NEW STUDENT REGISTRATION/ENROLLMENT CHECKLIST & PROCEDURE

Please help us serve you better by using this checklist as you collect the information and documentation necessary for enrolling your student at Kennewick High School.

FORMS INCLUDED IN PACKET

Student Records Release Request – Complete the form and sign it. Registration/Enrollment Form - Complete both sides of the form and sign it. Include any court documents

relating to guardianship or a parenting plan, if applicable. Verification of Residence – Complete form and sign. Attach address verification document. Student Housing Questionnaire – Complete and sign the form. Student Health History – Complete and sign the form. Certificate of Immunization Status (CIS) – Washington State law requires the use of the official CIS form, which is

to be completed and signed by the parent/guardian. Home Language Survey – Complete and sign the form. KHS Student Behavior Expectations – Student will complete and sign the form with their counselor. Kennewick High School Map and Bell Schedule – For your information only. Legal Guardianship Verification Requirements – For your information only. RCW 28A225330 – For your information only. Electronic Policy – For your information only.

DOCUMENTS NEEDED

At least one address verification document – Current telephone, utility or cable bills; lease or mortgage information. We will make a photo copy of the required documents.

Court Documents pertaining to guardianship or parenting plan – Attach to Registration Packet (if applicable). REGISTRATION PROCESS AND PROCEDURE – FOR YOUR INFORMATION

1. Pick up New Student Registration/Enrollment Packet from the Kennewick High School Main Office. 2. Complete and sign all forms and return them to the Counseling Office. 3. Counseling Office will request records from the previous school. You can help expedite this process by bringing

an unofficial transcript, withdraw grades, test scores and immunizations with you when you return the packet. 4. When records are received, we will schedule a meeting with an administrator – parents and students are

REQUIRED to be present at this meeting. 5. A Measure of Academic Progress Test (MAP Test) will be scheduled after the meeting to assist in placement of

your student to the appropriate classes. 6. Last, an appointment with your student’s counselor will be made to create a schedule of courses. 7. Information & Application for Free or Reduced Price Meals is available upon request.

KENNEWICK HIGH SCHOOL

500 South Dayton

Kennewick, WA 99336-5674

(509) 222-7100

Fax (509)222-7101

LIONS -s>*

KENNEWICK HIGH SCHOOL

Attn: Ashlee Hagadorn

500 S. Dayton Street

Kennewick, WA 99336

Phone: (509) 222-6576

Fax: (509) 222-7116

Records.KEHS@ksd.org

SCHOOL RECORDS RELEASE REQUEST Please fax or email the following indicated records to Kennewick High School:

__ UnOfficial Transcript __Achievement (MAP) Test

__Immunization/Health Record __Psych. Testing & Special Ed.

__Withdrawal Grades __Cumulative Files (Please mail)

__Discipline Records __Bilingual Test Scores

__Attendance Records

__State Exit Exam Scores W/State Cut Scores

__WA State History Middle School Report

(Please complete the following information for our records)

Student’s Full Name________________________________________________________

Date of Birth_________________________ Year of Graduation_________Grade______

Previous School Name____________________________District_____________________

Previous School Phone________________________Fax____________________________

Address___________________________________________________________________

City, State, Zip Code________________________________________________________

Parent or Guardian _____________________________________Date________________

Parent or Guardian Phone #__________________________________________________

Thank-you,

Ashlee Hagadorn Kennewick High School

Counseling Secretary

Date:

First Attempt:

_______________________________

Second Attempt:

_______________________________

Kennewick HS ~ 9/23/16

TODAY’S DATE: _________________________

STUDENT INFORMATION

Student Legal Last Name: Student Legal First Name: Student Middle Name:

Birth date: Month Day Year Gender: (Circle One)

Male Female Does this student have school records by any other names? YES NO

If yes, please list all names:

Home Phone: ( ) Grade Level:

Student’s primary language is English: YES NO

If not English, list primary language spoken at home:

Birth City: Birth State: Birth Country:

Student’s Residence Address: Apt: City: State: Zip:

Mailing Address: (If different from residence) Apt: City: State: Zip:

Parent/Guardian E-mail Address:

Mother/Guardian Information Relationship (circle one): Stepmother Foster /Legal Guardian Grandparent Other______________

Mother’s Last Name: Mother’s First Name: Does student live with mother? Yes No

Daytime Phone: Employer: Work Phone: ( ) Home Phone: ( )

Cell Phone: ( ) Mother’s Street Address (if different than student): City State: Zip:

Father/Guardian Information Relationship (circle one): Stepfather Foster /Legal Guardian Grandparent Other_______

Father’s Last Name: Father’s First Name: Does Student live with father?

Yes No

Daytime Phone: ( ) Employer: Work Phone: ( ) Home Phone: ( )

Cell Phone: ( ) Father’s Street Address (if different than student): City State: Zip:

Is there a NO CONTACT Order, Parenting Plan or Shared Custody? Yes or No

ETHNICITY: Is this student of Hispanic or Latino origin? YES NO (Circle All That Apply)

Mexican/Mexican American/Chicano

Cuban

Dominican

Spaniard

Puerto Rican

Central American

South American

Latin American

Other Hispanic/Latino

Other Hispanic/Latino

What race do you consider this student? (Circle All That Apply)

African American or Black

White or Caucasian

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Indonesian

Japanese

Korean

Laotian

Malaysian

Pakistani

Singaporean

Taiwanese

Thai

Vietnamese

Other Asian

Native Hawaiian

Fijian

Guamanian or Chamorro

Mariana Islander

Melanesian

Micronesian

Samoan

Tongan

Other Pacific Islander

Alaska Native

Chehalis

Colville

Cowlitz

Hoh

Jamestown

Kalispell

Lower Elwha

Lummi

Makah

Muckleshoot

Nisqually

Nooksack

Port Gamble Clallam

Puyallup

Quileute

Quinault

Samish

Sauk-Suiattle

Shoalwater

Skokomish

Snoqualmie

Spokane

Squaxin Island

Stillaguamish

Suquamish

Swinomish

Tulalip

Yakama

Other Washington Indian

Other American Indian

Kennewick School District Enrollment Form KENNEWICK HIGH SCHOOL 500 S. Dayton Street

