STUDENT REGISTRATION FORM
DATE
DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY
SCHOOL ENTRY DATE / SCHOOL OF ENTRY / HOMEROOM/TEACHER / IBE STATUS / BOUNDARY EXCEPTION/NON-HIGH / BUS ROUTE
AMPM
STUDENT NAME: Legal Last Name / Legal First Name / Legal Middle Name / Also known as:
BIRTHDATE (Month/Day/Year) / GRADE LEVEL / GENDER M/F / BIRTHPLACE: City State Country / If NOT born in US, list # years attended school in
US:
RACE: PLEASE FILL OUT ATTACHED ETHNICITY / RACE COLLECTION FORM
**This is a required form** / PRIMARY LANGUAGE STUDENT SPEAKS AT HOME:
English Spanish Russian Other
Do you need forms sent in a language other than English? If yes, which one:
PRIMARY HOUSEHOLD (parent/guardian of student’s primary residence)
Last Name First Name
EMAIL ADDRESS: / PRIMARY PHONE # **
(include area code)
Home Work Cell
**This # will be used for automated call system. / PHONE #2 (include area code)
Home Work Cell / PHONE #3 (include area code)
Home Work Cell
Last Name First Name
EMAIL ADDRESS: / PHONE #1 (include area code)
Home Work Cell / PHONE #2 (include area code)
Home Work Cell / PHONE #3 (include area code)
Home Work Cell
STUDENT LIVES WITH: Both parents Mother/Stepfather Grandparents Self
Mother only Father/Stepmother Guardian Other
Father only Stepmother/Stepfather Foster parent
RESIDENT
ADDRESS /
Street
/ Apt # / City State Zip / CountyMAILING ADDRESS /
Street or P.O. Box
/ Apt # / City State ZipSECOND HOUSEHOLD (parent/guardian of student’s secondary residence)
Last Name First Name
EMAIL ADDRESS: / PHONE #1 (include area code)
Home Work Cell / PHONE #2 (include area code)
Home Work Cell / PHONE #3 (include area code)
Home Work Cell
Last Name First Name
EMAIL ADDRESS: / PHONE #1 (include area code)
Home Work Cell / PHONE #2 (include area code)
Home Work Cell / PHONE #3 (include area code)
Home Work Cell
RELATIONSHIP TO STUDENT: Both parents Mother/Stepfather Grandparents Other
Mother only Father/Stepmother Guardian
Father only Stepmother/Stepfather Foster parent
MAILING
ADDRESS /
Street or P.O. Box
/ Apt # / City State ZipSCHOOL/PRESCHOOL LAST ATTENDED / SCHOOL DISTRICT LAST ATTENDED / PREVIOUS SCHOOL LOCATION (City and State)
HAS STUDENT EVER ATTENDED WASHOUGALPUBLIC SCHOOLS? Yes No
IF YES, NAME OF SCHOOL ATTENDED: / DATE ATTENDED(Month/Year)
HAS STUDENT EVER BEEN ENROLLED IN A STATE OF WASHINGTON SCHOOL? Yes No
IF YES, NAME OF SCHOOL ATTENDED:
RESIDENT DISTRICT: IS STUDENT ATTENDING WASHOUGAL PUBLIC SCHOOLS VIA AN INTER-DISTRICT TRANSFER? Yes No
IF YES, WHAT IS YOUR RESIDENT DISTRICT(district that you reside in)?
IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? Yes No (If yes, plan must be on file with the school) Copy Attached
IS THERE A RESTRAINING ORDER IN EFFECT? Yes No (If yes, legal papers must be on file with the school) Copy Attached
Restraining order is against: Mother Father Other
Please completeadditional registration information on back…
HAS THE STUDENT EVER BEEN SUSPENDED FOR A WEAPONS VIOLATION? Yes NoDate:HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL ED PROGRAM? Yes No
HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN? Yes No
HAS YOUR CHILD EVER PARTICPATED IN: Title LAP Gifted ELL Other / HAS YOUR CHILD EVER BEEN RETAINED?
Yes No
If yes, at what grade level(s)
IS STUDENT BUSED TO/FROM CHILD CARE?
