Student Enrollment Fact Sheet

Student Enrollment Fact Sheet All children in the United States are entitled to a basic public elementary and secondary education regardless of their race, color, national origin, citizenship, immigration status, or the immigration status of their parents/guardians. The items listed below will be requested at time of enrollment: Proof of Residency within District Boundaries The District will accept a gas bill, water bill, electric bill, mortgage or a lease agreement in the parent or guardians name as proof of residency within district boundaries. Students are deemed to be homeless, when they do not have an address with which to meet school residency requirements. Birth Certificate A birth certificate is used only for verifying the student s legal name, date of birth, and the parent s name. A foreign birth certificate is an acceptable document for verifying the student s information. Ethnicity Form Parents should complete form. If ethnicity form is not completed, school personnel will be left to determine student s ethnicity and race. Immunizations The law requires that students be fully vaccinated against the specified diseases, which may be found on the Dallas Independent School District website at www.dallasisd.org. Students enrolling in the District for the first time must provide evidence of required immunizations. All immunizations should be completed by the first date of attendance. Please contact Student Health Services for information or assistance with immunization requirements. Social Security Number (optional) Providing a social security card or number is optional. The Dallas Independent School District will not refuse enrollment of any student opting not to provide a social security card/number. In lieu, a state identification number will be provided for educational purposes only. The Dallas Independent School District complies with Titles IV and VI of the Civil Rights Act of 1964, which prohibit discrimination on the basis of race, color or national origin by public elementary and secondary schools. SC 0300940

SC-03-01355 11 WHITE CRC CANARY Nurse WHITE TAG Office *To be completed by Campus Date of Enrollment Last Grade Completed Year Into Grade 9 STUDENT ENROLLMENT/ REGISTRATION FORM The completion of the information on the Student Enrollment Registration Form does not determine the parental relationship nor does it affect legal right of access to the student or the student s records. (Form should be completed by parent/ guardian.) SCHOOL TEA Code Student ID State ID Advisory Assignment Advisory Name Advisory Room Student s Legal Name (Last, First, Middle) Student s Date of Birth (mm/dd/yy) Student s Social Security Number (if available) SEX Male Female ETHNICITY (Check one) Black Asian/ Pacific Islander White Hispanic American Indian/Alaskan Native Grade Level Special Programs (check all that apply) Has your child lived out of the U.S. for 2 or more Special Education Section 504 consecutive years? Yes No Bilingual/ ESL Other If yes, indicate dates: From: To: When your child lived outside the U.S., did he/she attend school regularly? Yes No Previous School (School Name, City, State) Reason for Leaving Previous School: Name of Parent/ Guardian with whom Student Lives DOB (mm/dd/yy) Relationship to Student Foster Parent Yes No Student s Address (Street name, building and/or apt. #, City, State, ZIP) Temporary Arrangement Residence Telephone Number Father s/ Guardian Name and Address (if different from above) DOB Place of Employment Home Phone: (mm/dd/yy) Work Phone: Cell Phone: Mother s/ Guardian Name and Address (if different from above) DOB Place of Employment Home Phone: (mm/dd/yy) Work Phone: Cell Phone: (Within the past 3 years, have you moved from one city or state to another so that you or your family could work or look for work in agriculture or fishing? Yes HEALTH SERVICES INFORMATION OTHER PERSONS WHO MAY BE CONTACTED IN THE EVENT OF EMERGENCY: Student s Place of Birth (City, State, Country) If student s birthplace is outside U.S., date he/ she entered U.S. No *Person s Name and Relationship Release Authorized* Telephone Number Yes No *Person s Name and Relationship Release Authorized* Telephone Number Yes No Name of Sibling(s) Attending DISD School Date of Birth Name(s) of School(s) Name of Physician Phone Number Preferred Hospital Health Insurance: Medicaid CHIP Commercial Uninsured (*Please list all guardianship or custody arrangements about which school administrators should be aware: Attach all copies of legal documents.) * I authorize DALLAS INDEPENDENT SCHOOL DISTRICT to contact above named persons, and authorize the named physician to render treatment for the health of my child in an emergency. In the event parent/guardian or physician cannot be contacted, school officials are authorized to take whatever action is considered necessary for the health of my child. I will not hold the school district financially responsible for the emergency care and/ or transportation for my child. * Knowingly falsifying information on this document is a criminal offense punishable by law. (TX Penal Code 37.10). I certify that the information contained in this enrollment/ registration form is true and correct. Parent/Guardian Signature Date: Parent/Guardian Email Address TEC 25.002(f) requires that the name, address and date of birth of the person enrolling a student be provided to the school district. *Student is permitted to be released into the custody of the individual listed in case of emergency.

