Fillable Enrollment Checklist Student Name School The following checklist

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Updated January 2021
Enrollment Checklist
The following checklist is provided to assist you in gathering and completing all information that is needed to
successfully enroll your child(ren). Please return all documents to the Enrollment Center or email:
enrollmentcenter@isd191.org.
Student Name School
Item and Description
Required
Office Use
ONE91 Registration Forms:
1. Checklist (1 per student)
2. Family Information form (1 per family)
3. Student Information form (1 per student)
4. Ethnic and Racial Demographic Designation Form (1 per student)
5. Minnesota Language Survey (1 per student)
6. Consent to Release Educational Information (1 per student)
7. High School Student Transportation Registration Form (1 per student – high school students only)
8. Digital Equity Survey
X
Proof of Legal Name and Birth Date – e.g. birth certificate, passport, I-94 or hospital birth record
X
Proof of Residency – e.g. home purchase agreement, rent/lease agreement or utility bill
X
Pupil Immunization Record - State or Health Care Provider form
X
Additional Forms and Descriptions
Application for Educational Benefits: If your family qualifies, your student(s) can receive free or reduced-price
meals as well as potential discounts for participation in athletics, band, and other activities. By completing an
application, you are helping to ensure every school in District 191 gets the much-needed state and federal funding
it deserves. Apply on the www.isd191.org website by clicking on the “Apply for Educational Benefits” button.
Early Childhood Screening: Required for Kindergarten entry. Can be done anytime between ages 3-5.
Schedule an appointment at www.communityed191.org or call 952-707-4117.
Student Child Care Information: Used to arrange transportation to and from in district day care. Form available at
the Enrollment Center or on the Transportation webpage at: www.isd191.org
School District Enrollment Options Program State Form: Used to request enrollment into a District
ONE91 school when living
outside of District ONE91's boundary area. Form available at the Enrollment
Center or on the Enrollment webpage at: www.isd191.org/enroll
Variance Request Form: Used to request enrollment into a District ONE91 school other than the
school serving
your residential area. Form available at the Enrollment Center or on the Enrollment webpage at:
www.isd191.org/enroll
District Communication Log (for office use only)
Student ID:
Start:
School:
Grade:
Last Loc:
OE: Y / N
Var: Y / N
Intake:
Data Entry:
-1-
Updated January 2021
REGISTRATION FORM-FAMILY INFORMATION
Street Address
Apt./Lot# City State
Zip Code
Primary Household – Legal Guardian(s) that Student lives with:
1.
Last Name First Name Cell Phone Work Phone
Legal Guardian No Yes
Email Address Relationship to Student
Interpreter Needed? No Yes Translated Communications Needed? No Yes If yes, what language?
2.
Last Name First Name Cell Phone Work Phone
Legal Guardian No Yes
Email Address Relationship to Student
Interpreter Needed? No Yes Translated Communications Needed? No Yes If yes, what language?
Secondary Household – Legal Guardian that Student DOES NOT live with:
Last Name First Name Cell Phone Work Phone
Email Address Relationship to Student
Street Address
Apt./Lot# City State
Zip Code
Interpreter Needed? No Yes Translated Communications Needed? No Yes If yes, what language?
List ALL CHILDREN (birth to grade 12) in primary household including those children attending elsewhere. Use legal name as listed on birth record.
Last Name
First Name
Birth Date
Mo / Day / Yr
Gender
Grade
School Attending
M F
M F
M F
M F
M F
M F
Emergency Contact Information: List a minimum of TWO emergency contacts who will assume temporary care of your child if you cannot be reached.
Name
Relationship to Student
Cell Phone
Work Phone
Please answer the following questions regarding the family.
Have you moved to this school district for temporary or seasonal agricultural work (migrant)?
No Yes
Are you currently residing in temporary housing (shelter, with relatives/friends, hotel)?
No Yes
Currently, does the student(s) have a parent, guardian, sibling or relative in the military?
No Yes
If a family member is currently on active duty in the military, is this person currently deployed?
No Yes
-2-
Updated January 2021
REGISTRATION FORM-STUDENT INFORMATION
Student Legal Name as listed on birth record.
Student Last Name Student First Name Middle Name Student ID (Office use)
Gender: Male Female
Date of Birth Grade Level
Please answer the following questions regarding the student.
Has the student moved to the United States from another country?
