KINDERGARTEN REGISTRATION

2020-2021

Social Security Number ___________________________________Today’s Date___________________________________

Initial here______, if you wish to have a different number assigned.

Student’s Name______________________________________________________________________________________ First Middle (Legal) Last

Current Grade________ Sex _______ Birth date ________________Language Spoken at Home____________________

IS this student a twin (or a triplet, quadruplet, etc.)? YES NO

Student 911 Address______________________________City___________________________Zip______________________

Student Mailing Address___________________________City___________________________Zip______________________

Home Telephone _________________Mother’s Cell #_______________________Father’s Cell #_______________________

RACE/ETHNICITY (Please answer BOTH questions)

1. Is this student Hispanic or Latino? _____No, not Hispanic or Latino (choose ONE) _____Yes, Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, South or Central America, or other Spanish culture or origin, regardless of race)

2. What is the student’s race? _____ American Indian or Alaska Native – A person having origins in any of the original (Choose ONE or MORE. Peoples of North and South America, including Central America, and who maintains If more than one race applies, tribal affiliation or community attachment. Please rank in order – 1,2,3…. _____ Asian – A person having origins in any of the original peoples of the Far East, with 1 being the primary race) Southeast Asia, or the Indian subcontinent including: 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 an of the original peoples of Hawaii, Guam, Samoa, other Pacific Islands. _____ White – A person having origins in an of the original peoples of Europe, the Middle East, or North Africa ______Hispanic

PARENT/GUARDIAN INFORMATION Student lives with: _______________________________________________________________________________________

(Please be specific about all members living in the home – for example - mother, father, grandfather, aunt, sister, etc.) Does anyone other than this student, his/her siblings, & his/her parents live in your home or does your family live in a household with another family? Y/N If yes, please explain. _______________________________________________________________

(An example would be: the student and parents/guardians are living with grandparents in the grandparent’s home)

Number of individual families living in the household : ____________________________

Other siblings in the Huntsville School District (names/grades) ___________________________________________________

Parents/Guardians living in the home (first/last names) __________________________________________________________

In what language do you prefer to receive written communication from the school in? _________________________

In what language would you prefer to communicate with school staff when speaking? ________________________

Relationship of the guardian(s) to the student__________________________________________________________________ Workplace of Male Guardian _______________________________________________Work Phone #____________________

Workplace of Female Guardian_____________________________________________ Work Phone #____________________

Parent’s e-mail address___________________________ Parent’s e-mail address_____________________________________

HUNTSVILLE SCHOOL DISTRICT

NEW STUDENT REGISTRATION FORM

2nd Parent/Guardian Information (not living in the home, but having legal parental rights to the student/school information)

Name___________________________________________________Relationship to the student_________________________

Mailing Address____________________________________________________________Home Phone#__________________

Workplace of Male Guardian ____________________________Work Phone #_________________Cell #__________________

Workplace of Female Guardian __________________________Work Phone #_________________Cell #__________________

In what language do you prefer to receive written communication from the school in? _________________________

In what language would you prefer to communicate with school staff when speaking? ________________________

Who may pick up your child? (please list)_____________________________________________________________________ _______________________________________________________________________________________________________

Who may NOT pick up your child? (please list)__________________________________________________________________

Legal documentation (custody papers, divorce decree, etc.) should be submitted if biological/non-custodial parent is listed and this parent is also named on birth certificate.

MEDICAL INFORMATION

Should we be unable to reach you by phone, we will attempt to call the ‘contact’ names listed below. Please be aware that these individuals will also be allowed to pick up your child should there be a need (illness, injury, etc). Please be sure they are listed on the above ‘may pick up list’.

Contact Person Other Than Parent (Required) _________________________________Daytime Phone___________________

Daytime Phone___________________ 2nd Contact Person Other Than Parent________________________________________

Name of Family Physician/Pediatrician______________________

Preferred Hospital (in case of emergency) __________________

The school has my permission to treat my child or seek medical treatment for my child if unable to obtain parent/guardian permission.

_______________________________________________________________ (Signature required if permission is given)

TRAVEL INFORMATION

What will student do upon daily dismissal? Select one: Walk Ride Bus #_____ Parent or Other Adult Will Pick Up

Detailed directions to student’s home (even if your child will not ride a bus): __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

DEMOGRAPHIC INFORMATION

Does student live within 2 miles of the school? Select one: Yes No

Resident County________________________________ Distance you live from school (miles) _______________________________

City of Birth_______________________________ State of Birth ____________________Birth Certificate Number_______________

Is this child a dependent of an active or reserve member of a branch of the United States Armed Services? YES NO (select one) If this child resides in a household with an active or reserve member of a branch of the United States Armed Services, please select the branch below.

