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3120P – Exhibit A
Bellevue School District 7/25/2019
Welcome to the Bellevue School District
ESTABLISHING AND VERIFYING RESIDENCY
State law requires that a student reside within the District boundaries and be able to prove
residency or have been approved for an Interdistrict transfer in order to enroll in school. In order to establish or
reestablish residency in the Bellevue School District you will need to complete the steps below.
STEP ONE: ESTABLISH RESIDENCY – If you live within the Bellevue School District, before your student
may be enrolled, you must establish residency within the attendance boundaries of your neighborhood school.
Residency is defined as the physical location where the student resides. For families with shared custody (i.e.
divorced, separated) this is generally defined as the location where students spend a minimum of four nights a
week. Parents/guardians must supply documentation as listed in one of the options below:
To verify residency, you must provide two of the items listed below; each bullet counts as one item.
All addresses on the documents must match the address of your residence
STEP TWO: RESIDENCY VERIFICATION – During the Enrollment Process, you will be required to carefully
read, agree to, and sign a Residency Verification Form.
Misrepresentation of residency information or failure to follow through with the statements on the
Residency Verification Form will result in your student's withdrawal from the District, and may result
in referral to the District Attorney’s office for further action.
STEP THREE: ENROLLMENT PROCESS -- Once you have established your student’s residency and
have agreed to the terms on the Residency Verification form, you may enroll your student at the local school.
Government Mail (e.g. car registration; Good to Go! bill; letter from Social Security, immigration,
unemployment, health finder exchange or DMV; USPS Change of Address form; election ballot.
Correspondence from the Bellevue School District does not qualify as Government Correspondence
)
Homeowner’s Insurance Policy Declaration
Property Tax bill (must have been received in the mail, not printed off a website)
Redacted 1099 or W-2 (Social Security Number and dollar amounts blacked out)
Unexpired Lease Agreement (must be signed by both parties with 2 months cancelled checks or proof of
online banking payment of lease)
Utility Bills (2 consecutive utility bills from the same utility company dated within the last 3 months –
accepted utilities include water, sewer, gas, electricity, or garbage; the mailing and service address must
be the residence address. Cable, internet and phone bills are not accepted.)
If you are part of the Washington State Address Confidentiality Program (ACP), you may establish
residency directly with the Supervisor of Student Placement who will verify and return your residency
documents. To maintain a confidential address in the student information system, an official letter from
ACP stating the attendance area school is required each year before the start of school.
If you are unable to provide any of the above items, please contact the District Student Placement office at
SPResidency@bsd405.org or at 425-456-4200 to create and sign a Residency Agreement. This Agreement
will give you extra time to collect the needed documents.
3120P – Exhibit B
Page 1 of 3
Bellevue School District 4/1/2020
(Please complete one form for each
student)
HOME OWNER RENTER
OTHER (Specify)
Washington law generally requires schools to be open to the admission of all persons between the
ages of 5 and 21 residing in that school district. (RCW 28A.225.160). The Bellevue School District
("District") is required to take appropriate steps to ensure that students attending our schools
satisfy applicable laws. This Residency Verification Form must be completed, signed and
submitted with appropriate documentation demonstrating compliance with Washington’s residency
laws.
Student:
Last Name First Name BSD Attendance Area School
Date of Birth mm/dd/yyyy
Grade
(Effective Year)
Parent/Guardian: ________________________________________________________________________ Phone 1:
Parent/Guardian Email:
Phone 2:
Address:
Number Street City Zip Code
Student:
Student:
Student:
NOTE: There is no provision for nonresident families who live in the region to claim residency for their student(s) in the
District by stating they live with a family member or friend who lives within the District boundaries. Nor is there a provision
for nonresident families to maintain a secondary residence within the District solely for the purpose of enrollment.
The District presumes that the person who enrolls a student in school is the residential parent/guardian of the
student and the address provided above is the family's primary residence. (Policy 3126, Procedure 3120P).
Please list below the names of additional students at this address who attend the Bellevue School District:
Student:
(Last Name) (First Name) School
Date of Birth (mm/dd/yyyy)
Grade
(Last Name) (First Name) School
Date of Birth (mm/dd/yyyy)
Grade
(Last Name) (First Name) School
Grade
(Last Name) (First Name)
School
Grade
Welcome to the Bellevue School District
RESIDENCY VERIFICATION FORM
Unit #
Cell Home Work
Cell Home Work
STUDENT #
For BSD use only
Date of Birth (mm/dd/yyyy)
Date of Birth (mm/dd/yyyy)
Last Name First Name
3120P – Exhibit B
______ My student (listed above) resides with me at the address listed above, which is my primary residence.
(Initial)
NOTE: For families with shared custody (i.e. divorced separated):
If your child does not reside with you at least four (4) nights per week at the above-listed
address, please initial here_______, and attach a written explanation of where and with
whom your child resides each day of the week.