Kennewick WA 99336

(509) 222-7100

Office Use Only:

Student ID # _________________________________

Entry Date:__________ Assigned School: __________

Room #:_________________

Home Language Survey Form: YES NO

Kennewick HS ~ 9/23/16

PARENT MILITARY SERVICE

Father Mother Yes No Yes No

Active Duty Yes No

Reserve Duty Yes No

Branch:

EMERGENCY CONTACT INFORMATION

CONTACT # 1 Last Name First Name Relationship

Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )

CONTACT # 2 Last Name: First Name: Relationship:

Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )

CONTACT # 3 Last Name: First Name: Relationship:

Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )

MEDICAL ALERTS

Medical Alert/Allergies

Medication Taken Daily Physician Telephone # / Ext. ( )

ADDITIONAL INFORMATION

Circle previous / current participation in: (Circle All That Apply)

Gifted Title 1 ELL/Bilingual Math or Reading Assistance OT/PT Services Speech Special Education (IEP) 504 Plan

READY for Kindergarten

NAME AND ADDRESS OF SCHOOL LAST ATTENDED

School: Grade: Phone: ( )

Address: City: State: Zip:

Date of withdrawal: Month Day Year

SIBLING INFORMATION

Name: School: Grade:

Name:

Name:

Name:

EMERGENCY TREATMENT AUTHORIZATION

In the event of injury or illness and your family physician is not available or not located in the immediate vicinity and we are unable to

contact a parent/guardian, does the supervising person have your permission to seek medical attention from the nearest licensed

physician and/or hospital? (Parents of students who do not live within the city limits of Kennewick will be charged by the City of

Kennewick $425.00 should an ambulance be dispatched to the school to take your child to the hospital).

YES_______________ NO_________________

If you answer “NO”, Please specify the procedure you wish the supervising person to follow:_________________________________

____________________________________________________________________________________________________________

PRINTED NAME OF PARENT or LEGAL GUARDIAN: ___________________________________________________________________

SIGNATURE OF PARENT or LEGAL GUARDIAN: _______________________________________________________________________

DATE:________________________________

Parent/Guardian Signature: _____________________________________________Date:________________

Student Legal Last Name: Student Legal First Name: Student Middle Name:

Verification of Residence

Student Name:______________________________________________

Present Address: ___________________________________________

__________________________________________________________

Telephone: ________________________________________________

Parent/Guardian/Legal Custodian:______________________________

Please attach one of the following for Proof of Residence to show you are living

in our boundary area:

Utility Bill

Phone Bill

Approved Transfer Request

My signature below indicates that the above mentioned student is in

compliance with the residency requirements of the Kennewick School District to

attend Kennewick High School.

I understand that falsification of any of the requested information will be

considered sufficient cause for immediate withdrawal of the student from

Kennewick High School.

If, at any time, the student’s residency becomes different from that stated

above, the school may review the criteria for enrollment and modify its

previous decisions.

Parent/Guardian Signature: _________________________________

Date:_____________________________________________________

Note: Students residing outside of Kennewick High Schools boundaries may apply

for admissions through a District Transfer Request. All requests will be considered

on an individual basis.

Kennewick School District

1000 W. 4th Ave

Kennewick, WA 99336

Student Housing Questionnaire

Please use one form per student. Return to school registration office within 14 days of receipt. If you require additional

copies, please contact your school.

Name of Student: First Middle Last

Name of School: Grade: Birthdate: Age: Month/Day/Year

Sex: Male Female

The answers to the following questions can help determine the services this student may be eligible to receive under the

McKinney-Vento Act 42 U.S.C. 11435.

1. Is this student’s home address a temporary living arrangement? Yes No

2. Is this a temporary living arrangement due to a loss of housing or economic hardship? Yes No

3. Is this student awaiting foster care placement? Yes No

4. As a student, are you living with someone other than your parent or legal guardian? Yes No

If you answered YES to any of the above questions, please complete the remainder of this form.

If you answered NO to all of the above questions, you may stop here.

Where is this student currently living? (check box)

Temporarily with another family because we cannot afford or find affordable housing.

With an adult that is not a parent or legal guardian, or alone without an adult.

In a hotel/motel.

In a vehicle of any kind, RV park or campground, abandoned building or substandard housing.

In an emergency/transitional shelter.

Other

ADDRESS OF CURRENT RESIDENCE:

(OR)

NAME OF MOTEL/SHELTER OF CURRENT RESIDENCE:

(OR)

NAME OF “GENERAL AREA” OF CURRENT RESIDENCE:

PHONE NUMBER OR CONTACT NUMBER: NAME OF CONTACT:

Print name of parent(s)/legal guardian(s):

(Or unaccompanied youth)

Signature of parent/legal guardian: Date:

(Or unaccompanied youth)

For School Staff Only: Forward questionnaire to Federal Programs, Attn: Homeless Support Coordinator

Distrito Escolar de Kennewick

1000 W. 4th Ave

Kennewick, WA 99336

Estudiante Cuestionario de Vivienda

Por favor llene una forma por cada estudiante. Regrese esta forma a la oficina de la escuela a más tardar 14 días que lo

reciba. Si requiere más copias, por favor póngase en contacte la escuela.

Nombre del estudiante: Primer Segundo Apellido

Nombre de la escuela: Grado: Fecha de nacimiento: Edad: Mes/Día/Año

Género: Hombre Mujer

Las respuestas a estas preguntas podrán ayudar en determinar la elegibilidad de los servicios que el estudiante podría

recibir bajo la ley “McKinney-Vento Act 42 U.S.C. 11435.”

1. ¿Es la dirección del estudiante una vivienda temporal? Sí No

2. ¿Esta vivienda temporal es debido a la pérdida de su hogar o dificultad económica? Sí No

3. ¿Está el estudiante esperando que lo coloquen en un “hogar de crianza” (Foster Home)? Sí No

4. Como estudiante, ¿estás viviendo con otra persona que no sea tu padre/madre o guardián legal? Sí No

Si usted contesto “SI” a cualquier de las preguntas arriba, por favor llene el resto de la forma.

