Vermilion Parish School Board

Pre-Kindergarten Round-Up

Round-up will be held at Abbeville Parks & Recreation Center/Boys & Girls Club 8:30 a.m. to 12:00 p.m. on the following dates:

• February 24, 2015 for students who live in DOZIER ELEMENTARY, LEBLANC ELEMENTARY,

EATON PARK ELEMENTARY, or HEROD ELEMENTARY school zones

• February 25, 2015 for students who live in CECIL PICARD ELEMENTARY, MEAUX ELEMENTARY, or INDIAN BAYOU ELEMENTARY school zones

• February 26, 2015 for students who live in KAPLAN ELEMENTARY, JESSE OWENS

ELEMENTARY, SEVENTH WARD ELEMENTARY, or F.I.E.B. ELEMENTARY school zones Children must attend this registration and will be screened in the following areas: academic, vision and dental. The entrance age for pre-kindergarten is 4 years old on or before September 30th. Your child should be potty trained to participate in the program.

Registration Requirements: • Child must be 4 years old on or before September 30, 2015 • Child must be present to complete an academic screener • The legal guardian or designee must present the following documents at the time of registration:

o Child’s birth certificate o Child’s social security card o Child’s updated immunization record o 2 proofs of domicile (one must be a current electric bill if electric bill is not in parent’s name an affidavit

must be completed and notarized) Documents must show a physical address not a post office box number The following can be an second proof: water or gas bill, apartment or house lease receipt or

documentation providing ownership, filed Homestead Exemption Application Form o 2 proofs of income (most recent check stubs, current W-2, social security check, federal income tax

return) Proof of income is required to help identify non at-risk students based on socio-economic status. Tuition will apply to some students.

o Food stamp card if applicable o Custody papers/IEP if applicable o Placement by Department of Child/Family Services if applicable (provide paperwork)

Copies will be made and originals will be immediately returned to you.

Registration is not complete until all of the above items are provided and child completes the academic screener at the end of registration process. Incomplete applications cannot be considered for placement

Vermilion Parish School Board Pre-Kindergarten Eligibility Criteria

Classes will be determined using the following criteria:

• Children whose parents qualify for free and/or reduced school lunch or parents qualify at or below 300% poverty level

• Children with an Individualized Education Plan (IEP) from the Vermilion Parish School Board Special Services Department

• Children identified as homeless, in foster care, and/or previously enrolled in the Head Start Program • Children with academic needs as identified by the Vermilion Parish Pre-kindergarten screening instrument

**Once classes have been filled with students who meet any of the above criteria, Vermilion Parish School employees’ children will be placed. CHILDREN IN ATTENDANCE AT ROUND-UP REGISTRATION WITH COMPLETE PACKETS WILL BE GIVEN FIRST CONSIDERATION FOR AVAILABLE CLASS SLOTS. YOUR CHILD WILL NOT BE REGISTERED AND PLACED IN A CLASS UNTIL ALL REGISTRATION REQUIREMENTS HAVE BEEN MET. CLASSES HAVE LIMITED SLOTS.

Information on Tuition Charges

Tuition eligibility for non at-risk students, based on socio-economic status will be determined by proof of income documents. 1. All students who are placed in a class will need to re-certify at the start of the school year by completing a 2015-2016

free/reduced lunch application. If your income status changes, this may mean a change in meal status. 2. Non at-risk students may be charged tuition divided into 10 increments from August to May. 3. Tuition will be made by bank draft. Paperwork will be provided at the time of eligibility. Incidents of default payment will

result in removal from the program.

VERMILION PARISH PRE-KINDERGARTEN APPLICATION FORM 2015-2016

School _____________________________________________________

Child’s Name ________________________________________________________________________________ (CHILD’S FULL NAME AS IT APPEARS ON BIRTH CERTIFICATE) Child’s Social Security Number _________________________________________ Gender: Male or Female

Child’s Birthday ___________/__________/___________ Current Age ___________________

Ethnicity (Please circle ONE): Black/African American White Hispanic

American Indian/Alaskan Native Asian/Pacific Islander Parent Name: Mother __________________________________ Father _____________________________________ Child lives with: Mother Father Both Other: ________________________________________________ Address: ________________________________________ City _______________________ Zip Code ______________ Mailing Address (if different from physical address): _______________________________________________________