_______I agree to notify the District/School within (5) days when I change my residence or that of my student to a
(Initial) new address, either within or outside the District.
_______Home visitation and/or other residency verification is part of a periodic process to confirm current residency
(Initial) status.
_______The District will investigate all cases where it has reason to believe that residency status has changed and/or
(Initial) false information has been provided, which may include the use of private investigators to verify residency
status. Verification may include home visits.
_______Investigations that reveal students have enrolled on the basis of providing false information will be cause for
(Initial) revocation of the student’s school assignment and disenrollment from the District.
I certify the foregoing information to be true and correct, and that any and all copies of documents submitted to
verify my residency are true and correct copies of the original documents, and that any and all documents submitted
have not been altered except for the redaction of dollar amounts and account numbers, which is permitted for the
purposes of this Residency Verification Form. Furthermore, I recognize that falsification or omission of information
could result in modification of the school or program placement for this student including withdrawal from school.
Signature of Parent/Guardian
I acknowledge and agree to the following: (initial each statement below):
Bellevue School District
RESIDENCY VERIFICATION FORM
Page 2 of 3
Bellevue School District 4/1/2020
DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ARE INCORRECT.
Evidence that false information was provided will be cause for immediate revocation of the student’s school
assignment and withdrawal from the District, and may lead to criminal and/or financial penalties.
Please sign and date
click to sign
signature
click to edit
STUDENT HOUSING QUESTIONNAIRE
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. The McKinney-Vento Act provides services and supports for children and youth experiencing
homelessness. All information will be kept confidential and will not be shared with anyone other than designated BSD staff.
DO YOU OWN/RENT YOUR OWN HOME/APARTMENT?
If yes, skip to Section
3
If no
, complete the remainder of this form.
If you do not own/rent your own home,
where are you and your family staying? Please check all that apply below:
In an emergency / transitional shelter
With an adult not a parent or legal guardian or alone without an adult
Temporary In someone else’s house or apartment with another family due to economic hardship or similar reason
Moving from place to place/couch surfing
In a motel / hotel
In a residence with inadequate facilities (no water, heat, electricity, etc.), abandoned building or substandard housing
A car, park, campsite, RV, tent or similar location
Student(s): Last
First
Date of Birth:
Grade:
Name of School:
Student is unaccompanied (not living with a parent or legal guardian)
The undersigned certifies that the information provided above is accurate.
Parent(s)/legal guardian(s):
(Or unaccompanied youth)
Address of current residence:
*Signature of parent/legal guardian:
(Or unaccompanied youth)
*
I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true
and correct and understand that it will be verified. I authorize the release of information to the Bellevue School District
by State and local emergency and/or transitional housing programs, and/or other business or government agencies.
Office Managers and/or Registrars: If parent marked any box in Section 1, please forward a copy of this form to:
BSD McKinney-Vento/Foster Care Liaison, ESC email: McKinneyFoster@bsd405.org, phone: 425-456-4241
Month/Day/Year
Student is living with a parent or legal guardian
2. STUDENT INFORMATION
3. PARENT/GUARDIAN OR UNACCOMPANIED YOUTH INFORMATION
Bellevue School District 4/1/20
1. CURRENT LIVING SITUATION:
Phone number or contact number:
(PDLODGGUHVV:
Page 3 of 3
Please list all students residing with you
Cell Home
Home Work
Last Name First Name
Please sign and date
Additional comments:___________________________________________________________________________
click to sign
signature
click to edit
Legal last name:
Legal first /middle initial name:
Gender:
Entering grade
level:
Birthdate: __________________
______________________ _______ __________________
*
This form is available in the following languages:
Chinese, Japanese, Korean, Russian, Spanish, and Vietnamese
Preferred last name:
Preferred first name:
Has your student gone by any other name?
yes no
If yes, what was the previous name?
