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Spokane Public Schools Student Registration

School:

OFFICE USE
Student Identification

PERMIT

FTE

PROGRAM

TEACHER

ROOM

Entry Date

_______________________________________________________________________________________________________________________________

Student Name (Must be LEGAL name)

Last

First

Middle

_______________________________________________________________________________________________________________________________
Other Name (If different from LEGAL NAME)


________________ ___________________
Entering Grade
Gender

Male

Birthdate

Verified

_________________ __________________________
Sibling(s)

Language

Female

PARENT / GUARDIAN INFORMATION EMANCIPATED STUDENT


UNACCOMPANIED YOUTH
PRIMARY RESIDENCE
Student resides with this household Yes

FOSTER CARE
No

1. Relationship to Student: Mother Father Name _________________________________________________________________________________


Other ____________________ Responsible for Student

Residence Address_______________________________________________________________________________ Zip____________________________


Mailing Address if Different__________________________________________________________________________ Zip____________________________
Primary Phone Number________________________________________
Unlisted

Cell/Other Phone__________________________________________

Employer________________________________________________________________ Work Phone______________________________________________


E-mail__________________________________________________________________________________________________________________________
2. Relationship to Student: Mother

Father Name _________________________________________________________________________________


Other ____________________ Responsible for Student
Primary Phone Number_________________________________________
Unlisted

Cell/Other Phone__________________________________________

Employer________________________________________________________________ Work Phone______________________________________________


E-mail__________________________________________________________________________________________________________________________

SECONDARY RESIDENCE

Student resides with this household

Yes

No

1. Relationship to Student: Mother Father Name _________________________________________________________________________________


Other ____________________ Responsible for Student
Address_________________________________________________________________________________________ Zip____________________________
Mailing Address if Different__________________________________________________________________________ Zip____________________________
Primary Phone Number_________________________________________
Unlisted

Cell/Other Phone__________________________________________

Employer________________________________________________________________ Work Phone______________________________________________


E-mail__________________________________________________________________________________________________________________________
2. Relationship to Student: Mother

Other ____________________

Father Name _________________________________________________________________________________


Responsible for Student

Primary Phone Number_________________________________________


Unlisted

Cell/Other Phone__________________________________________

Employer________________________________________________________________ Work Phone______________________________________________


E-mail__________________________________________________________________________________________________________________________
Form 02-0020 0F-2024 Rev. 02/2016
Retention: Enrollment +2 years

Page 1 of 4

Spokane Public Schools Student Registration


I authorize my child to participate
in field trips conducted under the
supervision of Spokane Public
Schools:

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

Name______________________________________ Relationship _______________________________________________


I authorize emergency treatment
of this child by staff of any
hospital emergency room:

Yes No

Primary Phone_______________________________ Cell/Other ________________________________________________


hone________________________ Before School After School
Daycare____________________________________ P

M
T
W
TH
F
hone_________________ HOSPITAL__________________________
Doctor_____________________________________ P

Name and Address of Other Responsible Legal Agency ___________________________________________________________________________________


Contact person____________________________________________________________________ Phone ________________________________________
PHYSICIAN ORDERS AND NURSING CARE PLAN MUST BE IN PLACE BEFORE ANY CHILD WITH A LIFE-THREATENING HEALTH CONDITION MAY
ATTEND SCHOOL. RWA28A.210
IF MEDICATION WILL BE TAKEN AT SCHOOL, PLEASE OBTAIN THE NECESSARY FORMS FOR AUTHORIZATION FROM THE SCHOOL OFFICE.
Is a language other than English spoken at home?

No Yes_

What Language _________________________________________________________

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

Childs Primary Language____________________________________________

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.

Withhold directory information ONLY from the military.

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 Assumption of Risk

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.

Form 02-0020 0F-2024 Rev. 02/2016


Retention: Enrollment +2 years

I understand that this

Page 2 of 4

Spokane Public Schools Student Registration


ETHNICITY AND RACE
Question 1. Is your child of Hispanic or Latino

origin? (Check all that apply.)
NOT HISPANIC/LATINO
CUBAN
DOMINICAN
SPANIARD
PUERTO RICAN
MEXICAN / MEXICAN AMERICAN / CHICANO
CENTRAL AMERICAN
SOUTH AMERICAN
LATIN AMERICAN
OTHER HISPANIC/LATINO
Question 2. What race(s) do you consider your

child? (Check all that apply.)

