RETURNING Students only - latta.k12.ok.us...The child is a tribal member with a CDIB card and/or a tribal membership card. 2. The parent of the child is a tribal member with a CDIB

Latta School 2019-2020 Enrollment

Packet for

RETURNING Students only

Parent Information

Welcome to the 2019-2020 school year. In an effort to reduce the amount of time it takes for our parents to complete enrollment forms, we have modified our enrollment. Enrollment packets are now available.

NEW STUDENTS

• New Students’ parents will open the New Students’ enrollment link below and fill out one enrollment packet per student. The completed enrollment packet will then need to be printed and brought to school on enrollment day—Tuesday, August 6.

• Parent(s) or Legal Guardian must attend enrollment. • New Students must provide the following documentation:

o Proof of residence o State Certified Birth Certificate o Transcript (10th—12th grade) o Name and address of previous school attended

• Latta Pre-Kindergarten and Kindergarten student, who have not attended a public school, must bring the following:

o Proof of residence o State Certified Birth Certificate o Immunization Records Immunization Requirements for Oklahoma o CDIB card (if applicable) o A readiness screening and/or a speech and hearing screening may also be scheduled at the

time of enrollment. Please be prepared to make time for these screenings. For more information, phone the elementary office at 580-332-7669.

o Additional paperwork may be required at enrollment.

CURRENT STUDENTS Pre-Kindergarten – 12th grade

Current/returning students will open the Current/Returning Student Enrollment Packet below and fill out the packet. The packet will then need to be printed and brought to the school on enrollment day—Monday, August 5.

Basic Information • All students who have received new immunizations need to bring an updated immunization record. • Additional paperwork may be required at enrollment. • Seniors will take pictures for senior panel at enrollment on August 5.

MEET THE TEACHER NIGHT

• Tuesday, August 13th at 5:30 p.m. to 7:00 p.m. This will be very informal and parents are encouraged to bring the student’s school supplies with them.

Please do not print enrollment forms double-sided. Each form must be on a separate page by itself.

Latta Public Schools Student Enrollment Questionnaire 2019-2020

Student Name Grade Date of Birth Today’s Date

Your child may be eligible for additional educational services through Title X, Part C McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire.

Where are you and your family currently living? Please check one of the boxes below: Section A:

Rent/own my own home or apartment Stop: If you checked the box that you rent/own your own home or apartment, skip to the bottom of the page, sign the form, and then submit to school personnel. If you do not rent/own your own home or apartment, please continue to the next section. Section B:

Temporarily with another family member or friend until we can locate affordable housing In an emergency or transitional shelter In a vehicle, park, campground or on the streets In a hotel or motel With an adult that is not a parent or legal guardian Alone or in a different location, without an adult serving as a caregiver Wherever I can find a place to stay a night Other, Please Explain

If you checked a box in section B, in the space below please list all children living with you who attend Latta Public Schools.

First & Last Name of Student Gender Date of Birth Grade School Name

Would you like to be contacted by an employee of the school to discuss additional educational services that may be available to your child? Yes No The undersigned certifies that the information provided is correct and accurate.

(Print) Parent/Guardian or Adult Caring for the Student:

Relation to the Student: Signature:

Phone Number:

Health Inventory Page 1

Latta Public Schools Student Health Inventory

Last Name First Name Gender Grade

Has student ever had chicken pox? Yes No Age if Yes Today’s Date

Check the following health concerns that pertain to student: List Allergies Allergies

To Drugs

To Food

To Insects

To Pollen

Has the allergy required emergency action in the past? Yes No

Bee Sting Allergy Yes No Difficulty breathing? Yes No

Need emergency care Yes No Epi-Pen Yes No

Asthma Yes No Inhaler Yes No How Often? Doctor Name

Diabetes Yes No Take Insulin Yes No Date Diagnosed

Epilepsy/Seizures Yes No

Date of Last Seizure Is the student currently under a doctor’s care for seizures? Yes No Medication:

Heart Condition Describe

Physical Restrictions

Medications

Bone/Joint Condition

Describe

Physical Restrictions

Eyes—check all that apply: Ears—check all that apply: Hearing Aid

Difficulty Seeing Frequent infections Left Glasses (reading or distance) Tubes Right Contacts Hearing Difficulty Crossed Eye Hearing Aid(s) Lazy Eye Wears at school

Health Inventory Page 2

ADD/ADHD: Yes No Medication at school? Yes No

Medication at home? Yes No Other Health Concerns or Problems: Check all that are a concern.

