Anacortes School District 103 2200 M Avenue Anacortes, Washington 98221

Phone: 360-293-1200 / Fax: 360-293-1222 http://www.asd103.org

Student Registration Packet

Welcome to Anacortes School District, We look forward to partnering with you to ensure your student has a successful, productive, and positive school year. The following items are required to register for school in the Anacortes School District: 1. Copy of your child’s birth certificate 2. Notarized guardianship form must be provided if a student is living in the home of someone other

than their legal custodian 3. Certificate of Immunization Status filled out, completed and signed by parent/guardian 4. Completed registration packet Please note that Anacortes School District supports a system of choice for elementary school placement. Students are placed in school according to Anacortes School Board Policy 3131 (included in elementary registration packet). If you will be living outside of Anacortes, but would like to enroll your student in our district, an Out of District Choice Transfer Request form must be completed. These forms are available at the district office or online at http://www.asd103.org Thank you, Kristi Lang Monique Starkovich Kim Kitchen Elementary Registrar Anacortes Middle School Registrar Anacortes High School Registrar Phone: 360-293-4820 Phone: 360-293-1246 Phone: 360-293-1337 Email: klang@asd103.org mstarkovich@asd103.org kkitchen@asd103.org

Welcome to Anacortes High School!

New Student Checklist Interview Form

The registration process can take three or more days – please plan ahead!

To enroll your student, we need:

☐Student’s official academic transcript ☐Copy of birth certificate ☐Immunization Records ☐Disciplinary information ☐Custody papers (if applicable) Check this box if your student has:

☐an IEP ☐a 504 Plan ☐Individual Health Plan (IHP)

Please complete the forms in this packet and return them to: Anacortes High School, Counseling Center 1600 20th Street Anacortes, WA 98221 Fax: 360-293-0744

After AHS has received the necessary information, the Counseling Office will schedule your student to meet with their counselor to choose classes.

If your student has been in a special needs program, with a current IEP, please contact Student Support Services, 360-293-1218, in the District Office, 2200 M Avenue.

If your student will not be residing in Anacortes, the parent(s) must obtain an Out-of-District Application from the Superintendent’s Office in the town they reside in, and then apply for a non-resident waiver at the Anacortes District Office.

Student’s Name: ________________________________ Grade: _____Sex: ____

Questions? Contact the AHS Counseling Office (360) 293-2166 or the Anacortes District Office (360) 293-1200

New Student Enrollment Form Students Last Updated: 2.2010; 3.2014; 3.2016, 5.2017 3121 F1

STU

DEN

T IN

FO

STUDENT NAME: Legal LAST Name Legal FIRST Name

Legal MIDDLE Name

BIRTHDATE (Month/Day/Year) / /

Has student’s name ever been legally changed? If yes, what was previous name?

PRIMARY LANGUAGE SPOKEN AT HOME English Spanish Other _________________

GRADE LEVEL:

GENDER Male Female

District Resident? Yes No

Birthplace: City: State: County: Country:

Birth Certificate RECEIVED BY DISTRICT

Proof of Immunization REQUIRED RECEIVED BY DISTRICT

PRIM

ARY

HO

USE

HO

LD

PRIMARY PARENT/GUARDIAN INFORMATION (Household information where student resides)

Legal Parent/Guardian #1 Last Name

First Name

Primary Phone ( ) Please check if confidential (will not be published)

Second Phone ( ) Home Work Cell

Third Phone ( ) Home Work Cell

Email Employer: Active Military YES NO

Relation to Student: Father Mother Guardian Other: Student Lives with: Both Parents Father only Mother only Grandparents Father/Stepmother Mother/Stepfather Guardian Agency Self Other

Parent/Guardian #2 Last Name

First Name

Email Second Phone ( ) Home Work Cell

Third Phone ( ) Home Work Cell

Relation to Student: Father Mother Guardian Other:

Employer: Active Military YES NO

Resident Address

Street Apt # City State Zip

Mailing Address (If different From above)

Street Apt # PO Box City State Zip

SECO

ND

HO

USE

HO

LD

SECOND HOUSEHOLD INFORMATION (Student does not primarily reside at this residence) Parent/Guardian #1 Last Name

