Kindergarten Enrollment 2020-2021 Overview · Kindergarten Enrollment 2020-2021 Overview Welcome to School Year 2020-2021 and the Class of 2033! The information below and the friendly

Kindergarten Enrollment 2020-2021 Overview

Welcome to School Year 2020-2021 and the Class of 2033!

The information below and the friendly staff at your child’s school will help walk you thru the kindergarten registration process so that everything is ready for the first day of school in September. This packet is a combination of information and required forms to register your child. The chart below is provided as an organizer and to help you know what you need to return to your child’s school.

Contents Explanation To Do Kindergarten Registration Letter

General information about registration. Info only

Kindergarten Enrollment Overview An organizer to help you know what forms that need to be returned. Info only

Welcome to Kindergarten Booklet Information for parents regarding their child and school. Info only

Early Learning Survey This form provides information about your child’s early learning experiences that will help plan for a path to success in kindergarten and beyond.

Return to School

New Student Registration This is the official district enrollment form. Information on this form will follow your child through high school; you will have an opportunity each year to update this information.

Return to School

Child’s Certified Birth Certificate

Birth certificates for children born in Washington State may be obtained at the Whatcom County Health Department Office 360-676-6724 or requested online at http://www.co.whatcom.wa.us/health/ Out of state birth certificates may be ordered from https://www.vitalchek.com/

Required Bring with you

District Nurse Letter Student health, immunization, medications and health services at school Info only

Vaccine Requirements Vaccinations required for entrance into Kindergarten. Info only

Certificate of Immunization Status

This documents what vaccines your child has received and when. (Ask your medical provider if they can print your child’s immunization records in this format for you.)

Return to School

Health History This form provides the school with important medical information about your child. Return to School

Ethnicity and Race Information on this form is required by the federal and state governments. If you do not provide data, we are required to select ethnicity and race data for you.

Return to School

Home Language Survey This form, required by the state, documents languages spoken in your home. Return to School

Title VI 506 Certification Native American heritage student certificate Return if applicable

Student Housing The information helps provide services to families who may need extra supports Return to School

http://www.co.whatcom.wa.us/health/

https://www.vitalchek.com/

Tel: 360.383.2000 Fax: 360.383.2009

PO Box 95 • 4956 Deming Rd. Deming, WA 98244-0095

www.mtbaker.wednet.edu

March 4, 2020

Dear Parents of Prospective Kindergarten Students:

Registration of all kindergartners in the Mount Baker School District will take place as listed below at each school. Besides the registration process in the office there is also time to visit and explore. Please come at a time most convenient for you and make sure to stop in both places before leaving. Further information regarding schedules and orientation times will be mailed home towards the middle of August. The registration dates and time are as follows:

Kendall Elementary 360-383-2055

Thursday, April 16, 2020 4 – 7 pm

Acme Elementary 360-383-2045


Harmony Elementary 360-383-2050


If this date or time is not convenient for you, please call your school secretary to make other arrangements.

Entering kindergartners must be five years old on or before August 31, 2020. All children entering kindergarten are required to furnish birth certificates and immunization records at the time of enrollment.

Enclosed with this letter you will find a Kindergarten Overview that gives a description of the forms and information contained in this packet.

It is important that you register your prospective kindergarten student at this time. This permits us to have adequate supplies and to give everyone a good start in the 2020-2021 school year. If you move or decide not to have your child start kindergarten in the registered school, we request you notify the office as soon as possible so we can make adjustments to class placements. And, if you are aware of other kindergarten age children in your area, please ask their parents to contact the school. Please bring with you all the completed forms on registration day and your child’s Birth Certificate, Immunization Records and most importantly, your Kindergartner! We look forward to seeing you Mount Baker School District

Board of Directors Karen Reich, President Brian Kelly Russ Pfeiffer-Hoyt Annie Elder Kelly Zender

District Administration Superintendent Mary Sewright 360.383.2000

Director of Finance & Operations Ben Thomas 360.383.2005

Director of Curriculum

Bridget Rossman 360.383.2013

Director of Special Programs Ian Linterman 360.383.2012

Families: Please return this form to the school secretary with your Kindergarten Registration Packet. School Secretary: Please forward to Special Programs Office.

