2016 - 2017

____________________________________ __________ __________________

Student Name Grade Teacher

NEW STUDENT

__________ Enrollment Form

__________ Parents Application for Student Transfer (If from another district)

__________ Request for Student Records

__________ Discipline Authorization

__________ Classroom Discipline Plan

__________ Authorization for Emergency Care for Minor

__________ Child Pick Up Permission Form

__________ Talent Release

__________ Release of All Claims (Climbing Wall)

__________ Impact Aid Survey Form

__________ Title VII (506)

__________ Internet Safety Policy

__________ Parent-School Compact

__________ Enrollment (After School Program)

__________ After-School Emergency & Trip Authorization

__________ Lunch Application/Letter to Household (Only one per household) – Separate Sheets

Information Sheets Included in Enrollment Packet: Immunization Schedule, School Calendar, School Supply List

Please provide copies:

__________ Social Security Card __________ Birth Certificate

__________ CDIB Card __________ Citizenship – Card or Certificate

__________ Shot Records

Revised 6/2016

2016 – 2017 DATE OF ENROLLMENT ___________________________

NAME OF STUDENT _____________________________________________________ GRADE ENTERED ____________

First Middle Last

SOCIAL SECURITY NUMBER: _________-______-_________ Male: ________ Female: ________

PLACE OF BIRTH: (CITY & STATE)______________________________DATE OF BIRTH _______-_______-_______

MAILING ADDRESS: __________________________________________________________________________________

PHYSICAL ADDRESS: _________________________________________________________________________________

HAS THIS ADDRESS CHANGED SINCE LAST YEARS ENROLLMENT: ________YES _________NO

ARE YOU OF HISPANIC/LATINO CULTURE OR ORIGIN? _______YES _______NO

ETHNICITY: _____WHITE _____AFRICAN AMERICAN _____AMERICAN INDIAN _____ASIAN _____OTHER

FATHER’S NAME:________________________________ PLACE OF EMPLOYMENT___________________________

HOME # ____________________________ E-Mail Address ___________________________________________________

CELL # _____________________________ WORK # __________________________________

MOTHER’S NAME: _________________________________ PLACE OF EMPLOYMENT _________________________

HOME # ____________________________ E-Mail Address ___________________________________________________

CELL # _____________________________ WORK # __________________________________

DOES CHILD LIVE WITH BOTH PARENTS? _______YES ________ NO

IF NO, WHO IS THE GUARDIAN? ______________________________________________________________________

CHILD HAVE A CDIB? ____YES ____NO PARENT? ____YES ____ NO ANY INDIAN BLOOD? _________

TRANSPORTATION: ______ SCHOOL BUS ______ BIG 5 ______ PARENT ______ WALK

DO YOU LIVE IN NATIVE AMERICAN HOUSING? _____ YES _____ NO

FEDERAL HOUSING? ______ YES ______ NO

IS PARENT OR GUARDIAN IN THE MILITARY? ______ YES _____ NO

WORK FOR THE MILITARY? ______ YES _____ NO

DOES PARENT OR GUARDIAN WORK FOR AN INDIAN TRIBE? _____ YES _____ NO

(IF YES, WHERE?) _____________________________________________________

PERSON TO CALL IF PARENTS ARE NOT AVAILABLE: _____________________________________________________

PHONE # _______________________________________ RELATION _______________________________________________

HEALTH REMARKS: (DIABETES, ASTHMA, ETC…) __________________________________________________________

FAMILY DOCTOR: ___________________________________ EMERGENCY # ______________________________________

LAST SCHOOL ATTENDED: SCHOOL NAME: ___________________________ ADDRESS _________________________

CITY _____________________________ STATE ___________________ ZIP _______________

Phone: (580) 927-2937 Fax: (580) 927-2938

Request for Student Records

PREVIOUS SCHOOL DISTRICT ATTENDED

STREET ADDRESS/P.O. BOX CITY STATE ZIP

In accordance with the Family Education Rights and Privacy Act (FERPA), 34 CFR 99.31,

transfer of education records is requested for:

Student Name Date of Birth Grade

Request for education records includes, but is not limited to: health, grades, cumulative

discipline records, and special education records. Transfer of student records, including

disciplinary records, must be made in a timely manner, within three business days of receipt of

request, under state law (70 O.S. 24-101.4).

