Fillable ANCHORAGE SCHOOL DISTRICT K-12 ENROLLMENT FORM I. STUDENT (Anchorage School District)

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ANCHORAGE SCHOOL DISTRICT K-12 ENROLLMENT FORM I. STUDENT (Anchorage School District)

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  • 110 check-boxes
  • 442 other fields

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Office Use Only School Name/Code:
_____________________
School Entry Date:
______
/
_______
/
______
Student District ID:
_____________________
Student State ID (SSID):
_____________________
Copy of court order legal documentation was provided by parent/guardian.
q Yes
q No
Received Date:
____
/
____
/
____
ANCHORAGE SCHOOL DISTRICT K-12 ENROLLMENT FORM
Parent / Guardian to complete Sections I-V. Please print legibly using black or blue pen.
I. STUDENT INFORMATION
1. Student's Legal Last Name: Student's Legal First Name: Student Middle Name:
Suffix: Other Name Student Uses:
2. Grade level: 3. Gender:
q Male
qFemale
4. Is student Hispanic or Latino?
qYes qNo
4a. Select one or more of the race categories:
qWhite
qAsian
qBlack
qAK Native
qAmerican Indian
qNative Hawaiian or Pacific
Islander
5. Student Birthdate:
MM / DD / YY
6. Birth place:
7. Student primary language: 8. Student home language:
9. Student Residence address:
City, State: ZIP + 4:
10. Student mailing address (if other than residence):
City, State: ZIP + 4:
11. Student Email address and Phone Number (For HS student is taking on-line or King Tech courses)
Student Email:
Student Phone:
12. Is there a court order in effect for the student?
qYes
qNo (If yes, please furnish a copy of the legal documentation to the school office.)
13. Is student: Non-ASD Home Schooled?
qYes
qNo
Attending a Private School?
qYes
qNo
A Foreign Exchange Student?
qYes qNo
Name of Private/Home School:
____________________________________________________________
14. Please list previous out of Anchorage School District history including Preschool: (If additional space is needed, please see the registrar.)
School name:
_______________________
Address:
_______________________________
City:
_________________
St:
_____
Zip:
_______
School phone number (
_____
)
________________
Date last attended:
____
/
____
/
____
Years Attended:
______
Grade level last year:
_________
15. Previously enrolled in the ASD (including Preschool)?
qYes
qNo
*If yes, school name
____________________________________________________
Last year attended
________________
16. Does student have a current or past IEP?
q
Yes
q No 17. Does student have a current 504 plan?
q
Yes
q
No
18. If your student was not born in the United States (including the District of Columbia and Puerto Rico), please provide the first known date that
they began attending school in the United States:
____
/
____
/
____
II. SIBLING INFORMATION (If additional space is needed, please see the registrar.)
Complete this section only if applicable. Include only siblings who are currently enrolled in Grades K-12 in the Anchorage School District.
Sibling 1 full name: Grade: School name:
Sibling 2 full name:
Grade:
School name:
Sibling 3 full name: Grade:
School name:
Sibling 4 full name: Grade:
School name:
Sibling 5 full name: Grade:
School name:
The information provided is true to the best of my knowledge
X Parent/Guardian signature (required)
___________________________________________
Date:
____________
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ATT-#004 Enrollment V7.3 01.24.2020
III. PRIMARY CONTACT INFORMATION
CONTACT

PARENT/GUARDIAN CONTACT

PARENT/GUARDIAN
Title (check one):
q
Mr.
q
Mrs.
q
Ms.
q
Mr.
q
Mrs.
q
Ms.
Contact full name(last,first):
Type of Contact:
Check only one:

qParent qGuardian
q
*Other Check only one:

qParent
qGuardian
q *Other
Relationship to Student:
Check only one: qMother
qFather
qStepmother qStepfather
qFoster Mother
qFoster Father
qGrandmother
qGrandfather
qAunt
qUncle
qSibling
qGuardian ad Litem
qCourt Appointed Special Advocate
qOCS Caseworker
Check only one: qMother
qFather
qStepmother
qStepfather
qFoster Mother
qFoster Father
qGrandmother
qGrandfather
qAunt
qUncle
qSibling
qGuardian ad Litem
qCourt Appointed Special Advocate
qOCS Caseworker
Contact lives with student:
At least one must be "Yes"
(No. & Street name)
(City, State, Zip + 4)
qYes
qNo*
*If no, or if Co-custody, residential address:
______________________________________________
______________________________________________
qYes
qNo*
*If no, or if Co-custody, residential address:
______________________________________________
______________________________________________
Military Affiliation
qYes
þ No
If "yes" complete this section.
q
Active
Rank:
____________________________________
Branch of Service:
__________________________
q
Nat.Guard Active/A.D.O.S
q
Nat. Guard Traditional
q
Reserves Active/Title X
q
Reserves Traditional
q
Inactive or Retired
q
Active
Rank:
____________________________________
Branch of Service:
__________________________
q
Nat.Guard Active/A.D.O.S
q
Nat. Guard Traditional
q
Reserves Active/Title X
q
Reserves Traditional
q
Inactive or Retired
Contact employer name:
Contact work address:
(Required if on a Federal Property)
City:
State:
Zip: City:
State:
Zip:
Name of Federal Property
(e.g. JBER, BLM, courthouse)
1st Phone # to Call:
qCell
qHome
qWork qCell
qHome
qWork
2nd Phone # to Call:
qCell
qHome qWork qCell
qHome
qWork
3rd Phone # to Call:
qCell
qHome
qWork qCell
qHome
qWork
Contact preferred language:
Contact email address:
Contact needs access to the
following student records:
q
Web Access (ParentConnect)
q
Web Access (ParentConnect)
q
DO NOT RELEASE (Please provide court order)
IV. EMERGENCY CONTACT INFORMATION
Emergency Contacts are utilized when school staff is unable to reach Primary Contact(s).