(Rev. 02/2015)

Early Learning Survey 2020-2021 Early learning begins before your child is born and continues into the early elementary years.

This survey will tell us about your child’s early learning experiences and resources that supported you as a family. It will help us plan with our community partners for a path to success in kindergarten and beyond!

Child’s Name ________________________________ Elementary School _____________________

1. In a typical week, how many hours does your child spend in early learning programs or in the care of others?

# Hours per week Name of preschool and/or child care provider

Preschool

Head Start or ECEAP

Licensed child care center / home

Child care arrangement with FFN: (family, friends or neighbors)

2. What other early learning experiences has your child participated in? (Check all that apply.) Kaleidoscope Play & Learn Library Story Time Music/Art/Dance Swim/Sports Other (please list): _________________________________________________________

3. What community resources supported you as a family during your child’s early learning years?

Pediatrician/Dr. visits Public Library Family/Friends/Neighbors Other (please list): ___________________________________________________________

4. Do you have younger children at home? Please list the names and birth dates of children in your

home who aren’t yet old enough to go to kindergarten:

Name ________________________________ Birth Date (including year born) ___________________

Name ________________________________ Birth Date (including year born) ___________________

Thank you!

Updated 02/2016

Dear Kindergarten Parent:

State law requires that before attending a licensed child care or school, children must get immunized against

certain diseases that vaccines can prevent. Parents and guardians meet this requirement by filling out and turning

in a Certificate of Immunization Status, showing their child has the required vaccinations as per the required

guidelines.

Beginning July 22, 2011, parents or guardians who wants to exempt their child from immunization requirements

must fill out and return a Certificate of Exemption form to their school or child care. To find more information and

the form go to: http://www.doh.wa.gov/YouandYourFamily/Immunization

The 2011 Washington State Legislature passed a law that changes the process for getting an immunization

exemption. All other parts of the law remain the same. The new law says that:

For Personal or Philosophical Exemption: Parents or guardians who want to exempt their child from school

or child care immunization requirements for personal reasons, must first talk to a licensed health care

provider about the benefits and risks of immunization. The provider must sign the Certificate of Exemption

verifying that the parent got this information.

A Provider may also write and sign a letter that verifies the same information instead of signing the form.

Schools and child care can accept copies of the exemption form and provider letter.

Providers signing the form in good faith won’t face legal liability.

Skipping vaccinations or missing vaccine doses makes it more likely that your child can catch and spread serious

illnesses like whooping cough and measles, which vaccines can prevent. Getting kids all their recommended

immunization protects them, their classmates, friends and families from preventable disease. Kids who don’t get

fully immunized may have to stay home from school, preschool or child care if a disease outbreak occurs.

Medication Administration Policy: Washington State law defines how children with a life-threatening condition will

be served. A life-threatening condition is defined as one ”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.” If your child has a life

threatening condition (e.g., an allergy requiring an EpiPen, diabetes, or severe asthma, etc.) both the Medication

Authorization Order for treatment/medication and the medication must be received in the health room before your

child can begin school. State law requires that this Medication Authorization Order shall be completed prior to

attendance at school.

Every effort should be made for medication to be given outside of school hours, but if it is necessary for your child

to receive medication or treatment during the school day, a medication/treatment order form needs to be

completed and signed by your licensed health care provider and the parent/guardian. These forms are available at

your child’s school and can be picked up any time during the school day. The forms are also available on the Mount

Baker website under Health Services. No medication/treatment can be given at school without this form in place.

We welcome all questions about student health and urge you to contact the District Nurse, Susan Windnagel, at

(360) 383-2000 ext. 4607 or [email protected]

Please notify your school throughout the year regarding updates in your contact information.

