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WINDOW ROCK UNIFIED SCHOOL DISTRICT #8 RETURNING STUDENT
ENROLLMENT FORM Please mark school your child will be enrolled at:
Tsehootsooi Primary Learning Center (K-3) Tsehootsooi Middle School
(7-8) Window Rock High School (9-12) Tsehootsooi Intermediate
Learning Center (4-6) Tsehootsooi Dine Bi’ Olta (K-6) Integrated
Pre-School
School Year 2020-2021 GRADE:
STUDENT INFORMATION Student Name (Last, First, M.) Age Gender
Birthdate Birthplace
NOTE: This information is required by the US Department of
Education. Ethnicity: (check one) Hispanic/ Latino NOT Hispanic/
Latino RACE: (check one) White Black or African AmericanAmerican
Indian / Alaskan NativeAsian
Tribe Enrolled Census Number Custody Issues: YES NO If YES,
provide court documents to school office. Child Lives with: both
parents fathermother Legal Guardian
Mailing Address
City/Zip Code
Home Phone
Cell/ Message Phone
Physical Address
City/Zip Code
RA#
Last School Attended
School Address
Grade
Has this student ever received special education services? YES
NO If YES, is there a current IEP for this student? YES NO If YES,
contact the ESS Office. Has this student received any of the
following services? ELL/ESL Classes Gifted / Advanced 504 Plan
Remedial Reading Individual Counseling
PARENT(S) OR LEGAL GUARDIAN(S) Father/Guardian Full Name
Tribe
Chapter
Census No.
Employer Work Phone
Cell Phone Email Address
Mother/Guardian Full Name
Tribe
Chapter
Census No.
Employer
Work Phone
Cell Phone Email Address
EMERGENCY CONTACT AND/OR STUDENT CHECK OUT If the school is
unable to contact the parent(s)/guardian(s), I authorize the
following persons to take/check out my child(ren). Please list
individuals over the age of 18 years old. Local Friend /Relative
Name Relationship Home Phone Work Phone Cell Phone
1.
2.
3.
4.
5. SIBLING LISTPlease list ALL brothers and sisters of school
age and younger (oldest first). Name(Last, First) Age School (if
attending) Grade
STUDENT HEALTH CONDITIONS-Medical Consent:
Heart Asthma Diabetes Hearing Allergies • Is your Child on daily
medication? YES NO Specify: ___________________________________
• Specify health problems or any severe allergies:
___________________________________________________________________________________________________
• History of Diabetes (high blood sugar), please list family
member and relationship
_______________________________________________________________________
• My child may be given an antacid for upset stomach? YES NO• My
child may be given Tylenol and/or Ibuprofen for fever or
discomfort? YES NO
• I give my consent for my child to be included in the WRUSD
Health Program. All treatments performed are in compliance with the
School Health Laws of the State of Arizona. • I give my consent for
the following medical care to be administered. Care of mild illness
and minor injuries by the school nurse, using Standard Basic First
Aid procedures. • In case of an emergency, illness or accident, the
school is authorized to take the child to the Tsehootsooi Medical
Center for examination and treatment of other services:General
Health Screening (vision, hearing, etc.); Personal Hygiene (shower,
brushing teeth, etc.); Dental Examination, Fluoride Rinse; School
based Teen Health Clinic - Mental Health/Counseling.
I confirm that all Registration & Emergency Information on
this form is accurate and correct including my medical consent for
my child.
Parent/Guardian
Signature:___________________________________________
Date:__________________
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STUDENT MAP: Please draw directions to your residence. STUDENT
DIRECTORY INFORMATION
RELEASE FORM I, hereby give consent for the release of student
directory information as it applies to school and related
activities such as yearbook, athletics, musical programs, honors,
awards, commencement, etc. This release shall not apply to
confidential student records such as test scores, transcripts,
evaluations, etc. This consent will remain in effect unless or
until permission is revoked by the parents requesting in writing
such a revocation. Details of board policy as to the release of
directory information may be secured by contacting the school
office.