Si usted contesto “NO” a todas las preguntas por favor pare aquí.

¿Dónde vive el estudiante actualmente? (Marque la casilla)

Temporalmente vive con otra familia porque nosotros no podemos pagar o encontrar una vivienda económica

Con un adulto que no es su padre o guardián legal, o solo sin un adulto.

En un hotel/motel.

En un vehículo (cualquier tipo; como un RV), o un área de campamento o un edificio abandonado o vivienda precaria

En un refugio/albergue de emergencia/temporal

Otro

Dirección actual:

(O)

Nombre del Motel/ refugio/albergue:

(O)

Nombre del área general donde vive actualmente:

Número de teléfono: Nombre del contacto:

Nombre de los padres / guardianes:

(O del joven no acompañado)

Firma de los padres / guardián: Fecha:

(O del joven no acompañado)

For School Staff Only: Forward questionnaire to Federal Programs, Attn: Homeless Support Coordinator

STUDENT HEALTH HISTORY

TO BE COMPLETED BY PARENT/GUARDIAN

KSD:Health History form: 1/2015

Name of Student:_______________________________ Date of Birth:___________Grade: _____Sex: Male Female

VISION AND HEARING

No Yes Glasses/Contacts Date of last eye exam:_____________________________________

No Yes Hearing aids Date of last hearing exam:__________________________________

MEDICATION No Yes Medication needed at home (list):_______________________________________________

No Yes *Medication needed at school (list):_______________________________________

*Daily Medications Needed at School – Medication at School form required State law requires written permission from a Health Care Provider and parent before any medication can be given at school. (prescription/over-the-counter). A form is available from the school office.

LIFE THREATENING CONDITIONS -WILL require Health Care Provider order & Individual Health Plan (IHP)

Life Threatening Medical Conditions Washington State law mandates that students with life-threatening health conditions, where the condition would “...put the child in danger of death during the school day”, have 1) medication/treatment orders written by a health care provider that is reviewed by the nurse and signed by the parent 2) an Individual Health Plan (IHP)/nursing plan 3) staff trained in place at school before your child can attend school. Forms are available from the school office.

(*note a SEVERE allergy is one that has been diagnosed by a Health Care Provider and medication has been ordered)

No Yes *Severe Allergic reaction to Nuts/other foods(list):____________EpiPen ordered: ___yes ___no

No Yes *Severe Allergic reaction to Bee Stings EpiPen ordered: ___yes ___no

No Yes *Other Severe Allergies-affecting school. Specify:___________ _ Epipen ordered: ___yes ___no

No Yes Severe Asthma: regularly takes medication for asthma, or has been hospitalized within last 5 years for asthmatic condition

No Yes Diabetes Type 1 Type 2

No Yes Other:___________________________________________________________________________

POTENTIALLY LIFE THREATENING CONDITIONS The school nurse may contact the parent/guardian for further information. Healthcare provider orders, IHP and/or nursing care plan may be needed. No Yes Asthma: takes medication only when needed

No Yes Food aversions/sensitivities_________________________________________________________

No Yes Seizure Disorder Type of Seizures and date of last Seizure__________________________

No Yes Heart Condition: __________________________________________________________________

No Yes Behavioral/Emotional Concerns: _____________________________________________________

No Yes Orthopedic Condition: ______________________________________________________________

No Yes Other Health Concerns: _____________________________________________________________

Does your child have any other condition that would affect his/her classroom performance or P.E. activities? No Yes If yes, explain:_____________________________________________________________________

This information is considered confidential. It will be shared with school staff as needed, including the school health alert, during the time your child is enrolled in Kennewick School District in order to ensure the health and safety of your child, unless otherwise requested by you in writing.

Parent/guardian signature ______________________________________________Date___________________

IHP Packet given to Parent

Date ___________

Initial___________

KSD:Health History:2/09

HISTORIA DE SALUD DEL ESTUDIANTE

DEBE SER LLENADO POR LOS PADRES/GUARDIÁN

Nombre del estudiante: _________________________________ FDN: ___________ Grado: ____ Hombre Mujer

VISION Y AUDICION No Si Lentes/Lentes de contacto, fecha del último examen: __________________________ No Si Aparatos de Audición, fecha del último examen: __________________________

MEDICAMENTO No Si Medicamento necesario el hogar (especifique):___________________________________________

No Si *Medicamento necesario en la escuela (especifique): __________________________________

LAS CONDICIONES QUE PONENE EN PELIGRO LA VIDA – Requieren ordenes de parte de un médico y un plan

de salud individualizado (IHP)

(* Una alergia severa significa que ha sido diagnosticado por un médico y el medicamento ha sido ordenado)

No Sí * Reacción alérgica severa a cualquier clase de nuez / alimento: __________ EpiPen ordenado: __ si __ no No Sí * Reacción alérgica severa a la picadura de abejas: EpiPen ordenado: __ si __ no No Sí * Otras alergias severas que afecten la asistencia a clases. Especifique: ______ EpiPen ordenado: __ si __ no No Si Asma severa: Toma medicamento regularmente, ha sido hospitalizado en los últimos 5 años por una

condicione asmática No Sí Diabetes Tipo 1 Tipo 2

No Sí Otros:________________________________________________________________________________

CONDICIONES POTENCIALES QUE PONEN EN PELIGRO LA VIDA - La enfermera de la escuela podrá contactar a los padres/ guardián para más información. Se podría necesitar órdenes del médico, IHP y/o un plan de parte de la enfermera. No Si Asma: Toma medicamento solo cuando es necesario No Sí Convulsiones: Tipo de convulsión y fecha de la última convulsión: ___________________________ No Sí Problemas con el corazón: ________________________________________________________________ No Sí Problemas de Comportamiento/Emocionales: ________________________________________________ No Sí Problemas ortopédicos: __________________________________________________________________ No Sí Otros problemas de salud: ________________________________________________________________

¿Hay alguna otra condición que afectaría el desempeño de su estudiante en el salón de clases o en educación física? No Si Explique si marco que sí: __________________________________________________________________

Esta información se considera confidencial. Será compartida con el personal de la escuela, según sea necesario durante el tiempo que su hijo esté inscrito en el Distrito Escolar de Kennewick, para asegurar la seguridad y la salud de su hijo, a menos que usted solicite por escrito lo contrario.