The student intends to enroll or is enrolled in our school district/agency. Therefore,

please send records to:

Cottonwood Public School

John Daniel, Superintendent

P.O Box 347

Coalgate, OK 74538

From: __________________________________________________________________

Signature of School District/Agency Official Date

Education records are maintained and released in accordance with the Family Educational Rights and Privacy Act

(FERPA). Parents or eligible students shall be provided a copy of the records to be disclosed if requested. Further

disclosure of the above records will be in accordance with 34 CFR 99.31.

Discipline Authorization

Parent & Guardians:

One of the provisions of House Bill 1017 is to provide school personnel materials for

dealing with effective classroom discipline techniques as an alternative to the use of corporal

punishment (paddling). Local school districts still have the discretion of using or not using

corporal punishment.

Corporal punishment will be administrated as a last resort. Students will not receive

corporal punishment for low academic grades or low scores on tests.

Ninety eight percent of our students would never need corporal punishment for

misbehaving, however, on occasion the 2% of students who misbehave do disrupt the academic

process at Cottonwood School. We want to provide our student body with a proper learning

atmosphere where each student can succeed with minimum disruption.

Please circle the choice below.

As a last resort for misbehaving, I want _____________________________________ to:

Student Name

1. Receive a paddling.

2. Three (3) days out of school suspension.

PLEASE CIRCLE ONLY ONE OPTION ABOVE.

_________________________________________________ __________________

Parent/Guardian Signature Date

Please note: This Discipline Authorization will remain in effect as long as your child is

attending Cottonwood Public School. You may request a new form at anytime if you desire to

change your choice of discipline.

CLASSROOM DISCIPLINE PLAN

Dear Parent:

I am delighted that ___________________________________ is in my class this year. With

your encouragement, your child will participate in and enjoy many exciting and rewarding

experiences this academic year.

Since lifelong success depends in part on learning to make responsible choices. I have

developed a classroom discipline plan, which guides very student to make good decisions about

his or her behavior. Your child deserves the most positive educational environment possible for

his or her growth, and I know together we will make a difference in this process. The plan below

outlines our rules, positive recognition for appropriate behavior and consequences for

inappropriate behavior.

RULES:

1. Follow directions

2. Keep hands, feet and other objects to yourself.

3. No bullying, swearing or teasing.

4. No running in the buildings.

POSITIVE RECOGNITION:

To encourage students to follow these classroom rules I will recognize appropriate behavior with

praise, notes home and positive phone calls.

DISCIPLINE POLICY

After 3 In-Class Detention – 1 Day In-School Suspension (ISS)

(work permitted, parents notified, conference required)

After 6 In-Class Detention – 2 Days In-School Suspension (ISS)

(work permitted, parents notified, conference required)

After 9 In-Class Detentions – 3 Days Suspension from School

(work permitted, parents notified, conference required)

After 12 In-Class Detentions – Suspension for the remainder of school year.

(parents notified, conference required)

Sever disruption – automatically send to principal.

Fighting and leaving school without permission – please refer to handbook.

BUS DISCIPLINE POLICY

1st Trip to Office – Verbal warming and 30 minutes detention

2nd

Trip to Office – Parent conference and 1 day suspension from bus

3rd

Trip to Office – 1 week suspension from Bus

4th

Trip to Office – Suspension from bus for remainder of school year

Be assured that my goal is to work with you to ensure the success of your child this year. Please

read and discuss this classroom discipline plan with your child, then sign and return the form.

________________________________ _______________________ ___________

Teacher Signature Class Date

I have read the discipline plan and have discussed it with my child.

________________________________ _______________________

Parent/Guardian Signature Date

________________________________ _______________________

Student Signature Date

AUTHORIZATION FOR EMERGENCY CARE TO MINOR(S) Cottonwood Public School

Student________________________________________________ Grade______________

Last First Middle

Home Phone___________________ Emergency Contact Number(s) ______________________

In case of emergency illness or accident, the child is given first-aid and the parents are notified. If the parents or the

child's doctor cannot be located, the child will be taken to the Emergency Room of your choice. Cottonwood Public School

does not assume responsibility for the payment of hospital, doctor, or ambulance fees.

