step #1 - student services enrollment questionnaire · i am providing the following original...

STEP #1 - Student Services Enrollment Questionnaire Ardmore City Schools

Your child may be eligible for additional educational services through the McKinney-Vento Education Assistance Act or Title I, Part A of the Foster Plan. Eligibility may be determined by completing this questionnaire.

Student Name: ______________________________________________________________ Today’s Date: __________________________

Date of Birth: ______________________ Grade Level: ________________ School: _________________________________________

Is the student currently accompanied by a parent/guardian/caregiver? _____ Yes _____ No

Please complete Section A or B below based on your family situation

SECTION A

At night, the student stays with parent(s)/guardians(s) who RENT/OWN home or apartment.

Is this student in foster care? _____ Yes _____ No

Print Name/Guardian/Adult Caring for Student: ____________________________________________________________________________

Relationship to Student: ___________________________________________________ Phone Number: _______________________________

Street Address: ______________________________________________________________________________________________________________

Email Address: __________________________________________ Signature: ______________________________________________________

Thank you. STOP HERE & PROCEED TO THE VERIFICATION OF RESIDENCY

SECTION B

At night, the student stays with:

Temporarily with another family member or friend until we can locate affordable housing.

In an emergency or transitional shelter.

In a vehicle, park, campground or on the streets.

In a house, building, or trailer WITHOUT running water or electricity.

In a hotel or motel.

With an adult that is not a parent or legal guardian.

Alone or in different locations, without an adult serving as a caregiver.

Wherever I can find a place to stay at night.

Community Children’s Shelter. Is this student awaiting foster placement? ____ Yes ____ No

Shared housing due to a natural disaster. List Disaster: ____________________________________________________________________

Since __________________ [date], our family/I have not had a permanent residence.

Below, list all children currently living with you, under the same circumstances, who attend Ardmore City Schools.

Name of Student M/F Date of Birth Grade School Attending

Would you like to be contacted by an employee of the school district to discuss additional educational services that may be available to your child? _____ Yes _____ No

I signify by my signature below that the information provided is correct & accurate.

________________________________________________________________________

Original Form to be filed in the office of Federal Programs

Step #2 - Verification of Residency for 2018-2019

Oklahoma State Law provides that a child’s residence for school purposes is the school district

in which the parent or legal guardian, or legal custodian holds legal residence.

Name of Child [Children] Enrolling: ____________________________________________________________________________________________

Physical Address of your Legal Residence: _____________________________________________________________________________________

Billing notices must be current. No service bills older than 30 days will be accepted and no “cut off” notices will be accepted.

I am providing the following original documentation for verification of residency indicating my “service address”.

Gas Bill Propane Bill On-Line Utility Pymt Printout Homestead Exemption Form

Water Bill Direct TV/Dish Bill Home Phone Bill [No Cell] Mortgage Statement

Electric Bill Internet/Cable Bill Lease/Renter Agreement

It shall be unlawful for any person to willfully make a false or misleading statement, either verbal or written, to any officer

or employee of any school in the Ardmore School District for the purpose of obtaining enrollment in the Ardmore School

District and/or for the purpose of enrolling in any particular school within the Ardmore School District. Any willful

misstatement on this form shall be a misdemeanor punishable by imprisonment not to exceed one (1) year or a fine not to

exceed five hundred dollars ($500) or both such fine and imprisonment.

Elementary Enrollment Note If it is determined that the following statement was false or misleading for enrollment purposes at one of our elementary schools, Ardmore City Schools reserves the right to require the student in question to be placed in the elementary school district that corresponds with their correct address, as required by Board Policy FBDA. I am the parent or legal guardian or the above-listed student and am seeking to enroll the above student into Ardmore

City Schools. I certify under penalties of perjury that I have read and understand the above statement and I further certify,

under penalty of perjury, that the above-named school-age child actually resides at the address given above.

____________________________________________________________ ________________________________________

Printed Name Relationship to Enrollee(s)

Signature: _____________________________________________________________ Date: __________________________________________

To Be Completed by School Enrolling Officer

I have verified that this address is within the

Ardmore City Schools attendance area

The address provided is not within the Ardmore City

Schools attendance area.

