1 

Sec on 1 Student Informa on 

Student Name  LEGAL Last Name  LEGAL First Name  LEGAL Middle Name 

Student Preferred Last Name  Preferred First Name  Student’s Cell Phone 

School Name  Student’s Birth Date (Month/Day/Year) 

Student’s Primary Address—where they live FOUR or more nights per week: 

Address   Apt/Unit       City      State      Zip 

Gender   M        F    X 

        (Male )  (Female)  (Not exclusively M or F) 

Grade Entering  Student’s Email Address 

Country of Birth (If outside USA)  When did your student first a end school in 

USA? (M/Y) 

Number of months in school outside of USA 

State Required Home Language Survey—This is for your student 

What language does your child use the most outside of the home? _________________________________________________ 

What language did your child first learn to speak? _______________________________________________________________ 

(If other than English, your child will be tested for the Limited English Proficient program)

What language does your child use the most at home? ___________________________________________________________ 

(If other than English, your child will be tested for the Limited English Proficient program)

Previous Schools A ended 

School Name  City  State 

Has student a ended a Mukilteo School in the past?  Yes     No      School: 

List Siblings A ending Mukilteo Schools 

Name         Brother or Sister                       School    Grade 

List any  and provide copies of Legal Binding Informa on that is per nent to this student and their safety 

Office Use Only: 

Verified Boundary/Address  Verified Immuniza ons Transcript IEP release  Nurse copy     Student ID:_______________  ESL copy

Military Affilia on 

Please select one op on below that best describes student/family military affilia on: 

No military affilia on One parent US Armed Forces ac ve duty  One parent Na onal Guard member 

One parent US Armed Forces reserves More than one parent member of the Armed Forces/Na onal Guard 

Student Enrollment Form 

Today’s Date (Month/Day/Year) __________________ 

DP-013 ENGLISH Rev. 2-2021

2 

Ethnicity and Race Data Collec on 

Ques on 1:  Is your child of Hispanic or La no origin?   

If NO, mark this op on and con nue to Ques on 2: 

Not Hispanic or La no 

If Yes, mark all that apply, and con nue with Ques on 2: 

Argen neBolivianBrazilian 

Chicano(MexicanAmerican) Chilean 

ColombianCosta RicanCuban 

Dominican Equadorian Guatemalan 

Mexican Na veNicaraguan 

Hispanic/La no Write In ____________________________________

Panamanian Paraguayan Peruvian 

Puerto RicanSalvadoran Spainard

SurinameseUruguayanVenzuelan 

Guyanese HonduranJamaican 

Ques on 2:  What race(s) do you consider your child?  (mark at least one or all that apply)  

White BosnianHerzegovinian Polish Romanian Russian UkranianEastern European Write In _________________Algerian Amazigh or Berber Arab or Arabic AssyrianBahraini BedouinChaldean Copt Druze Egyp an Emira  Iranian Iraqi Israeli JordanianKurdish Kuwai  Lebanese Libyan Moroccan Omani Pales nian QatariSaudi ArabianSyrian Tunisian YemeniMiddle Eastern Write In_________________ North African Write In _________________ White Write In _________________

African American/Black 

African American African Canadian Anguillan An guan Bahamian Barbadian Barthelemois/

Barthelemoises Bri sh Virgin Islander Caymanian Cuba DominicanDominicanDutch An lleanGrenadianGudeloupianHai anJamaicanMar nquals/

Mar niquaise Montserra anPuerto RicanCaribbean Write In_________________ AngolanCameroonianCentral African Chadian Congolese (Republic of the

Congo) Congolese (Democra c 

Republic of the Congo)

Equatorial Guinean GaboneseSao Tomean Principe Central AfricanWrite In _________________BurundianComoran Djibou an Eritrean Ethiopian Kenyan

Malagasy (Madagascar)

Malawian 

Mauri an (Mauri us) 

Mahoran (Mayo e) 

Mozambican

Reunionese

Rwandan

Seychellois/Seychelloise SomaliSouth SudaneseSudaneseUgandanTanzanian ZambianZimbabweanEast African Write In _________________ Argen neBelizean Bolivian Brazilian Chilean Colombian Costa Rican EcuadorianEl Salvadoran Falkland Islander French Guianese Guatemalan Guyanese HonduranMexican Nicaraguan Panamanian Paraguayan Peruvian South Georgia and the South Sandwich Islands SurinameseUruguayanVenezuelanLa n American  Write In _________________ BotswananMosotho (Lesotho)Namibian South African SwaziSouth AfricanWrite In _________________BenineseBissau‐Guinean BurkinabeCabo VerdeanIvorian (Cote d’lvoire)GambianGhanaian Liberian Malian Mauritanian 