First Name

Primary Phone ( ) Please check if confidential (will not be published)

Second Phone ( ) Home Work Cell

Third Phone ( ) Home Work Cell

Email

Relation to Student: Father Mother Guardian Other:

Employer: Active Military YES NO

Parent/Guardian #2 Last Name

First Name

Email:

Second Phone ( ) Home Work Cell

Third Phone ( ) Home Work Cell

Relation to Student: Father Mother Guardian Other:

Employer: Active Military YES NO

Resident Address

Street Apt City State Zip

Mailing Address (If different from above)

Street Apt # PO Box City State Zip

SIBL

ING

S Sibling Name

Sibling Age School Attending

Sibling Name

Sibling Age School Attending

STUDENT ENROLLMENT FORM Date: _________________________

New Student Enrollment Form Students Last Updated: 2.2010; 3.2014; 3.2016, 5.2017 3121 F1

EM

ERG

ENCY

MED

ICAL

IN

FORM

ATIO

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AUTH

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IZAT

ION

EMERGENCY MEDICAL INFORMATION Please list any medications your child will be taking during school hours: ____________________________________________ If the student needs medications/treatment while at school, a Medication at School Authorization Form must be completed for each medication/treatment.

Please list any known allergens: ____________________________________________________________________________ Required treatment for allergies: ______________________________________________________________________________________________ Other life threatening conditions (please provide information in writing to school): ______________________________________________________________________________________________ EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of an accident or illness, every effort will be made to contact the parent/guardian immediately. If the parent/guardian cannot be reached, I authorize school authorities to obtain emergency medical care for my child.

X Legal Parent/Guardian SIGNATURE __________________________________________________________________________Date:_____________________

EMER

GEN

CY C

ON

TACT

AU

THO

RIZA

TIO

N

EMERGENCY CONTACT INFORMATION: When illness, injury or other non-emergency situations occur involving your child, we want to be able to quickly reach family members or other responsible adults. Our first contact is always a parent or guardian, but in the event that a parent/guardian cannot be reached, please list the persons you trust who are available during the day to provide care for your child

STUDENT RELEASE AUTHORIZATION: In the event that the school in unable to contact the parent/guardian, I authorize that my child may be released to the person(s) below:

X Legal Parent/Guardian SIGNATURE __________________________________________________________________________Date:_____________________

EMER

GEN

CY C

ON

TACT

S

PRIMARY EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

SECOND EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

THIRD EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

FOURTH EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

FIFTH EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

New Student Enrollment Form Students Last Updated: 2.2010; 3.2014; 3.2016, 5.2017 3121 F1

CHIL

D C

ARE

DOES STUDENT ATTEND CHILD CARE? BEFORE SCHOOL AFTER SCHOOL BEFORE AND AFTER SCHOOL

BEFORE SCHOOL CHILD CARE PROVIDER NAME: _______________________________________________________________________

PHONE: __________________________________ _____ CELL PHONE: _____________________________

ADDRESS: ___________________________________________________________________________________________________________

AFTER SCHOOL CHILD CARE PROVIDER NAME: _________________________________________________________________________

PHONE: __________________________________ _____ CELL PHONE: _____________________________

ADDRESS: ____________________________________________________________________________________________________________

Additional Child Care Arrangements: Please provide additional information to school in writing.

SCH

OO

L H

ISTO

RY

School previously attended (most recent)

Entry Date Withdrawal Date Previous School Address (Street, City, State and Zip)

Has student ever attended a school in the Anacortes School District?

Yes No

If yes, name of school attended:

School Year:

PRES

CHO

OL/

EA

RLY

CHIL

D

CARE

Did student attend preschool/early childhood care center? Yes No

If yes, name of preschool/early childhood care center:

STU

DEN

T H

ISTO

RY

Has your child ever received services in any of the following programs? Check all applicable programs

Special Education 504 Accommodations Highly Capable ELL Title 1 Services LAP Services Speech

Migrant Services Other

Name of school where services were received ___________________________________________________

Does your child have any past, current, or pending disciplinary actions or any history of violent behavior? Yes No Date ________

Is your child presently on suspension from another school? Yes No If yes, reason _________________________________________

Is your child a military dependent? Yes No Is there a joint-custody or parenting plan in effect? Yes No (If yes, a certified copy of the most recent plan must be on file with the school for enforcement.)