Student Name: _______________________________________
Parent/Guardian: _____________________________________
*This release form is necessary to meet the requirements of AZ
State Statue 15-142
STUDENT MEDIA PERMISSION WRUSD is requesting permission to use
your child’s picture for news releases. Your child(ren) are
sometimes involved in school programs, awards, and other
recognitions that WRUSD would like to share with the community
through newspapers, radio announcements, and videos that maybe
televised. WRUSD will release photos and other media only with your
permission to do so. I, Parent/Legal Guardian, provide release of
photographs and other media for the purposes stated below: •
Newspaper journalists, (The Navajo Times, and other newspapers), to
photograph my child for use in newspaper articles. • Researchers to
photograph my child for use in publications. • Approved Television
crews to televise my child for use in community education and
awareness programs. • WRUSD#8’s schools to photograph or videotape
my child for use in school newsletters, and other public displays
in the interest of public education. • WRUSD#8 schools’ staff to
videotape my child for program documentation and evaluation. •
WRUSD#8 schools’ staff to use photographs, but not names, of my
child on school’s internet website.
Please check one of the boxes: YES NO
ATTENDANCE State Law mandates that the school record reasons for
all student absences. Therefore, when a student is absent, it will
be necessary for the parent to call the school on or before the day
of the absences in order to advise the school as to the reason for
the absence. When it is impossible to call on the day of the
absence, the school should be notified on the morning the student
returns, in time for the student to obtain an admission slip prior
to the student’s first class. All absences not certified by
parental or administrative authorization will remain unexcused.
Students will be withdrawn from school after missing 10 consecutive
days. If a parent does not have access to a phone, either at home
or at work, a note will be accepted for verification purposes. For
absences greater than on day in length, the school should be
notified each day of the absence. All personnel will solicit
cooperation from parent in the matter of school attendance and
punctuality, particularly in regard to the following: - The
scheduling of medical and dental appointment after school hours
except
in the case of emergency. - The scheduling of family vacations
during school vacation and recess periods. The school may require
an appointment card or a letter from a hospital or clinic when the
parent has not notified the school of an appointment of medical or
dental nature.School administrators are authorized to excuse
students from school for necessary and justifiable reasons. Legal
Ref: ARS 15-346, 15-802, 15-806, 15-807, 15-843, 15-873, 15-902,
Cross Ref: JE-Student Attendance- District Manual
I have reviewed and agree with the policies above:
Parent/Guardian
Signature:__________________________________________________________
Date: _________________
OFFICE USE ONLY Birth Certificate Certificate of Indian
BloodImmunizationOfficial Withdraw Form Official Transcripts
BUS ROUTE To School To Home Daycare Teacher
Staff Initial First Day of Attendance Date Entered Powerschool
Student ID#
Continuous Notice of Nondiscrimination- The Window Rock Unified
School District #8 does not discriminate on the basis of race,
color, religion, national origin, sex, disability, age or sexual
orientation in admission or access to its programs, services,
activities, or in any aspect of their operations and provides equal
access to
all programs. The Window Rock Unified School District #8 also
does not discriminate in its hiring or employment practices. The
following individual has been designated to handle inquiries
regarding the nondiscrimination policies: Superintendent; Navajo
Route 12; Fort Defiance, AZ 86504; 928-729-6706
***Translation services are available through the Office of the
Superintendent. Please see call (928) 729-6706 for translation
services.
N
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Continuous Notice of Nondiscrimination- The Window Rock Unified
School District #8 does not discriminate on the basis of race,
color, religion, national origin, sex, disability,
age or sexual orientation in admission or access to its
programs, services, activities, or in any aspect of their
operations and provides equal access to all programs. The
Window
Rock Unified School District #8 also does not discriminate in
its hiring or employment practices. The following individual has
been designated to handle inquiries regarding the
nondiscrimination policies: Superintendent; Navajo Route 12;
Fort Defiance, AZ 86504; 928-729-6706
***Translation services are available through the Office of the
Superintendent. Please see call (928) 729-6706 for translation
services.
Window Rock Unified School District No. 8
MCKINNEY-VENTO ELIGIBILITY QUESTIONNAIRE SY 2020-2021
Confidential Information This questionnaire is intended to
address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this
residency information help determine the services the student may
be eligible to receive. Eligibility must be reviewed and
reevaluated every school year.
Student Name:___________________________________ Male Female
Age: _____ Birth Date:_____________
Grade: ______
Tsehootsooi Primary Learning Center (K-3) Tsehootsooi Middle
School (7-8) Tsehootsooi Dine Bi’ Olta (K-6)
Window Rock High School (9-12) Tsehootsooi Intermediate Learning
Center (4-6) Integrated Pre-School
Do any of the following situations apply to the student? Please
circle the appropriate answers.