_____________________________________
BSD ID#_________________
DATE RECEIVED
______________
Home Address:_____________________________________________Unit#________City_______________________Zip__________
Student cell phone number (if applicable):_____________________________________________
Mailing address: _____________________________Unit #______PO Box____________City______________________Zip__________
(If different from above)
School Experience Data: Has this student:
previously attended the Bellevue School District (BSD)?
been enrolled in any special education program (served with
an Individual Education Plan, IEP )?
had a 504 Plan?
had an IHP to address known medical issues?
been enrolled in ELL programs?
ever been suspended or expelled for disciplinary reason(s)?
had a history of violent or criminal behavior?
had any history of weapons possession?
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
If yes, school______________ Year _______
If yes, school______________ Year _______
If yes, school ______________ Year _______
If yes, school ______________ Year _______
If yes, school ______________ Year _______
If yes, school ______________ Year _______
If yes, school ______________ Year _______
If yes, school ______________ Year _______
Dates Grade
From School City State Zip To
Levels
Last school attended:__________________________________ Dates: from__________ to ___________ Grade level(s)___________
Street___________________________________________ City________________________ State_____________ Zip_________
Other schools attended (list most recent first)
yes no
other preschool
playgroup
childcare
with family, friends, neighbors
Previously enrolled in an early learning program?
If yes, check all that apply: BSD preschool
If yes, preschool attended:_______________________ # of years:_____
Is your student a foster child?
yes no
For this purpose, a foster child is a child whose care and placement is the responsibility of the State or local Welfare agency OR
who is placed by a court with a caretaker household.
STUDENT INFORMATION
STUDENT ENROLLMENT FORM
1 of 5
Bellevue School District 4/1/20
Please Print Clearly
Month Day Year Birth City State Country
If your student was NOT born in the United States, date first entered:_______________________
Has your student lived outside the United States during the last 12 months?
yes no If yes, which country?:_______________________
STUDENT ENROLLMENT FORM
Male
Female
X
Address____________________________________________Unit #________City__________________________ State_________Zip__________
N - No military affiliation
R- U.S. Armed Forces Reserves
A - Active duty U.S. Armed Forces
G - Active duty Washington National Guard
Military Affiliation check one box:
Last name_________________________________________First name ______________________________________ ____________________
SECONDARY HOUSEHOLD
For families with shared custody (i.e. divorced, separated)
#1 phone _______________________#2 phone ____________________________ email ___________________________________________
Relationship
to Student
Do you need an interpreter (for school meetings)? yes no
Do you need official school materials to be translated? yes no
If yes, in what language?____________________________
cell home work
cell home work
Secondary Household Parent/guardian #2:
N - No military affiliation
R- U.S. Armed Forces Reserves
A - Active duty U.S. Armed Forces
G - Active duty Washington National Guard
Military Affiliation check one box:
Last name_________________________________________First name ______________________________________ ____________________
#1 phone _______________________#2 phone __________________________ email ___________________________________________
R
elationship
to Student
Do you need an interpreter (for school meetings)? yes
n
o
Do you need official school materials to be translated? yes no
If yes, in what language?____________________________
cell home work
cell home work
Secondary Household Parent/guardian #1:
N - No military affiliation
R- U.S. Armed Forces Reserves
A - Active duty U.S. Armed Forces
G - Active duty Washington National Guard
Military Affiliation check one box:
Last name_________________________________________First name ______________________________________ ____________________
#1 phone _______________________#2 phone ___________________________ email ___________________________________________
R
elationship
to Student
Do you need an interpreter (for school meetings)? yes
n
o
Do you need official school materials to be translated? yes no
If yes, in what language?____________________________
cell home work
cell home work
Parent/guardian #2 :
N - No military affiliation
R- U.S. Armed Forces Reserves
A - Active duty U.S. Armed Forces
G - Active duty Washington National Guard
Military Affiliation check one box:
Last name_________________________________________First name ______________________________________ ____________________
#1 phone _______________________#2 phone ___________________________ email ___________________________________________
R
elationship
to Student
Do you need an interpreter (for school meetings)? yes
n
o
Do you need official school materials to be translated? yes no
If yes, in what language?____________________________
cell home work
cell home work
Legal Parent/guardian #1 :
STUDENT ENROLLMENT FORM
Student Name
STUDENT ENROLLMENT FORM
2 of 5
Bellevue School District 4/1/20
Second Household Address:
THE CONTACT INFORMATION PROVIDED WILL BE USED IN CASE OF EMERGENCY
EMERGENCY CONTACTS (OTHER THAN PARENT/GUARDIAN)
In the case of an emergency if you cannot be reached, please prioritize below the persons who are authorized to pick up your student:
#1 Full Name___________________________________________ Phone ________________________ __________________
cell home work Relationship
#2 Full Name___________________________________________ Phone ________________________ __________________
cell home work Relationship
#3 Full Name___________________________________________ Phone ________________________ __________________
cell home work Relationship
PRIMARY HOUSEHOLD
(Where the student resides)
PARENT/GUARDIAN INFORMATION
Student Name
STUDENT ENROLLMENT FORM
Please complete Part I and Part II
WASHINGTON STATE RACE AND ETHNICITY CATEGORIES:
Hispanic or Latino
Write in:
STUDENT ENROLLMENT FORM 3 of 5
Bellevue School District 4/1/20
Part I: HISPANIC OR LATINO:
Is your student of Hispanic or Latino origin?
yes no
(If "yes" please check all that apply)
Colombian Dominican
Guyanese Mestizo
Peruvian
Costa Rican Ecuadorian
Honduran
Nicaraguan
Native
Chicano (Mexican American)
Jamaican
Panamanian
Puerto Rican
Spaniard
Surinamese
Uruguayan
Venezuelan
Argentine
Bolivian
Brazilian
Cuban
Guatemalan Mexican
Paraguayan
Salvadoran
Please note: these race and ethnicity categories are provided by the State of Washington, and the Bellevue School District is
mandated to collect this information for every student under applicable State and Federal laws. If you do not self-identify, you will be
contacted by the school who needs to collect this information for every student under applicable State and Federal laws.
NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER:
Carolinian
Chamorro
Chuukese
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Pacific Islander
:ULWHLQ____________________________
ASIAN:
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Malaysian
Mien
Mongolian
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Asian :ULWHLQ___________________________
NATIVE AMERICAN INDIAN or ALASKAN NATIVE:
Chinook Tribe
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Confederated Tribes of the Chehalis Reservation
Confederated Tribes of the Colville Reservation
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Duwamish Tribe
Hoh Indian Tribe
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Kikiallus Indian Nation
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Marietta Band of the Nooksack Tribe
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Alaska Native :ULWHLQ__________BBBBBBBBBBBBBBB
Port Gamble S'Klallam Tribe
Puyallup Tribe of the Puyallup Reservation
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Snohomish Tribe
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Snoqualmoo Tribe
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Steilacoom Tribe
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Part II: What race(s) do you consider your student? You may check categories and use write-in
(check all that apply)
Chilean
Asian
Native Hawaiian/Other Pacific Islander
Washington State Tribes:
Native American Indian/Alaskan Native
Native American Indian :ULWHLQBBBBBBBBBBBBBBBBBBBBBBBBBB
If you select any of these please also complete this form:
Support for: Native American Students (Title VI Program) form
Student Name
STUDENT ENROLLMENT FORM
WASHINGTON STATE RACE AND ETHNICITY CATEGORIES:
WHITE:
Eastern European:
Bosnian
Herzegovinian
Polish
Romanian
Russian
Ukrainian
Eastern European :ULWHLQ
______________________
By law, a student (or the parent/guardian on behalf of the student) is not required to identify their race and/or ethnicity on school
forms. However, if a student (or parent/guardian on behalf of the student) does not complete the two-part question on race and
ethnicity, by law, school personnel must use ‘observer identification’ to select the race and ethnicity of the student.