Nigerien (Niger)Nigerian (Nigeria) Saint Helenian SenegaleseSierra LeoneanTogoleseWest African Write In _________________ Black Write In _________________

Asian Asian Indian Bangladeshi Bhutanese Burmese/Myanmar Cambodian/Khmer Cham Chinese Filipino HmongIndonesian Japanese Korean Lao Malaysian Mien Mongolian Nepali OkinawanPakistani Punjabi SingaporeanSri LankanTaiwanese ThaiTibetan VietnameseAsian Write In _________________

Na ve Hawaiian/Other Pacific Islander Carolinian ChamorroChuukeseFijan i‐Kirba /GilberteseKosraeanMaoriMarshallese Na ve Hawaiian Ni‐Vanuatu Palauan Papuan Pohpeian SamoanSolomon Islander 

Tahi an TokelauanTonganTuvaluan YapesePacific Islander Write In_________________ 

American Indian/Alaska Na veChinook TribeConfederated Tribes and Bands of the Yakama Na onConfederated Tribes of the Chehalis Reserva onConfederated Tribes of the Colville Reserva onCowlitz Indian Tribe Duwamish TribeHoh Indian Tribe Jamestown S’Klallam Tribe Kalispel Indian Community of the Kalispel Reserva onKikiallus Indian Na onLower Elwha Tribal CommunityLummi Tribe of the Lummi Reserva onMakah Indian Tribe of the Makah Indian Reserva onMarie a Band of Nooksack TribeMuckleshoot Indian Tribe Nisqually Indian Tribe Nooksack Indian Tribe of WashingtonPort Gamble S’Klallam Tribe Puyallup Tribe of Puyallup Reserva onQuileute Tribe of the Quileute Reserva onQuinault Indian Na onSamish Indian Na onSauk‐Suia le Indian Tribe of Washington Shoalwater Bay Indian Tribe of the Shoalwater Bay Indian Reserva on Skokomish Indian TribeSnohomish Tribe Snoqualmie Tribe Snoqualmie Indian TribeSnoqualmoo TribeSpokane Tribe of the Spokane Reserva onSquaxin Island Tribe of the Squaxin Island Reserva onSteilacoom Tribe S llaguamish Tribe of Indians of Washington Suquamish Indian Tribe of the Port Madison Reserva‐on Swinomish Indian Tribal CommunityTulalip Tribes of WashingtonAlaska Na ve Write In _______________________________________American Indian Write In _______________________________________

Is the parent or grandparent a member of a federally  recognized tribe? Yes No

 

3 

Primary Household Informa on 

A student’s primary residence is defined as the physical loca on where they reside four or more nights per week.

Sec on 2:  Family/Guardian Informa on 

 

Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Email Address  Employer 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

 

Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Email Address  Employer 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

Residen al Address                   Street                                         Apt/Unit                                                         City                                         State/Zip 

 Mailing Address                         Street                                         Apt/Unit                                                         City                                         State/Zip 

(If different than above)

Pare

nt/G

uard

ian 2 

Pare

nt/G

uard

ian 1 

Secondary Household Informa on 

Residence of non‐custodial parents/guardians not living with the student OR loca on where the student lives less than four nights per week.

 

Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Email Address  Employer 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

 Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Email Address  Employer 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

Residen al Address                   Street                                         Apt/Unit                                                         City                                         State/Zip 

 Mailing Address                         Street                                         Apt/Unit                                                         City                                         State/Zip 

(If different than above)

What is the primary language used in the home, regardless of the language spoken by your child?   

English       Other _________________________________________________ 

If available, do you need an interpreter (e.g. school mee ngs)?    Yes    No 

If available, do you need official school materials to be translated?     Yes    No 

Pare

nt/G

uard

ian 1 

Pare

nt/G

uard

ian 2 

What is the primary language used in the home, regardless of the language spoken by your child?   

English       Other _________________________________________________ 

If available, do you need an interpreter (e.g. school mee ngs)?    Yes    No 

If available, do you need official school materials to be translated?     Yes    No 

 

4 

Have any of the following services ever been provided to your student? 

Special Educa on (IEP)  Gi ed/Highly Capable  Alterna ve School Program 

504 Plan  English Language Development  Early Educa on (ECEAP, Head Start, etc.)  

If yes, Where? Other  

Sec on 3:  Addi onal General Informa on 

Emergency Contact Informa on In case of an emergency, we will always a empt to contact the parents/guardians first. Please list local persons other than parent/guardians

usually available during the school day who have agreed to care for and provide transporta on for your student in an emergency situa on or if they become ill or injured and you cannot be reached.

