Keys Elementary School 19061 East 840 Road

Park Hill, Oklahoma 74451

Phone (918) 456-4501 Fax (918) 456-7559

DOCUMENTS REQUIRED TO ENROLL

2019-20 School Year

Verification of Residency:

#1—Statement from the Cherokee County Assessor’s office listing residence and school district

OR filed Homestead Exemption Form. Co. Assessor’s office (918) 456-3201 and have

faxed to Keys Elementary at (918) 456-7559.

AND

#2—(One of the following): A copy of a current utility bill (gas, electric, water), phone bill,

lease agreement, or valid driver’s license of parent/legal guardian with physical address

(P.O. Boxes are not acceptable).

Shot/Immunization Record—all series must be complete or up-to-date

Social Security Card

Birth Certificate

CDIB/Tribal Membership Card (if applicable)

Sooner Care/Medicaid (if applicable)

Proof of Custody (if applicable)

Student Contact Detail Sheet (must be signed & dated)

Completed Keys Enrollment Packet— All forms must be complete, signed by a parent/legal

guardian, and include ALL REQUIRED DOCUMENTS. (If a form does not apply, please

write “Does Not Apply” and sign the form. Your student will not be placed in classes or given a

schedule until they have returned a COMPLETED ENROLLMENT PACKET.

**Students must enroll using their legal name. Using a name other than the one shown on

Birth Certificate requires legal documentation of name change.

Keys Elementary School 19061 East 840 Road Park Hill, OK 74451

Phone: 918-4501 Fax: 918-456-7559 STUDENT ENROLLMENT FORM 2019-20

Social Security#: Student’s Legal Name: First Middle Last

Race: (Circle) White/Caucasian, American Indian, Asian, Black, Pacific Islander Gender: (Circle) Male Female If American Indian please list Tribe: Tribal Membership # (blue card) : Date of Birth: Place of Birth: Mo Day Year City State

Grade in which student is enrolling: Physical Address: (Street or Road, City, State)

Mailing Address: (If different from Physical Address If the same please enter “same” in the line provided.)

Home Phone: Parent/Guardian #1: Resides in home with student: (Circle) Yes No First Name Last Name

Home Phone: (if different than above) Cell Phone: Employer: Work Phone: Email Address: Parent/Guardian #2: Resides in home with student: (Circle) Yes No First Name Last Name

Home Phone: (if different than above) Cell Phone: Employer: Work Phone: Email Address: Emergency Contact Information:

1. Name: __________________________ Relationship to student: _______________ Phone#______________

2. Name:___________________________Relationship to student:________________Phone#______________

3. Name:___________________________Relationship to student:________________Phone#______________

PREVIOUS ENROLLMENT: Last school student attended: School Name City St Phone

Was student enrolled in any special education classes (IEP) please circle? YES NO

Has student ever been retained? Yes No Grade __________

DISCIPLINE:

Was student suspended from school last year for any reason? (Please circle) Yes NO

If yes please explain why:

Parent Signature Date

Keys Public Schools

Internet Usage / Website / Newspaper and Press / Permission to Transport Form

The information below will remain in effect until your student graduates from Keys High School unless you come into the Principal’s office and make changes. Please review and check your preferences on the 4 items below: (1) Internet Use; (2) Website images of your child and/or work shown on our website; (3) Newspaper / Press; (4) Permission to transport your child.

Internet Usage

YES, I DO want my child to have access to the internet at school. (If yes, complete information below)

I, xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx (Students Name), understand and will abide by the Terms and Conditions for Internet access. I further understand that any violation of the regulations is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked and school disciplinary and/or appropriate legal action may be taken. As the parent or guardian of the student, I have read all the Terms and Conditions for Internet access. I understand that this access is designed for educational purposes. However, I also recognize that it is impossible for Keys Public School District and/or the Oklahoma State Department of Education to restrict access to all controversial materials and I will NOT hold the Keys Public School District or the Oklahoma State Department of Education responsible for materials acquired on the network. By signing the form, I, the parent or guardian, hereby give my permission to grant Internet access for my child at school.

