FOR OFFICE USE

Start Date:

Key Pad #:

WASHOUGAL SCHOOL DISTRICT STUDENT REGISTRATION FORM

STUDENT NAME: Legal Name (Last, First, Middle)

Also known as: Grade Level

BIRTHDATE (Month/Day/Year) BIRTHPLACE (City/State/Country) GENDER Male Female

PRIMARY LANGUAGE STUDENT SPEAKS AT HOME: English Spanish Russian Other:

PRIMARY HOUSEHOLD WHERE STUDENT RESIDES PARENT/GUARDIAN First Name Last Name

PRIMARY PHONE FOR NOTIFICATIONS – Used for automated call system (include area code)

Home Cell ( )

STUDENT RESIDES WITH

Both parents Father only Mother only Joint Custody Grandparent(s) Father/Stepmother Mother/Stepfather Other Family Member Legal Guardian Self Agency Foster Home Other (specify)

Email Address Additional phones: ( ) Home Cell Work ( ) Home Cell Work

First Name Last Name Additional phones: ( ) Home Cell Work ( ) Home Cell Work

Email Address:

PHYSICAL ADDRESS WHERE FAMILY RESIDES – Required City State Zip MAILING ADDRESS – If different from physical address City State Zip

USE THIS SECTION TO PROVIDE INFORMATION FOR STUDENTS WITH A SECOND HOUSHOLD

SECONDARY HOUSEHOLD PARENT/GUARDIAN First Name Last Name

PRIMARY PHONE FOR NOTIFICATIONS – Used for automated call system (include area code)

Home Cell ( )

Relationship to student

Emergency Contact

Email Address Additional phones: ( ) Home Cell Work ( ) Home Cell Work

First Name Last Name Additional phones: ( ) Home Cell Work ( ) Home Cell Work

Relationship to student

Emergency Contact Email Address: PHYSICAL ADDRESS WHERE FAMILY RESIDES City State Zip

MAILING ADDRESS – If different from physical address City State Zip

IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? Yes No (provide copy to school) IS THERE A RESTRAINING ORDER IN EFFECT? Yes No (provide copy to school) RESTRAINING ORDER AGAINST: Father Mother Other:_____________________________ IS THERE A LEGAL RESTRICTION PREVENTING THE NON-CUSTODIAL PARENT FROM VISITING THE SCHOOL OR REMOVING THE STUDENT FROM THE SCHOOL: Yes No (provide copy to school) IS THERE A LEGAL RESTRICTION PREVENTING THE SCHOOL FROM SENDING COPIES OF REPORT CARDS TO 2nd HOUSEHOLD? Yes No

SCHOOL PREVIOUSLY ATTENDED

SCHOOL DISTRICT PREVIOUSLY ATTENDED PREVIOUS SCHOOL LOCATION (City & State)

DID STUDENT FORMALLY WITHDRAW: Yes No If yes, date of withdrawal:

HAS STUDENT EVER ATTENDED WASHOUGAL PUBLIC SCHOOLS? Yes No If yes, name of school attended:

If enrolling from out of state, has student ever attended Washington State Public Schools? If yes, name of school & district:

ETHNICITY AND RACE - PLEASE ANSWER BOTH QUESTIONS 1 AND 2

BOTH RESPONSES ARE PER WASHINGTON STATE AND FEDERAL REQUIREMENTS Question 1: Is your child of Hispanic or Latino origin? à (Check all that apply)

Answer: NOT HISPANIC-10

CENTRAL AMERICAN-75 CUBAN-55

DOMINICAN -60 LATIN AMERICAN-85 MEXICAN / CHICANO /

MEXICAN AMERICAN-30

PUERTO RICAN-70 SOUTH AMERICAN-80 SPANIARD-65 OTHER HISPAN./LATIN-90

Question 2: What race do you consider your child? à (Check all that apply)

