Student Enrollment Fact Sheet

All children in the United States are entitled to a basic public elementary and secondary education regardless of their race, color, national origin, citizenship, immigration status, or the immigration status of their parents/guardians. The items listed below will be requested at time of enrollment: •

Proof of Residency within District Boundaries The District will accept a gas bill, water bill, electric bill, mortgage or a lease agreement in the parent or guardians name as proof of residency within district boundaries. Students are deemed to be homeless, when they do not have an address with which to meet school residency requirements.

•

Birth Certificate A birth certificate is used only for verifying the student’s legal name, date of birth, and the parent’s name. A foreign birth certificate is an acceptable document for verifying the student’s information.

•

Ethnicity Form Parents should complete form. If ethnicity form is not completed, school personnel will be left to determine student’s ethnicity and race.

•

Immunizations The law requires that students be fully vaccinated against the specified diseases, which may be found on the Dallas Independent School District website at www.dallasisd.org. Students enrolling in the District for the first time must provide evidence of required immunizations. All immunizations should be completed by the first date of attendance. Please contact Student Health Services for information or assistance with immunization requirements.

•

Social Security Number (optional) Providing a social security card or number is optional. The Dallas Independent School District will not refuse enrollment of any student opting not to provide a social security card/number. In lieu, a state identification number will be provided for educational purposes only.

“The Dallas Independent School District complies with Titles IV and VI of the Civil Rights Act of 1964, which prohibit discrimination on the basis of race, color or national origin by public elementary and secondary schools.”

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Health Services Immunization Requirements 2016-2017 Students enrolling in the Dallas Independent School District for the first time must provide evidence of required immunizations. Official records from a physician or health clinic, which provide documentation of current immunizations, are required. All immunizations should be completed by the first date of attendance. The law requires that students be fully vaccinated against the specified diseases. See notes at end for other provisions or exceptions. 1.

2. 3.

4. 5. 6.

7. 8.

9.

Diphtheria-Tetanus-Pertussis/Tetanus-Diptheria-acellular-Pertussis containing vaccine:  Students who started the series before age 7 years – Five doses, with one after the fourth birthday, unless the fourth dose was received after the fourth birthday, in which case only four doses are required.  Students who started the series after age 7 years – Three doses of any combination of diphtheria, pertussis, and tetanus.  Students in grade 7 – one dose of Tdap if it has been five years since previous dose of tetanus-containing vaccine.  Students in grade 8-12 – one booster dose of Tdap if it has been 10 years since previous dose of tetanus-containing vaccine. Poliomyelitis (to age 18 years):  Four doses with one dose on or after the fourth birthday.  Three doses meet the requirement if the third dose is given on or after the fourth birthday. Measles, mumps, and rubella (MMR):  One dose on or after the first birthday for students under age 4.  Two doses on or after the first birthday beginning in pre-kindergarten – seventh.  Students in grades 8-12 are required to have two doses of a measles-containing vaccine, and one dose each of mumps and rubella vaccine  Serologic* confirmation of rubeola, rubella and mumps immunity is acceptable in lieu of the vaccine. Haemophilus Influenza Type B: (Students through age 4 years):  One dose vaccine since 15 months of age through 4 years or a series of three doses before 15 months of age with one dose after 12 months of age.  Serologic* confirmation of Hib immunity is acceptable in lieu of the vaccine. Hepatitis B:  Three doses  Serologic* confirmation of Hepatitis B immunity is acceptable in lieu of the vaccine Varicella (Chicken Pox):  One dose received on or after the first birthday.  Two doses for all students entering Pre- Kindergarten through twelfth grades with first dose on or after first birthday.  Students who start varicella immunization after age 13 years – two doses are required.  Serologic* confirmation of immunity is acceptable in lieu of the vaccine.  Previous varicella illness documented by a written statement from the parent or physician is acceptable in lieu of the vaccine. Pneumococcal: (24 months to age 59 months):  One dose after age 24 months or a minimum of three doses with one after 12 months of age. Hepatitis A:  Two doses are required for students entering pre-Kindergarten –seventh grade with the first dose received on or after the first birthday.  Eighth through twelfth grades, two doses recommended, but not required.  Vaccines given four days before the minimum age or interval are acceptable.  Serologic* confirmation of immunity is acceptable in lieu of the vaccine. Meningococcal:  One dose vaccine for all students entering seventh – twelfth

