The following information is needed for each student at the time of re-enrollment. Students will not be permitted to start school until all the required documentations are received.

Completed Application packet. Do not sign if you are not the custodial parent or have legal or temporary guardianship documents attached.

Current 2019 or later Immunization Record (We will not be accepting handwritten records). According to Arizona Revised Statutes §15-871-874; and Arizona Administrative Code, R9-6-701–708, students must have proof of all required immunizations, or a valid exemption, in order to attend school.

[If applicable] Boundary Waiver, if you recently relocated outside the district area. Out of boundary students requires their local School Board Official’s approval for enrollment. Must be completed before student can start class.

[If applicable] Legal Documentation. If you are not the legal guardian or custodial parent of a student we require one of the following documents for enrollment:

o Court Custody Documents o Social Service Placement Letter o Power of Attorney Form signed & notarized.

[If applicable] Other copies of Court Documents, Restraining Orders, etc,

If enrolling in the dormitory, student must first be approved for re-enrollment with K-8 school.

10 years and older may participate in School Athletics. Physical Exam forms are available in the Elementary Office and available for download at our school’s website. All required Athletic Forms are due before first day of practice.

CHECKLIST

2 0 1 9 - 2 0 2 0

RETURNING STUDENT

If you should have any questions, please contact the K-8 Registrar at 928-672-3530. Thank you

SHONTO PREPARATORY SCHOOL

APPLICATION FOR BUREAU FUNDED SCHOOLS AND FERDERAL BOARDING SCHOOLS UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF INDIAN EDUCATION

Start Date

End Date GRADE

STUDENT INFORMATION

Last

Name First Middle

Mailing

Address City State Zip

Physical

Address

Primary Household Contact Number (This number will be used for our School Closure Notifications and Emergencies.)

Date Of Birth Gender Male Female Student

Status: Dorm Walk Bus Route:

Tribal

Affiliation/Agency

Enrollment

Number Degree

What is the language that the student first acquired? Navajo English Other:

What is the language most often spoken by the student? Navajo English Other:

What is the primary language used in the home regardless

of the language spoken by the student? Navajo English Other:

FAMILY & BACKGROUND INFORMATION If other than birth parents, court orders, legal issues, guardianship and/or Power Of Attorney forms must be on file.

Lives with Father Guardian

Lives with Mother Guardian

Same As Above Address

Same As Above Address

City, State, Zip City, State, Zip

Home Location Home Location

Contact Number Contact Number

Email Email

Tribal Affiliation/Agency Tribal Affiliation/Agency

Enrollment Number Enrollment Number

Chapter Chapter

Documents on

File? YES NO

Valid

Dates

Documents on

File? YES NO

Valid

Dates

EMERGENCY CONTACT (OTHER THAN PARENT)

Name Contact # Physical Address

Contact 1

Contact 2

THE FOLLOWING ADDITIONAL PEOPLE HAVE PERMISSION TO PICK UP MY CHILD FROM SCHOOL

Limit four (4). The person(s) on the list MUST BE OVER 21 YEARS OF AGE. Any release of a student requires proper check out

procedures in the office. The parents/guardians are to notify the office of any changes. This policy is written in the Student Parent Handbook.

1. Relationship 3. Relationship

2. Relationship 4. Relationship

|Page 1 of 2

OFFICE USE ONLY

PREVIOUS SCHOOL for new enrollment only.

School

Address

Phone Fax

Dates Attended Grade Completed

Reason for transferring:

Has your child been

suspended/expelled from

previous school? If yes, reason?

YES NO

Reason:

Retained?

(Grade/Year) YES NO

Has your child participated in

an Exceptional Education

Program or have an IEP?

YES NO

DISCLAIMER AND SIGNATURE to be signed by Parent/Legal Guardian.

I am legally responsible for this student and hereby apply for his/her admission to this school. Therefore I certify that the foregoing information is accurate and complete to the best of my knowledge. I also understand that additional information may be requested by the school from myself and other public agencies in accordance with the rules and regulations or the Family Privacy Act to complete the enrollment of my child.

________________________________________________ /______________________________________________ ____________________________

Print Name Signature Date

OFFICAL USE ONLY THIS STUDENT PROVIDED ALL NECESSARY DOCUMENTS AND BACKGROUND CLEARANCE TO ATTEND SHONTO PREPARATORY K-8 SCHOOL.

Degree of Indian Blood/CIB

Birth Certificate

Current Immunization

Approval of School Application:

Approved Approved with Contract

Denied Principal Initials:____________

_______________________________________________/_____________________ Signature of Registrar Date

__________________________________________/___________________ Signature of Education Program Administrator Date

2019-2020 SY

Notes:

|Page 2 of 2

Student Parent Handbook Page | 46

S H O N T O P R E P A R A T O R Y K-8 S C H O O L S PO Box 7900 • Shonto, AZ 86054-7900 • (928) 672-2652 • www.shontoprep.org

PHOTOGRAPHIC and MEDIA CONSENT AND RELEASE FORM

I hereby authorize the Shonto Preparatory Schools (SPS) and those acting pursuant to its authority to:

(a) Record my likeness and/or voice on a video, audio, photographic, digital, electronic or any other medium;

(b) Use my name in connection with these recordings;

(c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/www) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts.

