I/¡11 Public Schools NEW STUDENT REOPEN ENROLLMENT FORM

School Name: ___________

STUDENT HEALTH APPRAISAL: (Th1s information wi/1be used byO1strictHealthstaffto help ourstudent

Student Legal Name:

Does yourstudenthave a physical disability? No Yes---------------------------------

2 Doesyourstudentwearglassesorcontacts? l'ilo Yes--------------------------------

3 ls yourstudenttaking any medication?

No Yes ________________________________

il Will yourstudenttake medicine at school?

No Yes (list medicine and condition) _______________________

5 Is your student able to participate fully in activities al school? Yes No (if no, please explain) _____________________

6 Check ifyour student has anyof thefollowing?

Allergies-food: _____________ Allergies-insects: ____________ Allergies-seasonal: ____________

O Allergies-misc: _____________

Asthma

O Check if Life Threatening O Check if Life Threatening O Check if Life Threatening O Check if Life Threatening

Check if LifeThreatening

Diabetes Heart Problem SeizureDisorder

O Hearing Loss

O Speech Disorder

O Check if Life Threatening O Check if Life Threatening O Check if Life Threatening

Explain health conditions: (attach additional sheet if needed) __________________________________

Other: -------------------------------------------------

SIGNATU RE: I declare that the above information is true to the best of my knowledge and belief. I understand I commit the erime offalse swearing if J

make a false statement, knowing it to be false. (ORS 162.075). Further, I understand that my student could be returned to their neighborhood school upan determination of a falseaddress.

Parent/Guardian Signature:__________________________________Date: ________

i/?11 Springfield Public Schools

School Name:

NEW STUDENT REOPEN ENROLLMENT FORM

2020-21 New Student Reopening Enrollment Form

/School Use Only

' School Year: ____ School: ____________________ Student ID# _______1

This enroflment form is a legal document. The information you provide must be accurate and complete.

This information is protected by the Family Educational Rights and Privacy Act (FERPA).

SPECIAL SERVICES: (Please check al/ serv1ces needed by th1s student)

Section 504 Plan Talented& Gifted Program

SpecialEd IEP ELL/LEP Services

STUDENT'S LEGAL NAME:

Legal Last Name

First

Grade:(startingatthisschool) ________ Birthdate:__/__/__

Home Language

Preferred First Name

First Language Spoken

Student Cell Phone Number

Birth City

Birth State

O Speech Services

TitleVll lndianEd:Tribe ___________

Middle

Suffix

Gender: Female Male Non-Binary

Last Name Goes By

Birth Country

ETHNICITY & RACE:

Federal Regulations require this information. Jf ethnicity and race fields are not entered, school staff must select for you.

ETHNICITY:

O Hispanic

Non-Hispanic

RACE: (Mark al/ that apply)

White Black/African American

Asian American lndian or Alaska Native

O Non-US Native American

O Native Hawaiian or Pacific lslander

STUDENT'S HOME ADDRESS:

MAILING ADDRESS:

Home Address

Apt#

Mailing Address (if different than home address)

Apt#

City

State

Zip

City

State

Zip

CountyofResidence: ___________________

AddressVerification: (Provide Photo ID and One UtilityBi/1) Mustbe currentcopies-validinthe past 30days. Verifica/ioncanbe submitted through scannedor photo

copy as we/1 as mail-in documentation.

Oregon Drivers License Oregon ID

UtilityBill

O Cable/Satellite Bill

Primary Phone: !..____.,_\ ________(Used for Attendance & Emergency Calling)

200113-0820

 Aretherecustodyissuesthat theschool should be madeawareof? Yes No Aretherecustodypapers? Yes No

Relationship toStudent:

Father

Living with student? Yes No

Mother

Guardian (mustprovidelegalguardianshipdocumentation) Other: (specify) ________

Paren! Legal Las! Name

Legal FirstName

Mark ali that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased

Primary Language: ____________Dlnterpreter needed Email Address: ______________________

Employer:______________________ Job Tille: _______________________

Home Address (if differentfrom student's)

City

State

Zip

HomePhone: (__)________Work: ('-___________Cell: '-----' _________

Primary Phone (preferred contact): Home Work Cell

Active Military? Yes No

Relationship toStudent:

Father

Living with student? Yes No

Mother

Guardian (mustprovidelega/guardianship documentation) Other: (specify) ________

ParentLegalLastName

Legal FirstName

Mark ali that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased

Primary Language:____________Dlnterpreter needed Email Address: ______________________

Employer:______________________ Job Tille: ______________________

HomeAddress (if differentfrom student's)

City

State

Zip

HomePhone: (__)________Work: !_____________Cell: (___________

Primary Phone (preferred contact): Home Work Cell

Active Military? Yes No

Relationship toStudent:

Father

Living with student? Yes No

Mother

Guardian (mustprovidelegalguardianshipdocumentation) Other: (specify) ________

ParentLegal Las!Name

Legal FirstName

Mark ali that apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased

Primary Language:____________Dlnterpreter needed Email Address: ______________________

Employer:______________________ Job Tille: _______________________

HomeAddress (ifdifferentfrom student's)

City

State

Zip

HomePhone: (__)________Work: '--- ________Cell: -- _________

Primary Phone (preferred contact): Home Work Cell

Active Military? Yes No

Relationship toStudent:

Father

Living with student? Yes No

Mother

Guardian (mustprovidelegalguardianshipdocumentation) Other: (specify) ________

Paren!LegalLastName

Legal FirstName

Mark ali !ha! apply: Contact allowed Ed. Rights Has Custody Mailings Allowed Release To Deceased

Primary Language:____________Dlnterpreter needed Email Address: ______________________

Employer:______________________ Job Tille: _______________________

Home Address (if differentfrom student's)

City

State

Zip

HomePhone: (__)________Work: '--- ________Cell: '--- ________

Primary Phone (preferred contact): Home Work Cell

Active Military? Yes No

In an emergency, Parents/Guardians Jisted on page 2 with "Contact Allowed" checked, will be called befare Other Emergency Contacts listed below. L?st on/y !hose authorized to pickup your student. lndividua/s listed below wi/1 be contacted to pickup your student in the event of an emergency e/asure.

