SEGUIN ISD ENROLLMENT FORM

Student Name: _________________________________ Local ID # ______________________ Grade _____ Campus ___________________ Social Security #: _______________________ DOB: ______________ City of Birth: __________________ State of birth: _______________ Current Age (as of Sept. 1): ______ Gender ______ Home Language: _____________________ Ethnicity/Race: (TEA Appendix F-Office Use) Homeroom Teacher: ___________________________________ Bus Number: _______ Car: ________ Walk: ________ Last School Attended: ________________________________ Last School Attended Address: __________________________________________ (Circle) Special Services at previous school: Bilingual/ESL, Migrant, At-Risk, GT, Title 1, Special Education, Other_________________________

#1 Contact Name: __________________________________________________________________________ DL #:___________________________ Contact Type: Parent, Guardian, Other Relationship: ________________________________ Lives With: _______ (Circle one) Address is private ___ Home Address: ___________________________________________________________________________ _______ Mailing address is private ___ Mailing Address: _____________________________________________________________________ _______ Phone is private ___ Home Phone: ______________________ Private Cell? _____ Cell Phone: ______________________________ Email is private ___ Email: ______________________________________________________________________________________________ Employer: ________________________________________________________________ Employer’s Phone: ____________________________

#2 Contact Name: __________________________________________________________________________ DL #:_________________________ Contact Type: Parent, Guardian, Other Relationship: ________________________________ Lives With: _______ Circle one

Address is private ___ Home Address: _____________________________________________________________________________ _______ Mailing Address is private ___ Mailing Address: _____________________________________________________________________ _______ Phone is private ___ Home Phone: _______________________ Private Cell? ____ Cell Phone: ________________________________ Email is private ___ Email: __________________________________________________________________________________________________ Employer: ________________________________________________________________ Employer’s Phone: _______________________ _________________________________________ Phone: ___________________________ Relation: _______________________ Name: _________________________________________ Phone: ___________________________ Relation: _______________________ Name: _________________________________________ Phone: ___________________________ Relation: _______________________

Sibling’s Name: __________________________________ Sibling’s Campus: ________________________ Age (Sept 1st this year):____________

Sibling’s Name: __________________________________ Sibling’s Campus: ________________________ Age (Sept 1

st this year):____________

Sibling’s Name: __________________________________ Sibling’s Campus: _________________________ Age (Sept 1

st this year):___________

Presenting false information or false records for identification is a criminal offense and enrolling a child under false documentation makes the person liable for tuition and other costs. X _______________________________________________________________________________________________________________________ Signature of Parent/Guardian Date I, the parent/guardian, authorize officials of the Seguin ISD to contact the person(s) named on this form and authorize the physician named below to render treatment of this child as may be necessary in an emergency. In the event that I, the parent, or any other person(s) whom I have listed on this form, cannot be contacted, I authorize Seguin ISD officials to take whatever action, including calling EMS, that they deem necessary (Family Code 32.001). I will not hold Seguin ISD financially responsible for emergency care and/or transportation to home, to a doctor, to a dentist, or to the home of a relative or friend. I grant school personnel my permission to transport this child. Name of Family Doctor (please print): ________________________________City ________________________ Phone # ___________________ X _______________________________________________________________________________________________________________________ Signature of Parent/Guardian Date

Changes in legal guardian and/or lives with fields require documentation – See Elementary Attendance Clerk or Secondary Registrar

Registrar

Sibling Information: children who live in your home and are currently attending school, do not list student entered above.

Contact Information: (other than parent) Persons listed below are authorized to be contacted in case of an emergency or to whom the

student may be released during the school day. Please indicate any restrictions on releasing your child’s records.

SEGUIN ISD ENROLLMENT FORM Addendum (for additional contacts/siblings) Changes in legal guardian and/or resides with fields require documentation- see Elementary Attendance Clerk/Secondary Registrar.

