ID #________________ Grade _____________ Grid Code _________ Entry Date _________ Entry Code ________ Teacher/Counselor_________
REGISTRATION FORM
Mesa County Valley School District 51 2115 Grand Avenue
Entered in SASI __ Copy to ESL ___
Grand Junction, CO 81501
School ___________________________
Please print and fill in all the information below.
Student Information Section 1
Last Name First Name
Date ________________
Middle Name
Grade
Gender M__
F__
Has student attended a U.S. school for more than 3 full academic years? Yes___ No____
Temporary Housing Yes__ No__
Resident Address Mailing Address (If different) Date of Birth Birth State Social Security # Birth Country
City
State
Zip
Phone
Ethnic Code (Please check only
one)
___1=Am. Indian/Alaskan Native ___ 2=Asian/Pacific Islander ___ 3=Black ___ 4=Hispanic ___ 5=White
Health Insurance (Please check one) ___ Private ___ CHP+ ___ Uninsured ___ Medicaid
Consent to bill Medicaid ____ Yes ____ No ____ N/A
Birth Name
(Please Print)
Parent /Guardian Information Section 2 Is this student subject to a court order regarding school attendance, custody or a major decision making agreement? Yes_____ No _____ Please complete the attached custody statement. If student does not live with parent/guardian, student lives with: Name _________________________________
Phone Address Relationship
Who makes major educational decisions for student? Both Parents____ Mother____ Father____ Guardian____
1. Parent/Guardian Name Address Relationship
Other____(Specify)
Relationship Phone Other Work Phone
2. Parent/Guardian Name
Phone Address Other Employer Work Phone Employer List names of brothers, sisters and other school age children living in this home:
Emergency Information Section 3
1. Last Name 2. Last Name First Name First Name
If a parent/guardian cannot be reached, please contact the following:
Phone Phone Home Work Home Work Relationship to Student Relationship to Student
Medical Emergency Information: Section 4 Phone # Hospital Physician name Takes medications: No____ Yes____ List: Medical information (allergies, chronic illness, disabilities) Please fill out Health History sheet. Previous School Information Section 5 Has student ever attended any District 51 school? No___ Yes___ Last school attended? City/State Has student ever been retained? No___ Yes ___ Has this student ever received special education services? What grade?________ What school?__________________ Yes____ No____ Has student been involved in any early childhood experience? No____ Yes ____
____Private Preschool 1. 2. 3. 4. 5. 6. ____Childcare Center ____Head Start ____District #51 Preschool ____Home Child Care ____Other
Home Language Survey Section 6
Mark only those that apply to your family (Please don’t include languages you’ve learned in school)
What was the first language spoken by the student? English ____ Spanish ____ Other Identify all languages spoken in the home English ____ Spanish ____ Other List all languages understood by student English ____ Spanish ____ Other Language spoken in the home by student English ____ Spanish ____ Other Has your child ever been enrolled in an English as a Second Language Program? No _______ Yes _____ Do you require district information translated in a language other than English? No ____ Yes____ If yes, what language?
I request the school to notify me in case of an emergency or serious illness. If I am unable to be reached, I grant permission for the school to contact appropriate emergency agency/facility.
Parent / Guardian Signature:
(White –Cum Folder Yellow-Building Copy)
______
___________________________________Date______________
Revised 3/2007 Form WH008093
Pink-ESL Department
CUSTODY STATEMENT
Name student goes by: ________________________ Last Name ______________________ First Name __________ Grade __________ Middle
______________________________________________________ Student’s name as shown on Birth Certificate
Please complete the following:
1. Who has legal custody or major decision making responsibility?
_______Mother ________Father ________Both __________Other
Please Specify.
2. Please complete Parent(s) or Legal Guardian(s) name and address:
Father/Guardian Address City, State, Zip Home Phone Work Phone Mother/Guardian Address City, State, Zip Home Phone Work Phone
3. Is any one else allowed to pick up your child in case of an emergency that is not listed on Registration
form?
Name Address City, State, Zip Phone Name Address City, State, Zip Phone
4. Does a current legal custody agreement exist?__________ If yes, please attach a copy of the agreement.
Attendance, grades, etc., may be released to the following if requested by them: Name Name Relationship to the child Relationship to the child
If both parents share joint decision making regarding educational decisions and are unable to reach an agreement for the child, or in the absence of parent authorization, the school will make a decision based on the best interest of the child. Under the Privacy Act of 1974, parents are entitled to copies of their child’s records, unless their rights have been terminated by the courts or the district has received a Colorado Court Restraining Order specifically requesting we not release student records to the requesting parent. PLEASE NOTE: If possible, both parents must sign this statement indicating they agree with the above information. If there is only one signature, District 51 requires an explanation as to why there is only one signature.