Answer: AFRICAN AMER./BLACK-200

WHITE / CAUCASIAN-300

ASIAN INDIAN-505 CAMBODIAN-507 CHINESE-510 FILIPINO-520 HMONG-525 INDONESIAN-530 JAPANESE-535 KOREAN-540 LAOTIAN-545 MALAYSIAN-550 PAKISTANI-555 SINGAPOREAN-560 TAIWANESE-565 THAI-570 VIETNAMESE-575 OTHER ASIAN-599

NATIVE HAWAIIAN-605 FIJIAN-615 GUAMANIAN/CHAMORRO-620 MARIANA ISLANDER-625 MELANESIAN-630 MICRONESIAN-632 SAMOAN-635 TONGAN-640 OTHER PACIFIC ISLAND-699 ALASKAN NATIVE-405 CHEHALIS-410 COLVILLE-416 COWLITZ-416 HOH-418 JAMESTOWN-421 KALISPEL-424 LOWER ELWHA-427 LUMMI-430 MAKAH-433 MUCKLESHOOT-436

NISQUALLY-439 NOOKSACK-442 PORT GAMBLE

CLALLAM-445 PUYALLUP-448 QUILEUTE-451 QUINAULT-454 SAMISH-457 SAUK-SUIATTLE-460 SHOALWATER-463 SKOKOMISH-466 SNOQUALMIE-469 SPOKANE-472 SQUAXIN ISLAND-475 STILLAGUAMISH-478 SUQUAMISH-484 TULALIP-487 YAKAMA-490 OTHER WA INDIAN-495 OTHER AMER. IND.-499

STUDENT PROGRAMS/ADDITIONAL INFORMATION Are there any school activities in which

your student should not participate? Yes No If yes, please provide

information to school in writing on a separate sheet. Does student have a Boundary Exception? Yes No If yes, from what district: _________________________________ Has student ever been retained?

Yes No Grade? ______________

Indicate if student has ever been enrolled in the following programs: Special Education 504 Plan Title/Lap ELL Gifted/HiCap Other

Yes No If yes: Current IEP Exited Program

Yes No If yes: Current Plan Exited Program

Yes No If yes: Current Plan Exited Program Yes No If yes: Current Plan Exited Program Yes No If yes: Current Plan Exited Program Yes No Specify: ___________________________

Has student ever been suspended for a weapons violation? Yes No Date: _________________________________ Has student ever been long-term suspended or expelled? Yes No Date: _________________________________ Has student ever had a drug violation? Yes No Date: _________________________________ Has student ever had an alcohol violation? Yes No Date: _________________________________ Has student ever been adjudicated or had diversion agreements? Yes No Date: _______________________________ Does student have a probation officer or caseworker? Yes No Name: ______________________________________

PLEASE LIST OTHER SIBLINGS ATTENDING WASHOUGAL PUBLIC SCHOOLS Student Name School Grade

IS STUDENT BUSED TO/FROM CHILD CARE?

Before school After school Before & after school

CHILD CARE PROVIDER: Address: Phone:

DOES THE STUDENT HAVE ANY LIFE THREATENING HEALTH CONDITIONS? If yes, please list: _____________________________________________________________________________________________________________________ (More detailed information will be requested on Student Health Inventory Form)

VERIFICATION OF ENROLLMENT: The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Washougal School District. _______________________________________________________________________ Student Name _______________________________________________________________________ __________________________

Parent/Legal Guardian/Adult Student Signature Date 9/2015

EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of an accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child. Parent/Guardian Signature __________________________________________________________________ Date _________________________ *If health exemptions exists based on religious beliefs, please list those here: ______________________________________________________ ____________________________________________________________________________________________________________________ If injury, illness or other nonemergency situations occur involving your child, the District needs to be able to quickly reach families or other responsible adults. In the event you cannot be reached, please list persons you trust who are available during the day to provide care for your child (local area only please). If you wish to add more than 4 emergency contacts, please list on an additional page. Student Release Authorization: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed below. Parent/Guardian Signature __________________________________________________________________ Date _________________________ EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

EMERGENCY CONTACT (Other than parent/guardian) Last Name First Name

RELATIONSHIP TO STUDENT Home Phone ( )