Student Name:_______________________________________________ ID#___________________________________________ Contact Name: ________________________________________________ DL #:_________________________________

Contact Type: Parent, Guardian, Other Relationship: ________________________________ Lives With: ___ (Circle one)

Address is private ___ Home Address: ___________________________________________________________________ Mailing Address is private ___ Mailing Address: ___________________________________________________________ Phone is private ___ Home Phone: ____________________ Private Cell? ____ Cell Phone: _____________________ Email is private ___ Email: _____________________________________________________________________________ Employer: _______________________________________________________ Employer’s Phone: ___________________

Contact Name: ________________________________________________ DL #:_________________________________

Contact Type: Parent, Guardian, Other Relationship: ________________________________ Lives With: ___ (Circle one)

Address is private ___ Home Address: ___________________________________________________________________ Mailing address is private ___ Mailing Address: ___________________________________________________________ Phone is private ___ Home Phone: ____________________ Private Cell? ____ Cell Phone: _____________________ Email is private ___ Email: _____________________________________________________________________________ Employer: _______________________________________________________ Employer’s Phone: ___________________

Contact Name: ________________________________________________ DL #:_________________________________

Contact Type: Parent, Guardian, Other Relationship: ________________________________ Lives With: ___ (Circle one)

Address is Private ___ Home Address: ___________________________________________________________________ Mailing address is private ___ Mailing Address: ___________________________________________________________ Phone is private ___ Home Phone: ____________________ Private Cell? ____ Cell Phone: _____________________ Email is private ___ Email: _____________________________________________________________________________ Employer: _______________________________________________________ Employer’s Phone: ___________________

Contact Information: (Other than Parent) Persons listed below are authorized to be contacted in case of an emergency or to whom the student may be released during the school day. Please indicate any restrictions on releasing your child’s records.

Name: _________________________________________ Phone: _____________________ Relation:_______________________ Name: _________________________________________ Phone: _____________________ Relation: _____________________

Sibling’s Name: _____________________________ Sibling’s Campus:_______________ Age (Sept 1st this year):____________

Sibling’s Name: _____________________________ Sibling’s Campus:_______________ Age (Sept 1

st this year):____________

Sibling’s Name:______________________________ Sibling’s Campus:_______________ Age (Sept 1

st this year):____________

Sibling’s Name:______________________________ Sibling’s Campus:_______________ Age (Sept 1

st this year):____________

Sibling’s Name:______________________________ Sibling’s Campus:_______________ Age (Sept 1

st this year):____________

Parent Signature: _____________________________________ Date: ________________________________

Sibling Information: children who live in your home and are currently attending school, do not list student entered above.

Seguin ISD Parent-Student Authorization Form (Parent initials by each choice that applies.)

1. Acknowledgment of Receipt of Student/Parent Handbook (Grades PK-12)

I understand that the Student/Parent Handbook contains information that my child and I may need during the school year and that

all students will be held accountable for their behavior and will be subject to the disciplinary consequences outlined in the Student

code of Conduct. If I have any questions regarding this handbook or the Student Code of Conduct, I should direct those questions

to the campus principal.

_____ I have chosen to receive a paper copy of the Student/Parent Handbook.

_____ I accept responsibility for accessing the Student/Parent Handbook by visiting the Seguin ISD Website at

www.seguin.k12.tx.us.

2. Notice Regarding Directory Information (PK-12)

If you do not want Seguin ISD to disclose directory information from your child’s education records without your prior written

consent, you must notify the district in writing within ten school days of your child’s first day of instruction for this school year.

Directory information includes, student name, address, telephone number, email address, photograph, date and place of birth,

honors and awards received, dates of attendance, grade level, most recent school previously attended, participation in officially

recognized activities and sports, weight and height, if a member of an athletic team.

_____ I do give the district permission to release the information in this list in response to a request.

_____ I do not give the district permission to release the information in this list in response to a request.

3. Use of Student work and Photo in district Publications including Websites (Grades PK-12)

Occasionally, the Seguin ISD wishes to display student photos and/or publish student artwork or special projects on the campus,

teacher, or district’s website and in district publications. The district agrees to only use these photos and student projects in this

manner.