 

Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Residen al Street Address                               City                                            State/Zip 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

 

Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Residen al Street Address                               City                                            State/Zip 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

Emerge

ncy C

ontact 1

  

Legal Last Name  Legal First Name  Legal Middle Name 

Rela onship to Student  Residen al Street Address                               City                                            State/Zip 

Primary Phone 1 Cell  Home  Work  Other  Phone 2 Cell  Home  Work  Other  Phone 3 Cell  Home  Work  Other 

Emerge

ncy C

ontact 3

 Em

erge

ncy C

ontact 2

 

In accordance with Washington State law (RCW 28A.255.330), please answer the following ques ons: 

Does your student have any history of violent behavior? 

Does your student have any past, current or pending suspension or expulsion from their prior school? 

Has your student ever been expelled? 

Has your student officially withdrawn from your previous school? 

Does your student owe any fines or fees for any book, uniform or property damage at their prior school? 

If yes, please explain. 

If yes, please explain. _____________________________________________________________________________________ 

If yes, please explain. ______________________________________________________________________________________ 

Yes     No 

Yes     No 

Yes     No 

Yes     No 

Yes     No 

Is there any other informa on that would help us serve your student?  If needed you may add an a achment. 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

Signature I a est that the informa on herein is complete, true and accurate, and may be verified with the appropriate ins tu on(s). I understand that false informa on may be grounds for revoca on of enrollment in the Mukilteo School District. Thank you for assis ng us with the enrollment process. Parent/Guardian Signature X ___________________________________________________________________ Date ______________________

▲Required for School ● Required 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

Required Vaccines for School or Child Care Entry

●▲ DTaP (Diphtheria, Tetanus, Pertussis)

▲ Tdap (Tetanus, Diphtheria, Pertussis) (grade 7+)

●▲ DT or Td (Tetanus, Diphtheria)

●▲ Hepatitis B

● Hib (Haemophilus influenzae type b)

●▲ IPV (Polio) (any combination of IPV/OPV)

●▲ 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 Disease types A, C, W, Y)

MenB (Meningococcal Disease type B)

Rotavirus

Certificate of Immunization Status (CIS) Reviewed by: Date:

Signed COE on File? Yes No

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

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YYYY):

I give permission to my child’s school/child care to add immunization information into the Immunization Information System to help the school maintain my child’s record.

Conditional Status Only: I acknowledge that my child is entering school/child care in conditional status. For my child to remain in school, I must provide required documentation of immunization by established deadlines. See back for guidance on conditional status.

Parent/Guardian Signature Date Parent/Guardian Signature Required if Starting in Conditional Status Date

Documentation of Disease Immunity (Health care provider use only)

If the child named in this CIS has a history of varicella (chickenpox) disease or can show immunity by blood test (titer), it must be veri-fied by a health care provider. I certify that the child named on this CIS has: A verified history of varicella (chickenpox) disease. Laboratory evidence of immunity (titer) to disease(s) marked below.

Diphtheria Hepatitis A Hepatitis B

Hib Measles Mumps

Rubella Tetanus Varicella

Polio (all 3 serotypes must show immunity)

►

Licensed Health Care Provider Signature Date

►

Printed Name

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

Health Care Provider or School Official Name: ______________________________ Signature: ______________________ Date:___________ If verified by school or child care staff the medical immunization records must be attached to this document.

X X

Reference guide for vaccine trade names in alphabetical order For updated list, visit https://www.cdc.gov/vaccines/terms/usvaccines.html

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 (PV5)

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 November 2019

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

To print with the immunization information filled in: Ask if your health care provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide registry). 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 and birthdate, and sign your name where indicated on page one. 2. 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 Pediatix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. 3. 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 health care 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. If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign and date the form. You must provide lab reports with this CIS. 5. Provide proof of medically verified records, following the guidelines below. Acceptable Medical Records All vaccination records must be medically verified. Examples include:

A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state’s IIS.

A completed hardcopy CIS with a health care provider validation signature.

A completed hardcopy CIS with attached vaccination records printed from a health care provider’s electronic health record with a health care provider signature or stamp. The school administrator, nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.

Conditional Status Children can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school or child care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care. Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete. If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.