____________________________________________________

Enrollment Officer

STUDENT ENROLLMENT CARD | 2018-2019 Please Provide Complete Information about this Student

Date Grade Level School

STUDENT INFORMATION

________________________________________ __________________________________ ________________________________________________

First Name Middle Name Last Name

Social Security Number: ____________________________________________ Gender: Male Female

_______________________________ _________________________________________ ________________ ______________________________________

Date of Birth Birth City Birth State Birth Country

CONTACT INFORMATION

The first contact below should be the person the student lives with

____________________________________________________________________ __________________________________________________________________

First Name Last Name

___________________________________________________________________ __________________________________________________________________

Street Address City, State & ZIP

___________________________________________________________________ __________________________________________________________________

Mailing Address [If Different than Street Address] City, State & ZIP

_______________________________________ ________________________________ ________________________________________________________

First Call Phone # 2nd Call Phone # Email

NOTE: The first call phone number above is necessary and an email address is helpful in order to receive information via our

School Messenger system for emergency & non-emergency school notifications.

What is your Relationship to this Student?

Mother Stepmother Grandmother Legal Guardian

Father Stepfather Grandfather Aunt/Uncle

Other: _____________________________________________________________________

What relationship permissions do you have for this student? Please check all that apply.

Has Custody Access to Records Lives With Has Pickup Rights Emergency Contact

Who is your employer? ___________________________________________________________________________________________________________________

CONTACT #2

____________________________________________________________________ __________________________________________________________________


___________________________________________________________________ __________________________________________________________________

Address City, State & ZIP

CONTACT #2 - CONTINUED

_______________________________________ ________________________________ ________________________________________________________


What is Contact #2’s Relationship to this Student?



Other: _____________________________________________________________________

What relationship permissions does Contact #2 have for this student? Please check all that apply.


Who is Contact #2’s employer? ____________________________________________________________________________________________________________

CONTACT #3

____________________________________________________________________ __________________________________________________________________


___________________________________________________________________ __________________________________________________________________


_______________________________________ ________________________________ ________________________________________________________





Other: _____________________________________________________________________




CONTACT #4

____________________________________________________________________ __________________________________________________________________


___________________________________________________________________ __________________________________________________________________


_______________________________________ ________________________________ ________________________________________________________





Other: _____________________________________________________________________




Signature: _____________________________________________________________________________

Ardmore City Schools Permissions for Media | Communications | Library

School Year Student’s Printed Name School

A. Media Release _____ Yes _____ No

I consent to my child being interviewed, photographed and/or video-taped by representatives of Ardmore City Schools, its agents and independent contractors. Any information, images or videos obtained from those activities may be reproduced by the school district and/or the public media for use in advertising, publicity or educational activities, including but not limited to, district and school publications, Facebook, Instagram, cable television, print and TV news and district and/or school websites. I hereby waive any claims I may have and release the school district and its employees for any liability or claims arising out of such activities.

B. Staff/Student Communications

_____ I do not authorize Ardmore City Schools or its staff to communicate with my child outside of school.

Please contact me to relay information to my child.

_____ I authorize Ardmore City Schools or its staff to communicate with my child outside of school for issues

related to: List:

I approve communication through the following methods. [Check all that apply.}

_____ Home Phone _____ Cell Phone _____ Email _____ Social Networking Site

C. Library Permissions

_____ I give permission for the above-named child to check out library books from this school’s library. I

understand that if the book gets lost, stolen or damaged, it will be our responsibility, the parents, to

reimburse the school for the book.

_____ You may release my child’s directory information to military recruiters

_____ You may not release my child’s directory information to military recruiters.

____________________________________________________________________ _____________________________________________________________

Parent/Guardian PRINTED Name Signature

THIS PART FOR AHS STUDENTS ONLY

Board Policy

SECTION: Information Technology

CE-A.1

Ardmore City Schools

ADOPTED: May 2001

REVISED: Mar 2010

Page 1 of 1

Internet Access Conduct Agreement

Every student, regardless of age, must read and sign below:

I have read, understand, and agree to abide by the terms of the foregoing Acceptable Use

and Internet Safety Policy. Should I commit any violation or in any way misuse my access to

the school district’s computer network and the Internet, I understand and agree that my

access privilege may be revoked and school disciplinary action may be taken against me. I

understand I have no expectation of privacy with regard to my use of the school district’s

technology.

User’s Name (print clearly) _________________________________________

User’s Signature: _______________________________________________________ Date: _______________

Status

Student Staff Patron I am 18 or older I am under 18

If I am signing this policy when I am under 18,

I understand that when I turn 18, I will have to sign another policy.