Is there a restraining order against anyone pertaining to your student? Yes No (If yes, most recent certified legal papers must be on file with the school for enforcement.) Restraining order is against Mother Father Other _______________________________________________________

Special instructions regarding religious beliefs (please provide information to the school in writing): _______________________________________________________________________________________________________________

New Student Enrollment Form Students Last Updated: 2.2010; 3.2014; 3.2016, 5.2017 3121 F1

ETH

NIC

ITY

AND

RAC

E Ethnicity and Race

School districts in Washington State are required to report student data by ethnicity and race categories to the state’s Office of Superintendent of Public Instruction. Ethnicity and race categories used in our district are the same as used in all Washington school districts. They are set by the federal government, the Washington State Legislature, and the state Superintendent of Public Instruction. Please complete the following: 1. Is your child of Hispanic or Latino origin?

No, my child is not Hispanic or Latino Yes, my Child is Hispanic or Latino - (Check all that apply): Cuban Puerto Rican South American Dominican Mexican/Mexican American/Chicano Latin American Spaniard Central American Other Hispanic/Latino

2. What race do you consider your child? (Check all that apply)

African American or Black White or Caucasian Asian Asian Indian Cambodian Chinese Filipino Hmong Indonesian Japanese Korean Laotian Malaysian Pakistani Singaporean Taiwanese Thai Vietnamese Other Asian

Native Hawaiian/Other Pacific Islander Native Hawaiian Fijian Guamanian or Chamorro Mariana Islander Melanesian Micronesian Samoan Tongan Other Pacific Islander

Native American Alaskan Native Chehalis Colville Cowlitz Hoh Jamestown S’Klallam Kalispel Lower Elwa Klallam Lummi Makah Muckleshoot Nisqually Nooksack Port Gamble S’Klallam Puyallup Quileute

Quinault Samish Sauk-Suiattle Shoalwater Bay Skokomish Snoqualmie Spokane Squaix Island Stillaguamish Suquamish Swinomish Tulalip Yakima Other Washington Indian

Tribe Other American Indian

Tribe/Alaska Native

PAR

ENT

SIG

NAT

UR

E

“I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Anacortes Public Schools. I agree to notify the Anacortes School District in writing within five (5) school days following any change of my/our residency.”

X Legal Parent/Guardian SIGNATURE _________________________________________________________Date:_____________________

DIS

TRIC

T U

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NLY

DISTRICT USE ONLY Birth Certificate Immunizations District Staff SIGNATURE ______________________________________________________________Date:__________________________

ANACORTES SCHOOL DISTRICT #103 REQUEST FOR EXCHANGE OF STUDENT INFORMATION

DATE OF REQUEST:

TO: Previous School Name: __________________________________________________________

Street Address: _________________________________________________________________

City, State, Zip: _________________________________________________________________

Please send school records for the following student, who has recently enrolled in the Anacortes School District:

Student Name: _________________________________________________________________

Date of Birth: Last Grade Attended: ___________________

Date of Withdrawal from Previous School: ____________________________________________ Parents: Please provide above information, and return this form with registration packet. Please route this form to the proper departments to include the following information:

• Student Transcript (grades, report cards, attendance records, immunization records) • Group testing and diagnostic data • Individual test data • Special program placement data • Special health history • Other ______________________________________________________________________