Sincerely,

Mount Baker School Staff

http://www.doh.wa.gov/YouandYourFamily/Immunization

mailto:[email protected]

Revised 03-29-2019

MOUNT BAKER SCHOOL DISTRICT NEW STUDENT REGISTRATION FORM

For School Use Only: Entry Date: ___________________ Bus#: ________________ Bus Times: ___________________________

District ID: ____________________ Teacher: ____________________________________________________

Today’s Date: ______________________________ School: _________________________________ Entering Grade: __________

Student Legal Name (Proof required): ____________________________ ______________ ______________________________ First Middle Last Date of Birth: ____________________ Age: _________ Gender: F M Gender Identity: F M

Student Cell Phone: _________________________________________________

Yes No Has your child ever attended a Mt. Baker School? School: ____________________________________________

Main Household Parent/Guardian #1 – with whom child resides

Legal Name: __________________________________________________________ Relationship: ___________________________ Yes No Are you a foster parent for this student?

Home Phone: _______________________________________________ Confidential

Cell Phone: _________________________________________________ Text

Work Phone: _______________________________________________ Please check the best way to reach you.

Email Address: ______________________________________________

Physical Address: _____________________________________________________________________________________________

Mailing Address: ______________________________________________________________________________________________

Name and Address of Employer: __________________________________________________________________________________

Main Household Parent/Guardian #2 – with whom child resides

Legal Name: __________________________________________________________ Relationship: ___________________________

Cell Phone: _________________________________________________ Text


Email Address: ______________________________________________


Household #2 Parent/Guardian #3 – living elsewhere


Home Phone: _______________________________________________ Confidential

Cell Phone: _________________________________________________ Text


Email Address: ______________________________________________

Physical Address: _____________________________________________________________________________________________

Mailing Address: ______________________________________________________________________________________________


Household Parent/Guardian #4 – living elsewhere


Cell Phone: _________________________________________________ Text


Email Address: ______________________________________________

Name and Address of Employer: __________________________________________________________________________________ Yes No Is there a joint custody agreement, parenting plan or restraining order in effect?

Note: If yes, copy of agreement/order must be provided in order for the school district to enforce. Yes No Is this parent/guardian to receive forms and report cards?

Revised 03-29-2019

Reason For This Transfer: Yes No Does your child have a juvenile record? If yes, is your child currently on probation? Yes No

If yes, who is the probation officer assigned? _________________________________________________________ Yes No Is your child presently on suspension from another school? Yes No Is your child ever been suspended or expelled from school?

If yes, list when suspension occurred, number of days and reason: ________________________________________

______________________________________________________________________________________________

EMERGENCY MEDICAL AUTHORIZATION/PERMISSION TO TREAT: If below name parent/guardian cannot be reached at the time of emergency and if immediate observation or treatment is urgent in the judgment of school authorities, do you authorize and direct the school authorities to take or send the child (properly accompanied) to the hospital or doctor most accessible. Yes No

Yes No Does your child have any life threatening illness or allergies?

Legal Parent/Guardian Signature: _______________________________________________________ Date: ___________________

Student Release Authorization: When injury, illness or other non-emergency situation occur involving your child, we want to be able to quickly reach families or other responsible adults. In the event we cannot reach a parent/guardian, please list 3 local persons you trust who are available during the day to provide care and transportation for your child if needed.

1. Name:________________________________________________________ Relationship to student: _______________________

Home Phone: _________________________ Work Phone: _______________________ Cell Phone: ________________________

Address: ___________________________________________________________________________________________________



Address: ___________________________________________________________________________________________________



Address: ___________________________________________________________________________________________________

Other Children In The Family: Legal First/Last Name Age Grade

_____________________________________________________________________ _____________ ______________

_____________________________________________________________________ _____________ ______________

_____________________________________________________________________ _____________ ______________

_____________________________________________________________________ _____________ ______________

Do You or Your Spouse Have Any of These Military Affiliations? US Armed Forces Active Duty National Guard Member More than one member of Armed Forces/National Guard No affiliation U.S. Armed Forces Reserves Don’t want to answer

Important Information:

District/School Previously Attended: _______________________________________________________________________________

Phone/Fax: ______________________________________________________________________________State: ________________

Teacher/Advisor: _______________________________________________________________________________________________ Yes No Has your child ever received Special Education Services? Yes No Has your child ever received accommodations through a 504 Plan? Yes No Has your child ever participated or identified as gifted/highly capable?

