ELGIN MIDDLE SCHOOL 7TH GRADE ENROLLMENT 2016-2017 Full Legal Name: __________________________________________ SSN _____-_____-______ Date of Birth ____/____/____ Race: (Please list ALL codes that apply) ______________________________ 01 Black 06 Caucasian

02 American Indian

Please check if Hispanic _________

Gender: M _____ F _____

04 Asian

05 Pacific Islander

Nondiscrimination Statement: Elgin Public Schools does not discriminate on the basis of race, color, national origin, sex, disability or veteran.

Mailing Address: __________________________________________ City

Zip Code

Exact Location of Home (driving directions): ___________________________________________________________________________________ ___________________________________________________________________________________ Do you live in the Elgin Public School District? YES NO Admission: ______ Transfer Student (student who lives in a school district other than Elgin) ________ Therapeutic Foster Student For Office Use Only: Parent Email: ____________________________________________

PLEASE CHECK ALL THAT APPLY:

Bus # ________________ Driver Notified of Pick Up ___

____ CURRENTLY ON AN IEP (SPECIAL EDUCATION PROGRAM) ____ SPEECH THERAPY ____ 504 ACCOMMODATION PLAN ____ PHYSICAL THERAPY ____ TITLE I PROGRAM ____ OCCUPATIONAL THERAPY ____ IDENTIFIED AS GIFTED/TALENTED

Name of Parent(s)/Guardian(s) with whom student lives: ___________________________ Home Phone #

__________________________________________________________________________________ Parent/Guardian#1

Relationship to Student

Place of Employment

Work#/Cell #

___________________________________________________________________________________________________ Parent/Guardian #2 Relationship to Student Place of Employment Work #/Cell #

Emergency Contact (in case parent/guardian cannot be reached):

___________________________________________________________________________________________________ Name Phone # Relation to Student

Family Doctor ________________Phone ___________Health Concerns __________________ •If your student is under the care of a physician for diabetes, allergies or any other condition that requires care here at school, you will need to contact the school nurse, Debbie Fox, at 492-3692, to fill out the appropriate care plan.

For those new to Elgin Schools for the 2016-2017 school year: If you did not attend Elgin Schools at the end of the last school year, please provide the name, address and phone number of your previous school:

_____________________________________________________________________________ School Name

Address

Is student under any disciplinary actions from that school? YES

Phone # NO

Fax # If so, please explain________________

Joy Hofmeister State Superintendent of Public Instruction Oklahoma State Department of Education 16 - 20____ 17 HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS 20____

Name of Student: Last Name

First Name

Student ID #:

Middle Name

Gender:

Male

School Site: ELGIN MIDDLE SCHOOL

Female Grade:

Date of Birth:

Place of Birth (City/State/Country):

Is the student of Hispanic or Latino culture or origin? Select one or more of the following races:

Yes

No

African American/Black

American Indian/Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Caucasian/White

Parent’s/Guardian’s Name: Parent’s/Guardian’s Address:

Street

Parent’s/Guardian’s Telephone Number:

(

City

)

Cell Phone:

1. Is a language other than English used in your home? If NO, go to numbers 6 and 7. 2. Is that language spoken in the home

Zip Code

Yes

No

If YES, what is that language? MORE OFTEN than English?

LESS OFTEN than English?

3. What language is spoken by adults in the home? 4. What was the first (1st) language your child learned to speak? 5. What was the date (month and year) your child first enrolled in a school in the United States? 6. Parent/Guardian Signature: 7. Date: FOR SCHOOL USE ONLY THIS FORM MUST BE COMPLETED EVERY YEAR WITH CURRENT TEST DATA FOR STATE ACCREDITATION. If a language other than English is spoken MORE OFTEN (see question #2), the student automatically qualifies as bilingual on application for accreditation.

OR 1. 2. 3.

