Professional Documents
Culture Documents
School:
OFFICE USE
Student Identification
PERMIT
FTE
PROGRAM
TEACHER
ROOM
Entry Date
_______________________________________________________________________________________________________________________________
Last
First
Middle
_______________________________________________________________________________________________________________________________
Other Name (If different from LEGAL NAME)
________________ ___________________
Entering Grade
Gender
Male
Birthdate
Verified
_________________ __________________________
Sibling(s)
Language
Female
FOSTER CARE
No
Cell/Other Phone__________________________________________
Cell/Other Phone__________________________________________
SECONDARY RESIDENCE
Yes
No
Cell/Other Phone__________________________________________
Other ____________________
Cell/Other Phone__________________________________________
Page 1 of 4
Student Name:
OTHER EMERGENCY CONTACTS In case of illness/injury or other emergency, when household cannot
be contacted, I authorize Spokane Public Schools to call and/or release my child to one of the following:
Name______________________________________ Relationship _______________________________________________
Primary Phone_______________________________ Cell/Other ________________________________________________
Yes No
Yes No
No Yes_
What is the students country of birth? ____________________________ If NOT the U.S., please list the students U.S. entry date: ______________________
Does your child speak a language other than English at home?
English?
Yes No
Yes_ No
If yes, is the students first learned or home language anything other than
Interpreter needed?
Yes No
PRIVACY INFORMATION
Spokane Public Schools policy defines directory information as: name, address, telephone numbers, date of birth, field of study, photographs, participation in
officially recognized activities/sports, weight/height, attendance data, awards, previous schools attended, and other similar information that would not generally
be considered harmful or an invasion of privacy if disclosed. Directory information is NOT deliberately given to solicitors for commercial purposes.
PLEASE CHECK ONE OF THE BOXES BELOW
It is OK for Spokane Public Schools to release directory information to various agencies such as parent organizations, the media, colleges/universities, Free
Application for Federal Student Aid (FAFSA) Information and the military.
Withhold directory information. Students Name/Photo will NOT appear on Rosters, Honor Rolls, Yearbook, arts performance programs, Grad
Announcements, etc.
STUDENT EMAIL (This section for Middle School & High School Student Parent/Guardians only.)
Purposes and Benefits of Student Email
With parent/guardian approval we are offering students in grades 8 -12 an unrestricted e-mail account that will have full access to communicate with any other
Internet e-mail account. This account will be important to your student in college and career preparation activities, collaboration work with other students
and communication regarding school activities and events. If you choose to not authorize your student for district email it may be difficult for them to fully
participate and benefit from some classroom and career/college readiness activities as more and more services require students to provide an email address
for communication and registration. While the account is unrestricted, this email account is intended to be used by students solely and exclusively for purposes
consistent with Spokane Public Schools curricular and educational needs.
The School District will not voluntarily share student e-mail addresses with any party outside of the school district. However, the School District may be
compelled by public records laws or other laws to disclose district-provided student e-mail addresses and/or e-mail messages. Students have no right to privacy
or expectations of privacy when using a District issued e-mail account because, among other reasons, student e-mail accounts are subject to inspection by the
District at any time and shall be monitored by the District to assure compliance with district policy.
Email accounts carry with them certain inherent risks, which may include but are not limited to: the inadvertent dissemination of personal information or
other information that is desired to be private whether by the sender or as a result of an email being forwarded; receiving communication from unwanted,
unauthorized and/or dangerous persons; access to the email account by unauthorized persons; accessing email account when such distractions could result in
harm, such as while driving; and receiving threatening, harassing, sexually explicit, obscene or illegal emails.
PLEASE CHECK BOX IF APPROVED
It is OK for Spokane Public Schools to issue my student an unrestricted email address pursuant to the above information.
authorization will remain in effect for my student unless I provide further communication withdrawing my approval.