I release Shonto Preparatory Schools and those acting pursuant to its authority from liability for any violation of any

personal or proprietary right I may have in connection with such use. I understand that all such recordings, in

whatever medium, shall remain the property of SPS. I have read and fully understand the terms of this release.

Name: ___________________________________________________________

Signature: ____________________________________________ Date: ________

Parent/Guardian Signature: ______________________________ Date: ________

(If under 18 years of age)

Student Parent Handbook Page | 43

S H O N T O P R E P A R A T O R Y K8 S C H O O L S PO Box 7900 • Shonto, AZ 86054-7900 • (928) 672-3500 • www.shontoprep.org

ACCEPTABLE USE POLICY AGREEMENT FORM

Sign and return this page only. Do not return the entire policy.

I have read and will abide by the Shonto Preparatory Schools Acceptable Use

Policy. I understand that I am responsible for my actions while using the District’s

academic computer systems and the Internet. I understand that my Internet activities

will be monitored by the District, and any violation may result in the loss of computer

privileges, discipline as per the District Discipline Policy, and/or appropriate legal action.

Printed Name of Student:

STUDENTS (For students under the age of eighteen, a parent or guardian must also sign the agreement.)

I have read and understand that my child must abide by the Shonto Preparatory Schools

Acceptable Use Policy. I understand that some materials on the Internet may be

objectionable, but I release Shonto Preparatory Schools and its employees from any

liability resulting from my child’s activities on the Internet. I understand that my child’s

Internet activities will be monitored by the District, and any violation may result in the loss

of computer privileges, discipline as per the District Discipline Policy, and/or appropriate

legal action.

Signature of Student: Date:

Printed Name of Parent or Guardian:

Signature of Parent or Guardian:

Date:

Revised 5/22/19 (Revised)

NO YES NO YES NO YES

NO YES NO YES

NO YES NO YES NO YES

NO YES NO YES

NO YES NO YES NO YES

NO YES NO YES NO YES

NO YES NO YES NO YES

NO YES NO YES NO YES

NO YES NO YES NO YES

NO YES NO YES NO YES

GRADE: _________________

(HOME) (CELL PHONE) (MESSAGE)

"My child's prescription medication(s) will be provided in a labeled container with his/her name, the prescription name, specific instructions and

expiration date. If at any time the information must be changed, I will notify the school nurse or administrator in writing. I agree to and do

hereby hold SPS and its employees harmless from any and all claims, demands, causes of actions, liability of loss or any sort, because of or

arising out of act or omissions with respect to this/these medication(s)."

Special Instructions: _________________________________________________________________________________________________________

Parent Signature: _______________________________________________________Print Name: ____________________________________________Date: ______________________________

Parent(s): __________________________________________________________________

Pneumonia

Rheumatoid Arthritis

Scoliosis

Vision/Hearing Problems

Allergic to food(s);

*Submit a Dietary Restriction Form.

Allergic to Medicine(s);

________________________________

Allergic to insect bites

Allergic to pet dander

Thyroid problem

Tuberculosis

Under Physician's Care

Other:_________________

Hepatitis

High Blood Pressure

Kidney Disease

Meningitis

Migraine Headache

___ Ibuprofen (200 mg) ___ Throat Lozengers ___ Tribiotic Ointment ___ Children's Benadryl

___ Orajel Toothache ___ Children's Sudafed ___ Mouth Sore Gel (Administered only as a temporary relief)

If the school cannot contact either parent/guardian, please list a "Next of Kin" or a relative who would have authority to advise us regarding

your child and/or to locate you immediately.

DOB: _____________________________Gender: Male ( ) or Female ( )Student Name: __________________________________________________

ADD/ADHD

Anemia

Asthma (diagnosed)

Bleeding Disorder

Bronchitis

Chicken Pox

Diabetes

Dietary Restrictions

Epilepsy/Seizures

Eyeglasses/Contacts

"I, ________________________________________, (Parent or Legal Guardian), authorize the following non-prescription medication(s)

to be administered as needed for my child by the School Nurse or designated SPS personnel";

___ Children's Tylenol ___ Allergy Relief Eye Drop ___ Blistex Ointment ___ Children's Pepto Bismol Tablets

___ Tylenol (325 mg) ___ Eye Lubricant ___ Carmex Oinment ___ Hydrocortisone 1% Cream

___ Children's Ibuprofen ___ Cough Suppressant ___ Neosporin Ointment ___ Head Lice Shampoo

HEALTH HISTORY QUESTIONNAIRE

NON-PRESCRIPTION MEDICATION CONSENT

SHONTO PREPARATORY SCHOOL

STUDENT HEALTH QUESTIONNAIRE & CONSENT FORM

Has your child had any of the following health conditions listed below? Circle YES or NO.