Health Insurance with:

Policy Holder:___________________________________________ Policy # :_________________________

I/We the undersigned, parent(s) or legal guardian of the minor(s) listed below:

________________________________________________________________________________________

Birth Date____________________ (Minor's Name) ______________________________________________

It is understood that this consent is given in advance of any specific diagnosis or treatment being do hereby authorize

any x-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist licensed by

the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific, or special consent of

an acting agent of Cottonwood Public School, the temporary Custodian of the minor, whether such diagnosis or treatment is

rendered at the office of the physician or dentist, or at a hospital licensed by the State of Oklahoma. I/We authorize the

physician or dentist to call in any necessary consultants, in his/their own discretion. We further authorize said physician or

dentist to exercise his/their discretion in authorizing the disposal of any severed tissues or member.

It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given

to encourage those persons who have temporary custody of the minor, and said physician and/or dentist to exercise his/their

best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment.

This consent shall remain effective until revoked in writing, delivered to said physician or dentist or to said persons entrusted

with the custody, care, and control of said minor children. To be signed and witnessed during registration.

DATED_______________________________ _________________________________

Father

Witness: (Other than custodian(s) _________________________________

Mother

______________________________________ _________________________________

Legal Guardian

AUTHORIZATION OF NON-PRESCRIPTION MEDICATION

The Staff of Cottonwood Public School has my permission to administer the following if needed to my child:

Yes Initial No Initial

Tylenol ____ _____ ____ _____

Motrin ____ _____ ____ _____

Known Medication or Food Allergies:

____________________________________________________________________________________________________

CHILD PICK UP PERMISSION SHEET

Please list people who have permission to pick up your child from school.

__________________________________________ ________________________

Child Name (First and Last) Date

The following people have my permission to pick up my child:

1. _________________________________________

2. _________________________________________

3. _________________________________________

4. _________________________________________

5. _________________________________________

6. _________________________________________

_________________________________________________ __________________

Parent/Guardian Signature Date

If you need someone who is not listed on this permission sheet to pick up your child only for a specific

date, please send a note with your child.

TALENT RELEASE

PERFORMER NAME: ___________________________________________

ADDRESS: ___________________________________________________

___________________________________________________

CLIENT: COTTONWOOD SCHOOL

JOB NAME: Photography for school publications including but not limited to the schools Web site,

promotional brochures, newsletters, postcards, presentations, etc. Also use for monitoring classrooms for

teacher, school improvement and student discipline.

For the consideration received, including but not limited to publicity, the adequacy of which is hereby

acknowledged, I hereby grant to the Cottonwood school, their successors and assigns, and those acting

under their permission or upon their authority, or those by whom they are commissioned:

1. The unqualified right and permission to reproduce, copyright, publish, circulate and otherwise

photographs and /or motion-pictures of me, and voice reproduction, whether taken in a studio or

elsewhere, in black-and-white or in colors, alone or in conjunction with other persons or

characters, real or imaginary, in any part of the world. I hereby waive the opportunity or right to

copy or inspect or approve the finished photographs, films or tapes or the use to which it may be

put or the copy or illustrations used in connection therewith. This authorization covers composite,

stunt, comic, freak or any unusual photograph and/or motion picture, or voice reproduction,

caused by optical illusion, distortion, alteration or made by retouching or by using parts of several

photographs or by any other method. All such use shall be for the purpose of promotion

supporting or otherwise furthering the mission of Cottonwood School.

2. All my right, title and interest in and to all negatives, prints, tapes, and reproductions thereof, and I

so hereby release the aforesaid parties and their successors and assigns, if any, from any and all

rights, claims, demands, actions or suits which I may or can have against them on account of the

use of publication of said photographs and/or motion pictures or tapes. I have read and understand

the release slated above and do hereby agree to its terms and conditions.

__________________________________________________ __________________

Signature Parent/Guardian Date

Impact Aid Program Survey Form

The survey date is

STUDENT INFORMATION Student’s Last Name First Name M.I. Date of Birth Grade School Name

Address City State Zip Code

If the above property is a federal property, enter the name

of the property.

Name of federal property

PARENT/GUARDIAN EMPLOYMENT INFORMATION: CIVILIAN

Enter information in this section regarding the parent/guardian if 1) neither parent/guardian with whom the student resided was on active duty in the

Uniformed Services of the United States and 2) either parent/guardian with whom the student resided was employed on federal property, or 3) either

the parent/guardian reported to work on federal property on the survey date. Enter the parent/guardian’s name as it appears on the employer’s payroll

record. Parent/Guardian’s Last Name First Name and M.I. Name of Parent/Guardian’s Employer

Address of Parent/Guardian’s Employer City State Zip Code

Name of federal property

Address of federal property City State Zip Code

PARENT/GUARDIAN EMPLOYMENT INFORMATION: UNIFORMED SERVICES

Enter information in this section regarding the parent/guardian if either person was on active duty in the Uniformed Services of the United States on

the survey date.