If yes, last school district services/accommodations were provided: ________________________________________

Yes No Has your child ever been retained? What grade? _________________

Verification of Information: The statements as answered by me are true and accurate to the best of my knowledge. I understand the falsification of any statement/records regarding my child may result in immediate school exclusion of my child from attendance in the Mount Baker School District.

Legal Parent/Guardian Signature: _______________________________________________________ Date: ____________________

If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). DOH 348-295 December 2019

Parents - Are Your Kids Ready for School?

Required Immunizations for School Year 2020-2021

Hepatitis B DTaP/Tdap (Diphtheria, Tetanus,

Pertussis) Vaccine doses required may

be fewer than listed

Polio Vaccine doses required

may be fewer than listed

MMR (Measles, Mumps,

Rubella)

Varicella (Chickenpox)

Kindergarten through

6th Grade

3 doses within the correct timeframes





OR Healthcare provider verified

child had disease

7th Grade through

12th Grade


5 doses DTaP

AND 1 dose Tdap,

all within the correct timeframes




OR Healthcare provider verified

child had disease (Exceptions are allowed for

certain students)

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

you have questions about school immunization requirements.

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

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

http://www.immunize.org/cdc/schedules/

▲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: [email protected] 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.

Updated 2/2016

Mount Baker School District Health History This questionnaire is designed to aid school staff in anticipating any health concerns that might affect your child’s learning

Student’s Name ________ _____ First Middle Last

Grade: _______________ Sex: _____________ Date of Birth: _______________________

MEDICAL Does your child have a doctor or nurse practitioner? No Yes Doctor/nurse practitioner name: __________________________________________________ phone number __________________ In the past 12 months, did you have problems obtaining medical care for your child? No Yes

DENTAL Does your child have a dentist? No Yes Dentist’s Name: _____________________________ phone number _____________ Did your child receive a dental exam in the last 12 months? No Don’t Know Yes Describe the condition of your child’s teeth? Good Fair Poor Don’t know In the past 12 months, did you have problems obtaining dental care for your child? No Yes

INSURANCE Does your child have medical insurance coverage? No Don’t Know Yes Name of provider______________________ Does your child have dental insurance coverage? No Don’t Know Yes Name of provider______________________ Does Medicaid insure him/her? (Healthy Options, DSHS, “medical coupon”) No Don’t Know Yes

MEDICAL HISTORY Have you ever been told by a physician or health care professional that your child has:

Asthma Seizure disorder Bleeding disorder ADD/ADHD Diabetes Bone/muscle disease Skin condition Learning disability Heart condition Mental health condition (i.e. depression, anxiety, eating disorder) Health plan:________________

Does your child experience any of the following? Nose bleeds Frequent ear aches Overweight for age Physical disability Poor appetite Frequent stomach aches Frequent headaches Fainting spells Tires easily Emotional concerns Underweight for age 504 ______________________

Do any of the above condition(s) limit/effect your child at school? ________________________ __________ LIFE THREATENING CONDITIONS Does your child have a life threatening health condition? No Yes: __________________ __________

*If yes, a meeting with the school nurse is required. Washington State Law requires that medication or treatment orders and a health care plan be in place prior to starting school.

ALLERGIES

Plants Animals Food: ________________ Molds Drugs Bees Other: __________ Please describe the allergic reaction and the treatment________________________________________________________________ MEDICATION Does your child take any medication? No Yes Name of medication: ______________________________________________ Purpose: ______________________________________________________ Is medication needed at school No Yes

If your child needs to take medication at school please contact the office for the necessary authorization form. This form must be completed prior to the administration of any medication at school.

HEARING/VISION Do you have concerns about your child’s hearing? No Yes Does your child wear hearing aides? No Yes Do you have concerns about your child’s vision? No Yes Does your child wear glasses or contacts? No Yes SPEECH/LANGUAGE Do you have concerns about your child's speech and/or language? No Yes: _________________________________________ Do others have difficulty understanding your child? No Yes:_____________________________________________________

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT I understand that the information given above will be shared with appropriate school staff on a need to know basis to provide for the health and safety of my child. If either I or an authorized emergency contact person cannot be reached at the time of a medical emergency, I authorize and direct school staff to send my child to the most easily accessible hospital or physician. I understand that I will assume full responsibility for payment of any transport or emergency medical services rendered.