YES NO Student is not homeless.
YES NO Living with parent or legal guardian (legal guardianship
can only be granted by a court).
If no, with whom is student living? _____________________
Relationship: ___________________
YES NO Living in car, campground, public places, or housing not
fit for habitation.
If yes, provide physical location where student sleeps at
night:________________________________________
YES NO Living in a motel/hotel.
YES NO Living in a shelter. Check one. □ Domestic Violence □
Emergency Housing □ Transitional Housing
YES NO Living in the residence of another family.
If yes, please answer the following:
1. Living arrangement due to : □ Economic hardship □ Loss of
Housing
2. Date living arrangement began _____________________ Date
living expected to end _______________ 1.
SIBLING LIST Please list ALL brothers and sisters of school age
and younger (oldest first).
Name Brother or Sister Staying at the same place (x) Grade
School (if attending)
McKinney-Vento Education of Homeless Children and Youth Act was
reauthorized under the Every Student Succeeds Act of 2015
(Elementary and Secondary Education Act Reauthorized). Changes to
the law may be found in Title IX Part A of ESSA or Section 724(c)
of the McKinney-Vento Homeless Assistance Act (McKinney-Vento Act
42 U.S.C. 11431 et seq.) Changes to the law took effect on October
1, 2016. Presenting a false record or falsifying records is an
offense, and enrollment of the student under false documents
subjects the person liability for tuition or other costs. (ARS
Section 13-2704 and Section 39-161)
By signing below, I attest the above information is correct.
__________________________________
________________________________
_________________ Print Name of Parent/Legal Guardian/
Caregiver/or Unaccompanied Student
Signature of Parent/Legal Guardian/ Caregiver/or Unaccompanied
Student
Date
Mailing Address:________________________________________________
Email: _________________ Phone: _____________
For Official Use Only
McKinney-Vento Certificate of Eligibility: The student named
above is eligible for McKinney-Vento services. District Homeless
Liaison:_________________________ Signature: _____________________
Date: _________
Original Eligibility Form remains at the school in a
McKinney-Vento binder per current SY, NOT in student’s CUMULATIVE
folder. Immediately forward copy to WRUSD McKinney-Vento District
Liaison.
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Continuous Notice of Nondiscrimination- The Window Rock Unified
School District #8 does not discriminate on the basis of race,
color, religion, national origin, sex, disability, age or sexual
orientation in admission or access to its programs, services,
activities, or in any aspect of their operations and provides equal
access
to all programs. The Window Rock Unified School District #8 also
does not discriminate in its hiring or employment practices. The
following individual has been designated to handle inquiries
regarding the nondiscrimination policies: Superintendent; Navajo
Route 12; Fort Defiance, AZ 86504; 928-729-6706
***Translation services are available through the Office of the
Superintendent. Please see call (928) 729-6706 for translation
services.
WINDOW ROCK UNIFED SCHOOL DISTRICT NO. 8 STUDENT INTERNET USE
FORM
SY 2020-2021
The Window Rock Unified School District (WRUSD) offers
world-wide web Internet access to your child at his/her school.
This access offers vast, diverse, and unique resources to students
and district personnel to promote educational excellence in the
Window Rock District School. The purpose of this document is to
inform parents/guardians and students of the availability of the
Internet resources as well as the rules governing its use and to
obtain parental/guardian permission for an individual student to
use the Internet while at school. The educational value of
appropriate information on the Internet is abundant. The Internet
is composed of Information provided by institutions and people all
over the world and includes material that is not of educational
value in the context of the school setting. WRUSD does not condone
or permit the use of this material. It is a joint responsibility
when using the Internet. One of the district goals is to support
students with responsible use of this technological information.
Student educational Internet access is available to students only
on computers that are in highly traveled areas of the school
building such as classrooms, computer laboratories and the media
center. Parents/Guardians must be aware that while at school,
direct supervision by school personnel to each student using the
computers is not always possible. Thus, students are expected to
use the resources in a manner consistent with this contract and
will be held responsible for their use. Additionally, parents
should discuss with their children their own expectations for their
child’s Internet use.
PROPER AND ACCEPTABLE USE: The use of the Internet, including
the world-wide web in any WRUSD School must be in support of
education and academic research and consistent with the educational
objectives of the WRUSD.