All materials received will be placed in the student’s record and will be available for inspection and review in accordance with the requirements of the Family Educational Rights and Privacy Act of 1974. ___________________________________________ School Representative Please send the records to the location noted below: Anacortes High School Island View Elementary Fidalgo Elementary 1600 20th Street 2501 J Avenue 13590 Gibralter Road Anacortes, WA 98221 Anacortes, WA 98221 Anacortes, WA 98221 360-293-2166 FAX: 293-4824 360-293-3149 FAX: 299-1853 360-293-9545 FAX: 299-1852 Anacortes Middle School Mount Erie Elementary Whitney Elementary 2202 M Avenue 1313 41st Street 1200 M Avenue Anacortes, WA 98221 Anacortes, WA 98221 Anacortes, WA 98221 360-293-1230 FAX: 293-1231 360-293-9541 FAX: 299-1854 360-293-9536 FAX: 299-1845 Anacortes School District Anacortes School District ATTN: Special Services 2200 M Avenue 2200 M Avenue Anacortes, WA 98221 Anacortes, WA 98221 360-293-1200 FAX: 360-293-1222 360-293-1218 FAX: 299-4822 (for special ed records requests only) smatto@asd103.org Federal Law 99.31: “No parent signature is required for educational records sent to another educational agency.” X:\Registration Information\Req for exch of student info Revised 12/01/15

If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). DOH 348-295 December 2016

Parents - Are Your Kids Ready for School?

Required Immunizations for School Year 2017-2018

Hepatitis B

DTaP/Td/Tdap (Diphtheria, Tetanus,

Pertussis) Vaccine doses required may

be fewer than listed

Polio Vaccine doses required

may be fewer than listed

MMR (Measles, Mumps,

Rubella)

Varicella (Chickenpox)

Kindergarten – 5th Grade

3 doses within the correct timeframes

5 doses within the correct timeframes

4 doses within the correct timeframes

2 doses within the correct timeframes

2 doses within the correct timeframes

OR Healthcare provider verified

child had disease

6th – 12th Grade 3 doses within the correct timeframes

5 doses DTaP

AND

1 dose Tdap, all within the correct timeframes

4 doses within the correct timeframes

2 doses within the correct timeframes

2 doses within the correct timeframes

OR Healthcare provider verified

child had disease (Exceptions are allowed for

certain students)

Students must get vaccine doses at correct timeframes to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements.

Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/

Parent/Guardian Instructions: To see which vaccines are required for school, find your child’s grade and look only at that row going across to find the vaccines and number of doses required.

Certificate of Immunization Status (CIS) For Kindergarten-12th Grade / Child Care Entry

Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex: ____________________________________________________________________________________________________________________________________________________

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record. ______________________________________________________________ Parent/Guardian Signature Required Date

I certify that the information provided on this form is correct and verifiable.

______________________________________________________________ Parent/Guardian Signature Required Date

♦ Required for School and Child Care/Preschool Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Documentation of Disease Immunity Healthcare provider use only

If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider I certify that the child named on this CIS has: a verified history of Varicella (Chickenpox). laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. Diphtheria Mumps Other: Hepatitis A Polio __________ Hepatitis B Rubella __________ Hib Tetanus Measles Varicella

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name

● Required Only for Child Care/Preschool

Required Vaccines for School or Child Care Entry

♦ DTaP / DT (Diphtheria, Tetanus, Pertussis)

♦ Tdap (Tetanus, Diphtheria, Pertussis)

♦ Td (Tetanus, Diphtheria)

♦ Hepatitis B 2-dose schedule used between ages 11-15

● Hib (Haemophilus influenzae type b)

♦ IPV / OPV (Polio)

♦ MMR (Measles, Mumps, Rubella)

● PCV / PPSV (Pneumococcal)

♦ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV / MPSV (Meningococcal)

MenB (Meningococcal)

Rotavirus

Office Use Only:

Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide

database). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: waiisrecords@doh.wa.gov or 1-866-397-0337.

To fill out the form by hand: #1 Print your child’s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against

several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.

If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.

#4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.

Reference guide for vaccine trade names in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB® Hib Fluarix® Flu Havrix® Hep A Menveo® Meningococcal Rotarix® Rotavirus (RV1)

Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® DTaP + Hep B + IPV RotaTeq® Rotavirus (RV5)

Afluria® Flu FluLaval® Flu HibTITER® Hib PedvaxHIB® Hib Tenivac® Td

Bexsero® MenB FluMist® Flu Ipol® IPV Pentacel® DTaP + Hib + IPV Trumenba® MenB

Boostrix® Tdap Fluvirin® Flu Infanrix® DTaP Pneumovax® PPSV Twinrix® Hep A + Hep B