Home Language Survey Encuesta del idioma en el hogar Ngôn ngử được xử dụng tại nhà အ မ သ ဘ သ စက စ ရင က က ယ ၿခင ا ستفتاء اللغه الام घरम ब ल न भ ष सव Student Name Student DOB Nombre del Estudiante Fecha de nacimiento Tên họ học sinh Ngày sanh က င သ အမည က င သ မ သက ရဇ ا سم الطالب تاريخ الميلاد बध य थ क न म जन म म त To Be Completed By Parent/Guardian Or Student (Grades 9-12) Para ser completado por el padre, tutor legal o estudiante (Grados 9-12) Cha mẹ hay người dám hộ hoặc học sinh từ lớp 9-12 điền vào phần dưới မ ဘ/အ ပ ထ န သ (သ ႕) ( ၉-၁၂ ) တန တက ရ က န သ က င သ ၿဖည ရန ماهي اللغة المستخدمه في منزلك في اغلب الاحيان Uअ भभ वक व वध य थ ल भन र पन (क ९-१२) l. What language is spoken in your home most of the time? Qué idioma se habla con mayor frecuencia en su hogar? Ngôn ngử nào thường dùng tại nhà? နအ မ တ င မည သည ႕ဘ သ စက က အဓ က အသ ၿပ ပ သနည? يجب اكمالها بواسطه الاباء او اولياء الامور ) الطلاب في المرحلة 9 الى 12 يمكن ان يكملوا هذه الاستمارة بانفسهم घरम ध र क न भ ष ब ल न ह न छ? 2. What language does your child (do you) speak most of the time? Qué idioma habla su hijo (o usted) con mayor frecuencia? Ngôn ngử nào học sinh thường nói tại nhà? မည သည ႕ဘ သ စက က သင က လ (သ ႕) သင အဓ က အသ ၿပ ပ သနည? ماهي اللغة المستخدمه في منزلك في اغلب الاحيان तप इर क न न ल ध र म त रम क न भ ष ब ल न ह न छ? Parent/Guardian Name (print) Parent/Guardian Signature Date Nombre del padre/ tutor legal Firma del Padre/Tutor legal Fecha Tên phụ huynh / người giám hộ (chữ in) Chữ ký phụ huynh / người giám hộ Ngày မ ဘ/ အ ပ ထ န သ န မည မ ဘ/ အ ပ ထ န သ လက မ တ န႔စ التاريخ توقيع ولي الامر اسم ولي الامر अ भभ वकक न म अ भभ वकक सह म त SC 0503730 **Campus Use Only ** Student Name Student ID Org # School Name