Please provide additional contact information below. (Not Primary Contacts)
My child may be released to the contacts below.
EMERGENCY CONTACT EMERGENCY CONTACT
Contact full name:
Contact relation:
Contact phone #:
qCell
qHome
qWork qCell
qHome
qWork
Contact phone #:
qCell
qHome qWork qCell
qHome
qWork
EMERGENCY CONTACT EMERGENCY CONTACT
Contact full name:
Contact relation:
Contact phone #:
qCell
qHome qWork
q
Cell
qHome qWork
Contact phone #:
qCell
qHome
qWork qCell
qHome
qWork
Anchorage School District
Media Release Form
We need student and parent permission to use a person’s photograph, voice, and/or name in
various media projects. Please read the following, then date and sign where indicated. ank
you.
❑ Yes – I consent. I grant permission for my child to participate and appear in video or
audio recordings, lms, photographs, written articles, or on websites and social media
sites. is consent includes the use and editing of my child’s image, voice and name
in media projects by the Anchorage School District to print, broadcast or Internet
media outlets, such as newspapers, radio and television stations and news websites. In
consideration of the opportunity for my child to participate, I release the Anchorage
School District, including its employees and contractors, from all claims resulting from
the use and editing of my child’s image, voice or name, and the use, sale, editing and
release to media outlets.
❑ No – I do not consent to non-ASD use of my child’s photograph, voice and/or name in
various media projects.
Your selection remains valid for all media projects occurring during the school year in which
this form is signed. You may change your selection at any time by completing a new form at
your school.
Date: __________________________________________________________________
(day, month, year)
Student name: ___________________________________________________________
Student signature: ________________________________________________________
Parent or legal guardian signature is required if the participant is under 18 years of age.
Parent or legal guardian name: _______________________________________________
Parent or legal guardian signature: ____________________________________________
Zangle default: Denied Rev 02-17
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Student Media-Release Forms
Parent-signed media releases are NOT needed when:
• Photographing or videotaping anonymous students engaged in normal classroom/
school activities.
• Photographing, videotaping or interviewing students at events that are open to the
public, such as music, theater or athletic events.
Parent-signed media releases are ALWAYS needed when:
• Students are interviewed or will be identied by name in a photograph/news article.
• An individual student(s) is the focus of the story.
• Photographing, videotaping or interviewing students who are in special education classes/
services or certain specialized programs (drug/alcohol, detention/work detail, etc.).
• You feel the photograph, videotape or interview may be used in a negative way.
Anchorage School District
Release of Student Directory Information
5530 E. Northern Lights Blvd.
Anchorage, AK 99504-3135 (907) 742-4607
Dear Parents/Guardians,
As a parent (or a student 18 or over), you have the right to prohibit the Release of Student Directory Information
about your student.
What is Student Directory Information?
“Student Directory Information” is information about students that may be disclosed by the Anchorage School
District (ASD) to identify enrollment and to publicize student accomplishments and activities. Examples of
publication include:
A playbill showing your student’s role in a drama production
The annual yearbook
Honor roll or other recognition lists
Graduation programs
Sports activity sheets, such as for wrestling, showing weight and height of team members
Directory information may also be requested from ASD by education-related vendors, colleges, or military recruiters
who want contact information for ASD high school students. Disclosure to outside organizations includes, but is not
limited to, companies that manufacture class rings or publish yearbooks.
What Categories of Information Are Included?
The District has identified the following information as directory information. (See School Board Policy 5125 for
more details)
Student’s Name
Grade Level
Address Degrees, Honors and Awards
Telephone Number
Scholarship Eligibility
E-mail Address Enrollment Status
Year of Birth Name of school most recently attended
Enrollment Status
Participation in officially recognized activities and sports
Dates of Attendance Height and weight of members of athletic team members
What Are Your Rights as a Parent (or Student 18 or Over)?
The Family Educational Rights and Privacy Act (FERPA), a federal law, requires that ASD, with certain exceptions,
obtain your written consent prior to the disclosure of personally identifiable information from your student’s
education records. However, ASD may disclose appropriately designated “directory information” without written
consent, unless you decline by completing this form.
In addition, federal law requires ASD to provide military recruiters, upon request, with three pieces of directory
information – names, addresses and telephone listings, unless you decline by completing this form. State law
requires ASD to provide contact information for students who have dropped out of high school to the Alaska
Military Youth Academy, a program for students to finish their education and obtain a high school diploma or GED.
You can decline this disclosure by completing this form.
Release of Scholarship Eligibility Information
State law requires ASD to provide information about the eligibility of high school seniors for University of Alaska
Scholarships including the names and addresses of those students who qualify for a scholarship. However, you can
decline to have eligibility information disclosed to the University of Alaska Scholarship program by completing
this form.
School officials may release directory information, as set forth above, about a student without first obtaining
parental consent, unless you decline by signing and returning this Release of Student Directory Information
form.
