Fillable APPLICATION FOR STUDENT REGISTRATION FORM

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APPLICATION FOR STUDENT REGISTRATION FORM

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  • 177 check-boxes
  • 172 other fields

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Olympia School District
APPLICATION FOR STUDENT REGISTRATION FORM
Date Received: ALERT FLAG
Medical
1
LegalSCHOOL
DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY
SCHOOL START
DATE (M/D/Y)
TEACHER/ADVISOR
HOMEROOM #
LOCKER #
WITHDRAWAL
DATE (M/D/Y)
STUDENT’S NAME: LEGAL LAST NAME
LEGAL FIRST NAME
Has student’s name been legally changed? Yes No
Preferred Name
:
If yes, what was previous name(s)?
BIRTHDATE: (M/D/Y)
Verification of Age: Yes No
(e.g. birth certificate, hospital or physician’s certificate showing date of birth, adoption record)
GRADE LEVEL:
LEGAL GENDER: Female Male X
PHYSICAL RESIDENT ADDRESS: (where student resides)
Street Apt.# City State Zip
Verification of Residency Statement Received: Yes No
School Resident? Yes
No, Transfer Student
Home School:
Within-District Transfer Form Completed
District Resident? Yes
N
o, Transfer Student
Resident District: Out-of-District Transfer Form Completed
Are you, the parent/legal guardian, a full-time employee of the Olympia School District? Yes No
If yes, at what location:
FEDERAL FUNDING / MILITARY FAMILIES:
We are required by state law to request the military connected status of all students. Additionally, Public Law No.874 allows the
district to receive additional funding for students of families who live or work on Federal land.
Federal Land:
L
ives On Federal Land Works on Federal Land
Does not apply
MILITARY FAMILIES:
N/A Retired /Not Affiliated Prefer not to state
Primary Guardian 1
Active Duty:
Reserves:
National Guard:
Primary Guardian 2
Active Duty:
Reserves:
National Guard:
STUDENT LIVES WITH:
Both parents
Father only
Mother only
Father/Stepmother
Mother/Stepfather
Legal Guardian
Stepfather/Stepmother
Self
Agency
Grandparents
Other:
PRIMARY GUARDIAN 1
(parent/legal guardian where student resides)
Last Name
First Name
MAILING ADDRESS (If different from above)
(Street/Apt. #, City, State, Zip)
PRIMARY GUARDIAN 1
PHONE
Home
unlisted
Cell
Work
Email Address
PRIMARY GUARDIAN 2 (parent/legal guardian where student resides)
Last Name:
First Name:
PRIMARY GUARDIAN 2
PHONE
Home
unlisted
Cell
Work
Email Address
Copy Received? Yes No
PRIMARY GUARDIAN 1 EMPLOYER (Company Name) Employer Phone
PRIMARY GUARDIAN 2 EMPLOYER (Company Name) Employer Phone
2
Last Name First Name
SECOND HOUSEHOLD
(non-custodial parent/guardian not residing with student)
Father Guardian
Father/Stepmother Self
Mother Agency
Mother/Stepfather Stepfather/Stepmother
Grandparents Other
RELATIONSHIP TO STUDENT
Home unlisted
Work
Cell
Email Address
SECOND HOUSEHOLD
PHONE
Last Name First Name
SECOND HOUSEHOLD (non-custodial parent not residing with student)
SECOND HOUSEHOLD ADDRESS (Street/Apt #, City, State, ZIP)
Additional Mailings Requested?
Yes No
IS THERE A CUSTODY OR PARENTING PLAN IN EFFECT? Yes No
If yes, please provide a copy for your child’s school file.
IS THERE A RESTRAINING ORDER IN EFFECT? Yes No
If yes, legal papers must be on file with the school for enforcement. Copy Received? Yes No
Restraining order is against: Mother Father Other
SCHOOL PREVIOUSLY ATTENDED: SCHOOL DISTRICT PREVIOUSLY ATTENDED:
PREVIOUS SCHOOL LOCATION: (Address, City, State)
Has Student Ever Attended Olympia School District Schools? Yes No If yes, School:
Has Your Child Ever Been Enrolled In A Preschool Program? Yes No
Has Student Ever Attended A Washington State School? Yes No Date(s) Attended (Month/Year)
DOES YOUR CHILD HAVE A LIFE THREATENING CONDITION? No Yes
If yes, additional information is required prior to your child attending school. Please complete and return the supplemental Life
Threatening Conditions packet. According to RCW 28A.210.320: Children with life-threatening health conditions – Medication or
treatment orders – Rules, the medication or treatment order must address the life-threatening condition and it must be on file with the
school prior to the child attending school. Under the law, “life-threatening condition” means a health condition that will put the child in
danger of death during the school day if a medication or treatment order is not in place. The law provides that a child may not attend
school in the absence of a medication or treatment order if the child has a life-threatening condition that might require medical services
to be provided at school.
Packet given to parent/legal guardian
Date packet given: Authorized office staff signed Parent/Legal Guardian signed
THIS SECTION IS FOR OFFICE USE ONLY
Has your child ever qualified for, or been enrolled in, a special education program? No Yes If yes, at what grade level(s)?
Has your child ever qualified for, or had, a 504 plan? No Yes If yes, at what grade level(s)?
Title 1
Has your child ever participated in:
LAP Gifted Other? No Yes If yes, at what grade level(s)?
Has your child ever been enrolled in an, English Learner (EL) Program? No Yes If yes, at what grade level(s)?