1st Name

Relationship to Student

(__ )

Phone

Home Cell

Address

2nd Name

City Relationship to Student

(__ )

Phone

State

Zip

Home Cell

Address

3rd Name

City Relationship to Student

(__ )

Phone

State

Zip

Home Cell

Address

4th Name

City Relationship to Student

(__ )

Phone

State

Zip

Home Cell

Address

City

State

Zip

EMERGENCYSCHOOLCLOSURE To prepare for an unexpected early school dismissal, please assist us by establishing a plan with your child and indicating your choice below:

Mychildwill ride !he busand has beeninstructed by me about what to do. 1 will make arrangements for mychild to bepicked up al schoolwithinan hour of emergencyclosure. My child may be released towalk andhasbeeninstructedby meaboutwhat to do.

SIBLINGS: (L?st ali brothers, sisters, step and half brothers and sisters of this student attendmg Springfield Pubilc Schools )

Student Name

Relationship to Student

Grade

School Enrolled

Student Name

Relationship to Student

Grade

School Enrolled

Student Name

Relationship to Student

Grade

School Enrolled

Student Name

Relationship to Student

Grade

School Enrolled

Student Name

Relationship to Student

Grade

School Enrolled

OTHER INFORMATION: PreviousSchool:_________________________________ Phone: (__) ________

Address

City

State

Zip

Special Circumstances:

lsthisstudentcurrentlysuspended? No Yes, from (name ofschool) _____________________________ lsthisstudentcurrentlyexpelled? No Yes, from (name ofschool) ______________________________

SchoolAddress, City and State: -------------------------------------------

Permissions:

My student may participate in all school field trips. Yes No

SERVICES AND PROGRAMS

Checklist for New Students

Student's Name:

If your student had services or was involved in certain programs in the past year, we want to know in order to better serve your child. Please check those that apply.

Home Language: No English Both another language and English

Migrant Education Native Youth. Tribe, Band or Group: McKinney-Vento Program/Foster Care Student Talented and Gifted Title I

Reading Math Individualized Education Plan (I.E.P.) Reading Math Written Language Speech/Language Services Emotional Disturbed Physical/Occupational Therapy Adaptive P.E. English Language Learner (ELL/ESL) Behavior Support Hearing Vision Counseling Head Start/EC Cares/Preschool Promise Other (please describe):

PERMISSION TO RELEASE STUDENT RECORDS TO SPRINGFIELD SCHOOL DISTRICT,OREGON

Previous School City/State/Zip

Phone Fax

Student Name Date of Birth Parent Signature

Grade Enrolling Phone

1st Request

2nd Request

Fax #

Initial

Please FAX the following: Transcript/Immunizatons Copy of IEP/Eligibility Withdraw Grades

if applicable if applicable

Please forward the following records in their entirety to the school checked below:

?All permanent Records

?Current Official Transcript

?All Special Education Recofrds (IEP and 504 accommodations)

?Behavioral Records (including attendance, suspensions and expulsions)

?Health Records

Centennial Elementary School 1315 Aspen St., Springfield OR 97477 Attn: Registrar Douglas Gardens Elementary School 3680 Jasper Rd., Springfield OR 97478 Attn: Registrar Guy Lee Elementary School 755 Harlow Rd., Springfield OR 97477 Attn: Registrar Maple Elementary School 2109 J St., Springfield OR 97477 Attn: Registrar Mt Vernon Elementary School 935 Filbert Ln., Springfield OR 97478 Attn: Registrar Page Elementary School 1300 Hayden Br Rd., Springfield OR 97477 Attn: Registrar Ridgeview Elementary School 526 66th St., Springfield OR 97478 Attn: Registrar Riverbend Elementary School 320 51st St., Springfield OR 97478 Attn: Registrar Thurston Elementary School 7345 Thurston Rd., Springfield OR 97478 Attn: Registrar Two Rivers Elementary School 1084 G St., Springfield OR 97477 Attn: Registrar Walterville Elementary School 40589 McKenzie Hwy., Springfield OR 97478 Attn: Registrar Yolanda Elementary School 2350 Yolanda Ave., Springfield OR 97477 Attn: Registrar Agnes Stewart Middle School 900 S 32nd St., Springfield OR 97478 Attn: Registrar Briggs Middle School 2355 Yolanda Ave., Springfield OR 97477 Attn: Registrar Hamlin Middle School 326 Centennial Blvd., Springfield OR 97477 Attn: Registrar Thurston Middle School 6300 Thurston Rd., Springfield OR 97478 Attn: Registrar Academy of Arts and Academics 615 Main St., Springfield OR 97477 Attn: Records/Counseling Gateways High School 425 10th St., Springfield OR 97477 Attn: Records/Counseling Springfield High School 875 7th St., Springfield OR 97477 Attn: Records/Counseling SPS OnLine (K-12) 425 10th St., Springfield OR 97477 Attn: Records/Counseling Thurston High School 333 58th St., Springfield OR 97478 Attn: Records/Counseling

Received Records On:

Checked In by:

Federal Law 99.31 Requires No Parent Signature for educational records sent to another agency. Permission is required for transfer of Special Education records.

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