Records Management Release of Student Directory Information REC #009 Revised 01/2018
OFFICE USE ONLY STUDENT ID
NO
SCHOOL NAME SCHOOL CODE__
Q default is Granted
Anchorage School District
Release of Student Directory Information
All Students K-12
_____YES _____ Grant Directory Information Release for the following types of publications:
A playbill showing your student’s role in a drama production
Annual yearbook
Sports activity sheets, such as for wrestling, showing weight and height of team members
and athletic programs
For awards recognition, achievements, certificates or
Honor Roll
All High School Students
YES _____ NO _____
_____YES _____ NO
_____
YES _____ NO
_____
YES _____ NO
_____YES _____ NO
Grant Directory Information Release for the following types of graduation related activities:
Publicized Graduation lists
Vendors for
Class Rings and Photos
Requests from
outside agencies acknowledging Graduates with letters or certificates.
Grant Directory Information Release (student contact information) to College/Universities
Grant Directory Information Release (contact information for students who have
dropped out) to Alaska Military Youth Academy
Grant Directory Information Release (student contact information) to Military Recruiters
Grant Release of Scholarship Eligibility information to the University of Alaska. Unless you
select YES, your student’s eligibility for the University of Alaska Scholarships cannot be
disclosed to the organization that administers this scholarship program.
Student Information: Required fields (*)
*Student Name (
Please Print)
______________________________________________________________________
*Parent/Guardian Name (Please Print)
______________________________________________________________________
*Parent/Guardian Signature
______________________________________________________________________
*Signature Date
______________________________________________________________________
Records Management Release of Student Directory Information REC #009 Revised 01/2018
_________________________ __________________________________ ________
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Anchorage School District
Educating All Students for Success in Life
2020-21 Income Declaration Form
Each year the Anchorage School District must collect an income declaration form from families
in order to follow state rules. This information is collected so ASD can accurately count the
number of families who are economically disadvantaged.
Reporting this data may help schools receive discounts on phone and internet use and may
help schools qualify for grants.
This information is NOT used to determine if a child may receive free or reduced price lunch.
This form is confidential and individual family information will NOT be shared with anyone.
Student Name: ASD ID# Grade:
Directions:
1.
Circle the number of people who live in your household.
2.
Look at the amount to the right of the number you circled.
3.
Check the “is less than” box if your family income is less than this amount.
4.
Check the “is more than” box if your family income is more than this amount.
Example: A family of 3 with an income
of less than $50,228
Circle the
number of
people
who live
in your
home
Total
Income
Check if
your family
income is
“less than”
Check if your
family income
is
“more than”
1
$29,508
o
o
2
$39,868
o
o
3
$50,228
o
o
4
$60,588
o
o
5
$70,948
o
o
6
$81,308
o
o
7
$91,668
o
o
8
$102,028
o
o
9
$112,388
o
o
I attest that the information provided on this form is true and accurate.
Signature: Date:
Circle the
number of
people who
live in your
home
Total Income
Check if
your family
income is
“less than”
Check if
your family
income is
“more than”
1
$29,508
o
o
2
$39,868
o
o
3
$50,228
o
o
4
$60,588
o
o
5
$70,948
o
o
6
$81,308
o
o
7
$91,668
o
o
8
$102,028
o
o
9
$112,388
o
o
OFFICE USE ONLY STUDENT ID SCHOOL NAME SCHOOL CODE
Default is Denied
Anchorage School District and Alaska Public Library - Library Card Project
Anchorage Public Library (APL) in partnership with the Anchorage School District will give parents/guardians the
choice to get a public library card for their student when they register for school in the Anchorage School District.
The ASD library card number will serve as the APL library card.
In order for students to use their ASD library card at APL, ASD will need to disclose the following information to
APL:
•
Student’s Name, Gender and DOB
•
School
•
Address
•
Parent/Guardian Name, Email and Phone
•
ASD Library Card Number and PIN
Student Name (Please Print):
Parent/Guardian Name (Please Print):
Parent/Guardian Signature:
Date:
YES, I give consent for ASD to disclose this information to APL
NO, I do not give my consent for ASD to disclose this information to APL
Explore the world with a library card!
An Anchorage Public Library card gives your student access to:
Online resources
•
20,000+ downloadable ebooks and eaudiobooks
•
Tumblebooks: ebooks & online learning portal for K-6th grade
•
Lynda.com online learning and training
•
Hoopla: streaming movies, television, music, books, and more
•
Downloadable music from Freegal
•
Research databases & more!
•
No fines or fees ever associated with online materials
Print and more resources at your library
•
Almost a million books, DVDs, CDs, audiobooks, & more!
•
Check out 3 items at any public library
•
Use a computer to access the internet and do school work at the library
•
Anchorage Public Library does not charge overdue fees but does charge for lost/damaged items.
•
Events and activities for youth of all ages
For more information visit the APL web site: http://www.anchoragelibrary.org/about/using-the-library/library-cards-borrowing/
CUR #004
Updated 3/10/20
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Anchorage*School*District*School*Year*2020/21*
Student*Housing*Questionnaire*
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Your*child*or*children*may*be*eligible*for*additional*educational*services*through*the*Title*I,*Part*
A,*Federal*McKinney-Vento*Homeless*Assistance*Act.**El igibility*can*be*determined*by*completing*
this*questionnaire.*
Since&July&1,&of&2019&has&there&been&a&period&of&time&when&you&have&NOT&rented&or&owned&a&home?&
,,YES, ,NO,, ,REFUSED,
If&yes,&please&check&all&of&the&following&living&situations&you&have&used&since&July&1.&If&no,&nothing&else&needs&to&
be&completed.&
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If*you*checked*yes,*please*list*all*the*preschool*and*school-aged*children*currently*living*with*you.*
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-----------------------------------------------------FOR*OFFICE*USE*ONLY--------------------------------------------------------*
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ASD Student Handbook Acknowledgement
The Anchorage School District is committed to providing families and students with
the most up-to-date information about its schools, programs, activities, and student
behavior expectations.