Page 2 of 4
AFRICAN AMERICAN/BLACK
WHITE
ASIAN INDIAN
CAMBODIAN
CHINESE
FILIPINO
HMONG
INDONESIAN
JAPANESE
Student Name:
KOREAN
LAOTIAN
MALAYSIAN
PAKISTANI
SINGAPOREAN
TAIWANESE
THAI
VIETNAMESE
OTHER ASIAN
KALISPEL
LOWER ELWHA
LUMMI
MAKAH
MUCKLESHOOT
NISQUALLY
NOOKSACK
PORT GAMBLE KLALLAM
PUYALLUP
QUILEUTE
QUINAULT
SAMISH
SAUK-SUIATTLE
SHOALWATER
SKOKAMISH
SNOQUALMIE
SPOKANE
SQUAXIN ISLAND
STILLAGUAMISH
SUQUAMISH
SWINOMISH
TULALIP
YAKAMA
OTHER WASHINGTON INDIAN
OTHER AMERICAN INDIAN / ALASKAN
NATIVE HAWAIIAN
FIJIAN
GUAMANIAN or CHAMORRO
MARIANA ISLANDER
MELANESIAN
MICRONESIAN
SAMOAN
TONGAN
OTHER PACIFIC ISLANDER
ALASKA NATIVE
CHEHALIS
COLVILLE
COWLITZ
HOH
JAMESTOWN
NATIVE
ELEMENTARY GRADES:
Did your child attend any of the following prior to kindergarten? Special Ed Preschool
HeadStart ECEAP Child Care Preschool
Other ____________________________________________________________________________________________________________________
Please indicate any behavior problems
Has your child been retained?
At home
In class
YES
NO
Playground
Towards: Students
School Staff
Family
YES
YES NO
Speech
Current IEP?
YES
NO
Physical Therapy
NO
Please describe any physical limitations that would necessitate special accommodations._______________________________________________________
Has the student attended an English Language Development (ELD) Program, or English as a Second Language (ESL) Program?
Has the student been involved in any of the following programs ?
Attendance Problems
YES
YES
NO
Title 1
Violence (fighting, harassment, etc.)
NO
Is middle or high school student planning to participate in extra curricular activities, sports, or clubs.
(If Yes, student must be passing all classes and have current physical on file.)
YES
NO
Please give any additional information that may help in the placement of this student in our school: ________________________________________________
______________________________________________________________________________________________________________________________
Page 3 of 4
Student Name:
9 - 12 GRADE
( This information is required content for the Washington State High School Transcript )
FROM DATE
TO DATE
Yes
No
No
PLEASE VERIFY ALL INFO IS COMPLETE and ACCURATE, COMPLETE PRIVACY INFORMATION ON PAGE 2 and PLACEMENT INFORMATION ON
PAGE 3, THEN SIGN AND DATE BELOW:
__________________________________________________________________________________
PARENT / GUARDIAN SIGNATURE___________________________
__________________________________________
DATE
Page 4 of 4
Part C
Date of Birth:
School Name:
Grade:
______
Your child may be eligible for additional educational services through Title X, Part C, Federal McKinney-Vento
Assistance Act. Eligibility can be determined by completing this questionnaire. The information you provide
is confidential. If eligible, students are to be immediately enrolled in accordance with The McKinney-Vento
Assistance Act.
1. Do you/your student live in any of these following situations?
In emergency or transitional shelter or program
Sharing the housing of other persons due to: (select one)
Loss of housing, economic hardship or a similar reason (i.e. evicted)
Long term, cooperative living arrangement
Other (please specify): _______________________________________
In a vehicle of any kind, park, public space, abandoned building, substandard housing, bus or
train station or similar setting
In a motel, hotel, campground or similar setting due to: (select one)
Lack of alternative adequate accommodations
A convenient living arrangement (i.e. waiting for apartment/home to be ready)
Other (please specify):________________________________________
None of the above
2. What is your/your students living situation? Please check one box.
Living with your legal parent or guardian
Living in an awaiting foster care placement (30 day dependency hearing has not occurred)
Living alone
Living with an adult that is not a legal parent or guardian
The undersigned certifies that the information provided is accurate:
Print name of person completing form:
Signature:
Date:
Address of current residence:
Phone number or message number:
For more information please contact the HEART program office at 354-7302.
Enrollment staff: Please forward questionnaire to the HEART program at the Administration Building.
02-0057 Web 20-0057W Rev. 3/14
Reviewed by:
Date:
Signed Cert. of Exemption on file? Yes No
Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System.
Childs Last Name:
First Name:
Middle Initial:
Birthdate (mm/dd/yyyy): Sex: I give permission to my childs school to share
immunization information with the Immunization
Information System to help the school maintain my
I certify that the information provided on this
Symbols below: Required for School and Child Care/Preschool
childs school record.
form is correct and verifiable.