_____ I do give the district permission to display my student’s photo(s) on the district website and/or publications.

_____ I do not give the district permission to display my student’s photo(s) on the district website and/or publications.

_____ I do give the district permission to display my student’s artwork or special projects on the district website and/or

publications. _____ I do not give the district permission to display my student’s artwork or special projects on the district website and/or

publications.

4. Release of Student Information to Military Recruiters and Institutions of Higher Education (Grades 9-12)

Federal law requires that the district release to military recruiters and institutions of higher education, upon request, the name,

address, and phone number of secondary school students enrolled in the district, unless the parent or eligible student directs the

district not to release information to these types of requestors without prior written consent.

_____ I request that the district Not release my child’s name, address, and telephone number to a military recruiter or institutions

of higher education upon their request without prior written consent .

Printed Name of student _______________________________________ Campus _______________________

Signature of student: __________________________________________________Date: __________________

Signature of parent: __________________________________________________ Date: __________________

PHO

NE

#S

SEGUIN INDEPENDENT SCHOOL DISTRICT HEALTH SERVICES

School Year: / STUDENT HEALTH HISTORY ID #:

Student: _________________________________________ DOB:__________________ Grade:________ Sex : M / F

Address: _____________________________________________ City:_________________________ Zip: _________

Mother:______________________________ Cell:__________________________ Work: _________________________

Father:______________________________ Cell:__________________________ Work: _________________________

Emergency contacts who can assume responsibility for your child. MUST COMPLETE THIS INFORMATION WITH TWO

CONTACTS. (Please make sure these are additional phone numbers to the ones listed above)

Name:_____________________________ Relationship:____________________ Phone: ________________________

Name:_____________________________ Relationship:____________________ Phone: ________________________

How is health care provided for this student? Private Insurance____ Medicaid____ SSI____ CHIPS____ Other _____

Please give the name of your child’s health provider(s) / Doctor(s)? ___________________________________________

Phone number(s) for Doctor(s): ________________________________________________________________________

CIRCLE BELOW AND COMMENT ON PAST OR CURRENT HEALTH PROBLEM(S) NO Health Problems:________ (PLEASEINITIAL)

Allergies (please include all medication and food allergies) _____________________________________________________

ADD/ADHD: _____________________________________ Kidney / Bladder: __________________________________

Asthma: ________________________________________ Orthopedic: ______________________________________

Blood Pressure: __________________________________ Respiratory: ______________________________________

Dental: _________________________________________ Serious illness/injury: _______________________________

Diabetes: _______________________________________ Special Diet: ______________________________________

Head Injury: _____________________________________ Surgeries: ________________________________________

Hearing / Hearing Aid: _____________________________ Vision: ______glasses ______contacts _____reading only

Heart / Murmurs: _________________________________ Other: ___________________________________________

Seizures / date of last seizure: ________________________________________________________________________

�PLEASE LIST ALL MEDICATIONS: Daily meds: _____________________________________________________________

�Meds to be taken at school (meds provided by parent): ___________________________________________________

Has your child been hospitalized for a major illness? If yes, please explain: _____________________________________

_________________________________________________________________________________________________

Is your child currently under medical care? Yes____ No____ If yes, please explain: _____________________________

_________________________________________________________________________________________________

Is there anything we need to know about your child’s health? Yes____ No____ If yes, please explain: ________________

_________________________________________________________________________________________________

I authorize officials of Seguin ISD to contact persons named on this form or on the enrollment card and authorize the physician or emergency room personnel to render treatment of this child as may be necessary in an emergency. If I or the designated persons I have listed are not available, I authorize the officials of Seguin ISD to take whatever action is deemed necessary in their judgment for the health of my child.

I understand that we as parents or guardians are responsible for providing transportation in case of our child’s illness or accident, including costs of an EMS ambulance if necessary. I am aware that school officials may have to arrange transportation for our child in a serious situation. I authorize for the physician/health care provider(s) named on this card to be contacted for the pertinent health information to be received and given on my child.

