Student Enrollment Form - Mukilteo School District€¦ · Student/family has parent or guardian who is a member of Armed Forces. Student/family has parent or guardian who is a member

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Last Name

First Name

Middle Name

Gender Male Female

Student’s Country of Birth __________________________________

If your student was not born in the United States, what was the first date of education in ?

Number of months of education in another country before first date of education in United States:

What language does

If available, in what language would you prefer to receive communication from the school?

What language(s) do use the most when you speak to your child?

Do grandparent(s) or parent(s) have a Native American tribal affiliation? Yes No

Home Phone (_____)___________________ Unlisted

Father’s First/Last Name ______________________________________ Mother’s First/Last Name

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US

YOUR CHILD use the most at home?

parent/guardians

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Legal Last Name

Legal First Name

Legal Middle Name

(if different)

(if different)

(if different)

Grade ____________ Birthdate _____ / ______ / _________

City ______________________________ State

Office use only: Attend verify Immu Transcript release Nurse copy Copy� � � � � �IEP ESL

School Name Today’s DateSection 1: Student Information

Student Enrollment Form

_______________________

____________________

____________________

____________________

____________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

mo day yr

Student E-mailAddress:

PhoneType:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Student’sHome Address City State Zip

Mailing Address City State Zip

List Previous Schools Attended

School Name City __________________________________ State ____________________

School Name_____________________________________________ City __________________________________ State ____________________

School Name City __________________________________ State ____________________

Has student attended a Mukilteo School in the past? Yes No

Name_________________________Brother Sister to this student ( ) Attending what School______________________Grade




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List Siblings Attending Mukilteo Schools:

or please circle

or please circle

or please circle

or please circle

**Please list any Legal Binding Information that is pertinent to this student and his/her safety:

_________________________________

_________________________________

(If other than English, your child will be tested for the Program)EL

(If other than English, your child will be tested for the Program)ELWhat language did your child first learn to speak?

DP-013 ENGLISH Rev. 2-2020

Emergency Contacts: Starting with Parent/Guardian, list all other contacts including Daycare (other) in order of preference calling.P

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Section 2: Contact Information Page: 2 of 4

First Name Telephone 1 (_____)__________________ Phone type ________________ Contact Mailing Status:

Last Name

Address

City

State Zip Employer Occupation

Email Address Alt. email

Lives with Student� �Student’s Guardian: Relationship to Student

Telephone 2 (_____)___________________ Phone type



Grade Reports

Conduct Reports

Other Mailings

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Last Name

Address

City







Grade Reports

Conduct Reports

Other Mailings

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Last Name

Address

City







Grade Reports

Conduct Reports

Other Mailings

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Last Name

Address

City







Grade Reports

Conduct Reports

Other Mailings

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Last Name

Address

City







Grade Reports

Conduct Reports

Other Mailings

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Tell us about any services that your student has received:

• Has your child ever received special education services ( )?

(This could include: Speech Therapy, Physical Therapy, Occupational Therapy, Resource Room, etc.)

• Has your child ever been on a 504 Plan?

• Has your child ever been enrolled in a Gifted Program?

• Did your child receive English language development support through the Transitional Bilingual Instruction Program

in the last school your child attended?

IEP

• Did your child ever participate in an Early Education Program? (Examples: , Headstart, Special Ed, etc..)ECEAP Yes No

Yes No

Yes No

Yes No Don’t Know

Is there any other information that would help us better serve your student?

Any other comments?

Thank you for assisting us with the enrollment process. We know that this documentcontains a great deal of information regarding your student and we appreciate you taking

the time to fill it out as completely and accurately as possible. Please contact us as soon as possiblewhenever student or contact information changes in the future.

Welcome to the Mukilteo School District. We are looking forward to serving your student!

Parent/Guardian Signature X Date

In accordance with Washington State law ( 28A.255.330), please answer the following questions:RCW

1. Has your student been enrolled in Mukilteo School District before?

If yes, which school?

2. Has your student been enrolled in a Washington State School District?

If yes, where?

3. Does your student have any history of violent behavior?

If yes, please explain.

4. a. Does your student have any past, current or pending suspension or expulsion from your prior school?