• Internet activities that are permitted and encouraged: •
Investigation of topics being studied in school; • Investigation of
opportunities outside of school-related to community service,
employment or further education.
INTERNET ACTIVITES ARE NOT PERMITTED:
• Searching, viewing or retrieving materials that are not
related to school work, community service, employment or further
education (thus, searching or viewing sexually explicit, profane,
violence promoting or illegal materials is not permitted), copying,
saving or redistributing copyrighted material (users should assume
that all material(s) is copyrighted unless explicitly noted);
• Subscription to any services or ordering of any goods or
services; • Sharing of the student’s home address, phone number or
other information; • Playing games or using other interactive sites
such as chats, MUDs and MOOs unless specifically assigned by a
teacher; • Any activity that violates a school rule or a local,
state or federal law.
If a student has any questions about whether a specific activity
is permitted, he or she should ask a teacher or administrator. If a
student accidentally accesses inappropriate material she or he
should back out of that information at once. RELIABILITY: WRUSD
makes no warranties of any kind, whether expressed or implied, for
the service it is providing. WRUSD will not be responsible for any
damages you suffer. This includes non-deliveries, mis-deliveries,
or service interruptions caused by negligence or your errors or
omissions. Use of any information obtained via the Internet is at
the user’s own risk. WRUSD specifically denies any responsibility
for the accuracy or quality of information obtained through the
Internet. EXCEPTION OF TERMS OF CONDITIONS: All terms and
conditions as stated in this document are applicable to the WRUSD.
These terms and conditions reflect the entire agreement of the
parties and supersede all prior oral or written agreements and
understandings of the parties for in-school Internet access. These
terms and conditions shall be governed and interpreted in
accordance with the laws of the State of Arizona, United States of
America MISUSE: Violation of the terms of this agreement may result
in suspension or revocation of a student’s access to the Internet.
Any action taken by a student which is in violation of a school
guideline will be subject to the usual disciplinary actions. Your
signature(s) below this agreement is (are) legally binding and
indicates the party (parties) who signed has (have) read the terms
and conditions carefully and understand(s) their significance.
PARENT OR GUARDIAN: (if the applicant is under the age of 18 a
parent or guardian must read and sign this agreement.) As the
parent or guardian of this student I have read and agree to the
Terms and Conditions for In-school Use of Internet Resources. I
understand that this access is designed for educational purposes
and the student named below is expected to use the resources
according to the specified guidelines. I have discussed these
guidelines with the student and believe he or she has an
understanding of them. I also recognize that it is impossible for
WRUSD to control information available to students through the
Internet and I will not hold the student’s school or the WRUSD or
any one its employees responsible for materials this student may
acquire on the network. I hereby give my permission for the student
named above to use the Internet at school and certify that the
information contained on this form is correct. Print Student
Name___________________________________ Print Parent or Guardian’s
Name __________________________________
Parent or Guardian’s Signature
_______________________________________ Date:
_______________________
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WINDOW ROCK UNIFIED SCHOOL DISTRICT NO. 8
POWERSCHOOL PARENT PORTAL REGISTRATION FORM SY 2020-2021
Please fill out this form to receive your ID and password to
view your student’s grades and attendance using the PowerSchool
Parent Portal. Ensure Up-to-the-Minute Data Powerschool is a
web-based student information system with a centralized database.
When teachers enter grades and attendance information for their
class, data is immediately available to the school, district
office, parents and students.
Print Student Name:
Increase Parental Involvement With Powerschool,
parents/guardians can access attendance and grades about their
children quickly and accurately. They can see the results of tests
and assignments as soon as they are recorded, enabling them to
intervene quickly, if necessary. Parents can check the latest
homework assignments and offer their children help with their
schoolwork. Day in and day out, Powerschool helps parents help
children achieve their potential.
School: Grade:
Email: Phone:
Print Parent Name: Address:
Parent Signature Date: Official Use Only Approved/Verified By:
__________________________________ Date: ______________________
(Parent Educator/Registrar Signature) Entered Into System □
Applicant Email Sent □
Continuous Notice of Nondiscrimination- The Window Rock Unified
School District #8 does not discriminate on the basis of race,
color, religion, national origin, sex, disability, age or sexual
orientation in admission or access to its programs, services,
activities, or in any aspect of their operations and provides equal
access to
all programs. The Window Rock Unified School District #8 also
does not discriminate in its hiring or employment practices. The
following individual has been designated to handle inquiries
regarding the nondiscrimination policies: Superintendent; Navajo
Route 12; Fort Defiance, AZ 86504; 928-729-6706
***Translation services are available through the Office of the
Superintendent. Please see call (928) 729-6706 for translation
services.
