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Welcome to Vera Beach High School's Freshman Learning Center
gth grade New Student Enrollment Packet
•!• Please complete the attached enrollment packet in full •!• It is necessary for you to sign ·in all places where indicated •!• Please do not write or sign in Pencil, Black or Blue Ink only •!• We need Proof of Residency ,.., Utility bill OR Lease signed by Landlord
Mrs. Pope will be more than happy to answer any questions you may have concerning the attached forms.
Thank you!
Principal: Shawn O'Keefe Director of Guidance: Jessica Wood
Counselors: Rachel Holderman, Karen Bailev
//It's Great To Be A Fighting Indian!/'
To the Parents/Guardians of New Enrollees:
For enrollment purposes the following documents need to be provided
to the Freshman Learning Center at Vero Beach High School
Student Name: _________ _____ ID# ____ _
Parent E-Mail:--- -------------,.-------
D Previously attended schools
o Addresses
o Telephone numbers
o Fax numbers
D Residential address and Telephone/cell phone numbers
D Current Transcript from Previous School
D IEP or 504 (If Applicable)
D Attendance Records from Previous School
D Discipl ine Records from Previous School
D Transcripts from Any Programs
D Immunization Records (on a Florida Health 680 Form) I Physical Exam
D School Health Certificate Completed within Last Twelve Months
D Copy of Birth Certificate
0 Copy of Social Security Card (Optional, but necessary to obtain a FOCUS account and for
certain classes.)
D Proof of Address - Lease Agreement, Mortgage or Copy of Util ity Bil l
D Name, address & Telephone numbers of Parents/Guardian and Emergency Contacts
D Notarized Letter from Parent If Student is not Residing with Parent and a Verification
of Address Form Notarized Plus Copy of Utility Bill
D Copy of Custody Papers if a Custody Agreement is in Effect
D All Admissions Forms Completed and Signed by Parent/Guardian/Student
SCI IOOL DIST R ICT O F INDIAN RIVER COUNTY
K-12 STUDENT ENROlLMENT FORM PLEASE PRINT PLEASE PRINT
l<indcrgat1en Students Only: Did student ever attend a special program prior to l<indergarlen? Yes 0 No 0
If yes, complete Special Programs Information Form and see reverse side of this form to enter appmpriato codo: ------
Student's Legal Name: -------- - ----------- -,-------- --------- Home Phone:-'-- -1-------- Sox: M-Male 0 F-FernaiEl 0 /Lust) (ltppon<lagu) (F/r$1) (Mkldl~)
Residential Address: - =--,.:::-::--=-..,-------,-...,-..,...,.---·--,.,.,..,---- - --=...,-,-- ---:::,...,-- ---ISuooVP.o. Dox) (/lpiA.ot11) (CRy) (Stato) (Zip)
Mailing Address: ---=__,="",....,.-.,----__,.,~....,..,.,..---111 dilferont from a/Jove) (StfootiP.O. Dox) (/tt>IA.ot H) --(.,.,City,,...,.1------..,-(S""ta..,.lo-=-} - - (Zip)
Student's Birth Dale: I / ___ _ mm dd yy
Student's Place or Birth: ----- --(COunty) (C.~y) (Slate)
Student's Social Security #: Student's former last name-------- - - - - - Grade in School: ·- Student's Driver License: ______ _ (OptlonaQ
Last School attended In Florida: - ---------- Florida ID# School Last Altenclecl: (If 001
a Florida Scl>ool) ··----------·---------- ·-Address: (County) Date First Entered US School: --------------
(CHy) (Sinle) (CoUIIIty) (Zip)
Circle all ap}llicable race codes: (see list on back} I A B P W 0 Visual Only l·lispanic I Latino §!.l:lnicity Yes 0 No 0 If yes, to any of tho statements below, see reverse side of form and ontor appropriate language cotlc(s):
YesCI NoD Is a language olherU1an English used in tho home? Does the student have an Individual Education Plan (IEP)/ESE? YesCI NoD
Yes D No D Did student have anrst languageo!herUmn Eng'ish? Has student ever I tad a 504 plan? I Yes D No 0
YesCI NoD Does student freq_uently speak a languAge other than English? Is student a child of a militory family? . YesO NoD Have you or your farnlly moved across county or state lines within the lflst three years . for the purpose of seeking employment in tho aren of agriculture, fishing or forestry? I Yes D No D
Has student been arrested, charged, convicted, or pled guilty to a O O felony? Yes No Ill Ha5 student been expelled or rofened to an alternative program for
Has student ever been in a residential treatment center? I y~ D No 0 I di:;ciplinary te:Json? . Yes a No 0 til Other programs: (check one) English for Speakers of Other Languages a ESE 0 Migrant 0 Title I a Gifted a Compensatoty Eciw:olion 0 Other 0 !!!!!~!!!:;:~- ~ -.. --,.....n- ~ .,._ - ...... ~ ~ ~ ~ - ----.....__... ~· ----
rr--::==--~ co'"NT ACT TVPE:'"'ir RELATIONSHIP "'*NOTE: Only tho parent, guardian or "any person in-~ pa~nla l rela;onshlp to a student: 0; a~1Y t~erson exorc i Sitl~J 4 supetvlsory aulhorlty over a student in placo of the parent" may update emergency contacts. CODES: .M = Mother E = Father
1l G = Guardian AS c Author! over Stdt SP ::: Stc Paront GP = Grand arent D = Doctor 0 :: Other
Circle One Each: Y =Yes N = No Phone numbers -Include area code:
CODES: P = Parent G :: Guardian 0 = Other
'l!L1 -Con"" No:c - 111 1
~~ Pick-up I Custody I Lives with 1 Home 1 Cell 1 Work 1 Ext Y N Y N Y N
2 Y N IY N IY N IY N
3 Y N I Y N IY N IY N
4 Y N IY N IY N I Y N
list other children in immediate family enrolled in Indian River Schools (name and school):
0 I am a resident of Indian River County
0 Out-<>f..CountvWaiver Attached Print Name
Office Use Only
School Assigned:
Birth Verincatlon: ------- White· School AdmlnlslraUon Yellow·Allondonco
Date Entered:
Resident Status: - - ----
Signature Dale
Enter Code: Student ldlt:
Cf-2620 001·1991-AMS. Rev: 1012912012 GS7-IIem#163.