Our Student Handbooks are now available online at
http://www.asdk12.org/students/handbooks/. It is the responsibility of students
and families to read and follow the guidance contained in the handbook. Questions
about the handbook can be forwarded to your school’s administrators. Please see
your school’s office staff to request a paper copy of the Student Handbook.
By checking this box, I acknowledge that the ASD Student Handbook is
school at any time.
available to read online and that I can request a copy from my student’s
Student Name Date of Birth
Parent/Guardian Name Signature
Date
INST #030
Ancho r age School Di.strict
1:m,u1rhfK All S1dnrJ
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Anchorage School District
Student Internet User Agreement
5530 E. Northern Lights Blvd.
Anchorage, AK 99504-3135
Dear Parent or Guardian,
We
are pleased
to
offer students
in
the Anchorage
School
District
access
to
the
District
computer
network
for
Internet
access.
ASD
requires this agreement form be filled out annually for students to obtain Internet access.
District Internet Use Responsibilities
Students are expected to act in a considerate and responsible manner when accessing network services.
Students are responsible for good behavior on school computer networks just as they are in a classroom or a school hallway.
Communicaons on the network are often public in nature. General school rules for behavior and communicaons apply. The
network is provided to students for educaonal use only. Parent permission is required and students who do not have such
permission are responsible for not accessing the Internet at school. Access is a privilege, not a right, and entails responsibility.
Individual
users
of
the
District
computer
networks
are
responsible
for
their
behavior
and
communicaons
over
those
networks.
It
is
expected that users will comply with District standards and will honor the agreements they have signed.
Network
storage
areas
may
be treated
like
school
lockers.
Network administrators
may
review
files
and
communicaons
to
maintain
system integrity
and
ensure
that
students
are
using
the
system
responsibly.
Students
should
not
expect
that
files
stored
on
District
servers will always be private.
Within reason,
freedom of speech and access to informaon will be honored.
During
school,
teachers
of
younger
students
will
guide
students toward appropriate materials.
The following are not permied:
●
Sending or displaying offensive messages or pictur
es
● Using obscene language
● Harassing, insulng, or aacking others
● Violang copyright laws
●
Trespassing in another’s f
olders, work or files
● Employing the network for commercial purposes
● Deliberate damage to hardware or software
● Use of District computers for illegal acvies
●
Using another’s passwor
d
Violation may result in a loss of access as well as other disciplinary or legal action. For more information, see the School Board
Policies and the ASD Student Rights and Responsibilities document.
District G Suite Access
All students with permission to access the Internet are also given a G Suite account. This account does not include a district email but
does give students access to:
1. Google Drive
2. Google Docs
3. Google Sheets
4. Google Slides
5. Google Classroom
This account is intended to give students the ability to seamlessly work between home and school. More info about G Suite security
and privacy can be found at hps://edu.google.com/k-12-soluons/privacy-security/
Information Technology Student Internet User Agreement IT #102 2/2018
OFFICE USE ONLY: STUDENT ID
______________________________
SCHOOL NAME
________________________________
SCHOOL CODE
_________
Q Default is Granted
Anchorage School District
Student Internet User Agreement
The Anchorage School District is not liable for any harm or injury that a user may suffer as a consequence of any
inaccurate informaon the user may obtain through the Internet. By entering into this User Agreement, the user agrees
to be bound by this release of liability and waives any and all rights to assert claims which may arise due to use of the
Internet. (6 AAC 96.400-420)
As a user of the Anchorage School District Computer network, I hereby agree to comply with the rules stated on the
reverse side of this form regarding communicaons over the network, while honoring all relevant laws and restricons.
Student Information:
Student ID#
Grade
Student Name (Please print)
Student Signature
Date
I have read the Student Internet User Agreement and as a parent or legal guardian of the minor student above, I grant
permission for my student to access networked computer services such as electronic mail and the Internet. I recognize it
is impossible for the Anchorage School District to restrict access to all controversial materials. I hereby give permission
for my child to access the Internet and to publish informaon on web pages (except for home addresses and phone
numbers) and cerfy that the informaon contained on this form is correct. I may at any me revoke this permission by
nofying the student’s school in wring.
Parent/Guardian Information:
Parent/Guardian Name (Please print)
Parent/Guardian Signature
Date
_______
Parent/Guardian of Elementary-Aged Student:
I agree to discuss the expectaons and responsibilies outlined in this agreement with my elementary- aged student in
lieu of his/her signature. ( Initial)
**************************************************
Information Technology Student Internet User Agreement IT #102 2/2018
Student ID________________________
Anchorage School District Migrant Education Program!
Seasonal Work/Activity Eligibility Screener
Student’s Legal Name:____________________________________________________ Date of Birth:_________!
Current Phone Number:__________________________________!
1. Within the past three years has anyone in your family engaged in any of the following activities:
_____" Commerical fishing or other fishing activites (including shrimping, crabbing, & clamming) for
the purpose of producing food for your family’s use and needs?!
