4-year- old program general information for 2021-2022

4-YEAR- OLD PROGRAM GENERAL INFORMATION

FOR 2021-2022 SCHOOL YEAR

Moore Public Schools will offer a 4-year old program for students who are four years old on or before

September 1, 2021. This is an exciting opportunity we hope will prove to be a benefit to the parents and

students involved. Because of the limited availability of space in our district, the program will only be available

at selected sites. Program time will be a half-day session (two and one-half hours) in the morning or afternoon.

Class times will correspond to those of the sites selected for the programs. The district will not be able to

provide transportation for their children. Parents will need to plan for timely delivery and pick-up

of students. The programs will be available to all residents of the district; however, our capacity is limited by

space. Enrollment information is listed below. All sessions must have full enrollment in order to open.

Spring Enrollment Information:

Enroll your pre-kindergarten student at their home school (the school they will attend for K-6 grades). Enroll

during the time period of February 16 – 19, 2021. The parent/guardian will need to submit for photocopying

a certified birth certificate (not hospital certificate), the child’s up-to-date immunization record, and two (2)

proofs of residence in the Moore Public Schools district. These may be any two of the following: gas, water, or

electric bill (no telephone or cable bills), mortgage statement, lease agreement, contract on home or warranty

deed in the name of the parent or legal guardian of the child. The parents will also need to provide a valid state

issued ID or driver license.

The procedure for actual class assignments will be a random drawing on February 27th to complete school

assignments. Phone calls will be made on February 27th to notify you of your student’s placement in pre-

kindergarten. If you do not receive a phone call or email regarding placement, your student has been placed

on the waiting list.

The list of schools with a 4-year-old program for 2021-2022 are:

Bryant Earlywine Red Oak Sooner

9400 S Bryant 12800 S May Ave 11224 S Pennsylvania 5420 SE 89th St.

OKC OKC OKC OKC

Broadmoore Fairview Santa Fe Southgate

3401 S Broadway 2431 SW 89th St. 501 N Santa Fe 500 N Norman

Moore OKC Moore Moore

Central Elem Houchin Sky Ranch Timber Creek

123 NW 2nd St. 3200 N Webster 9501 S Western 3501 S Sunnylane

Moore Moore OKC Moore

If an opening occurs at any of the 4-year-old sites, applicants on the waiting list will be contacted by telephone,

in the order of their place on the waiting list, to determine if they remain interested in placement for their child.

If a parent/guardian is interested only in a particular site, a note will be made of the preference. The child will

retain their place on the waiting list until a space in the school of their preference is offered.

TRANSPORTATION:

The district will not provide transportation.

GENERAL INFORMATION:

Moore Public Schools 4-year-old program is a voluntary, space available half day program. Each class will be

taught by an Early Childhood certified teacher and will have a teacher assistant. There will be morning and

afternoon classes.

STUDENT ENROLLMENT CHECKLIST

Required Documents: (missing documents will delay the enrollment process)

❑ Certified Birth Certificate

❑ Two (2) Proofs of Residency

-Current utility bills (within the past 2 months): water, gas, or electric only (cut off

notices and telephone/cable bills will not be accepted). If the utility bill is not in the

parent/guardian’s name, an affidavit is required.

-Mortgage or lease/rental contract (each student’s name must be listed on lease).

❑ Parent/Guardian Oklahoma Driver’s License or State Issued Photo ID

The parent who is enrolling the student must be on the birth certificate. The guardian

must show legal documents proving they have the right to enroll the student. In cases of

divorce, custody papers will be required.

❑ Academic History (If Applicable)

-IEP or 504 documentation

❑ Immunization Record

Immunizations must be up to date prior to starting school.

❑ Completed Enrollment Packet

State Department of Education Immunization Requirements

Please bring the following items to your home school site to complete enrollment for your student.

*IMPORTANT!1. You must first download a copy of the enrollment

forms. The forms will not save unless downloaded toyour device first.