SPECIAL PROGRAM CODES (PK & KG Students Only) C Title 1 Pre-K- A federal funded preschool program serving three and four year olds who live In Title I attendance zones and are educationally disadvantaged
D Pre-K Program for Children with Disabilities -A federal and state funded program within the Florida Education Finance Program (FEFP) for three and four year olds with disabilities
F Fee for Service -A pre-k program operated by local school district In which parents pay tuition
H Head Start - A federal funded preschool program serving three and four year olds who meet income eligibility requirements; program may be operated by school district or community agency
L Readiness Program Operated by Local Coalition - These programs operate under contract with local readiness coalitions and are supported by state or federal funds and/or a sliding fee scale based on the parents' income. These include programs formerly known as Subsidized Child Care and Pre-K Early Intervention.
M Migrant Pre-K- A federal or state funded preschool program for eligible three and four year old children of migratory agricultural, fishing or forestry laborers
RACE EKAkateko DA - Danish I - American Indian I AL- Albanian, Shqip DL- Deccan Alaskan Native WJ -American Sign Lan DU - Dutch, Netherland A-Asian AM-Amharic DO - Dzongkha 8- Black AR-Arablc EN- English P - Pacific Islander I AN -Armenian, Hayeren EO - Esperanto Hawaiian AS - Assamese ES - Estonian W-White WK-Awadhi FO- Faroese
AZ -Azerbaijani FA- Farsi, Persian BA - Bantu FJ- Fijian
ETHNICITY BC- Bashklr FL Filipino Hispanic or Latino- Check: BQ - Basque, Euskera Fl - Finnish, Suomi Yes or No BS- Bassa FR - French
BIRTH VERIFICATION BJ - Belarusian FY- Frisian BE • Bengali, Bangia FU- Fulfl!lde, Nigeria 1 - Birth Certificate BR- Berber GL-Gallcian 3 - Baptismal Certificate BP - Bhojpurl KA - Georgian, Kartuli 4 -Insurance Policy DZ - Bhutan! GE-German 5 - Bible Record BH - Blharl GR- Greek 6-Passport Bl- Bislama KL - Greenlandic, Kala 7 - School Record BF- Breton GU -Gujarati 8- Certificate of Examination
T - Transfer or Automated BL- Bulgarian HC - Haitian-Creole (I
Migrant System (MSRTS) BU - Burmese, Myanmasa HY - Haryanvi BD - Byelorussian HA-Hausa 9- No Verification CA - Cambodian. Khmer HE -Hebrew, lwrith
RESIDENT STATUS CN - Cantonese HL - Hillgaynon 0- Not U.S. Resident CT- Catalan HI- Hindi A- Out of County I ESE ZA- Cebuano HM- Hmong B-Out of County I Other ZB - Chhattisgarhi HU - Hungarian, Magyar 2- Out of State ZC - Chinese, Hakka IC- lcelandic, lslenzk 3 - In County Resident ZD - Chinese, Min Nau 10 -lgbo
CH - Chinese, Zhongwen IL- IIacano LANGUAGE CODES ZE - Chlttagonian IN -Indonesian, Bahas AB - Abkhazian CO - Corsican lA - lnterllngua AA- Afar ZF- Creole IE -lnterlingue AK - Afrikaans HR - Croatian, Hrvatsk GA - Irish, Gaellge EF -Akan CZ- Czech
N None- The student did not participate in a Pre-K program
P Private Pre-K Program -A student parentally placed in a private preschool
T Teenage Parent Program - A child care program provided by the district for the child(ren) of a parent or parents who are enrolled in or who have completed a Teenage Parent Program and who are enrolled full-time in a public school in the district
S Funded Through Other Source(s) - A Pre-Kindergarten program operated by a local school district which Is funded through a source or sources other than those listed above
V Voluntary Pre-Kindergarten Education Program- A Pre-Kindergarten education program delivered by a public school for children who have attained the age of four years old on or before September 1 of the school year In which the child Is eligible to attend
Z Not Applicable -The student Is not a Kindergarten student
IT -Italian NE- Nepali TG- Tajlk JC - Jamaican Creole ( NO - Norwegian TB- Tamil JA - Japanese, Nihongo OC- Occitan -TT - Tatar JW -Javanese, Bahasa OR -Orlya TE- Telugu KV- Kannada OM - (Afan) Oromo TH- Thai KS - Kashmir! PX- Pamlamento Tl - Tibelan, Bodskad KK- Kazakh PJ - Panjabi. Punjabi TC - Tlgrinya RW - Kinyarwanda PA- Pashto (Includes TO - Tonga KY - Klrghlz, Kyrgyz PO-Polish TS- Tsonga RN- Klrundl PR - Portuguese TU- Turkish KO - Korean, Choson-o RA - Rhaeto-Romance TK- Turkmen KZ Kpelle (Guerze) RM - Rumanian, Romania TD- Twi KU - Kurdish, Zimany K RS- Russian UK - Ukranlan LO- Lamnso RB -Rwanda UR- Urdu LA - Laotian, Pha Xa L SG- Sangha UY- Uyghur LB- Latin SA - Sanskrit UZ- Uzbek LV- Latvian, Lettish XQ -Saraiki VI - Vietnamese LN - Llngala GD - Scots Gaelic VS- Visayan Ll - Lithuanian EP- Se-pedi VO- Volapuk LM - Lombard SK - Serbian, Srpski WE-Welsh MB - Macedonian SR - Serbo-Croatian WO-Wolof NJ- Madura ST- Sesotho XH -Xhosa XI-Magahi TN - Setswana Yl -Yiddish. Jlddlsch XJ- Malthill SN -Shona YO- Yoruba MA - Malagasy SD -Sindhl ZH - Zhuan, Northern ML- Malayalam SC - Singhalese ZU -Zulu MS - Malay, Bahasa Mal XL-Sinhala OT- Other MT- Maltese · Sl- Slswati ZZ- 0 I cable MD - Mandarin SL- Slovak •complete Language Code NR- Maori SJ - Slovenlan Descriptions & Additional MR-Marathl SO- Somali Codes of Indigenous XK- Marwari SP- Spanish Languages of the Americas MC - Moldavian SU - Sundanese are available at: MO - Mongolian SH- Swahili htt~:!/www. fldoe .orgls;lias/data NS - Napoletano - Gala SW - Swedish, Svenska web/database 1 011/aooendn NA- Nauru TA - Tagalog .J!Qf