Home Language Survey Encuesta del idioma en el hogar Ngôn ngử được xử dụng tại nhà အ မ သ ဘ သ စက စ ရင က က ယ ၿခင ا ستفتاء اللغه الام घरम ब ल न भ ष सव The State of Texas requires each school district to conduct a language background survey of all students upon entrance into a public school. To comply with this mandate and to better serve your children, please complete the reverse side of this form for each child who is enrolling in the Dallas Independent School District for the first time. El estado de Texas requiere que cada distrito escolar lleve a cabo una encuesta de idioma de todos los estudiantes que ingresan a una escuela pública. Para cumplir con este reglamento y para servir mejor a sus hijos, por favor complete la parte de atrás de esta encuesta por cada hijo que esté inscrito en el Dallas ISD por primera vez. Tiểu bang Texas yêu cầu mỗi học khu chánh phải làm một bảng nghiên cứu lý lịch ngôn ngữ đươc xử dụng trong nhà của tất cả học sinh khi vào học ở trường công. Để thực hiện sự ủy nhiệm trên của chính quyền tiểu bang và để phục vụ tốt hơn cho con em của quí vị. Xin quý vị vui lòng điền vào phần sau của tấm giấy này cho mổi em khi ghi tên học lần đầu tiên vào một trường của khu học chánh Dallas. Nếu quý vị có điều chi thắc mắc, xin vui lòng gọi điện thoại đến trường học. တက (စ )စက (စ ) ၿပည နယ အစ ရ မ အရ ၿပည သ ပ င က င တ င တက ရ က သည က င သ တ င န က ၾက င ခ မ ခင ဘ သ စက က ၿပည သ ပ င က င တ င စ ရင က က ယ ရန လ အပ ၾက င ၿပ ဌ န ထ ပ သည ၄င ၿပ ဌ န ထ သ မ က လ က န ဆ င ရ က ရန န င ပ မ သင တ သ ပည ရ ၀န ဆ င မ မ က ဒ လက (စ ) အင ဒ ဘ(ဖ )န ဒန ႕စက လ ဒ စတ တ တ င တက ရ က န သ က င သ တ င ရရ န င ရန အတ က ရ စ မ က န တ င ရ သ အခ က မ က က ဇ ၿပ ၿပ ၿဖည ပ ပ ولايه تكساس تتطلب من كل منطقه تعليميه استفتاء حول اللغه الاصليه للطلاب عند تسجيلهم في المدارس الحكومية. للامتثال للتعليمات والمتطلبات ولخدمة طفلك بصورة افضل, الرجاء اكمال الجهه الامامية من هذه الاستمارة لكل طفل من الاطفال المسجلين لاول مرة في مدرسة من مدارس المنطقة التعليمية لدالاس. الرجاء ارجاع هذه الاستمارة لمعلم طفلك. اذا كان لديك اي سو ال الرجاء الاتصال بمدرستك. स ट ट अफ ट क ससक स क लम ल ग नह न वध य थ ल सव फम आफ न भ ष म भ र ब ज उन ह ल लप इर क न न क स एत क ल ग, ड ल स इ न डप न ड न ट स क ल ड स ट रकम प हल पल ट ल ग न ह न न न पछ ड दएक फमर भ र क पय ब झ उन ह ल SC 0503730

Texas Education Agency Texas Public School Student Ethnicity and Race Data Questionnaire Student Name Student DOB Student Grade School Name Student ID The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). Parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student s ethnicity and race. United States Federal Register (71 FR 44866) Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic/Latino Part 2. Race: What is the person s race? (Choose one or more) American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment. Asian - A person 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. Black or African American - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. **CAMPUS USE ONLY** School observer- upon completion and entering data in student software system, file this form in student s permanent folder. Ethnicity- choose only one: Hispanic / Latino Not Hispanic / Latino Race- choose one or more: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Observer Signature Org # School Name Date SC 0301688

Family Educational Rights and Privacy Act (FERPA) Notice for Directory Information The Family Educational Rights and Privacy Act (FERPA), a federal law, requires that Dallas Independent School District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child s education records. However, Dallas Independent School District may disclose appropriately designated directory information without written consent, unless you have advised the District to the contrary in accordance with District procedures. Student directory information is available to the public unless the parent/guardian restricts the release of the information. According to the Texas Public Information Act (TPIA), Dallas Independent School District must release directory information promptly upon request and may not ask requestors the reason for the requested information. Per Board Policy FL (LOCAL), the written objection to the release of directory information shall be sent to the student s principal within 15 school days after the annual notice is given concerning directory information. Certain information about district students is considered directory information and will be released to anyone who follows the procedures for requesting the information unless the parent or guardian objects to the release of the directory information about the student. If you do not want Dallas Independent School District to disclose directory information from your child s education records without your prior written consent, you must notify the district in writing within 15 school days of receiving this notice. Dallas Independent School District has designated the following information as directory information: student name, address, telephone listing, date and place of birth, major field of study, participation in an officially recognized activity or sport, weight and height of members of athletic teams, dates of attendance, degrees and awards received, and most recent previous educational agency or institution attended. In addition, federal law requires districts receiving assistance under the Elementary and Secondary Education Act of 1965 to provide a military recruiter or an institution of higher education, on request, with the name, address, and telephone number of a secondary student unless the parent has advised the Dallas Independent School District that the parent does not want the student s information disclosed without the parent s prior written consent. SC 0301960