Cervarix® 2vHPV Fluzone® Flu Kinrix® DTaP + IPV Prevnar® PCV Vaqta® Hep A

Daptacel® DTaP Gardasil® 4vHPV Menactra® MCV or MCV4 ProQuad® MMR + Varicella Varivax® Varicella

Engerix-B® Hep B Gardasil® 9 9vHPV Menomune® MPSV4 Recombivax HB® Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 December 2016

Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 Meningococcal Conjugate Vaccine OPV Oral Poliovirus

Vaccine Tdap Tetanus, Diphtheria, acellular Pertussis

DTaP Diphtheria, Tetanus, acellular Pertussis

Hep B Hepatitis B MenB Meningococcal B PCV / PCV7 / PCV13

Pneumococcal Conjugate Vaccine VAR / VZV Varicella

DTP Diphtheria, Tetanus, Pertussis Hib Haemophilus

influenzae type b MPSV / MPSV4 Meningococcal Polysaccharide Vaccine

PPSV / PPV23 Pneumococcal Polysaccharide Vaccine

Flu (IIV) Influenza HPV (2vHPV / 4vHPV / 9vHPV)

Human Papillomavirus MMR Measles, Mumps,

Rubella Rota (RV1 / RV5) Rotavirus

HBIG Hepatitis B Immune Globulin IPV Inactivated

Poliovirus Vaccine MMRV Measles, Mumps, Rubella with Varicella

Td Tetanus, Diphtheria

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

English

May 2014

Office of Superintendent of Public Instruction (OSPI) Home Language Survey

Student Name:

Date:

Birth 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__ Don’t 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

”Formal education” does not include refugee camps or other unaccredited programs for children.

If yes, in what language(s) was instruction given? _____________________ For how many months? ____

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

English

May 2014

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 student’s first language and language(s) used in the home?

The two questions about the student’s 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 student’s 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 student’s 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 student’s previous education?

Information about a student’s education will help ensure that the student’s education both within and outside of the United States is considered in any recommendations made for participation in programs and district services. The student’s 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 child’s school.

Spanish (Español)

May 2014

Oficina de la Superintendente Estatal de Enseñanza Pública (OSPI) Encuesta sobre el idioma que se habla en el hogar

Nombre del alumno:

Fecha:

Fecha de nacimiento: Sexo: Grado:

Este formulario fue completado por:

Nombre del padre/madre/tutor: Relación con el alumno:

Firma del padre/madre/tutor: Si está disponible, ¿en qué idioma desea recibir información de la escuela?

¿Su hijo recibió apoyo para el aprendizaje del idioma inglés a través del Programa Estatal de Educación Bilingüe de Transición en la última escuela a la que asistió? Sí__ No__ No sé__

1. ¿En qué país nació su hijo? _____________________

2. ¿Qué idioma aprendió su hijo primero?* ___________________

3. ¿Qué idioma usa más SU HIJO en casa?* _____________________

4. ¿Qué idioma(s) usan más los padres/tutores cuando hablan con su hijo?

_____________________ _____________________

5. ¿Ha recibido su hijo educación formal* fuera de los Estados Unidos? (Kinder a 12.º grado)

_____Sí _____No

"Educación formal" no incluye programas en campos de refugiados ni otros programas no acreditados para niños.

En caso afirmativo, ¿en qué idioma se le dio la instrucción? _____________ ¿Por cuántos meses? ______

6. ¿Cuándo asistió su hijo a la escuela en los Estados Unidos por primera vez? (Kínder a 12.º grado)

_______________________ Día Mes Año

*WAC 392-160-005: "Idioma principal" significa el idioma que el alumno usa con más frecuencia (no necesariamente el idioma que usan los padres, tutores u otros) para comunicarse en el lugar donde vive el alumno.

Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing.

Spanish (Español)

May 2014

Propósito de la Encuesta sobre el idioma que se habla en el hogar

La Encuesta sobre el idioma que se habla en el hogar se proporciona a todos los estudiantes que se inscriben en escuelas de Washington. La siguiente información debería contribuir a responder a algunas de las preguntas que podría tener sobre este formulario.

¿Cuál es el propósito de la Encuesta sobre el idioma que se habla en el hogar?