Freshman Learning Center at Vero Beach High School Guidance Office
School District of Indian River County 150719th Street
Vera Beach, -FL 32960 Phone (772) 564-5677 Fax (772) 564-5679
Email all records to [email protected]
Permission for Release of Records & Information
Name of School Student is coming from
Address City & State
Phone Number Fax Number
Name of Student Date of Birth Grade
Please Email or fax all records as soon as possible. Student is waiting to enroll. Thank you!! Records Request: _Attendance/Discipline Records _Transcript & withdrawal grades _ Health Records (including Immunization & Physical) _IEP (Individual Education Plan)
504 _ ESOL records
_ Psychologist, Psychiatric Neurological or Pertinent Information _All Mental Health Referral/Records _Test Scores ACT/SAT
Parent/Guardian or School Official's Signature Date
Signature of Student over 18 (Federal Law 99.21- No parent signature is required for educational records to be sent to another educational agency.)
VERO BEACH HIGH SCHOOL
Date:
1707 16TH STREET, Vero Beach, Florida 32960
Telephone: (772) 564-5526 • Fax: (J72) 564-5551
----------------
Parents,
Please be aware that you are responsible for ensuring Vero Beach High School receives all requited student records from your child's previous school('s).
If we do not receive grades in a timely manner, it could affect your child's Grade Point Average, Credits and ability to graduate on time.
Thank you,
Vero Beach Guidance
Parent Signature __________________ Date:----- --- -
Student Name: ------------------------------
Principal: Shawn O'Keefe Director of Guidance: Jessica Wood
Counselors: Rachel Holderman (A-L) , Karen Bailey (M-Z)
Indian!"
Vero Beach High School 1707 16th Street, Vero Beach, Florida 32960
Mr. Shawn O'Keefe, Principal
All students must comply with immunization requirements as stated below.
The following requirements are based on the Department of Health Immunization
Requirements and Florida Statue 1003.22. Parents are responsible for keeping Immunization,
Physical Exam, and emergency information current in the School Health Room. Students will not
be allowed to return to any school activity until compliance to the Immunization/ Physical Exam
Requirements are met. Students will be excluded from school for the following reasons: 1)
Immunizations have expired 2) Records are not complete by the 30th school day after
transferring into Indian River County from another County.
If enrolling from Out of Country or from Homes School for the first time, School Health Exam
must be per FL Statute 1003.22 AND DOH, 680 Immunization form showing proof of required
immunizations for that student's grade level MUST BE completed PRIOR TO enrollment into
school.
Immunizations and Student Health Exams are available at the Department of Health or your
pediatrician's office. VNA also does Student Health Exams, but does not do immunizations.
Please call the department of Health (794-7400) or VNA (567-5551) for schedules and
appointments. If there are any questions concerning health requirements, please call your
school's Health Assistant at the school 's number on the Health Assistant Contacts Page or t he
Coordinator of Health Services at 772-564-5940.
VBHS Main Campus
Telephone: (772) 564-5600
Fax: (772) 564-5553 "It's Great To Be A Fighting Indian!'
Freshman Learning Center
Telephone: (772) 564-5800 Fax: (772) 564-5679
tED School District of Indian River County 6500 57th Street • Vero Beach, Florida, 32967 • Telephone: 772-564-3000 • Fax: 772-564-3054
Emergency Contact Information Health & Wellness Form School year 20_to 20_. FOR HEALTH ROOM USE ONLY
School ________________________ ~ Student's ID# ____________ _
Student's Legal Name {print)-----------------------
Student's Date of Birth---------------- Student's Grade-----------------
Parent/Guardian: Name. ______________________ Relation------------------
1st Phone # ------------ 2nd Phone# __________ Email Address--------------
Parent/Guardian: Name Relation----------------
1st Phone#-------- 2nd Phone# ______ Email Address---------
Emergency Contact: Name Authorization to Pick up: Yes No
Relation ________ 1st Phone# __________ 2nd Phone# ___________ _
Emergency Contact: Name Authorization to Pick up: Yes No
Relation ________ 1st Phone#-------------- 2nd Phone# ________ _
Medical Diagnosis:-----------------------------
A/1 current medical diagnosis/conditions and activity restrictions require documentation from the student's licensed health care provider each school year. Please see the school Health Assistant for the required forms. It is the parent's responsibility to provide the required medical documentation to the school district.