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

If YES, in what grade?_________________

PLACEMENT (Information will be kept confidential.)


WE BELIEVE THOUGHTFUL PLACEMENT IMPROVES THE LIKELIHOOD OF SCHOOL SUCCESS.
Does student have a history of placement in a Special Education Program?
Please indicate special programs in which your child has been enrolled.
Does the student have a current 504 plan ?


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 ?

LAP (Learning Assistance)

Has the student been involved in any of the following ?


Suspension(s)
Weapons

Expulsion(s)
BECCA Petition (Court order to attend school)


Attendance Problems

Does student have unpaid fines or fees imposed by other schools?


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: ________________________________________________
______________________________________________________________________________________________________________________________

Form 02-0020 0F-2024 Rev. 02/2016


Retention: Enrollment +2 years

Page 3 of 4

Spokane Public Schools Student Registration

Student Name:

SCHOOLS ATTENDED AT OTHER SCHOOL DISTRICTS

9 - 12 GRADE

( This information is required content for the Washington State High School Transcript )

SCHOOL NAME, CITY, STATE

FROM DATE

TO DATE

___________________________________________________________________________________________ ________________ _______________


___________________________________________________________________________________________ ________________ _______________
___________________________________________________________________________________________ ________________ _______________
___________________________________________________________________________________________ ________________ _______________
___________________________________________________________________________________________ ________________ _______________

Attended SPOKANE PUBLIC SCHOOLS before?

Yes

No

If YES, indicate school and year __________________________________________

If transferring from another School District, what District/School? ___________________________________________________________________________


City/State: ________________________________________ , ___________ Does student now reside within Spokane Schools boundary? Yes

No

If NO, what District/School? ________________________________________________________________________________________________________

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___________________________

Form 02-0020 0F-2024 Rev. 02/2016


Retention: Enrollment +2 years

__________________________________________
DATE

Page 4 of 4

Part C

McKinney-Vento Questionnaire Form


Student Name:

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

White Copy: HEART Program

Yellow Copy: Parent

Certificate of Immunization Status (CIS)


DOH 348-013 January 2015

Office Use Only:

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

Tetanus, Diphtheria (Td)

1
2
Haemophilus influenzae type b (Hib)
1
2
3
4
Influenza (flu, most recent)

Vaccine

Dose

Date
Month

Day

Year

Pneumococcal (PCV, PPSV)


1
2
3
4
5
Polio (IPV, OPV)
1
2
3
4
Measles, Mumps, Rubella (MMR)
1
2

Varicella (chickenpox)
1
2

Hepatitis A (Hep A)
1
2

Human Papillomavirus (HPV) does not


print from the IIS; write dates in by hand
1
2
3

Meningococcal (MCV, MPSV)


1
2

If the child named on this CIS had chickenpox


disease (and not the vaccine), disease history
must be verified.
Mark option 1, 2, OR 3 below (see # 5 on back)
1) Chickenpox disease verified by printout from
the Immunization Information System (IIS)
Must be marked by printout (not by hand) to be valid.
2) Chickenpox disease verified by healthcare
provider (HCP)
If you choose this box, mark 2A OR 2B below.
2A) Signed note from HCP attached OR
2B) HCP sign here and print name below:
Licensed healthcare provider signature
(MD, DO, ND, PA, ARNP)

Date

Printed Name:
3) Chickenpox disease verified by school staff
from the Immunization Information System

If the child can show immunity by blood test


(titer) and hasnt had the vaccine, ask your HCP
to fill in this box.

Documentation of Disease Immunity

I certify that the child named on this CIS has


laboratory evidence of immunity (titer) to the
diseases marked.
Signed lab report(s) MUST also be attached.