2. Complete the downloaded forms and save again when finished.

Rev Jan- 2020

1500 SE 4th Street 20____ - 20_____ Enrollment FormMoore, OK 73160 Grade

Student Information

Full name: ______________________________________________________________________

Legal Last Name First Middle

Birth Date: ___________________City & State of Birth:_________________________________

Male_____Female_____ Is student on an IEP? Y_____N______ Is student on a 504 plan? Y_____N______

Native Hawaiian or Other Pacific Islander ___ Caucasian/White____

Must check at least one or more of the following Races: American Indian or Alaskan Native ___ Asian___ Black/African American____

Is the Student Hispanic or Latino Culture or Origin? Y_____N_____

Country of Birth _______________ Date entered U.S. ____-____-________

American Indian ancestry (regardless of degree) Y___N___Tribe ____________________________ (Eligible for Title VII program)

Resident Address: __________________________________________________________Hm Phone (_____) _________________ *Please include suffix (Ave, Dr, Pl, etc) and Apt # City State Zip

Mailing Address____________________________________________________________________________________________ *If different from resident address City State Zip

Parents(s)/ Legal Guardian(s) Living with Student

(1) Parent / Guardian Name ________________________________________________ Relationship to Student _______________Last First Middle

Cell (____)__________________Work (____)__________________Email________________________________

Place Employed __________________________Located on Federal Property? Y___ N____ Active Military Y____N____

(2) Parent/Guardian Name/Step Parent______________________________________ Relationship to Student________________Last First Middle

Cell(____)__________________Work(____)_________________Email__________________________________

Place Employed __________________________Located on Federal Property? Y____ N____ Active Military Y____N____

Are there any other children in the household attending Moore Public Schools? Y ____ N____(1) _______________________________ Relationship to student _________________ School _________________________

(2) _______________________________ Relationship to student _________________ School _________________________

(3) _______________________________ Relationship to student _________________ School _________________________

Check One are natural parents Married _____ Divorced _____ Never Married _____To secure your child’s safety, are current required court documents on file at the school (if applicable)? Y____N____

Legal custodian(s) __________________________________________________

Please list any additional Household members that are Military or Civilian working on federally owned Property:

Name:_________________ Employer location/Address: ________________________________Active Military Y____N____

Parent / Legal Guardian NOT living with student

Name _________________________________________________________ Relationship to Student ____________________ Last First Middle

Address __________________________________________ Home (____)_________________ Cell (____)_________________ Street City State Zip

Work (____)___________________ Email ___________________________________________@________________________

Place Employed __________________________Located on Federal Property? Y____ N___ Military/Branch/Rank____________________

Non-Parent Emergency Contacts (Please list in order that they are to be contacted, persons listed below will be able to check students out) Name and relationship to student Home Cell Work

(1) ______________________-____________ (____)_______________ (____) _______________ (____)_______________

(2) ______________________-____________ (____)_______________ (____)________________ (____)_______________

(3) ______________________-____________ (____)_______________ (____)________________ (____)_______________

Name of last school attended: __________________________________________ City________________________ State ________

Has student ever attended a Moore Public School ______ Yes ______ No Year Attended ___________

Please check special programs that student has received: Gifted___ Lab_____Speech___OT / PT_____ Special Ed___ OK Promise___ Title I Reading___ Title IX___ JOM___ Other_____Health Care Management Plan______

Parent / Guardian Signature X __________________________________________ Date ___________

For Office Use Only

SCHOOL______________________

ID # ________________________

Entry Date __________________

Grade _______Bus#___________

Affidavit ______ Transfer _______

Name of Student: ______________________________________________________________Student ID #_________________ Last Name / Apellido(s) First Name / Primer Nombre Middle Name / Segundo Nombre

Gender: Male _____ Female _____ Date of Birth: ___________________________ School: ______________________________________________________

Select one or more of the following races:

______ African American/Black ______ Caucasian/White ______ Asian

______ Native Hawaiian/Pacific Islander ______ American Indian/Alaskan Native ______ Other

Is the student of Hispanic or Latino culture or origin? Yes _____ No: _____

1. What is the primary language used in the home, regardless of the language spoken by the student? ______________________________________

2. What is the language most often spoken by the student? ___________________________________________________________________________

3. What language did the student learn first? _______________________________________________________________________________________

4. Does the parent/guardian need interpretation services? Yes _____ No _____ If so, what language? _________________________________________

5. Does the parent/guardian need translated materials? Yes _____ No _____ If so, what language? ___________________________________________

____________________________________________________________________________________________________ Parent/Guardian Signature Date

Nombre del Estudiante Identificación del Estudiante #

Masculino Femenino Fecha de Nacimiento Escuela

Seleccione una o más de las siguientes razas:

(Afroamericano/Negro)

(Nativo de Hawái o Islas del Pacífico) (Indio Americano/Nativo de Alaska)

(Blanco) (Asiático)

(Otro)

¿El estudiante es de origen o cultura Hispana o Latina?