Recommended vaccines (consult your health care provider):  HUMAN PAPILLOMAVIRUS VACCINE – Three doses series with the first dose at 11-12 years, the second dose two months after the first dose, and a third dose six months after the first dose. Adolescents ages 13-18 years may receive the series if previously not vaccinated.  INFLUENZA VACCINE – Two doses for children ages 5-9 years receiving the vaccine for the first time. One dose for children ages 5-21 receiving the vaccine after previous year(s) of vaccinations. *Blood test NOTE 1: A 30-day provisional enrollment is available only to the following student groups:  Students transferring from one Texas school to another Texas school.  Students who are defined as homeless according to the federal McKinney-Vento Act 42 U. S. C. Section 111434a. NOTE 2: A student may be enrolled provisionally if the student has an immunization record that indicates the student has received at least one dose of each specified age-appropriate vaccine required by this rule. To remain enrolled, the student must complete the required subsequent doses in each vaccine series on schedule and as rapidly as is medically feasible, and provide acceptable evidence of vaccination to the school. A school nurse or school administrator shall review the immunization status of a provisionally enrolled student every 30 days to ensure continued compliance in completing the required doses of vaccination. If, at the end of the 30-day period, a student has not received a subsequent dose of vaccine, the student is not in compliance and the school shall exclude the student from school attendance until the required dose is administered. NOTE 3: Exemptions from immunization requirements may be granted on a medical basis or for reasons of conscience. A medical exemption, signed by the physician, is required annually if not otherwise stated by the physician. Exemption for reasons of conscience must be submitted on an affidavit provided by the Texas Department of State Health Services. Exemption for reason of conscience is granted for two years. Exemptions are not recognized in time of epidemics. Students will need to be immunized or cannot attend school in case of an epidemic declared by the Commissioner of Health. May 2011sk/vj

DFW Care Van® Program Community Outreach Program providing Free Immunizations for eligible children 2 months through 18 years of age*

August 2016 July 30th

Sat

Lewisville

Lewisville High School, 1098 W. Main St., 75067 9am-noon

Aug 1st

Mon

Mesquite

Town East McDonalds, 1531 N. Town East Blvd., 75150 5pm-7pm

Aug 2nd

Tues

Grand Prairie

1st United Methodist Church, 121 N. Center St., 75050 5pm-7pm

Aug 4th

Thurs

Fort Worth

(New Location!) Ironwood Crossing, 2600 Western Ctr. Blvd., 76131 5pm-7pm

th

Sat

Rockwall

1st United Methodist Church, 1200 E. Yellow Jacket Ln, 75087 9am-10:45am

Aug 6th

Sat

Richardson

Greenville Ave Church of Christ, 1013 S. Greenville, 75081 noon-2pm

Aug 9th

Tues

Forney

1st United Methodist Church, 414 Broad St., 75126 5pm-7pm

Aug 10th

Weds

Fort Worth

(New Location!) Diamond Hill, 3601 Dean St., 76106 5pm-7pm

Aug 11th

Thurs

Lake Dallas

(New Location!) Lake Dallas M.S., 425 Hundley Dr., 75065 5pm-7pm

Aug 13th

Sat

Arlington

*Back to School Rally @ AT&T Stadium -Arlington ISD Students only-

Aug 6

*(Contact district to learn more)

Aug 16th

Tues

Duncanville

Trinity United Methodist Church, 1320 S. Clark Rd., 75137 5pm-7pm

Aug 17th

Weds

Carrollton

CFB-ISD, Community Learning Ctr., 1820 Pearl St., 75006 5pm-7pm (Parking beside building - entrance next to the playground)

Aug 18th

Thurs

McKinney

Lawson Early Childhood Ctr., 500 Dowell St., 75069 5pm-7pm

Aug 20th

Sat

Richardson

St. Barnabas Presbyterian Church, 1220 W. Beltline Rd., 75080 9am-noon

Aug 20th

Sat

Dallas

Church of the Incarnation, 3966 McKinney Ave., 75204 1pm-3pm

nd

Mon

Garland

GISD Student Services Center, 720 Stadium Dr., 75040 5pm-7pm

rd

Aug 23

Tues

DeSoto

DeSoto ISD Health Services Bldg., 200 E. Beltline Rd., 75115 5pm-7pm

Aug 25th

Thurs

Bedford

HEB-ISD Pat May Center, 1849 Central Dr., 76022 5pm-7pm

Aug 22

Please bring most complete immunization/shot records with you. Por favor traiga la tarjeta de vacunas. Child must be accompanied by parent or guardian. No appointment needed. Ninos tienen que estar acompanados con sus padres o guardian legal. No se necesita cita. Families are welcome to visit any one of our "public" community outreach locations to receive immunizations. Familias son bienvenidas a visitar cualquiera localizacion "publica" de communidad para recibir sus vacunas-- a pesar de la ciudad en que residen. *Your child is eligible if he/she has no insurance, has insurance that does not cover vaccine, has Medicaid, or is American Indian/Native American or Alaskan Native. *Su nino es eligible si no tiene seguro medico, si tiene seguro medico que no paga por las vacunas, si tiene Medicaid , o es Indio Americano or nacido en Alaska. Cambio de Eventos pueden pasar si no hay suficiente vacunas o hay mal tiempo o tempestad. Caring for Children Foundation of Texas

Follow us @carevantexas

SC-03-01355—11

*To be completed by Campus

WHITE — CRC CANARY — Nurse WHITE TAG — Office

Date of Enrollment Last Grade Completed Year Into Grade 9

STUDENT ENROLLMENT/ REGISTRATION FORM The completion of the information on the Student Enrollment Registration Form does not determine the parental relationship nor does it affect legal right of access to the student or the student’s records. (Form should be completed by parent/ guardian.) SCHOOL