CONTINUED ON REVERSE

MUKILTEO SCHOOL DISTRICT | STUDENT HEALTH SERVICES INTAKE FORM

Print Student Name: (last)_____________________ (first) _______________ Birthdate: ___________ Grade: ______

OB Does your student have a LIFE-THREATENING health condition? ☐ Yes ☐ No Note conditions below and please make arrangements with your school nurse at time of registration to meet and discuss care planning. State law requires that students with life-threatening conditions such as anaphylaxis, severe asthma, diabetes or seizures have a care plan completed prior to starting school. Contact the school nurse.

RG ☐ Asthma

Needs inhaler for school? ☐ Yes ☐ No Triggers (mark all that apply) ☐ illness / colds ☐ exercise ☐ allergies ☐ strong odors ☐ smoke ☐ weather changes ☐ stress/emotions

EG ☐ Anaphylaxis: epinephrine prescribed for severe allergy

Life threatening allergens: (mark all that apply) ☐ peanuts ☐ tree nuts ☐ egg ☐ shellfish ☐ latex ☐ bee sting

☐ other: __________________ Date of last time EpiPen was used:

NP ☐ Seizures ☐ febrile ☐ absence ☐ focal ☐ tonic-clonic ☐ other ☐ unknown

Are seizures well-controlled? ☐ Yes ☐ No Date of last seizure: Describe seizure:

EK ☐ Diabetes Type 1 Attach current diabetic orders from specialist. The school nurse will be contacting you for additional information.

Rides bus to school? ☐ Yes ☐ No Preferred language for communications: _____________________ Interpreter needed? ☐ Yes ☐ No

My child’s primary healthcare provider is: ________________ at (clinic): ________________________ Preferred hospital: __________________

PLEASE CHECK BOXES BELOW IF YOUR CHILD HAS ANY OF THE FOLLOWING HEALTH CONDITIONS Allergy, Immune, Endocrine, Metabolic and Nutritional

GG ☐ Dietary preference: ED ☐ Allergy, food(s): EE ☐ Allergy, insect: EM ☐ Allergy, medication(s): ______________________ EF ☐ Allergy, latex EC ☐ Allergy, environmental: EB ☐ Allergy, other: EL ☐ Diabetes Type 2 EO ☐ Other Endocrine, Immune, Nutritional or Metabolic

Ears/ Hearing Please provide most recent audiology report to school

YA ☐ History of chronic ear infections YA ☐ Current chronic ear infections YB ☐ Hard of Hearing ☐ Hearing Aids ☐ Cochlear Implant YC ☐ Other ear condition:

Gastrointestinal, Dental and Oral GA ☐ Celiac disease GG ☐ Food intolerance:___________________________ GL ☐ Lactose intolerance GH ☐ Gastric reflux GF ☐ Encopresis Date diagnosed: _______________ GO ☐ Chronic constipation GI ☐ Change of clothes, wipes needed at school GJ ☐ Inflammatory Bowel Disease GK ☐ Irritable Bowel Syndrome GI ☐ Other Gastrointestinal, Liver, Dental, Oral condition:

Respiratory/Breathing RG ☐ Asthma, current RH ☐ Asthma, ever diagnosed (history of) RA ☐ Asthma, exercised Induced RE ☐ Reactive Airway Disease RF ☐ Other Respiratory Condition: ________________

Eyes/Vision Please provide most recent notes from eye doctor to school

YF ☐ Glasses YF ☐ Contact lenses YF ☐ Vision is not fully corrected YE ☐ Color blindness YD ☐ Visual impairment: _________________

Skin SB ☐ Eczema, contact dermatitis or psoriasis SH ☐ Other Skin Condition: _______________

Musculoskeletal MC ☐ Juvenile Rheumatoid / Idiopathic Arthritis ME ☐ Other Musculoskeletal: _______________

Nervous System NE ☐ Cerebral Palsy NF ☐ Developmental Disability NH ☐ Migraines NI ☐ Headaches, recurring NP ☐ Seizure Disorder – Type ______________________ ☐ Current ☐ History NU ☐ Traumatic Brain Injury Other Neurological condition: _________________

Medical History, continued

MSD health intake form.docx (6/2020 rev. 11/2020)

MUKILTEO SCHOOL DISTRICT | STUDENT HEALTH SERVICES INTAKE FORM

Blood / Hematology BA ☐ Anemia BB ☐ Hemophilia BC ☐ Sickle Cell ☐ Disease ☐ Trait OJ ☐ History of severe nosebleeds ☐ Other blood condition: _________________

Cardiac/ Heart CC ☐ Heart Birth Defect CD ☐ Heart Murmur ☐ Activity restrictions related to heart condition? ☐ Yes ☐ No CG ☐ Other Cardiovascular condition, include symptoms

