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Fremont County School District #215 Student Enrollment Form

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Home Address City Zip

Mailing Address (if different from home address) City Zip

Primary Guardian: Relationship: _______________

Secondary Guardian: Relationship: _______________

Other Contact #1: Relationship to Student:

Other Contact #2: Relationship to Student:

Babysitter/Daycare Provider:

Custody Information:

Fremont County School District #215

Student Enrollment Form

Henry's Fork Elementary

tel: (208) 624-7422fax: (208) 624-7438 425 N 3 WSt. Anthony, ID 83445

__________________________ __________________________ _________________ _________________

Date of Enrollment Birthdate Grade Male/Female

Student's Information:

Legal First Name Legal Middle Name Legal Last Name

E-mail:

First Name Last Name Home Phone Cell Phone Work Phone

E-mail:

First Name Last Name Home Phone Cell Phone Work Phone

First Name Last Name Home Phone Cell Phone Work Phone

First Name Last Name Home Phone Cell Phone Work Phone

Babysitter/Provider's Name Address Home/Work Phone Cell Phone

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Race and Ethnicity: (Note: Both Part A and Part B of the question must be answered.)

Part A: Is this student Hispanic/Latino? (Choose only one) ________ No, not Hispanic/Latino

________ Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)

The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your student's race to be. Part B: What is the student's race? (Choose one or more)

________ American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.)

________ Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

________ Black or African American (A person having origins in any of the black racial groups of Africa.)

________ Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)

________ White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

Medical Information:

Doctor's Name: ______________________________ Work Phone: _________________________________

I attest that the information contained herin is correct to the best of my knowledge.

(Legal Parent/Guardian Signature) (Date)

(School Representative) (Date)

Fremont County School District #215

Student Enrollment Form

Henry's Fork Elementary

tel: (208) 624-7422fax: (208) 624-7438 425 N 3 WSt. Anthony, ID 83445

Does your student have any medical conditions (e.g. allergies, diabetes) or other needs we should be aware of? If any, please explain:

Does your student require medication for his/her medical condition? If any, please explain:

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DATE: _____________ Student's Name:

Legal Last Name Statewide Home Language Survey:

Our school district along with the Idaho State Department of Education and the Office for Civil Rights require that students' language(s) are identified. This survey's purpose is to determine whether they are potentially eligible for language services.

1. What language(s) are spoken in the home? _____________________________________________________ 2. What language(s) does your student speak most often? ___________________________________________ 3. What language(s) did your student first learn? ___________________________________________________ 4. Which language does your child speak with you? ________________________________________________ 5. Which language do you use when speaking with your child? ________________________________________ 6. Which language do you want phone calls and letters? _____________________________________________ 7. What is your relationship to the child? ___Father ___Mother ___Guardian ___Other (specify) _________ 8. Is there any additional information you would like the school to know about your child? __________________ ___________________________________________________________________________________________

Special Services Survey: Check one:

Yes No

________ ________ 1. Does your child have a current Individualized Education Plan (IEP)? ________ ________ 2. Does your child have a current IEP for speech and/or language services? ________ ________ 3. Does your child have a current 504 Plan?

________ ________ 4. Has your child been enrolled in a Gifted and Talented program?

________ ________ 5. Has your child been enrolled in an English as a Second Language (ESL) program? ________ ________ 6. Has your child been enrolled in a Title I program for reading or math?

________ ________ 7. Has your child had behavior problems at school?

________ ________ 8. Has your child been seen by a school counselor or psychologist? Student/Family Residency Survey:

Check those that apply:

Child's night time residency ________ 1. both parents living together ________ 5. mother/step-father

is with: ________ 2. mother ________ 6. father/step-mother

________ 3. father ________ 7. foster parents ________ 4. grandparent(s) ________ 8. other

Check one:

Yes No Is night time residency:

________ ________ 1. with family or friends due to a loss of housing or economic hardship? ________ ________ 2. in a temporary shelter, hotel, or motel?

