ANOSS PUBLIC SCHOOLS

2019-2020 STUDENT INFORMATION/ENROLLMENT FORM

Name: ______________________________________________________________________ Gender: Male or Female (circle one)

First Middle Last

Grade: ______________ Birthdate: _______/_______/________ Social Security Number: _____________________________

Home Address: ______________________________________________________________________________________________

Street/P.O. City Zip Code

County: ______________________ Home Phone: _____________________ Birth City: ___________________ State: _________

Are you Hispanic? Yes_____ No _____

Race: (circle)

1 – Black 2 –* American Indian 4 – Asian 5 – Pacific Islander

6 – White/Caucasian 9 – Other _________________________

*If Race is American Indian, which tribe is the child on roll? _______________________________

Side of Family: Father, Mother or Both Child’s Roll Number: ________________________________

Limited English: YES or NO (circle yes ONLY if language other than English is used in the home)

Previous School Attended: __________________________________________ Has student ever been retained? ___ Yes ___ No

Admission: 1 – Resident 2- Resident of transported area 3- Transferred

Authenticity: (method used to verify birth date)

1 – Birth certificate 2 – Attending physician certificate 3- Last year’s register or other school records

Immunization: ___ YES – If new student does not have shot records, see Peggy Wood.

Transportation Code: (circle one) - Transfer transported – Resident transported - Resident transported

over than 1.5 miles under 1.5 miles

Resident District: (circle one)

I-009 Vanoss I-02 Stratford I-16 Byng I-19 Ada I-24 Latta

I-30 Stonewall I-37 Roff Other: ______________________

Directions to residence from school: ____________________________________________________________________________

____________________________________________________________________________Bus Number/Driver: _____________

Guardian #1: ______________________________________ Guardian # 2:______________________________________

Driver’s License or Social Security# _____________________ Driver’s License or Social Security#_____________________

Relationship to student: _______________________________ Relationship to student: ______________________________

Employer: __________________________________________ Employer: _________________________________________

Work Phone: ________________________________________ Work Phone: _______________________________________

Cell Phone: _________________________________________ Cell Phone: ________________________________________

With whom does the student live? ______________________________________________________________________________

Emergency Contacts:

____________________________________________________________________________________________________________

Name Relationship to Student Phone Number

____________________________________________________________________________________________________________

Name Relationship to Student Phone Number

Date Enrolled: ______________

Homeroom: ________________

Bus Driver: ________________

Locker # ___________________

Student ID: ________________

The Vanoss Board of Education does not discriminate on the basis of disability,

race, color, religion, national origin, sex, age, or veteran status.

Doctor: ___________________________________________________ Phone Number: ___________________________________

List any health problems or allergies: ____________________________________________________________________________

____________________________________________________________________________________________________________

List any medications the student takes on a regular basis: (prescription and/or over the counter: ______________________________

____________________________________________________________________________________________________________

Special precautions or instructions regarding these medications: ______________________________________________________

____________________________________________________________________________________________________________

AUTHORIZED to pick up student:

______________________________________________________ ___________________________________________________

______________________________________________________ ___________________________________________________

PROHIBITED from picking up student:

______________________________________________________ ___________________________________________________

______________________________________________________ ___________________________________________________

Federally Connected: (office use only) _____ (Refer to code sheet for valid entries.)

Special Services: (check all that apply)

___ IEP ___ Oklahoma Promise (OHLAP/High School only) ___ RSA (grades K-4)

___ Gifted and talented ___ Other Specify: _______________________

Please read all documentation included in this packet, register your agreement/non-agreement,

and sign below.

Parent Signature: __________________________________________________ Date: ___________________

Student Signature: _________________________________________________ Date: ___________________

Staff Signature: ___________________________________________________ Date: ___________________

Check Yes or No Yes No

I have received a copy of the Vanoss Public Schools Handbook OR I will access the handbook on the

school website.

I have been given information regarding student accident insurance.

I wish to purchase student accident insurance. I understand that my child must be in attendance 90% of the school year. (See complete handbook

for complete policy).

I am aware of the requirements listed in the current Reading Sufficiency Act regarding retention in the 3rd

grade (See handbook).

Vanoss Public School has permission to publish, announce, or publicly acknowledge any

accomplishments of my child.

I have been given a copy of the Vanoss Schools Drug and Alcohol Policy and understand the designated

student will be governed by such a policy (handbook and Vanoss website).

I have been given a copy of the Vanoss Schools Internet Policy and understand that the designated student

will be governed by such a policy (handbook and Vanoss website).

I understand the A.C.E. (Achieving Classroom Excellence Act of 2006). (See handbook) I am aware of the Extra Curricular Activity Policy. (See handbook)

4665 County Road 1555 ∙ Ada, OK 74820 ∙ 580-759-2503

Growing in Excellence and Education

PARENTAL CONSENT FOR EMERGENCY MEDICAL TREATMENT

2019-2020 Student’s Name ___________________________________________ Grade _______ Birth Date ________________

Address ____________________________________________________ Home Telephone ___________________________

City ________________________________________________________ Zip Code __________________________________

TO PARENT OR GUARDIAN: To serve your child in case of ACCIDENT OR SUDDEN ILLNESS, it is necessary

that you provide (and keep current) the following information for emergency calls:

Mother/Guardian ____________________________________________ Contact Number ___________________________

Father/Guardian _____________________________________________ Contact Number ___________________________

LIST TWO NEIGHBORS OR NEARBY RELATIVES WHO WILL ASSUME TEMPORARY CARE OF YOUR CHILD IF

YOU CANNOT BE REACHED:

Name ______________________________________________________ Number ___________________________________

Name ______________________________________________________ Number ___________________________________

HEALTH INFORMATION: List any health conditions such as heart disease, diabetes, epilepsy, severe allergies,

eye or ear problems, or any chronic condition, etc. List medications taken on regular basis.