El propósito principal de la Encuesta sobre el idioma que se habla en el hogar es contribuir a identificar a los estudiantes que podrían calificar para obtener ayuda con el fin de desarrollar las habilidades del idioma inglés necesarias para tener éxito en la clase y de recibir otros servicios. Es importante que esta información se registre correctamente, ya que puede afectar la elegibilidad de los estudiantes para recibir los servicios que necesitan para tener éxito en la escuela. Es posible que sea necesario evaluarlos a fin de determinar si precisan servicios de apoyo adicionales en relación con el idioma y académicos. Ningún estudiante será asignado al programa de desarrollo del idioma inglés solo en función de las respuestas a este formulario.

¿Por qué preguntan acerca de la primera lengua del estudiante y del (de los) idioma(s) que se habla(n) en el hogar?

Las dos preguntas sobre el idioma del estudiante nos ayudan a determinar: • si el estudiante puede ser elegible para obtener ayuda con el aprendizaje del inglés, y • si el personal de la escuela debería conocer otros idiomas utilizados por el estudiante en su hogar.

El idioma que su hijo aprendió primero puede ser distinto del idioma que su hijo utiliza para comunicarse en el hogar ahora. Las respuestas a estas dos preguntas ayudarán a la escuela a proporcionarle instrucción adecuada según las necesidades individuales del estudiante, y también contribuirán con las necesidades de comunicación que puedan surgir. Los estudiantes que primero aprendieron un idioma que no sea inglés pueden calificar para obtener servicios de apoyo adicionales. Incluso los estudiantes que hablan bien inglés podrían precisar apoyo para desarrollar habilidades del idioma necesarias para tener éxito en la escuela.

¿Por qué preguntan dónde nació el estudiante?

Esta información ayuda al distrito escolar y al estado a determinar si al estudiante le corresponde la definición de inmigrante a los fines del financiamiento federal. Esto se aplica incluso cuando ambos padres del estudiante son ciudadanos estadounidenses, pero el estudiante nació fuera de los Estados Unidos. Este formulario no se utiliza para identificar a estudiantes que quizás sean indocumentados.

¿Por qué preguntan sobre la educación anterior del estudiante?

La información sobre la educación de un estudiante contribuirá a garantizar que la educación del estudiante tanto dentro como fuera de los Estados Unidos sea tenida en cuenta en las recomendaciones para la participación en programas y servicios del distrito. Los antecedentes educativos del estudiante también constituyen información importante para ayudar a determinar si el estudiante está avanzando lo suficiente hacia los estándares estatales en función de sus antecedentes educativos anteriores.

Gracias por proporcionar la información necesaria en la Encuesta sobre el idioma que se habla en el hogar. Comuníquese con su distrito escolar si tiene otras preguntas sobre este formulario o sobre los servicios disponibles en la escuela de su hijo.

Anacortes School District 103 2200 M Avenue Anacortes, Washington 98221

Phone: 360-293-1200 / Fax: 360-293-1222 http://www.asd103.org

Student Housing Questionnaire

Please use one form per student. Return to school registration office within

14 days of receipt. If you require additional copies, please contact your school.

NAME OF STUDENT:__________________________ ________________________ _________________________ FIRST MIDDLE LAST NAME OF SCHOOL: ____________________________ GRADE:_____ BIRTH DATE: ____/____/____ AGE:_______ GENDER: MALE FEMALE CURRENT HOME ADDRESS: _______________________________________________________________________ CURRENT PHONE NUMBER: ____________________ (HOME) _______________ (CELL) _______________(WORK) CURRENT E-MAIL ADDRESS: ____________________________________________________ **Is the address and/or phone number new information for your student? Yes No Students from Military Families Data Collection: (You are not required to answer these questions.) School Districts are required to acquire information on Military affiliations per Substitute Senate Bill 5163 2015.

1. Is this student living with a parent/guardian who is active duty in the U.S. Military? Yes No 2. Is this student living with a parent/guardian who is a member of the reserves of the

United States Armed Forces or the Washington National Guard? Yes No Your student may qualify for services under the McKinney-Vento Act 42 U.S.C. 11435. The answers to the following questions will help determine if your student is eligible for those services.