Aile rgies: -----------------------------------------------------------
Healthcare Providers name. _______________ _ Phone# _____ _
Health Screening: Vision, hearing, BMI and/or scoliosis, are provided to students in accordance with state mandates.
Cl Check the box at if you DO NOT want your student to participate in health screenings.
The above information is accurate and will be shared on a need to know basis verbally/written/electronically. I acknowledge that it is my responsibility to inform school of all changes. In the event of an accident/illness, attempts to notify custodial I emergency contacts will be made. If contact attempt is unsuccessful, after a reasonable time, the school is authorized to handle the emergency as trained and directed under Florida Statute FS743.064."
Parent/Guardian Name {print):----------------------
Parent/Guardian Signature:-------------Date:-------------
"Educate and inspire every student to be successful" Revised 12/18/2019
School District of Indian River County
Temporary Attendance Authorization: Out-of-State or Out-ofCounty Transfers
Children entering school for the first time or out-of-country students must have a physical exam
and proof of required immunizations prior to entry- There is no grace period for first time or
out-of-country students.
Student Name: ______________________________________________________ __
School: Vero Beach High School Freshman Learning Center Grade: __ Date:. ____ _
Your child attended __________________________ school in _______ (city/state).
Has he/she ever been enrolled in an Indian River County School? 0 Yes 0 No
Dates in Indian River: ____________ _
Dear Parent
A physical exam performed within the last 12 months is required for a student entering the
Florida schools for the first time along with immunization records on a Florida Form 680 and
singed by a Florida doctor showing completed vaccinations required for your child's grade.
Your child is being admitted to school while awaiting health records to be transferred to your
county schools district. Your child will be allowed to attend school for a period of 30 school days
from the date of enrollment. By signing below, you understand the health requirements and wil l
assist in obtaining these records from your child's previous school.
The child will not be permitted to continue in school after 30 school days unless records or
new forms have been received. When the records come in from your child's pervious school, you will be notified if they are incomplete.
Parent Signature:. ______________________________________________________ _
REQUEST TO WITHHOLD INFORMATION
Two federal laws require school districts receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to provi.de military recruiters and institutions of higher education, upon request, with three directory information categories- names, addresses and telephone listings- unless parents have advised the school district that they do not want their student's information disclosed without their prior written consent.1
In order for Vero Beach High School to withhold the release of your child's directory information, you must complete and sign the form below and then return to your child's school within the first 10 days of enrollment.
1 These laws are: Section 9528 of the ESEA (20 U.S.C. 7908), as amended by the No Child Left Behind Act of 2001 (P.L. 107-110), the education bill, and 10 U.S.C. 503, as amended by section 544, the National Defense Authorization Act for Fiscal Year 2002 (P. L. 1 07-1 07), the legislation that provides funding for the Nation's armed forces.
REQUEST TO WITHHOLD INFORMATION
DO NOT DISCLOSE my child's name, address and telephone number to the entity(s) checked below.
__ Military recruiters
__ Institutions of higher education
Student's Name: 10#: Grade -------------------------- ---------
Parent/Guardian Name: ------------------------------------------Signature: ---:::::-:--:--:--:::---:----:-::-:-::------:-,..,....-----------------
(Student Signature if 18 years old) Date: -----
School District of Indian River County
Student Data Collection Form
Parent(s)/Guardian(s) - United States Department of Education has changed the way Race and
Ethnicity identification is reported. Please complete this form. Failure to provide this information
will result in the determination of your student's Ethnicity/Race being determined by school staff
as directed by the Florida Department of Education.
Student Name: ______________ Student ID#: _____ Grade: __
Please answer BOTH questions .... 1 and 2.
1. Ethnicity -Is your child Hispanic or Latino? (Please mark only one)
0 No, my child is not Hispanic or Lat ino
0 Yes, My Child is Hispanic or Latino- A person of Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish culture or other Spanish culture or origin,
regardless of race.
2. Race- What is your child's race: (Please mark all that apply)
0 American Indian or Alaska Native- A person having origins in any of the original
peoples of North and South America (including Central America) and who
maintains tribal affiliation or community attachment.
0 Asian- A person having origins in any of the original peoples of the Far East,
Southeast Asian or the Indian subcontinent, e.g. Cambodia, china, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
0 Black African American, Haitian- A person having origins in any of the black racial groups of Africa.
0 Native Hawaiian or Other Pacific Islander- A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
0 White- A person having origins in any of the original peoples of Europe, the Middle East or North America.
ParenVGuardian Signature: _______________ Date: ___ _ School: VBHS/FLC
School District of Indian River County
Student Residency Form
This survey is intended to address the requirements of the Every Students Succeeds Act (ESSA); responses help to determine eligibility of services that may be provided through the Federal McKinney Vento Act (Homeless Education Program) and/or the Migrant Education Program. This form is required to be completed annually for ALL students enrolled in SDIRC Schools and may be requested upon notification of change of address, residence, and/or living situation.
Parent/Guardian Name:
Please Print
Current Street Address: Length of time
at this address
Mailing Address:
If Different [rom Above
Cell Phone: Work Phone: Alternate Phone:
Email:
Former Street Address: Length of time
at this address
Please list ALL children in your family, (including pre-K children) enrolled or to be enrolled at ANY SDIRC school.