Home Phone Number: _________________________________

Dad’s Work _______________________________________ Mom’s Work ___________________________________

Dad’s Cell _________________________________________ Mom’s Cell _____________________________________

Additional/Emergency Number(s) & Name(s)

______________________________________________________________________

________________________________________ Total Number Living in Household: _______________________

IEP with VPSB: Yes No VPSB Employee: Yes No Where? ____________________________________

Circle if applicable: Homeless Foster Care

For the past six months my child has been (circle one): license day care head start home with me with a sitter outside the home at home with a sitter other: ______________________________ I certify that all the information I have provided is correct to the best of my knowledge. I understand that providing false information is subject to penalty under the law. ________________________________________________________ ____________________________ Parent Signature Date _____________________________________________________________ _______________________________ Pre-Kindergarten Facilitator/Designee Signature Date

Louisiana Pre-K Program Intake Form 2015-2016

Confidential: All information that would identify any individual will be held strictly confidential. Instructions: Please complete all of the requested information for the items listed below. Child Identification (If both the Social Security Number (SSN) and State identification number are available, please provide the SSN.) Child’s Last Name: Child’s First Name: Middle: Suffix:

Child’s SSN or State ID: (If both the Social Security Number (SSN) and State identification number are available, please provide the SSN.)

Teacher’s Name: School/Site Code: Entry Date: Date of Birth: Ethnicity: Hispanic/Latino ______ Is the child Hispanic/Latino? Not Hispanic/Latino ______

Race – Choose one or more, regardless of ethnicity

__ American Indian or Alaska Native __ Asian __ Black or African American __ Native Hawaiian or Other Pacific Islander __ White What is the highest grade in school that the mother/female guardian completed?

__ No mother or female guardian __ High school graduate __ Below 6th grade __ Some education after high school

__ 7th grade __ Associate or vocational degree __ 8th grade __ Some college __ 9th grade __ College graduate __ 10th grade __ Some education after college __ 11th grade __ Graduate degree __ 12th grade __ Don’t know __ GED __ Other

What is the highest grade in school that the father/male guardian completed?

__ No father or male guardian __ High school graduate __ Below 6th grade __ Some education after high school __ 7th grade __ Associate or vocational degree __ 8th grade __ Some college __ 9th grade __ College graduate __ 10th grade __ Some education after college __ 11th grade __ Graduate degree __ 12th grade __ Don’t know __ GED __ Other

Intervention: Before the age of 3, did the child receive special services for a special need through Part C, such as speech/language, physical therapy, occupational therapy, or special instruction? ___ Yes ___ No Indicate the current annual household income in United States dollars: __Under $10,000 __$20,000-29,999 __$40,000-49,999 __$10,000-19,999 __ $30,000-39,999 __Over $50,000 How many children under the age of 18 currently live in the child’s household? __1 __2 __3 __4 __5 __6 __7 __8 __9 __10 or more Was the child in any type of non-parental care for a period of 6 months or longer before entering the pre-kindergarten program? __Yes __No If yes, indicate all types of child care used for 6 months or longer since birth:

__Child care center __Registered family day care __Care center in a church __At child’s home with relatives __Early Head Start (ages 0-2) __At relative’s home __Head Start __At neighbor’s home __At child’s home with paid babysitter __Other (specify) _________________

PRE-KINDERGARTEN REGISTRATION FORM

School _________________________________________________________

Last Name: ___________________________________ First Name: ____________________________________

Middle Name: ________________________________ (CHILD’S NAME AS IT APPEARS ON BIRTH CERTIFICATE) Birthdate- month/date/year: ______________________________________ Circle: Male or Female

Social Security Number: ___________________________________ Does your child have any allergies which may

require immediate medical attention?___________________________________________________

Ethnicity (Please circle one): Black/African American White Hispanic Asian/Pacific Islander American Indian/Alaskan Native Home Address: __________________________________ City: _______________ Zip Code: ________________

Home Phone Number: ________________________________________

Additional/Emergency Phone Number(s): ________________________________________________________________

Mailing Address (if different): _____________________________ City: ______________ Zip Code: _____________

Birth Father’s Name: _______________________________________________________

Birth Mother’s Name: _______________________________________________________

Guardian’s Name (if other than above names): _________________________________________________________

Guardian’s Phone Number: ___________________________________________________

Father’s Place of Employment : _______________________________________ Work Number: _________________

Mother’s Place of Employment:_______________________________________ Work Number: __________________

Whom does this child live with: (check one)

______Both Biological Parents ______Biological Mother ______Biological Father

______Biological Mother/Step-Father ______Biological Father/Step-Mother ______Court Appointed Guardian

Other (Explain): _____________________________________________________________________________________

Do you have custody of this child by virtue of a court order? YES NO

IF YES, YOU MUST INCLUDE COPY OF COURT ORDER.