4. b. Has your student ever been expelled from school?


5. Has your student officially withdrawn from your previous school?

6. Does your student owe any fines or fees for any book, uniform or property damage at your prior school?

Section 4: Additional and General Information Page: 4 of 4

DP-013 Rev. 2/20

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If so, where

Please select only below that best describes student/family military affiliation.one option (box)

Student/family has

Student/family has parent or guardian who is a member of Armed Forces.

Student/family has parent or guardian who is a member of Armed Forces .

Student/family has parent or guardian who is a member of the .

Student/family has parent of guardian who is a member of the Armed Forces (active duty or reserves) or the Washington

National Guard.

no military affiliation.

one active duty US

one reservesUS

one Washington National Guard

more than one US

CONTINUED ON REVERSE

MUKILTEO SCHOOL DISTRICT | STUDENT HEALTH SERVICES INTAKE FORM Student name: (last)____________________________ (first)________________________ Birthdate: _____________

OB Does your student have a LIFE-THREATENING health condition? □ Yes □ No Note conditions below and please make arrangements with your school nurse at time of registration to meet and discuss care planning. State law requires that students with life-threatening conditions such as anaphylaxis, severe asthma, diabetes or seizures have a care plan completed prior to starting school. Contact the school nurse.

RG Severe Asthma EG Anaphylaxis (severe allergy) Epinephrine prescribed

NP Seizures EK Diabetes Type 1 Attach current diabetic orders from specialist.

Triggers (please circle) illness / colds exercise allergies strong odors smoke weather changes stress/emotions

Please list allergens:

How many times have you needed to use the EpiPen?

Are seizures well-controlled? Y / N Date of last seizure: Describe seizure:

The school nurse will be contacting you for additional information.

Rides bus to school? Yes No Preferred language for communications: _________________________ Interpreter needed? Y / N

My child’s primary healthcare provider is: ________________ at (clinic): ________________________ Preferred hospital: __________________

PLEASE CHECK BOXES BELOW IF YOUR CHILD HAS ANY OF THE FOLLOWING HEALTH CONDITIONS

Allergy, Immune, Endocrine, Metabolic and Nutritional DP Dietary Preference: ______________________________

ED Allergy, food(s): _________________________________

EE Allergy, insect: __________________________________

DP Allergy, seasonal/other: ___________________________ EL Diabetes Type 2

ENDO Other Endocrine, Immune, Nutritional or Metabolic: Ears/ Hearing

YA History of chronic ear infections YA Current chronic ear infections YB Hearing Impaired

Hearing Aid/s Cochlear Implant Other ear condition: _________________________ Please provide most recent audiology report to school

Gastrointestinal, Dental and Oral GA Celiac disease GG Food Intolerance: __________________________ GL Lactose Intolerance GF Encopresis Date diagnosed: ________________ Change of clothes, wipes needed at school GO Chronic Constipation GH Gastric Reflux GJ Inflammatory Bowel Disease GK Irritable Bowel Syndrome GI Other Gastrointestinal, Liver, Dental, Oral condition:

Respiratory/ Breathing RG Asthma, current RH Asthma, ever diagnosed (history of) RA Asthma, exercised Induced RE Reactive Airway Disease RF Other Respiratory Condition

__________________________________________ Eyes/Vision

VF Glasses / contacts Vision is not fully corrected YE Color blindness YD Other vision concerns: _________________

Please provide most recent notes from eye doctor to school Skin

SB Eczema, contact dermatitis or psoriasis Other Skin Condition: ____________

Musculoskeletal MC Juvenile Rheumatoid / Idiopathic Arthritis

Other: ____________________________________ Nervous System

NE Cerebral Palsy NF Developmental Disability NH Migraines NI Headaches, Recurring NP Seizure Disorder, type __________________ Current History NU Traumatic Brain Injury Other Neurological Condition:

Medical History, continued

MSD health intake form.docx (January 2020)

MUKILTEO SCHOOL DISTRICT | STUDENT HEALTH SERVICES INTAKE FORM

Blood / Hematology BA Anemia BB Hemophilia BC Sickle Cell Disease Trait OJ History of severe nosebleeds Other Blood Condition: _________________________