Firma de los padres/guardián ________________________________________ Fecha: _____________________

*Medicamento diario en la escuela – Se requiere la forma de medicamento en la escuela La ley del Estado requiere que la escuela reciba el permiso por escrito del doctor antes de que se le pueda administrar cualquier tipo de medicamento (con / sin receta) al estudiante en la escuela. La forma está disponible en la oficina de la escuela.

Condiciones médicas que ponen en peligro la vida. La ley del Estado de Washington obliga que los

estudiantes con condiciones médicas que ponen en peligro la vida, cuya condición podría “…poner al niño en peligro de muerte durante el día escolar”, deben tener: 1) ordenes escritas por un doctor, que hayan sido revisadas por la enfermera de la escuela y firmadas por los padres, acerca de los medicamentos y tratamientos. 2) un plan de salud individualizado (IHP) / plan de la enfermera. 3) el personal escolar debe ser entrenado antes que su estudiante asista a la escuela. Las formas están disponibles en la oficina principal de la escuela.

Packet given to Parent

Date ___________

Initial___________

Parents of Children Graduating the year 2017 or 2018,

The vaccine requirements for school attendance will be changing for the 2016/2017 school year.

The new requirements will be two varicella (chicken pox) vaccines for grades K-12. If your child

has not had 2 varicella shots or doctor documentation of chicken pox in the school records, it

will be required at school.

If your child gets their Varicella vaccines, please provide a copy of your child’s vaccine record to

school. Getting a jump start on this would help with this transition.

Thank you,

High School Nurses

Mary Jo Wilkins RN Pam Kirkpatrick RN Jeanne Bakker RN Kathy Perez RN

Kennewick Kamiakin Southridge Legacy & Phoenix

Fax (509) 222-7101 Fax (509) 222-7001 Fax (509) 222-7201 (509) 222-5059 (509) 222-5153

Cer

tific

ate

of Im

mun

izat

ion

Stat

us (C

IS)

DO

H 3

48-0

13 J

anua

ry 2

015

Ple

ase

prin

t. S

ee b

ack

for i

nstru

ctio

ns o

n ho

w to

fill

out t

his

form

or g

et it

prin

ted

from

the

Imm

uniz

atio

n In

form

atio

n S

yste

m.

Chi

ld’s

Las

t Nam

e:

F

irst N

ame:

M

iddl

e In

itial

:

Birt

hdat

e (m

m/d

d/yy

yy):

Sex

:

I g

ive

perm

issi

on to

my

child

’s s

choo

l to

shar

e im

mun

izat

ion

info

rmat

ion

with

the

Imm

uniz

atio

n In

form

atio

n S

yste

m to

hel

p th

e sc

hool

mai

ntai

n m

y ch

ild’s

sch

ool r

ecor

d.

Pare

nt/G

uard

ian

Sign

atur

e R

equi

red

Dat

e

Sym

bols

bel

ow:

R

equi

red

for S

choo

l and

Chi

ld C

are/

Pre

scho

ol

Req

uire

d fo

r Chi

ld C

are/

Pre

scho

ol O

nly

■ R

ecom

men

ded,

but

not

requ

ired

I cer

tify

that

the

info

rmat

ion

prov

ided

on

this

fo

rm is

cor

rect

and

ver

ifiab

le.

Pare

nt/G

uard

ian

Sign

atur

e R

equi

red

Dat

e

Vacc

ine

D

ose

Dat

e M

onth

D

ay

Year

Hep

atiti

s B

(Hep

B)

1

2

3

or H

ep B

- 2

dose

alte

rnat

e sc

hedu

le fo

r tee

ns

1

2

■ R

otav

irus

(RV1

, RV5

)

1

2

3

D

ipht

heria

, Tet

anus

, Per

tuss

is (D

TaP,

DTP

, DT)

1

2

3

4

5

T

etan

us, D

ipht

heria

, Per

tuss

is (T

dap)

1

■ Te

tanu

s, D

ipht

heria

(Td)

1

2

H

aem

op

hilu

s in

flu

en

za

e ty

pe b

(Hib

)

1

2

3

4

■ In

fluen

za (f

lu, m

ost r

ecen

t)

Vacc

ine

Dos

e D

ate

Mon

th

Day

Ye

ar

P

neum

ococ

cal (

PCV,

PPS

V)

1

2

3

4

5

P

olio

(IPV

, OPV

)

1

2

3

4

M

easl

es, M

umps

, Rub

ella

(MM

R)

1

2

V

aric

ella

(chi

cken

pox)

1

2

■ H

epat

itis

A (H

ep A

)

1

2

■ H

uman

Pap

illom

aviru

s (H

PV) –

doe

s no

t pr

int f

rom

the

IIS; w

rite

date

s in

by

hand

1

2

3

■ M

enin

goco

ccal

(MC

V, M

PSV)

1

2

If th

e ch

ild n

amed

on

this

CIS

had

chi

cken

pox

dise

ase

(and

not

the

vacc

ine)

, dis

ease

his

tory

m

ust b

e ve

rifie

d.

Mar

k op

tion

1, 2

, OR

3 b

elow

(see

# 5

on

back

) 1)

C

hick

enpo

x di

seas

e ve

rifie

d by

prin

tout

from

th

e Im

mun

izat

ion

Info

rmat

ion

Syst

em (I

IS)

Mus

t be

mar

ked

by p

rinto

ut (n

ot b

y ha

nd) t

o be

val

id.