Cell Phone ( )

Work Phone ( )

WASHOUGALSCHOOLDISTRICT

REQUESTFORSENDINGPERSONALLYIDENTIFIABLERECORDS

StudentName______________________________________________________________________Grade:_____________Birthdate_________________________________NewSchoolStartDate:___________________________

CapeHorn-SkyeElementary GauseElementary HathawayElementary9731WashougalRvrRd 110034thSt 63024thStWashougal,WA98671 Washougal,WA98671Washougal,WA98671Ph360-954-3600 Ph360-954-3702 Ph360-954-3802Fax360-837-3906 Fax360-954-3799 Fax360-335-0511

CanyonCreekMiddleSchool JemtegaardMiddleSchool9731WashougalRvrRd 35300SEEvergreenHwyWashougal,WA98671 Washougal,WA98671Ph360-954-3500 Ph360-954-3406Fax360-837-1500 Fax360-835-9145

WashougalHighSchool ExcelsiorHighSchool120139thSt 140139thStWashougal,WA98671 Washougal,WA98671Ph360-954-3105 Ph360-954-3300Fax360-954-3981 Fax360-835-1182Pleaseforwardthefollowingpertinentrecords:____PermanentRecords ____HealthRecords ____SpecialEducation/ESL/ELL ____StateHistoryRequirement____Attendance ____Discipline ____LegalDocs(courtorders) ____Other:____504Plan ____OfficialTranscript ____BirthCertificate(copy)PREVIOUSSCHOOLATTENDED:

_________________________________________________________ ____________________________________________________________NameofSchool Parent/GuardianName–PLEASEPRINT_________________________________________________________ ___________________________________________________________AddressofSchool Parent/GuardianSignature _________________________________________________________ ___________________________________________________________City/State/ZipCode RelationshiptoStudent_________________________________________________________ DateRecordsRequested:______________________________SchoolPhone#________________________________________________________ SecondRequestSent:__________________________________SchoolFax#

AsprovidedundertheFamilyRightsandPrivacyActof1974,IunderstandthatImayobtainacopyofmychild’spersonallyidentifiablerecords.IamawarethatImaychallengethecontentoftheserecords.Ialsounderstandthattheschoolwilltreattheserecordswithconfidentiality.Finally,noonewillsendtheserecordstoanon-publicschoolagencywithoutmywrittenconsent.Parentalpermissionisnolongerrequiredwhenachildenrollsinaschoolandrecordsarerequestedbyauthorizedschoolpersonnel.[FamilyEducationalRightsandPrivacyActof1974(FERPA)20USC&232g;34CFR&99.31] FormRevised4/17/15

Certificate of Immunization Status (CIS) DOH 348-013 January 2015

Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System. Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex:

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record.

Parent/Guardian Signature Required Date

Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only

■ Recommended, but not required

I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Date

Vaccine Dose Date

Month Day Year Hepatitis B (Hep B) 1 2 3 or Hep B - 2 dose alternate schedule for teens 1 2

■ Rotavirus (RV1, RV5) 1 2 3 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 1 2 3 4 5 Tetanus, Diphtheria, Pertussis (Tdap) 1

■ Tetanus, Diphtheria (Td) 1 2 Haemophilus influenzae type b (Hib) 1 2 3 4

■ Influenza (flu, most recent)

Vaccine Dose Date

Month Day Year Pneumococcal (PCV, PPSV) 1 2 3 4 5

Polio (IPV, OPV) 1 2 3 4

Measles, Mumps, Rubella (MMR) 1 2

Varicella (chickenpox) 1 2

■ Hepatitis A (Hep A) 1 2

■ Human Papillomavirus (HPV) – does not print from the IIS; write dates in by hand 1

2

3

■ Meningococcal (MCV, MPSV) 1 2

If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option 1, 2, OR 3 below (see # 5 on back) 1) Chickenpox disease verified by printout from the Immunization Information System (IIS) Must be marked by printout (not by hand) to be valid. 2) Chickenpox disease verified by healthcare provider (HCP) If you choose this box, mark 2A OR 2B below.