________________________________________ Last cardiology visit: ________________

Congenital / Genetic AH ☐ Down Syndrome AJ ☐ Fetal Alcohol Spectrum Disorder ☐ Other: ___________________________________

Renal / Kidney History (describe) Cancer/ Tumor History (describe) Medical Devices

OLA ☐ Vagal Nerve Stimulator OLB ☐ Heart Birth Defect OLC ☐ Pacemaker OLD ☐ Gastrostomy Tube OLE ☐ Jejunostomy Tube OL ☐ Brace OL ☐ Prosthesis OL ☐ Other medical device: ________________________

Mental and Behavioral Health NB ☐ ADHD / ADD diagnosed by: ______________ NC ☐ Autism Spectrum Disorder PA ☐ Anxiety PC ☐ Depression PE ☐ Oppositional Defiant Disorder (ODD) PH ☐ Sleep Disorder PJ ☐ Other Mental or Behavioral Health Condition

☐ My student is seeing a counselor.

Frequency: ______________

☐ My student is seeing a behavior therapist. Frequency: ______________

Transplant History OD List Organ _____________ Date: _________ Stoma

OKA ☐ Gastrostomy OKB ☐ Colostomy OKD ☐ Tracheostomy OKE ☐ Urostomy OK ☐ Other: ______________________

Physical Activity / Mobility Issues ☐ Wheelchair ☐ Crutches ☐ Other: ______________________

Other Health Concerns:

Medication History State law requires written permission from guardian and health care provider before any medication (prescriptions and over-the-counter) may be taken at school. Forms are available from your school office or on our district website. Medication forms must be completed annually.

Medication Dose Frequency Home, School or both? Prescribed by

I understand the information I have provided is kept in strict confidence and will only be shared with appropriate school staff who need to know in order to provide for the health and safety of my student. This information is true and correct to the best of my knowledge. I also understand it is my responsibility to notify the school nurse should health concerns arise or conditions change, and to provide correspondence as needed from my child’s healthcare provider regarding their condition(s). Parent/Guardian (print) __________________________ Signature ____________________________Date _________

□ My child has NO KNOWN HEALTH CONDITIONS Initials ___________

Attendance Policies and Procedures Letter

____________________________________ ___________________________ _____________ Student’s Name School Grade Mukilteo School District is making a special effort to ensure that all students fully benefit from their education by attending school regularly. Attending school regularly helps children feel better about school—and themselves. Consistent attendance will help children do well in high school, college, and at work. It is important to understand our school policies and procedures, as well as Washington State Law, to ensure your child is successful in school. State law for mandatory attendance, called the Becca Bill, requires children from age 8 to 17 to attend a public school, private school, or a District-approved home school program. We, the school, are required to take daily attendance and notify you when your student has an unexcused absence. If your student has three unexcused absences in one month, State law (RCW 28A.225.020) requires we schedule a conference with you and your student to identify the barriers and supports available to ensure regular attendance. There are many people in our building prepared to help you if you or your student face challenges in getting to school regularly or on time. We promise to track attendance daily, to notice when your student is missing from class, communicate with you to understand why they were absent, and to identify barriers and supports available to overcome challenges you may face in helping your student attend school. I understand and agree to the following:

Communication: For each absence from school a written notice, email or call to the school will be made to excuse the absence. We will make a priority to excuse absences as soon as possible but not later than three days of return to school. Meetings: An attendance meeting will take place whenever a student has missed 10% of the school year, to develop an attendance success plan. Withdrawal: Withdrawal from school will occur after 20 consecutive days of absences. Your signature below indicates that you have read and understand the attendance policies and procedures in the Mukilteo School District.

I ___________________________, will ensure that my student attends all schedule classes every day, on time, without

any unexcused absences, skips or tardies.

_______________________________________ _____________________ Parent/Guardian Signature Date

2/5/21

Carta de Políticas y Procedimientos de Asistencia

____________________________________ ___________________________ _____________ Nombre del estudiante Escuela Grado El Distrito Escolar de Mukilteo está haciendo un esfuerzo especial para garantizar que todos los estudiantes se beneficien plenamente de su educación al asistir a la escuela regularmente. Asistir a la escuela regularmente ayuda a los niños a sentirse mejor acerca de la escuela y de su mismos. La asistencia diaria ayudara al éxito de los niños en la escuela secundario, la universidad y el trabajo. Es importante entender las políticas y procedimientos escolares del distrito, así como la Ley del Estado de Washington, para garantizar el éxito de su hijo en la escuela. La ley estatal de asistencia obligatoria, llamada Becca Bill, requiere que los niños de 8 a 17 años asistan a una escuela pública, privada o a un programa de escuela en casa aprobado por el Distrito. La escuela está obligada a tomar asistencia y notificarle cuando su estudiante tenga una ausencia injustificada.