¿Cuál es el lenguaje principal usado en el hogar, independientemente del idioma que habla el estudiante?

¿Cuál es el lenguaje hablado con mayor frecuencia por el estudiante?

¿Qué idioma aprendió primero el estudiante?

¿El padre / tutor necesita servicios de interpretación?

¿El padre / tutor necesita servicios de traducción?

(Firma de los padres/Tutor) (Fecha)

Sí

Sí

Sí

Si contestó sí, ¿qué idioma?

Si contestó sí, ¿qué idioma?

Sexo:

ENCUESTA DEL IDIOMA HABLADO EN CASA–DISTRITOS ESCOLARES CON GRADOS PRE - K-12

HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

Name of Student: _______________________________________________________________ Student ID # _______________ Last Name First Name Middle Name

Gender: Male _____ Female _____ Date of Birth: ___________________________ School: ________________________

Select one or more of the following races: ______ African American/Black ______ American Indian/Alaskan Native ______ Asian ______ Native Hawaiian/Pacific Islander ______ Caucasian/White ______ Other


1. What is the primary language used in the home, regardless of the language spoken by the student? ___________________

2. What is the language most often spoken by the student? ______________________________________________________

3. What language did the student learn first? __________________________________________________________________

4. Does the parent/guardian need interpretation services? Yes _____ No _____ If so, what language? _________________

5. Does the parent/guardian need translated materials? Yes _____ No _____ If so, what language? ___________________

☐ Other language than English indicated two or more times on questions 1 – 3 above. The student is classified as MORE OFTEN and automatically qualifies as bilingual onthe accreditation report.

☐ Other language than English indicated only once on questions 1 – 3 above. The student is classified as LESS OFTEN and only qualifies as bilingual on the accreditationreport if he or she meets one of the following:

☐ Scored 35% of below on norm-referenced test (NRT) on the composite reading score. ☐ Scored limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Test (OCCTs). ☐ Designated English Learner on one of the Oklahoma English language proficiency assessments: ACCESS for ELLs 2.0, Alternate ACCESS for ELLs,

WIDA Screener, WIDA MODEL, K-WAPT, WAPT or Oklahoma Pre-K Language Screening Tool.

DOCUMENTATION OF A TEST RESULT FOR STUDENTS MARKED LESS OFTENDate(s) Norm Reference Test (NRT) Name of the NRT Reading Total Composite Score(s) %

Date(s) of Reading OCCT Score(s) on Reading OCCTLimited Knowledge Unsatisfactory Satisfactory Advanced Limited Knowledge Unsatisfactory Satisfactory Advanced Limited Knowledge Unsatisfactory Satisfactory Advanced Limited Knowledge Unsatisfactory Satisfactory Advanced

Date(s) of ACCESS for ELLs 2.0 orAlternate ACCESS Test

Score(s) on ACCESS forELLs 2.0 or

Alternate ACCESS

Date(s) of WIDA Screener orK-WAPT/WAPT or

WIDA MODEL

Score(s) on WIDA Screener orK-WAPT/WAPT or

WIDA MODEL Composite

Score LiteracyScore

CompositeScore

Literacy Score

1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2.

Date of the OklahomaPre-K LanguageScreening Tool

Score on Pre-KLanguageScreening Tool

20____- 20____

SCHOOL USE ONLYPlease have test score documentation available for the Regional Accreditation Officer to review.

STUDENT INFORMATION HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS


















Alternate ACCESS


WIDA MODEL


WIDA MODELComposite

Score LiteracyScore

CompositeScore

Literacy Score

1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2.



20____- 20____


STUDENT INFORMATION

HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS


















Alternate ACCESS


WIDA MODEL


WIDA MODELComposite

Score LiteracyScore

CompositeScore

Literacy Score

1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2.