NO, I DO NOT want my child to use the Internet at school.

Website

YES, I WILL ALLOW images and/or work of my child on the school or class website

NO, I WILL NOT ALLOW images and/or work of my child on the school or class website

Each school’s website is a growing part of the school experience and a good way to show parents some of the many great things that take place at school. In addition, it offers an opportunity to praise, reward, and spotlight students for their accomplishments, thus enhancing their self-esteem.

Newspaper / Press

YES, I WILL ALLOW my child’s name and/or images to be shown in the local newspaper and/or other press related publications

NO, I WILL NOT ALLOW my child’s name and/or images to be shown in the local newspaper and/or other press related publications

Permission to Transport

There may be occasions during the upcoming school year when it will be necessary to transport students during the school day (testing, presentations, field trips, competitions, medical reasons, discipline reasons, etc.). Transporting students will be on Keys Public School buses driven by certified drivers or by school officials in school or private vehicles.

YES, I WILL ALLOW my child to be transported by Keys Public Schools.

NO, I WILL NOT ALLOW my child to be transported by Keys Public Schools.

Parent or Guardian (print):

Parent’s Signature:

Home Phone: Work Phone: Cell Phone:

Email:

Student’s Name (print):

Student’s Signature:

Parental Authorization to Administer Medication Without this information and parent signature, no child will receive treatment for any illness or injury at

school.

I am the parent with legal custody or the legal guardian of _______________________enrolled in the

______________ grade. I hereby give my consent and authorize the school nurse or designated substitute

to administer a non-prescription medication in the event my child is injured or becomes ill at school.

OVER THE COUNTER MEDICATIONS AVAILABLE IN THE NURSE'S OFFICE-PLEASE CHECK

THE MEDICATIONS YOU WISH TO BE GIVEN TO YOUR CHILD.

___ Acetaminophen 160 mg, 325 mg, 500 mg, as recommended for age

___ Upset stomach relief (tums or pepto)

___ Cough Drops

___ Saline Eye Drops

___ Hydrocortisone Cream for rashes

___ Diphenhydramine Cream for poison ivy, oak or stings

___ Ibuprofen as recommended for age

___ Sunscreen

Yes_____ No_____ Administer a filled prescription medication, which I am supplying you, in accordance

with written instructions of the physician prescribing the medication, which is listed on the label.

Yes_____No_____CALL ME before NON-PRESCIPTION medication is given. (IF YOU CHECK YES,

you must list numbers you can be reached at during the day.) Failing to do so will result in no treatment

for your child.

ANY KNOWN MEDICAL CONDITIONS OR ALLERGIES:

________________________________________________________________________________

ALL MEDICATIONS MUST BE KEPT IN NURSE'S OFFICE

All over the counter medications brought to school must be in their ORIGINAL CONTAINERS.

All prescription medication must have a label bearing the students name, name of the drug, and how to

administer the medication properly. ALL OF THIS INFORMATION IS ON THE PRESCRIPTION

LABEL.

I UNDERSTAND AND UNDER STATE LAW, THE BOARD OF EDUCATION, THE SCHOOL DISTRICT,

OR EMPLOYEES OF THE DISTRICT SHALL NOT BE LIABLE TO THE STUDENT OR THE STUDENTS'

PARENT OR GUARDIAN FOR PERSONAL INJURIES TO THE STUDENT WHICH RESULTS FROM

SCHOOL EMPLOYEES ADMINISTERING THE MEDICATION I HAVE HEREBY AUTHORIZED.

Dated this ____ Day of __________________, 20_____

_____________________________________ ___________________

Parent with Legal Custody or Guardian Child's date of birth

EMERGENCY PHONE NUMBERS:_____________________________(Relationship) ___________

_____________________________(Relationship)___________

I agree to let Keys Public School access the OSIIS system to get copies of my child’s shot records.

__________ Yes I give consent _______ No I do not give consent

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 _______________

IMPACT AID PROGRAM SURVEY FORM

KEYS PUBLIC SCHOOLS

Name of Student:

Last First Middle Birthdate Grade

Circle School Enrolled in: Elementary Middle School High School

Student’s address:

Street City State Zip Code

Do you live on any of the following tax except property?