School Year 2019 - 2020

Phone #'s: ________________________________________________________________________________________________________________________

Home Location: ____________________________________________________

Teacher: _________________

Name: __________________________________________________Relation to Child: __________________Phone #: _______________________________________

Explain "YES" answers here or "other"; ______________________________________________________________________________________________________________

Heart Murmur/Disease

FLUORIDE VARNISH AND DENTAL SEALANT CONSENT FORM

Dental sealants are one of the best ways we have to prevent tooth decay. They are hard plastic

coatings which protect the grooved surfaces of permanent teeth. They seal the deep pits and grooves of

teeth, keeping bacteria out and preventing decay. By having sealants placed now, your child may be

spared future, more extensive dental work. The application is painless and does not require numbing of

the mouth or drilling.

This preventative measure has very few risks. In rare cases, as with any dental procedure,

gagging or swallowing of dental materials may occur. In addition, your child may notice minor changes

in bite that should become less noticeable as excess material wears away over time. Please keep in mind

that sealants only protect the chewing (grooved) surfaces of teeth. Therefore, fluoride toothpaste and

mouth-rinse are also recommended to protect the smooth surfaces of the enamel.

Fluoride varnish can be painted on the teeth to prevent tooth decay delivering a safe and effective

dose of fluoride. The varnish sets up on contact with saliva so children usually cannot swallow the

varnish. The varnish will cause the teeth to look yellow for several hours and will gradually wear off.

Used at the right levels, it is safe and effective. Swallowing too much fluoride can cause stomach upset

or make white or brown spots on permanent teeth.

As a service to our patients, students are transported in with their teachers and classes to the

Inscription House Health Center IHS Dental Clinic for screening exams and, if indicated, the placement

of sealants.

Please answer ALL of the questions below, sigh, and return to the school.

MEDICAL HISTORY

Has your child EVER had:

Allergies Yes___ No___ Liver Disease/Hepatitis Yes___ No___

If Yes, to what?___________________ Heart Murmur Yes___ No___

Bleeding tendencies Yes___ No___

Seizures Yes___ No___ Heart/Vascular Disease Yes___ No___

Medication Usage Yes___ No___ Under MD’s care Yes___ No___

If yes, what ?_____________________ If yes, for what?_________________________

I ______DO ______DO NOT give consent for my child to receive fluoride varnish.

I ______DO ______DO NOT give consent for my child to participate in the dental sealant program.

Student’s name: _________________________________________________

Mailing Address: _________________________________________________

School: _________________________________________________

Grade & Teacher: _________________________________________________

Date of Birth: _________________________________________________

Chart Number: _________________________________________________

_____________________________________________________ __________________

Signature of Parent or Legal Guardian Date

SHONTO PREPARATORY SCHOOL (KDG – 8TH)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC & INDIAN HEALTH SERVICE CONSENT FORM CONSENT OF PARENT OR LEGAL GUARDIAN OR OTHER PERSON WITH PRIMARY RESPONSIBILITY FOR THE CARE OF THE CHILD

I (We), _________________________________, Parent(s) of _______________________________

(Parent/Legal Guardian) (Student)

have read the Consent Form for the Public and Indian Health Service to arrange for or to provide the following

health services for my child. (Please Check Mark)

1. ___Dental Care include dental examinations, preventive use of sealant & fluorides and necessary

emergency dental care.

2. ___Emergency health care for accident or illness.

3. ___Health care include medical examinations, sport physicals, annual health screenings, x-ray

procedure, skin tests and routine immunizations.

4. ___Mental Health services include evaluation and treatment as necessary.

5. ___Optometry care for eye examinations and eye glasses.

6. ___Psychiatric services to include assessment, treatment, and medication as necessary.

7. ___Transportation of child to and/or from a health facility for these services.

PLEASE CHECK THE APPROPRIATE BOX (ES):

- I hereby give consent for all of the above services.

- Exceptions or special instructions: ________________________________________________________

- I hereby give consent for reasonable cause and essential need to assure the health and safety of my child

to Shonto Preparatory School staff while my child is in attendance.

Parent/Guardian Signature: __________________________________________ Please Print Name: __________________________________________________ Address: _____________________________City: _____________ Zip: __________ Phone#: ______________________ Alternate Phone #: _____________________ Relationship: __________________________________

Date: ___________________________ *Valid Until: June 2020

Check the one that applies: ___-Enrolled in AHCCCS, ___-No Health Insurance,

___-Other Health Insurance, #___________

--------------------------------------------------------------------------------------------------------------------

Please be advised that Shonto Preparatory School staff will make every attempt to contact you before any of the above

services are rendered. *This consent is only valid for one year from the date it was signed.