Last Name First Name Ml Date of Birth Grade School Student 10
1. My family and I have moved from one school district to another within the last three years due to economic necessity ... YES NO
AND have engaged in seasonal or temporary work in agriculture o r fishing.
AND have a recent history of moves to work or seek work in agriculture or fishing.
2. A child/youth in my home has been placed in foster care or is awaiting foster care placement YES NO
3. Please indicate YES or NO for the following YES NO We are temporarily doubled up/sharing housing with others due to lack of housing, economic hardship, or similar
reason (Note: This is NOT living with someone else by choice in o house or apartment thot properly accommodates all residents)
We are living in a motel or hotel due to lack of adequate accommodations We are sleeping in a vehicle or park, a public space, temporary trailer park or campground, an abandoned building,
or other substandard housing due to lack of adequate accommodations We are living in an emergency or transitional shelter
A child/youth in my home is not in the physical custody of a parent/guardian (unaccompanied youth)
I am a student not in the physical custody of a parent/guardian (unaccompanied youth)
We are living in other situation(s) that are NOT fixed, regular, or adequate for nighttime residence 4. If YES to any of the statements in question #3, please check the applicable box
0 Economic hardship due to the COVID pandemic (illness, loss of job, etc.) that resulted in loss of housing
0 Economic hardship or other circumstances (NOT Related to the COVID pandemic) that resulted in foreclosure, eviction, or
inability to obtain a residence at this time
0 Loss of housing due to a Natural Disaster (hurricane, flood, fi re, etc.) and have no place else to go. Please indicate the Natural
Disaster type & name here:
0 Loss of housing due to a Man-made Disaster (mold, poison gas release, etc.) and have no place else to go
0 If the above do not apply, please specify:
Verification of Information- The undersigned certifies that the information provided is accurate.
For more information, contact the SDIRC
Federal Programs Department Signature
Phone: (772)564-3096
Print Name www.indian riverschools.orP./deoa Website: rtments[federal ~rograms
Date
Directions [or School Stoff Revised:
Please maintain a copy of this form as part of the student record. For forms with affirmative responses, forward to: Federal July 2020
Programs Department Email: [email protected]; Telephone: (772) 564-3096; FAX: (772) 564-3016.
DISTRITO ESCOLAR DEL CONDADO DE INDIAN RIVER
FORMA DE REGISTRO PARA ESTUDIANTES DE K-12 LETRA DE IMPRENTA POR FAVOR LETRA DE IMPRENTA POR FAVOR
Solo Para Estudiantes de Kindergarten: (,Asisti6 el estudiante a un programa especial antes de iriiciar el kindergarten? Sf 0 No 0
Si es Sf, Uene Ia Forma de lnfonnaci6n de Programas Especia/es y vea Ia parte de atnls de esta forma para el OOdigo apropiado: ____ _
Nombre Legal del Estudiante: --:-:----:::--:-:-----:::----:---:--:::-:--:------=-:--:-:-------=----:-:---:-:-----<APellldo) (Segundo Ape/lido) (Pdmer Nombre) (Segundo Nombre)
Telefono del Hogar: Sexo: M-Masc. 0 F-Fem. 0
Direcci6n : ---:::-::-:::-:-:--::--:-,.------~c-::c---:--:-:-------:=--:-::--------=:-:--:-:-----=-::-:------(Ca/le/ Caf6n Postal) (# De DepotA.ote) (Ciudad) (Estedo) (C.P.)
Fecha de Nacimiento del Estudiante: I ! ___ _ dd mm sa
Direcci6n Postal: -,-o-=-.,....,,....,.-=--,....,.---,.,...,--=--,.,....,....,...- --:=--:-::----- --=-.,..--,...,.---- -----,=-=-.,----(sf es diforente a Ia de arriba) (Calle!Caj6n Postal) (#De DepotA.ole) (Ciudad) (Estado) (C.P.)
Lugar de Nacimiento del Estudiante: -=---:-~c------c-:,.,-,...-,----c::-:--,--(Condado) (Ciudad) (Eslado)
# de Segura Social del Estudiante: Antigua apellldo del estudiante _______ _ Grado Escolar: ___ _ Licencia de Manejo del Estudiante:. _ __ _ (Opcional}
Ultima Escuela a Ia que asisti6 en Florida: #de 10 Florida--------------- Ultima Escuela a Ia que Asisti6: ------···----·------··------------·--·----------------------------- (Sino es una Escuefa de' Florida)
Direcci6n: (Condado) (Ciudad) (Estado)
Fecha de Primer lngreso a una Escuela en EU: ------ ----(Pals) (C.P.)
.. - --- - - . - · '1' - ·t'"'1'--· •• ·--·- ··- --·-"'1• .. - .. --·- .. ·----· _ .. , ,, ...,,....., __ .__ .. ,, ·-·. ··-l"-· ·- -·- ,,._,. ._
Si su respuesta es sf a cualqulera de las siguientes preguntas, vea Ia parte de atras y anote el c6digo (s) de lenguaje apropiado:
i,Se usa en su hogar otro idioma ademas del ingh~s? SID NoD LTiene ei estudiante un Plan Individual de Educaci6n (IEPl/ESE? SiD NoD
i.. Tuvo el estudiante un primer idioma adem as del inoles? SID NoD {.Ha tenido el estudiante un Plan 504? Si D No D
i_Habla el estudiante con mas frecuencia otro idioma adem as del ingles? Si D No D ,;,Es el estudiante un hila (al de una familia en las fuerzas armadas? Si D NoD
LUsted o su familia se ha movido o salida fuera del distrito o del estado en los ultimos tres Si D No D
(..Ha sido el estudiante arrestado, acusado; deciarado culpable, srD NoD anos con el prop6sito de buscar trabajo en el area de aQricultura, pesca o forestal? declarase culoable de un acto criminal?