TEA Code

Advisory Assignment

Advisory Name

Student’s Legal Name (Last, First, Middle)

Student’s Date of Birth (mm/dd/yy)

SEX

Male

Grade Level

Female

ETHNICITY (Check one)

Black Hispanic

Special Programs (check all that apply) Special Education Section 504 Bilingual/ ESL Other

Student ID State ID Advisory Room Student’s Social Security Number (if available) Asian/ Pacific Islander American Indian/Alaskan Native

White

Previous School (School Name, City, State)

Has your child lived out of the U.S. for 2 or more consecutive years? Yes No If yes, indicate dates: From: To: When your child lived outside the U.S., did he/ she attend school regularly? Yes No Reason for Leaving Previous School:

Name of Parent/ Guardian with whom Student Lives DOB (mm/dd/yy)

Relationship to Student

Student’s Address (Street name, building and/or apt. #, City, State, ZIP)

Foster Parent Yes No

Temporary Arrangement

Residence Telephone Number

Father’s/ Guardian Name and Address (if different from above)

DOB (mm/dd/yy)

Place of Employment

Mother’s/ Guardian Name and Address (if different from above)

DOB (mm/dd/yy)

Place of Employment

Home Phone: Work Phone: Cell Phone: Home Phone: Work Phone: Cell Phone:

(Within the past 3 years, have you moved from one city or state to another so that you or your family could work or look for work in agriculture or fishing? Yes

No

HEALTH SERVICES INFORMATION OTHER PERSONS WHO MAY BE CONTACTED IN THE EVENT OF EMERGENCY: Student’s Place of Birth (City, State, Country)

If student’s birthplace is outside U.S., date he/ she entered U.S.

*Person’s Name and Relationship

Release Authorized* Yes No

Telephone Number

*Person’s Name and Relationship

Release Authorized* No Yes

Telephone Number

Name of Physician Health Insurance:

Phone Number Medicaid

Name(s) of School(s)

Date of Birth

Name of Sibling(s) Attending DISD School

Preferred Hospital CHIP

Commercial

Uninsured

(*Please list all guardianship or custody arrangements about which school administrators should be aware: Attach all copies of legal documents.)

* I authorize DALLAS INDEPENDENT SCHOOL DISTRICT to contact above named persons, and authorize the named physician to render treatment for the health of my child in an emergency. In the event parent/guardian or physician cannot be contacted, school officials are authorized to take whatever action is considered necessary for the health of my child. I will not hold the school district financially responsible for the emergency care and/ or transportation for my child. * Knowingly falsifying information on this document is a criminal offense punishable by law. (TX Penal Code §37.10). I certify that the information contained in this enrollment/ registration form is true and correct. Parent/Guardian Signature

Date:

Parent/Guardian Email Address TEC §25.002(f) requires that the name, address and date of birth of the person enrolling a student be provided to the school district. *Student is permitted to be released into the custody of the individual listed in case of emergency.

Home Language Survey Encuesta del idioma en el hogar Ngôn ngử được xử dụng tại nhà အိမ္သုံး ဘာသာစကား စာရင္းေကာက္ယူၿခင္း ‫ﺃﺳﺘﻔﺘﺎء ﺍﻟﻠﻐﻪ ﺍﻻﻡ‬ घरमा बोल्न भाषा सव�

The State of Texas requires each school district to conduct a language background survey of all students upon entrance into a public school. To comply with this mandate and to better serve your children, please complete the reverse side of this form for each child who is enrolling in the Dallas Independent School District for the first time. El estado de Texas requiere que cada distrito escolar lleve a cabo una encuesta de idioma de todos los estudiantes que ingresan a una escuela pública. Para cumplir con este reglamento y para servir mejor a sus hijos, por favor complete la parte de atrás de esta encuesta por cada hijo que esté inscrito en el Dallas ISD por primera vez. Tiểu bang Texas yêu cầu mỗi học khu chánh phải làm một bảng nghiên cứu lý lịch ngôn ngữ đươc xử dụng trong nhà của tất cả học sinh khi vào học ở trường công. Để thực hiện sự ủy nhiệm trên của chính quyền tiểu bang và để phục vụ tốt hơn cho con em của quí vị. Xin quý vị vui lòng điền vào phần sau của tấm giấy này cho mổi em khi ghi tên học lần đầu tiên vào một trường của khu học chánh Dallas. Nếu quý vị có điều chi thắc mắc, xin vui lòng gọi điện thoại đến trường học. တက္(စ္)စက္(စ္) ၿပည္နယ္အစုိးရ ၏မူ အရ ၿပည္သူပိုင္ေက်ာင္းတြင္ တက္ေရာက္သည့္ ေက်ာင္းသားတိုင္း၏ ေနာက္ေၾကာင္းခံ မိခင္ဘာသာ စကားကို ၿပည္သူပိုင္ေက်ာင္းတိုင္း စာရင္းေကာက္ယူရန္ လိုအပ္ေၾကာင္း ၿပ ဌာန္းထားပါသည္။ ၄င္း ၿပ ဌာန္းထားေသာ မူကို လုိက္နာေဆာင္ရြက္ရန္ နွင့္ ပုိမိုသင့္ေတာ္ေသာ ပညာေရး ၀န္ေဆာင္မူမ်ားကို ဒါးလက္(စ္) အင္ဒီဘ(ဖ္)န္းဒန္႕စကုိလ္းဒီစတိတ္ တြင္တက္ေရာက္ေနေသာ ေက်ာင္းသားတိုင္း ရရိွနိုင္ရန္အတြက္ ေရွ့စာမ်က္နာ တြင္ ရိွေသာ အခ်က္မ်ားကုိေက်းဇူးၿပဳၿပီး ၿဖည့္ေပးပါ။။။

‫ ﻟﻼﻣﺘﺜﺎﻝ ﻟﻠﺘﻌﻠﻴﻤﺎﺕ‬. ‫ﻭﻻﻳﻪ ﺗﻜﺴﺎﺱ ﺗﺘﻄﻠﺐ ﻣﻦ ﻛﻞ ﻣﻨﻄﻘﻪ ﺗﻌﻠﻴﻤﻴﻪ ﺍﺳﺘﻔﺘﺎء ﺣﻮﻝ ﺍﻟﻠﻐﻪ ﺍﻻﺻﻠﻴﻪ ﻟﻠﻄﻼﺏ ﻋﻨﺪ ﺗﺴﺠﻴﻠﻬﻢ ﻓﻲ ﺍﻟﻤﺪﺍﺭﺱ ﺍﻟﺤﻜﻮﻣﻴﺔ‬ ‫ ﺍﻟﺮﺟﺎء ﺍﻛﻤﺎﻝ ﺍﻟﺠﻬﻪ ﺍﻻﻣﺎﻣﻴﺔ ﻣﻦ ﻫﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻟﻜﻞ ﻁﻔﻞ ﻣﻦ ﺍﻻﻁﻔﺎﻝ ﺍﻟﻤﺴﺠﻠﻴﻦ ﻻﻭﻝ ﻣﺮﺓ ﻓﻲ ﻣﺪﺭﺳﺔ‬, ‫ﻭﺍﻟﻤﺘﻄﻠﺒﺎﺕ ﻭﻟﺨﺪﻣﺔ ﻁﻔﻠﻚ ﺑﺼﻮﺭﺓ ﺍﻓﻀﻞ‬ . ‫ ﺍﺫﺍ ﻛﺎﻥ ﻟﺪﻳﻚ ﺍﻱ ﺳﺆﺍﻝ ﺍﻟﺮﺟﺎء ﺍﻻﺗﺼﺎﻝ ﺑﻤﺪﺭﺳﺘﻚ‬. ‫ ﺍﻟﺮﺟﺎء ﺍﺭﺟﺎﻉ ﻫﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻟﻤﻌﻠﻢ ﻁﻔﻠﻚ‬. ‫ﻣﻦ ﻣﺪﺍﺭﺱ ﺍﻟﻤﻨﻄﻘﺔ ﺍﻟﺘﻌﻠﻴﻤﻴﺔ ﻟﺪﺍﻻﺱ‬ स्टे ट अफ टे क्ससको स्कूलमा लाग्नहुने �वध्याथ�ले सव� फम आफ्नो भाषामा भ�र बज ु ाउनु होला। लपाइर्को नानीको साएताको ला�ग, डालास इिन्डपेन्डेन्ट स्कूल �डिस्ट्रकमा प�हलो पल्ट लाग्नह ु ु ने नानी पछा�ड �दएको फमर् भ�र कृपया बझ ु ाउनु होला।

SC 0503730

Home Language Survey Encuesta del idioma en el hogar Ngôn ngử được xử dụng tại nhà အိမ္သုံး ဘာသာစကား စာရင္းေကာက္ယူၿခင္း ‫ﺃﺳﺘﻔﺘﺎء ﺍﻟﻠﻐﻪ ﺍﻻﻡ‬ घरमा बोल्न भाषा सव�

Student Name ________________________________ Nombre del Estudiante Tên họ học sinh ေက်ာင္းသားအမည္ ‫ﺃﺳﻢ ﺍﻟﻄﺎﻟﺐ‬ �बध्याथ�को नाम

Student DOB ___________________ Fecha de nacimiento Ngày sanh ေက်ာင္းသား ေမြးသကၠရဇ္ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬ जन्म �म�त

To Be Completed By Parent/Guardian Or Student (Grades 9-12) Para ser completado por el padre, tutor legal o estudiante (Grados 9-12) Cha mẹ hay người dám hộ hoặc học sinh từ lớp 9-12 điền vào phần dưới

မိဘ/အုပ္ထိန္းသူ (သုိ႕) ( ၉ - ၁၂ ) တန္းတက္ေရာက္ေန ေသာ ေက်ာင္းသား ၿဖည့္ရန္ ‫ﻣﺎﻫﻲ ﺍﻟﻠﻐﺔ ﺍﻟﻤﺴﺘﺨﺪﻣﻪ ﻓﻲ ﻣﻨﺰﻟﻚ ﻓﻲ ﺍﻏﻠﺐ ﺍﻻﺣﻴﺎﻥ؟‬

अ�भभावक वा �वध्याथ�ले भनप ुर् न� (क�ा ९-१२) U

l. What language is spoken in your home most of the time? ¿Qué idioma se habla con mayor frecuencia en su hogar? Ngôn ngử nào thường dùng tại nhà?

__________________________

ေနအိမ္တြင္ မည္သည္႕ဘာသာစကား ကို အဓိက အသုံးၿပဳပါသနည္း? ‫ ﻳﻣﻛﻥ ﺍﻥ ﻳﻛﻣﻠﻭﺍ ﻫﺫﻩ ﺍﻻﺳﺗﻣﺎﺭﺓ ﺑﺎﻧﻔﺳﻬﻡ‬12 ‫ ﺍﻟﻰ‬9 ‫ﻳﺟﺏ ﺍﻛﻣﺎﻟﻬﺎ ﺑﻭﺍﺳﻁﻪ ﺍﻻﺑﺎء ﺍﻭ ﺍﻭﻟﻳﺎء ﺍﻻﻣﻭﺭ ) ﺍﻟﻁﻼﺏ ﻓﻲ ﺍﻟﻣﺭﺣﻠﺔ‬ घरमा धेरै कुन भाषा बोल्नह ु ु न्छ?

2. What language does your child (do you) speak most of the time? ¿Qué idioma habla su hijo (o usted) con mayor frecuencia? Ngôn ngử nào học sinh thường nói tại nhà?

__________________________

မည္သည္႕ဘာသာစကား ကို သင့္ ကေလး (သို႕) သင္ အဓိက အသုံးၿပဳပါသနည္း? ‫ﻣﺎﻫﻲ ﺍﻟﻠﻐﺔ ﺍﻟﻤﺴﺘﺨﺪﻣﻪ ﻓﻲ ﻣﻨﺰﻟﻚ ﻓﻲ ﺍﻏﻠﺐ ﺍﻻﺣﻴﺎﻥ؟‬ तपाइर्को नानीले धेरै मात्रमा कुन भाषा बोल्नुहुन्छ? __________________________ Parent/Guardian Name (print) Nombre del padre/ tutor legal Tên phụ huynh / người giám hộ (chữ in)

_________________________ Parent/Guardian Signature Firma del Padre/Tutor legal Chữ ký phụ huynh / người giám hộ

________________ Date Fecha Ngày

မိဘ/ အုပ္ထိန္းသူ ၏ နာမည္

မိဘ/ အုပ္ထိန္းသူ ၏ လက္မွတ္

ေန႔စြဲ

‫ﺍﺳﻢ ﻭﻟﻲ ﺍﻻﻣﺮ‬

‫ﺗﻭﻗﻳﻊ ﻭﻟﻲ ﺍﻻﻣﺭ‬

‫ﺍﻟﺘﺎﺭﻳﺦ‬

अ�भभावकको नाम

अ�भभावकको सह�

�म�त

**Campus Use Only ** __________________________________________ Student Name

SC 0503730

__________________ Student ID

____________________ Org #

_____________________________________________ School Name

Texas Education Agency Texas Public School Student Ethnicity and Race Data Questionnaire Student Name ________________________________

Student Grade __________

Student DOB _________________

School Name ______________________________

Student ID

_________________

The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). Parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student’s ethnicity and race. United States Federal Register (71 FR 44866)

Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic/Latino Part 2. Race: What is the person’s race? (Choose one or more) American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment. Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

__________________________

___________________________

________________

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

**CAMPUS USE ONLY** School observer- upon completion and entering data in student software system, file this form in student’s permanent folder. Ethnicity- choose only one: Hispanic / Latino Not Hispanic / Latino Race- choose one or more: American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Asian

Black or African American White

___________________________ ________ ______________________________ ____________ Observer Signature Org # School Name Date SC 0301688

Family Educational Rights and Privacy Act (FERPA) Notice for Directory Information

The Family Educational Rights and Privacy Act (FERPA), a federal law, requires that Dallas Independent School District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s education records. However, Dallas Independent School District may disclose appropriately designated “directory information” without written consent, unless you have advised the District to the contrary in accordance with District procedures. Student directory information is available to the public unless the parent/guardian restricts the release of the information. According to the Texas Public Information Act (TPIA), Dallas Independent School District must release directory information promptly upon request and may not ask requestors the reason for the requested information. Per Board Policy FL (LOCAL), the written objection to the release of directory information shall be sent to the student’s principal within 15 school days after the annual notice is given concerning directory information.

Certain information about district students is considered directory information and will be released to anyone who follows the procedures for requesting the information unless the parent or guardian objects to the release of the directory information about the student. If you do not want Dallas Independent School District to disclose directory information from your child’s education records without your prior written consent, you must notify the district in writing within 15 school days of receiving this notice. Dallas Independent School District has designated the following information as directory information: student name, address, telephone listing, date and place of birth, major field of study, participation in an officially recognized activity or sport, weight and height of members of athletic teams, dates of attendance, degrees and awards received, and most recent previous educational agency or institution attended. In addition, federal law requires districts receiving assistance under the Elementary and Secondary Education Act of 1965 to provide a military recruiter or an institution of higher education, on request, with the name, address, and telephone number of a secondary student unless the parent has advised the Dallas Independent School District that the parent does not want the student’s information disclosed without the parent’s prior written consent.

SC 0301960

Family Educational Rights and Privacy Act (FERPA) Notice for Directory Information Student Name ________________________________

Student Grade __________

Student DOB _________________

School Name ______________________________

Student ID

_________________

STUDENT DIRECTORY INFORMATION RELEASE FORM Parents/guardians are to determine what, if any, directory information is to be restricted from release. Please check one box in each applicable section. Making no selection will result in student directory information being made available upon receipt of a properly submitted request. This consent and/or opt-out is valid through June 30 of the current school year.

ALL STUDENTS Release of Directory Information YES, Dallas ISD does have my permission to release directory information. NO, Dallas ISD does not have my permission to release directory information. SECONDARY STUDENTS ONLY (Grades 6-12) Release of Directory Information to Military Recruiter or Institution of Higher Education Military Recruiter YES, I do want the name, address, and telephone number of my secondary student released to a military recruiter. NO, I do not want the name, address, and telephone number of my secondary student released to a military recruiter. Institution of Higher Education YES, I do want the name, address, and telephone number of my secondary student released to an institution of higher education. NO, I do not want the name, address, and telephone number of my secondary student released to an institution of higher education.

__________________________

___________________________

________________

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

SC 0301960

Annual Student Health Information Form Student Name ______________________________

Student Grade __________

Gender (Circle)

M

F

Student DOB _________________ Student ID _________________ Parent Name __________________________ Parent Cell # _______________ Parent Home #________________ Parent Work # ________________________

Parent Email _________________________________

In an effort to provide safe, informed care for your child at school, each year the Dallas lSD Health Services Department requires updated health information as part of student enrollment. Dallas lSD keeps all medical information about your child confidential as required by the Family Educational Rights and Privacy Act and other applicable laws. However, health information about your child will be communicated to Dallas lSD school personnel who require the information to better serve your child. If your child has an acute or chronic medical condition, or any medical changes occur during the school year, it is your responsibility as the parent/guardian to notify the school nurse and update this information.

ABDOMINAL ISSUES: Due to: __ Irritable bowel syndrome __ Gastric reflux __ Crohn’s disease __ Ulcerative colitis __ Constipation __ Other: _______________________ What medications are taken for this? ______________________ ADD/ADHD: When was your child diagnosed? ____________ Is your child under medical care at this time? Yes No What medications are taken for this? ______________________ ALLERGY: (other than seasonal allergies) __ Food allergy (specify food): ___________________________ __ Medication allergy (specify med): ______________________ __ Insect allergy (specify insect): _________________________ __ Latex allergy Symptoms of reaction? ________________________________ Has a physician prescribed epinephrine for this allergy? Yes No (If yes, please contact school nurse) What medications are taken for this? _____________________ BLOOD DISORDERS: __ Sickle cell anemia __Sickle cell trait __ Clotting disorder (i.e. hemophilia) __ Other ____________________________________________ What medications are taken for this? ______________________ BREATHING ISSUES: __ Asthma __ Cystic fibrosis __ Tracheostomy __ Other ____________________________ When was your child diagnosed? _______________________ Is your child under medical care at this time? Yes No What medications are taken for this? ____________________ How often does your child use rescue inhaler? ____________ Does your child use a nebulizer? Yes No Does your child wake at night with a cough? Yes No

DIABETES: __ Type 1 __ Type 2 What medications are taken for this? ____________________ EARS, EYES, NOSE: __ Frequent ear infections __ Hearing Loss R / L Wears hearing aid? Yes No __ Frequent Nosebleeds caused by: ______________________ __ Wears glasses or contacts Yes No __ Vision loss not corrected with glasses/contacts R / L EMOTIONAL ISSUES: __ Depression __ OCD __ Bipolar __ School phobia __ Other _____________________________ When was your child diagnosed? ________________________ Is your child under medical care at this time? Yes No What medications are taken for this? ______________________ HEART CONDITIONS: __ Long Q/T syndrome __ High blood pressure __ Irregular heart rate __ Heart defect, type: ____________ Repaired? Yes No __ Other ____________________________________________ What medications are taken for this? ______________________ MUSCLE, BONE, JOINT DISORDERS: __ Arthritis __Scoliosis __ Other: ___________________________________________ Are there any P.E. restrictions for this condition? Yes No Is your child under medical care at this time? Yes No What medications are taken for this? ______________________ NEUROLOGICAL: __ Migraines __ Autism spectrum disorder __ Seizures, type: ________________ Date of last? _________ __ Cerebral palsy __ Spina bifida __ Other _______________ What medications are taken for this? ______________________

OTHER HEALTH CONDITIONS: _________________________ ___________________________________________________ ___________________________________________________ Special procedures: (tube feeding, catheterization, etc) COMMUNICABLE DISEASES: Has your child had chicken pox? Yes No Date: __________ ___________________________________________________ Has your child had a positive TB test? Yes No Date: ________ ___________________________________________________ ALL medications taken during school hours and school related activities must be brought to the clinic. A separate permission form is required for each medication.Texas law requires parent and physician permission to carry an inhaler or emergency epinephrine at school. Contact your school nurse for information. Medications not listed above ______________________________ ______________________________

Amount _______________ _______________

Reason __________________________________ __________________________________

At Home/At School _______________________ _______________________

My child has NO KNOWN HEALTH CONDITIONS and does not require any medications at home or school.

__________________________

___________________________

________________

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

SC 0300019

Photography and Video Release Form

Student Name ________________________________

Student Grade __________

Student DOB _________________

School Name ______________________________

Student ID

_________________

I do hereby give my consent to the Dallas Independent School District and its designees to photograph, audio record, and/or video record my child. I understand that any such photographs, audio recordings, and/ or video recordings become the property of the Dallas Independent School District. I understand that the District may use and/or reproduce the photographs, likeness or the voice of my child for any internal or external educational, instructional, or promotional activities determined by the District in broadcast and electronic media formats now existing or in the future created. I further understand that external educational, instructional, or promotional activities may include the release of the photographs, audio recordings, and/or video recordings to newspapers, radio and television stations. I also agree to allow my child’s work and/or photograph to be published on the Dallas Independent School District internet, intranet and/or Dallas ISD publications. I further understand that by signing this release, I waive any and all present or future compensation rights to the use of the above stated material(s). By signature below, I release the Dallas Independent School District, its Board of Trustees, agents, employees or other representatives from any liabilities, known or unknown, arising out of the use of this material. I have read the Photography and Video Release Form and fully understand the terms and conditions outlined. I certify that I have full legal capacity to sign this Photography and Video Release Form on behalf of myself and my child.

YES, I do give permission to use my child’s photo or likeness as described above. NO, I do not give permission to use my child’s photo or likeness as described above.

__________________________

___________________________

________________

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

SC 0301320

Military Connected/Foster Care Form

Student Name ________________________________

Student Grade __________

Student DOB _________________

School Name ______________________________

Student ID

_________________

Military Connected Student

Student is a dependent of an Active Duty member of the United States military (Army, Navy, Air Force, Marine Corps or Coast Guard) Student is a dependent of a member of a reserve force in the United States military (Army, Navy, Air Force, Marine Corps or Coast Guard)

Student is a dependent of a member of the Texas National Guard (Army, Air Guard, or State Guard) Pre-kindergarten student is a dependent of: an active duty uniformed member of the U.S. military (Army, Navy, Air Force, Marine Corps, or Coast Guard) OR an activated/mobilized member of the U.S. reserve (Army, Navy, Air Force, Marine Corps or Coast Guard) or the Texas National Guard (Army, Air Guard or State Guard) OR member of U.S. military, U.S. Reserve or Texas National Guard who was injured or killed while serving on active duty Student is none of the above

Foster Care Student

Student is currently in the conservatorship of the Department of Family & Protective Services (Enrolling caregiver must provide a copy of Texas DFPS Placement Authorization Form 2085 or court order designating conservatorship of the DFPS)

Pre-kindergarten student was previously in the conservatorship of the Department of Family & Protective Services Student is none of the above

__________________________

___________________________

________________

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

v 1.2

Student Residency Questionnaire Student Name ________________________________

Student Grade __________

Student DOB _________________

School Name ______________________________

Student ID

_________________

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine services the student may be eligible to receive.

SECTION A Is your current address a temporary living arrangement? Yes No Is this temporary living arrangement due to loss of housing or economic hardship? Yes Are you an unaccompanied youth? Yes No

No

If you answered YES to ANY of the above questions, please complete Sections B and C of this form; otherwise skip to Section D.

SECTION B

Where is the student presently living? (Check boxes that apply) Motel/Hotel Shelter Moving from place to place Abandoned house or building With more than one family in a house or apartment In a car, park or campsite Other (please explain) _______________________

SECTION C Do you have any children AGES 0-5 who are NOT enrolled in school? Yes No If yes, how many? _____________ Age(s) _____________________________________ Do you have other school age children who are not living with you? Yes No If yes, how many? ____________ Age(s) _____________________________________ Where are they currently living? ________________________________________________

SECTION D __________________________

___________________________

________________

Parent/Guardian Name (Print) Parent/Guardian Signature Date ______________________________________ ________________________________________________ Phone(s) Address **CAMPUS USE ONLY** If the answer is “yes” to any of the Section A questions, mail this form to Box 141 or scan and email it to: [email protected]. Service requested by campus

Uniform

School Supplies

Food

Registrar/Data Controller Name ___________________________________

Backpack

Phone Number ___________________

If you or the family need any services or further assistance, please contact our office at (972) 749-5789. SC 0300008 Rev. Jan 2015

Other ______________

Socioeconomic Information Form 2016-2017

*CONFIDENTIAL* Student Name ________________________________

Student Grade __________

Student Date of Birth _________________

School Name ______________________________

Student ID

_________________

Dallas ISD is required to collect the socioeconomic status of each student as a performance indicator for student achievement (TEC 39 for Texas state requirements and ESEA sections 1111 and 1116 for U.S. Department of Education requirements) and for use in disbursement of federal funds (ESEA section 1113). This information may also be shared with district education and health programs to help them evaluate, fund, or determine benefits for their programs.

