DEPARTMENT OF EDUCATION



|*** REGISTRATION CHECKLIST *** |

Name of student: ___________________________________

Has your child previously been enrolled in a Guam Public School?

___no ___yes (please specify school and grade) __________________________________

Note:

1. ALL documents listed below are required prior to your child being registered at HS Truman Elem.

2. INCOMPLETE REGISTRATIONS will not be accepted.

3. Please present a picture ID for identification purposes when registering your child. If you are not the parent or guardian, a letter of authorization accompanied by an ID of the parent is required.

New Entry (Pre-gate, Headstart, Off island, Private School, Homeschool, & Charter School )

|Required documents |(√) if |Comments |

| |submitted | |

|Completed Registration Packet | | |

|(demographics & student emergency information) | | |

|Shot Record / Health Audit & Physical Exam | | |

|(TB skin test & Physical Exam must be within a year) | | |

|Birth Certificate | | |

|Mayor’s Verification | | |

|Certificate of Promotion and Report Card | | |

|(only if student is coming from a private, off island, home or charter school)| | |

|Withdrawal from previous school | | |

|(only if student is coming from a private, off island, home or charter school)| | |

|Home Language Survey | | |

On island transferee from another Public School

|Required documents |(√) if |Comments |

| |submitted | |

|Completed Registration Packet | | |

|(demographics & student emergency information) | | |

|Health Audit | | |

|Mayor’s Verification | | |

|Certificate of Promotion, Progress Report or Report Card | | |

|Withdrawal from previous school | | |

|Home Language Survey | | |

The information provided below will be your child’s regular route unless a written parent consent is provided to your child’s teacher or the school’s Main Office.

Telephone authorizations will not be honored.

Student is a:

____ Bus Rider (Street Name)______________________________/ ____ Walker / ____ Car Rider

Do not write below this line. For school use only.

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Reviewed & Received by: ______________________________ Date Received: ___________

NOTES: ______________________________________________________________________

Inputted by: ______________________________ Date Inputted: ____________________ Assigned Teacher: __________________________

GUAM DEPARTMENT OF EDUCATION

HARRY S. TRUMAN ELEMENTARY SCHOOL

PLEASE PRINT ALL ENTRIES

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DATE:____________________________

(Please Circle One Code)

ENTRY CODES

E1 Original Entry (Only First Time Kindergarten) R5 From Another Public School after

R2 From Another Public School on Guam Withdrawal or Expulsion

R3 From a Non-Public School on Guam R6 From the same Guam Public School

R4 From a School Off Island After Withdrawal or Expulsion

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NAME _____________________________________________________________ GR. Level _______ SEX (M or F)_______

Last First MI

D.O.B.____________________ Place of Birth__________________ Tel. #___________________________

Home Address: _________________________________________________________________________________________________

House # Street Name Village

Mailing Address: _______________________________________________________________________________________________

Home or PO Box # Village Zip

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RESIDES WITH

Name: _________________________________________________ Relationship: _________________

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PREVIOUS SCHOOL (circle one)

Name of school: __________________________________ Contact Number: _____________________

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ETHNIC BACKGROUND (needed for statistical purposes – circle one only)

A Chamorro E Japanese K Pohnpeian Q Hispanic

AR Rota F Chinese L Chuukese R Amer Indian,

AT Tinian G Korean M Yapese Alaskan Nat

AS Saipan H Hawaiian N Marshallese S Indonesian

B Filipino I Samoan O Belauan T Other Pacific

C White Non-Hispanic J Kosraean P Vietamese Islander

D African-American

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

FEDSTAT (circle one)

A Navy (Military) G Coast Guard (Military) M All others

B Navy (Civilian) H Coast Guard (Civilian) N Reserves (Inactive/Part Time)

C Air force (Military) I Marine Corp (Military) O National Guard (Inact/Part Time)

D Air force (Civilian) J Marine Corp (Civilian) P Retired Military

E Army (Military) K Other Federal Agencies Q Active Reserves/Nat. Guard

F Army (Civilian) L Student 1-20

LIVSTAT (circle one)