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Window Rock Unified School District No. 8 P.O. Box 559 Office:
928.729.6706 Navajo Route 12 Fax: 928.729.6841 Fort Defiance,
Arizona 86504 www.wrschool.net
Yvonne Kee-Billison Dr. Jacquelyne Wauneka Wilson C. Stewart Jr.
Geraldine V. Benally Josephine Dawes Board President Board Clerk
Board Member Board Member Board Member
JFAA-EA © EXHIBIT
ADMISSION OF RESIDENT STUDENTS
RESIDENCY DOCUMENTATION FORM
Student School
School District or Charter Holder
Therefore, I have provided an original affidavit signed and
notarized by an Arizona resident who attests that I have
established residence in Arizona
with the person signing the affidavit.
WINDOW ROCK UNIFIED SCHOOL DISTRICT #8
Parent/Legal Guardian
As the Parent/Legal Guardian of the Student, I attest that I am
a resident of the State of Arizona and submit in support of this
attestation a copy of
the following document that displays my name and residential
address or physical description of the property where the student
resides:
_____ Valid Arizona driver's license, Arizona identification
card or motor vehicle registration
_____ Valid U.S. passport
_____ Real estate deed or mortgage documents
_____ Property tax bill
_____ Residential lease or rental agreement
_____ Water, electric, gas, cable, or phone bill
_____ Bank or credit card statement
_____ W-2 wage statement
_____ Payroll stub
_____ Certificate of tribal enrollment or other identification
issued by a recognized Indian tribe that contains an Arizona
address
_____ Documentation from a state, tribal or federal government
agency (Social Security Administration, Veteran's Administration
Arizona
Department of Economic Security)
_____ I am currently unable to provide any of the foregoing
documents.
Signature of Parent/Legal Guardian Date Continuous Notice of
Nondiscrimination- The Window Rock Unified School District #8 does
not discriminate on the basis of race, color, religion, national
origin, sex, disability, age or sexual orientation in admission or
access to its programs, services, activities, or in any aspect of
their operations and provides equal access to all programs. The
Window Rock Unified School District #8 also does not discriminate
in its hiring or employment practices. The following individual has
been designated to handle inquiries regarding the nondiscrimination
policies: Superintendent; Navajo Route 12; Fort Defiance, AZ 86504;
928-729-6706 ***Translation services are available through the
Office of the Superintendent. Please see call (928) 729-6706 for
translation services.
http://www.wrschoo.net/�
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Window Rock Unified School District No. 8 P.O. Box 559 Office:
928.729.6706 Navajo route 12 Fax: 928.729.6841 Fort Defiance,
Arizona 86504 www.wrschool.net
Yvonne Kee-Billison Dr. Jacquelyne Wauneka Wilson C. Stewart Jr.
Geraldine V. Benally Josephine Dawes Board President Board Clerk
Board Member Board Member Board Member
JFAA-EB © EXHIBIT ADMISSION OF RESIDENT STUDENTS
AFFIDAVIT OF SHARED RESIDENCE
I swear or affirm that I am a resident of the State of Arizona
and that the persons listed below reside with me at my residence,
described as follows: Persons who reside with me: Location of my
residence: I submit in support of this attestation a copy of the
following document that displays my name and current residence
address or physical description of my property: _____ Valid Arizona
driver's license, Arizona identification card or motor vehicle
registration
_____ Valid U.S. passport
_____ Real estate deed or mortgage documents
_____ Property tax bill
_____ Residential lease or rental agreement
_____ Water, electric, gas, cable, or phone bill
_____ Bank or credit card statement
_____ W-2 wage statement
_____ Payroll stub
_____ Certificate of tribal enrollment or other identification
issued by a recognized Indian tribe that contains an Arizona
address
_____ Documentation from a state, tribal or federal government
agency (Social Security Administration, Veteran's
Administration,
Arizona Department of Economic Security)
Printed Name of Affiant: Signature of Affiant:
Acknowledgement State of Arizona ~ County of Apache
The foregoing was acknowledged before me this day of , 20
Continuous Notice of Nondiscrimination- The Window Rock Unified
School District #8 does not discriminate on the basis of race,
color, religion, national origin, sex, disability, age or sexual
orientation in admission or access to its programs, services,
activities, or in any aspect of their operations and provides equal
access to all programs. The Window Rock Unified School District #8
also does not discriminate in its hiring or employment practices.
The following individual has been designated to handle inquiries
regarding the nondiscrimination policies: Superintendent; Navajo
Route 12; Fort Defiance, AZ 86504; 928-729-6706 ***Translation
services are available through the Office of the Superintendent.
Please see call (928) 729-6706 for translation serves.
, By
___________________________________________________________. My
Commission Expires:
Notary Public
http://www.wrschoo.net/�
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Please fax Disclosure of Protected
Health Information form to:
Tsehootsooi Medical Center
Medical Records at:
(928) 729-8271
Please attach a copy of the Parent or
Guardians
ID or Driver License w/fax.
If any questions please call TMC
Medical Records at:
(928) 729-8272
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DEPARTMENT OF HEAL TH AND HUMAN SERVICES Indian Health
Service
FORM APPROVED: 0MB NO. 09 17-0030 Expiration Date: 07-3 1-2020
See 0MB Statemenl on Reverse.
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH
INFORMATION
COMPLETE ALL SECTIONS, DATE, AND SIGN
I. I, , hereby voluntarily authorize the disclosure of
information from my ------------------------
he a Ith record . (Name of Patient)
II. The information is to be disclosed by: And is to be provided
to:
NAME OF FACILITY NAME OF PERSON/ORGANIZATION/FACILITY
Tsehoostooi Medical Center
ADDRESS ADDRESS
P.o Box 649
CITY/STATE CITY/STATE Fort Defiance, Arizona
III. The purpose or need for this disclosure is:
D Further Medical Care D Attorney ~ School D Research D Other
(Specify) ________________ _ D Personal Use D Insurance D
Disability D Health Information Exchange (I HS/Other
IV. The information to be disclosed from my health record:
(check appropriate box(es))
~ Only information related to (specify) Current Immunization
Record
D Only the period of events from ___________________ to
_____________________ _ D Other (specify) (CHS, Billing, etc.)
________________________________________ _ D Entire Record If you
would like any of the following sensitive information disclosed,
check the applicable box(es) below:
D Alcohol/Drug Abuse TreatmenUReferral D HIV/AIDS-related
Treatment D Sexually Transmitted Diseases D Mental Health (Other
than Psychotherapy Notes) D Psychotherapy Notes ONLY (by checking
this box, I am waiving any psychotherapist-patient privilege)
v. I understand that I may revoke this authorization in writing
submitted at any time to the Health Information Management
Department, except to the extent that action has been taken in
reliance on this authorization. If this authorization was obtained
as a condition of obtaining insurance coverage or a policy of
insurance, other law may provide the insurer with the right to
contest a claim under the policy. If this authorization has not
been revoked , it will terminate one year from the date of my
signature unless a different expiration date or expiration event is
stated. For Health Information Exchange authorizations, it is
recommended to expire in at least five years .
(Specify new date)
I understand that IHS will not condition treatment or
eligibility for care on my providing this authorization except if
such care is: (1) research related or (2) provided solely for the
purpose of creating Protected Health Information for disclosure to
a third party.
I understand that information disclosed by this authorization ,
except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may
be subject to redisclosure by the recipient and may no longer be
protected by the Health Insurance Portability and Accountability
Act Privacy Rule [45 CFR Part 164), and the Privacy Act of 1974 [5
USC 552a].
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE (State
re/ationshiQ o patient) DATE
SIGNATURE OF WITNESS (If signature of patient is a thumbprint or
mark) DATE
This information is to be released for the purpose stated above
and may not be used by the reci pient for any other purpose. A ny
person who knowingly and will fully requests or obta ins any record
conce rning an indi vidual from a Federal age ncy und er false
pretenses shall be guilty of a mi sdemeanor (5 USC 552a(i)(3)).
··PA'i'ii:NT ii:iiiNTiFiCA TION
·········································· ··· ··· ···· ··· ··· ""'
/Las
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Instructions for Completing IHS Form 810 --AUTHORIZATION FOR USE
OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
1. Print legibly in all fields using dark permanent ink.
2. Section I, print your name or the name of patient whose
information is to be released.