2A) Signed note from HCP attached OR 2B) HCP sign here and print name below:

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name: 3) Chickenpox disease verified by school staff from the Immunization Information System

If the child can show immunity by blood test (titer) and hasn’t had the vaccine, ask your HCP

to fill in this box. Documentation of Disease Immunity

I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached.

Diphtheria Hepatitis A Hepatitis B Hib Measles

Mumps Polio Rubella Tetanus Varicella

Other: _______________

_______________

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name:

Office Use Only: Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

EXAMPLE

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

#1 To print with information filled in: First, ask if your healthcare provider’s office puts vaccination history into the WA Immunization Information System (Washington’s statewide database). If they do, ask them to print the CIS from the IIS and your child’s information will fill in automatically. Be sure to review all the information, sign and date the CIS, and return it to school or child care. If your provider’s office does not use the IIS, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):

#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the

“Vaccine” column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here

#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#5 If your child had chickenpox (varicella) disease and not the vaccine, use only one of these three options to record this on the CIS: 1) If your child’s CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box 1 is automatically

marked. To be valid, this box must be marked by the IIS printout (not by hand). 2) If your healthcare provider can verify that your child had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your provider, or

2B if your provider signs and dates in the space provided. Be sure your provider’s full name is also printed. 3) If school staff access the IIS and see verification that your child had chickenpox, they will mark box 3.

#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your healthcare provider fill in this box. Ask your provider to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.

#7 Be sure to sign and date the CIS, and return to the school or child care.

Vaccine Trade Names in alphabetical order (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)

Trade Name Vaccine Trade

Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB Hib FluLaval Flu Ipol IPV PedvaxHIB Hib Twinrix (Twnrx) Hep A + Hep B

Adacel Tdap FluMist Flu Infanrix DTaP Pentacel (Pntcl) DTaP + Hib + IPV Vaqta Hep A

Afluria Flu Fluvirin Flu Kinrix (Knrx) DTaP + IPV Pneumovax PPSV or PPV23 Varivax Varicella

Boostrix Tdap Fluzone Flu Menactra MCV or MCV4 Prevnar PCV or PCV7 or PCV13

Cervarix HPV2 Gardasil HPV4 MenHibrix (Mnhbrx)

Meningococcal C/Y- HIB-PRP

ProQuad (PrQd) MMR + Varicella

Daptacel DTaP Havrix Hep A Menomune MPSV or MPSV4 Recombivax HB Hep B

Engerix-B Hep B Hiberix Hib Menveo Meningococcal Rotarix Rotavirus (RV1)

Fluarix Flu HibTITER Hib Pediarix (Pdrx) DTaP + Hep B + IPV RotaTeq Rotavirus (RV5)

Vaccine Abbreviations in alphabetical order (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf) Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A (HAV) Hep B (HBV)

Hepatitis A Hepatitis B

MPSV or MPSV4 Meningococcal Polysaccharide Vaccine

Rota (RV1 or RV5)

Rotavirus

DTaP Diphtheria, Tetanus,

acellular Pertussis Hib

Haemophilus influenzae

type b MMR / MMRV

Measles, Mumps, Rubella /

with Varicella Td Tetanus, Diphtheria

DTP Diphtheria, Tetanus, Pertussis

HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Tetanus, Diphtheria, acellular Pertussis

Flu

(IIV or LAIV) Influenza IPV

Inactivated Poliovirus

Vaccine

PCV or PCV7 or

PCV13

Pneumococcal Conjugate

Vaccine TIG Tetanus immune globulin

HBIG Hepatitis B Immune Globulin

MCV or MCV4 Meningococcal Conjugate Vaccine

PPSV or PPV23 Pneumococcal Polysaccharide Vaccine

VAR or VZV Varicella

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 January 2015

Vaccine Dose Date Month Day Year

Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 1 01 12 2011 DTaP 2 03 20 2011 DTaP 3 06 01 2011