If a language is spoken LESS OFTEN, student qualifies as bilingual on application for accreditation if he or she meets ONE OF THE FOLLOWING: Scores 35% or below on norm-referenced test (NRT) on the composite reading score. Scores limited knowledge or unsatisfactory on Reading Oklahoma Core Curriculum Tests (OCCTs). Designated Limited English Proficient on an Oklahoma English language proficiency assessment: WIDA ACCESS for English language learners (ELLs) Test, WIDA Placement Test (including K W-APT, W-APT, and Kindergarten MODEL), or the Oklahoma Pre-K Language Screening Tool.

Documentation of a test result for students who marked LESS OFTEN: 1. NRT Test Date:

Name of the NRT:

2. Reading OCCT Date:

Score on Reading OCCT:

Reading Total Composite Score: Limited Knowledge

3. ACCESS for ELLs Test Date: WIDA Placement Test (K W-APT, W-APT, or Kindergarten MODEL) Date: Oklahoma Pre-K Language Screening Tool Date: Note: Have test score documentation available for regional accreditation officer review.

Unsatisfactory

Satisfactory

Advanced

Score on ACCESS for ELLs: 1 Score on K W-APT, W-APT, or MODEL: 1 Score on Pre-K Language Screening Tool:

1

2

2 2

EMERGENCY DISMISSAL FORM STUDENT:__________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE NAME PARENT/GUARDIAN:________________________________________________________________________________ LAST NAME FIRST NAME ____________________________________________________________________________________________________

HOME ADDRESS

CITY

STATE

ZIPCODE

____________________________________________________________________________________________________

HOME PHONE

WORK PHONE

CELL PHONE

The following people MAY check the above listed student out of school: 1.____________________________________________________

___________________________

2.____________________________________________________

___________________________

3.____________________________________________________

___________________________

FIRST AND LAST NAME FIRST AND LAST NAME FIRST AND LAST NAME

RELATIONSHIP TO STUDENT RELATIONSHIP TO STUDENT RELATIONSHIP TO STUDENT

AUTHORIZATION FOR MEDICAL CARE OF A MINOR I, _________________________, the undersigned parent/legal guardian, having legal custody of _____________________ PARENT/GUARDIAN

STUDENT’S NAME

do hereby authorize Elgin School to consent to any x-ray, examination, anesthetic, medical, surgery, or dental diagnosis or treatment and hospital care to be rendered to the above named minor under general or special supervision and upon the advice of a physician, surgeon, or dentist licensed under the laws of the state of Oklahoma. In giving this consent, I recognize and understand that in situations where the above named minor requires immediate medical or hospital care it may not be possible to contact me. When this situation arises, I will not be able to knowledgeably evaluate and choose among the available alternative treatments or procedures, if any, or to evaluate the risks attendant upon each, and the risks attendant to foregoing all treatment. In such situations, I authorize a physician, surgeon, or dentist to exercise his professional judgment and assess risks incident to and choose the necessary treatment from any available alternatives and to render such care and perform such treatment as he in his professional judgment determines to be necessary for the health or safety of the above named minor. In the past year, has your child had any outside evaluations: medical, neurological, orthopedic, psychiatric, psychological, speech and language or special test?

Type of Evaluation

Date

Place

Phone

Follow Up

Last vision exam: Date _______ Examiner _______________________________________ Wears glasses? Yes___ No ___ Last hearing exam: Date _______ Examiner _____________________________________ Has Ear Tubes? Yes___ No ___ Recent Health Problems Illnesses

Type

Date

Doctor/Hospital

Treatment

Surgery/Hospitalizations Allergies Does your child have seizures? Yes ___ No ___ Current Medications Doctor

Date of Last Seizure _______________ Length __________________ Date Began Dosage Problems with Meds

To request for administration of medicine at school, please ask for medication forms. It is the responsibility of the parent or guardian to fill out the form and supply the medication. Medication must be in its original container and administered only in compliance with the written directions on the label of the medication or as otherwise authorized in writing by your child’s physician. Due to the risk of Reyes Syndrome, aspirin will not be administered at school unless authorized by your child’s physician. Prescription medication will be administered by the nurse and kept in the nurse’s office. My signature below represents my understanding and acceptance of emergency and medical procedures.