SECTION A Do you receive Supplemental Nutrition Assistance (SNAP)? Do you receive Temporary Assistance to Needy Families (TANF)?

Yes Yes

No No

If you answered YES on either of the above, skip SECTION B and continue to the SIGNATURE section. SECTION B (Complete only if all answers in SECTION A are NO) How many members are in the household (include all adults and children)? ____________ TOTAL YEARLY INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS (check one box below): Include wages, salary, welfare payments, child support, alimony, pensions, Social Security, worker’s compensation, unemployment and all other sources of income (before any type of deductions) $0 – 21,978 $21,979 – 29,637 $29,638 – 37,296 $37,297 – 44,955

$44,956 – 52,614 $52,615 – 60,273 $60,274 – 67,951 $67,952 – 75,647

$75,648 – 83,343 $83,344 – 91,039 $91,040 – 98,735 $98,736 – 106,431

$106,432 – 114,127 $114,128 – 121,823 $121,824 – 129,519 $129,520 and above

SIGNATURE Please check one of the following two boxes as appropriate. In accordance with the provisions of the Protection of Pupil Rights Amendment (PPRA) no student shall be required, as part of any program funded in whole or in part by the U.S. Department of Education, to submit to a survey, analysis, or evaluation that reveals information concerning income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program), without the prior written consent of the adult student, parent or legal guardian.

I certify that all the information on this form is true and that all income is reported. I understand the school will receive federal funds and will be rated for accountability based on the information I provide. I choose not to provide this information. I understand that the school’s disbursement of federal funds and accountability rating may be affected by my choice.

__________________________

___________________________

________________

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

V 1.4 SC 0301357

STUDENT/PARENT ACKNOWLEDGMENT RECEIPT FORM The Student Handbook and the Student Code of Conduct are available online at www.dallasisd.org/domain/11. A printed copy may be obtained from the school or the website. The Dallas Independent School District fosters a climate of mutual respect for the rights of others. Each student is expected to respect the rights and privileges of other students, teachers, and district personnel. The student’s responsibilities for achieving a positive learning environment at school and/or school-related activities include the following:

• Attend all classes each day, and be on time • Prepare for each class with appropriate materials and completed assignments • Dress according to the dress code adopted by each individual school • Know that the possession, use, and sale of illegal or unauthorized drugs, alcohol, and weapons is unlawful and prohibited • Show respect toward others • Conduct yourself in a responsible manner • Know and obey all school rules in the Student Code of Conduct and in the School-Based Discipline Management System • Cooperate with staff members in investigations of disciplinary matters • Understand that all cell phones must be turned off during instruction time • Report threats for the safety of students and staff members as well as misconduct on the part of any other students or staff members to the principal, a teacher, or another adult

• Be familiar with and comply with the Student Technology Acceptable Use Policy • Understand that principals, coaches, and sponsors of extracurricular activities may develop and enforce standards of conduct that are higher than the district-developed Student Code of Conduct. The Student Code of Conduct, the Student Handbook, and the Student Technology Acceptable Use Policy, which is contained in the Student Handbook, have been written so that students gain the greatest possible benefit from their school experience. However, our schools need the help and cooperation of parents to attain this goal. It is important that every student understand their responsibilities and be expected by their parent(s) or guardian(s) to follow the rules and regulations set forth in these documents. Please read and discuss the Student Code of Conduct, the Student Handbook, and the Student Technology Acceptable Use Policy with your child. When you have done so, you and your child must sign this form and return it to the school.

Parents and students: Please read the statements below, check each box, sign and date the form, and return to your school.  I accept the responsibilities expected of me as a student enrolled in the Dallas ISD.  I accept the responsibilities expected of me as a parent/guardian of a student enrolled in the Dallas ISD.  We acknowledge that we have read the policies, procedures, rules, regulations, and practices presented in the Student Code of Conduct and the Student Handbook.  We confirm we have read the Student Technology Acceptable Use Policy that is included in the Student Handbook, understand the associated administrative regulations and user agreement, and agree to abide by their provisions, including the district’s guidelines for responsible online behavior and use of social networking websites. We understand that violation of these provisions may result in suspension or revocation of access to the district’s technology resources or other disciplinary action in accordance with the Student Code of Conduct.  We have read the procedures listed in the appeal process.  We accept any consequences should we fail to abide by these provisions.

Name of Student (please print)

Student's Signature

Date

Name of Parent/Guardian

Parent’s/Guardian’s Signature

Date

The completed form is to be returned within five days from receipt of the enrollment packet. The signed form will be filed in the student’s permanent record folder for the current school year.