Superintendent ◆ Michael Stromme

IMMUNIZATIONRECORDSREQUIRED–FIRSTNOTICEStudentName:Toparentorguardian,Thisletterisyourfirstnotificationthatweneedacopyofyourstudent’simmunizationrecord.WashingtonStateImmunizationLaw(RCW210.080)requiresthatallstudentsbeproperlyimmunizedinordertoattendorcontinueattendingschool.AllstudentsmustalsosubmitasignedCertificateofImmunizationStatusformattimeofregistration.Pleaseturnindocumentationofimmunizationtotheschoolofficeassoonaspossible.WashougalSchoolDistrictwillexcludeyourstudent30daysafterhe/shestartsschoolwithoutdocumentationforcomplianceasstatedintheStateImmunizationLawlistedabove.Thankyouforyourhelpinthismatter.WashougalSchoolDistrict_______________________________________________________Parent/GuardiansignatureacknowledgingreceiptofthisnotificationDatereceived:__________________

Student Health History & Emergency Medical Treatment Consent Form School Year _____________

Rev. 4/2009 Reviewed by School Nurse:

Student

School Grade/Teacher

Address

Birth Date Gender

Parent/Guardian/Emergency Contacts Relationship ☎ Phone Call 1st: Home: Cell: Work: Call 2nd: Home: Cell: Work: Call 3rd: Home: Cell: Work:

Student’s doctor/healthcare provider: _________________________________________ Phone: _______________ Insurance Information: ____________________________________________________________________________ (Include Group’s Name, ID Number, Group Number, and Subscriber) INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH ANY OF THE FOLLOWING:

If your child has a life-threatening condition, state law requires that medication and/or treatment orders from your licensed healthcare provider, and an Emergency Plan prepared by the School Nurse, must be in place before your child can attend school.

The information on this form may be shared confidentially with school staff and emergency responders as needed. In the event of a medical emergency with my child, I understand every effort will be made to inform me. If emergency care is needed, I authorize qualified professionals to provide assessment, diagnosis and any necessary emergency treatment. I understand that the school district assumes no financial liability for expenses incurred due to accident, injury and/or unforeseen circumstance.

_____________________________________ _________________________________ __________ PARENT/GUARDIAN SIGNATURE PRINTED NAME DATE

Health Condition Yes No Explanation if “Yes” Medication Allergies List: Food Allergies

Food(s): peanut dairy eggs other ____________________________ Rate the reaction: mild moderate life-threatening Does your child require an EpiPen? yes no

Allergy to Bees Stings

Rate the reaction: mild moderate life-threatening Does your child require an EpiPen? yes no

Allergies (other) List: Asthma

Rate the severity: mild moderate life-threatening Asthma medication taken at home: Medication required at school:

Diabetes

Type 1 (Insulin Dependent) Type 2 Diabetes medication(s) taken at home:

Seizure Disorder Type of Seizure: Medications:________________________________ Neurological Disorder Specify: Heart Condition Specify: Blood Disorder Specify: Treatment: Cancer Specify: Treatment: Bowel/Bladder Issues Specify: Migraine Headaches Triggers: Treatment: Bone/Muscle Problems Specify: Activity Restrictions: ADD/ADHD Medication for ADD/ADHD: Mental Health Behavioral Issues

Specify: Treatment/Medication:

Wears Glasses/Contacts Glasses Contacts For Distance For Reading Hearing Loss Hearing Loss Right Ear Hearing Loss Left Ear Hearing Aid(s) Other Serious Illness Specify: Date of Onset: Serious Injury Specify: Date(s): Surgery Specify: Date(s): Medication Taken at Home (if not already listed)

List:

English

May 2014

Office of Superintendent of Public Instruction (OSPI)

Home Language Survey

Student Name:

Date:

Birth Date: Gender: Grade:

Form Completed by:

Parent/Guardian Name Relationship to Student

Parent/Guardian Signature

If available, in what language would you prefer to receive communication from the school?

