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School Year: _________ School: ___________________________________________________ Student ID# _________________
This enrollment form is a legal document. The information you provide must be accurate and complete.This information is protected by the Family Educational Rights and Privacy Act (FERPA).
SPECIAL SERVICES: (Please check all services needed by this student)
Section 504 Plan Talented & Gifted Program
Special Ed IEP ELL/LEP Services
Speech Services Title VII Indian Ed: Tribe ________________________
STUDENT’S LEGAL NAME:
__________________________________________________ __________________________________________________ ____________________________________ __________Legal Last Name First Middle Suffix
Grade: (starting at this school) ______________________ Birthdate: ______ / ______ / ______ Gender: Female Male Non-Binary
__________________________________________________ __________________________________________________ __________________________________________________Home Language Preferred First Name Last Name Goes By
__________________________________________________ __________________________________________________First Language Spoken Student Cell Phone Number
__________________________________________________ __________________________________________________ __________________________________________________Birth City Birth State Birth Country
ETHNICITY & RACE:
Federal Regulations require this information. If ethnicity and race fields are not entered, school staff must select for you.
ETHNICITY: Hispanic Non-Hispanic
RACE: (Mark all that apply) White Black/African American Non-US Native American
Asian American Indian or Alaska Native
Native Hawaiian or Pacific Islander
200113-0818
STUDENT HEALTH APPRAISAL: (This information will be used by District Health staff to help your student.)
Student Legal Name: ________________________________________________________________________________________________________________________________________
No Yes ______________________________________________________________________________________________1. Does your student have a physical disability?
2. Does your student wear glasses or contacts? q No q Yes ______________________________________________________________________________________________
3. Is your student taking any medication? No Yes ______________________________________________________________________________________________
4. Will your student take medicine at school? No Yes (list medicine and condition) ___________________________________________________________________
5. Is your student able to participate fully in activities at school? Yes No (if no, please explain) ____________________________________________________________
6. Check if your student has any of the following?
Allergies—food: ____________________________________ Check if Life Threatening
Allergies—insects: __________________________________ Check if Life Threatening
Allergies—seasonal: ________________________________ Check if Life Threatening
Allergies—misc: ____________________________________ Check if Life Threatening
Asthma Check if Life Threatening
Diabetes Check if Life Threatening
Heart Problem Check if Life Threatening
Seizure Disorder Check if Life Threatening
Hearing Loss
Speech Disorder
Explain health conditions: (attach additional sheet if needed) ______________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
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Other: _______________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
SIGNATURE: I declare that the above information is true to the best of my knowledge and belief. I understand I commit the crime of false swearing if I make a false statement, knowing it to be false. (ORS 162.075). Further, I understand that my student could be returned to their neighborhood school upon determination of a false address.
Parent/Guardian Signature: ____________________________________________________________________________________________________ Date: ____________________
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_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
School Name: ___________________________ School Name: ___________________________
School Use Only
NEW STUDENT REOPEN ENROLLMENT FORM
STUDENT’S HOME ADDRESS: MAILING ADDRESS:
____________________________________________________________ _____________Home Address Apt #
______________________________________________ _________ _____________City State Zip
____________________________________________________________ _____________Mailing Address (if different than home address) Apt #
______________________________________________ _________ _____________City State Zip
County of Residence: _______________________________________________________
Primary Phone: ( _______)_______________________ (Used for Attendance & Emergency Calling)
Oregon Drivers License Oregon ID
Utility Bill Cable/Satellite Bill
Address Verification: (Provide Photo ID and One Utility Bill) Must be current copies—valid in the past 30 days. Verification can be submitted through scanned or photo copy as well as mail-in documentation.
2020-21 New Student Reopening Enrollment Form
PARENT/GUARDIAN INFORMATION:
Are there custody issues that the school should be made aware of? Yes NoAre there custody papers? Yes No
Relationship to Student: Father Mother Guardian (must provide legal guardianship documentation) Other: (specify) ________________________Living with student? Yes No
____________________________________________________________________ ____________________________________________________________________Parent Legal Last Name Legal First Name
Mark all that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased
Primary Language: ____________________________________ Interpreter needed Email Address: ________________________________________________________________
Employer: _________________________________________________________________ Job Title: _____________________________________________________________________
__________________________________________________________________ ________________________________________________________ ___________ ________________Home Address (if different from student’s) City State Zip
Home Phone: ( _______ ) _______________________ Work: ( _______ ) _______________________ Cell: ( _______ ) _______________________Primary Phone (preferred contact): Home Work Cell Active Military? Yes No
Living with student? Yes No
____________________________________________________________________ ____________________________________________________________________Parent Legal Last Name Legal First Name
Mark all that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased
Primary Language: ____________________________________ Interpreter needed Email Address: ________________________________________________________________
Employer: _________________________________________________________________ Job Title: _____________________________________________________________________
__________________________________________________________________ ________________________________________________________ ___________ ________________Home Address (if different from student’s) City State Zip
Home Phone: ( _______ ) _______________________ Work: ( _______ ) _______________________ Cell: ( _______ ) _______________________Primary Phone (preferred contact): Home Work Cell Active Military? Yes No
Living with student? Yes No
____________________________________________________________________ ____________________________________________________________________Parent Legal Last Name Legal First Name
Mark all that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased
Primary Language: ____________________________________ Interpreter needed Email Address: ________________________________________________________________
Employer: _________________________________________________________________ Job Title: _____________________________________________________________________
__________________________________________________________________ ________________________________________________________ ___________ ________________Home Address (if different from student’s) City State Zip
Home Phone: ( _______ ) _______________________ Work: ( _______ ) _______________________ Cell: ( _______ ) _______________________Primary Phone (preferred contact): Home Work Cell Active Military? Yes No
Living with student? Yes No
____________________________________________________________________ ____________________________________________________________________Parent Legal Last Name Legal First Name
Mark all that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased
Primary Language: ____________________________________ Interpreter needed Email Address: ________________________________________________________________
Employer: _________________________________________________________________ Job Title: _____________________________________________________________________
__________________________________________________________________ ________________________________________________________ ___________ ________________Home Address (if different from student’s) City State Zip
Home Phone: ( _______ ) _______________________ Work: ( _______ ) _______________________ Cell: ( _______ ) _______________________Primary Phone (preferred contact): Home Work Cell Active Military? Yes No
1st _________________________________________________________ ______________________________________ ( _______ ) _______________________ Home Cell Name Relationship to Student Phone
_________________________________________________________ _________________________________________________________ ___________ ________________ Address City State Zip
2nd _________________________________________________________ ______________________________________ ( _______ ) _______________________ Home Cell Name Relationship to Student Phone
_________________________________________________________ _________________________________________________________ ___________ ________________ Address City State Zip
3rd _________________________________________________________ ______________________________________ ( _______ ) _______________________ Home Cell Name Relationship to Student Phone
_________________________________________________________ _________________________________________________________ ___________ ________________ Address City State Zip
4th _________________________________________________________ ______________________________________ ( _______ ) _______________________ Home Cell Name Relationship to Student Phone
_________________________________________________________ _________________________________________________________ ___________ ________________ Address City State Zip
SIBLINGS: (List all brothers, sisters, step and half brothers and sisters of this student attending Springfield Public Schools.)
______________________________________________________________ ______________________________________ ______________ _______________________________Student Name Relationship to Student Grade School Enrolled
______________________________________________________________ ______________________________________ ______________ _______________________________Student Name Relationship to Student Grade School Enrolled
______________________________________________________________ ______________________________________ ______________ _______________________________Student Name Relationship to Student Grade School Enrolled
______________________________________________________________ ______________________________________ ______________ _______________________________Student Name Relationship to Student Grade School Enrolled
______________________________________________________________ ______________________________________ ______________ _______________________________Student Name Relationship to Student Grade School Enrolled
OTHER INFORMATION:
Previous School: __________________________________________________________________________________________________ Phone: ( _______ ) _______________________
__________________________________________________________________ ________________________________________________________ ___________ ________________Address City State Zip
Special Circumstances:Is this student currently suspended? No Yes, from (name of school) ______________________________________________________________________________________Is this student currently expelled? No Yes, from (name of school) ________________________________________________________________________________________School Address, City and State: ________________________________________________________________________________________________________________________________
Permissions:My student may participate in all school field trips. Yes No
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Relationship to Student: Father Mother Guardian (must provide legal guardianship documentation) Other: (specify) ________________________
Relationship to Student: Father Mother Guardian (must provide legal guardianship documentation) Other: (specify) ________________________
Relationship to Student: Father Mother Guardian (must provide legal guardianship documentation) Other: (specify) ________________________
EMERGENCY SCHOOL CLOSURETo prepare for an unexpected early school dismissal, please assist us by establishing a plan with your child and indicating your choice below:
My child will ride the bus and has been instructed by me about what to do. I will make arrangements for my child to be picked up at school within an hour of emergency closure. My child may be released to walk and has been instructed by me about what to do.