Required for Child Care/Preschool Only
Recommended, but not required
Parent/Guardian Signature Required
Date Parent/Guardian Signature Required
Date
Vaccine
Dose
Date
Month
Day
Year
Hepatitis B (Hep B)
1
2
3
or Hep B - 2 dose alternate schedule for teens
1
2
Rotavirus (RV1, RV5)
1
2
3
Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
1
2
3
4
5
Tetanus, Diphtheria, Pertussis (Tdap)
1
1
2
Haemophilus influenzae type b (Hib)
1
2
3
4
Influenza (flu, most recent)
Vaccine
Dose
Date
Month
Day
Year
Varicella (chickenpox)
1
2
Hepatitis A (Hep A)
1
2
Date
Printed Name:
3) Chickenpox disease verified by school staff
from the Immunization Information System
Diphtheria
Hepatitis A
Hepatitis B
Hib
Measles
Mumps
Polio
Rubella
Tetanus
Varicella
Other:
_______________
_______________
Date
Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization
Information System (IIS) or filling it in by hand.
#1 To print with information filled in: First, ask if your healthcare providers office puts vaccination history into the WA Immunization
Information System (Washingtons statewide database). If they do, ask them to print the CIS from the IIS and your childs information will fill in automatically.
Be sure to review all the information, sign and date the CIS, and return it to school or child care. If your providers office does not use the IIS, ask for a
copy of your childs vaccine record so you can fill it in by hand using steps #2-7 (below):
EXAMPLE
#2 To fill in by hand: Print your childs name, birthdate, sex, and your own name in the top box.
#3 Write each vaccine your child received under the correct disease. Write the vaccine type under the
Vaccine
Dose
Month
Date
Day
Year
Vaccine
Trade
Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Ipol
Infanrix
Kinrix (Knrx)
Menactra
MenHibrix
(Mnhbrx)
Menomune
Menveo
Pediarix (Pdrx)
IPV
DTaP
DTaP + IPV
MCV or MCV4
Meningococcal C/YHIB-PRP
MPSV or MPSV4
Meningococcal
DTaP + Hep B + IPV
PedvaxHIB
Pentacel (Pntcl)
Pneumovax
Prevnar
Hib
DTaP + Hib + IPV
PPSV or PPV23
PCV or PCV7 or PCV13
Twinrix (Twnrx)
Vaqta
Varivax
Hep A + Hep B
Hep A
Varicella
ProQuad (PrQd)
MMR + Varicella
Recombivax HB
Rotarix
RotaTeq
Hep B
Rotavirus (RV1)
Rotavirus (RV5)
ActHIB
Adacel
Afluria
Boostrix
Hib
Tdap
Flu
Tdap
FluLaval
FluMist
Fluvirin
Fluzone
Flu
Flu
Flu
Flu
Cervarix
HPV2
Gardasil
HPV4
Daptacel
Engerix-B
Fluarix
DTaP
Hep B
Flu
Havrix
Hiberix
HibTITER
Hep A
Hib
Hib
DT
Diphtheria, Tetanus
DTaP
DTP
Flu
(IIV or LAIV)
Diphtheria, Tetanus,
acellular Pertussis
Diphtheria, Tetanus,
Pertussis
Abbreviations
Hep A (HAV)
Hep B (HBV)
Hib
HPV
Abbreviations
Human Papillomavirus
OPV
MPSV or MPSV4
MMR / MMRV
Abbreviations
Rota
(RV1 or RV5)
Td
Tetanus, Diphtheria
Tdap
TIG
VAR or VZV
Varicella
Inactivated Poliovirus
PCV or PCV7 or
Pneumococcal Conjugate
Vaccine
PCV13
Vaccine
Hepatitis B Immune
Meningococcal
Pneumococcal Polysaccharide
HBIG
MCV or MCV4
PPSV or PPV23
Globulin
Conjugate Vaccine
Vaccine
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711).
Influenza
IPV
Rotavirus
English
Student Name:
Birth Date:
Date:
Gender:
Grade:
Relationship to Student
Parent/Guardian Signature
If available, in what language would you prefer to receive communication from the school?
Did your child receive English language development support through the Transitional
Bilingual Instruction Program in the last school your child attended? Yes__ No__ Dont Know__
____________________
__________________
____________________
_____________________
_____________________
to your child?
5. Has your child ever received formal education* outside of the United
States?
_____Yes
_____No
_______________________
Month
Day
Year
affiliation?
_____Yes
_____No
*WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by
parents, guardians, or others) for communication in the student's place of residence.
Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing
May 2014
English
Thank you for providing the information needed on the Home Language Survey. Contact your school
district if you have further questions about this form or about services available at your childs school.
May 2014