Durango High School Enrollment Checklist

Durango High School requires that the following information be on file in the counseling

office in order to enroll your student and schedule him/her into the appropriate courses.

This Checklist

Student Name: _______________________________________________________

Date of Birth: ________________________________________________________

Incoming Grade: ______________________________________________________

Previous School: ______________________________________________________

Has the student been identified for Special Education programs (IEP, 504, ESL)? _ ___

If yes, please list: ______________________________________________________

Has the student ever had any disciplinary issues? ____________________________

If yes, please explain: __________________________________________________

Has the student ever had any attendance issues? ____________________________

If yes, please explain: ___________________________________________________

Has the student ever been suspended or expelled from school? _________________

If yes, please explain: ___________________________________________________

Parent/Guardian Name and Phone: _______________________________________

Does the student live within the DHS attendance boundary? ___________________

Completed 9-R Enrollment Packet (attached)

Student Census Data

Health Information Sheet

Request for Student Records

Home Language Survey

Title VI Student Eligibility Certification

Proof of Residency

Birth Certificate

Immunization Record

Previous School Transcript

Previous School Attendance Record

Previous School Discipline Record

Last Name First Name Middle Name Preferred Name Grade Home Language

Date of Birth Gender Home Phone Student E-mail (Optional)

Household Address Student Cell Number (Optional)

Street Address

City, State, Zip

Mailing Address (only if different from Household)

Street Address Hispanic/Latino Origin?

City, State, Zip (yes/no)

American Indian/Alaskan

Asian

Black

Reading SPED White

Hawaiian/Pacific Island

Starting with 1st grade, student has been continuously enrolled in:

Durango 9R

Since what date?

Name, City and State of previous school or preschool attended: ______________________________________________________

CONTACTS: The school will use the Student's home address and phone number for routine communication. In an emergency,

the school will attempt to contact the people listed below. All contacts listed are presumed to have permission to pick up the student.

Parent/Guardian 2nd Contact 3rd Contact 4th Contact

Full Name

Gender

Relationship

Home Phone

Work Phone

Cell Phone

Street Address

City, State, Zip

E-mail

Live with student?

Legal issues? Yes or No

If yes, please provide documentation.

List names of siblings in 9R schools

I hereby certify that all the information given on this form is correct.

Parent or Guardian Signature Date

Durango School District 9R - Student Census Data

Choose at least one

504 ESL GT

Student has been identified for these programs (please check all that apply).

United States

Federal Ethnicity/Race Information

Y or N (circle one) Y or N (circle one) Y or N (circle one) Y or N (circle one)

Colorado

Check All That Apply:

Transportation:

Bus

Kids Camp

Education Needs:

IEP

504

Health Information Sheet

First Middle Grade

Gender Home Phone

Street Address City, State Zip Code

Parent/Guardian

2nd Contact

Name Home Phone Work Phone Cell Phone

3rd Contact

Please check health problems your child has now, OR has had in the past:

Birth weight less than 5 lbs

Disabilities/Limitations

Developmental Delay

Ear Infections/Earaches

Allergies,bee,food,medicine,list below

Hearing Loss

Other (explain below)

Sleeping Problem

Concussion/Head Injury

Stomach Problem/Ulcer

Headaches

Significant Injury

Vision Problems

Bone/Joint Disease

Glasses

Asthma

Eating/Weight Problem Blood Disease Frequent Bronchitis Seizures

Frequent Strep Throat

Pneumonia

Diabetes/Hypoglycemia

Nervous/Attention Disorder

Significant Skin Problem

Emotional Problem

Operations

Heart Condition

If you have checked any of the above, please explain:

Do you have vision insurance? Yes No

Is your child currently under medical care? Yes No If yes, please describe:

Does your child take medication? Yes No At School? Yes No (Medication permission form required).

If Yes, Type: Dosage: Time(s) given:

Emergency medications taken: Epipen Inhaler Other

Doctor's Name: Dentist's Name:

Doctor's Phone: Optometrist's Name:

9R_HealthForm_Blank 3/1/2017

I, the undersigned, do hereby authorize officials of Durango School District 9-R to contact directly the persons named on this form, and do authorize the

named physicians/dentist such treatment as may be deemed necessary in an emergency, for the health of said child. In the event physicians, other persons

named on this form, or parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their

judgment, for the health of said child. I will not hold the school district financially responsible for the emergency care and/or transportation for said child. I

also understand that my child’s immunization records could be entered into the Colorado Immunization Information System.