In an emergency, Parents/Guardians listed on page 2 with “Contact Allowed” checked, will be called before Other Emergency Contacts listed below.List only those authorized to pick up your student. Individuals listed below will be contacted to pick up your student in the event of an emergency closure.
OTHER EMERGENCY / RELEASE TO CONTACTS
School Name: ___________________________ School Name: ___________________________
SERVICES AND PROGRAMS Checklist for New Students
Student’s Name:
If your student had services or was involved in certain programs in the past year, we want to know in order to better serve your child. Please check those that apply.
q Home Language:q No Englishq Both another language and English
q Migrant Educationq Native Youth. Tribe, Band or Group:q McKinney-Vento Program/Foster Care Studentq Talented and Giftedq Title I
q Readingq Math
q Individualized Education Plan (I.E.P.)q Readingq Mathq Written Languageq Speech/Language Servicesq Emotional Disturbedq Physical/Occupational Therapyq Adaptive P.E.
q English Language Learner (ELL/ESL)q Behavior Supportq Hearingq Visionq Counselingq Head Start/EC Cares/Preschool Promiseq Other (please describe):
Previous School PhoneCity/State/Zip Fax
Student Name Grade EnrollingDate of Birth PhoneParent Signature
1st Request 2nd Request Fax # Initial
Please FAX the following: Transcript/ImmunizatonsCopy of IEP/Eligibility if applicableWithdraw Grades if applicable
Please forward the following records in their entirety to the school checked below:
•All permanent Records •Current Official Transcript •Health Records•All Special Education Recofrds (IEP and 504 accommodations)•Behavioral Records (including attendance, suspensions and expulsions)
Centennial Elementary School 1315 Aspen St., Springfield OR 97477 Attn: RegistrarDouglas Gardens Elementary School 3680 Jasper Rd., Springfield OR 97478 Attn: RegistrarGuy Lee Elementary School 755 Harlow Rd., Springfield OR 97477 Attn: RegistrarMaple Elementary School 2109 J St., Springfield OR 97477 Attn: RegistrarMt Vernon Elementary School 935 Filbert Ln., Springfield OR 97478 Attn: RegistrarPage Elementary School 1300 Hayden Br Rd., Springfield OR 97477 Attn: RegistrarRidgeview Elementary School 526 66th St., Springfield OR 97478 Attn: RegistrarRiverbend Elementary School 320 51st St., Springfield OR 97478 Attn: RegistrarThurston Elementary School 7345 Thurston Rd., Springfield OR 97478 Attn: RegistrarTwo Rivers Elementary School 1084 G St., Springfield OR 97477 Attn: RegistrarWalterville Elementary School 40589 McKenzie Hwy., Springfield OR 97478 Attn: RegistrarYolanda Elementary School 2350 Yolanda Ave., Springfield OR 97477 Attn: RegistrarAgnes Stewart Middle School 900 S 32nd St., Springfield OR 97478 Attn: RegistrarBriggs Middle School 2355 Yolanda Ave., Springfield OR 97477 Attn: RegistrarHamlin Middle School 326 Centennial Blvd., Springfield OR 97477 Attn: RegistrarThurston Middle School 6300 Thurston Rd., Springfield OR 97478 Attn: RegistrarAcademy of Arts and Academics 615 Main St., Springfield OR 97477 Attn: Records/CounselingGateways High School 425 10th St., Springfield OR 97477 Attn: Records/CounselingSpringfield High School 875 7th St., Springfield OR 97477 Attn: Records/CounselingSPS OnLine (K-12) 425 10th St., Springfield OR 97477 Attn: Records/CounselingThurston High School 333 58th St., Springfield OR 97478 Attn: Records/Counseling
Checked In by:
Federal Law 99.31 Requires No Parent Signature for educational records sent to another agency.Permission is required for transfer of Special Education records.
PERMISSION TO RELASE STUDENT RECORDS TO SPRINGFIELD SCHOOL DISTRICT, OREGON
Received Records On:
