Location: Tumwater FRESH
Summer 2020 Application
Tumwater Farm: 146 Linwood Ave SW
Tumwater, WA 98512
Please turn in this application to a Tumwater Fresh staff member.
Legal Name ____________________________ __________________ _____ Grade________ Gender _______ Birth Date _______/_______/_______
Last First MI
Student Email _______________________________________________________ Student Cell __________________________________________________
Student Lives With Father_____ Mother_____ Both_____ Guardian_____ On Own_____
Student’s Place of Birth (City, State, Country) ________________________
Parent/Guardian Full Name _________________________________________ Email __________________________________________________________
Street Address ____________________________________________________ City ____________________ Zip __________________________________
Mailing Address (if different than above) _______________________________ City ____________________ Zip __________________________________
Parent/Guardian (1) Home Phone ____________________________________ Work ___________________ Cell _________________________________
Parent/Guardian (2) Home Phone ____________________________________ Work ___________________ Cell _________________________________
Emergency Contact Person #1 _______________________________________ Relationship _____________ Phone _______________________________
Emergency Contact Person #2 ________________________________________ Relationship _______________ Phone ________________________________
Has the student previously attended New Market Skills Center? YES___ NO___
I authorize New Market to have access to all of my student’s school records. I understand that completing this application does not assure my student’s enrollment at New Market Skills Center.
Parent/Guardian Signature ____________________________________________________________________ Date ________________________________
Student Signature ____________________________________________________________________________ Date ________________________________
T
umwater School District does not discriminate in any programs or activities on the basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender expression, gender identity, disability, or the use of a
trained dog guide or service animal and provides equal access to the Boy Scouts and other designated youth groups. The following employee(s) has been designated to handle questions and complaints of alleged discrimination:
Civil Rights Coordinator: Assistant Superintendent Shawn Batstone, shawn.batstone@tumwater.k12.wa.us, (360)709-7030; Title IX Officer: Assistant Superintendent Shawn Batstone, shawn.batstone@tumwater.k12.wa.us
, (360)709-7034;Section 504
Coordinator: Director Kelli Ehresmann,kelli.ehresmann@tumwater.k12.wa.us, (360)709-7040 Tumwater School District, 621 Linwood Avenue SW, Tumwater, WA 98512 Telephone: (360) 709-7000
Date Received _____________________
Approved _________________________
Start _____________________________
School 53 _________________________
#FTE _____________________________
SSID ___________________
DOES YOUR STUDENT HAVE A LIFE-THREATENING OR OTHER MEDICAL CONDITION THAT REQUIRES MEDICATION AT SCHOOL OR A SCHOOL HEALTH PLAN? YES___ NO__
DOES YOUR STUDENT CARRY AN EPIPEN? YES___ NO___ DOES YOUR STUDENT CARRY AN INHALER? YES___ NO ___
If yes to any of the above, please describe_________________________________________________________________________________________________
Please note: The medication and treatment order must address the life threatening medical condition & must be on file with the school prior to the first day of attendance.
Reference RCW 28A.210.320
Required for Federal and State Reporting:
Student Ethnicity Not Hispanic____ Hispanic_____
American Indian_____ Asian_____ Black_____ Pacific Islander_____ White_____ 2 or more races _____
High School: _______________________
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