Sumner School District...Guamanian or Chamorro-620 Tongan-640 Port Gamble Klallam-445 Other WA Indian-495 Mariana Islander-625 Other Pacific Islander-699 Puyallup-448 Other American

Updated 1/12/15

Sumner School District Student Registration

Checklist Sumner School District requires residency verification at time of enrollment. Please provide one of the following as proof of residency – utility bill, purchase papers for home, lease/rental agreement, affidavit of residence with sponsor or landlord. NOTE: This is required for all families completing a registration packet. Please check items you have completed and return with this cover sheet. Form used for Verification of Residency (Check one only):

Gas, Water or Electric bill. This bill must include the parent/guardian name, the address and be less than 30 days old.

Purchase Papers for home Lease/Rental Agreement Affidavit of Residence with a Sponsor or Landlord—sponsor/landlord must also provide

proof of residency as outlined above.

Student Registration Form Certificate of Immunization Status Form Health History Form Student Housing Questionnaire Birth Certificate – required for Kindergarten Registration Grade 1-8 Copy of last report card Grade 9-12 Students – Transcript from previous school

Name of Country

Month/Year

Student Registration Form DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY

Other ID# Grade WA Grad Yr Entry Date Records Requested Y N

Waivered From Overflowed From Teacher

Student Information – Please Print

Student Legal Last Name Student Legal First Name

Student Legal Middle Birthdate (Mth/Day/Yr) Grade Gender Male Female

Has your child ever been registered in the Sumner School District? Yes No If yes, what school

Has your child ever attended school under a different name? If yes, what name(s)

Only check one box per line Language student currently speaks English Spanish Korean Tagalog Ukrainian Russian Other

First language spoken by the student English Spanish Korean Tagalog Ukrainian Russian Other

Language student speaks at home English Spanish Korean Tagalog Ukrainian Russian Other

Birth City/State/Country If birth country not United States, please complete the following:

• My child attended a school outside of the United States for months in (10 months equals one school year)

• My child attended school in the United States before enrolling in Sumner School District. Their initial US enrollment date was

Washington State Ethnicity and Race Data Collection School districts in Washington State are required to report student data by ethnicity and race categories to the state’s Office of Superintendent of Public Instruction. The same ethnicity and race categories are used in all Washington school districts. They are set by the federal government, the Washington State Legislature, and the state Superintendent of Public Instruction. We need you to identify your child as either Hispanic/Latino or not Hispanic/Latino and by one or more racial groups. Is your child of Hispanic or Latino origin? Yes - If yes, the state requires information in both section 1 and 2.

No - Not Hispanic-10 - If no, proceed to section 2 and check all that apply. Section 1. Check all that apply.

Mexican/Mexican American/Chicano-30 Central American-75 Other Hispanic/Latino-90

Cuban-55 South American-80

Dominican-60 Latin American-85

Spaniard-65 Puerto Rican-70

Section 2. What race(s) do you consider your child? Check all that apply.

African American/Black-200 American Indian or Alaskan Native Do grandparent(s) or parent(s) have a tribal affiliation? Yes No

White-300 Alaska Native-405 Quinault-454

Asian Chehalis-410 Samish-457

Asian Indian-505 Laotian-545 Colville-413 Sauk-Suiattle-460

Cambodian-507 Malaysian-550 Cowlitz-416 Shoalwater-463

Chinese-510 Pakistani-555 Hoh-418 Skokomish-466

Filipino-520 Singaporean-560 Jamestown-421 Snoqualmie-469

Hmong-525 Taiwanese-565 Kalispel-424 Spokane-472

Indonesian-530 Thai-570 Lower Elwha-427 Squaxin Island-475

Japanese-535 Vietnamese-575 Lummi-430 Stillaguamish-478

Korean-540 Other Asian-599 Makah-433 Suquamish-481

Native Hawaiian or Other Pacific Islander Muckleshoot-436 Swinomish-484

Native Hawaiian-605 Micronesian-632 Nisqually-439 Tulalip-487

Fijian-615 Samoan-635 Nooksack-442 Yakama-490

Guamanian or Chamorro-620 Tongan-640 Port Gamble Klallam-445 Other WA Indian-495

Mariana Islander-625 Other Pacific Islander-699 Puyallup-448 Other American Indian/Alaska Native-499 Melanesian-630 Quileute-451

Page 1 of 3

SUMNER SCHOOL DISTRICT A GREAT PLACE TO LEARN

Household #1 Information

Household #1 - Parent/Guardian #1

Last Name First Name

Relationship to Student Father Mother Guardian Foster Other

Phone Numbers - with Area Code

Home Phone - - Unlisted Work Phone - - Ext: Cell Phone - -

Primary contact phone number (check one) home cell work e-mail

Street Address Apt# City, State, ZIP Code

Mailing Address/PO Box City, State, ZIP Code (Complete if different than street address)

Household #1 - Parent/Guardian #2

Last Name First Name

Relationship to Student Father Stepfather Mother Stepmother Guardian Foster Other

Work Phone - - Ext: Cell Phone - - e-mail

Household #2 Information

Household #2 - Parent/Guardian #1

Last Name First Name

Relationship to Student Father Mother Guardian Foster Other

Phone Numbers - with Area Code

Home Phone - - Unlisted Work Phone - - Ext: Cell Phone - -

Primary contact phone number (check one) home cell work e-mail

Street Address Apt# City, State, ZIP Code

Mailing Address/PO Box City, State, ZIP Code (Complete if different than street address)

Household #2 - Parent/Guardian #2

Last Name First Name

Relationship to Student Father Stepfather Mother Stepmother Guardian Foster Other

Work Phone - - Ext: Cell Phone - - e-mail

Emergency Contacts - One Name per Line

Name (other than guardian) Relationship to Student

Phone number-with area code - - home cell work

Name (other than guardian) Relationship to Student

Phone number-with area code - - home cell work

Name (other than guardian) Relationship to Student

Phone number-with area code - - home cell work

Name (other than guardian) Relationship to Student

Phone number-with area code - - home cell work

Other Children Attending School in Sumner

Legal Last Name Legal First Name School Grade

Legal Last Name Legal First Name School Grade

Legal Last Name Legal First Name School Grade

Legal Last Name Legal First Name School Grade Page 2 of 3

Student History Name of school student last attended District City State

Has your child ever been retained? Yes No If yes, at what grade level(s)?

Has your child ever received services in any of the following programs? Check all applicable programs.

Special Education (Including Speech) 504 Accommodations Highly Capable ELL Title 1 Services LAP Services Migrant Services

Name of school where services were received

Does your child have any past, current, or pending disciplinary actions or any history of violent behavior? Yes No Date

Is your child presently on suspension or expulsion from another school? Yes No If yes, reason

Is there a joint-custody or parenting plan in effect? Yes No If yes, a certified copy of the most recent plan must be on file with the school for enforcement.

Is there a restraining order against anyone pertaining to your student? Yes No If yes, most recent certified legal papers must be on file with the school for enforcement. Restraining order is against Mother Father Other

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

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

Childcare Does student attend childcare? Before school Afterschool Before and afterschool

Provider’s name Phone Number – with area code - -

Street Address City, State, ZIP Code

Release of Information The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that the Sumner School District, with certain exceptions, obtain written consent prior to the disclosure of personally identifiable information from your child’s education records. However, it is permissible to disclose designated information without written consent, unless the District has been advised otherwise.

The District may include directory information about your child in certain school publications including: listing their name on a playbill showing your student’s role in a drama production; in the annual yearbook; on Honor Roll or other recognition lists; in graduation programs; and on athletic team rosters. Directory information, which is information that is generally not considered harmful or an invasion of privacy if released, can also be disclosed to outside organizations without a parent’s prior written consent. Outside organizations include, but are not limited to, companies that manufacture class rings or publish yearbooks.

Please do NOT include my student’s information in Directory Information that may be released without my consent.

Two federal laws require the District to provide military recruiters, upon request, with three directory information categories: names, addresses and telephone listings unless parents have advised the high school that they do not want their student’s information disclosed without their prior written consent.

Please do NOT release my student’s Directory Information to the Armed Forces.

Sumner School District likes to celebrate the achievements of our students and staff. Throughout the year, the Communications Department and district staff may take photographs of students and school activities. These photographs may appear in various District materials, including the District’s website www.sumnersd.org, newsletters, yearbooks, brochures, the Report Card, district calendar, etc.

Please do NOT publish my student’s photo/image.

Verification of Residency – Sumner School District requires residency verification at time of enrollment. Please provide one of the following as proof of residency.

Utility Bill – gas, water or electric. This bill must include the parent/guardian name, the address and be less than 30 days old. Purchase Papers for home Lease/Rental Agreement Affidavit of Residence with a Sponsor or Landlord —sponsor/landlord must also provide proof of residency as outlined above.

Verification of Information The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Sumner School District.

Parent/Guardian Signature Date Original signature required. Equal Opportunity Employer The Sumner School District complies with all applicable federal and state rules and regulations and does not discriminate on the basis of race, creed, color, national origin, families with children, sex, marital status, sexual orientation, age, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability or the use of a trained dog guide or service animal by a person with a disability. This holds true for all district employment opportunities. Inquiries regarding compliance and/or grievance procedures should be directed to the school district’s Equal Opportunity Officer and/or Section 504/ADA coordinator, telephone 253 891-6000. RCW 49.60.010. B/10/201-A January 2015

Page 3 of 3

Certificate of Immunization Status (CIS) DOH 348-013 January 2015

Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System. Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex:

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record.

Parent/Guardian Signature Required Date

Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only

■ Recommended, but not required

I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Date

Vaccine Dose Date

Month Day Year Hepatitis B (Hep B) 1 2 3 or Hep B - 2 dose alternate schedule for teens 1 2

■ Rotavirus (RV1, RV5) 1 2 3 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 1 2 3 4 5 Tetanus, Diphtheria, Pertussis (Tdap) 1

■ Tetanus, Diphtheria (Td) 1 2 Haemophilus influenzae type b (Hib) 1 2 3 4

■ Influenza (flu, most recent)

Vaccine Dose Date

Month Day Year Pneumococcal (PCV, PPSV) 1 2 3 4 5

Polio (IPV, OPV) 1 2 3 4

Measles, Mumps, Rubella (MMR) 1 2

Varicella (chickenpox) 1 2

■ Hepatitis A (Hep A) 1 2

■ Human Papillomavirus (HPV) – does not print from the IIS; write dates in by hand 1

2

3

■ Meningococcal (MCV, MPSV) 1 2

If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option 1, 2, OR 3 below (see # 5 on back) 1) Chickenpox disease verified by printout from the Immunization Information System (IIS) Must be marked by printout (not by hand) to be valid. 2) Chickenpox disease verified by healthcare provider (HCP) If you choose this box, mark 2A OR 2B below.

2A) Signed note from HCP attached OR 2B) HCP sign here and print name below:

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name: 3) Chickenpox disease verified by school staff from the Immunization Information System

If the child can show immunity by blood test (titer) and hasn’t had the vaccine, ask your HCP

to fill in this box. Documentation of Disease Immunity

I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached.

Diphtheria Hepatitis A Hepatitis B Hib Measles

Mumps Polio Rubella Tetanus Varicella

Other: _______________

_______________

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name:

Office Use Only: Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

SUMNER SCHOOL DISTRICT A GREAT PLACE TO LEARN HEALTH HISTORY FORM

Student Full Name: DOB: Male Female Grade: School: Does your child ride the bus? Yes No

HEALTH CONCERNS Have you ever been told by a health care professional that your child has:

ADD ADHD

Allergies: Type Date of Last Reaction: Describe Reaction: Medication Required *Yes No Medication Name:

Asthma Uses Inhaler *Yes No Exercise Induced Yes No Bowel/Bladder Issues: Type

Diabetes: Dental Issues: Type

Drug/Alcohol Treatment: Year

Emotional Concerns: Depression Anxiety Eating Disorder Other:

Frequent Colds Sore Throats Earache

Headaches: Frequency

Head Injury: Concussion Yes No Date: Lost Consciousness: Yes No

Hearing: Aids Preferential Seating Tubes

Major Illness/Surgery/Hospitalization: Year: Describe:

Neurological Conditions: Nose Bleeds: Other Bleeding Conditions: Other Heath Condition: Restrictions/Limitations:

PE Limitations: For what reason?

Seizure Disorder: Type Last seizure:

Skin Condition: Speech Difficulty Therapy

Stomachache Cramps Tires Easily

Vision Problem: Contacts Glasses Reading Distance Both

LIFE THREATENING CONDITIONS

Does your child have a life threatening health condition? **Yes No Specify: **If yes, you will be contacted by a District RN to discuss a healthcare plan. Washington State Law requires that a medication, treatment, and/or healthcare plan is in place prior to starting school.

MEDICATION Does your child take any medication? Yes No Name of medication: Purpose: Name of medication: Purpose: Name of medication: Purpose:

Will the medication be needed at school? *Yes No

*For medications to be administered at school, by state law, RCW 28A.31.150, written permission from parent and Health Care Provider must be provided. The intent of the state law concerning medication administration at school obligates school districts to obtain written Health Care Provider orders and parental permission for both prescription and over-the- counter medication (i.e. Tylenol, medicated throat lozenges, vitamins). Is there any other health related information that school staff should know? Washington State Immunization Law 28A.31.118 requires that a Certificate of Immunization be completed for each child attending school or day care center.

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

I understand that the information given above will be shared with appropriate school staff to provide for the health and safety of my child. If either I or an authorized emergency contact person cannot be reached at the time of medical emergency, I authorize and direct school staff to send my child to the most accessible hospital. I understand that I will assume full responsibility for payment of any transport or emergency medical services rendered. Printed Name of Parent/Legal Guardian Signature of Parent/Legal Guardian - Original signature required. Date

ATTN School Staff: Please send this questionnaire to the STARR Project – Central Office. For Central Office Use Only: Date Received: ___________; Initials: __________; Referral to School BPC: ________________ Follow Up Comments: _____________________________________________________________________________________

Student Housing Questionnaire Students may be eligible for additional educational services through Title X, Part C, Federal McKinney-Vento Assistance Act. Identification of eligible students by districts is required under federal law. This form is being sent to all parents and legal guardians to complete for that purpose. Questions? Call Marilee Hill-Anderson, STARR Project Director & Homeless Liaison at (253) 891-6066, or Carlene Hurd, Homeless Education Coordinator at (253) 891-6537. Parent/Guardian: Please answer the questions below and return the form to your child’s school office. Name of Student: Name of School: Birth Date: Age: Grade: Sex: Male Female I (parent/guardian) rent/own my own home or apartment:

Yes

If yes, please skip section A and proceed to Section B at the bottom of the form and sign.

No If no, please fill out Section A and B of this form to help us determine services your child may be eligible to receive.

Section A: Please check the box that best explains your current living arrangements.

Temporarily sharing the housing of others due to loss of housing, economic hardship or similar reason

Student is an Unaccompanied Youth: Lives with an adult that is not a parent or legal guardian; or lives alone without an adult

Currently staying in a hotel/motel due to lack of alternative housing

In a vehicle of any kind, RV Park, campground, or abandoned building

In an emergency or transitional shelter, awaiting foster care, transitional housing, or other setting designed to provide temporary living accommodations

Other, please describe: _____________________________________________________

Current Address: ___________________________________________ Phone Number: _______________

Contact Name: Contact Number: ______________

Section B: The undersigned certifies that the information provided above is accurate.

________________________________________________________________________________ Printed name of parent/legal guardian or unaccompanied youth _______________________________________________________________ _______________ Signature of parent/legal guardian or unaccompanied youth Date

SUMNER SCHOOL DISTRICT A GREAT PLACE TO LEARN

2015-2016

Parents - Are Your Kids Ready for School? Required Immunizations for School Year 2015-2016

Hepatitis B DTaP/Td/Tdap* (Diphtheria, Tetanus,

Pertussis) Polio*

MMR (Measles, Mumps,

Rubella)

Varicella (Chickenpox)

Kindergarten – 5th Grade

3 doses 5 doses 4 doses 2 doses

2 doses

OR Healthcare provider

verifies child had disease

6th – 8th Grade 3 doses

5 doses DTaP

AND

1 dose Tdap

4 doses 2 doses

2 doses OR

Healthcare provider verifies child had

disease

9th – 12th Grade 3 doses

5 doses DTaP

AND

1 dose Tdap

4 doses 2 doses

Recommended, but not required**

*Vaccine doses required may be fewer than listed. **In school year 2016-2017, all students in 9th – 12th grade will be required to have 2 doses of varicella vaccine.

Students must meet minimum intervals and ages to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have

questions about school immunization requirements. Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-295 January 2015

Parent/Guardian Resource

EXAMPLE

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

#1 To print with information filled in: First, ask if your healthcare provider’s office puts vaccination history into the WA Immunization Information System (Washington’s statewide database). If they do, ask them to print the CIS from the IIS and your child’s information will fill in automatically. Be sure to review all the information, sign and date the CIS, and return it to school or child care. If your provider’s office does not use the IIS, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):

#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the

“Vaccine” column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here

#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#5 If your child had chickenpox (varicella) disease and not the vaccine, use only one of these three options to record this on the CIS: 1) If your child’s CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box 1 is automatically

marked. To be valid, this box must be marked by the IIS printout (not by hand). 2) If your healthcare provider can verify that your child had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your provider, or

2B if your provider signs and dates in the space provided. Be sure your provider’s full name is also printed. 3) If school staff access the IIS and see verification that your child had chickenpox, they will mark box 3.

#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your healthcare provider fill in this box. Ask your provider to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.

#7 Be sure to sign and date the CIS, and return to the school or child care.

Vaccine Trade Names in alphabetical order (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)

Trade Name Vaccine Trade

Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB Hib FluLaval Flu Ipol IPV PedvaxHIB Hib Twinrix (Twnrx) Hep A + Hep B

Adacel Tdap FluMist Flu Infanrix DTaP Pentacel (Pntcl) DTaP + Hib + IPV Vaqta Hep A

Afluria Flu Fluvirin Flu Kinrix (Knrx) DTaP + IPV Pneumovax PPSV or PPV23 Varivax Varicella

Boostrix Tdap Fluzone Flu Menactra MCV or MCV4 Prevnar PCV or PCV7 or PCV13

Cervarix HPV2 Gardasil HPV4 MenHibrix (Mnhbrx)

Meningococcal C/Y- HIB-PRP

ProQuad (PrQd) MMR + Varicella

Daptacel DTaP Havrix Hep A Menomune MPSV or MPSV4 Recombivax HB Hep B

Engerix-B Hep B Hiberix Hib Menveo Meningococcal Rotarix Rotavirus (RV1)

Fluarix Flu HibTITER Hib Pediarix (Pdrx) DTaP + Hep B + IPV RotaTeq Rotavirus (RV5)

Vaccine Abbreviations in alphabetical order (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf) Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A (HAV) Hep B (HBV)

Hepatitis A Hepatitis B

MPSV or MPSV4 Meningococcal Polysaccharide Vaccine

Rota (RV1 or RV5)

Rotavirus

DTaP Diphtheria, Tetanus,

acellular Pertussis Hib

Haemophilus influenzae

type b MMR / MMRV

Measles, Mumps, Rubella /

with Varicella Td Tetanus, Diphtheria

DTP Diphtheria, Tetanus, Pertussis

HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Tetanus, Diphtheria, acellular Pertussis

Flu

(IIV or LAIV) Influenza IPV

Inactivated Poliovirus

Vaccine

PCV or PCV7 or

PCV13

Pneumococcal Conjugate

Vaccine TIG Tetanus immune globulin

HBIG Hepatitis B Immune Globulin

MCV or MCV4 Meningococcal Conjugate Vaccine

PPSV or PPV23 Pneumococcal Polysaccharide Vaccine

VAR or VZV Varicella

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 January 2015

Vaccine Dose Date Month Day Year

Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 1 01 12 2011 DTaP 2 03 20 2011 DTaP 3 06 01 2011

Helping to create educational opportunities for students living in transition.

Homeless Education Coordinator Carlene Hurd

1503 Valley Avenue Sumner, WA 98390

Phone: 253.891.6537 Fax: 253.891.6530

Homeless Liaison - Dispute Resolution: Marilee Hill-Anderson Sumner School District Phone: 253.891.6066

OSPI – Homeless Education State Coordinator

Melinda Dyer – 360.725.6050

Community Resources

Food Bank: Sumner Food Bank Phone #: 253.863.3793 Address: 15625 East Main Hours: 1-3pm (Monday, Tuesday, Wednesday,

Friday) 5 – 7 pm Thursday evenings Appointments are appreciated! Serves families/individuals once a month

Food Bank: Bonney Lake Food Bank Phone #: 253.863.4043 Address: 410 to B.L. Left at light. Next to Fire Station. Hours: 9:30 – 12:00 Tuesday & Thursday

Friday evenings: 5:00 – 7:00 pm Serves Bonney Lake area families

Free government commodities twice a month

Food Bank: St. Andrews Emmanuel Food Pantry Address: 1402 Valley Ave. , Sumner Hours: Tuesday & Friday 10-11:45 am,

Wed. 3-5pm Current ID and proof of address

Free dinners

Monday through Thursdays: National Guard Armory 622 4th Avenue SE, Puyallup 253.840.4670

Fri. @ 5:00 pm Puyallup Nazarene Church 1026 – 7th Ave. SW, Puyallup 253.845.7508

Sat.@ 10:30am Peace Lutheran Church 214 East Pioneer Avenue, Puyallup

Sun. @ 5:00-5:40pm Sumner Family Church 1400 Silver St., Sumner

Other Useful Numbers/Information Sumner/Bonney Lake Family Center.………...253.891.6535 Sumner School District…………….…………253.891.6000 State McKinney Coordinator……...…………..360.725.6050 National Center for Homeless Education…...1.800.308.2145 National Runaway Switchboard……………..1.800.621.4000 Lions 4 Kids Clothing Bank………..…...…….253.447.3844 Other Resources………………………………..…..…..211

Services for Students Experiencing Homelessness

The McKinney-Vento Act is a federal law that gives students in homeless situations the

right to:

• Stay in their school even if they move • Enroll in a new school without regularly

required documentation • Get transportation to school • Receive free breakfast and lunch • Go to pre-school programs • Get all the school services they need • Have disagreements with schools settled

quickly • To go to school while disagreements are

being settled

If you disagree with a decision regarding McKinney-Vento services, you have the

right to appeal our decision: • Submit this form to the school’s office,

homeless liaison, or coordinator within 15 days of the district’s decision (Level I).

• You will be notified in writing within five business days of the homeless liaison’s decision about your complaint.

• You may further appeal in writing to the District Superintendent if you still disagree within 10 business days (Level II);

• Then, if still in disagreement you may notify OSPI (Level III).

Complete details of the Dispute Resolution Process are available through the Sumner School District Homeless Liaison or at OSPI.

Please complete the following questionnaire and return it to your school or call the Sumner School District Homeless Coordinator at 253.891.6537

This is a: (please check one) □ New referral □ Request for dispute resolution □ Request for additional services or change in services

Student Name: Parent Name: Brothers or Sisters: □ Yes □ No Please list names and ages:

What school is student currently attending? How long has student been at this school? Where are you currently staying? Contact phone number if available: Do you have any safety concerns for your students or family? Has your child or teen been in any special programs? □ Yes □ No If so, what programs: Is your child/teen participating in after school activities? Does your child/teen need assistance with transportation to/from school?

We may be able to help if you or your family live in any of the following

situations:

• Living with a friend, relative, or someone else

• Staying in a motel or hotel • Living in an emergency or transitional

shelter or a domestic violence shelter • Staying in sub-standard housing • Living in a car, park, public place,

abandoned building, or a bus/train station

• Awaiting permanent foster care placement

• Living in a campground or an inadequate trailer home

• Abandoned in a hospital • Living in a runaway or homeless youth

shelter

How can we help?

• We make sure students are enrolled in school immediately

• Help families and youth get records • Help set up transportation services • Make sure students get all the school

services they need • Help preschoolers who are homeless

enroll in Head Start, ECEAP, and other preschool programs

• Coordinate with social services and housing agencies to ensure access to education

• Make sure students have a full and equal chance to do well in school