Cardiac/ Heart

CC □ Heart Birth Defect CD □ Heart Murmur □ Activity Restrictions related to heart condition? Y / N

□ Other Cardiovascular condition, include symptoms: ______________________________________________

□ Last cardiology visit: ________________

Congenital / Genetic AH Down Syndrome AJ Fetal Alcohol Spectrum Disorder

Other: ___________________________________ Renal / Kidney History (describe) Cancer/ Tumor History (describe) Medical Devices OLA Vagal Nerve Stimulator OLB Automatic Internal Cardiac Defibrillator OLC Pacemaker OLD Gastronomy Tube OLE Jejunostomy Tube Brace Prosthesis: ____________________________

Other medical device ________________________

Mental and Behavioral Health NB ADHD / ADD diagnosed by: ______________ NC Autism Spectrum Disorder PA Anxiety PC Depression PE Oppositional Defiant Disorder (ODD) PH Sleep Disorder PJ Other Mental or Behavioral Health Condition:

My student is seeing a counselor

Frequency: ________________________ My student is seeing a behavior therapist Frequency: ________________________

Transplant History OD List Organ _____________ Date: _________ Stoma OKA Gastrostomy OKB Colostomy OKD Tracheostomy OKE Urostomy OK Other: __________________________________ Physical Activity / Mobility Issues Wheelchair Crutches Other: __________________________________ Other Health Concerns:

Medication History State law requires written permission from guardian and health care provider before any medication (prescriptions and over-the-counter) may be taken at school. Forms are available from your school office or on our district website. Medication forms must be completed annually.

Medication Dose Frequency Home, School or both? Prescribed by

I understand the information I have provided is kept in strict confidence and will only be shared with appropriate school staff who need to know in order to provide for the health and safety of my student. This information is true and correct to the best of my knowledge. I also understand it is my responsibility to notify the school nurse should health concerns arise or conditions change, and to provide correspondence as needed from my child’s healthcare provider regarding their condition(s). Parent/Guardian (print) __________________________ Signature ____________________________Date _________

□ My child has NO KNOWN HEALTH CONDITIONS Initials ___________

▲Required for School ● Required Child Care/Preschool

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Required Vaccines for School or Child Care Entry

●▲ DTaP (Diphtheria, Tetanus, Pertussis)

▲ Tdap (Tetanus, Diphtheria, Pertussis) (grade 7+)

●▲ DT or Td (Tetanus, Diphtheria)

●▲ Hepatitis B

● Hib (Haemophilus influenzae type b)

●▲ IPV (Polio) (any combination of IPV/OPV)

●▲ OPV (Polio)

●▲ MMR (Measles, Mumps, Rubella)

● PCV/PPSV (Pneumococcal)

●▲ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV/MPSV (Meningococcal Disease types A, C, W, Y)

MenB (Meningococcal Disease type B)

Rotavirus

Certificate of Immunization Status (CIS) Reviewed by: Date:

Signed COE on File? Yes No

Please print. See back for instructions on how to fill out this form or get it printed from the Washington State Immunization Information System.

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YYYY):

I give permission to my child’s school/child care to add immunization information into the Immunization Information System to help the school maintain my child’s record.

Conditional Status Only: I acknowledge that my child is entering school/child care in conditional status. For my child to remain in school, I must provide required documentation of immunization by established deadlines. See back for guidance on conditional status.

Parent/Guardian Signature Date Parent/Guardian Signature Required if Starting in Conditional Status Date

Documentation of Disease Immunity (Health care provider use only)

If the child named in this CIS has a history of varicella (chickenpox) disease or can show immunity by blood test (titer), it must be veri-fied by a health care provider. I certify that the child named on this CIS has: A verified history of varicella (chickenpox) disease. Laboratory evidence of immunity (titer) to disease(s) marked below.

Diphtheria Hepatitis A Hepatitis B

Hib Measles Mumps

Rubella Tetanus Varicella

Polio (all 3 serotypes must show immunity)

►

Licensed Health Care Provider Signature Date

►

Printed Name

I certify that the information provided on this form is correct and verifiable.