A. On Restricted Indian Land Yes No

B. On Indian Trust Land Yes No

C. In a Cherokee Tribal Housing Authority House or Property Yes No

A. EMPLOYMENT DATA: (Civilian Employee’s Only)

1. On October 1, 2018 was either parent/guardian with whom student resides employed:

Bureau of Indian Affairs Yes No Cherokee Nation Tribal Complex Yes No

Cherokee Nation Tag Office Yes No Cherokee Nation Industries Yes No

Cherokee Nations Housing Authority Yes No Cherokee Tribal Dev. Yes No

Talking Leaves Job Corp. Center Yes No Sequoyah Indian School Yes No

W.W. Hasting Indian Hospital Yes No VA Medical Center Yes No

Creek Nation Muskogee Casino Yes No Cherokee Nation Enterprises Yes No

Cherokee Nation Early Childhood Center Yes No Hard Rock Casino Yes No

Cherokee Adult Education Cultural Center Yes No Corp of Engineers Yes No

United Keetowah Yes No Wilma Mankiller Clinic Yes No

Was either parent/guardian with whom pupil resides employed on "other" Federal Property or

work on "other" Federal Property (not listed above): Yes No

If yes, give name and address of employer:

Name Address

B. EMPLOYMENT DATA: (Uniformed Services Only)

Was either parent/guardian on active duty in the Uniformed Services on October 1, 2018?

Yes No If yes, give name, rank and branch of service:

Name Rank Branch of Service

I certify that the above information is correct:

Parent/Guardian Signature Date

HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

Name of Student: ____________________________________________________________________ Grade:____________ Last Name First Name Middle Name Date of Birth: __________________ School: _____________ Student ID # ___________________ Gender: Male_______ Female________ MM/DD/YYYY Is the student of Hispanic or Latino culture or origin? Yes________ No_________ Select one or more of the following races: ______ African American/Black ______ American Indian/Alaskan Native ______ Asian ______ Native Hawaiian/Pacific Islander ______ Caucasian/White

1. What is the dominant language most often spoken by the student?

2. What is the language routinely spoken in the home, regardless of the language spoken by the student?

3. What language was first learned by the student?

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? _______________________________ 6. What was the date the student first enrolled in a school in the United States? ________________________

MM/YYYY

______________________________________________________________________________________________________________________

☐ 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 on

the 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 accreditation

report if he or she meets one of the following (any selection below REQUIRES appropriate documentation):

☐ 1. 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, W-APT or Oklahoma Pre-K Language Screening Tool (PKST).

☐ 2. Scored Basic or Below Basic in ELA on the Oklahoma State Testing Program (OSTP).

☐ 3. Scored at or below the 35th percentile (or equivalent) composite reading score from spring of the previous school year on a state approved norm-referenced test (NRT).

DOCUMENTATION OF A TEST RESULT FOR STUDENTS MARKED LESS OFTEN

Date (MM/DD/YYYY) Parent / Guardian Signature

Date(s) of Kindergarten ACCESS, ACCESS for ELLs 2.0, or Alternate ACCESS Test

Score(s) on Kindergarten ACCESS, ACCESS for ELLs 2.0,or

Alternate ACCESS

Date of WIDA Screener or K-WAPT/WAPT or

WIDA MODEL

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

WIDA MODEL Composite / Overall Score Composite / Overall Score

1. 1.

1.

1.

20____- 20____

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

STUDENT INFORMATION

Date(s) of ELA OSTP Score(s) on ELA OSTP

Below Basic Basic Proficient Advanced

Below Basic Basic Proficient Advanced

Below Basic Basic Proficient Advanced

Date of the Oklahoma Pre-K Language Screening Tool

Score on Pre-K Language

Screening Tool

%

Date(s) Norm Reference Test (NRT) Name of the NRT Composite / Percentile Score(s)

Question 1: Reference WAVE code 1036 Question 2: Reference WAVE code 1037 Question 3: Reference WAVE code 1038