______ Agriculture (may include berry picking)!
______ Logging (with a logging company)!
______ Fish processing (cannery work)!
______ None of the above!
If you did not check at least one activity above please stop.
This form does not enroll your child(ren) in the ASD Migrant Education Program.
Eligibility is determined based on an interview with a Migrant Education Recruiter.
Please be prepared to provide details regarding the activity, including dates, location, gear, catch/harvest.
2. Did the activity require staying overnight away from your residence and outside the Anchorage School
District area?
YES" NO
3. Is the activity an economic necessity for your family, meaning you need the income, harvest, or catch
meet your household’s basic needs?
YES" NO
ASD School Front Office Staff only Do not file in CUM
Front Office Staff: Enter information into Q upon new student enrollment and return all completed forms to
the Migrant Education Program by inter-departmental mail. Thank you.
5530 East Northern Lights Blvd., Anchorage, AK 99504" 907.742.4275!
MEP #001 1.20
2021 Alaska Youth Risk Behavior Survey
Parent/Guardian Permission Form
The Anchorage School District is participating in the Alaska Youth Risk Behavior Survey (YRBS). The
survey is sponsored by the Alaska Department of Health and Social Services. It will be given sometime
between January – March 2021.
The YRBS is an anonymous survey that is conducted in high schools throughout Alaska and the United
States. Students complete the survey on paper or electronically. The U.S. Centers for Disease Control
and Prevention (CDC) developed the survey to collect information about behaviors related to the
health and well-being of students. The survey results will be used to learn about and address the
health concerns of Alaska teenagers. School districts and community organizations use YRBS results to
identify emerging health issues and track changes in the health behaviors of the overall Alaska
adolescent population over time. The results also help school districts and other organizations create
and obtain funding for programs for youth.
After the results are analyzed, reports are provided to the school districts. School districts are given
45 days to review the results. After review, the results are shared with the public upon request.
Survey results for individual students are never identified, analyzed or reported.
The survey is given in a way that protects your student’s privacy. Students will not put their names or
any other identifying information on the survey. Students are allowed to skip any questions they do
not want to answer. All students’ responses will remain anonymous. Individual student responses are
never studied or shared with others. Results from the survey are only ever reported out in aggregate,
for example by school district or borough/census area.
The 2019 survey questionnaire is still being developed. Anchorage School District will let parents know
when it is available for review. The 2017 YRBS questionnaire and results from past YRBS surveys are
posted online at http://dhss.alaska.gov/dph/Chronic/Pages/yrbs/yrbs.aspx. The 2019 questionnaire
will be posted on this website when it is completed.
We would like all selected students to participate to ensure meaningful results from the survey. It is
your decision whether your student participates. Your written consent is required for your student to
participate. There will be no actions against you or your student if your student does not participate.
Please read the section below. Check the appropriate box and return the form to your student’s
school. If you have any questions, please contact the Alaska YRBS Statewide Coordinator, Tazlina
Mannix, at (907)-269-8107.
2021 Alaska Youth Risk Behavior Survey
[ ] YES, my student may participate in the survey.
[ ] NO, my student may not participate in the survey.
Student’s Name: Grade:
Parent/Guardian Signature: Date:
English Language Learner Program
5530 E Northern Lights Blvd. • Anchorage, AK 99504 • 907-742-4452 • www.asdk12.org/ELL
Dear Parent or Guardian,
Welcome! The Anchorage School District is committed to supporting
students who speak or understand languages other than English.
Specially trained teachers and tutors who understand, respect and
appreciate different languages and cultures will work with eligible
students.
In order to help us determine which students may qualify for our
program, please take a minute to complete the attached form. If a
language other than English is indicated, language assessments will be
done and families will be notified of the results.
If you have questions, or need help with the form, we will be happy to
assist you.
Sincerely,
Christine Garbe
Director English Language Learner Program
907-742-4452
PARENT LANGUAGE QUESTIONNAIRE
(Home Language Survey)
If a language other than English is part of a student’s language background, state
and federal law require us to test his/her English proficiency.
Student name: _________
_________________________________ Place of birth: _____________________________________
(last name, first name)
Has this student attended school outside of the U.S.? □ no □ yes, in _____________________
(country)
Circle grades completed
outside of the U.S.: K 1 2 3 4 5 6 7 8 9 10 11 12
Date student first entered a U.S. school _____________ Participating in an exchange student program? □ no □ yes
If English is the only language above,
please sign and date at the bottom of the form.
If a language other than English is written above, please complete the entire form.
□ English □ other _______________________
□ English
□ other _________________________
A. What language(s) does this student speak?
*Do NOT include languages that your child is learning/has learned in school.
B. What language(s) does this student understand?
C. What was the first language spoken by mother/guardian? □ English □ other ________________________
D. What was the first language spoken by father/guardian? □ English □ other ________________________
E. Is there another adult who influenced this student’s language development? □ no
□ yes
relationship to student ______________________ language spoken _____________________________
Parent/Guardian signature _________________________________ Date ____________________
Parent/Guardian printed name __________________________________________
Anchorage School District
District ID #
__________________________
________________________________________
grade: ____ Date of Birth _________________________________
(school)
This form should be placed in the student’s cumulative file.