Parent or Guardian: (If applicant is under 18 years of age, a parent or guardian must also read and sign

this agreement.) As the parent or legal guardian of the above student, I have read, understand, and

agree that my child or ward shall comply with the terms of the school district’s Acceptable Use and

Internet Safety Policy for the student’s access to the school district’s computer network and the Internet.

I understand that access is being provided to the students for educational purposes only. However, I

also understand that it is impossible for the school to restrict access to all offensive and controversial

materials and understand my child’s or ward’s responsibility for abiding by the policy. I am, therefore,

signing this policy and agree to indemnify and hold harmless the school, the school district, and the

Data Acquisition Site that provides the opportunity to the school district for computer network and

Internet access against all claims, damages, losses, and costs, of whatever kind that may result from my

child’s or ward’s use of his or her access to such networks and/or his or her violation of the foregoing

policy. Further, I accept full responsibility for supervision of my child’s or ward’s use of his or her access

account if and when such access is not in the school setting. I hereby give permission for my child or

ward to use the building-approved account to access the school district’s computer network and the

Internet.

Parent/Guardian (please print): ________________________________________

Signature: _____________________________________________________________ Date: _______________

This agreement is valid for the current school year only.

Parent Awareness Agreement for the 2018-2019 School Year

Student’s Printed Name School

My signature on this form indicates that I am receiving:

1) The Student Handbook

2) Title I – Parent’s Right to Know Letter from the Superintendent

3) Vaccines Required to Attend School in Oklahoma

4) Inclement Weather Guidelines for Parents

5) Internet/Computer Usage Information, which is also included in the Student Handbook

6) Information on Civility

I understand that I am responsible for reading the student handbook that has been provided to me

for my child. I am responsible for discussing the student handbook with my child. I also understand

that while all areas of the handbook are important, the following specific items of interest in the

handbook will closely be reviewed.

Attendance

Cell Phone Use & Possession

School Dress Code

Tobacco

Student Behavior/Discipline

The Student Conduct Code

Harassment/Bullying

Weapons of Any Kind (which includes toy guns, cap guns, bb guns, pellet guns, etc) I understand that

my child should not bring any weapons to school to include toy items and that the consequences for

having a weapon at school are severe.

Civility Notice

I understand that any non student or non staff member who interferes with the peaceful, orderly

conduct of school activities, to include all athletic events, will be removed from campus for a period

of six months, as per Oklahoma law.

EMERGENCY/DISASTER NOTICE

In the event of an emergency/disaster, this student will remain in their assigned school or evacuation center for up to 72

hours, until you or the person designated by your signature comes to the site and personally signs the student out. After 72

hours, your child may be transferred to the nearest Red Cross shelter. To ensure the safety of this student, only designated

school personnel or the authorities will be able to release this student. To be certain that the release of this student during

an emergency is handled in a calm, orderly way, we ask you print all information as accurately as possible and to keep

your school informed of any changes in your contact information.

Parent Printed Name Parent Signature

The Ardmore Board of Education does not discriminate on the basis of disability, race, color, religion,

national origin, sex, age, or veteran status.

Compact for Learning [School: _____________________________]

In partnership with parents and the community, the mission of Ardmore City Schools is to

educate all students through an unconditional commitment to quality and high standards.

We believe that student success is a joint effort of the home, school and community The purpose of this

Compact for Learning is to communicate a common understanding of home and school responsibilities to

assure that every student attains high standards, receives a quality education, and is, indeed, prepared for the

future.

Parent Name: Signature:

As a parent, I will strive to:

Provide a quiet place and set aside a specific time to do homework.

Look over homework assignments to check for understanding.

Sign and return all papers that require a parent’s or guardian’s signature.

Encourage positive attitude toward school.

Ensure that my child attends school daily and arrives to school on time.

Attend parent/teacher conferences and other school functions.

Encourage my child to follow the rules and regulations of the school.

Encourage positive attitudes toward school.

Teacher Name: Signature:

As a teacher, I will strive to:

Believe that each child can learn.

Respect and value the uniqueness of each child and his or her family.

Provide an environment that promotes active learning.

Assist each student in achieving success each day.

Maintain open lines of communication with students and parents.

Seek ways to involve parents in the school program.

Give assignments that are an extension of what is learned in the classroom and not merely “busy work”

or untaught concepts that may cause parents and students undue stress at home.

Give corrective feedback.

Respect cultural, racial, and ethnic differences.

Student Name: Signature:

As a student, I will strive to:

Attend school regularly.

Comply with school rules.

Accept responsibility for my own actions.

Work to resolve conflicts in positive, nonviolent ways.