Si su estudiante tiene tres ausencias injustificadas en un mes, la ley estatal (RCW 28A.225.020) requiere que programemos con usted

y su estudiante una reunión para identificar las razones y apoyo disponible para garantizar la asistencia regular.

Hay muchas personas en la escuela preparadas para ayudarlo si usted o su estudiante enfrentan obstáculos para asistir a la escuela

con regularidad o a tiempo. Prometemos hacer un seguimiento diario de la asistencia, anotar cuando su estudiante falte a clase,

comunicarnos con usted para entender por qué estuvo ausente e identificar obstáculos y apoyo disponible para superar los desafíos

que puede enfrentar para ayudar a su estudiante a asistir a la escuela.

Entendemos y aceptamos lo siguiente: Comunicación: Por cada ausencia a la escuela, se tendrá que enviar un aviso por escrito, por correo electrónico o por medio de una llamada telefónica a la escuela para justificar la ausencia. Es prioridad justificar las ausencias lo antes posible, a más tardar tres días después de regresar a la escuela. Reuniones: Se llevará a cabo una reunión de asistencia cada vez que un estudiante haya perdido el 10% del año escolar, para desarrollar un plan de asistencia. Absentismo escolar: Después de 7 días injustificados en un mes o 10 en un año escolar, se presentará una demanda de absentismo escolar ante el tribunal de menores y se llevará a cabo una reunión de intervención y/o una reunión de la Junta de absentismo comunitario. Retiro: Se dará de baja en la escuela al estudiante con 20 días consecutivos de ausencia. Su firma indica que ha leído y comprende las políticas y procedimientos de asistencia del Distrito Escolar de Mukilteo.

Yo, ___________________________ me asegurare de que mi estudiante asista todos los días a tiempo a todas sus

clases, sin ausencias injustificadas, faltas o tardanza.

Please note: THIS FORM IS OPTIONAL.Complete this form ONLY if you DO NOT want Directory Information released about

your child and/or if you DO NOT want your child’s name released to the military.IF YOU HAVE MORE THAN ONE CHILD, COMPLETE SEPARATE FORMS FOR EACH CHILD.

Child’s name (please print clearly): ______________________________________________________________

School: ______________________________________________________ Grade: _______________________

If you do NOT want Directory Information released about your child during the 2021-22 school year, please mark the box below and sign your name at the bottom. (Please consider carefully the consequences of this decision. If you check this box and sign below, it means that your child’s name and/or photograph will not be included in school publications (such as the yearbook) or won’t be mentioned in media coverage of school events or in announcements of awards.)

Do NOT release ANY Directory Information about my child.

Are there any exceptions? If you check the box above and sign below, your child’s name and/or photograph can still be used for certain purposes if you mark the appropriate box or boxes below:

I agree to allow my child’s name and/or photograph to be included in the school yearbook, school newsletter and school directory. [LOCAL]

I agree to allow a photograph in which my child appears, but is not identified, to be published in a school district publication (such as the wall calendar or newsletter) or district social media. [DISTRICT]

I agree to allow my child’s name and/or photograph to be released to the news media. [MEDIA]

FOR HIGH SCHOOL STUDENTS ONLY: Federal law requires high schools to provide military recruiters with a list of student names and addresses. Parents have the right to request that their child’s name be omitted from that list, however. If you object to your child’s name and address being provided to the military during the 2020-21 school year, please mark the box below, sign your name at the bottom, and return the form to your child’s school by October 1.

Do NOT give my child’s name to military recruiters.

Parent/Guardian signature: _____________________________________________ Date: _________________

Please call 425-356-1215 if you have any questions. 2021-22

DO NOT RELEASE DIRECTORY INFORMATION

IMPORTANT INFORMATION ABOUTYOUR CHILD’S PRIVACY RIGHTS

A federal law called the Family Educational Rights and Privacy Act gives schools and school districts the authority to publish “Directory Information” about students and to make that information available to certain people or institutions, such as

the news media or colleges. Directory Information is defined as a student’s first and last name; photographic and electronic images; parent email address; dates of school attendance; participation in officially recognized activities

and sports; weight and height of members of athletic teams; degrees, honors, and awards received; and most recent school attended. (The Mukilteo School District does not release directory information for commercial purposes.) Another federal law requires that high schools provide a list of student names to military recruiters. Parents and guardians have the right to tell the school district and its schools to keep private any directory information about

their child and have the right to prevent their child’s name from being given to military recruiters.