Si D No D {.Ha sido el estudiante expulsado o referido a un programa
Si D NoD {..Ha estado el estudia.nte en un centro residencial de tratamiento? alternativo por motivos de disciolina?
Otros programas: (marque uno) Ingles Para Parlantes de Otros ldiomas 0 ESE D Migrante 0 Titu lo I D Talentoso 0 Educaci6n compensatoria 0 Otro D
TIPO DE CONTACTO P ARENTESCO *'NOTA: Solo el padre, guardian o cualquier persona con un parentesco de patemidad con el estudiante, o cualquier persona CODIGOS: E = Padres §=Guardian Q=O~o ejerciendo autotidad de supervisiOn sobre el estudiante en Iugar de los padres puede actualizar los contactos de emergenda. C6digos:
M= Madre F= Padre G= Guardian AS= Autoridad sobre el Est SP= Padrastro/a GP= Abuelo/a D= Doctor 0= Otro
Circule Cada Uno: S= Si N= No Ntimeros de teletono - lncluir c6diQo de area:
ld Nombre de Co.ntacto 'I r- 1..,"' r Recoger Custodia Viva con Emergencia Cas a Celu lar Trabaio Ext.
1 s N s N s N s N
2 s N s N s N s N
3 s N s N s N s N
4 s N s N s N s N
Anotar a los nilios de su familia inmediata que asisten a escuelas en Indian River (nombre y escuela): --0 Soy residents del Condado de Indian River
0 Se Anexa Permiso de Fuera del Condado Nombre en Letra de lmprenta Firma Fecha
Oflk:e Use Only
Schoo!Assigned: Date Entered: Enter Code: Student ldft:
Birth Verification: Resident Status: - - - .,---- -White- School Administration Yellow- Allendanco CF-2622 001 -1991-AMS. Rev: 10/29/2012 GS7-Itcm ll163.
CODIGOS DE PROGRAMAS SPECIALES (Solo Estudiantes de PK y KG) C Pre-K de Titulo I - Programa pre escolar de fondos federates que slrve a nii\os de 3 y 4 alios que viven en zonas de asistencia de Titulo I y tienen desventajas educativas .
D Program a de Pre-K para ninos con discapacidades- Programa de fondos federales y estatales dentro del Programa Flnanclero de Educaci6n de Florida (FEFP) para ninos de Ires y cuatro ai\os de edad con discapacidades.
F Pago por Serviclos- Un programa de Pre-K manejado por un dislrito escolar local en el cual los padres pagan por los servicios
H Head Start - Programa pre escolar de fondos federates que sirve a ninos de 3 y 4 aiios que cubre requisitos de ingreso econ6mico; el program a puede ser opera do por el distrito escolar o agencia de Ia comunidad.
L Programa de Preparaci6n Operado por Coallci6n Local - Estos programas operan bajo contra con coaliciones locales de preparaci6n y estan apoyadas con fondos federates y del estado ylo una cuota basada en el ingreso econ6mlco de los padres. lncluye programas conocidos antiguamente como Guarderla Subsldiada e lntervenci6n Temprana de Pre-K
M Pre-K Migrante- Program a pre escolar de fondos federales o estatales para ninos elegibles de familias de trabajadores migratorios de agricuKura y pesca de Ires y cualfo af\os de edad.
RAZA I - Indio Americana I Nativo de Alaska A- Aslatico B-Negro P -Islas del Pacifico I Hawaiano W -Bianco
ETNICIDAD Hispano o Latino- Marque: Slo No
VERJFICACION DE NACIMIENTO 1 -Acta de Nacimiento 3 - Certificado de Bautizo 4 - R61iza de Segura 5 - Record Blbllco 6 - Pas a porte 7 - Record Escolar 8 - Certificado de Examlnaclqn T-TransferenclaoSistema Automatioo Migrante (MSRTS) 9- No Verlficad6n
CATEGORIA RESIDENCIAL 0 - No Residente de U.S. A- Fuera del CondadoiESE B - Fuera del Condado I Otro 2- Fuera del Estado 3 - Residents del Condado
CODIGOS DE LANGUAGE AB - Abkhazlan AA- Afar AK - Afrikaans EF -Akan
EKAkateko AL -Albanian, Shqip WJ -American Sign Lan AM-Amharic AR- Arabic AN - Armenian, Hayeren AS - Assamese WK-Awadhi AZ- Azerbaijani BA- Bantu BC - Bashkir BQ- Basque, Euskera BS- Bassa BJ- Belarusian BE - Bengali, Bangia BR- Berber BP - Bhojpuri DZ- Bhutani BH- Bihar! Bl- Bislama BF- Breton BL- Bulgarian BU - Burmese, Myanmasa BD - Byelorussian CA - Cambodian, Khmer CN - Cantonese CT- Catalan ZA- Cebuano ZB - Chhattlsgarhl ZC - Chinese, Hakka ZD - Chinese, Min Nau CH -Chinese, Zhongwen ZE - Chittagonian CO - Corsican ZF- Creole HR- Croatian, Hrvatsk CZ - Czech
DA- Danish DL- Deccan DU - Dutch, Netherland DO - Dzongkha EN- English EO - Esperanto ES - Estonian FO- Faroese
·FA - Farsi, Persian FJ- Fijian FL Filipino Fl - Finnish, Suomi FR- French FY - Frisian FU- Fulfulde, Nigeria GL - Gallcian KA - Georgian, Kartuli GE -German GR- Greek KL - Greenlandic, Kala GU- Gujaratl HC - Haitian-Creole (I HY - Haryanvi HA- Hausa HE - Hebrew, lwrith HL - Hiligaynon HI - Hindi HM - Hmong HU- Hungarian, Magyar IC - lcelandic,lslenzk 10 -lgbo IL -llacano IN- Indonesian, Bahas lA - lnterlingua IE - lnterlingue GA -Irish, Gaeilge
N Ninguno- el estudiante no partlcipo en un programa de Pre-K
P Program a Privado de Pre-K- Un estudiante que esluvo en un programa pre escolar privado
T Programa de Padres Adolecentes - Programa de guarderla proporcionado por el distrito para los hijos de los padres que estan registrados o termlnaron un Programa de Padres Adolecentes y que estan registrados de tiempo completo en una escuela publica del distrito.