Did your child receive English language development support through the Transitional

Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__

1. In what country was your child born?

____________________

2. What language did your child first learn to speak?*

__________________

3. What language does YOUR CHILD use the most at home?* ____________________

4. What language(s) do parent/guardians use the most when you speak

to your child?

_____________________

_____________________

5. Has your child ever received formal education* outside of the United

States? (Kindergarten – 12th grade)

_____Yes _____No

”Formal education” does not include refugee camps or other unaccredited

programs for children.

If yes, in what language(s)

was instruction given?

_____________________

For how many months? ____

6. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________

Month Day Year

7. Do grandparent(s) or parent(s) have a Native American tribal

affiliation?

_____Yes _____No

*WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by

parents, guardians, or others) for communication in the student's place of residence.

Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing

English

May 2014

The Purpose of the Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools. The following

information should help answer some of the questions you may have about this form.

What is the purpose of the Home Language Survey?

The primary purpose of the Home Language Survey is to help identify students who may qualify for

support to help them develop the English language skills necessary for success in the classroom and who

may qualify for other services. It is important that this information be correctly recorded since it can

affect the eligibility of students for services they need to be successful in school. Testing may be

necessary to determine whether or not additional language and academic supports are needed. No

student will be placed in an English language development program based solely on responses to this

form.

Why do you ask about the student’s first language and language(s) used in the home?

The two questions about the student’s language help us to determine:

if your student may be eligible for assistance with learning English, and

whether staff at the school should be aware of other languages being used by the student at home.

The language your child first learned may be different from the language your child uses for

communication at home now. The responses to both of these questions will assist the school in providing

instruction appropriate to the individual student’s needs as well as help with communication needs that

may arise. Students who first learned a language other than English may qualify for additional supports.

Even students who speak English well may still need support in developing the language skills needed to

be successful in school.

Why do you ask where the student was born?

This information helps the school district and the state determine if the student meets the definition of

immigrant for the purposes of federal funding. This applies even when the student’s parents are both US

citizens, but the student was born outside of the United States. This form is not used to identify students

who may be undocumented.

Why do you ask about my student’s previous education?

Information about a student’s education will help ensure that the student’s education both within and

outside of the United States is considered in any recommendations made for participation in programs and

district services. The student’s educational background is also important information to help determine if

the student is making adequate progress toward state standards based on their prior educational

background.

Thank you for providing the information needed on the Home Language Survey. Contact your school

district if you have further questions about this form or about services available at your child’s school.

Washougal School District 4855 Evergreen Way

Washougal, WA 98671

Student Housing Questionnaire Please use one form per student. Return to school registration office. Also, please fill out this form if you have a pre-school aged student. If you require additional copies, please contact your school. Name of Student:

First Middle Last Name of School:

Grade:

Birthdate:

Age:

Month/Day/Year Sex: Male Female The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. 1. Is this student’s home address a temporary living arrangement? Yes No 2. Is this a temporary living arrangement due to a loss of housing or economic hardship? Yes No 3. Is this student in a temporary foster care placement or awaiting foster care? Yes No 4. As a student, are you living with someone other than your parent or legal guardian? Yes No If you answered YES to any of the above questions, please complete the remainder of this form. If you answered NO to all of the above questions, you may stop here.

Where is this student currently living? (check box)

In a motel Transitional Housing

In a shelter Group Home

With more than one family in a house or apartment

Moving from place to place

In a location not designed for sleeping accommodations such as a car, park or campsite

ADDRESS OF CURRENT RESIDENCE:

(OR)

NAME OF MOTEL/SHELTER OF CURRENT RESIDENCE:

(OR)

NAME OF “GENERAL AREA” OF CURRENT RESIDENCE:

PHONE NUMBER OR CONTACT NUMBER:

NAME OF CONTACT:

Print name of parent(s)/legal guardian(s):

(Or unaccompanied youth) Signature of parent/legal guardian:

Date:

(Or unaccompanied youth)

For School Staff Only: If student may qualify for McKinney-Vento services, forward to building liaison, then district liaison. Revised 3/9/16