Diphtheria
Hepatitis A
Hepatitis B
Hib
Measles

Mumps
Polio
Rubella
Tetanus
Varicella

Other:
_______________
_______________

Licensed healthcare provider signature


(MD, DO, ND, PA, ARNP)
Printed Name:

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

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


Vaccine column and the date each dose was received in the Month, Day, and Year columns (as
DTaP
01
12
2011
1
mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, 11, fill in as shown here
DTaP
03
20
2011
2
#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the
Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria,
DTaP
06
01
2011
3
Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.
#5 If your child had chickenpox (varicella) disease and not the vaccine, use only one of these three options to record this on the CIS:
1) If your childs CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box 1 is automatically
marked. To be valid, this box must be marked by the IIS printout (not by hand).
2) If your healthcare provider can verify that your child had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your provider, or
2B if your provider signs and dates in the space provided. Be sure your providers full name is also printed.
3) If school staff access the IIS and see verification that your child had chickenpox, they will mark box 3.
#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your healthcare provider fill in
this box. Ask your provider to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.
#7 Be sure to sign and date the CIS, and return to the school or child care.
Vaccine Trade Names in alphabetical order
Trade Name

Vaccine

(For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)

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

Vaccine Abbreviations in alphabetical order


Abbreviations

Full Vaccine Name

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

(For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)


Full Vaccine Name
Hepatitis A
Hepatitis B
Haemophilus influenzae
type b

Abbreviations

Human Papillomavirus

OPV

MPSV or MPSV4
MMR / MMRV

Full Vaccine Name


Meningococcal
Polysaccharide Vaccine
Measles, Mumps, Rubella /
with Varicella

Abbreviations
Rota
(RV1 or RV5)

Full Vaccine Name

Td

Tetanus, Diphtheria

Oral Poliovirus Vccine

Tdap

Tetanus, Diphtheria, acellular


Pertussis

TIG

Tetanus immune globulin

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

DOH 348-013 January 2015

English

Office of Superintendent of Public Instruction (OSPI)


Home Language Survey

Student Name:
Birth Date:

Date:
Gender:

Grade:

Form Completed by:


Parent/Guardian Name

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__

1. In what country was your child born?

____________________

2. What language did your child first learn to speak?*

__________________

3. What language does YOUR CHILD use the most at home?*

____________________

4. What language(s) do parent/guardians use the most when you speak

_____________________
_____________________

to your child?
5. Has your child ever received formal education* outside of the United

States?

(Kindergarten 12th grade)

_____Yes

_____No

If yes, in what language(s)


was instruction given?
_____________________
For how many months? ____

Formal education does not include refugee camps or other unaccredited


programs for children.
6. When did your child first attend a school in the United States?
(Kindergarten 12th grade)

_______________________
Month
Day
Year

7. Do grandparent(s) or parent(s) have a Native American tribal

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

The Purpose of the Home Language Survey


The Home Language Survey is given to all students enrolling in Washington schools. The following
information should help answer some of the questions you may have about this form.
What is the purpose of the Home Language Survey?
The primary purpose of the Home Language Survey is to help identify students who may qualify for
support to help them develop the English language skills necessary for success in the classroom and who
may qualify for other services. It is important that this information be correctly recorded since it can
affect the eligibility of students for services they need to be successful in school. Testing may be
necessary to determine whether or not additional language and academic supports are needed. No
student will be placed in an English language development program based solely on responses to this
form.
Why do you ask about the students first language and language(s) used in the home?
The two questions about the students language help us to determine:
if your student may be eligible for assistance with learning English, and
whether staff at the school should be aware of other languages being used by the student at home.
The language your child first learned may be different from the language your child uses for
communication at home now. The responses to both of these questions will assist the school in providing
instruction appropriate to the individual students needs as well as help with communication needs that
may arise. Students who first learned a language other than English may qualify for additional supports.
Even students who speak English well may still need support in developing the language skills needed to
be successful in school.
Why do you ask where the student was born?
This information helps the school district and the state determine if the student meets the definition of
immigrant for the purposes of federal funding. This applies even when the students parents are both US
citizens, but the student was born outside of the United States. This form is not used to identify students
who may be undocumented.
Why do you ask about my students previous education?
Information about a students education will help ensure that the students education both within and
outside of the United States is considered in any recommendations made for participation in programs and
district services. The students educational background is also important information to help determine if
the student is making adequate progress toward state standards based on their prior educational
background.

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

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