_____________________________________________________________________________________________________________ Signature of Parent or Guardian Date

Absences: A student is only allowed to miss ten (10) class periods, whether excused or unexcused/absent without valid excuse, in one semester (with the exception of school related absences). Eleven (11) or more absences will result in loss of credit for the class and/or losing the privilege of attending end of the year field trips. Missing 20 minutes or more of a class is considered an absence Seventh/Eighth Grade Students: Will be enrolled in English, Reading, Math, Social Studies and Science. Any student interested in taking an honors class/Pre-AP class will need to have their current teacher in that subject sign their enrollment form below. Please select three classes from the list of electives and number them on the lines in order of preference. Students will be enrolled in two electives. *Students interested in the following classes must see the designated teacher to complete further paperwork before being considered for the class: ** Students entering the 7th grade must have the Tdap vaccine before attending the first day of school. Please fax updated shot records to the following grade-level offices: 5th & 6th grade: (580) 492-6382, 7th & 8th grade: (580) 492-3658.

7th AND 8th GRADE ELECTIVE CHOICES PLEASE SELECT THREE ELECTIVES, NUMBERING IN ORDER OF PREFERENCE. OUTDOOR SKILLS* ART (RETURNING STUDENTS MUST HAVE MR. WILSON’S SIGNATURE AND NEED TO ART APPRECIATION COMPLETE FURTHER PAPERWORK BEFORE BEING CONSIDERED FOR THE CLASS.) BAND PE COMPETITIVE ATHLETICS* SPANISH (8TH GRADE ONLY – HIGH SCHOOL CREDIT) PLEASE CIRCLE ATHLETIC CHOICES BELOW* STUDY HALL COMPUTER APPLICATIONS TEACHER/LIBRARY/OFFICE AIDE* INTRO TO AGRICULTURE (8TH GRADE ONLY)

(RETURNING STUDENTS MUST HAVE TEACHER, LIBRARY OR SECRETARY SIGNATURE TO BE CONSIDERED.)

INTRO TO ENGINEERING I INTRO TO ENGINEERING II LIFE SKILLS NATIVE AMERICAN LANGUAGE

VOCAL MUSIC YEARBOOK* (RETURNING STUDENTS MUST HAVE MRS. BUCHER’S SIGNATURE AND NEED TO COMPLETE FURTHER PAPERWORK BEFORE BEING CONSIDERED FOR THE CLASS.

*COMPETITIVE ATHLETICS:

IF YOU PLAY A SPORT, YOU WILL STAY ENROLLED IN ATHLETICS ALL YEAR. WHEN YOUR SPORT IS NOT IN SEASON, YOU WILL ATTEND OFF-SEASON ATHLETICS.

GIRLS

SEASON

BOYS

SEASON

Basketball

October-February

Baseball

March-April

Cross Country

August-October

Basketball

October-February

Golf

March-April

Cross-Country

August-October

Softball

Summer-October

Football

Summer-November

Track & Field

March-April

Golf

March-April

Volleyball

Summer-October

Track & Field

February-April

Wrestling

November-January

Wrestling

November-January

***FOR TEACHER USE ONLY*** HONOR COURSES

RETURNING STUDENTS: TEACHER SIGNATURE REQUIRED IF REQUESTING HONOR CLASSES. NEW STUDENTS: PLEASE CIRCLE ANY DESIRED HONOR CLASSES. PLACEMENT WILL BE BASED ON TRANSCRIPT AND AVAILABILITY. TH 7 ENGLISH 8TH ENGLISH TH 7 GEOGRAPHY 8TH HISTORY TH 7 READING 8TH READING 7TH SCIENCE 8TH SCIENCE PRE-ALGEBRA ALGEBRA I* *ALGEBRA I REQUIRED PREREQUISITE: 7th grade Pre-Algebra, Algebra I replaces 8th grade math. THIS IS A HIGH SCHOOL COURSE. THREE ADDIONAL MATH COURSES ARE REQUIRED WHEN ENTERING HIGH SCHOOL.)