Explanation ________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

DOCTOR: 1ST choice: ____________________________________ Telephone Number ________________________

2nd choice: ____________________________________ Telephone Number ________________________

HOSPITAL CHOICE: ________________________________________ Telephone Number ________________________

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I, the undersigned, do hereby authorize officials of the Vanoss School District to contact directly the persons named

on this card, and do authorize the named physicians to render such treatment as may be deemed necessary in an

emergency, for the health of said child.

In the event physicians, other persons named on this card, or parents cannot be contacted, the school officials are

hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the aforesaid

child.

I will not hold the school district financially responsible for the emergency care and/or transportation for said child.

_______________________ _____________________ _____ ______________________________ ______________

Student’s Last Name First Initial Signature of Parent or Guardian Date

Parent Consent to Release Personally Identifiable

Student Information via E-Mail

The Family Education Rights and Privacy Act, 20 U.S.C. and 1232g, prohibit the

release of personally identifiable student records/information without the consent

of a student’s parent/guardian.

Recognizing the transmission via e-mail may not be absolutely secure, I hereby

consent to Vanoss Public School’s release of student records/information via email

in response to any request received from the e-mail address set forth below.

While Vanoss School District will take precautions to avoid accidental release of

personally identifiable student data, I recognize that Vanoss School District cannot

assure confidentiality in all transmissions via e-mail. It is my intent that this

Consent Form shall remain in effect unless specifically withdrawn or modified in

writing for the entire 2019-2020 school year.

I further understand that it is my responsibility to notify the school district if my

email address changes.

Student’s Name: _____________________________________ Grade: _________

Parent’s Name: _____________________________________________________

Parent’s email: ______________________________________________________

Parent’s Signature: ___________________________________ Date: __________

School Year 2019 - 2020Economically Disadvantaged Application

This application should be completed even if your student attends a Community Eligibility Provision or Provision School.

School: Grade: Student Number:

Student Name: _____________________________________

Signature: I certify that all information provided on this form is true to the best of my knowledge and that all household income is reported. I understand that this information will impact federal and state funding to the school.

Sign Here: Date: _______________________________

Print Name: _____________________________________________________________________________________

Qualified Not Qualified

Less than $22,459

Between $22,459 and $30,451

Between $30,451 and $38,443

Between $38,443 and $46,435

Between $46,435 and $54,427

Between $54,427 and $62,419

Between $62,419 and $70,411

Between $70,411 and $78,403

Between $78,403 and $86,395

Between $86,395 and $94,387

Between $94,387 and $102,379

Between $102,379 and $110,371

One (1) Five (5) Nine (9)

Two (2) Six (6) Ten (10)

Three (3) Seven (7) Eleven (11)

Four (4) Eight (8) Twelve (12)

Please select the income range that represents the total gross income:

Please select the total number of people in your household:

For Office use only:

4665 County Road 1555 ∙ Ada, OK 74820 ∙ 580-759-2503

Many Cultures: One “Wolf Pack”

“Enter to Learn: Leave to Serve”

Child Find Notice

The purpose of this policy is to state the intention of the Vanoss Public Schools to fulfill the responsibility to establish and implement an ongoing Child Find system to locate, identify, and evaluate students ages 3 through 21, who are suspected of having a disability and may need special education, regardless of the severity of the disability, and to coordinate with SoonerStart Early Intervention Program regarding the Child Find system for ages birth to 3 years of age. The District’s Child Find system will include all children within the District’s geographic boundaries. Vanoss School will coordinate with other agencies and promote public awareness to locate children who may have disabilities. Vanoss School will take appropriate and necessary steps to ensure that District staff and the general public ae informed of:

The availability of special education services

A student’s rights to a free appropriate public education

Confidentiality protections, and

The special education referral process The District will provide this information through a variety of methods. In the identification process, Vanoss School may use screening or coordinated early intervening services. The District’s general education interventions will not delay the initial evaluation for special education services of a student suspected of having a disability. If through Child Find activities, a child is identified as possibly having a disability and needing special education services, Vanoss School may seek parent consent to evaluate the child. All such evaluations will be conducted in compliance with applicable federal and state laws and regulations.

Vanoss Public School – Parent Compact

ESSA, SECTION 1116(d)

Any school receiving Title I funds must have a School – Parent compact. A compact is a voluntary agreement between groups of people and is a component of the school – level parent involvement policy. It outlines how parents, school staff, and students will share the responsibility for improved student academic achievement. School Responsibilities:

▪ Provide high-quality curriculum and instruction;

▪ Provide a supportive and effective learning environment; and

▪ Enable children to meet the challenging academic state standards. ESSA, Section 1116 (d) (1) Parent’s Responsibilities:

▪ Volunteer in their child’s classroom;

▪ Participate, as appropriate, in decisions relating to the education of their children; and

▪ Monitor the positive use of extracurricular time. ESSA, Section 1116 (d) (1) Communication between teachers and parents on an ongoing basis:

▪ Conduct parent-teacher conferences in elementary schools, at least annually, during which the compact should be discussed as the compact relates to the child’s achievement;

▪ Provide frequent progress reports to parents on their children’s progress; and

▪ Provide reasonable access to staff, opportunities to volunteer and participate in their child’s class, and observation of classroom activities.

▪ Ensuring regular two-way, meaningful communication between family members and school staff and, to the extent practicable, in a language that family members can understand.

ESSA, Section 1116 (d) (2) (A) (B) (C) _______________________________________ ______________________________________ Student Signature Parent Signature _______________________________________________________________ ___________________________________________________________ Teacher Signature Principal Signature

______________________________________________________________ Date