EL staff, please initial:
_____ Parent was given
an ELLP brochure.
rev 2/20
1. What is the primary language used in the home, regardless of the language spoken by the student?
□ English □ other _________________________
2. What is the first language this student learned to speak? □ English □ other _________________________
3. What is the language most often spoken by the student? □ English □ other _________________________
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Department Name
5530 E. Northern Lights Blvd• Anchorage, AK 9950 • 907-742-4445 •http://www.asdk12.org/titlevi
!
2020-21 School Year
Dear Parent/Guardian,
Your child may be eligible to enroll in the Title VI Indian Education Program if you, your child, or his/her
grandparent are an enrolled member of an
• American Indian tribe, band or group
• Alaska Native tribe
or if you, your child or a grandparent have a Certificate of Degree of Indian Blood.
Title VI Indian Education supports American Indian and Alaska Native students to meet and exceed state
academic and cultural standards. Upon enrollment, your child will be eligible to participate in various (K-
12) programs including
• Academic Tutoring
• Cultural Enrichment
• Cultural Connection Activities
• Summer Programs
• Career and post-secondary training and exploration
• Native Advisory Committee (parents too)
Attached find a TITLE VI STUDENT ELIGIBILITY CERTIFICATION (506) FORM. Complete ALL of the
506 form and return the signed original to your child’s school office. Be sure to include an
enrollment number or a copy of documentation (CIB, village or tribal ID, etc.). The address of the
‘Organization maintaining membership” is needed.
The 506 form is needed for student eligibility and to generate federal funding for the Title VI Indian
Education program. However, enrollment in the program does not obligate a student to participate.
Perhaps your family does not have documentation or declines eligibility for Title VI Indian Education
services. Please write “No documentation” or “Decline” on the form, along with your student’s name and
date of birth. Then return it to your school office. If you change your mind or acquire documentation please
contact the Title VI Indian Education office at 742-4449.
Sincerely,
Doreen Brown
Senior Director
Title VI Indian Education Program
!
____________________ ___________________________
Student ID #
0000000
OMB Number: 1810-0021 Expiration Date: 02/29/2020
U.S. Department of Education
Office of Indian Education
Washington, DC 20202
TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM
Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the
student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child
cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year.
Where applicable, the information contained in this form may be released with your prior written consent or the prior written
consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family
Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.
STUDENT INFORMATION
*No Nicknames
Name of the Child
Jimmy Neutron
(As shown on school enrollment records)
Date of Birth
07/20/2002
Grade
3
__________________________________________________ ______________ ______
Name of School
Lindberg Elementary
____________________________________________________________________________________________
TRIBAL ENROLLMENT
*Write the name of person enrolled with the tribe
Name of the in dividual with tribal enrollment:
Jimmy Neutron
(Individual named must be a descendent in the first or second generation)
___________________________________________________________________
The individual with tribal membership is the: __
X
Child _____ Child's Parent ________ Child's Grandparent
*Only check one box
Name
of tribe or band for which individual above claims membership:
White Mountain Apache Tribe
*Must write out full name of village or tribe
The Tribe or Band is (select only one):
*Only
X
_
__ __ Federally Recognized
check
_____
State Recognized
one
_____ Terminated
Tribe
(Documentation required.
Must attach to form)
box
_____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988
as it was in effect October 19, 1994.
(Documentation required.
Must attach to form)
Proof of
enrollment in tribe or band listed above, as defined by tribe or band
is:
*Enrollment # must be provided
A. Membership or enrollment number (if readily available)
123-45-6789
_____________________________________________________ OR
B. Other
Evidence of Membership
in the tribe listed above
(describe
and attach)
CIB
_______________________________________
*Copy of documentation must be attached
Name
and
address of
tribe or band
maintaining enrollment
data for the
individual listed above:
Name
Bureau of Indian Affairs
*Address must be for the village or tribe
Not personal address
____________________________________________ Address
3601 C. St Suite 1100
________________________________________________
City
Anchorage
State
AK
Zip Code
99504
_______________________________ ______ ____________
ATTESTATION STATEMENT
I verify that the
information provided above is accurate.
*Form is void without signature
Name Parent/Guardian
Judy Neutron
______________________________________ Signature
_______________________________________
Address
1234 A Street
City
Anchorage
State
AK
Zip
Code
99508
______________________________________ ____________________________ ______ __________
Email Address
________________________________________
_______________Date
09/22/17
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signature
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OMB Number: 1810-0021 Expiration Date: 02/29/2020
U.S. Department of Education
Office of Indian Education
Washington, DC 20202
TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM
Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the
student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child
cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year.
Where applicable, the information contained in this form may be released with your prior written consent or the prior written
consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family
Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.
STUDENT INFORMATION
Name of the Child __________________________________________________
(As shown on school enrollment records)
Date of Birth ______________ Grade ______
Name of School
TRIBAL ENROLLMENT
Name of the individual with tribal enrollment: ___________________________________________________________________
(Individual named must be a descende
nt in the first or second generation)
The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent
Name of
tribe or band for which individual above claims membership: _______________________________________________
The Tribe or Band is (select only o
ne):
_____ Fe
derally Recognized
_____ State Recognized
_____ Terminated
Tribe (Documentation required. Must attach to form)
_____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988
as it was in effect October 19, 1994. (Docu
mentation required. Must attach to form)
Proof of enrollment in tribe or band listed above, as defined by tribe or band is:
A.
Mem
bership or enrollment number (if
readily available) _____________________________________________________ OR
B.
Oth
er Evidence of Membership in the tribe listed above (describe and attach) _______________________________________
Name and address of tribe or band maintaining enrollment data for the individual listed above:
Name ____________________________________________ Address _______________
_________________________________
City _______________________________State ______Zip Code ______
______
ATTESTATION STATEMENT
I verify that the information provided above is accurate.