20____- 20____


STUDENT INFORMATION

STUDENT INFORMATION


HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS20____- 20____

White - Bilingual Count/Accreditation Yellow - Cumulative Folder Pink - ELL Folder

MOORE PUBLIC SCHOOLS

LEGAL CUSTODY DOCUMENTS

The safety of our students is an on-going concern and our district makes every

effort to comply with all state and federal regulations regarding this issue. For

the protection of your child, we are requesting the following information for our

records.

On your child’s most recent enrollment form, you indicated that:

a. _____ The parents are divorced. A copy of current court documents

indicating the name of the custodial parent have been provided to the

school.

b. _____ The student is living with a person other than a parent.

Paperwork in the form of a court document or DHS custody orders

indicating that this is a legal arrangement, have been provided to the

school.

c. _____ Legal documents are not available. I understand the school will

have to release my child to any parent, on request, without such

documents.

d. _____ I prefer not to provide the school with a copy of legal

documents. I understand the school will have to release my child to

any parent, on request, without such documents.

e. _____ Parents are not divorced.

f. _____ Parents never married.

g. ____ Parent deceased.

_______________________________________________ _________________

Parent/Guardian – PLEASE PRINT Date

_______________________________________________

Parent/Guardian Signature 2-27-12

Moore Public Schools Health Form

This health and development form must be completed by the parent or guardian each school year. It is not a part of your student’s permanent record.

Student’s Name ______________________________________________ Birthdate ________________ Today’s Date _________________

School Year _______________________ Grade __________________

Does your child take medication on a routine basis? No Yes

Medication _______________________________________ Purpose ____________________________ At School At home



Please contact the office at your child’s school regarding the Medication Policies. If your child must take prescription or over-the-counter medication during the school day, he or she must have a current Medication

Consent form on file signed by a physician and a parent or guardian.

Asthma Mild Moderate Severe

Rescue Inhaler Prescribed

Allergies Mild Moderate Severe

EpiPen Prescribed

Bees/Insects

Latex

Medication ________________________________

Reaction _________________________________

Foods Contact Ingestion

Please List ________________________________

_________________________________________

_________________________________________

Reaction _________________________________

_________________________________________

Other ____________________________________

Diabetes Type 1 Type 2

No Pump

Has Pump

ADD/ADHD

Medication at Home

Medication at School

Heart Problems

Congenital Heart Defect

Please Explain ___________________________

_______________________________________

Other __________________________________

_______________________________________

Seizures

Febrile Seizures

Last Occurrence __________________________

Epilepsy/Seizure Disorder

Last Occurrence __________________________

Use Emergency Plan if Occurs at School

Has Emergency Medication Prescribed

Physical Limitations

Special Equipment Needed at Home

Special Equipment Needed at School

Please Explain _______________________________

___________________________________________

Other

Please Explain _______________________________

___________________________________________

___________________________________________

Do you give Moore Public Schools permission to screen your child? (Example: Vision/Hearing screenings) No Yes

My child DOES NOT have any health issues or concerns at this time.

I sign that the above is true and accurate to the best of my knowledge.

Parent/Guardian Signature ______________________________________________ Today’s Date ________________________

Revised 01/2017

Check the box and explain if your child has a history of or currently has the following conditions or concerns.

01/2019

OSIIS - Authorization to Use or Share Protected Health Information with School

Student Name __________________________________________ Date of Birth ________________________

Oklahoma State Immunization Information System (OSIIS) is a statewide immunization registry operated by

the Oklahoma State Department of Health, designed to collect and maintain accurate, complete, and current

immunization records for Oklahomans of all ages. OSIIS began operations in 1994 and some clinics do not

participate in OSIIS, therefore OSIIS does not contain the immunization records of all Oklahomans.

Moore Public Schools uses OSIIS to access student immunization records in compliance with Oklahoma state

law regarding school requirements for vaccines. Parent permission is required for Moore Public Schools to

access this information.

Choose One I DO authorize the release my child’s records and information located within OSIIS to Moore Public

Schools. I DO NOT authorize the release my child’s records and information located within OSIIS to Moore

Public Schools.

The information may be disclosed for the following purpose(s):

To ensure the student meets Oklahoma eligibility requirements for schools/day cares as outlined in Title 70

O.S. § 1210.191 and Oklahoma Administrative Code ("OAC") 310:535-1-2 and OAC 310: 535-1-3

I understand that by voluntarily signing this authorization:

• I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.