Before school After school Before after school / CHILD CARE PROVIDER:Name:
Address Phone Number
PLEASE LIST OTHER SIBLINGS ATTENDING WASHOUGAL PUBLIC SCHOOLS
Last NameFirst Name / School / Grade
SPECIAL INSTRUCTIONS REGARDING RELIGIOUS BELIEFS (Please provide information to school in writing on a separate sheet)
MEDICAL CONDITIONS: LIFE THREATENING? Yes No
MEDICATIONS STUDENT TAKES ON A REGULAR BASIS:
STUDENT RELEASE AUTHORIZATION/EMERGENCY CONTACTS
When injury, illness or other non-emergency situations occur involving your child, we want to be able to quickly reach families or other responsible adults. In the event we cannot reach a parent/guardian, please list persons you trust who are available during the day to provide care for your child. If you wish to add more than 3 emergency contacts, please list on an additional page.
FIRST CONTACT (other than parent/guardian)Last Name First Name / RELATIONSHIP TO CHILD / PHONE #1 (include area code)
Home Work Cell / PHONE #2 (include area code)
Home Work Cell
SECOND CONTACT (other than parent/guardian)
Last Name First Name / RELATIONSHIP TO CHILD / PHONE #1 (include area code)
Home Work Cell / PHONE #2 (include area code)
Home Work Cell
THIRD CONTACT (other than parent/guardian)
Last Name First Name / RELATIONSHIP TO CHILD / PHONE #1 (include area code)
Home Work Cell / PHONE #2 (include area code)
Home Work Cell
STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above.
Legal Parent/Guardian Signature ______Date______
EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child.
Legal Parent/Guardian Signature ______Date ______
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 Washougal Public Schools.
Legal Parent/Guardian Signature ______Date ______
Notes: ______
______
Revised for 2013-14 School Year
Washougal School District
Ethnicity and Race Data Collection Form
Student Name: Grade: School:
PLEASE ANSWER QUESTIONS 1A OR 1B AND QUESTION 2
QUESTION 1.A : Is your child of Hispanic or Latino origin? (If so, check all that apply)
CUBAN – 55MEXICAN/MEXICAN AMERICAN/CHICANO – 30
DOMINICAN – 60CENTRAL AMERICAN - 75
SPANIARD – 65SOUTH AMERICAN - 80
PUERTO RICAN – 70LATIN AMERICAN – 85
OTHER HISPANIC/LATINO – 90
QUESTION 1.B : Child is not Hispanic/Latino
NOT HISPANIC/LATINO – 10
QUESTION 2 : What race(s) do you consider your child (Check all that apply)
AFRICAN AMERICAN/BLACK – 200ALASKA NATIVE - 405
WHITE – 300CHEHALIS – 410
ASIAN INDIAN – 505COLVILLE - 416
CAMBODIAN – 507COWLITZ - 416
CHINESE – 510HOH - 418
FILIPINO – 520JAMESTOWN - 421
HMONG – 525KALISPELL - 424
INDONESIAN – 530LOWER ELWHA - 427
JAPANESE – 535LUMMI - 430
KOREAN – 540MAKAH - 433
LAOTIAN – 545MUCKLESHOOT - 436
MALAYSIAN – 550NISQUALLY - 439
PAKISTANI – 555NOOKSACK - 442
SINGAPOREAN – 560PORT GAMBLE KLALLAM - 445
TAIWANESE – 565PUYALLUP - 448
THAI – 570QUILEUTE - 451
VIETNAMESE – 575QUINALT - 454
OTHER ASIAN – 599SAMISH - 457
NATIVE HAWAIIAN – 605SAUK-SUIATTLE - 460
FIJIAN – 615SHOALWATER - 463
GUAMANIAN OR CHAMORRO – 620SKOKOMISH - 466
MARIANA ISLANDER – 625SNOQUALMIE - 469
MELANESIAN – 630SPOKANE - 472
MICRONESIAN – 632SQUAXIN ISLAND - 475
SAMOAN – 635STILLAGUAMISH - 478
TONGAN – 640SWINOMISH - 484
OTHER PACIFIC ISLANDER – 699TULALIP - 487
UPPER SKAGIT - 488
YAKAMA - 490
OTHER WASHINGTON INDIAN - 495
OTHER AMERICAN INDIAN - 499
Verification of Residency
In order to verify residency within Washougal School District, a copy of one of the documents listed below must be provided. Please attach the requested copy to this document (showing parent/guardian/caregiver name and address), and return it to our office:
______Deed, escrow papers, mortgage book or statement, or property tax form
______Lease Agreement/Rental Contract and current rent receipt
______Letter on apartment complex or mobile home park letterhead, signed by the
Landlord, stating that parent/guardian/caregiver lives there. Include business phone number of landlord for verification.