Parent/Guardian Signature Date

QUESTION 1. Is your child of Hispanic or Latino origin?

____ Yes, check all that apply in section 1 and 2. _____ No, check all that apply in section 2.

30 Mexican/Mexican American/Chicano 75 Central American

55 Cuban 80 South American

60 Dominican 85 Latin American

65 Spaniard 90 Other Hispanic/Latino

70 Puerto Rican

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

200 African American/Black 405 Alaskan Native

410 Chehalis

300 White 413 Colville

416 Cowlitz

505 Asian Indian 418 Hoh

507 Cambodian 421 Jamestown

510 Chinese 424 Kalispel

520 Filipino 427 Lower Elwha

525 Hmong 430 Lummi

530 Indonesian 433 Makah

535 Japanese 436 Muckleshoot

540 Korean 439 Nisqually

545 Laotian 442 Nooksack

550 Malaysian 445 Port Gamble Clallam

555 Pakistani 448 Puyallup

560 Singaporean 451 Quileute

565 Taiwanese 454 Quinault

570 Thai 457 Samish

575 Vietnamese 460 Sauk-Suiattle

599 Other Asian 463 Shoalwater

466 Skokomish

605 Native Hawaiian 469 Snoqualmie

615 Fijian 472 Spokane

620 Guamanian or Chamorro 475 Squaxin Island

625 Marian Islander 478 Stillaguamish

630 Melanesian 481 Suquamish

632 Micronesian 484 Swinomish

635 Samoan 487 Tulalip

640 Tongan 488 Upper Skagit

699 Other Pacific Islander 490 Yakama

495 Other Washington Indian

499 Other American Indian

Ethnicity and Race Data Collection Form

Student Legal Last Name: ________________________ Legal First Name: ________________________

Parent/Guardian Signature: ____________________________ Date: ______________ 3.28.14

English/November 2016

Office of Superintendent of Public Instruction (OSPI)

Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools.

Student Name: Grade: Date:

Parent/Guardian Name: _______________________________________________________________

Parent/Guardian Signature: ____________________________________________________________

Right to Translation and

Interpretation Services

Indicate your language preference so

we can provide an interpreter or

translated documents, free of

charge, when you need them.

All parents have the right to information about their child’s

education in a language they understand.

1. In what language(s) would your family prefer to communicate

with the school?

________________________________________________

Eligibility for Language

Development Support

Information about the student’s

language helps us identify students

who qualify for support to develop

the language skills necessary for

success in school. Testing may be

necessary to determine if language

supports are needed.

2. What language did your child learn first?

________________________________________________

3. What language does your child use the most at home?

________________________________________________

4. What is the primary language used in the home, regardless of

the language spoken by your child?

_____________________________________________

5. Has your child received English language development support

in a previous school? Yes No Don’t Know

Prior Education

Your responses about your child’s

birth country and previous

education:

Give us information about the

knowledge and skills your child is

bringing to school.

May enable the school district to

receive additional federal funding

to provide support to your child.

This form is not used to identify

students’ immigration status.

6. In what country was your child born? ___________________

7. Has your child ever received formal education outside of the

United States? (Kindergarten – 12th grade) Yes No

If yes: Number of months: _________________________

Language of instruction: ______________________

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

_____________________________

Month Day Year

Thank you for providing the information needed on the Home Language Survey. Contact your school

district if you have further questions about this form or about services available at your child’s school.

Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.

Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative

Commons Attribution 4.0 International License.

http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx

http://www.k12.wa.us/MigrantBilingual/TranslatedMaterial.aspx

http://www.k12.wa.us/

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/licenses/by/4.0/

U.S. Department of Education Office of Indian Education

Washington, DC 20202 TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

Name of the Child Date of Birth Grade (As shown on school enrollment records) Name of School

TRIBAL ENROLLMENT

Name of the individual with tribal enrollment: (Individual named must be a descendent in the first or second generation) The individual with tribal membership is the:

Child Child's Parent Child's Grandparent

Name of tribe or band for which individual above claimsmembership:

The Tribe or Band is (select only one): Federally Recognized State Recognized Terminated Tribe (Documentation required. Must attach to form) Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994. (Documentation required. Must attach to form)

Proof of enrollment in tribe or band listed above, as defined by tribe or band is:

A. Membership or enrollment number (if readily available) OR

B. Other Evidence of Membership in the tribe listed above (describe andattach)

Name and address of tribe or band maintaining enrollment data for the individual listed above:

Name Address

City State Zip Code

ATTESTATION STATEMENT

I verify that the information provided above is accurate.

Name Parent/Guardian Signature

Address City State Zip Code

Email Address Date

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INSTRUCTIONS FOR THE ED 506 FORM FOR APPLICANTS:

PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under this subpart, and that otherwise meets the requirements of subsection (b)”.

MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year, which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.

FOR PARENTS/GUARDIANS:

DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band, including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.

STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level.

TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can provide membership information.

Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to this form.

• Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department of Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request.

• State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department of Education does not maintain a master list. It is recommended that you use official state websitesonly.

• Terminated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interior and had that designation terminated.

• Organized Indian Group- Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent, or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate. Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians.

ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.

The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act.

PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020.

Implementation of the ESEA Title VI Indian Education Formula Grants Program 84

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Mount Baker School District

4956 Deming Road, Deming WA 98244

Student Housing Questionnaire 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. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. (Please see reverse side for more information) If you own/rent your own home, you do not need to complete this form. If you do not own/rent your own home, please check all that apply below. (Submit to District Homeless Liaison. Contact information can be found at the bottom of the page).

In a motel A car, park, campsite, or similar location In a shelter Transitional Housing Moving from place to place/couch surfing Other________________________________ In someone else’s house or apartment with another family In a residence with inadequate facilities (no water, heat, electricity, etc.)

Name of Student: First Middle Last Name of School: Grade: Birthdate (Month/Day/Year): Age: Gender: Student is unaccompanied (not living with a parent or legal guardian) Student is living with a parent or legal guardian ADDRESS 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) *I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct. Please return completed form to:

Kate Davies 360-617-4303 Harmony Elementary and ELC Lauren Oswald 360-617-4511 Acme Elementary and Jr/Sr High Maryann Welch 360-617-4406 Kendall Elementary

For School Personnel Only: For data collection purposes and student information system coding

(N) Not Homeless (A) Shelters (B) Doubled-Up (C) Unsheltered (D) Hotels/Motels

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

SEC. 725. DEFINITIONS.

For purposes of this subtitle:

(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities.

(2) The term homeless children and youths' —

(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1)); and

(B) includes —

(i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals;

(ii) children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C));

(iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and

(iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).

(6) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian.

Additional Resources Parent information and resources can be found at the following: National Center for Homeless Education National Association for the Education of Homeless Children and Youth (NAEHCY) SchoolHouse Connection

https://nche.ed.gov/

http://naehcy.org/resources/

http://www.schoolhouseconnection.org/

Migrant Education Program Work Survey

The following form will be used to help us determine if your child(ren) might be eligible for extra support through the Migrant Education Program. This information will not be shared with anyone outside of the school system.

1. Have you moved to a new area for any amount of time (this could be as little as a week) to work within the last 3 years? ☐ Yes ☐ No

2. Did you work in agriculture or fishing within the last 3 years? Activities may include work in fields, any type of fishing or shellfish harvesting, work on dairy farms, lumbering, berry picking (including wild berries like salal and huckleberries), Christmas tree harvesting, work in canneries, or work in food processing plants. ☐ Yes ☐ No

3. Optional: List your employer here: ________________________________

Documents

Kindergarten Enrollment 2020-2021 Overview · Kindergarten Enrollment 2020-2021 Overview Welcome to School Year 2020-2021 and the Class of 2033! The information below and the friendly