• I have the right to withdraw permission for the release of my information and revoke this authorizationat any time in writing.

• I have the right to receive a copy of this authorization.

• I understand that unless the purpose of this authorization is to determine payment of a claim forbenefits, signing this authorization will not affect my eligibility for benefits, treatment, enrollment, orpayment of claims.

• I understand I may change this authorization at any time in writing. However, I understand I cannotrestrict information that may have already been shared based on this authorization.

• Information used or disclosed pursuant to the authorization may be subject to redisclosure by therecipient and may no longer be protected by HIPAA Privacy Regulations.

_______________________________________________ __________________________________________

Signature Date

_______________________________________________ __________________________________________

Name (Print) Relationship to Student

1500 SE 4th Street, Moore, OK 73160 (405) 735-4200

Student Name _______________________

Acknowledgment

Student Handbook

□ I understand the expectations and procedures as outlined in the MPS Handbook that can be located online at https://www.mooreschools.com/Page/723

I acknowledge that I have read these policies, procedures, guidelines and rules on

https://www.mooreschools.com/Page/56919 website

□ Family Educational Rights and Privacy Act (FERPA)

□ Protection of Pupil Rights Amendment (PPRA)

PPRA affords parents, students who are 18, or emancipated minors (“eligible students”)

certain rights regarding our conduct of surveys, collection, and use of information for

marketing purposes, and certain physical exams.

□ Cell Phone Policy

□ Meningococcal Meningitis

Acknowledged

Parent/Guardian Signature Date

Parent/Guardian Print Name

Student Signature Date

Student Name__________________________

2021-22 Moore Public Schools Release Form (Please sign and return to school)

Dear Parent/Guardian: As a part of Moore Public School’s (referred to as the “District”) promotion of school activities and recognition of student achievement, District staff members or members of the news media may photograph or film students while they are engaged in school activities not generally open to the public. District staff members or members of the news media may also photograph, film or display examples of your child or your child’s work. Because the District values your child’s privacy, your child’s last name will not appear in connection with any images of your child or any of your child’s work on the District’s Website.

I. Permission to Publish Student Work on the Internet

CHECK ONE (__) I, the undersigned, hereby authorize the District to display my child’s work on the Internet. I understand that my child’s last name and personal information will not be included. I understand that this work is accessible to anyone who is connected to the Internet and the ownership of intellectual property cannot be guaranteed. (__) I, the undersigned, DO NOT authorize any piece of my student’s work to be displayed on the Internet.

Name of Student (please print): _________________________________________________________________________________

Student Signature:________________________________________ Date: __________________________________________

Parent/Guardian Signature: __________________________ Parent/Guardian Name (please print): ________________________

II. Permission to Release Student Image to News Media

CHECK ONE (__) I, the undersigned, authorize the release of my child’s image to the news media, as a part of his or her class work, or to publicize district activities not normally open to the public. An image could take the form of a photograph, video, or multimedia project.

(__) I, the undersigned, DO NOT authorize the release of my child’s image to the news media.

Name of Student: ______________________________________________ Date: __________________________________________


III. Permission to Publish Student Image on the Internet

CHECK ONE (__) I, the undersigned, hereby give permission for the District to publish my child’s image (photo) on the Internet. I understand that my child’s last name and personal information will not be included. I understand that this image will be accessible to anyone who is connected to the Internet. (__) I, the undersigned, DO NOT give permission for the District to publish my child’s image (photo) on the Internet.

Name of Student: ______________________________________________ Date: __________________________________________


Moore Public Schools

2021-22 Student Electronic Network Usage Policy

Student Electronic Network Usage Policy

Carefully read this page, complete the information requested and sign.

______________________________________ ________ Student’s Name (Last, First) Grade

As the parent or legal guardian of the above student, I hereby grant permission for my son or daughter to access the

Internet through Moore Public Schools. I hereby acknowledge that I have read the Rules for Use of the Internet in

their entirety, have discussed the rules with my son or daughter and recognize that violation of the rules can result in

loss of access, disciplinary action, and possible legal action. I understand that some materials on the Internet may be

objectionable, but I accept responsibility for guidance for the use of the Internet, setting and conveying standards for

my son or daughter to follow when selecting, sharing or exploring information via the Internet.