3. Section 11, print the name and address of the facility
releasing the information. Also, provide the name of the person,
facility, and address that will receive the information.
4. Section Ill, state the reason why the information is needed,
e.g., disability claim, continuing medical care, legal,
research-related projects, etc. For an Health Information Exchange
(HIE) other than IHS, please provide the name of the HIE.
5. Section IV, check the appropriate box as applicable.
a. Only information related to -- specify diagnosis, injury,
operations, special therapies, etc.
b. Only the period of events from -- specify date range, e.g.,
Jan. 1, 2002, to Feb. 1, 2002.
c. Other (specify) -- e.g., Purchased Referred Care (PRC) ,
Billing, Employee Health.
d. Entire Record -- complete record including, if authorized,
the sensitive information (alcohol and drug abuse
treatment/referral, sexually transmitted diseases, HIV/AIDS-related
treatment, and mental health other than psychotherapy notes) .
e. IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING
ALCOHOL/DRUG ABUSE TREATMENT/REFERRAL, HIV/AIDS-RELATED TREATMENT,
SEXUALLY TRANSMITTED DISEASES, MENTAL HEALTH (OTHER THAN
PSYCHOTHERAPY NOTES), THE APPROPRIATE BOX OR BOXES MUST BE CHECKED
BY THE PATIENT.
f. Psychotherapy Notes ONLY -- IN ORDER TO AUTHORIZE THE USE OR
DISCLOSURE OF PSYCHOTHERAPY NOTES, ONLY THIS BOX SHOULD BE CHECKED
ON THIS FORM. AUTHORIZATIONS FOR THE USE OR DISCLOSURE OF OTHER
HEALTH RECORD INFORMATION MAY NOT BE MADE IN CONJUNCTION WITH
AUTHORIZATIONS PERTAINING TO PSYCHOTHERAPY NOTES.
IF THIS BOX IS CHECKED WITH OTHER BOXES, ANOTHER AUTHORIZATION
WILL BE REQUIRED TO AUTHORIZE THE USE OR DISCLOSURE OF
PSYCHOTHERAPY NOTES ONLY.
Psychotherapy notes are often referred to as process notes,
distinguishable from progress notes in the medical record . These
notes capture the therapist's impressions about the patient,
contain details of the psychotherapy conversation considered to be
inappropriate for the medical record , and are used by the provider
for future sessions. These notes are often kept separate to limit
access because they contain sensitive information relevant to no
one other than the treating provider.
g. When you opt-in to share information through the HIE, an
expiration date must be entered.
6. Section V, if a different expiration date is desired, specify
a new date. For HIE, a date 5 years in the future is recommended in
order to provide health information for continuity of care.
7. Section V, Please sign (or mark) and date.
8. A copy of the completed IHS-810 form will be given to you
.
0MB ST AT EM ENT
Public reporting burden for this collection of information is
estimated to average 10 minutes per response including time for
reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a co llection of
information unless it displays a currently va lid 0MB control
number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for
reducing this burden to: Indian Health Service, Office of
Management Services, Division of Regulatory Affairs, Mail Stop
09E70, 5600 Fishers Lane, Rockville, MD 20857, RE: 0MB No.
0917-0030. Please DO NOT SEND this form to this address.
IHS-810 (04/16) BACK
Student Internet Usage SY 20-21 revised 6-23-20.pdfPROPER AND
ACCEPTABLE USE: The use of the Internet, including the world-wide
web in any WRUSD School must be in support of education and
academic research and consistent with the educational objectives of
the WRUSD.RELIABILITY: WRUSD makes no warranties of any kind,
whether expressed or implied, for the service it is providing.
WRUSD will not be responsible for any damages you suffer. This
includes non-deliveries, mis-deliveries, or service interruptions
caus...EXCEPTION OF TERMS OF CONDITIONS: All terms and conditions
as stated in this document are applicable to the WRUSD. These terms
and conditions reflect the entire agreement of the parties and
supersede all prior oral or written agreements and understa...