Active Duty – US Marines Active Duty – US Navy Active Duty – US Air Force Active duty – US Army __ __ __ __

Reserves – US Navy Reserves – US Air Force Reserves – US Army Active Duty – United States Coast Guard __ __ __ __

Parents serve in multiple branches National Guard – US Air Force National Guard – US Army Reserves – US Marines __ __ __ __

PREVIOUS SCHOOL HISTORY (PRESCHOOL AND ABOVE)

Please list ALL previous schools your child has attended in the last 3 years beginning with the most recent: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has your child ever been retained? Y/N _________ If so, what grade were they retained in: ________________________________

Please list all special programs that your child has participated in (special education, speech, migrant, ESOL, GT, etc):____________

___________________________________________________________________________________________________________

Has your child ever attended Huntsville Schools? If so, when? ________________ Which campus? St. Paul Huntsville

Did this child attend a four year old preschool program (at least 20 hours per week for 9 months)? Yes_________ No__________

If you answered YES, please select the preschool program that this child attended – Program Choices are:

Arkansas Better Chance (ABC program)

21st Century Community Learning Center

Early Childhood Special Education

Public School Preschool

Private Preschool

Even Start

Head Start

Other (Name of Program___________________________)

Child attended one of the above, but not for 20 or more hours per week

AFFIDAVIT OF BIRTH

Child’s Full Name (First, Middle Last) ____________________________________________________________________________

Date of Birth______________________ City and State of Birth_______________________________________________________

Biological Mother’s Full Name (present) __________________________________________________________________________

Biological Mother’s Maiden Name___________________ Mother’s Age at Time of Child’s Birth____________________________

Biological Father’s Full Name__________________________________________________________________________________

Father’s Age at Time of Child’s Birth____________________________________________________________________________

I hereby declare the above information to be true and accurate. I understand that the Arkansas Public School System may use this affidavit as legal documentation of the above child’s birth.

_________________________________________________________ _____________________________________________ Signature of Parent or Legal Guardian Date

PURSUANT TO ACT 472 OF 1995:

Has your child ever been expelled from school in any other school district? ___________ Is your child currently under an order of expulsion in their former school district?_________ If so, when may your child return to their former district?_____________

Are expulsions proceedings currently pending against your child or have you been informed that such proceedings will be initiated against your child?____________________

I hereby acknowledge that all registration information provided by me to the Huntsville School District is true and accurate.

Date:____________________________ Parent/Guardian Signature_____________________________________________________

English/October 2017

Arkansas Department of Education (ADE) Home Language Usage Survey

The Home Language Usage Survey is completed by all students initially enrolling in Arkansas schools.

Student Name: Grade: Date:

School: Student State ID #: Gender: Date of Birth:

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. a) In what language do you prefer to receive written communication

from the school? __________________________________ b) In what language would you prefer to communicate with school staff when speaking?

__________________________________

Eligibility for Language Development Support Information about the student’s language usage helps us identify students who may qualify for extended 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(s) is (are) spoken in your home? _______________________________________ 3. What language did your child learn first?

__________________________________ 4. What language does your child use most often at home?

__________________________________ 5. What language does your family speak most often at home? __________________________________ 6. What language do adults speak most often with each other at home? ____________________________________

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. This form is not used to identify students’ immigration status.

7. Where was your child born? ___________________

8. When did your child first attend a school in the United States (this

includes all US territories)? (Kindergarten – 12th grade)

_______________________ Month Day Year

Thank you for providing the information needed on the Home Language Survey. Contact your child’s school 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.arkansased.gov/divisions/learning-services/english-learners A response that includes a language other than English to questions #1-6 indicates English language proficiency screening is needed.

This work, "Arkansas Department of Education (ADE), Home Language Survey", is a derivative of "OSPI Home Language Survey" by OSPI, used under CC BY . "Arkansas Department of Education (ADE), Home Language Survey" is licensed under CC BY by the English Learners Unit of the Arkansas Department of Education.

This form must be turned in with the student registration packet!

In order to satisfy the district’s residency requirements, the student, parent, military guardian, court-appointed

legal guardian or person acting as a parent must provide one (1) or more of the following items as proof of

residency:

Property Tax Statement

Utility Bill/Agreement

Rental Agreement/Receipt

Telephone bill

Other _________________________

NOTICE: According to Arkansas law §6-18-202, any person who knowingly submits false information to

satisfy residency requirements for public school enrollment shall be subject to a fine not to exceed five hundred

($500) dollars. By signing this form, you are certifying to the Huntsville School District that the above

information provided is accurate and that you are a resident of this school district.