Family Educational Rights and Privacy Act (FERPA) Notice for Directory Information Student Name Student DOB Student Grade School Name Student ID STUDENT DIRECTORY INFORMATION RELEASE FORM Parents/guardians are to determine what, if any, directory information is to be restricted from release. Please check one box in each applicable section. Making no selection will result in student directory information being made available upon receipt of a properly submitted request. ALL STUDENTS Release of Directory Information YES, Dallas ISD does have my permission to release directory information. NO, Dallas ISD does not have my permission to release directory information. SECONDARY STUDENTS ONLY (Grades 6-12) Release of Directory Information to Military Recruiter or Institution of Higher Education Military Recruiter YES, I do want the name, address, and telephone number of my secondary student released to a military recruiter. NO, I do not want the name, address, and telephone number of my secondary student released to a military recruiter. Institution of Higher Education YES, I do want the name, address, and telephone number of my secondary student released to an institution of higher education. NO, I do not want the name, address, and telephone number of my secondary student released to an institution of higher education. SC 0301960

Annual Student Health Information Form Student Name Student Grade Gender (Circle) M F Student DOB Student ID Parent Name Parent Cell # Parent Home # Parent Work # Parent Email In an effort to provide safe, informed care for your child at school, each year the Dallas lsd Health Services Department requires updated health information as part of student enrollment. Dallas lsd keeps all medical information about your child confidential as required by the Family Educational Rights and Privacy Act and other applicable laws. However, health information about your child will be communicated to Dallas lsd school personnel who require the information to better serve your child. If your child has an acute or chronic medical condition, or any medical changes occur during the school year, it is your responsibility as the parent/guardian to notify the school nurse and update this information. ABDOMINAL ISSUES: Due to: Irritable bowel syndrome Gastric reflux Crohn s disease Ulcerative colitis Constipation Other: ADD/ADHD: When was your child diagnosed? Is your child under medical care at this time? Yes No ALLERGY: (other than seasonal allergies) Food allergy (specify food): Medication allergy (specify med): Insect allergy (specify insect): Latex allergy Symptoms of reaction? Has a physician prescribed epinephrine for this allergy? Yes No (If yes, please contact school nurse) What medications are taken for this? BLOOD DISORDERS: Sickle cell anemia Sickle cell trait Clotting disorder (i.e. hemophilia) Other BREATHING ISSUES: Asthma Cystic fibrosis Tracheostomy Other When was your child diagnosed? Is your child under medical care at this time? Yes No What medications are taken for this? How often does your child use rescue inhaler? Does your child use a nebulizer? Yes No Does your child wake at night with a cough? Yes No COMMUNICABLE DISEASES: Has your child had chicken pox? Yes No Date: Has your child had a positive TB test? Yes No Date: DIABETES: Type 1 Type 2 What medications are taken for this? EARS, EYES, NOSE: Frequent ear infections Hearing Loss R / L Wears hearing aid? Yes No Frequent Nosebleeds caused by: Wears glasses or contacts Yes No Vision loss not corrected with glasses/contacts R / L EMOTIONAL ISSUES: Depression OCD Bipolar School phobia Other When was your child diagnosed? Is your child under medical care at this time? Yes No HEART CONDITIONS: Long Q/T syndrome High blood pressure Irregular heart rate Heart defect, type: Repaired? Yes No Other MUSCLE, BONE, JOINT DISORDERS: Arthritis Scoliosis Other: Are there any P.E. restrictions for this condition? Yes No Is your child under medical care at this time? Yes No NEUROLOGICAL: Migraines Autism spectrum disorder Seizures, type: Date of last? Cerebral palsy Spina bifida Other OTHER HEALTH CONDITIONS: Special procedures: (tube feeding, catheterization, etc) ALL medications taken during school hours and school related activities must be brought to the clinic. A separate permission form is required for each medication.texas law requires parent and physician permission to carry an inhaler or emergency epinephrine at school. Contact your school nurse for information. Medications not listed above Amount Reason At Home/At School My child has NO KNOWN HEALTH CONDITIONS and does not require any medications at home or school. SC 0300019