Parent/Guardian Signature:___________________________________________ Date: _________________

2019-2020 Texas Education Data Standards Appendix 8.F – PEIMS Supplemental Information for Reporting Ethnicity and Race Data Reporting

Preliminary Version 2020.0.0

4

Exhibit 1A Student/Staff Ethnicity and Race Data Questionnaire in English Texas Education Agency

Texas Public School Student/Staff Ethnicity and Race Data Questionnaire

The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race. United States Federal Register (71 FR 44866)

Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one)

Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic/Latino

Part 2. Race: What is the person’s race? (Choose one or more)

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Student/Staff Name (please print) (Parent/Guardian)/(Staff) Signature

Student/Staff Identification Number Date

This space reserved for Local school observer – upon completion and entering data in student software system, file this form in student’s permanent folder.

Ethnicity – choose only one:

Hispanic / Latino

Not Hispanic/Latino

Race – choose one or more: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Observer signature: Campus and Date:

Texas Education Agency – March 2018

LPAC Framework Manual 2018-2019 Texas Education Agency

SEGUIN INDEPENDENT SCHOOL DISTRICT

HOME LANGUAGE SURVEY-19 TAC Chapter 89, Subchapter BB, §89.1215 (Home Language Survey applicable ONLY if administered for students enrolling in pre-kindergarten through grade 12)

TO BE COMPLETED BY PARENT OR GUARDIAN FOR STUDENTS ENROLLING IN PREKINDERGARTEN THROUGH GRADE 8 (OR BY STUDENT IN GRADES 9-12): The state of Texas requires that the following information be completed for each student who enrolls in a Texas public school for the first time. It is the responsibility of the parent or guardian, not the school, to provide the language information requested by the questions below.

NAME OF STUDENT: ______________________________ STUDENT ID#: _______________________________ CAMPUS: ___________________ ADDRESS: _______________________________________ TELEPHONE #: _______________________________

NOTE: PLEASE INDICATE ONLY ONE LANGUAGE PER RESPONSE.

1. What language is spoken in the child’s home most of the time? ________________________ 2. What language does the child speak most of the time? ________________________

_______________________________________ ________________________________ Signature of Parent/Guardian Date

_______________________________________ ________________________________ Signature of Student if Grades 9-12 Date NOTE: If you believe you made an error when completing this Home Language Survey, you may request a correction, in writing, only if: 1) your child has not yet been assessed for English proficiency; and 2) your written correction request is made within two calendar weeks of your child’s enrollment date.

Dear Parent or Guardian: To determine if your child would benefit from Bilingual and/or English as a Second Language program services, please answer the two questions below. If either of your responses indicates the use of a language other than English, then the school district must conduct an assessment to determine how well your child communicates in English. This assessment information will be used to determine if Bilingual and/or English as a Second Language program services are appropriate and to inform instructional and program placement recommendations. If you have questions about the purpose and use of the Home Language Survey, or you would like assistance in completing the form, please contact your school/district personnel. For more information on the process that must be followed, please visit the following website: https://projects.esc20.net/upload/page/0084/docs/EL%20Identification_ReclassificationFlowchart%202018.pdf

This survey shall be kept in each student’s permanent record folder.

SEGUIN ISD

STUDENT MILITARY QUESTIONNAIRE

Due to recent House Bill 525 and Senate Bill 833, it has become necessary for Seguin ISD to collect the status of students in regards to military and foster care. This information must be reported to TEA in our District PEIMS submissions. Please mark one box in each section and return this form to your campus as soon as possible. Military – Is your student a dependent of an active military member? Please check one box below.

0 - My Student is not a military connected student 1 - US Military - Army, Navy, Air Force, Marine Corps or Coast Guard on active duty 2 - Texas National Guard on active duty 3 - Reserve Force of the US Military on active duty 4 – PK Student is a dependent of any of the above

Student Name (Please Print) Campus Student ID Number Grade Level Parent Signature Date