__________________________________
Parent/Guardian Signature Date
______________________________
Parent/Guardian Signature Date
If only one signature, please explain why:_________________________________________________________________________________
Revised 03/26/09 pg
2009-2010 IMMUNIZATION REQUIREMENTS For Elementary Schools
Please provide the school with your child's current immunization records. Colorado State Board of Health requires the following immunizations for compliance with the school entry Immunization Law. Kindergarten, 1st, 2nd grades: DTaP Polio Hepatitis B MMR Varicella 5 doses required, unless 4th dose given after 4 years old Td given if age 7 – 9 4 doses required unless 3rd dose given after 4 years old 3 doses required 2 doses required (1st dose must be given on or after 1st birthday) 2 doses required (1st dose must be given on or after 1st birthday) OR documentation of disease history by a health care provider
3rd, 4th, 5th grades DTaP Polio Hepatitis B MMR Varicella 5 doses required, unless 4th dose given after 4 years old Td given if age 7 – 9 4 doses required unless 3rd dose given after 4 years old 3 doses required 2 doses required (1st dose must be given on or after 1st birthday) 1 dose or documentation of disease history by a health care provider
Contact school personnel if you would like to obtain a personal, religious or medical exemption. You may have your child immunized at his/her doctor’s office or at the Mesa County Health Department (248-6900).
Colorado School Entrance Immunization Law requires all students to provide proof of immunizations to attend school. FAILURE TO SUPPLY THE NECESSARY INFORMATION MAY RESULT IN YOUR STUDENT BEING SUSPENDED FROM SCHOOL.
Please note:
HEALTH HISTORY 2009-10
MUST BE COMPLETED BY PARENT / GUARDIAN EACH SCHOOL YEAR STUDENT: PHYSICIAN:
Last Name: First Name:
BIRTHDATE: SCHOOL:
GENDER:
GRADE:
DR. PHONE:
Please fill in the information below if your child has been diagnosed and treated for any of the following conditions
DIAGNOSIS / TREATMENT Describe (write details) in the area provided DATE of DIAGNOSIS DATE of LAST EPISODE PRESCRIPTION and/or ROUTINE OVER-THE-COUNTER MEDICATIONS Med needed at school? YES/NO
Allergy (Severe) or Allergic Reaction Symptoms: Asthma: Diabetes: Seizure Disorder: ADD or ADHD (circle one): Birth History/Delivery/Congenital problems:
YES/NO YES/NO YES/NO YES/NO YES/NO
Acquired Traumatic Brain Injury: Other injuries or illnesses
YES/NO YES/NO
My child wears glasses _____ contacts _____.
The Health Offices in Mesa County School District 51 are staffed by Health Assistants under the supervision of a Registered Nurse.
The above information is considered confidential and is shared on a “need to know” basis between the Registered Nurse (District/School Nurse) and School Staff who will be in contact with and responsible for your child during the school day. Medications given at school must be accompanied by a signed physician order, signed parental permission (forms are available in the school Health Office), and must be in the original labeled container. Parents/Guardians are responsible for informing the school of any health issues that have changed for their student throughout the school year. Parent/Guardian Signature:___________________________________________________________ Date_______________
Oficina de Adquisición del Idioma Inglés Si Ud. necesita una traducción en español favor de llamar a 254-5339. Estamos para servirle.
Attention Parents: Do you find yourself in one of the following temporary or transitional living situations? Living in a hotel or motel Living in a shelter or “safe house” Living doubled up with friends or relatives Living in a park or campground Living in a camper, camp trailer or vehicle Living in sub standard housing as outlined by HUD definitions An unaccompanied or runaway youth If so, Mesa County Valley School District 51’s REACH program has some ways to support you with your school- related needs, as well as access to other community resources and supports. Contact your child’s school or call our offices at 254-5350 and ask for the REACH department. There is an advocate assigned to each school that will assist you.
Atención Padres: ¿Se encuentra Ud. en una de las siguientes viviendas temporales o transitorias? Vive en un hotel o motel Vive en una casa de refugio Vive con parientes o amigos Vive en un parque o en un campamento Vive en un camper, en una tráiler o en su vehículo Vive en una casa inadecuada según el departamento de HUD Es Ud. un joven abandonado o un joven que anda huyendo Si es así, el programa de REACH del Distrito Escolar 51 del Condado de Mesa tiene algunas maneras para apoyarlo a Ud. con sus necesidades escolares, y también para darle acceso a los recursos de la comunidad. Comuníquese con la escuela de su criatura o llame a nuestra oficina al número 254-5350 y pregunte por el departamento de REACH. Hay una persona asignada a cada escuela que le puede ayudar.
CONSENT TO PHOTOGRAPH AND RELEASE NAME
I, (PRINT NAME) _______________________________________________________,parent/guardian of
(PRINT CHILD'S NAME)___________________________________________________________________,
consent to the use of photographs, video/audio tape (television or radio), and use of my child’s name for school or district communication purposes, including media interviews, district publications and website.