Photography and Video Release Form Student Name Student DOB Student Grade School Name Student ID I do hereby give my consent to the Dallas Independent School District and its designees to photograph, audio record, and/or video record my child. I understand that any such photographs, audio recordings, and/ or video recordings become the property of the Dallas Independent School District. I understand that the District may use and/or reproduce the photographs, likeness or the voice of my child for any internal or external educational, instructional, or promotional activities determined by the District in broadcast and electronic media formats now existing or in the future created. I further understand that external educational, instructional, or promotional activities may include the release of the photographs, audio recordings, and/or video recordings to newspapers, radio and television stations. I also agree to allow my child s work and/or photograph to be published on the Dallas Independent School District internet, intranet and/or Dallas ISD publications. I further understand that by signing this release, I waive any and all present or future compensation rights to the use of the above stated material(s). By signature below, I release the Dallas Independent School District, its Board of Trustees, agents, employees or other representatives from any liabilities, known or unknown, arising out of the use of this material. I have read the Photography and Video Release Form and fully understand the terms and conditions outlined. I certify that I have full legal capacity to sign this Photography and Video Release Form on behalf of myself and my child. YES, I do give permission to use my child s photo or likeness as described above. NO, I do not give permission to use my child s photo or likeness as described above. SC 0301320

Student Residency Questionnaire Student Name Student DOB Student Grade School Name Student ID This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine services the student may be eligible to receive. SECTION A Is your current address a temporary living arrangement? Yes No Is this temporary living arrangement due to loss of housing or economic hardship? Yes No Are you an unaccompanied youth? Yes No If you answered YES to ANY of the above questions, please complete Section B of this form; otherwise skip to Section C. SECTION B Where is the student presently living? (Check boxes that apply) Motel/Hotel Shelter Moving from place to place Abandoned house or building With more than one family in a house or apartment In a car, park or campsite Other (please explain) What is your relationship with the family you are living with? How long have you lived here? How long do you plan to stay? SECTION C **CAMPUS USE ONLY** If the answer is yes to any of the Section A questions, mail this form to: Box 141 OR Fax (972) 794-4578 Service requested by campus Uniform School Supplies Food Backpack Other Org # School Name Registrar/Data Controller Name Phone Number Please note, upon receipt of this form, a follow up call to the Homeless Education Program (972) 794-4519 is required in order to coordinate the delivery of available services. SC 0300008

Military Connected Student Student Name Student DOB Student Grade School Name Student ID Not a military connected Student Student is a dependent of an ACTIVE DUTY member of the United States military (Army, Navy, Air Force, Marine Corps or Coast Guard) Student is a dependent of a member of the Texas National Guard (Army, Air Guard, or State Guard) Student is a dependent of a member of a reserve force in the United States military (Army, Navy, Marine Corps, Coast Guard) PRE-KINDERGARTEN STUDENT is a dependent of: 1) an ACTIVE DUTY uniformed member of the U.S. military (Army, Navy, Air Force, Marine Corps, or Coast Guard) 2) an ACTIVATED/MOBILIZED uniformed member of the Texas National Guard (Army, Air Guard, or State Guard) 3) an ACTIVATED/MOBILIZED member of the U.S. reserve (Army, Navy, Marine Corps, Air Force, or Coast Guard) 4) member of U.S. military or reserve or TX National Guard who was injured or killed while serving on active duty.