S Patroclnado con otro (s) fondo (s)- Un programa de educaci6n pre kindergarten operado por un distrito escolar local el cual recibe fondos de otras fuentes dlferentes a las menclonadas arriba.
V Programa Voluntarlo Educacl6n de Pre kindergarten- Un programa de educaci6n de Pre-kindergarten proporcionado por una escuela publica para nifios que han cumplido 4 anos el o antes del1° de septiembre del a no escolar en el cual el nino (a) es elegible para aslstir.
Z No Apllcable- (el esludiante noes un estudiante de kindergarten.)
IT -Italian JC -Jamaican Creole ( JA- Japanese, Nihongo JW- Javanese, Bahasa KV- Kannada KS - Kashmlri KK- Kazakh RW - Kinyarwanda KY- Kirgh iz, Kyrgyz RN - Kirundi KO - Korean, Choson-o KZ Kpelle (Guerze) KU - Kurdish, Zimany K LO- Lamnso LA- Laotian , Pha Xa L LB - Latin LV - Latvian, Lettish LN- Lingala Ll - Lithuanian LM- Lombard MB - Macedon ian NJ - Madura XI- Magahi XJ- Mailhill MA - Malagasy ML - Malayalam MS - Malay, Bahasa Mal MT- Maltese MD - Mandarin NR- Maori MR- Marathi XK- Marwari MC - Moldavlan MO - Mongolian NS - Napoletano - Cal a NA- Nauru
NE- Nepali NO - Norwegian OC- Occitan OR· Oriya OM- (Afan) Oromo PX - Pamiamento PJ- Panjabi, Punjabi PA- Pashto (Includes PO- Polish PR - Portuguese RA - Rhaeto-Romance RM .: Rumanian, Romania
· RS : Russian RB- Rwanda SG - Sangha SA - Sanskrit XQ- Saraikl GD - Scots Gaelic EP- Sepedl
. SK- Serbian, Srpski SR - Serbo-Croatian ST- Sesotho TN - Setswana SN- Shona SD • Sindhl SC- Singhalese XL- Slnhala Sl- Slswatl SL - Slovak SJ - Slovenian SO - Somali SP- Spanish SU - Sundanese SH - Swahili SW - Swedish, Svenska TA- Tagalog
TG- Tajik TB- Tamil TT- Tatar TE - Telugu TH- Thai Tl - Tibetan, Bodskad TC - Tigrinya TO- Tonga TS- Tsonga TU- Turkish TK- Turkmen TD - Twi UK - Ukranian UR- Urdu UY- Uyghur UZ- Uzbek VI - VIetnamese VS- Visayan VO- Volapuk WE-Welsh WO -Wolof XH- Xhosa Yl - Yiddish, Jiddisch YO- Yoruba ZH - Zhuan, Northern ZU- Zulu OT- Other ZZ - Not Applicable
•complete Ia Descripci6n de C6digos de Lenguaje y C6digos Adicionales de Leng. indlgenas de las Americas disponlbles en http://www.fldoe.org/eias/data web/database 1 011/appendn &2!
~ School District of Indian River County 6500 57th Street • Vero Beach, Florida, 32967 • Telephone: 772-564-3000 • Fax: 772-564-3054
Distrito Escolar del Condado de Indian River Forma de Salud Escolar/ Bienestar 20_to 20_
PARA SALON DE SALUD UNICAMENTE
Escue Ia: ------------------------------------------- Ng de ID: -------------------------Nom bre Legal del Estudia nte (tetra de imprenta): ----------------------------------------------
Fecha de Nacimiento del Estudiante: Grado del Estudiante: __________ _ -----------------------------Nombre de Padre/Guard ian: ------------------------------Parentesco: -----------------------
l er Teletono: ------------ 2g Telefono: ------------- Correa electr6nico: -----------------------
Nombre de Padre/Guardian:---------------- Parentesco: --------------
ler Teletono: ---------- 2g Telefono: ------------- Correa electr6nico: - ------------ -
Nombre del Contacto de Emergencia: ----------------Autorizaci6n para recoger: o Si o No
Parentesco: --------------- ler Teletono: -------- 2g Telefono: --------
Nombre del Contacto de Emergencia: ----------------Autorizaci6n para recoger: o Si o No
Parentesco: -------------- ler Telefono: -------- 2g Teletono: ----------
Diagn6stico: ---------------------------------------------Todos los diagn6sticos medicos I condiciones actuates y las restricciones de actividad requieren Ia documentaci6n del proveedor de atenci6n medica con licencia del estudiante coda ano escolar. Por favor, consulte a/ Asistente de Salud de Ia escue/a para los formularios requeridos. Es responsabilidad de los padres proporcionar Ia documentaci6n medica requerida a/ distrito escolar.