Parent/Guardian’s Last Name First Name and M.I. Branch of Service Rank

PARENT/GUARDIAN EMPLOYMENT INFORMATION: FOREIGN MILITARY

Enter information in this section regarding the parent/guardian if either person was both an accredited foreign government official and a foreign

military officer on the survey date.

Parent/Guardian’s Last Name First Name and M.I. Branch of Service Rank

Name of Foreign Government

PARENT/GUARDIAN EMPLOYMENT INFORMATION: FARMING, GRAZING, LUMBERING AND MINING

Enter information in this section if either the parent or guardian spent more than 50 percent of his or her working time on federal property (whether as

an employee or self-employed) engaged in farming, grazing, lumbering or mining.

Parent/Guardian’s Last Name First Name and M.I. Name of Parent's/Guardian’s Employer

Address of Parent/Guardian’s Employer City State Zip Code

Name of federal property Address of federal property

Permit Number Township Range Section

This information is the basis for payment to your school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and

Secondary Education Act), and may be provided to the U.S. Department of Education if your school district’s application for payment is audited.

This form must be signed and dated for your school district to receive funds based on this information.

Signature of Parent/Guardian________________________________Date_________________

Cottonwood Public School Internet Safety Policy

The following is a contract between the student parent or guardian, and the school system. Please read carefully before signing. With access to such vast storehouses of information and instant communication with millions of people from all over the world, material will be available that may not be considered to be of educational value by the District or which is inappropriate for distribution to children. Cottonwood has taken available precautions, including but not limited to enforcing the use of filters that block access to obscenity, child pornography and other materials harmful to minors. However, on a global network, it is impossible to control all material and an industrious user may obtain access to inappropriate information or material. The District firmly believes that the value of the information and interaction available on the Internet far outweighs the possibility that students and employees may procure material which is not consistent with our educational goals. It is all staff members’ responsibility to educate students about appropriate online behavior, including interactions with other individuals on social networking sites/chat rooms, and cyber bullying awareness and response. This may be done in a variety of ways, such as once a year short training sessions, one-on-one education with individual students, and/or via educational handouts. It is also the responsibility of all staff members to monitor students’ online activity for appropriate behavior.

As a student I agree to the following terms and conditions: I will not use the Internet for transmission of any materials in violation any federal or state

regulations. Transmission of copyrighted material threatening or obscene materials, materials protected by trade secrets, product advertisement or political lobbying is also prohibited.

I will refrain from using profanity and vulgarities on the Internet. I will not use the Internet for illegal activities.

I will not give my home address, location of my school phone number or any personal information about myself or and other student or school personnel to anyone via the Internet.

I understand that use of e-mail or any other communications over the Internet are not private; any messages related to or in support of illegal activities may be reported to authorities.

I understand that I am prohibited from conducting any actions that may endanger my safety, or the safety of other students/staff members while using any component of the school’s internet access and/or network (email, chat rooms, etc.).

I will not use the Internet in a way that would disrupt the use of the network by others.

I will respect the trademark and copyrights of materials on the Internet and assume anything accessed via the network is private property.

The school system and service provider are not responsible for any damages or losses resulting from using Internet services or information obtained from the Internet.

If you discover any way to access unauthorized information or defeat any security measures you must inform the lab teacher immediately. You must not share any unauthorized information with any other user.

Vandalism of any kind is prohibited.

These terms and conditions shall be governed and interpreted in accordance with the laws of the state and the United States of America.

I understand access to the Internet through Cottonwood Public School is a privilege. School authorities can deny any student access to the Internet at any time, and their decisions are final.

My instructor/school sponsor has explained the terms and conditions for using the Internet to me and I agree to abide by them. Student's Signature: _____________________________________________________ Date ________________ I have read the above forms and conditions and understand that violation of these can result In the denial of Internet privileges. I also agree not to hold the school, state and local boards of education or the Internet provider responsible for the consequences resulting from the violation of these terms and conditions by the student Parent/Guardian's Signature: ______________________________________________ Date __________________

Please note: This Internet Safety Policy agreement will remain in effect as long as your child

is attending Cottonwood Public School.