I attest that the information provided by me, in answer to the above questions contained in this form, is true

and correct.

Parent/Guardian Signature _____________________________________________________________

Date__________________________________________

(OVER)

VERMILION PARISH SCHOOL BOARD

2015-2016 DOMICILE FORM

_____________________________________ __________________________________

NAME OF SCHOOL NAME OF CHILD

Dear Parent or Legal Guardian:

In order for your child to attend school in this parish, your domicile must be established. Your

domicile is the place where you actually reside. The address listed for enrolling in school must

be the physical location of your home or the address used to receive mail at your home and NOT

a post office box.

List the address at which you currently reside:

____________________________________________________________________________

Physical Address (Street, City, State, Zip)

Phone Numbers:

___________________________ ______________________ _______________________

Home Work Cell

Name on electric bill: _________________________________________________________

Relation to student: ___________________________________________________________

Address of previous domicile (home):

____________________________________________________________________________

Previous Physical Address (Street, City, State, Zip)

Who does the child live with:

______both biological parents ______biological mother/step-father

______biological mother ______biological father/step-mother

______biological father ______court-appointed guardian

______other (explain): _________________________________________________________

____________________________________________________________________________

Marital status of child’s biological parents: ____married _____single ___ separated

____ divorced _____widowed ____ natural/legal guardians (never married)

If you are SEPARATED, DIVORCED, OR NOT THE PARENT of the above child:

Do you have custody of the above named child by virtue of a court order?

____ Yes (ATTACH A COPY OF THE COURT ORDER)

____ No (give name and address of the parent or parents of the above named child)

____________________________________________________________________________

Name of Parent(s) Parent(s) Phone Number(s)

____________________________________________________________________________

Parent(s) Physical Address (Street, City, State, Zip)

I attest that the information provided by me, in answer to the questions contained in this form, is

true and correct.

RS 14:133

§133. Filing or maintaining false public records

A. Filing false public records is the filing or depositing for record in any public office or with

any public official, or the maintaining as required by law, regulation, or rule, with

knowledge of its falsity, of any of the following:

(1) Any forged document

(2) Any wrongfully altered document

(3) Any document containing a false statement or false representation of a material fact

B. The good faith inclusion of any item of cost on a Medical Assistance Program cost report

which is later determined by audit to be non-reimbursable under state and federal

regulations shall be an affirmative defense to a violation of this Section.

C. Whoever commits the crime of filing false public records shall be imprisoned for not more

than five years with or without hard labor or shall be fined not more that five thousand

dollars, or both. Amended by Acts 1980, No. 454, §1; Acts 1982, No. 676, §1; Acts 1992,

No. 539, §1; Acts 1995, No. 787, §1.

I HEREBY VERIFY THAT MY CHILD RESIDES WITH ME IN VERMILION PARISH AT

THE ABOVE ADDRESS.

I UNDERSTAND THAT UNDER THE LAW, I AM TO NOTIFY THE SCHOOL OFFICIALS

WHERE MY CHILD ATTENDS SCHOOL WITHIN 30 DAYS IF THERE IS A CHANGE OF

RESIDENT/ADDRESS, EITHER FROM WITHIN OR OUT THE PARISH.

___________________________________ ______________________________________

Signature of Parent/Legal Guardian Date

******************************************************************************

The following two or more acceptable documents are submitted to verify the above residence.

Please check appropriate documents below. The documents are current and include name and

address of the parent/legal guardian.

_____ Current electric bill is required, regardless of name on bill, and one of the following:

_____ Filed Homestead Exemption Application Form

_____ Apartment or house lease receipt or documentation providing ownership

_____ Water or Gas bill

_____ Vermilion Parish School Board Affidavit by parent/legal guardian verifying

student residence.