1 Live and Work on Federal Property 3 Live on Federal Property (includes low cost housing)

2 Work on Federal Property 4 Non-Federally Connected

CITIZEN STATUS (circle one)

1 US Citizen 5 FSM Citizen

2 CNMI Citizen 6 Marshallese Citizen

3 Permanent Resident Alien(Green Card) 7 Belauan Citizen

4 1-20/Foreign Student/F-1 Visa

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

PARENT / GUARDIAN INFORMATION

MOTHER’S NAME: __________________________________ FATHER’S NAME: ____________________________________

Employer’s Name: ___________________________________ Employer’s Name: ____________________________________

Work Telephone: ____________________________________ Work Telephone: _____________________________________

Home Phone: ________________________________________ Home Phone: _________________________________________

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

PLEASE DRAW A MAP TO YOUR HOUSE: (DIRECTIONS TO WHERE YOU LIVE)

I certify that the above statements I have made above are true and correct.

______________________________________________________ ___________________________________

Signature of Parent/Guardian Date

Guam Department of Education

HARRY S. TRUMAN ELEMENTARY SCHOOL

Student Emergency Information SY 2017-2018

Student Name: ____________________

Last First Middle Initial

Date of Birth: ____/_____/____ Male or Female Grade:____ Room: ______ Ethnicity:_______________

Mon Day Year (circle one)

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Father/Guardian: Mother/Guardian: ________________

Home Address: Home Address:

Home Phone: Home Phone:

Employer/Dept.: Employer/Dept.:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

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It is required to provide an alternate contact name and number of an adult who can pick your child up from school if you cannot be contacted. All adults will be required to show photo identification when picking up your child. Students will be released ONLY to those listed below.

|Name |Relationship to child |Home Phone |Work Phone |Pager/Cellular |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

In the event of a food borne illness, DOE/DPHSS is authorized to obtain stool/vomit samples from my child in the interest of public health. [ ] Yes [ ] No

I give permission for the ambulance to transport my child to [ ] GMH [ ] Naval Hospital

My child is able to participate in regular PE classes.

[ ] Yes [ ] No If answer is “No”, doctor’s note is required.

Parent/Guardian(s) Signature: Date:_________

(Please turn over and complete the back of the form)

Basic Health Data

(To be filled out by Parent/Guardian(s) to effectively meet the health needs of your child at school.)

|YES |NO |Complete checklist below regarding your child. |

| | |Rheumatic Fever |

| | |Diabetes |

| | |Heart Disease |

| | |Skin Problems [ ] Eczema [ ] Other |

| | |Seizures Date of last seizure: |

| | |Hearing Problems Hearing Aid: [ ] Yes [ ] No |

| | |Vision Problem [ ] Glasses [ ] Contact |

| | |Lenses |

| | |Asthma [ ] Inhaler [ ] Nebulizer Date of last asthma attack: |

| | |Allergy to: [ ] Food [ ] Drug [ ] Other Specify: |

| | |Allergy to: [ ] Bee Sting [ ] Insect Bite Type of reaction: |

| | |Epipen [ ] Yes [ ] No ER visit for reaction [ ] Yes [ ] No |

| | |Current Medications: Reason: |

| | |Other Serious Illness or Injury: Please Specify: |

| | |Other Physical or Mental Problems: Please Specify: |

Please draw a map to your house.

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List the names of all your children who are attending this school (Including Head Start) from oldest to youngest.

|Child’s Name |Grade |Room |

|1. | | |

|2. | | |

|3. | | |

|4. | | |

|5. | | |

|6. | | |

|7. | | |

-----------------------

HARRY S. TRUMAN ELEMENTARY SCHOOL

182 Pale Ferdinand Way, Santa Rita

Department of Education

500 Mariner Avenue Barrigada, Guam 96913

Tel: 565-5195

Jon P. Fernandez

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y“5 Superintendent of Education

Daisy G. Ramirez

Principal

SY 2017 – 2018

SY 2017 – 2018

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