Lungs Menstruation Nosebleeds Phobias Skin Neurologic (brain) Bedwetting Sleeping Bladder/Bowel Requires catheterization Requires diapering

Daily medications at home? Yes No Name of medications:

Reason for taking.

List of serious illness, disease, or injuries: List all Surgeries: Signature of Parent/Guardian Email Address:

Home Phone # Work Phone #

Latta Public Schools

Authorization for Medical Care of a Minor

The undersigned parent or guardian has legal custody of the child named below. As such he/she grants to the listed custodian, into whose care the child has been entrusted, permission to authorize the following: x-ray examination, anesthetic, medical/surgical/dental diagnosis or treatment and hospital care for the child. All procedures must be recommended by a physician, surgeon, or dentist licensed by the State of Oklahoma.

The consent, given in advance of a specific event, encourages the custodian to seek needed treatment for the child in the absence of a parent or guardian. This consent is effective until it is withdrawn in writing.

Date: Grade:

Name of Child:

Date of Birth:

Name of

Custodian(s): Latta School Personnel

Special Medical Information Regarding Child (Allergies, Current Medications, and Medical Condition: i.e. asthma, epilepsy, diabetes, etc.) Signature of Parent or Legal Guardian: Signature of Witness:

Minor children must have parent or legal guardian consent for medical treatment. Except in a life-threatening situation, treatment could not be administered without it. Persons entrusted with the care of your child cannot give consent for treatment, unless legally authorized by a parent or guardian. The consent form is legal authorization for emergency medical and/or dental treatment and insures that your child will receive treatment without delay.

Latta Public Schools

Publication Permission

Some Latta school activities may include students in pictures, in videos or articles written about students. At times there may be opportunity to publish those articles, pictures or videos in school newsletters, on the school/district web site/Facebook page or submit to state and/or local newspapers for possible publication.

Please check one of the choices: ☐ YES, my child may be photographed, videotaped or have his/her work included in all publications.

☐ No, my child may not be photographed, videotaped or have his/her work included in all publications.

☐ My child’s picture may appear ONLY in the school yearbook. Student’s Name

Student’s Grade

Signature of Parent/Legal Guardian only

Date

The 2019-2020 Latta School Student Handbook is available online at http://www.latta.k12.ok.us. My signature below affirms that I have been given access to the online handbook and I understand that I am responsible for the following policies written therein.

Student’s Signature Grade

Parent’s/Guardian’s Signature Today’s Date

Note: A bound copy of the Student Handbook is available from the HS/MS office upon request.

Latta School Student Handbook Acknowledgement

Latta Public Schools

Tribal Membership Form

Year

Dear Parent/Guardian

Latta Public Schools would appreciate your cooperation in a school-wide survey of Native American students. All parents /guardians (Indian and Non Indian) are asked to complete the survey and return it to any school office as soon as possible.

Your child may qualify as Native American if one of the statements is true for your child:

1. The child is a tribal member with a CDIB card and/or a tribal membership card. 2. The parent of the child is a tribal member with a CDIB card and/or a tribal membership card. 3. The grandparent of the child is a tribal member with a CDIB card and/or a tribal membership

card.

Please check one of the statements below that qualifies your child as tribal member or not. If your child does qualify as Native American, please write in the tribe name and fill out the Title VII form provided if your child is a new student to Latta.

Student’s Name: Grade: Date:

Tribe • My child has a CDIB card and/or a tribal membership card. ☐Yes • The parent has a CDIB card and/or a tribal membership card. ☐Yes • The grandparent has a CDIB card and/or a tribal membership

card. ☐Yes

• My child has no Indian blood. (Do not fill out the Title VII form.) ☐Yes

A copy of the CDIB card and membership will need to be left at the school office

Latta Public Schools TITLE VI INDIAN EDUCATION

Completion of the 506 form will assist the school district in applying for federal funds related to Indian education. The amount of funds received is based upon a district count of Indian students. The participation of your qualified student is vital to the funding for the district.