Parent Information Regarding Full-Day Kindergarten

Mukilteo School District offers full-day kindergarten to all students. Each classroom will provide a high-quality learning

experience that not only provides instruction in the key academic areas, but also meets the social and emotional needs of

children, provides creative and hands-on experiences, and addresses the needs of the “whole child.” Developmentally

appropriate practices will focus on each child’s unique learning needs, whether the child has participated in early learning

settings or is transitioning to school for the first time.

Students will be served at either their home school or the Pathfinder Kindergarten Center. Attendance areas for kindergarten

students assigned to attend the Pathfinder Kindergarten Center will be communicated to parents each spring at the time of

kindergarten registration.

Guiding Principles for High-Quality Kindergarten

The full-day kindergarten program will follow state guidelines to create a nurturing, rigorous, high-quality program that

meets the individual characteristics of each child. The following principles serve to guide staff and parents in supporting

students:

• Families are a child’s first and most important teachers.

• Collaboration among families, schools and communities supports each child’s growth and development.

• All children are capable and competent learners.

• Children thrive when they have secure relationships with adults and are supported by environments that are safe,

positive, age-appropriate, use purposeful play, and have a balance between independence and structure.

• Children learn best through active participation and when provided opportunities to learn through discovery,

interaction, creativity, problem-solving, conversation, and play.

• A high-quality kindergarten program provides developmentally appropriate and academically rigorous learning

opportunities that are balanced between child-initiated and teacher-guided.

• A high-quality kindergarten program recognizes and supports differences in the needs, skills and abilities of

children as they develop as individuals.

• Kindergarten is a transition year, a bridge between early learning experiences and the K-12 system.

• Leaders of high-quality kindergarten programs have an understanding of child development and appropriate

instructional practices to effectively support teachers.

Getting to Know You

During the first three days of school, kindergarten teachers will schedule conferences to meet with students and parents. The

purpose of the conference is to help your child make a smooth transition to kindergarten. You and your child will have a

chance to get to know the teacher and you will be able to ask questions and share important information about your child,

such as:

• Activities your child enjoys

• Things you do together as a family

• What comforts your child when he or she is frustrated, angry or sad or in new situations

• How your child learns best

• Important people in your child’s life

• Health or other information necessary to keep your child safe at school

Full-Day Kindergarten Curriculum

Kindergarten teachers will use the district-adopted curriculum for academic areas in reading, writing, mathematics, and

science. This curriculum is research-based and meets the Washington State Learning Standards.

Requirements for State-Funded Full-Day Kindergarten

Critical components of a high-quality, full-day kindergarten program:

1. Provide at least a one-thousand-hour instructional program

2. Provide a curriculum that offers a rich, varied set of experiences that assist students in:

a. Developing initial skills in the academic areas of reading, mathematics, and writing

b. Developing a variety of communications skills

c. Providing experiences in science, social studies, arts, health, physical education, and a world language

other than English

d. Acquiring large and small motor skills

e. Acquiring social and emotional skills including successful participation in learning activities as an

individual and as part of a group

f. Learning through hands-on experiences

3. Establish learning environments that are developmentally appropriate and promote creativity

4. Demonstrate strong connections and communication with early learning providers

5. Participate in kindergarten program readiness activities with early learning providers and parents

6. Administer the Washington Kindergarten Inventory of Developing Skills (WaKIDS)

The kindergarten year is a magical time in a child’s development. Having a deep understanding of child development helps

educators create an environment that supports engaging, meaningful, and relevant learning opportunities. This knowledge

base supports children having a successful kindergarten year and builds a foundation for success.

Every child grows and develops at their own individual rate. There can be dramatic variation among kindergarten students

in the same classroom. Understanding the common and the individual learning needs among all students in a classroom will

allow a kindergarten teacher to successfully support each child’s foundation.

Early Learning and Development Guidelines

Washington’s Early Learning and Development Guidelines, which were written through the united work of early learning

professionals, communities, and cultural organizations, provide information for parents and educators regarding children

from birth through grade three.

Topics in the guidelines include:

• About me and my family and culture

• Building relationships

• Touching, seeing, hearing and moving around

• Growing up healthy

• Communicating (literacy)

• Learning about my world

These early learning and developmental guidelines, which were carefully crafted to recognize and honor the differences in

children, are a helpful tool for parents to understand the developmental stages of children. They can be downloaded at:

http//www.k12.wa.us/EarlyLearning/Guidelines.aspx.

