFOR APPLICANTS:

PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local edu-cational agency provides a free public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under this subpart, and that otherwise meets the requirements of subsection (b)”.

MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year, which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.

FOR PARENTS/GUARDIANS:

DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band, including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Con-sidered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.

STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level.

TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandpar-ent, for whom you can provide membership information.

Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of suf-ficient detail to permit verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional docu-mentation is required and must be attached to this form.

• Federally Recognized - an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Depart-ment of Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request.

• State Recognized - an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Depart-ment of Education does not maintain a master list. It is recommended that you use official state websites only.

• Terminated Tribe - a tribal entity that once had a federally recognized status from the United States Department of Interior and had that designation terminated.

• Organized Indian Group - Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent, or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate. Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians.

ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.

The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act.

PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this informa-tion collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the ac-curacy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, SW, LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020.

richmond community schools€¦ · richmond community schools 35276 division * richmond, michigan...

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