Instructions for Completion of the 506 Form Parents or guardians please complete all information required on the 506 form and return it to the school secretary.

In order for a 506 form to be complete, it must contain all of the following information:

• The child’s name and date of birth. • The school name. • The grade the child is in at the time the form is signed by the parent. • The complete name of the tribe, band or group in which tribal membership is held. • Whether the tribe listed is federally recognized (including Alaska Native); state recognized;

terminated; or an organized Indian group that meets the legislative definition on the form. • The name of the individual that is holding tribal membership to the student--the child; the

child’s parent, or the child’s grandparent. (NOTE: Tribal membership may not go farther back than the child’s grandparent to qualify for eligibility for this program.)

• Proof of membership (membership or enrollment number if readily available, or a description of other proof).

• The name and address of the organization maintaining membership data for the tribe, band, or group. (NOTE: A list of tribal addresses are provided on the back of these instructions.)

• The parent’s dated signature. • The parent’s mailing address and telephone number.

If further assistance is needed, contact Jamie Matthews, Indian Ed Coordinator at 580-332-3980.

NOTE: An additional request is that if the student (child) has a CDIB (Certificate of Degree of Indian Blood) card, the school would like to have a copy for our records. With a CDIB card on file, your student is eligible for JOM school supplies at the beginning of the school year.

OMB Number: 1810-0021 Expiration Date: 02/29/2020

U.S. Department of Education Office of Indian Education

Washington, DC 20202 TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

Name of the Child __________________________________________________ Date of Birth ______________ Grade ______ (As shown on school enrollment records)

Name of School ____________________________________________________________________________________________ TRIBAL ENROLLMENT

Name of the individual with tribal enrollment: ___________________________________________________________________

(Individual named must be a descendent in the first or second generation)

The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent

Name of tribe or band for which individual above claims membership: _______________________________________________ The Tribe or Band is (select only one):

_____ Federally Recognized _____ State Recognized _____ Terminated Tribe (Documentation required. Must attach to form) _____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994. (Documentation required. Must attach to form)

Proof of enrollment in tribe or band listed above, as defined by tribe or band is:

A. Membership or enrollment number (if readily available) _____________________________________________________ OR B. Other Evidence of Membership in the tribe listed above (describe and attach) _______________________________________ Name and address of tribe or band maintaining enrollment data for the individual listed above:

Name ____________________________________________ Address ________________________________________________ City _______________________________State ______Zip Code ____________ ATTESTATION STATEMENT I verify that the information provided above is accurate.

Name Parent/Guardian ______________________________________ Signature _______________________________________

Address ______________________________________ City ____________________________State ______Zip Code __________ Email Address ________________________________________ Date _______________

OMB Number: 1810-0021 Expiration Date: 02/29/2020

INSTRUCTIONS FOR THE ED 506 FORM

FOR APPLICANTS:

PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under this subpart, and that otherwise meets the requirements of subsection (b)”. MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year, which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.

FOR PARENTS/GUARDIANS:

DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band, including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994. STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level. TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can provide membership information. Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to this form.

• Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department of Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request.

• State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department of Education does not maintain a master list. It is recommended that you use official state websites only.

• Terminated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interior and had that designation terminated.

• Organized Indian Group- Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent, or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate. Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians. ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied.

The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act.

PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of

information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021.

The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian

student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete

and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this

form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your

individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W.,

LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020.

Attached is a Title VI 506 form. This form is for the parent/guardian of students enrolling at Latta. If the student, parent, or grandparent possesses a CDIB card or membership card of a federally recognized tribe, state recognized tribe, or a terminated tribe, then a 506 form needs to be completely filled out, signed, and dated by the parent/guardian of the student. Below are some addresses of different tribes that can be used to help fill out the 506 form. If you do not see your tribe, please contact Jamie Matthews for help at 580-332-3980.