For more information regarding full-day kindergarten, the Washington State Full-Day Kindergarten Guide can be

downloaded at: State-Funded Full-Day Kindergarten

Kindergarten Readiness

How can I help my child be ready for full-day kindergarten?

Each child is unique and comes from different backgrounds and experiences. It is important to recognize that children learn

at different rates. One skill might come easily to a child, while another skill may take more practice. Parents can help their

child practice many skills at home simply by reading to their child, helping them write their name, counting objects, naming

letters and sounds, naming shapes, using scissors, and talking about things they like such as books, their family, and pets.

The following ideas for helping your child are taken from the early learning and developmental guidelines, which were

carefully crafted to recognize and honor the differences in children. It is a helpful tool for parents to understand the

developmental stages of children. It can be downloaded at: Washington State Early Learning and Development Guidelines

About Me and My Family and Culture

• Share with your child information about your family and cultural traditions, rituals, routines, and

activities. Explain why they are important and make your child a part of them.

• Teach your child to help with the care of a younger child.

• Identify and help explore your child’s questions and interests. Find related books or information online.

• Help your child understand about his or her emotions and the emotions of others.

• Acknowledge your child for making an effort to stick with a task.

• Play memory games with your child.

Building Relationships

• Arrange for opportunities for your child to play with other children.

• Encourage your child to listen to others.

• Let your child know that different environments have different rules for relationships and behavior.

• Discuss the concept of sharing things such as food, toys, supplies, and playground equipment.

• Encourage your child to take turns.

• Encourage positive behavior toward animals and showing them respect.

• Let your child work out problems on their own with guidance.

Touching, Seeing, Hearing and Moving Around • Give your child the opportunity for physical activity every day.

• Encourage your child to try a variety of activities such as jumping, galloping, skipping, bending, twisting,

stretching, balancing (walking a line), and rolling, tossing and bouncing a ball.

• Dance to music, play follow-the-leader, and go on make-believe walks.

• Keep paper, markers, or crayons for your child to write his or her name, letters, or draw a picture.

• Remind your child that learning to do new things well takes practice. Stay close when he or she is trying

something difficult.

• Name the five senses with your child and discuss how they can help them.

Growing Up Healthy

• Try to keep a consistent routine or schedule for your child.

• Make sure your child gets enough sleep.

• Support your child to brush his or her teeth twice a day.

• Have your child practice hand washing.

• Encourage your child to drink water throughout the day.

• Take your child to regular dental and medical check-ups.

• Talk to your child about safety.

• Encourage your child to make decisions for play and to put away toys.

Communicating (literacy)

• Play word games, sing songs, dance and make rhymes together.

• Have conversations with your child throughout the day. Listen and respond to what he or she is saying and

expect

the same from your child.

• Read to your child every day. Ask and talk about what you have read.

• Ask your child to identify and spell his or her name.

• Help your child practice saying the alphabet and identify letters and sounds from books or magazines.

• Help your child write his or her name.

• Help your child to count to 100 and write numbers.

• Practice counting cars of a certain color as you drive.

• Help your child learn the months of the year.

• Talk about different shapes and sizes by comparing objects.

• Play card games or board games with your child.

• Explore the outdoors and talk about rocks, plants, bugs, and nature.

• Help your child understand where he or she lives and the neighborhood.

• Have your child express themselves through drawing, dance, movement, or music.

1/15/2021

H 108

Mukilteo School District

Health Services

Dear Parent,

State law requires that all children who have been diagnosed with a life threatening

condition must have a medication or treatment order and a nursing plan in place

before he or she can attend school.

A life-threatening condition is defined as a “health condition that will put the child in

danger of death during the school day if a medication or treatment order and a nursing

plan are not in place.” (WAC 392-380-020 10/25/2019). Examples of a diagnosed life

threatening condition include severe bee sting allergy, severe food allergy, severe or

unstable asthma, unstable diabetes, or severe or unstable seizure disorder.

The medication or treatment order for children with a life threatening condition must

be from the child’s licensed health care provider. If a medication or treatment order is

not provided for a child with a life threatening condition, the chief administrator of the

child’s school is required to exclude that child until the medication or treatment order

has been provided and a nursing plan has been prepared.

If your child has a life threatening health condition that may require medical services to

be performed at school, it is vital to your child’s safety that you notify your school’s

principal or school nurse. The necessary forms will be provided and a time will be

arranged for you to meet with your child’s school nurse to develop a nursing plan.

Please contact your child’s principal or school nurse if you have any questions.

Sincerely,

School Nurse

Revised 1/2021