SCHEDULE CHANGES: will take place ONLY after the first week of school is completed in August and again during the week prior to Christmas break. Schedules cannot be changed during a semester.

Parent Signature: ___________________________ Date: ___________

THE FOLLOWING INFORMATION IS REQUIRED FOR FEDERAL REPORTS: ____ Yes ____ No

Father, Mother, or legal guardian is in the military. (This includes divorced parents that student does not live with) Branch _____________________ Rank ___________________Commander _______________________ ____ Yes ____ No ANY parent/guardian that is a civil service, contract, or construction employee that reports to work on federal property such as Ft. Sill, Altus AFB, Tinker AFB, Sheppard AFB. ____ Yes ____ No Casino or Tribal Complex – Name: ______________________________________________________ ____ Yes ____ No Live on federal property (such as Ft. Sill) ____ Yes ____ No Live on Indian land (housing or trust) ____ Yes ____ No Leases Indian land or federal land (not school lease, works 50% farming, ranching, grazing or logging) ___________________________________________________________________________________________________________  I give Elgin Public Schools permission to do general diagnostic testing, routine speech, language, hearing screening and vision screening.  I give permission for my student to be published/photographed for any school sponsored media such as the EPS webpage, newspaper or yearbook. I ________________________(student name), understand and will abide by the terms and conditions for Internet access and computer use as noted on the informational handout. I further understand that any violation of the regulations is unethical and may constitute a criminal offense. Should I commit any violation, my access privileges may be revoked and school disciplinary and/or appropriate legal action may be taken. Parent/Guardian: As the parent or guardian of this student, I have read the terms for conditions for Internet access and computer use, I understand that the school district is providing this access for educational purpose only and hereby give permission to grant access for my child. I understand that this permission shall remain in effect until the end of the school year in which the dated signature falls, or until I revoke permission in writing.  The Elgin MS Handbook is posted on our school website under the MIDDLE SCHOOL tab: www.elginps.org. Students will receive a copy of the handbook on the first day of school.  Student Drug Testing Consent: I have read and understood the “Student Drug Testing Policy” and “Student Drug Testing Consent” as noted in the student handbook. I understand that, out of care for my safety and health, the Elgin School District enforces the rules applying to the consumption or possession of illegal and/or performance-enhancing drugs. If I choose to violate school policy regarding the use or possession of illegal and/or performance-enhancing drugs any time while I am involved in in-season or offseason activities, I understand upon determination of that violation I will be subject to the restrictions on my participation as outlined in the Policy.  Parent Drug Testing Consent: I have read and understood the Student Drug Testing Policy and Student Drug Testing Consent. I desire that the student named above participate in the extra-curricular interscholastic programs of District, and I hereby voluntarily agree to be subject to its terms. I accept the method of obtaining urine samples, testing and analysis of such specimens, and all other aspects of the program. I further agree and consent to the disclosure of the sampling, testing and results as provided in this program. The entire drug testing policy is in the Elgin Middle School Student Handbook and on our school website under the MIDDLE SCHOOL tab: www.elginps.org. The drug testing policy applies to students enrolled in the seventh and eighth grades who are participating in competitive school activities (i.e., academic team, agriculture, athletics, band, math counts, outdoor skills, intro to engineering, etc.)

Student:

_____ Yes, I choose to participate in the “Drug Testing Program” _____ No, I choose not to participate in the “Drug Testing Program”

Parent:

_____ Yes, I agree to the terms of the policy. _____ No, I do not want my son/daughter to be tested according to the terms of this policy.

Student Signature: ________________________________________________ Date: ______________ Parent Signature: _________________________________________________ Date: ______________