Health Care Provider or School Official Name: ______________________________ Signature: ______________________ Date:___________ If verified by school or child care staff the medical immunization records must be attached to this document.

X X

Reference guide for vaccine trade names in alphabetical order For updated list, visit https://www.cdc.gov/vaccines/terms/usvaccines.html

Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1)

Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix DTaP + Hep B + IPV RotaTeq Rotavirus (PV5)

Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td

Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib +IPV Trumenba MenB

Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B

Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A

Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella

Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 November 2019

Instructions for completing the Certificate of Immunization Status (CIS): Print the from the Immunization Information System (IIS) or fill it in by hand.

To print with the immunization information filled in: Ask if your health care provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide registry). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: [email protected] or 1-866-397-0337. To fill out the form by hand: 1. Print your child’s name and birthdate, and sign your name where indicated on page one. 2. Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediatix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. 3. If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your health care provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. 4. If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign and date the form. You must provide lab reports with this CIS. 5. Provide proof of medically verified records, following the guidelines below. Acceptable Medical Records All vaccination records must be medically verified. Examples include:

A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state’s IIS.

A completed hardcopy CIS with a health care provider validation signature.

A completed hardcopy CIS with attached vaccination records printed from a health care provider’s electronic health record with a health care provider signature or stamp. The school administrator, nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.

Conditional Status Children can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimum intervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school or child care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care. Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student is catching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete. If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Valid documentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.

Please note: THIS FORM IS OPTIONAL.Complete this form ONLY if you DO NOT want Directory Information released about

your child and/or if you DO NOT want your child’s name released to the military.IF YOU HAVE MORE THAN ONE CHILD, COMPLETE SEPARATE FORMS FOR EACH CHILD.

Child’s name (please print clearly): ______________________________________________________________

School: ______________________________________________________ Grade: _______________________

If you do NOT want Directory Information released about your child during the 2020-21 school year, please mark the box below and sign your name at the bottom. (Please consider carefully the consequences of this decision. If you check this box and sign below, it means that your child’s name and/or photograph will not be included in school publications (such as the yearbook) or won’t be mentioned in media coverage of school events or in announcements of awards.)

Do NOT release ANY Directory Information about my child.

Are there any exceptions? If you check the box above and sign below, your child’s name and/or photograph can still be used for certain purposes if you mark the appropriate box or boxes below:

I agree to allow my child’s name and/or photograph to be included in the school yearbook, school newsletter and school directory. [LOCAL]

I agree to allow a photograph in which my child appears, but is not identified, to be published in a school district publication (such as the wall calendar or newsletter) or district social media. [DISTRICT]

I agree to allow my child’s name and/or photograph to be released to the news media. [MEDIA]

FOR HIGH SCHOOL STUDENTS ONLY: Federal law requires high schools to provide military recruiters with a list of student names and addresses. Parents have the right to request that their child’s name be omitted from that list, however. If you object to your child’s name and address being provided to the military during the 2020-21 school year, please mark the box below, sign your name at the bottom, and return the form to your child’s school by October 1.

Do NOT give my child’s name to military recruiters.

Parent/Guardian signature: _____________________________________________ Date: _________________

Please call 425-356-1215 if you have any questions. 2020-21

DO NOT RELEASE DIRECTORY INFORMATION

IMPORTANT INFORMATION ABOUTYOUR CHILD’S PRIVACY RIGHTS

A federal law called the Family Educational Rights and Privacy Act gives schools and school districts the authority to publish “Directory Information” about students and to make that information available to certain people or institutions, such as

the news media or colleges. Directory Information is defined as a student’s first and last name; photographic and electronic images; parent email address; dates of school attendance; participation in officially recognized activities

and sports; weight and height of members of athletic teams; degrees, honors, and awards received; and most recent school attended. (The Mukilteo School District does not release directory information for commercial purposes.) Another federal law requires that high schools provide a list of student names to military recruiters. Parents and guardians have the right to tell the school district and its schools to keep private any directory information about

their child and have the right to prevent their child’s name from being given to military recruiters.

Student Enrollment Form - Mukilteo School District€¦ · Student/family has parent or guardian who is a member of Armed Forces. Student/family has parent or guardian who is a member

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