Cottonwood School Parent-School Compact

It is important that families and schools work together to help students achieve high academic standards.

Through a process that included teachers, families, students, and community representatives, the following are

agreed upon roles and responsibilities that we as partners will carry out and to support student success in school

and in life.

As a STAFF MEMBER, I will provide your child with every opportunity to learn and grow by:

Maintaining a quiet and organized workplace;

Having a high expectation of myself and my students;

Giving instruction and assignments appropriate for the skill and development required by state and

district standards;

Monitoring student work on a daily basis to ensure success and progress; and

Reporting regularly to parents with returned work, written notices, and conferences.

As a STUDENT, I will keep my focus on what is important in meeting my goal of learning by:

Being in class on time, every day, with my homework in hand and prepared to work;

Allowing the teacher to teach and everyone in class to learn;

Completing my work on time and accurately;

Keeping my hands, feet, objects and comments to myself; and

Respecting others and their property.

As a PARENT/GUARDIAN, I will support Cottonwood School’s programs and activities that give my child the

optimum opportunity for learning by:

Expecting my child to complete daily homework assignments independently and discuss his/her results

for improved learning, and check for a timely return to school;

Accentuating the positive events at school and help my child resolve issues of concern and conflict;

Supporting the discipline policy and reinforcing the highest expectations for the school staff;

Reading to and listening to my child read daily as a way of building a lifelong interest and joy of

reading;

Seeing that my child gets adequate rest and is in school on time with a positive outlook;

Attending conferences to discuss my child’s progress and attending events which showcase my child’s

work and learning experiences; and

Providing and maintaining accurate information on my child’s records for contact.

Parent/Guardian: Date:

Student: Date:

Teacher: Date:

Principal: Date:

COTTONWOOD PUBLIC SCHOOL

AFTER-SCHOOL ENROLLMENT FORM Available: Monday – Thursday 4:15 to 5:15PM

CHILD’S NAME __________________________________________ DATE_______________________

ADDRESS____________________________________________________ PHONE______________________

DATE OF BIRTH_________________________ GRADE OF CHILD______________________

PARENT/GUARDIAN___________________________________________________________

PLACE OF EMPLOYMENT______________________________________________________

WORK PHONE_________________________________________________________________

SOCIAL SECURITY #___________________________________________________________

PLEASE CHECK ALL THAT APPLY: RACE

___________MALE _______WHITE

___________FEMALE _______BLACK

_______HISPANIC

_______NATIVE AMERICAN

_______CDIB

_______ASAIN

_______OTHER__________________________

TRANSPORTATION

______ I WILL PICK UP MY CHILD.

______ MY CHILD WILL RIDE THE COTTONWOOD BUS.

______ MY CHILD WILL RIDE THE BIG FIVE BUS.

ATTENDANCE

______ MY CHILD WILL ATTEND ONE OR MORE DAYS A WEEK.

______ MY CHILD WILL NOT ATTEND AT LEAST ONE DAY A WEEK.

COTTONWOOD PUBLIC SCHOOL AFTER SCHOOL EMERGENCY RELEASE &

FIELD TRIP PERMISSION

CHILD’S NAME___________________________________________________ DATE_______________________________________ PARENT/GUARDIAN’S NAME_________________________________________ IN CASE OF EMERGENCY, PLEASE CALL

1. NAME______________________________________PHONE______________________

2. NAME______________________________________PHONE______________________

I HEREBY GIVE MY PERMISSION FOR THE SCHOOL AUTHORITIES TO RENDER FIRST AID

AND DO WHATEVER IS DEEMED NECESSARY TO OBTAIN MEDICAL HELP FOR MY

SON/DAUGHTER IN CASE OF AN EMERGENCY.

_________________________________________________________

PARENT/GUARDIAN SIGNATURE

FIELD TRIP PERMISSION

I GIVE MY PERMISSION FOR MY CHILD, ________________________________, TO GO ON

FIELD TRIPS WITH HIS/HER CLASS FOR THE SCHOOL YEAR 2016-2017 WITH THE

COTTONWOOD AFTER-SCHOOL PROGRAM.

___________________________________________________________

PARENT/GUARDIAN SIGNATURE