_____ Placement by OCS

_____ Home visit by school official

******************************************************************************

For School Officials Only:

________ Verification Accepted – permit to register is granted

________ Verification not Accepted – student is provisionally admitted pending

completion of the requirements within 2 weeks from child’s first date of

attendance.

________ Verification not Accepted

_________________________________

Signature of Principal Date

COMPLETE THIS FORM ONLY IF THE UTILITY BILL IS NOT IN THE PARENT’S NAME

VERMILION PARISH SCHOOL BOARD AFFIDAVIT BY PARENT/GUARDIAN VERIFYING STUDENT RESIDENCE

2015-2016 A parent/guardian who is residing with a friend or relative on a temporary or permanent basis must complete the official Vermilion Parish School Board Affidavit by Parent/Guardian Verifying Student Residence document.

If the school has reason to believe that information in this affidavit is incorrect, and the parent/legal guardian is in fact residing outside of the school district, the student will be required to return to the school in the district where he/she resides. Out of parish students will be withdrawn immediately from the school district.

PARENT/LEGAL GUARDIAN: ___________________________________________________________________

Physical Address (Street, City, State, Zip): ___________________________________________________________

Name of student:________________________________________________ Date of Birth: ___________________

School of attendance:_______________________________ School last attended:___________________________

_______________________________________________________________________________________________ Parent/legal guardian’s previous address: (Street, City, State, Zip)

Other children of parent/legal guardian:

Name Age School Name Age School

Parent/legal guardian and student residing with: _____________________________________________________

If resident does not own property, list the landlord/owner’s name, address, and phone number

______________________________ ____________________________________ ______________________ Landlord/Owner’s Name Address Phone Number

As the enrolling parent/legal guardian:

I, _______________________________, attest that my child/student and I are living and physically residing with the homeowner/resident at the homeowner/resident’s address. I also attest that I do not reside in any other home or residence outside of this school zone.

I’m a registered voter: ______yes ______no If yes, where do you vote: ______________________________

The parent/legal guardian has been advised and is aware that the making of intentionally false statements on this Affidavit may expose him/her and the residence owner to prosecution for false swearing under R.S. 14:125 or other laws of the state of Louisiana. (See back of page)

I have carefully read and signed this Affidavit and attest to the truth of all the information provided.

THUS SWORN AND SUBSCRIBED BEFORE ME, the undersigned Notary Public, with such civil and criminal penalties that may attach hereto this ______ day of _______________ 20_______.

_____________________________________________ ______________________________________________ Parent Signature Resident Signature ___________________________________ _____________________________________ __________________ NOTARY PUBLIC PRINTED Name of Notary Notary Seal/Number

RS 14:133 §133. Filing or maintaining false public records A. Filing false public records is the filing or depositing for record in any public office or with

any public official, or the maintaining as required by law, regulation, or rule, with knowledge of its falsity, of any of the following:

(1) Any forged document (2) Any wrongfully altered document

(3) Any document containing a false statement or false representation of a material fact B. The good faith inclusion of any item of cost on a Medical Assistance Program cost report

which is later determined by audit to be non-reimbursable under state and federal regulations shall be an affirmative defense to a violation of this Section.

C. Whoever commits the crime of filing false public records shall be imprisoned for not more than five years with or without hard labor or shall be fined not more that five thousand dollars, or both.

Amended by Acts 1980, No. 454, §1; Acts 1982, No. 676, §1; Acts 1992, No. 539, §1; Acts 1995, No. 787, §1.

I HEREBY VERIFY THAT MY CHILD RESIDES WITH ME IN VERMILION PARISH AT THE ABOVE ADDRESS. I UNDERSTAND THAT UNDER THE LAW, I AM TO NOTIFY THE SCHOOL OFFICIALS WHERE MY CHILD ATTENDS SCHOOL WITHIN 30 DAYS IF THERE IS A CHANGE OF RESIDENT/ ADDRESS, EITHER FROM WITHIN OR OUT THE PARISH. ___________________________________ ___________________________ Signature of Parent/Legal Guardian Date

Louisiana Student Residency Questionnaire Form(Form Must Be Included In School Enrollment Packet)

Date ______________ District/Parish _______________________________ School Name _______________________________

Student Name ____________________________________________________ SSN/ID# _______________________________________

Male/Female _____________ Date of Birth _____________ Address __________________________________________________

Telephone Number _____________ Last School Attended _________________________________ Current Grade ____________

Parent/Guardian/Adult Caring for Student ___________________________________________ Relationship _____________________

Disclaimer: This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant,

Individuals with Disabilities Education Act (IDEA) and/or Title X, Part C, Federal McKinney-Vento Assistance Act, 42 U.S.C.11435. Eligibility can be determined by completing this

questionnaire. It is illegal to knowingly make false statements on this form. If eligible, students are to be immediately enrolled in accordance with Bulletin 741, section 341.