____________________________________ ___________________________ Student’s signature Date

____________________________________ ___________________________ Parent’s signature Date

2021-22 RELEASE OF INFORMATION ‘OPT-OUT’

Please check your preference regarding Yearbook information and sign below:

Release my student’s name, phone number or address for marketing purposes ie. graduation services and photographers

YES

NO

I want to receive information about the yearbook

YES

NO

Name of Student (please print)______________________________________________

Name of Parent/Guardian (please print)_______________________________________

Signature________________________________________________Date__________________

https://www.mooreschools.com/Page/56979

OMB Number: 1810-0021 Expiration Date: 02/29/2020

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 claims membership: _______________________________________________

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 and attach) _______________________________________

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 _______________

OMB Number: 1810-0021 Expiration Date: 02/29/2020

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 ofInterior 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 ofEducation does not maintain a master list. It is recommended that you use official state websites only.

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

• Organized Indian Group- Member of an organized Indian group that received a grant under the Indian Education Act of 1988as 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.

HOME SCHOOL: ______________

Moore Public Schools Pre-Kindergarten Drawing Form

2021-2022

Child’s Name Birthdate

Parent / Guardian Name

Street Address City _______

Best Contact Information (to contact with placement information)

Cell Phone Number Parent Name ____________________________

Cell Phone Number Parent Name ____________________________

Email address ___________________

Please check one: In-Person Instruction ______ Virtual Instruction _

PARENTS WILL NEED TO PROVIDE TRANSPORTATION TO AND FROM SCHOOL FOR THE 4 YEAR OLD PROGRAM

Please list the schools of your choice (listed below)

1st Choice 2nd Choice

3rd Choice 4th Choice

If you have a need for either A.M. or P.M. class, please indicate below:

A.M. ________ P.M. _______ No Preference _______

*Early: 8:30-11:03 or 12:33-3:06Late: 9:15-11:48 or 1:18-3:51

^Pod: 9:00-11:33 or 1:00-3:33

Bryant, 9400 S Bryant, OKC Broadmoore, 3401 S Broadway, Moore ^Central Elem. 123 NW 2nd, Moore ^Earlywine, 12800 S May, OKC *Fairview, 2431 SW 89th, OKC Houchin, 3200 N Webster, Moore *Red Oak, 11224 S Pennsylvania, OKC Santa Fe, 501 N Santa Fe, Moore Sky Ranch, 9501 S Western, OKC Sooner, 5420 SE 89th, OKC Southgate/RLC, 500 N Norman, Moore Timber Creek, 3501 S Sunnylane Rd. Moore

PLEASE MAKE SURE YOUR DAYCARE WILL TRANSPORT TO THE CHOICES YOU MAKE AS THERE WILL BE NO CHANGES MADE AFTER PLACEMENT.

ALL PLACEMENTS ARE FINAL! If your child’s name is not drawn before the open classes are filled,

your child’s name will be placed on the waiting list in the order it was drawn.

Parent Signature: ______________________________________ Date: _________________

**Semester commitment. Students may not switch between in-person and virtual instruction mid semester

corinnemoody

Cross-Out

Forms are Completed. What do I do Next?

Please complete enrollment for your student at your student’s home school. To find the school that serves your address please click here.

Please bring all required documents to the front office at your student’s home school.

❑ Certified Birth Certificate

❑ Two (2) Proofs of Residency

-Current utility bills (within the past 2 months): water, gas, or electric only (cut off notices and telephone/cable bills will

not be accepted). If the utility bill is not in the parent/guardian’s name, an affidavit is required.

-Mortgage or lease/rental contract (each student’s name must be listed on lease).

❑ Parent/Guardian Oklahoma Driver’s License or State Issued Photo ID

The parent who is enrolling the student must be on the birth certificate. The guardian must show legal documents proving

they have the right to enroll the student. In cases of divorce, custody papers will be required.

❑ Academic History (If Applicable)

-IEP or 504 documentation

❑ Immunization Record

Immunizations must be up to date prior to starting school.

❑ Completed Enrollment Packet

The parent who is enrolling the student must be on the birth certificate or the guardian enrolling a student must show legal court ordered documents proving they have the right to enroll the student.

State Department of Education Immunization Requirements

https://www.mooreschools.com/Page/52027