No Yes
Country:
If yes, date the student first entered the United States
Month / Day / Year
If yes, date the student first attended school in the United States
Month / Day / Year
Educational History
If entering Kindergarten, has your child received an early childhood
screening?
No Yes
If yes, where?
Has your child ever attended District ONE91 Schools?
No Yes
If yes, where?
Has your child attended another Minnesota Public School?
No Yes
If yes, where?
Does this student participate in special services or programs?
No Yes
Does this student have a
current 504 plan?
No Yes
Does the student have a current IEP?
No Yes
Health Information
Asthma
No Yes
Other Medical Conditions (e.g. ADD/ADHD, surgeries, emotional concerns, GI issues, etc.)
Diabetes
No Yes
Allergies (e.g. bee stings, food, latex, pollen, etc.)
Seizures
No Yes
List ALL Medications
Hearing
Concerns
No Yes
Special Diet Restrictions (e.g. gluten, dairy, fruit, etc.)
Vision Concerns
No Yes
ALL medications and treatments both prescribed and over the counter require a parent signature and a signed authorization form which
can be found on the “Health Services” web page at www.ISD191.org
Physician/Clinic Name (optional)
Phone #
Minnesota Statutes and rules require the school district to keep accurate and updated records for all students. All data on this form is confidential and will only be shared
with authorized district personnel. The information will become a part of the student’s permanent cumulative record. Certain information, known as “directory
information”, is available to the public unless the district receives a written request from a legal guardian indicating otherwise.
I understand that I may refuse to provide the requested information and acknowledge that by doing so, school personnel may be unable to contact me in the event of an
emergency and as a result will contact 911. I verify that all information provided is accurate to the best of my knowledge.
Parent/Guardian Signature Date
-3-
[If no, go to Question 2.]
[If no, go to Question 1.]
Reset form
Ethnic and Racial Demographic Designation Form
Student’s First Name: Middle Name/Initial: _____ Last Name:
Date of Birth: _______________ District: ___________________________ School:
Schools are required to report ethnicity and race to the state and to the U.S. Department of Education. Because of recent changes to
Minnesota state law, Minnesota disaggregates each category into detailed groups to further represent our student populations.
Parents or guardians are not required to answer the federal questions (in bold) for their children. If you choose not to answer the
federal questions (in bold), federal law requires schools to choose for you. This is a last resort—we prefer if parents or guardians
complete the form. State questions are labeled as “Optional” and schools will not fill in this information for you.
This information helps improve teaching and learning for everyone and helps us accurately identify and advocate for students
currently underserved. The information this form collects is considered private information. You can review the privacy notice to
learn more about the purpose of collecting this information, how it will be used and not used, and how the detailed groups were
identified. The privacy notice can be found in our Frequently Asked Questions: Ethnic and Racial Designation Form.
Is the student Hispanic/Latino as defined by the federal government? The federal definition includes persons of Cuban,
Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
1
[You must select “yes” or “no” to this question.]
o Yes [If yes, go to Question A.] o No
Optional Question A: If yes was
chosen above, select all that apply from the list below (this question will not be
answered by school staff):
□ Decline to indicate □ Guatemalan □ Salvadoran □ Other Hispanic/Latino
□ Colombian □ Mexican □ Spaniard/Spanish/ □ Unknown
□ Ecuadorian □ Puerto Rican Spanish-American
Go to Ques
tion 1.
[Select “yes” to at least one of the Questions (1-6) below.]
Question 1: Does the student identify as American Indian or Alaska Native as defined by the state of Minnesota? The
state of Minnesota definition includes persons having origins in any of the original peoples of North America who
maintain cultural identification through tribal affiliation or community recognition. [This question is needed to calculate
state aid/funding.]
o Yes [If yes, go to Question 1a.] o No
Optional Question 1a: If yes was chosen above, select all that apply from the list below (this question will not be
answered by school staff):
□ Decline to indicate □ Cherokee □ Other North American Indian Tribal Affiliation
□ Anishinaabe/Ojibwe □ Dakota/Lakota □ Unknown
Go to Question 2.
1
Federal Register, Vol. 72, No. 202/Friday, October 19, 2007/Notices/59274
Question 2. Is the student American Indian from South or Central America?
o Yes [Go to Question 3.]
o No [Go to Question 3. ]
Question 3. Is the student Asian as defined by the federal government? The federal definition includes persons having
origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
1
o Yes
[If yes, go to Question 3a.] o No [If no, go to Question 4.]