_____ Gas & Electric Bill_____ Phone Bill_____ Cable Bill
_____ Water Bill_____ Garbage Bill
I, ______, the parent/guardian/caregiver of
(Please Print Your Name) (Please circle one)
______declare under penalty of perjury, this student
(Please Print Student’s Name)
resides at the following address:______
(Please Print)
Falsification of any information or document required for
residency verfication, or the use of the address of another
person, may result in the revocation of student enrollment.
Signature of Parent/Guardian/Caregiver______Date______
WASHOUGAL SCHOOL DISTRICT
NONDISCLOSURE FORM 2014-15(Optional Opt-Out)
FERPA (FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT)
***THIS FORM MUST BE FILLED OUT EACH YEAR IF YOU WISH TO OPT OUT OF ANY CATEGORIES LISTED BELOW***
The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that school districts, with certain exceptions, obtain written consent prior to the disclosure of personally identifiable information from a child’s education records. ( However, school districts may disclose appropriately designated “directory information” without written consent, unless you have advised the District to the contrary.
To request withholding of information pursuant to FERPA, please complete this form (one form per school) and return it to the office of that school. If this form is not completed and filed with the district, it will be assumed that the directory information listed below may be disclosed for the remainder of the current academic year. A nondisclosure form must be completed each academic year. You may revoke this nondisclosure in writing by filing consent with the school office.
CHECK ALL BOXES BELOW THAT APPLY:
DO NOT DISCLOSE toMilitary. (Applicable to high school students only)
DO NOT DISCLOSE toHigher Education. (Applicable to high school students only)
DO NOT DISCLOSE forPublic use.
Exclude student information from being sent outside the district such as newsletters, traditional media (newspaper, TV, radio, web site) and social media.
For example, if this is checked and your student makes honor roll, their name will not be printed in the newspaper listing. Also, if events are photographed at school, your child will not be included in published photographs.
DO NOT DISCLOSE for District use(which could become public).
Exclude student information from within the district likeyearbooks, photographs, sports information such as rosters and programs and/or articles where student’s information is identified. If you check this box, your child/children will NOT appear in the school yearbook.
List name(s) of student(s) attending current school in the Washougal School District
PARENT/GUARDIAN LEGAL NAME ______
______
Parent/Guardian Legal Name – PLEASE PRINT
______
Parent/Guardian Signature Date
Revised 4/19/13
Washougal School District
4855 Evergreen Way
Washougal, WA 98671
Student Housing Questionnaire
Please use one form per student. Return to school registration office.Also, please fill out this form if you have a pre-school aged student. If you require additional copies, please contact your school.
Name of Student:
FirstMiddleLast
Name of School: Grade: Birthdate: Age:
Month/Day/Year
Sex: Male Female
The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435.
- Is this student’s home address a temporary living arrangement? Yes No
- Is this a temporary living arrangement due to a loss of housing or economic hardship? Yes No
- Is this student in a temporary foster care placement or awaiting foster care? Yes No
- As a student, are you living with someone other than your parent or legal guardian? Yes No
If you answered YES to any of the above questions, please complete the remainder of this form.
If you answered NO to all of the above questions, you may stop here.
Where is this student currently living? (check box)
In a motelTransitional Housing
In a shelterGroup Home
With more than one family in a house or apartment
Moving from place to place
In a location not designed for sleeping accommodations such as a car, park or campsite
ADDRESS OF CURRENT RESIDENCE:
(OR)
NAME OF MOTEL/SHELTER OF CURRENT RESIDENCE:
(OR)
NAME OF “GENERAL AREA” OF CURRENT RESIDENCE:
PHONE NUMBER OR CONTACT NUMBER: NAME OF CONTACT:
Print name of parent(s)/legal guardian(s):
(Or unaccompanied youth)
Signature of parent/legal guardian: Date:
(Or unaccompanied youth)
For School Staff Only: Forward questionnaire to Carol Boyden, WHS or fax to (360) 835-3968
Revised 2/3/2012