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
***************************************************************************************************************
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
*****************************************************************************************************
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
***************************************************************************************************************
RESIDES WITH
Name: _________________________________________________ Relationship: _________________
***************************************************************************************************************
PREVIOUS SCHOOL (circle one)
Name of school: __________________________________ Contact Number: _____________________
**************************************************************************************************************************
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)
----------------------------------------------------------------------------------------------------------------------------------
Father/Guardian: Mother/Guardian: ________________
Home Address: Home Address:
Home Phone: Home Phone:
Employer/Dept.: Employer/Dept.:
Work Phone: Work Phone:
Cell Phone: Cell Phone:
----------------------------------------------------------------------------------------------------------------------------------
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.
--------------------------------------------------------------------------------------------------------------------------------
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
[pic] |()*+_`apzŽòäÜÔлäУ‹yÐmaTD7Dhrhd+ohd+o5?CJOJQJaJh`;¶5?CJOJQJaJhZh•Rù5?OJQJhZhµnæ5?OJQJ#h×bÔh•RùCJOJQJ\?^JaJ/h"ªh•Rù5?B*CJ OJQJ\?^JaJ phÿÿÿ/h"ªh
y“5 Superintendent of Education
Daisy G. Ramirez
Principal
SY 2017 – 2018
SY 2017 – 2018
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