Middle Eastern and North African:
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Assyrian
Bahraini
Bedouin
Chaldean
Qatari
Saudi Arabian
Syrian
Tunisian
Yemeni
0LGGOH(DVWHUQ:ULWHLQ
_____________________
1RUWK$IULFDQ:ULWHLQ
_____________________
Copt
Druze
Egyptian
Emirati
Iranian
Iraqi
Israeli
Jordanian
Kurdish Kuwaiti
Lebanese
Libyan
Moroccan
Omani
Palestinian
BLACK or AFRICAN AMERICAN:
African American
African Canadian
Central African:
Angolan
Cameroonian
Central African
(Central African Republic)
Chadian
Congolese
(Republic of the
Congo)
Congolese
(Democratic
Republic of the Congo)
Equatorial Guinean
Gabononese
São Toméan
Principe
Central African Write in:
____________________
East African Write in:
________________
East African:
Burundian
Comoran
Djiboutian
Eritrean
Ethiopian
Kenyan
Malagasy
(Madagascar)
Malawian
Mauritian
(Mauritius)
Mahoran
(Mayotte)
Mozambican
Reunionese
Rwandan
Seychellois/Seychelloise
Somali
South Sudanese
Sudanese
Ugandan
Tanzanian
(United
Republic of Tanzania)
Zambian
Zimbabwean
Argentine
Belizean
Bolivian
Brazilian
Chilean
Colombian
Costa Rican
Ecuadorian
El Salvadoran
Falkland Islander
French Guianese
Guatemalan
Guyanese
Honduran
Mexican
Nicaraguan
Panamanian
Paraguayan
Peruvian
South Georgia and the
South Sandwich Islands
Surinamese
Uruguayan
Venezuelan
South African:
Botswanan
Mosotho (Lesotho)
West African Write in:
________________
West African:
Beninese
Bissau-Guinean
Burkinabé
(Burkina Faso)
Cabo Verdean
Ivorian
(Cote d'Ivoire)
Gambian
Ghanaian
Liberian
Malian
Mauritanian
Nigerien
(Niger)
Nigerian
(Nigeria)
Saint Helenian
Senegalese
Sierra Leonean
Togolese
Black Write in: ________________________________
Black/ African American
Anguillan
Antiguan
Bahamian
Barbadian
Barthélemois/Barthélemoises
(Saint Barthélemy)
British Virgin Islander
Caymanian
(Cayman Island)
Cuba Dominican
Dominican
(Dominican Republic)
Dutch Antillean
(Netherlands Antilles)
Grenadian
Guadeloupian
Haitian
Jamaican
Martiniquais/Martiniquaise
Montserra tian
Puerto Rican
Caribbean Write in:
______________________
Namibian
South African
Swazi
South African Write in:
____________________
Latin American:
Latin American Write in:
___________________
Caribbean:
White
White Write in: ____________________________
STUDENT ENROLLMENT FORM
4 of 5
Bellevue School District 4/1/20
Part II (continued): What race(s) do you consider your student? You may check categories and use write-in
(check all that apply)
Last name (if different)
First name
Birth date
BSD Student ID#
(for office use only)
Living at Home
yes
no
yes
no
yes
no
Siblings in BSD:
STUDENT ENROLLMENT FORM
Student Name
ADDITIONAL INFORMATION
Schools are permitted to disclose information on students if it has been properly designated as directory information. By law,
GLUHFWRU\LQIRUPDWLRQ includes things that would generally not be considered harmful or an invasion of privacy if disclosed, such as
QDPHDGGUHVVSKRWRJUDSKDQGGDWHRIELUWK. Directory information may not include things such as a student’s social security
number or grades. If a school has a policy of disclosing directory information, it is required to give public notice to parents of the
types of information designated as directory information, and of the right to opt out of having your student’s information so designated
and disclosed. Also, secondary school students’ names, addresses, and telephone numbers may be released to military recruiters
or institutions of higher education. Parents and adult students have the right to deny release of directory information.
1RWLFH Only students who physically reside within the boundaries of the Bellevue School District and nonresident students who have
obtained a release from their resident districts and have been officially accepted by the Bellevue School District may legally
attend school within the Bellevue School District. Recognizing this legal requirement, I hereby verify that the student named
above physically resides within the Bellevue School District boundaries or has obtained a release from his/her resident district
and has been officially accepted by the Bellevue School District.
I certify the foregoing information to be true and recognize that falsification or omission of information could
result in modification of the school or program placement for this student, including withdrawal from school.
We are required by law to release your student’s directory information,
including address and phone number unless you tell us not to.
Release information to military recruiters?
To institutions of higher learning?
yes
no
yes
no
yes
no
Allow student photo or school work in BSD publications/news media/District/teacher/affiliate websites
yes
no
Allow student name and other directory information in the student directory, approved mailing lists,
school newspapers, commencement programs, honor rolls, and other similar purposes.
yes
no
Notice: The District will accommodate the religious beliefs of all students in all aspects of its program.
Please share special instructions for your student with the principal.
Allow student name and photo in school yearbook (if the school has one)
RELEASE OF INFORMATION ABOUT YOUR STUDENT
_____________________________________________________________________________
Parent/Guardian name (please print)
____________________________________________________________________________
Parent/Guardian signature
Bellevue School District 4/1/20
STUDENT ENROLLMENT FORM 5 of 5
Please sign and date
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signature
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English/November 2016
Office of Superintendent of Public Instruction (OSPI)
Home Language Survey
The Home Language Survey is given to all students enrolling in Washington schools.