Parent Signature: Date:

Do you have health insurance for your child? Private CHP+ Medicaid IHS None

Last

Birthdate

Authorization for Over the Counter Medications Parents: The school health office may stock some common over the counter medications. Please initial which of the following may be administered to your child by the school health service provider. The dose given will be the dose recommended on the packaging unless you indicate otherwise. ________ Ibuprofen (Advil, Motrin) liquid or tablet ________ Acetaminophen (Tylenol) liquid or tablet ________ Antibiotic ointment (Neosporin, Bacitracin) ________ Cough drops ________ Hydrocortisone cream ________ Burn cream ________ Tums ________ Zyrtec Liquid ________ Lubricating eye drops I give permission for qualified health office staff to administer the medications indicated above to my student following parent/guardian notification. ____________________________________ _______________________ Parent Signature Date OR I do not give permission for health office staff to administer medication to my student. _____________________________________ ________________________ Parent Signature Date

Durango High School 2390 Main Avenue Durango, CO 81301

Request for Student Records

Student Information

Last Name: _______________________________________ Date of Birth: _____________________________________

First Name: ______________________________________ Current Grade Level: _____________________________

Middle Name: ____________________________________

Previous School Information

Name, City, State: __________________________________________________________________________________________

Last Attendance Date: ______________________________

Telephone: ____________________________________ Fax Number: _____________________________________

Signatures

By signing this form, we give permission for the release of records from the identified previous school to Durango High School. Further, we understand that academic placement, enrollment and crediting will be based upon receipt and review of official records from the previous school.

___________________________________________________ ______________________________________________________ Parent/Guardian Signature Date Student Signature Date

The following records are hereby requested:

_____ Signed Transcript _____ ELL Scores (if applicable) _____ Withdrawal Grades _____ Copy of Birth Certificate _____ Immunization Records _____ IEP (if applicable) _____ Discipline Records (if applicable) _____ ILP (if applicable) _____ Attendance Records _____ 504 Plan (if applicable) _____ Test Data/Scores _________________________________________________ ______________________________________________________ Durango High School Representative Title Date Please mail official records to: Please send unofficial records to: Durango High School Email: smatheson@durango.k12.co.us Attn: Sharon Matheson, Registrar Fax: (970) 375-3997 2390 Main Avenue Telephone: (970)259-1630 ext. 2311 Durango, CO 81301

1

The Office of Civil Rights and the Colorado Department of Education require school districts to determine the dominant language spoken by your child to help provide meaningful instructional programs. Please answer the questions below as accurately and completely as possible. This information is necessary to provide the most appropriate placement and instruction for your child and will not be used for any other purposes. Thank you for your cooperation.

Parent Signature _________________________________________ Date: _____________________

For Office Use

Student has been identified as: English Only ELL: NEP LEP FEP

WAPT Placement Administered: Yes No

* Note: If another language is present in the home, the English language proficiency test MUST be administered.

Screened by: ____________________________________ Date: ___________

Student Information

First Name:

Last Name:

Date of Birth:

Gender: F M

School Information

Enrollment Date:

Current School:

Current Grade:

Child’s Birthplace:

Has the student ever received English as a Second Language (ESL) services? Yes No

Has the student ever been retained? Yes No

Has the student attended school regularly? Yes No

Parent/Guardian Questions Response

Is a language other than English spoken in your home?

Does your child speak a language other than English?

What language did your child first speak?

What language does your child speak with his/her friends?

What language does your child speak most often?

Additional Parent Information

Home Telephone # _________________ Cellular Telephone # _____________________

Please provide the names of other siblings within the District: ______________________________________________________ ___________________________

HOME LANGUAGE SURVEY

ENCUESTA SOBRE EL IDIOMA DEL HOGAR

OMB Number: 1810-0021 Expiration Date: 07/31/2019

U.S. Department of Education Office of Indian Education

Washington, DC 20202 TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

Name of the Child __________________________________________________ Date of Birth ______________ Grade ______ (As shown on school enrollment records)

Name of School ____________________________________________________________________________________________ TRIBAL ENROLLMENT

Name of the individual with tribal enrollment: ___________________________________________________________________

(Individual named must be a descendent in the first or second generation)

The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent

Name of tribe or band for which individual above claims membership: _______________________________________________ The Tribe or Band is (select only one):

_____ Federally Recognized _____ State Recognized _____ Terminated Tribe (Documentation required. Must attach to form) _____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994. (Documentation required. Must attach to form)

Proof of enrollment in tribe or band listed above, as defined by tribe or band is:

A. Membership or enrollment number (if readily available) _____________________________________________________ OR B. Other Evidence of Membership in the tribe listed above (describe and attach) _______________________________________ Name and address of tribe or band maintaining enrollment data for the individual listed above:

Name ____________________________________________ Address ________________________________________________ City _______________________________State ______Zip Code ____________ ATTESTATION STATEMENT I verify that the information provided above is accurate.

Name Parent/Guardian ______________________________________ Signature _______________________________________

Address ______________________________________ City ____________________________State ______Zip Code __________ Email Address ________________________________________ Date _______________