1. Yes No Is the student’s address a temporary living arrangement? (Note: If this is a permanent living arrangement or the family owns or rents their home, sign under item 9 and submit form to school personnel.)

2. Yes No Is the temporary living arrangement due to loss of housing or economic hardship?

3. Where is the student currently living? (Check all that apply)

In an emergency/transitional shelter. Awaiting foster care placement. Temporarily with another family because we cannot afford or find affordable housing. With an adult that is not a parent or legal guardian, or alone without an adult. In a vehicle of any kind, trailer park or campground without running water/electricity, abandoned building or substandard housing. Emergency Housing (i.e. FEMA Trailer or FEMA Rental Assistance) In a hotel/motel. Other specific information __________________________________________________________

4. Yes No Does your child have a disability or receive any special education services? (Check One)

5. Yes No Does your child exhibit any behaviors that may interfere with his or her academic performance?

6. Would you like assistance with uniforms student records school supplies transportation other? ____________________ (Describe: _____________________________________________________________________________________________________ )

7. Yes No Migrant - Have you moved at any time during the past three (3) years to seek temporary or seasonal work in agriculture (including poultry processing, dairy, nursery, and timber) or fishing?

8. Yes No Does your child have siblings (brothers or sisters)? Note: Use back of page if more space is needed.

9. The undersigned certifies that the information provided above is accurate.

__________________________________________________________________________________________________________________Print Parent/Guardian Name/Adult Caring for Student Signature Date

__________________________________________________________________________________________________________________(Area Code) Phone number Street Address City State Zip

School Use Only Free or Reduced Price Meals Form submitted/signed Copy Placed in Student’s Cumulative Record

Homeless Liaison Use Only- Check All That Apply

Sheltered Doubled-Up Unsheltered/FEMA Hotel/Motel Unaccompanied Youth Yes No Awaiting Foster Care Placement

__________________________________________________________________________________________________________________Print School Contact Title Signature (required) Date (Revised 3/2012)

Name __________________________ School ___________________________ Grade _____________ DOB _____________Name __________________________ School ___________________________ Grade _____________ DOB _____________Name __________________________ School ___________________________ Grade _____________ DOB _____________

HOME LANGUAGE SURVEY

Dear Parent/Guardian: The Vermilion Parish School Board is requesting the following information. We are required to know the language(s) spoken and heard in each child’s home. This information will be used to provide the best instruction possible for all students. Please answer the following questions. Even though your child may speak only English, it is absolutely necessary that you complete this form. Your cooperation in this matter is greatly appreciated.

SCHOOL: ______________________________________________________________ STUDENT’S NAME: ____________________________________________________ GRADE: Pre-Kindergarten PARENT’S NAME: (MOTHER) ___________________________________________

(FATHER) ___________________________________________ OR (LEGAL GUARDIAN):__________________________________________

ADDRESS: __________________________________ City ____________ Zip ___________ HOME PHONE: ________________________CELL PHONE: _______________________ CHILD’S GENDER (CHECK ONE): MALE___________ FEMALE___________ ETHNICITY OF CHILD (CIRCLE ONE): WHITE ASIAN, PACIFIC ISLANDER BLACK NATIVE AMERICAN-ALASKAN NATIVE HISPANIC

ENTRY DATE INTO THE UNITED STATES: ______________________________ CHILD’S COUNTRY OF BIRTH: _________________________________________ LANGUAGE OTHER THAN ENGLISH USED AT HOME: ___________________ FIRST LANGUAGE (NATIVE) LEARNED BY STUDENT: ___________________ LANGUAGE STUDENT USES MOST OFTEN: _____________________________

(Retain original in child’s cumulative folder)