SIGNATURE OF PARENT, GUARDIAN, PERSON ACTING AS A PARENT

____________________

DATE

HUNTSVILLE SCHOOL DISTRICT

Residency Verification Form

This form must be turned in

with the student registration

packet!HUNTSVILLE

Green Forest Schools

AGRICULTURAL SURVEY

Title l, Part C

Your child may qualify to receive Extra Services

In the last 3 years (including summer) did

anyone in your family go to another area to work

or try to get work in an agricultural/farming job

or a food processing job? Moving from school

district into another. Yes____ No ____

If YES, where?___________________________________________

If you checked “yes”, please mark any jobs you worked

or tried to get work in:

___ Food Processing--(Chicken, Turkey, ________________

Beef, Hog, Vegetables, Fruits)

___ Chicken Houses, Chicken Catching ________________

Or Vaccinating

___ Farm Work – (Cotton, Rice, Fruits, ________________

Vegetables, Cattle, Dairy, Chicken, Hog)

___ Working at a Cotton Gin, Granary or _______________

Seed Company

___ Tree Farms –(Planting, Marking, _______________

Girdling, Cutting, Skidding)

___ Plant or Tree Nursery _______________

___ Sod Farming _______________

___ Working with Bees ______________

___ Working on a Fish Farm ______________

___ Other Farm Work______________________

Father’s Name:

Mother’s Name:

Evening Phone:

Street Name and House/Apt #

City Zip Code

Where do you work now?

Father:____________________________________________

Mother:____________________________________________

Date you move to Huntsville:

Student Name Birth Date Grade

Please list all children in the home. ↓

Daytime Phone:

Place of Birth:

Student Name Birth Date Grade

Place of Birth:

Student Name Birth Date Grade

Place of Birth:

Student Name Birth Date Grade

Place of Birth:

Name of plant or farm?

Check all that apply: Date

Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act.

List all of your children birth through age 21.

Name of Child School Age Grade Date of Birth

Parent/Guardian ________________________________________________________

Address _____________________________________________________________________

City_________________________________________________________________________

Zip Code _____________________ Phone Number: ________________________________

Is this address Temporary or Permanent?

Please choose which of the following situations the student currently lives in (you can choose more

than one):

_____ House or apartment with parent or guardian

_____ Motel, car, or campsite

_____ Shelter or other temporary housing

_____ With friends or family members (other than or in addition to parent/guardian)

_____Living in inadequate housing (no heat, no water, mold infested, etc.)

If you are living in shared housing, please check all of the following reasons that apply:

_____ Loss of housing

_____ Economic situation

_____ Temporarily waiting for house or apartment

_____ Provide care for a family member

_____ Living with boyfriend/girlfriend

_____ Loss of employment

_____ Parent/Guardian is deployed

_____ Other (Please explain)

Are you a student living apart from your parents or guardians?

Yes No

HUNTSVILLE SCHOOL DISTRICT

Student Residency Questionnaire

Housing and Educational Rights

Students without fixed, regular, and adequate nighttime residences have the following rights:

1) Immediate enrollment in the school they last attended or the local school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations;

2) Transportation to the school of origin for the regular school day;

3) Access to free meals, Title I and other educational programs, and transportation to extra-curricular activities to the same extent that it is offered to other students.

Any questions about these rights can be directed to the local McKinney-Vento liaison at 479-738-6520, or the State Coordinator at 501-683-5428.

Arkansas law provides that anyone who knowingly gives a false residential address for purposes of public

school enrollment is guilty of a violation and subject to a fine of up to $1,000 (Ark. Code Ann. § 6-18-202(f)).

By signing below, I acknowledge that I have received and understand the above rights.

___________________________________________________________________________

Signature of Parent/Guardian/Unattached Youth Date

___________________________________________________________________________

Signature of McKinney-Vento Liaison Date

Services for McKinney-Vento Identified Students

Student: ____________________________

School: _____________________________

Grade ______________________________

Please check the services needed or desired:

______________________________________________________________________ Signature of Parent/Guardian/Unattached Youth Date ______________________________________________________________________ Signature of McKinney-Vento Liaison Date

___ Free Lunch

___ Transportation to the school of origin

___ Clothing/Uniform

___ School supplies

___ Counseling

___ Medical/dental referral

___ Vision referral

___ Medicaid/DSHS services – food stamps

___ Preschool Enrollment records

___ Missing enrollment records

___ Birth certificate

___ Immunization/medical records

___ Tutoring

___ After-school programs

___ Teen Center

___ Mentoring

___ Special Education

___ Gifted/talented

___ Vocational/technical

___ Community resource

___ Prior academic records

___ LEP/Bilingual program

___ Guardianship issues