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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