Respect the personal rights and property of others.

Complete homework in a thorough, legible, and timely manner.

As principal, I represent all staff in affirming this contract.

Principal Name: Signature:

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.

☐ 2. Scored unsatisfactory or limited knowledge in Reading 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(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(s) of WIDA Screener or K-WAPT/WAPT or

WIDA MODEL

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

WIDA MODEL Composite Score Literacy Score Composite Score Literacy Score

1. 2. 1. 2.

1. 2.

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

Unsatisfactory Limited Knowledge Satisfactory Advanced



Date(s) Norm Reference Test (NRT) Name of the NRT Reading Total Composite Score(s) %

Date of the Oklahoma Pre-K Language Screening Tool

Score on Pre-K Language Screening Tool

%

20____- 20____

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

STUDENT INFORMATION

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

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

Ardmore City Schools

Special Education (IDEA) or 504

Annual Questionnaire

Student Name Date of Birth Grade

School

Please check all that apply

Yes, my student has/had an IEP or 504 Accommodation Plan at our previous school.

Yes, my student was enrolled in special education classes.

Yes, my student received related services such as Speech Therapy, Occupational Therapy

(OT) or Physical Therapy (PT)

No, my student did not have an IEP or 504 Accommodation Plan at our previous school.

No, my student was not enrolled in special education classes.

No, my student did not receive related services such as Speech Therapy, Occupational

Therapy (OT) or Physical Therapy (PT)

I do not know if my student has/had an IEP or 504 Accommodation Plan at our previous

school.

I do not know if my student received related services such as Speech Therapy,

Occupational Therapy (OT) or Physical Therapy (PT)

Parent: _____________________________________________ _____________________ Date

For Official Use Only:

This form should be returned to the Special Education Department Head at your school for site

review. Originals should be maintained on-site by the SPED Department Head and a copy of this

form should be given to the school site counselor. Initial here to indicate review by special

education Department Head. ________

Name of Student: _______________________________________________ School: _________________________

Doctor’s Name:

Phone Number:

Dentist’s Name:

Phone Number:

HEALTH HISTORY

Does this student have any medical considerations? Example: food allergies, asthma, diabetes, chronic

illnesses, seizures, …..

No

Yes [Please tell us what they are & be sure to visit with your school nurse about these conditions]

Does this student wear glasses or contacts?

Yes No

Does this student use an Epi-Pen?

Yes No

What medications does this student take at home?

What medications will this student need to take at

school?

Please note that the “Administering Medications” form must be completed before any medications

can be given at school. Check with your school nurse or principal’s office.

If you have completed this form,

STOP BY AND SEE YOUR SCHOOL NURSE AT ENROLLMENT

This form is to be kept on file in the Nurse’s Office

and data entered into WenGAGE by the School Nurse.

Title VI | JOM | Impact Aid

School Year: 2018-2019

Student Name: __________________________ School: ____________________________ Grade: ________

PLEASE COMPLETE ALL THREE SECTIONS BELOW

1 TITLE VI

Does this student, parent or grandparent of this student have a Certificate Degree of Indian Blood

[CDIB] and/or Tribal Membership card? ____ Yes ____ No

If YES, in whose name? __________________________________________________________________

ATTENTION:

If student is not already on the Ardmore City Schools Indian Education Roster, parent/guardian must

complete the Title VI Student Eligibility Certification Form 506 on the following page.

2 JOHNSON O’MALLEY | JOM

Does this student have their very own CDIB card and/or tribal membership? ____ Yes ____ No

ATTENTION

If student’s card is not already marked on the Ardmore City Schools Indian Education Roster, please

provide a copy of the card(s).

3 IMPACT AID

Does either parent or guardian who resides with this student work for the Chickasaw Nation?

____ Yes ____ No

If yes, which Division? ___ Health ___ Tribal ___ Housing ___ Commerce

Chickasaw Nation Employee ID# or Social Security #: _____________________________________________

Please print each child’s name: __________________________________________________________________

Will either parent or guardian:

a. Be on active duty in the Informed Services of the United States during the year?

___ Yes ___ No

b. Be an accredited foreign government official and a foreign military officer during this school

year? ___ Yes ___ No

c. Spend more than 50% of his or her working time on FEDERAL PROPERTY, engaged in farming,

grazing, lumbering, or mining this school year? ___ Yes ___ No

Parent/Guardian Signature: ____________________________________________ Date: _______________

Original to be kept in the Office of Indian Education

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