3. Is this student’s current address a temporary living arrangement, other than a rental? Yes No 3a. If this is a temporary living arrangement, is it due to a loss of housing or economic hardship? Yes No

4. Is this student in a temporary foster care placement or awaiting foster care? Yes No 5. As a student, are you living with someone other than your parent or legal guardian? Yes No

If you answered YES to questions 3-5, please complete the remainder of this form. If you answered NO to questions 3-5, you may stop here.

***************************************************************************************************************************************************************************** If you answered “Yes” to questions 3-5, is the address listed above any of the following? (check 1 box) (No signature required for questions 1-2)

A motel/hotel Group home A shelter Transitional housing More than one family living in the house/apartment Foster care (waiting for permanent placement) Moving from place to place In a location not designed for sleeping accommodations such as a car, park

or campsite NAME OF MOTEL/SHELTER OF CURRENT ADDRESS:________________________________________________________________________ (OR) NAME OF “GENERAL AREA” OF CURRENT ADDRESS:________________________________________________________________________ MAIN CONTACT PERSON FOR THIS STUDENT:_____________________________________________ CONTACT PHONE #:_______________ I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct. Print name of parent(s)/legal guardian(s):______________________________________________________________________________________ (or unaccompanied youth) Signature of parent(s)/legal guardian(s): _______________________________________________________________ Date:__________________ (or unaccompanied youth) For school staff only: If homeless condition is noted, forward questionnaire to the Special Services Office or fax to 299-4822. Rev. 5/17

Anacortes School District

STUDENT HEALTH INFORMATION

Information on this form is to be filled out (updated) for each new school year. Please complete both sides of this form and return

to your school as soon as possible.

Name: ________________________________________________ Birthdate: ______________ Gender: ___________ Last First MI

School: __________________________________________ Grade: ______ Today’s Date: ______________________

LIFE THREATENING CONDITIONS Does your child have a life-threatening health condition? Yes* __ No __

*If yes, a meeting with the school nurse is required prior to starting school.

󠄵 My child has NONE of the health concerns/conditions listed above.

HEALTH CONDITIONS

󠄵 My child has NONE of the health concerns/conditions listed above.

PLEASE SEE OTHER SIDE

󠄵 Asthma *Severe – (If this box is checked, please answer the following questions.)

Yes 󠄵 No 󠄵 Does child use rescue inhaler routinely for asthma symptoms?

Yes 󠄵 No 󠄵 Has your child been hospitalized for asthma in the past year?

Yes 󠄵 No 󠄵 Has your child used steroids (Prednisone) for asthma symptoms in the past year?

If mild or moderate asthma, see box below - HEALTH CONDITIONS

󠄵 Allergy/Anaphylaxis - *Severe - with Epipen/epinephrine prescription (for example: food, insect stings.)

Allergen(s): _______________________________________________________________________________________________

Other: ___________________________________________________________________________________________________________

󠄵 Diabetes – Date of diagnosis: _____________________ My student has 󠄵󠄵 insulin pump 󠄵󠄵 insulin pen 󠄵 injected insulin

󠄵 Seizure Disorder - My student needs emergency medication for Seizures. Name of medication: ______________________________________

󠄵 Special Health Care Planning – My child has special health care needs such as – wheelchair, tube feedings, breathing tube, catheter, intravenous

tubes or other. Please describe your child’s condition(s): __________________________________________________________________________

_________________________________________________________________________________________

ALERT TO PARENTS/GUARDIAN: The school must know of LIFE THREATENING conditions (for example severe allergy with anaphylaxis,

diabetes, asthma) prior to the start of school, as these may require an Individual Health Plan (per RCW 28A.210.320). Contact your school nurse to

begin the process for the student health care plan.