In giving this consent I release (NAME OF SCHOOL) _____________________________________School and Mesa County Valley School District 51 from any liability for any violation of any personal or proprietary rights I may have in connection with the use of the photographs, video/audio tape (television or radio) and use of my child’s name.
I (the parent/guardian) am more than 21 years of age.
__________________________________________________________________
SIGNATURE OF PARENT/GUARDIAN
______________________________________________________________________________________ PRINT NAME
___________________________________________________________________
DATE
CYBERSCHOOL (ONLINE COURSE) INFORMATION
Student Name ______________________________________________________ SASI # ________________________
Last First Middle
School ______________________________________________________________ Grade ______________ Is student currently registered and using online courses with a Cyberschool in Colorado? No Continue to asterisk, read statement, sign and date – no other information is necessary. Yes Full-time Part-time Continue filling in form.
CYBERSCHOOL INFORMATION:
Name of Cyberschool ________________________________________________________________________________ Cyberschool’s sponsoring School District ________________________________________________________________ Name of Cyberschool contact _________________________________________ Position _________________________ Telephone __________________________________________ E-mail ________________________________________ Street _____________________________________________ City ____________________________ Zip ___________ List your online courses ______________________________________________________________________________ *If at any time during the school year you enroll your child in a Colorado Cyberschool (online courses) you must immediately notify this school/district. Enrollment in online courses is enrollment in another district. Students may not be served in two districts without agreement between districts. Parent/guardian name __________________________________________________
Last First MI
Parent/guardian signature _____________________________________________ Date ___________________________
INFORMACIÓN DE CYBERSCHOOL (CURSO EN LÍNEA INTERNET)
Nombre del Estudiante ______________________________________________________ SASI # _________________
Apellido Primer Nombre Segundo Nombre
Escuela ______________________________________________________________ Grado ______________ ¿Esta el estudiante actualmente registrado y utilizando los cursos en línea de una cyberschool en Colorado? No Continúe al asterisco, lea la declaración, firme y fecha - ninguna otra información es necesaria. Sí Tiempo Completo Parte del Tiempo Continúe llenando la forma completamente.
INFORMACION CYBERSCHOOL:
Nombre de la Cyberschool ____________________________________________________________________________ El Distrito Escolar que Patrocina la Cyberschool___________________________________________________________ Nombre de contacto de la Cyberschool___________________________________ Puesto _________________________ Teléfono __________________________________________ Correo Electrónico________________________________ Domicilio _________________________________________ Ciudad _______________________ Código ___________ Lista de cursos en línea ______________________________________________________________________________ * Si durante el año escolar Ud. inscribe a su niño/a en una Cyberschool de Colorado (cursos en línea) Ud. debe notificar a esta escuela/distrito escolar inmediatamente. Matriculación en los cursos en línea es matriculación en otro distrito. No podemos servir a los estudiantes en dos distritos sin entre los distritos. Nombre del Padre/guardián ________________________________________________________
Apellido
Nombre Segundo Nombre
Firma del Padre/guardián _____________________________________________ Fecha___________________________
John P. Pomaski Director – ELA/ Migrant 930 Ute Avenue Grand Junction, CO 81501 (970) 254-5336 ~ Office (970) 254-5391 ~ Fax jpomaski@mesa.k12.co.us
Student Name (Nombre del Estudiante): ____________________________________ School (Escuela): ______________________ Telephone (Teléfono) ______________ Does your Family qualify as Migrant? If the answers to the following four questions are YES, your child qualifies for the Migrant Education Program. 1. Did the child move (alone, with, or to join a parent, spouse, or guardian) within the last 36 months? _________ 2. Was the move from one school district to another? ________ 3. Was the purpose of the move to obtain work that is (1) temporary or seasonal AND (2) agricultural, fishing, or dairy? ________ 4. Was the work an important part of providing a living for the worker and his or her family? ________ Please return the following sheet to the Migrant Office on 930 Ute Avenue or to your child’s school if you have answered yes to all questions. If you have questions about immunizations please call 254-5338. Thank you John Pomaski/ ESL/Migrant Director ¿ Califica su Familia como Migrante? Si las respuestas a las siguiente cuatro preguntas son Sí, su niño califica para el Programa de Educación Migrante. 1. ¿Dentro de los últimos 36 meses, el niño se mudó (solo, con, o para reunirse con su padre(s), esposo, o guardián)? ______ 2. ¿La movida fue de un distrito escolar a otro? ________ 3. ¿El propósito de la movida era para obtener trabajo que es (1) temporal o estacional Y (2) agrícola, pesca, o lechería? ______ 4. ¿El trabajo fue una parte importante en proporcionar una vivienda para el obrero y su familia? _________ Si usted ha contestado sí a todas las preguntas, por favor devuelva la hoja a la Oficina Migrante en 930 Avenida Ute o a la escuela de su niño. Si usted tiene preguntas sobre inmunizaciones favor de llamar al 254-5338. Gracias, John Pomaski/Director ESL/Migrant