Optional Question 3a. If yes was chosen above, select all that apply from the list below (this question will not be
answered by school staff):
□ Decline to indicate □ Chinese □ Karen □ Other Asian
□ Asian Indian □ Filipino □ Korean □ Unknown
□ Burmese □ Hmong □ Vietnamese
Go to Question 4.
Question 4. Is the student black or African American as defined by the federal government? The federal definition
includes persons having origins in any of the black racial groups of Africa.
1
o Yes [If yes, go to Question 4a.] o No [If no, go to Question 5.]
Optional Question 4a. If yes was chosen above, select all that apply from the list below (this question will not be
answered by school staff):
□ Decline to indicate □ Ethiopian-Other □ Somali
□ African-American □ Liberian □ Other black
□ Ethiopian-Oromo □ Nigerian □ Unknown
Go to Question 5.
Question 5. Is the student Native Hawaiian or Other Pacific Islander as defined by the federal government? The
federal definition includes persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
1
o Yes
[Go to Question 6.] o No [Go to Question 6.]
Question 6. Is the student white as defined by the federal government? The federal definition includes persons having
origins in any of the original peoples of Europe, the Middle East, or North Africa.
1
o Yes o No
Parent(s)/Guardian Name Date __________________
Parent(s)/Guardian Signature
Print/Save
Updated January 2021
Minnesota Language Survey
Minnesota is home to speakers of more than 100 different languages. The ability to speak and understand multiple languages is valued. The
information you provide will be used by the school district to see if your student is multilingual. In Minnesota, students who are multilingual may qualify
for a Multilingual Seal upon further assessment. Additionally, the information you provide will determine if your student should take an English
proficiency test. Based upon the results of the test, your student may be entitled to English language development instruction. Access to instruction
is required by federal and state law. As a parent or guardian, you have the right to decline English Learner instruction at any time. Every
enrolling student must be provided with the Minnesota Language Survey during enrollment. Information requested on this form is important to us to be
able to serve your student. Your assistance in completing the Minnesota Language Survey is greatly appreciated.
Student Information
Student’s Full Name:
(Last, First, Middle)
Birthdate or Student ID:
Check the phrase that best describes your
student:
Indicate the language(s) other than
English in space provided:
1. My student first learned:
language(s) other than English
English and language(s) other than English
only English
2. My student speaks:
language(s) other than English
English and language(s) other than English
only English
3. My student understands:
language(s) other than English
English and language(s) other than English
only English
4. My student has consistent
interaction in:
language(s) other than English
English and language(s) other than English
only English
Language alone does not identify your student as an English learner. If a language other than English is indicated, your student will be
screened for English language proficiency.
Parent / Guardian Information
Parent / Guardian Name (Printed):
Parent / Guardian Signature:
Date:
* All data on this form is private. It will only be shared with district staff who need the information to best serve your student and for legally required
reporting about home language and service eligibility to the Minnesota Department of Education. At the district and at the Minnesota Department
of Education, this information will not be shared with other individuals or entities, except if they are authorized by state or federal law to access
the information. Compliance with this request for information is voluntary.
-6-
Updated January 2021
STUDENT TRANSPORTATION SERVICES
200 W. Burnsville Pkwy., Burnsville MN 55337 Tel. 952-
707-2067 or 952-707-2069
Fax: 952-707-2097
Email: transportation@isd191.org
SENIOR HIGH SCHOOL
STUDENT TRANSPORTATION
REGISTRATION FORM
SCHOOL YEAR
Students entering grades 9 through 12 MUST register their busing needs.
The Student Transportation Services department contracts for the number of buses and drivers required to transport only those
students who will require to-and-from school bus service. Obtaining an accurate count of students who will actually ride school
buses is very important to the
design of efficient, low cost routes.
Students and families eligible for transportation who decline bus service at this time may re-establish the service at any time during
the school year by contacting the Student Transportation Services office. If you believe your student would have only an occasional
need to ride the bus, you may call the office at any time during the school year to learn the location and time of the nearest bus
stop with seats available.
Will bus transportation to and from school be required for your senior high student?