ABSENTEE-SHAWNEE TRIBE OF OKLAHOMA 2025 S GORDON COOPER DR. SHAWNEE OK 74801

CADDO NATION PO BOX 487 BINGER OK 73009

CHEROKEE NATION PO BOX 948 TAHLEQUAH OK 74465

CHEYENNE RIVER SIOUX TRIBE PO BOX 590 2001 MAIN STREET EAGLE BUTTE SD 57625

CHEYENNE & ARAPAHO TRIBE 100 RED MOON CIRCLE CONCHO OK 73022

CHICKASAW NATION PO BOX 1548 ADA OK 74820

CHOCTAW NATION OF OKLAHOMA PO BOX 1210 DURANT OK 74702-1210

CITIZEN POTAWATOMI NATION 1601 S GORDON COOPER DR. SHAWNEE OK 74801

COMANCHE NATION 584 NW BINGO RD LAWTON OK 73507

KAW NATION P.O. Box 50 OR 698 Grandview Dr. Kaw City, OK 74641

KICKAPOO TRIBE OF OKLAHOMA PO BOX 70 OR 105365 S HWY 102 MCLOUD OK 74851

KIOWA TRIBE OF OKLAHOMA 100 KIOWA WAY PO BOX369 CARNEGIE OK 73015

MISSISSIPPI BAND OF CHOCTAW INDIANS 101 INDUSTRIAL ROAD CHOCTAW MS 39350

MUSCOGEE (CREEK) NATION PO BOX 580 HWY 75 LOOP 56 OKMULGEE OK 74447

NAVAJO NATION PO BOX 9000 WINDOW ROCK AZ 86515

NORTHERN CHEYENNE TRIBE PO BOX 128 LAME DEER MT 59043

OKLAHOMA MISSISSIPPI CHOCTAW TRIBE PO BOX 1560 DURANT OK 74702-1210

OTTAWA TRIBE OF OKLAHOMA 13 HIGHWAY 691 MIAMI OK 74354

PAWNEE TRIBE PO BOX 470 PAWNEE OK 74058

PRAIRIE BAND POTAWATOMI NATION 16281 Q RD MAYETTA KS 66509

QUAPAW TRIBE OF OKLAHOMA 5681 S 630 RD PO BOX 765 QUAPAW OK 74363

ROSEBUD SIOUX TRIBE 11 LEGION AVE ROSEBUD SD 57570

SAC & FOX NATION 920883 S HWY 99 BLDG A STROUD OK 74079

SALT RIVER PIMA/MARICOPA TRIBE 10005 E OSBORN RD SCOTTSDALE AZ 85256

SEMINOLE NATION PO BOX 1498 WEWOKA OK 74884-1498

SHAWNEE TRIBE PO BOX189 29 S HWY 69A MIAMI OK 74355

STANDING ROCK SIOUX TRIBE PO BOX D FORT YATES ND 58538

TE-MOAK TRIBE OF WESTERN SHOSHONE 525 SUNSET STREET ELKO NV 89801

Latta Public Schools

Impact AID Form

Student Name: Grade:

THE PURPOSE OF THIS FORM IS TO ENSURE THAT THE SCHOOL DISTRICT IS COMPENSATED FOR LOST REVENUE DUE TO TAX-EXEMPT FEDERAL PROPERTY.

This form should be completed by any student whose parent/guardian:

• Works on federal property o (Examples: Kerr Lab, Chickasaw Nation, BIA Office, Others may apply)

• Lives on federal property o (Examples: Chickasaw Housing, Ada Housing Authority, Indian Trust Land, Others may apply)

• Is on active military duty in the Uniformed Services of the United States

Name of Student(s) Grade 1.

2.

3.

4.

5.

Parent/Guardian Information

Father’s Name: Mother’s Name:

Home Phone Home Phone

Work Phone Work Phone

Cell Phone Cell Phone

StepFather/Guardian Name: StepMother/Guardian

Name:

Home Phone Home Phone

Work Phone Work Phone

Cell Phone Cell Phone

Employer Information IF YOU ARE COMPLETING THIS FORM BECAUSE YOU WORK ON FEDERAL PROPERTY, PLEASE CHECK THE CATEGORY THAT APPLIES.

IF YOU ARE COMPLETING THIS FORM BECAUSE YOU LIVE ON FEDERAL PROPERTY, PLEASE CHECK THE CATEGORY THAT APPLIES.

☐ Chickasaw Nation—Department: ☐ Chickasaw Nation ☐ Kerr Lab ☐ Ada Housing Authority ☐ Bureau of Indian Affairs ☐ Indian Trust Land ☐ Armed Forces ☐ Other ☐ National Guard Other: ☐ Other

Other: