Whitehouse ISD Proof of Residency and Educational Guardianship Information Parent/Guardian should bring the following information: Driver’s license or photo I.D. Year, Make, and Model vehicle information Resident of the District should bring the following information: Driver’s license or photo I.D. Utility Bill: Water, electric or gas. (Current month) A disconnect notice will not be accepted. Do you own? Provide a current tax statement Do you lease? Provide the district with a current lease agreement FYI: The lease must list all occupants, including any new occupants living on your property. Educational Guardianship Information Educational Guardianship documents are required when a student will be staying with another family in the district without the parent/guardian. Both parent/guardian and resident of the district are required to complete Educational Guardianship forms at the Administration office. The resident of the district will provide current proof of residency (as listed above). The student is required to live full time with the resident of the district.
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Whitehouse ISD Proof of Residency and Educational Guardianship Information
Parent/Guardian should bring the following information:
Driver’s license or photo I.D.
Year, Make, and Model vehicle information Resident of the District should bring the following information:
Driver’s license or photo I.D.
Utility Bill: Water, electric or gas. (Current month)
A disconnect notice will not be accepted.
Do you own? Provide a current tax statement
Do you lease? Provide the district with a current lease agreement
FYI: The lease must list all occupants, including any new occupants living on your property.
Educational Guardianship Information Educational Guardianship documents are required when a student will be staying with another family in the district without the parent/guardian.
Both parent/guardian and resident of the district are required to complete Educational Guardianship forms at the Administration office.
The resident of the district will provide current proof of residency (as listed above).
The student is required to live full time with the resident of the district.
Please Print
Student Name: Gender:
Student Social Security #: Student Cell Phone:
Birthdate: Birth City: Birth Country:
Student's Language: Grade Level:
Check Ethnicity: Hispanic/Latino: __ Yes, __ No Definition on Second Page
STUDENT LIVES WITH: ~~~Print Last, First, Middle name for each Parent/Guardian.~~~
Parent/Guardian Name #1: Relationship to Student:
#1 Birth Date: Primary Phone: 2nd Phone:
Physical Address: 3rd Phone:
Mailing Address:
Email Address:
Occupation: Employer:
Parent/Guardian Name #2: Relationship to Student:
#2 Birth Date: Primary Phone: 2nd Phone:
Physical Address: 3rd Phone:
Mailing Address:
Email Address:
Occupation: Employer:
Parent/Guardian Name #3: Relationship to Student:
#3 Birth Date: Primary Phone: 2nd Phone:
Physical Address: 3rd Phone:
Mailing Address:
Email Address:
Occupation: Employer:
Emergency Contact #1: Relationship to Student:
Local Phone: Phone #2: Phone #3:
Emergency Contact #2: Relationship to Student:
Local Phone: Phone #2: Phone #3:
Medical Alert Information:
For additional information, please use the back of the form.
Entry Date: ____________ Homeroom ____________ Bus # ________ Office Use only
Language spoken at home:
Whitehouse ISD Registration Form
Check if legal guardian of this child.
Years in US Schools:
Check if legal guardian of this child.
Check if legal guardian of this child.
Parents or guardians of students enrolling in school are required to provide race/ethnicity 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. Check both Race and Ethnicity.
Please list below individuals to contact other than Parents/Guardians listed above.
Severe Food Allergy:
Check Race: __ American Indian or Alaska Native, __ Asian, __ Black or African American, __ Native Hawaiian or Other Pacific Islander, __ White
Please complete the back portion. Then read and sign the Proof of Residency Statement.
Restricted Pickup: No Yes Can NOT be picked up by:
Will the student ride the bus? Yes No
Previous Campus (Most Recent):
Previous School District (Most Recent):
Previous City and State of Residence (Most Recent): Military Connection: Check the appropriate box.
Not a military-connected student Student is a dependent of a member of the Army, Navy, Air Force, Marine Corps, or Coast Guard on Active Duty Student is a dependent of a member of the Texas National Guard (Army, Air Guard, or State 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)
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
Anyone falsifying any document or documents for the purpose of school enrollment is a violation of 25.001 of the Texas Education Code and Article 37.10 of the Texas Penal Code.
For prosecution purposes, the proper authorities will be given a copy of this document in the event documents are falsified.
Additional Information
Signature
Whitehouse ISD Employee
Signature
Date
Black or African American - A person having origins in any of the black racial groups of Africa
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
Date
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
Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race
Other Children in the Family:
7-2012
New Enrollees
Counselor’s Program Verification Form
Name of Student: ________________________ Date of Birth __________________ Date: __________________
Name and city of any previous school: _______________________________ Current grade: ______
READ CAREFULLY and CIRCLE the correct response.
1. This child speaks another language, MOST of the time, at home. YES NO
If yes, what language? ______________
IF YES, ASK TO SEE THE COUNSELOR BEFORE YOU LEAVE
2. This child has been tested and identified as eligible for Special Education services. YES NO
IF YES, ASK TO SEE COUNSELOR BEFORE YOU LEAVE
3. This child is currently receiving Speech Therapy. YES NO
4. This child has repeated a grade. If yes, what grade? _________ YES NO
5. This child has taken the TAKS/STAAR tests and did not pass. YES NO
If yes, what grade level and subject did they fail? ______________
6. This child is in the custody/care of the Department of Protective Services or is a foster child. YES NO
7. This child has been reported to CPS in the last 12 months. YES NO
8. This child might be eligible for Free and Reduced Lunch Program. YES NO
9. This child is designated as homeless. YES NO
10. This child has been placed in an alternative school in the past 12 months. YES NO
11. This child has been expelled from school in the past 12 months. YES NO
12. This child is currently on parole or probation. YES NO
13. This child resides now or resided last school year in a residential placement facility such as: group foster home,
Home Phone #:______________Cell Phone #:_____________Other Emergency #:___________
Last District Attended:_____________________ Last School Attended:_____________________
Please answer Yes or No regarding the location where the student currently resides: 1. Yes___ No____ Is your current residence a temporary living arrangement?
2. Yes___ No____ Is this temporary living arrangement due to loss of housing, economic hardship,
or other contributing factors (i.e. loss of job, family violence, divorce, natural disaster, fire, etc.)
3. ____Not Applicable ___ In my own home, apartment or military housing with parent(s), legal guardian(s)
or caregiver(s) (Code N)
Please check the place that most closely describes where the student slept last night:
___Living in a motel (CODE HM)
___Living in a shelter or transitional housing (i.e. housing provided for a specific length of time & is
partially or completely paid for by a church or organization) (CODE S)
___Living with another family in a house or apartment (CODE D)
___Living in a place not designed for ordinary sleeping accommodations such as a car, park, or campsite (CODE U)
___Living in a place that has no electricity and/or water (CODE U)
List other school-age siblings: OFFICE USE Name Date of Birth Grade Campus Name District PEIMS HL PEIMS UY
Signature of Parent/Legal Guardian/Caregiver/Unaccompanied Student Date
Yo certifico que el estudiante nombrado en este formulario califica para los programas de nutrición escolares bajo las
provisiones del Acta McKinney-Vento.
___________________________ ______________________________________________________ Fecha Firma del oficial autorizado
WISD 2012
HOME LANGUAGE SURVEY Grades PreK-12 (Must be kept in Student’s Permanent File)
□Brown Elem. □Cain Elem. □Higgins Elem. □Stanton-Smith Elem. □Holloway □Jr. High □High School
TO BE COMPLETED BY PARENT OR GUARDIAN (OR STUDENT, IF GRADES 9-12): GRADE: _____________ NAME OF STUDENT_________________________________STUDENT ID#_________________ ADDRESS__________________________________________TELEPHONE#__________________ 1. What language is spoken in your home most of the time?_________________________________
2. What language does your child speak most of the time?__________________________________
3. Year (or grade) your child was first enrolled in a U.S. school: Year__________ Grade ___________
_____________________________________________ ___________________________ Signature of Parent/Guardian Date
_____________________________________________ ___________________________ Signature of Student (Grades 9-12) Date
CUESTIONARIO del idioma que se habla en el hogar DEBE DE COMPLETARSE POR EL PADRE/MADRE/O REPRESENTANTE LEGAL (O POR EL ESTUDIANTE SI ESTÁ EN LOS GRADOS 9-12): NOMBRE DEL ESTUDIANTE___________________________________ID#_________________ DIRECCIÓN_________________________________________TELÉFONO___________________ ESCUELA_______________________________________________________________________ 1. ¿Qué idioma se habla en su hogar la mayorίa del tiempo?__________________________________
2. ¿Qué idioma habla su hijo/a (o usted) la mayorίa del tiempo?_______________________________
3 Año o grado su estudiante fué matriculado por primera vez en una escuela en los Estados Unidos:
_____________________________________________ ___________________________ Firma del Padre/Madre/o Representante Legal Fecha
_____________________________________________ ___________________________ Firma del estudiante si está en los grados 9-12 Fecha
Whitehouse Independent School District
2015-2016 Family Survey / Encuesta de la Familia
Betty Lough, District Migrant Contact
Your child may be eligible for educational services through the Migrant Education Program. Contact the Office of Migrant Education at (903) 839-5500 ext. 6162 if you need additional information.
1. During the last three years has your family moved from one school district to another? ____Yes ____ No
2. Do you or does anyone from your family do the following temporary or seasonal work? ____ Yes ____ No
What type of work? _Farming _Ranching _Fencing _Dairying
_Fishing
_Baling Hay _Picking Fruit or Vegetables _Cotton Farming/Ginning _Combining/Harvesting Grain _Driving Tractors/Machinery
_Tree Growing or Harvesting
_Food Processing in Plants _Plant Nursery _Poultry Production _Clearing Land _Picking Nuts, Pecans, etc.
_Other Similar Work
Su nino/a puede ser elegible para recibir servicios escolares proporcionado por el programa
educacional migrante. Entre el contacto con la Oficina de Educaci6n Migrante si necesitas
informaci6n adicional Betty Lough (903) 839-5500.
1. Durante los ultimos tres afios ha viajado su familia de un distrito escolar a otro?
___Si ___No
2. Trabaja usted 0 alguien en su familia en una de las siguientes actividades temporalmente? ___Si ___ No
Parent’s Response to Release of Student Information
Whitehouse Independent School DistrictWhitehouse Independent School DistrictWhitehouse Independent School DistrictWhitehouse Independent School District
Corporal Punishment 2015-2016
I understand that according to WISD Student Code of Conduct for the
2015-2016 school year, corporal punishment is one discipline
management technique that may be used.
Please check the box that indicates your decision regarding corporal
punishment, sign and return to your child’s campus.
□ Yes - May use corporal punishment according to district policy
□ No - May NOT use corporal punishment
□Brown Elem. □Cain Elem. □Higgins Elem. □Stanton-Smith Elem. □Holloway □Jr. High □High School
Student Name ________________________________ Grade__________
Parent Name__________________________________ Date __________
(Print)
Parent Signature _______________________________
WISD Title I Updated 2011-2012
Whitehouse Independent School District
District Wide Parent-School Compact
The School’s Responsibility
Whitehouse Independent School District will:
• communicate with parents and notify them of school events in a timely, efficient manner
• communicate learning expectations for students at each grade level
• provide an environment that promotes positive communication between the teacher, parent and student
• provide homework assignments that will reinforce classroom instruction
• provide opportunities for parent conferences and school functions to maximize parent participation
The Parent’s Responsibility
As a parent, I will try to:
• see that my child is on time and attends school regularly
• establish a time for homework and review it regularly
• encourage my child’s efforts and be available for questions
• read aloud to my child and let my child see me read
• be an interested listener as my child reads to me
• help my child establish a routine for school days
• attend parent/teacher conferences
• support the school in its effort to maintain proper discipline
• help my child learn to resolve differences in positive ways
• stay aware of what my child is learning
• respect school staff and the cultural differences of others
The Student’s Responsibility
As a student, I will try to:
• attend school regularly
• work hard to do my best in class and schoolwork
• help to keep my school safe
• ask for help when I need it
• respect and cooperate with other students and adults
Occasionally, Whitehouse ISD wishes to display or publish student artwork or
special projects on the district’s Web site and in district publications. In
addition, this may include publication of student work in area newspaper or
organizational journals/Web sites. When a student’s work is published, the
publication may include the student’s name and grade level.
Please check one of the choices below:
I, parent of ___________________________________, a student at: Print Student’s Name
□Brown Elem. □Cain Elem. □Higgins Elem. □Stanton-Smith Elem. □Holloway □Jr. High □High School
□ Yes – DO
□ No – DO NOT
Give the district permission to use my child’s artwork or special project on
the district’s Web site, in district publications, and for publication in area
newspapers or organizational journals/Web sites.
Printed Name of Parent: ________________________________________
Signature of Parent: _______________________________ Date: ________
Whitehouse ISD
Public Display and Use of Student Work
in District Publications
AUTHORIZATION OF EMERGENCY MEDICAL TREATMENT/STUDENT HEALTH INFORMATION
WHITEHOUSE INDEPENDENT SCHOOL DISTRICT In an effort to provide safe, informed care for your child at school, the following information is required to complete your child’s enrollment. Medical information you provide about your
child is a confidential education record. WISD 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 WISD 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.
Student Name ___________________________________________________ Date of Birth ___________________ Gender: ______ Grade: ______ ID# ________________
Last First MI
Parent Name ____________________________ Home # ________________ Cell # ________________ Work # ________________ Email ___________________________N/A
Health Conditions: Please answer ALL questions below that are associated with your child’s condition(s). If your child has a significant health condition, requires medication or any special procedures, please contact your school nurse. All medication brought to the school must be brought and signed in by the parent, must be in the original container, and prescribed by a physician/dentist.
Does your child require any P.E. restrictions ? YES NO
If yes, please explain: ______________________________________________
My child has: �Medicaid �CHIP �Private insurance �No insurance
� My child has NO KNOWN HEALTH CONDITIONS and does not require any medications or special procedures at home or school.
My child's physician is _______________________________________________ Phone Number:_____________________________________
I hereby authorize the Superintendent of the Whitehouse Independent School District or a designated representative to secure any and all emergency medical care and treatment for
_______________________________________________(student’s name) for acute illness suffered or injury sustained while at school or participating in school-related activities. My
hospital preference is ________________________________. I understand that the cost of services provided by ambulance and the medical facility remains the responsibility of the
parent/guardian and will not be assumed by the District.
AUTORIZACIÓN PARA TRATAMIENTO MÉDICO DE EMERGENCIA INFORMACIÓN DEL ESTADO DE LA SALUD DEL ALUMNO
WHITEHOUSE INDEPENDENT SCHOOL DISTRICT
En un esfuerzo para ofrecer un cuidado seguro y a sabiendas de su niño en la escuela, la siguiente información es requerida para completar la matrícula. La información médica que
usted dé del niño es un récord escolar confidencial. WISD guarda toda la información médica del niño como es requerido por el Acta de los Derechos Escolares de la Familia y de
Privacidad y otras leyes aplicables. Sin embargo, la información sobre la salud del niño será dada al personal de las escuelas de WISD que necesite la información para poder servir al
niño.
Si su niño tiene una condición médica aguda o crónica, o algún cambio en el estado de la salud ocurre durante el año académico, es su responsabilidad como padre/guardián de avisarle a la enfermera de la escuela y actualizar esta información.
Nombre del Alumno _____________________________________________ Fecha de Nacimiento ________________ Sexo: ______ Grado: ______ ID# _________________
Apellido Primero Segundo
Nombre del Padre ___________________ Domicilio # ____________ Celular # ____________ Trabajo # ____________ Correo Electrónicol____________________________N/A
Estado de Salud: Por favor conteste TODAS las preguntas debajo que estén asociadas con el estado de salud de su niño. Si su niño tiene un problema de salud importante,
requiere medicinas o procedimientos especiales, por favor haga contacto con la enfermera de la escuela. Todas las medicinas que sean traídas a la escuela tienen que ser
traídas y firmadas por el padre, tienen que estar en los envases originales y recetados por un médico o dentista.
Problemas abdominales: �Colitis �Estreñimiento �Enfermedad de Crohn
�Reflujo Gástrico �G-Tube �Síndrome de Irritación del Intestino
____________________________________________________________________ Oídos, ojos, nariz: �Infecciones de oídos frecuentes �Pérdida
de audición: D / I ¿Usa un aparato para oir? SÍ NO ¿Usa �
espejuelos o �lentes de contacto?
¿Tiene problemas visuals que no pueden ser corregidos? SÍ NO
�Sangra frecuentemente por la nariz a causa de:___________________________
¿Necesita limitaciones en P.E.? SÍ NO
Si sí, por favor explique: _______________________________________________
Mi niño tiene: �Medicaid �CHIP �Seguro privado �No tiene seguro
� Mi niño no tiene NINGÚN PROBLEMA DE SALUD CONOCIDO y no necesita ninguna medicina o intervención especial en la casa o en la escuela.
El médico de mi niño es _______________________________________________ Teléfono:_____________________________________
Autorizo al Superintendente del Distrito Escolar Independiente de Whitehouse o a su representante designado para que asegure cualquier y todo cuidado médico y tratamiento para
_______________________________________________(nombre del niño) para una enfemedad aguda o lesión que tenga mientras esté en la escuela o participando en una actividad
relacionada con la escuela. Mi preferencia de hospital es ________________________________. Entiendo que los costos de los servicios rendidos por servicios de ambulancia y
servicios médicos son mi responsabilidad como padre/guardián y no serán asumidas por el Distrito.
Firma del Padre/Guardián:_____________________________________________________________________ Fecha:____________________________________