2)

Chi

cken

pox

dise

ase

verif

ied

by h

ealth

care

pr

ovid

er (H

CP)

If

you

choo

se th

is b

ox, m

ark

2A O

R 2

B b

elow

. 2A

)

Sig

ned

note

from

HC

P a

ttach

ed O

R

2B)

HC

P s

ign

here

and

prin

t nam

e be

low

: Li

cens

ed h

ealth

care

pro

vide

r sig

natu

re

D

ate

(MD

, DO

, ND

, PA

, AR

NP)

Prin

ted

Nam

e:

3)

Chi

cken

pox

dise

ase

verif

ied

by s

choo

l sta

ff fr

om th

e Im

mun

izat

ion

Info

rmat

ion

Syst

em

If th

e ch

ild c

an s

how

imm

unity

by

bloo

d te

st

(tite

r) a

nd h

asn’

t had

the

vacc

ine,

ask

you

r HC

P to

fill

in th

is b

ox.

Doc

umen

tatio

n of

Dis

ease

Imm

unity

I c

ertif

y th

at th

e ch

ild n

amed

on

this

CIS

has

la

bora

tory

evi

denc

e of

imm

unity

(tite

r) to

the

dise

ases

mar

ked.

Si

gned

lab

repo

rt(s

) MU

ST a

lso

be a

ttach

ed.

Dip

hthe

ria

Hep

atiti

s A

Hep

atiti

s B

Hib

Mea

sles

Mum

ps

Pol

io

Rub

ella

Teta

nus

Var

icel

la

Oth

er:

____

____

____

___

____

____

____

___

Lice

nsed

hea

lthca

re p

rovi

der s

igna

ture

Dat

e (M

D, D

O, N

D, P

A, A

RN

P)

Pr

inte

d N

ame:

Offi

ce U

se O

nly:

R

evie

wed

by:

Dat

e:

Sig

ned

Cer

t. of

Exe

mpt

ion

on fi

le?

Yes

N

o

EXAM

PLE

Inst

ruct

ions

for c

ompl

etin

g th

e C

ertif

icat

e of

Imm

uniz

atio

n St

atus

(CIS

): pr

intin

g it

from

the

Imm

uniz

atio

n In

form

atio

n Sy

stem

(IIS

) or f

illin

g it

in b

y ha

nd.

#1

To

prin

t w

ith

in

form

ati

on

fille

d i

n:

Firs

t, as

k if

your

hea

lthca

re p

rovi

der’s

offi

ce p

uts

vacc

inat

ion

hist

ory

into

the

WA

Imm

uniz

atio

n In

form

atio

n S

yste

m (W

ashi

ngto

n’s

stat

ewid

e da

taba

se).

If th

ey d

o, a

sk th

em to

prin

t the

CIS

from

the

IIS a

nd y

our c

hild

’s in

form

atio

n w

ill fil

l in

auto

mat

ical

ly.

Be

sure

to re

view

all

the

info

rmat

ion,

sig

n an

d da

te th

e C

IS, a

nd re

turn

it to

sch

ool o

r chi

ld c

are.

If y

our p

rovi

der’s

offi

ce d

oes

not u

se th

e IIS

, ask

for a

co

py o

f you

r chi

ld’s

vac

cine

reco

rd s

o yo

u ca

n fil

l it i

n by

han

d us

ing

step

s #2

-7 (b

elow

):

#2

To

fill in

by h

an

d:

Prin

t you

r chi

ld’s

nam

e, b

irthd

ate,

sex

, and

you

r ow

n na

me

in th

e to

p bo

x.

#3

Writ

e ea

ch v

acci

ne y

our c

hild

rece

ived

und

er th

e co

rrec

t dis

ease

. Writ

e th

e va

ccin

e ty

pe u

nder

the

“Vac

cine

” col

umn

and

the

date

eac

h do

se w

as re

ceiv

ed in

the

“Mon

th,”

“Day

,” an

d “Y

ear”

col

umns

(as

mm

/dd/

yyyy

). Fo

r exa

mpl

e, if

DTa

P w

as re

ceiv

ed J

an 1

2, M

arch

20,

Jun

e 1,

’11,

fill

in a

s sh

own

here

#4

If y

our c

hild

rece

ives

a c

ombi

natio

n va

ccin

e (o

ne s

hot t

hat p

rote

cts

agai

nst s

ever

al d

isea

ses)

, use

the

Ref

eren

ce G

uide

bel

ow to

reco

rd e

ach

vacc

ine

corr

ectly

. For

exa

mpl

e, re

cord

Ped

iarix

und

er D

ipht

heria

, Te

tanu

s, P

ertu

ssis

as

DTa

P, H

epat

itis

B as

Hep

B, a

nd P

olio

as

IPV.

#

5 If

you

r chi

ld h

ad c

hick

enpo

x (v

aric

ella

) dis

ease

and

not

the

vacc

ine,

use

onl

y on

e of

thes

e th

ree

optio

ns to

reco

rd th

is o

n th

e C

IS:

1)

If y

our c

hild

’s C

IS is

prin

ted

dire

ctly

from

the

IIS (b

y yo

ur h

ealth

care

pro

vide

r or s

choo

l), a

nd d

isea

se v

erifi

catio

n is

foun

d, b

ox 1

is a

utom

atic

ally

m

arke

d. T

o be

val

id, t

his

box

mus

t be

mar

ked

by th

e IIS

prin

tout

(not

by

hand

). 2

) I

f you

r hea

lthca

re p

rovi

der c

an v

erify

that

you

r chi

ld h

ad c

hick

enpo

x, m

ark

box

2. T

hen

mar

k ei

ther

2A

to a

ttach

a s

igne

d no

te fr

om y

our p

rovi

der,

or

2B if

you

r pro

vide

r sig

ns a

nd d

ates

in th

e sp

ace

prov

ided

. Be

sure

you

r pro

vide

r’s fu

ll na

me

is a

lso

prin

ted.

3

) I

f sch

ool s

taff

acce

ss th

e IIS

and

see

ver

ifica

tion

that

you

r chi

ld h

ad c

hick

enpo

x, th

ey w

ill m

ark

box

3.

#6

Doc

umen

tatio

n of

Dis

ease

Imm

unity

: If y

our c

hild

can

sho

w im

mun

ity b

y bl

ood

test

(tite

r) a

nd h

as n

ot h

ad th

e va

ccin

e, h

ave

your

hea

lthca

re p

rovi

der f

ill in

th

is b

ox. A

sk y

our p

rovi

der t

o m

ark

the

dise

ase(

s), s

ign,

dat

e, p

rint h

is o

r her

nam

e in

the

spac

e pr

ovid

ed, a

nd a

ttach

sig

ned

lab

repo

rts.

#

7 B

e su

re to

sig

n an

d da

te th

e C

IS, a

nd re

turn

to th

e sc

hool

or c

hild

car

e.

Va

ccin

e T

rad

e N

am

es i

n a

lph

ab

etic

al

ord

er

(F

or

up

dat

ed l

ists

, vis

it h

ttp

s://

fort

ress

.wa.

go

v/d

oh

/cp

ir/i

web

/ho

mep

age/

com

ple

teli

sto

fvac

cin

enam

es.p

df)

Tra

de

Na

me

Vacc

ine

Tra

de

Na

me

Vacc

ine

Tra

de

Na

me

Vacc

ine

Tra

de

Na

me

Vacc

ine

Tra

de

Na

me

Vacc

ine

Act

HIB

H

ib

Flu

Lav

al

Flu

Ip

ol

IPV

P

edvax

HIB

H

ib

Tw

inri

x (

Tw

nrx

) H

ep A

+ H

ep B

Ad

acel

T

dap

F

luM

ist

Flu

In

fan

rix

DT

aP

Pen

tace

l (P

ntc

l)

DT

aP +

Hib

+ I

PV

V

aqta

H

ep A

Afl

uri

a F

lu

Flu

vir

in

Flu

K

inri

x (

Kn

rx)

DT

aP +

IP

V

Pn

eum

ovax

P

PS

V o

r P

PV

23

Var

ivax

V

aric

ella

Boost

rix

Td

ap

Flu

zon

e F

lu

Men

actr

a M

CV

or

MC

V4

Pre

vn

ar

PC

V o

r P

CV

7 o

r P

CV

13

Cer

var

ix

HP

V2

G

ard

asil

H

PV

4

Men

Hib

rix

(Mnhb

rx)

Men

ingoco

ccal

C/Y

- H

IB-P

RP

Pro

Qu

ad (

PrQ

d)

MM

R +

Var

icel

la

Dap

tace

l D

TaP

H

avri

x

Hep

A

Men

om

un

e M

PS

V o

r M

PS

V4

Rec

om

biv

ax H

B

Hep

B

En

ger

ix-B

H

ep B

H

iber

ix

Hib

M

enveo

M

enin

goco

ccal

R

ota

rix

Rota

vir

us

(RV

1)

Flu

arix

F

lu

Hib

TIT

ER

H

ib

Ped

iari

x (

Pd

rx)

DT

aP +

Hep

B +

IP

V

Rota

Teq

R

ota

vir

us

(RV

5)

Va

ccin

e A

bb

rev

iati

on

s in

alp

ha

bet

ica

l o

rder

(

Fo

r up

dat

ed l

ists

, vis

it h

ttp

s://

fort

ress

.wa.

go

v/d

oh

/cp

ir/i

web

/ho

mep

age/

com

ple

teli

sto

fvac

cin

enam

es.p

df)

A

bb

revia

tio

ns

Fu

ll V

acc

ine N

am

e

Ab

brevia

tio

ns

Fu

ll V

acc

ine N

am

e

Ab

brevia

tio

ns

Fu

ll V

acc

ine N

am

e

Ab

brevia

tio

ns

Fu

ll V

acc

ine N

am

e

DT

D

iph

ther

ia, T

etan

us

Hep

A (

HA

V)

Hep

B (

HB

V)

Hep

atit

is A

H

epat

itis

B

MP

SV

or

MP

SV

4

Men

ingoco

ccal

P

oly

sacc

har

ide

Vac

cin

e R

ota

(R

V1

or

RV

5)

Rota

vir

us

DT

aP

Dip

hth

eria

, T

etan

us,

acel

lula

r P

ertu

ssis

H

ib

Haem

ophilus

influen

zae

typ

e b

M

MR

/ M

MR

V

Mea

sles

, M

um

ps,

Rub

ella

/

wit

h V

aric

ella

T

d

Tet

anu

s, D

iphth

eria

DT

P

Dip

hth

eria

, T

etan

us,

P

ertu

ssis

H

PV

H

um

an P

apil

lom

avir

us

OP

V

Ora

l P

oli

ovir

us

Vcc

ine

Td

ap

Tet

anu

s, D

iphth

eria

, ac

ellu

lar

P

ertu

ssis

Flu

(IIV

or

LA

IV)

Infl

uen

za

IPV

In

acti

vat

ed P

oli

ovir

us

Vac

cin

e

PC

V o

r P

CV

7 o

r

PC

V13

Pn

eum

oco

ccal

Conju

gat

e

Vac

cin

e T

IG

Tet

anu

s im

mu

ne

glo

bu

lin

HB

IG

Hep

atit

is B

Im

mu

ne

Glo

bu

lin

MC

V o

r M

CV

4

Men

ingoco

ccal

C

on

jugat

e V

acci

ne

PP

SV

or

PP

V2

3

Pn

eum

oco

ccal

Poly

sacc

har

ide

Vac

cin

e V

AR

or

VZ

V

Var

icel

la

I

f you

hav

e a

disa

bilit

y an

d ne

ed th

is d

ocum

ent i

n an

othe

r for

mat

, ple

ase

call

1-80

0-52

5-01

27 (T

DD

/TTY

cal

l 711

).

D

OH

348

-013

Jan

uary

201

5

Vacc

ine

Dos

e D

ate

Mon

th

Day

Ye

ar

D

ipht

heria

, Tet

anus

, Per

tuss

is (D

TaP,

DTP

, DT)

D

TaP

1

01

12

2011

D

TaP

2

03

20

2011

D

TaP

3

06

01

2011

WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by parents, guardians, or

others) for communication in the student's place of residence.

06/2014

Dave Bond, Superintendent

Dr. Chuck Lybeck, Associate Superintendent, Curriculum

Greg Fancher, Assistant Superintendent, Elementary Education

Ron Williamson, Assistant Superintendent, Secondary Education

Doug Christensen, Assistant Superintendent, Human Resources

Ron Cone, Executive Director, Information Technology

Vic Roberts, Executive Director, Business Operations

Robyn Chastain, Director, Communications and Public Relations

Home Language Survey

Student Last Name: First Name: Middle Name: Date:

Birth Date: Gender: Grade: School:

Address: Telephone Number:

Form Completed by:

Parent/Guardian Name Relationship to Student

Parent/Guardian Signature

If available, in what language would you prefer to receive communication from the school?

Did your child receive English language development support through the Transitional

Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__

1. In what country was your child born?

____________________

2. What language did your child first learn to speak?*

____________________

3. What language does YOUR CHILD use the most at home?* ____________________

4. What language(s) do parent/guardians use the most when you speak

to your child?

____________________

____________________

5. Has your child ever received formal education* outside of the United

States? (Kindergarten – 12th grade)

_____Yes _____No

”Formal education” does not include refugee camps or other unaccredited

programs for children.

If yes, in what language(s)

was instruction given?

____________________

For how many months? ___

6. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_____________________

Month Day Year

7. Do grandparent(s) or parent(s) have a Native American tribal

affiliation?

_____Yes _____No

8. Did you move to this area for the purpose of finding work in

agriculture or agricultural related work (such as farm equipment

operation, food processing)?

_____Yes _____No

WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by parents, guardians, or

others) for communication in the student's place of residence.

06/2014

Dave Bond, Superintendent

Dr. Chuck Lybeck, Associate Superintendent, Curriculum

Greg Fancher, Assistant Superintendent, Elementary Education

Ron Williamson, Assistant Superintendent, Secondary Education

Doug Christensen, Assistant Superintendent, Human Resources

Ron Cone, Executive Director, Information Technology

Vic Roberts, Executive Director, Business Operations

Robyn Chastain, Director, Communications and Public Relations

Home Language Survey Encuesta del Idioma en el Hogar

Apellido del alumno: Primer nombre: Segundo nombre:

Fecha:

Fecha de nacimiento: Sexo: Grado: Escuela:

Dirección: Teléfono:

Este formulario fue completado por:

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

Firma del padre/madre/tutor:

Si está disponible, ¿en qué idioma desea recibir información de la escuela?

¿Su hijo recibió apoyo para el aprendizaje del idioma inglés a través del Programa Estatal de

Educación Bilingüe de Transición en la última escuela a la que asistió? Sí__ No__ No sé__

1. ¿En qué país nació su hijo?

___________________

2. ¿Qué idioma aprendió su hijo primero?*

___________________

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

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

hijo?

___________________

___________________

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

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

En caso afirmativo, ¿en qué

idioma se le dio la

instrucción? ____________

¿Por cuántos meses? _____

6. ¿Cuándo asistió su hijo a la escuela en los Estados Unidos por

primera vez? (Kínder a 12.o grado)

__________________________

Mes Día Año

7. ¿Se mudó usted a esta área con el propósito de buscar trabajo en la

agricultura o trabajo relacionado con la agricultura (por ejemplo:

operación de equipo de siembra/cosecha, proceso de empaque)?

_____Sí _____No

KENNEWICK HIGH SCHOOL

500 South Dayton Street Kennewick, WA 99336 Phone: (509)222-7100

BEHAVIOR EXPECTATIONS

1. Kennewick High has an attendance policy which expects students to attend all classes regularly. At 12 absences, excused or unexcused, students will lose credit in that class.

2. Kennewick, School District strictly forbids alcohol and other drugs on any of its property. This includes all schools, parking lots, and athletic areas. There is a district policy which dictates student consequences for violation of these policies.

3. We have a no tolerance policy toward weapons on school district property. This includes

pocket knives or items which may be used as a weapon. Students will be expelled immediately for possession and/or use of a weapon.

Refer to the student handbook for further expectations. Ignorance is no excuse for not following expectations. I have been advised of school and district expectations concerning behavior, attendance, alcohol and other drugs, and weapons.

______________________________________ _________________________ Student Signature Date

______________________________________ _________________________ Student Name (Printed) Grade Level

______________________________________ _________________________ Counselor Signature Date

Kennewick High Bell Schedules

REGULAR SCHEDULE 2 HOUR LATE START

0 HOUR 6:45 – 7:39 NO “0” HOUR 1ST HR. 7:45 – 8:39 1ST HR. 9:45 – 10:19 2ND HR. 8:45 – 9:39 2ND HR. 10:25 – 10:59 3RD HR. 9:45 – 10:42 LUNCH 10:59 – 11:38 LUNCH 10:42 – 11:21 3RD HR. 11:43 – 12:20 4TH HR. 11:26 – 12:20 4TH HR. 12:26 – 1:00 5TH HR. 12:26 – 1:20 5TH HR. 1:06 – 1:40 6TH HR. 1:26 – 2:20 6TH HR. 1:46 – 2:20 7TH HR. 2:30 – 3:25 7TH HR. 2:30 – 3:25 QUEST ADVISORY EARLY RELEASE – 1:10 FINALS 0 HR. 6:45 – 7:39 0 HR. 6:45 – 7:39 1ST HR. 7:45 – 8:31 1ST HR. 7:45 – 8:28 2ND HR. 8:37 – 9:23 2ND HR. 8:34 – 9:17 QUEST 9:29 – 10:14 3RD HR. 9:23 – 10:08 3rd HR. 10:20 – 11:08 LUNCH 10:08 – 10:44 LUNCH 11:08 – 11:45 4HR. 10:49 – 11:32 4th HR. 11:50 – 12:36 5HR. 11:38 – 12:21 5TH HR. 12:42 – 1:28 6TH HR. 12:27 – 1:10 6TH HR. 1:34 – 2:20 7th HR. 2:30 – 3:25 10:30 EARLY RELEASE PEP ASSEMBLY SCHEDULE 0 HR. 6:45 – 7:39 0 HR. 6:45 – 7:39 1ST HR. 7:45 – 8:07 1ST HR. 7:45 – 8:33 2ND HR. 8:13 – 8:35 2ND HR. 8:39 – 9:27 3RD HR. 8:41 – 9:06 ASSEMBLY 9:35 – 10:03 4TH HR. 9:12 – 9:34 3RD HR. 10:11– 11:02 5TH HR. 9:40 – 10:02 LUNCH 11:02 – 11:39 6TH HR. 10:08 – 10:30 4TH HR. 11:44– 12:32 5TH HR. 12:38 – 1:26 6TH HR. 1:32 – 2:20 7TH HR. 2:30 – 3:25