N
ame Parent/Guardian ______________________________________ Signature _________________
______________________
Address ______________________________________ City _______________
_____________State ______Zip Code __________
Email Address ________________________________________ Date _______________
OMB Number: 1810-0021 Expiration Date: 02/29/2020
INSTRUCTIONS FOR THE ED 506 FORM
FOR APPLICANTS:
PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a
grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free
public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under
this subpart, and that otherwise meets the requirements of subsection (b)”.
MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT
have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year,
which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.
FOR PARENTS/GUARDIANS:
DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band,
including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A
descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary
of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that
received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.
STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level.
TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even
though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can
provide membership information.
Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears
exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit
verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or
Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to
this form.
Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department of
Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request.
State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department of
Education does not maintain a master list. It is recommended that you use official state websites only.
Termi
nated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interior
and had that designation terminated.
Organized Indian G roup- Member of an organized Indian group that received a grant under the Indian Education Act of 1988
as it was in effect October 19, 1994.
Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a
member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent,
or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate.
Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians.
ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of
the child verifies the accuracy of the information supplied.
The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals
and make such information available to the individual in accordance with the requirements of the Privacy Act.
PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021.
The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian
student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your
individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W.,
LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020.
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ASD Healthcare Services NUR #0305 Page 1 of 2 Revised 4/2020
Anchorage School District
HEALTH HISTORY FORM
PLEASE COMPLETE FOR ALL NEW-TO-DISTRICT, PRESCHOOL, KINDERGARTEN, 5
TH
, AND 9
TH
GRADE STUDENTS
OR AS NEEDED FOR OTHER GRADES TO UPDATE NEW / EXISTING HEALTH CONCERNS
LAST NAME
FIRST NAME
M.I.
DATE OF BIRTH (MM/DD/YYYY)
SCHOOL
GRADE
MEDICAL HISTORY
YES NO
Does your child have any health concerns?
If yes, please describe: _____________________________________________________________________
YES NO
Does your child have restrictions to participate in any activities?
If yes, please describe: _____________________________________________________________________
YES NO
Does your child have any allergies?
If yes, please list allergies: __________________________________________________________________
What does the allergic reaction look like? _____________________________________________________
YES NO
Is your child prescribed an EpiPen? For what allergies? ____________________________________________
YES NO
Does your child have asthma?
If yes, please describe type or triggers: _______________________________________________________
YES NO
Does your child have diabetes?
Type:____________________ Self manage Needs supervision Uses insulin pump Uses CGM
YES NO
Does your child have a heart condition?
If yes, please describe: ____________________________________________________________________
YES NO
Does your child have a bleeding disorder?
If yes, please describe: ____________________________________________________________________
YES NO
Does your child have an orthopedic condition?
If yes, please describe: ____________________________________________________________________
YES NO
Does your child have a history of seizures or another type of neurological disorder?
If yes, please describe: ____________________________________________________________________
YES NO
Does your child have any gastrointestinal concerns or issues with eating?
If yes, please describe: ____________________________________________________________________
YES NO
Does your child have any bowel or bladder concerns?
If yes, please describe: ____________________________________________________________________
YES NO
Does your child have behavioral, emotional, or mental health concerns?
If yes, please describe: _____________________________________________________________________
YES NO
Does your child have any vision concerns? GLASSES Other: _______________________
YES NO
Does your child have any hearing concerns? HEARING AID Other: _______________________
YES NO
Does your child currently take medications?
If yes, please list: __________________________________________________________________________
DO ANY PRESCRIBED MEDICATIONS OR TREATMENT PLANS NEED TO BE ADMINISTERED/AVAILABLE AT SCHOOL?
Diabetic medications/Diabetic Care Plan EpiPen/Allergy/Anaphylaxis Care Plan Inhaler/ Asthma Care Plan
Prescribed medications Seizure medications/Seizure Care Plan
Other Treatments (describe) _________________________________________________________________________________
The ASD Nurse must be notified if any medications need to be given during the school day. State law requires written authorization from a health
care provider and parent before any prescription medication can be given at school, including self-carry medication. All types of medication require
an authorization/consent form AND the medication(s) must be delivered to the school by a parent/guardian in a pharmacy labeled container.
Homeopathic and herbal remedies cannot be given at school.
Please continue to the second page to complete this form.
ASD Healthcare Services NUR #0305 Page 2 of 2 Revised 4/2020
Anchorage School District
HEALTH HISTORY FORM
PLEASE COMPLETE FOR ALL NEW-TO-DISTRICT, PRESCHOOL, KINDERGARTEN, 5
TH
, AND 9
TH
GRADE STUDENTS
OR AS NEEDED FOR OTHER GRADES TO UPDATE NEW / EXISTING HEALTH CONCERNS
MEDICAL PROVIDER / PEDIATRIC GROUP: _____________________________Phone___________________
OTHER PROVIDER: ________________________________________________ Phone___________________
PARENT / GUARDIAN CONSENT AND AUTHORIZATION
PERMISSION TO ACCESS STATE IMMUNIZATION REGISTRY
I CONSENT I DO NOT CONSENT
…for the nurse to review my child’s immunization information in the State of Alaska immunization registry (VacTrak).
The parent/guardian can remove permissions at any time by submitting your request in writing.