Primary language spoken at home:
Has your child ever been retained?
No Yes If yes, at what grade level(s)?
Has your child ever been promoted? No Yes If yes, at what grade level(s)?
Has your child ever had a BECCA petition filed on them? No Yes If yes, at what grade level(s)?
Has your child ever been suspended or expelled? No Yes If yes, at what grade level(s)?
Is your child currently living in: a shelter, car, motel, doubled-up with friends/relatives,
in temporary foster care or group home, or campground? No Yes If yes, at what grade level(s)?
DOES STUDENT ATTEND CHILDCARE? Before school After school Before and after school
Childcare Provider’s Name Address Phone Number
PLEASE LIST SIBLINGS
STUDENT’S MEDICAL HISTORY
(Check appropriate boxes and complete the health card for a more detailed description of the concerns.)
(Please provide information to school in writing.)
School
Grade
Age
Allergies: No Yes Doctor or Clinic Name:
Other Health Concerns: No Yes Doctor or Clinic Phone Numbe
r:
Yes No
EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to
contact parent/legal guardian immediately. If parent/legal guardian cannot be reached, I authorize school authorities to obtain
emergency care for my child.
Yes
No
STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/legal guardian, I authorize
that my child may be released to the person(s) listed as emergency contacts.
Legal Last Name First Name
RELATIONSHIP
TO CHILD
PHONE #1
Home
Work
Cell
PHONE #2
Home
Work
Cell
PRIMARY CONTACT ADDRESS Street City State ZIP
When injury, illness or emergency situations (earthquake, fire, etc.) 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/legal guardian, please list persons you trust
who are available during the day to provide care for your child (it would be helpful if one contact was from outside of the
area).
PRIMARY CONTACT (other than parent/legal guardian)
SECONDARY CONTACT (other than parent/legal guardian)
Legal Last Name First Name
RELATIONSHIP
TO CHILD
PHONE #1
Home
Work
Cell
PHONE #2
Home
Work
Cell
THIRD CONTACT (other than parent/legal guardian)
Legal Last Name First Name
RELATIONSHIP
TO CHILD
PHONE #1
Home
Work
Cell
PHONE #2
Home
Work
Cell
FOURTH CONTACT (other than parent/legal guardian)
Legal Last Name First Name
RELATIONSHIP
TO CHILD
PHONE #1
Home
Work
Cell
PHONE #2
Home
Work
Cell
FIFTH CONTACT (other than parent/legal guardian)
Legal Last Name First Name
RELATIONSHIP
TO CHILD
PHONE #1
Home
Work
Cell
PHONE #2
Home
Work
Cell
SIXTH CONTACT (other than parent/legal guardian)
Legal Last Name First Name
RELATIONSHIP
TO CHILD
PHONE #1
Home
Work
Cell
PHONE #2
Home
Work
Cell
3
Additional Childcare Arrangements? No Yes
Legal Last Name Legal First Name
ETHNICITY and RACE: School districts in Washington State are required to report student data by ethnicity and race categories
to the state’s Office of Superintendent of Public Instruction. Ethnicity and race categories used in our district are the same as used in
all Washington school districts. They are set by the federal government, the Washington State legislature, and the state
Superintendent of Public Instruction.
Please complete the following:
Question 1: Is your child of Hispanic or Latino origin?
4
No, my child is not Hispanic or Latino (continue to next question). (10)
Yes, my child is Hispanic or Latino (check all that apply and continue to next question).
Cuban (55) Puerto Rican (70) South American (80)
Dominican (60) Mexican/Mexican American/Chicano (30) Latin American (85)
Spaniard (65) Central American (75) Other Hispanic/Latino (90)
African American / Black (200)
White or Caucasian (300)
Asian Indian (505)
Alaska Native (405)
Samish (457)
Cambodian (507)
Chehalis (410)
Sauk-Suiattle (460)
Chinese (510)
Colville (413)
Shoalwater Bay (463)
Filipino (520)
Cowlitz (416)
Skokomish (466)
Hmong (525)
Hoh (418)
Snoqualmie (469)
Indonesian (530)
Jamestown (421)
Spokane (472)
Japanese (535)
Kalispel (424)
Squaxin Island (475)
Korean (540)
Lower Elwa Klallam (427)
Stillaguamish (478)
Laotian (545)
Lummi (430)
Suquamish (481)
Malaysian (550)
Makah (433)
Swinomish (484)
Pakistani (555)
Muckleshoot (436)
Tulalip (487)
Singaporean (560)
Nisqually (439)
Upper Skagit
Taiwanese (565)
Nooksack (442)
Yakima (490)
Thai (570)
Port Gamble Klallam (445)
Other Washington Indian Tribe (495)
Vietnamese (575)
Puyallup (448)
Other American Indian Tribe (499)
Other Asian (599)
Quileute (451)
Quinault (454)
Native Hawaiian (605)
Fijian (520)
Guamanian or Chamorro (620)
Mariana Islander (625)
Melanesian (630)
Micronesian (632)
Samoan (635)
Tongan (640)
Other Pacific Islander (699)
Question 2: What race(s) do you consider your child (check all that apply)?
Legal Parent/Guardian’s Signature: Date:
Printed Name:
VERIFICATION OF INFORMATION:
I attest that 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 Olympia School
District.
Revised 9.18.2018
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APPLICATION FOR STUDENT REGISTRATION FORM

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Completed 16 March 2021

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