________ ________ 3. in a temporary trailer, campground, car, or a place not designed to live in? ________ ________ 4. not with a parent/guardian and not in one of the above situations?

Student Enrollment Survey

Henry's Fork Elementary

tel: (208) 624-7422fax: (208) 624-7438 425 N 3 WSt. Anthony, ID 83445

Legal First Name Legal Middle Name

Fremont County School District #215

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The Fremont School District is pleased to offer student and staff access to a computer network for electronic information services. We strongly believe in the educational value of electronic services and recognize the potential to support curriculum and student learning by facilitating resource sharing, innovation and communication. The Fremont School District will make every effort to protect students and staff from any misuses or abuses as a result of their experience with an information service, but please review the following guidelines and sign where indicated. Your signatures will indicate acknowledgement and understanding of these standards. As a user of this service, you will be expected to abide by the generally accepted rules of network etiquette.

Accounts: Network login accounts shall be used only by the authorized owner of the account. No attempt to gain unauthorized access to accounts is permitted. Keep your passwords private.

Be Polite: Never send, or encourage others to send, messages that are impolite.

Language: Remember that you are a representative of your school and district when you are on-line. Always use language that is appropriate and respectful in your messages. Use of vulgarities or any other inappropriate language is unacceptable.

Privacy: Do not send any message that includes personal information, such as a home address or phone number, for yourself or any other person without express permission. Report to your teacher any person who asks for personal information. Do not read other people's mail or trespass into other people's files.

E-Mail: Electronic mail is not guaranteed to be private. The teacher may check e-mail to make sure that it is appropriate. Access to e-mail accounts may be disallowed if guidelines are not followed.

Information: The Fremont School District makes no guarantees of any kind about the accuracy of information found on-line. Transmission of any material in violation of any law is prohibited. This includes, but is not limited to: copyrighted material, threatening or obscene material, or material protected by trade secrets.

Copyright: Do not use other people's information as your own. Always give credit to the original creators of the information you find online.

Vandalism: Do not damage or attempt to gain unauthorized access to any school computer system (hardware or software). Never move, delete, modify, or damage any applications or files that are not yours.

Software: Do not load any program onto any computer without the permission of the teacher or a network administrator.

Services: The Fremont School District makes no warranties of any kind, whether expressed or implied, for the service it is providing. The District will not be responsible for any damages you suffer while on this system. Damages may include loss of data resulting from delays, non-deliveries, or service interruptions caused by negligence, errors, or ommissions.

Other: The school principal or network administrator may determine other behavior to be inappropriate.

I understand and will follow the guidelines listed in this document. I understand that the use of this electronic service is a privlege, and inappropriate use will result in the loss of that privilege and/or disciplinary action.

________

Date

Administrator Initials: __________ Student Grade ___________

Henry's Fork Elementary tel: (208) 624-7422 425 N 3 W

fax: (208) 624-7438 St. Anthony, ID 83445

Please read the following information carefully before signing this document.

Network Services Acceptable Use Policy

(Please Print) (If student is under 18 years of age)

Network Services Acceptable Use Guidelines

Required Signatures

_________________________ _________________________ _________________________

Student Name Student Signature Parent/Guardian Signature

Fremont County School District #215

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Date: ______________________________

Student's Name:

Legal Last Name Student's Grade: ____________________

Name of school student last attended: Telephone number of previous school: Fax number of previous school:

The student listed above has enrolled in our school. Will you please send us all educational records including but not limited to the following:

Student Cumulative File Attendance Records

Test Scores (e.g. ISAT, DWA, DMA, AIMSweb Transer File) Student Information System Report Card (e.g. PowerSchool) Birth Certificate

Health/Immunization Records

Special Services Records (if applicable) Psychological Records (if applicable) Offical Transcript (if applicable)

Federal Law 99.31 specifies that no parental signature is required for educational records to be released to another educational agency.

Thank you for your prompt attention. Sincerely,

DelRay Davenport, Principal Henry's Fork Elementary

St. Anthony, ID 83445

Legal First Name Legal Middle Name

( ) ( )

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