PERMISSION TO RELEASE AND/OR EXCHANGE MEDICAL INFORMATION
I CONSENT I DO NOT CONSENT
…for the
nurse to contact the healthcare provider listed above to clarify medical information provided on this form. The nurse
will share health information with school staff on a need-to-know basis for your
child’s safety and to foster academic success.
It is the responsibility of the parent/guardian to notify the nurse of any changes or updates in your child’s health history.
PARENT ACKNOWLEDGEMENT
My signature below is acknowledgement that the information provided is current and correct. I have reviewed the health
history form and understand that it is my responsibility to notify the school when my child’s health information has changed.
I agree to provide any medications or supplies needed for care of my child in school if needed. I will notify the school if my
consent for the above items needs to be updated or changed, per my preference.
PARENT / GUARDIAN NAME (PRINTED)
RELATIONSHIP TO CHILD
TELEPHONE NUMBER
PARENT / GUARDIAN (SIGNATURE)
DATE
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((((((((((((((((((((((((((((((((((
(
Anchorage School District
Educating All Students for Success in Ufe
Anchorage
School
District
5
th
and
6
th
Grade
Human
Growth
and
Development
Permission
Form
Parents (or(G uardians (of(5
th
(and( 6
th
(Grade (Students:(
The!i ntent !of!t his !form !is !to !gather !permission,!i n !advance,!f rom !parents !who !are!a lready!f amiliar !with !
the!A SD!c urriculum !materials !and !methods !of!d elivery!o r !who !otherwise!h ave!n o !objections !to !
developmentall y!a ppropriate!h uman !growth !and !development !content !for !5
th
!a
nd !6
th
!g
rade!s tudents.!!
Undecided !parents !can !select !to !postpone!t heir !decisions !until !a!l ater !date.!
Beginning !in !February/March !and !continuing !through !April,! the!E lementary!H ealth !curriculum,! The!
Great !Body!S hop,!w ill !cover !Human !Growth !and!D evelopment !and !Diseases.!T hese!u nits !provide!b asic,
relevant !information !about !growing !up,!i ncluding !the!o nset !of!p uberty!a nd !the!s tages !of!g rowth.! The!
meaning !of!f riendship !and !mutual !respect !are!e xamined.!E motional !matu rity!i s !defined,!d ecision-
making !steps !for !responsible!b ehaviors !are!d iscussed,!r efusal !skills !for !unhealthy!a nd !risky!b ehaviors!
are!r einforced,!a nd !the!i mportance!o f!s etting !goals !focused !on !responsibility!a re!e mphasized.! Our !
health !program !encourages !your !child !to !turn !to !you!f or !further !information.! !
The! 5
th
(grade (units !are( “Growing !Up” !and !“About !Blood !and !HIV.” !!
The! 6
th
(grades !units !are!“ The!R eproductive!S ystem” !and !“HIV/AIDS:!W hat !Yo u !Need !to !Know !Now.” !!
Your !child’s !Health !Sp ecialist !will !offer !a!p review !opportunity!o f!t he! materials !at !you r !school !prior !to !
the!b eginning !of!i nstr uction.! !
Student’s (name (________________________________________________________________ (((((Grade (______________________
Teacher’s (name (_______________________________________________________________
_____ Yes.!I !g ive!p ermission !for !my!c hild !to !participate!i n !the!H uman !Growth!& !D evelop ment !and !
HIV/AIDS !portions !of!t he! health !curriculum.!I !b elieve!t hat !I!h ave! enough !informatio n.!
_____ !No,!n ot !at !this !time.!I !r ealize!t he!H ealth !Specialist !will !be!i n !co ntact !t o !discern !if! more!i nformation !
is !needed !or !if!I !a m !resolute!i n !my!d ecision.!I !u nderstand !that !more!i nformation !will !be!f orthcoming!
and !that !I!c an !co ntact !t he!H ealth !Specialist !if!I !h ave!q uestio ns.!
Parent(S ignature (______________________________________________________________ (((((Date (__________________ _______
Curriculum Health/PE Department
Default in Q is not at this time
CEI #009
Sept. 2018
Student ID
Anchorage School District
2020-2021 School Year
Preschool Questionnaire
Student’s Legal Name: Date of Birth:
1. In what type of setting did your child receive early care between the ages of 3 and 5?
(check all that apply)
ASD Special Education Preschool
ASD General Education Preschool
Kids’ Corps, Inc. (KCI) Head Start
RurALCAP Head Start
Cook Inlet Native Head Start
Chugiak Children’s Services (CCS)
Head Start
Private Preschool Setting
Licensed Center-Based Childcare
Licensed Home-Based Childcare
Non-Relative Care
Parent/Guardian Care
Other:
2. Did your child attend a formal preschool setting between the ages of three and five years old?
Yes No
IF YOU ANSWERED YES TO QUESTION 2, PLEASE CONTINUE.
3. How many years did your child attend preschool? (select one)
Less than 1 year
1-2 years
2+ years
4. The year prior to kindergarten, how many hours per week did your child attend preschool?
(select one)
Less than 5 hours per week
5-15 hours per week
16-20 hours per week
21+ hours per week
Attended regularly?
Yes
No
Parent Signature: ____________________________________ Date: __________________
ASD Front Office Staff Only File in CUM
Front office staff enter this information into Q upon new student enrollment.
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ANCHORAGE SCHOOL DISTRICT K-12 ENROLLMENT FORM I. STUDENT (Anchorage School District)

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