Alergias: - ----------------------------------------------------
Proveedor de atenci6n medica __________ _________ Telefono -------- ---
Evaluaciones de salud: vision, auditiva, BMI y/o Escollosis se les proporcionan a los estudiantes en base a mandates del estado.
D .Marque con sus iniciales en el cuadro solamente si Ud. NO quiere que se hijo (a) participe en las evaluaciones de salud
·La informacion mencionada en Ia parte de arriba es correcta y se compartira en base a como sea necesario verbalmente/por escrito/electr6nicamente. Yo se que es mi responsabilidad informarle a Ia escuela todos los cambios. En caso de accidente/enfermedad, se haran esfuerzos para informar a los contactos de custodia/emergencia. Si el intento de contacto no tiene exito, despues de tiempo razonable, Ia escuela esta autorizada para manejar Ia emergencia conforme al entrenamiento y direcci6n bajo el estatuto FS743.064 de Florida."
Nombre de Padre/Guardian: -------------------------------------------------Firma de Padre/Guardian: - ------------------------- Fecha: ----------
"Educate and inspire every student to be successful" Revised 12/18/2019
Distrito escolar del Condado de Indian River Formulario de Residencia de Alumnos
Esta encuesta pretende abordar los requisites de Ia Ley de Todos los Estudiantes Tienen Exito (ESSA par sus siglas en ingh!s); las respuestas ayudan a determinar Ia elegibilidad para recibir los servicios que pueden ser prestados a traves de Ia Ley Fede ral McKinney Vento (Programa para Ia Educaci6n de Personas sin Hagar) y/o el Programa de Educaci6n para Migrantes. Este fo rmulario debe ser llenado anualmente para TODOS los alum nos matriculados en las Escuelas de SDIRC y puede
solicitarse al momenta de notificar el cambia de domicilio residencia yjo situaci6n de vivienda.
Nombre padre/representante :
Letra de imprenta
Direcci6n actual (calle): <Hace cuanta
tiempo vive alii?
Direcci6n postal:
Si es diferente a to anterior
Celu la r : Tel. Trabajo: Teh~fono alterno:
E-mail:
Direcci6n anterior (calle ) <Hace cuanto
tiempo vive alii?
Enumere TODOS los hiiios en su familia (induyendo en eda d pre-K) inscritos o que se inscribinin e n cualquie r escu ela de SDIRC. Apellido Nombre lnic. F. Nacimiento Grado Escue Ia ID Estud.
1. Mi fa m ilia y yo nos mudamos d e un distrito escolar a otro en los ultimos tres a iios por necesidad e conomica ... sf NO
Y hem os pa rticipado en trabajo temporal o estacio na l e n Ia agricultura o pesca .
Y nos he m os mudado recientement e pa ra t ra baja r o buscar trabajo e n Ia agricult ura o pesca .
2. Un nii'io o joven en mi casa ha s ido colocado en un hagar de a cogida o e s ta en espera de serlo sf NO
3 . Marque sf o NO e n cuanto a las siguientes sf NO Temporalmente estamos hacinados/compartimos vivienda con otros debido a Ia falta de vivienda, a dificultades econ6micas o a razones simi lares {Nota: Esto NO significa vivircon otra persona por e/ecci6n en una coso o apartamento que alaje adecuadamente a tadas las residentes)
Estamos viviendo en un motel u hotel debido a Ia falta de alojamiento adecuado
Estamos durmiendo en un vehfculo o parque, en un espacio publico, e n un parque de remolques tempora l o Iugar pa ra acampar, en un edificio abandonado o en otra vivie nda deficiente debido a Ia falta de alojamiento adecuado
Estamos viviendo en un refugio de emergencia ode transici6n
Un niiio/joven en mi casa no esta bajo Ia custodia ffsica de un padre/tutor Uoven no acompaiiado)
Soy un estudiante que no esta bajo Ia custodia ffsica de un padre o representante Uoven no acompaiiado)
Estamos viviendo en ot ra situaci6n que NO es fija, regular o adecuada para residir porIa noche
4. Si respondio que sf a cualquiera de las a lternativas de Ia pregunta #3, marque Ia casilla correspondiente
0 Dificultades econ6micas debidas a Ia pande mia del COVID (enfermedad, pe rdida de t rabajo, etc.) que ocasion61a perdida de vivienda
0 Dificultades econ6micas u otras circunstancias (NO relacionadas con Ia pandemia del COVID) que provocaron Ia ejecuci6n de una hipoteca, el desalojo o Ia imposibilidad de obtener una residencia en este mome nta
0 Perdida de Ia vivienda debido a un desastre natural (huracan, inundaci6n, incendio, etc.) y no tener otro Iugar a donde ir. Par favor, indique e l tipo y nombre del desast re natural aqui:
0 Perdida de Ia vivienda debido a un desastre provocado por el hombre (moho, gas venenoso, etc.) y no te ner otro Iugar a don de ir
0 Si las anteriores no corresponden, especifique:
Verificatio n de informacion- El firmante certifica q ue Ia informacio n provista es exacta. Para mas informacion, comunfquese con e l
Departamento de Programas Federales del
SDIRC Firma
Te lefono: (772) 564-3096
Nombre en tetra de imprenta www.indianriverschools.orgldega Sitioweb:
rtmentsLfederal grograms Fecha
lnstrucciones para el personal escalar s,..,~;v. vf"'',_
Mantenga una copia de este formula rio como parte del expediente del alum no. Los formularies con respuestas afirmativas debe enviarlos a: Departamento de Revised:
Programas Federales e·ma ii:Federa i [email protected]; Telefono: (772) 564-3096; FAX: (772) 564·3016. July2020