Check any of these conditions which your child has or has had:

󠄵 ADD/ADHD 󠄵 Blood Disorder 󠄵 Concussions 󠄵 Hearing/Vision 󠄵 Orthopedic/Bone

󠄵 Allergies mild or moderate (circle one) 󠄵 Bowel/Bladder 󠄵 Dental 󠄵 Heart problems 󠄵 Skin Condition 󠄵 Asthma mild or moderate (circle one) 󠄵 Cancer 󠄵 Headaches/Migraines 󠄵 Mental Health Conditions 󠄵 Other

If you have checked any of the above medical conditions/concerns, please explain: ___________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Has your student ever visited a hospital or an emergency room for the medical issue? YES / NO (circle) If yes, date ________________________________________

____________________________________________________________________________________________________________________________________

MEDICATONS List any medications taken by student:

Medication Taken: __________________________________________ For _______________________󠄵 At Home 󠄵 At School

Medication Taken: __________________________________________ For _______________________󠄵 At Home 󠄵 At School

Medication Taken: __________________________________________ For _______________________󠄵 At Home 󠄵 At School

SHARING HEALTH CARE INFORMATION

In order to provide a safe and healthy environment for your student, the school nurse may need to share

information about your student’s health condition with teachers and essential school staff. If you have questions,

please contact your school nurse.

CONTACT INFORMATION

Please provide correct and current contact numbers and inform school office of any changes.

Name of Health Care Provider: _________________________________________ Phone: ___________________

Name of Dentist: _______________________________________________________ Phone: ___________________

_______________________________________________________

Student’s Name

_____________________________________________________ _____________________________________________________ Parent/Guardian name printed Signature

__________________________________________ ___________________

Relationship to student Today’s date

3/2017

If your student needs to take any medication (over the counter, prescription, herbal) at school, a medication

authorization form is required. This form must be completed by physician and parent prior to any medication being

brought to school. This form is available through the ASD web site or any school office.

Anacortes School District 103

2200 M Avenue Anacortes, Washington 98221

Phone: 360-293-1200 / Fax: 360-293-1222

http://www.asd103.org

Library Card Partnership Program The Anacortes School District partners with the Anacortes Public Library to provide library cards to all district students, regardless of whether or not they live in city limits.

All students will receive one card for the entire course of their time with Anacortes Schools. If they lose their card, they should contact their school’s librarian.

New students can get a card from their school’s librarian.

If you would not like your child to participate in this program, please fill out the Opt Out Form below and return it to your school’s librarian within one week of your child’s enrollment at their school.

Anacortes Public Library Card OPT OUT Form Return to your child’s school as soon as possible if you DO NOT want your child to

receive an Anacortes Public Library Card.

I choose to have my child OPT OUT of the offer of a FREE, Anacortes Public Library card. Date _________

Parent/Guardian (print) ________________________________________________

Parent/Guardian (signature) ___________________________________________

Student Name _____________________________________ School_____________________

Grade_____

PLEASE COMPLETE ONE FORM PER CHILD AND RETURN IT TO YOUR CHILD’S SCHOOL LIBRARAN.

OPT-OUTS remain in effect for your child’s entire enrollment with ASD. If no documentation is on file, it will be assumed that permission has been granted for access to, and usage of, the Anacortes Public Library. For more details, please go to the Anacortes Public Library website or contact Diana Farnsworth (360) 293-1910 ext 2980, or Jeffrey Vogel (360) 293-1910 ext 2051.

Athletic Department

Anacortes High School

ATHLETIC ELIGIBILITY INFORMATION

The following information is provided to help you determine whether you are eligible to participate in interscholastic athletics at Anacortes High School. If you do not meet the following criteria, you may request to appeal. Please see the Athletic Director or Athletic Administrative Assistant if you have questions.

You are eligible if you:

• Are living with your parents/guardians in a residence located within our school district boundary.

• Attended school last semester. • Are not over the age of 19. • Have physical examination; good for 2 (two) years from date of last physical. • Have transferred to this school for reasons other than to participate in athletics. • Are not a professional athlete in the sport you wish to participate. • Do not use, provide others with or possess a controlled substance and have not

violated this school’s policies or codes on alcohol and tobacco.

To be eligible to compete against another school team or opponent, you must first:

• Be living with parents/guardians in this school district • Be academically eligible by standards set in the Anacortes School District

Athletic/Activity Code. • Complete the required number of practice days. • Be declared eligible by the Principal/Athletic Director.

Please read and understand the school district Athletic/Activity Code and the consequences for any violation.

If you need further information on school, league or state WIAA regulations, please feel free to contact the Athletic Director, Erik Titus, at (360) 293-1237.