Student Name:
Grade:
Date:
Parent/Guardian Name Parent/Guardian Signature
Right to Translation and
Interpretation Services
Indicate your language preference so
we can provide an interpreter or
translated documents, free of
charge, when you need them.
All parents have the right to information about their child’s
education in a language they understand.
1. In what language(s) would your family prefer to communicate
with the school?
__________________________________
Eligibility for Language
Development Support
Information about the student’s
language helps us identify students
who qualify for support to develop
the language skills necessary for
success in school. Testing may be
necessary to determine if language
supports are needed.
2. What language did your child learn first?
__________________________________
3. What language does your child use the most at home?
__________________________________
4. What is the primary language used in the home, regardless of
the language spoken by your child?
__________________________________
5. Has your child received English language development support
in a previous school? Yes___ No___ Don’t Know___
Prior Education
Your responses about your child’s
birth country and previous
education:
Give us information about the
knowledge and skills your child is
bringing to school.
May enable the school district to
receive additional federal funding
to provide support to your child.
This form is not used to identify
students’ immigration status.
6. In what country was your child born? ___________________
7. Has your child ever received formal education outside of the
United States? (Kindergarten – 12
th
grade) ____Yes ____No
If yes: Number of months: ______________
Language of instruction: ______________
8. When did your child first attend a school in the United States?
(Kindergarten – 12
th
grade)
_______________________
Month Day Year
Thank you for providing the information needed on the Home Language Survey. Contact your school
district if you have further questions about this form or about services available at your child’s school.
Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that
includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to
questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly
understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.
Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative
Commons Attribution 4.0 International License.
SCHOOL NURSE
HEALTH INFORMATION
2020-21
To make school a safe and healthy place for your
child this private form will be seen by the School
Nurse, school staff who help your child, and
emergency medical personnel.
Name:
____________________
_______________ Birthdate:
_______________
Last First MI
School:
__________________________________ Grade for 2020-21:
_______ Date:
_______________
SERIOUS HEALTH CONDITIONS (check box below):
If your child has a SERIOUS health condition, TELL YOUR SCHOOL NURSE NOW. State Law (RCW 28A.210.320) says
medication, medical orders, and a health care plan must be in place before the start of school.
☐ My child does not have any SERIOUS health conditions that will affect them at school.
☐ My child has the following SERIOUS health condition(s) – Check boxes below:
☐ Allergy (life threatening: requires an epinephrine prescription such as Epi Pen or Auvi-Q? ________ Yes or no?
☐ Allergic to: ________________________ Date of last reaction: _________________
☐ Asthma – Will your child require a rescue inhaler (such as Albuterol) at school? Yes or no?
☐ Heart condition and restrictions (if any): _______________________________________________
☐ Diabetes (Date of diagnosis:
_______________)
☐ Insulin Pump ☐ Insulin Pen ☐ Insulin via syringe
☐ Seizure Disorder (Date of diagnosis:
_________________)
Type:
_______________) (Date of last seizure:
Rescue Medication: _________ Yes or no?
☐ Other, including overnight hospitalizations in past 12 months: -- Please describe condition:
_______________________________________________________________________________________
OTHER HEALTH CONDITIONS (check appropriate box below):
☐ My child does not have any other health conditions that will affect them at school.
☐ History of a Concussion (diagnosed by a health care provider) - Date of concussion _______
☐ Hearing concerns? ☐ Does your child wear hearing aids? ☐ Does your child have a known hearing loss?
☐ Vision concerns? ☐ Glasses ☐ Contacts
☐ Food sensitivity: ☐ Other Allergies (e.g. medication, pollen): __________________
☐ Other: _______________________________________________________________________________
MEDICATIONS: Prescription, supplements, over-the-counter (pills, eye drops, ointments, etc.):
Does your child need to take medication every day at school? Yes ☐ No ☐
Does your child need to take medication at school sometimes? Yes ☐ No ☐
If Yes, a signed medical order form must be at school, for all medications (RCW 28A.210.206 and BSD Policy 4320).
CONTACT INFORMATION: Please provide correct & current contact numbers.
PARENT/GUARDIAN PARENT/GUARDIAN
Parents/Guardians:
Primary contact phone:
Email:
Signature (Parent/Guardian):____________________________________________________
Please sign and date
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Enrollment-packet-2020-2021-english Enrollment Packet 2020-2021 - English

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Completed 3 July 2020

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