AZ RESIDENCY FORM JFAA-EA SY 20-21 revised 6-23-20.pdfJFAA-EA ©
EXHIBIT
AZ RESIDENCY FORM JFAA-EB SY 20-21 revised 6-23-20.pdfJFAA-EB ©
EXHIBIT
Student Internet Usage SY 20-21 revised 6-23-20.pdfPROPER AND
ACCEPTABLE USE: The use of the Internet, including the world-wide
web in any WRUSD School must be in support of education and
academic research and consistent with the educational objectives of
the WRUSD.RELIABILITY: WRUSD makes no warranties of any kind,
whether expressed or implied, for the service it is providing.
WRUSD will not be responsible for any damages you suffer. This
includes non-deliveries, mis-deliveries, or service interruptions
caus...EXCEPTION OF TERMS OF CONDITIONS: All terms and conditions
as stated in this document are applicable to the WRUSD. These terms
and conditions reflect the entire agreement of the parties and
supersede all prior oral or written agreements and understa...
AZ RESIDENCY FORM JFAA-EA SY 20-21 revised 6-23-20.pdfJFAA-EA ©
EXHIBIT
AZ RESIDENCY FORM JFAA-EB SY 20-21 revised 6-23-20.pdfJFAA-EB ©
EXHIBIT
Tsehootsooi Primary Learning Center K3: OffTsehootsooi Middle
School 78: OffWindow Rock High School 912: OffTsehootsooi
Intermediate Learning Center 46: OffTsehootsooi Dine Bi Olta K6:
OffIntegrated PreSchool: OffGender: Birthplace: Hispanic Latino:
OffNOT Hispanic Latino: OffWhite: OffBlack or African American:
OffAmerican Indian Alaskan Native: OffAsian: OffTribe Enrolled:
Census Number: YES: OffNO If YES provide court documents to school
office: Offboth parents: Offfather: Offmother: OffLegal Guardian:
OffCityZip Code: Home Phone: Cell Message Phone: Physical Address:
CityZip Code_2: RA: Last School Attended: School Address: Has this
student ever received special education services: OffELLESL
Classes: OffGifted Advanced: Off504 Plan: OffRemedial Reading:
OffIndividual Counseling: OffFatherGuardian Full Name: Tribe:
Chapter: Census No: Employer: Work Phone: Cell Phone: Email
Address: MotherGuardian Full Name: Tribe_2: Chapter_2: Census No_2:
Employer_2: Work Phone_2: Cell Phone_2: Email Address_2: Heart:
OffAsthma: OffDiabetes: OffHearing: OffAllergies: OffYES_4: OffNO
Specify: Specify health problems or any severe allergies: History
of Diabetes high blood sugar please list family member and
relationship: My child may be given an antacid for upset stomach:
OffPlease check one of the boxes: OffLast yr grade: Local Friend
Relative Name1: Relationship1: Home Phone1: Work Phone1: Cell
Phone1: Local Friend Relative Name2: Local Friend Relative Name3:
Local Friend Relative Name4: Local Friend Relative Name5:
Relationship2: Relationship3: Relationship4: Relationship5: Home
Phone2: Home Phone3: Home Phone 4: Home Phone 5: Work Phone2: Work
Phone 3: Work Phone 4: Work Phone 5: Cell Phone 2: Cell Phone 3:
Cell Phone 4: Cell Phone 5: Name LastFirstRow1: Name LastFirstRow2:
Name LastFirstRow3: AgeRow1: Schoo if attendingRow3: AgeRow2:
AgeRow3: Student Name LastFirstM: Male: OffFemale: OffAge: Grade:
TPLC: OffTMS: OffTDB: OffWRHS: OffTILC: OffInt PS: OffWhom is
student living: Relationship: where student sleeps at night:
Emergency Housing: OffDomestic Violence: OffTransitional Housing:
OffEconomic hardship: OffLoss of Housing: OffDate living
arrangement: Date living expected to end: NameRow1: Brother or
SisterRow1: Staying at the same place xRow1: GradeRow1: School if
attendingRow1: NameRow2: Brother or SisterRow2: Staying at the same
place xRow2: GradeRow2: School if attendingRow2: NameRow3: Brother
or SisterRow3: Staying at the same place xRow3: GradeRow3: School
if attendingRow3: NameRow4: Brother or SisterRow4: Staying at the
same place xRow4: GradeRow4: School if attendingRow4: Print Name of
ParentLegal Guardian: Date: Mailing Address: Email: Phone: Print
Parent Name: Address: Date_2: School: ParentLegal Guardian: Persons
who reside with me: Location of my residence: Print Parent or
Guardians Name: Birthdate: NO_4: Off