KENNEWICK HIGH SCHOOL LEGAL GUARDIANSHIP VERIFICATION REQUIREMENTS

Students entering/attending Kennewick High School must present at the time of registration written proof that they reside with their custodial parent or legal (court mandated) guardian. This proof must be presented before the student is permitted to make an appointment for registration. This Kennewick School District Legal Office has prepared a packet of 3 forms that must be filled out and notarized. We will provide these forms for you if needed. Please follow the guidelines below:

1) Students 18 or over and living on their own must present written proof of residency (rental agreement, recent phone or utility bill, etc.).

2) Students 18 or over living with a custodial parent or legal (court mandated) guardian must present written proof of their parent’s or guardian’s permanent residency (rental agreement, recent phone or utility bill, etc.).

3) Students applying for admission to Kennewick High who do not reside with

their parent(s) must fill out the KSD Forms that are required to be notarized.

RCW 28a.225.330

Enrolling students from other districts — Requests for information and permanent records — Withheld transcripts — Immunity from liability — Notification to teachers and security personnel — Rules. (1) When enrolling a student who has attended school in another school district, the school enrolling the student may request the parent and the student to briefly indicate in writing whether or not the student has: (a) Any history of placement in special educational programs; (b) Any past, current, or pending disciplinary action; (c) Any history of violent behavior, or behavior listed in RCW 13.04.155; (d) Any unpaid fines or fees imposed by other schools; and (e) Any health conditions affecting the student's educational needs. (2) The school enrolling the student shall request the school the student previously attended to send the student's permanent record including records of disciplinary action, history of violent behavior or behavior listed in RCW 13.04.155, attendance, immunization records, and academic performance. If the student has not paid a fine or fee under RCW 28A.635.060, or tuition, fees, or fines at approved private schools the school may withhold the student's official transcript, but shall transmit information about the student's academic performance, special placement, immunization records, records of disciplinary action, and history of violent behavior or behavior listed in RCW 13.04.155. If the official transcript is not sent due to unpaid tuition, fees, or fines, the enrolling school shall notify both the student and parent or guardian that the official transcript will not be sent until the obligation is met, and failure to have an official transcript may result in exclusion from extracurricular activities or failure to graduate. (3) Upon request, school districts shall furnish a set of unofficial educational records to a parent or guardian of a student who is transferring out of state and who meets the definition of a child of a military family in transition under Article II of RCW 28A.705.010. School districts may charge the parent or guardian the actual cost of providing the copies of the records. (4) If information is requested under subsection (2) of this section, the information shall be transmitted within two school days after receiving the request and the records shall be sent as soon as possible. The records of a student who meets the definition of a child of a military family in transition under Article II of RCW 28A.705.010 shall be sent within ten days after receiving the request. Any school district or district employee who releases the information in compliance with this section is immune from civil liability for damages unless it is shown that the school district employee acted with gross negligence or in bad faith. The professional educator standards board shall provide by rule for the discipline under chapter 28A.410 RCW of a school principal or other chief administrator of a public school building who fails to make a good faith effort to assure compliance with this subsection. (5) Any school district or district employee who releases the information in compliance with federal and state law is immune from civil liability for damages unless it is shown that the school district or district employee acted with gross negligence or in bad faith. (6) When a school receives information under this section or RCW 13.40.215 that a student has a history of disciplinary actions, criminal or violent behavior, or other behavior that indicates the student could be a threat to the safety of educational staff or other students, the school shall provide this information to the student's teachers and security personnel. (7) A school may not prevent a student who is dependent pursuant to chapter 13.34 RCW from enrolling if there is incomplete information as enumerated in subsection (1) of this section during the ten business days that the department of social and health services has to obtain that information under RCW 74.13.631. In addition, upon enrollment of a student who is dependent pursuant to chapter 13.34 RCW, the school district must make reasonable efforts to obtain and assess that child's educational history in order to meet the child's unique needs within two business days.

In order to preserve an educational environment conducive to teaching and learning, our staff looked at ways to limit the use of electronic devices without completely eliminating them from campus. We understand that there are times when parents need to communicate with their students and we undestand that electronic devices can be used at times as a tool to enhance education. We tried to balance this need with the needs of the teacher to not have interruptions and distractions that impede a student’s ability to learn.

Electronic Policy

Electronic devices cannot be used at any time for illegal activities, violation of school rules, or to violate the privacy of others. Violations on this level will be treated as a disciplinary issue. To preserve an appropriate learning environment, video games, MP3, Ipods, cell phones and other electronic devices may not be used in any location during class time (classrooms, hallways, bathrooms, etc.) and must be turned off. Electronics will be permitted between classes, lunch, before and after school. Exceptions would be if used as a classroom tool as written in to a teacher’s classroom expectation approved by the principal, or emergency situations with teacher approval. Please note that if you need to contact your student during school hours, you can always call the attendance office at 222-5140 or 222-5207 and we will get a message to your student. This policy has been set up with your studen’t success in mind. We value our teacher’s time and the time that students are in class, and we are making every effort to make sure that when they are in class, there are the least number of of distractions and fewer reasons to leave class. If you have any questions about this policy, please call the main office number at 222-7100.

KENNEWICK HIGH SCHOOL

500 South Dayton

Kennewick, WA 99336-5674

(509) 222-7100

Fax (509)222-7101

LIONS -s>*