YES NO
Student will be attending:
Burnsville Senior High School
600 E. Highway 13
Burnsville, MN 55337
Burnsville Alternative High School
2140 Diffley Rd.
Eagan, MN 55122
Student Name (last, first, middle):
Student ID# Grade:
Address:
City: State: Zip:
Parent Signature: Date:
-7-
Updated January 2021
CONSENT TO RELEASE EDUCATIONAL DATA
STUDENT INFORMATION
Student Last Name Student First Name Middle Name
Gender: Male Female
Date of Birth Grade Level
PREVIOUS SCHOOL INFORMATION
Previous School / Organization Name City, State
Phone Fax Email
I authorize Independent School District 191 to obtain official school records, please include COPIES OF ALL of the following, if applicable:
Transcript and/or report cards, exit grades (if applicable), birth document, early childhood screening, if applicable.
• Academic Assessments: MAP, DIBELS, MCA, MTAS, ACCESS test scores.
• Attendance Data: days absent and truancy records.
• Medical & Health Records: vaccination history and other health records, if applicable.
• Special Education Records including; current IEP, assessment reports, evaluation reports.
• Disciplinary Records: in accordance with MN State Statute120A.22 Subd. 7(c).
PLEASE RELEASE RECORDS TO THE DESIGNATED ISD 191 SCHOOL:
School Name:
Email
Phone
Fax
ONE91 Virtual Academy
enrollmentcenter@isd191.org
952.707.4180
952.707.4181
Edward Neill Elementary
edwardneill@isd191.org
952.707.3100
952.707.3102
Gideon Pond Elementary
gideonpond@isd191.org
952.707.3000
952.707.3002
Harriet Bishop Elementary
harrietbishop@isd191.org
952.707.3900
952.707.3902
Hidden Valley Elementary
hiddenvalley@isd191.org
952.707.3800
952.707.3802
Rahn Elementary
rahn@isd191.org
952.707.3600
952.707.3602
Sky Oaks Elementary
skyoaks@isd191.org
952.707.3700
952.707.3702
Vista View Elementary
vistaview@isd191.org
952.707.3400
952.707.3402
William Byrne Elementary
williambyrne@isd191.org
952.707.3500
952.707.3502
Eagle Ridge Middle School
eagleridge@isd191.org
952.707.2808
952.707.2802
Nicollet Middle School
nicollet@isd191.org
952.707.2608
952.707.2602
Burnsville High School
bhsrecords@isd191.org
952.707.2108
email only
Burnsville Alternative High School
bahs@isd191.org
952.707.4020
952.707.4024
District Enrollment Center
enrollmentcenter@isd191.org
952.707.4180
952.707.4181
Parent/Guardian Signature Date
Designated School District Staff (if parent signature not obtained) Date
In accordance with MN State Statute 120A.22 Subd. 7(a), written permission of the parent/guardian is not necessary in the transfer of records to a school in which the
student intends to enroll.
-8-
2nd
Request:
Office Use:
1
st
Request:
2
nd
Request:
Student Digital Equity Survey | 1
Student Digital Equity Survey
Instructions
Please fill in the following information based on how you use electronic devices to complete schoolwork
at your home. This survey uses the primary address you provide as your “home.” You should answer the
questions below based only on the conditions at this address. There is an opportunity at the end of the
survey to say more about additional places you live and do homework.
Student Information
First name:
Last name:
Grade:
Student Primary Address:
Internet Access
1. Can the student access the Internet on their electronic device at home?
No – Internet is not available at home (skip to end of survey)
No – Internet is not affordable at home (skip to end of survey)
No – Other (skip to end of survey)
Yes (continue to 1a)
a. If yes, what kind of Internet service do you have at home?
Residential broadband (e.g. Cable, Fiber, DSL)
Cellular network
School-provided hotspot
Satellite
Dial-up
Other
I am not sure.
b. Can the student stream a video on their electronic device without pauses?
Yes – with no pauses or buffering
Yes – with some pauses or buffering
No – streaming doesn’t work
Student Digital Equity Survey | 2
Digital Device Access
2. Does the student use an electronic device like a computer, tablet or smart phone to complete
homework?
No
Yes (continue to 2a)
a. If yes, what type of electronic device does the student usually use to complete homework?
(select ONLY one)
Desktop or Laptop
Tablet
Chromebook
Smart phone
Other
b. Is the electronic device (from 2a) provided by the school?
Yes
No
c. Is the electronic device shared with anyone else in the home?
Yes
No
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Completed 23 February 2022

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