The following information must be provided to the school BEFORE students will be allowed to attend:

Please check with Administrative Assistant that these are on file: __________ Student Registration Packet __________ Copy of Social Security Card (If student is on an I.E.P.) __________ Certified Copy of Birth Certificate / Baptismal Record __________ Copy of Updated Immunization Records (ND State Law)

__________ Over-The-Counter/ Non Prescription Medication Consent Form And Annual Health History Form (Mandatory for all students not on daily meds)

If applicable: __________ Custody Papers / CPS Placement __________ Certified Degree of Indian Blood (CDIB)/ Tribal Enrollment TRANSFER STUDENTS ONLY: Has student been involved in a Special Education Program in former school? __________ If yes, please sign a release form with our Special Education Department.

Solen Public School District #3 – Vision and Mission Statements Vision Statement: “The Solen School District will empower all students to develop their skills and talents to become productive citizens and lifelong learners”. Mission Statement: “The mission of the Solen School District is to produce learners who excel academically, physically, spiritually, and socially by expanding curriculum and activities, increasing parent and community involvement, integrating culture into the school and providing a safe nurturing environment”.

SOLEN PUBLIC SCHOOL DISTRICT #3 Student Registration Packet

Returning Students K - 12TH Grade

Demographic Updating Form K – 12th Grade Child’s FULL Legal Name: ______________________________________________ Physical Address: ____________________________________________________ Mailing Address: _____________________________________________________ Grade ____________ School Last Year: ___________________________________ Age________ Date of Birth __________ Gender ________ SSN:_______________ Mother’s Name: _______________________ Employer: _____________________ Home Phone: _____________ Work #: ______________ Cell #: _______________ Father’s Name: ________________________ Employer: _____________________ Home Phone: _____________ Work #: ______________ Cell #: _______________ ** If different from Mother & Father Information Guardian’s Name #1 ___________________ Employer: ______________________ Home Phone: _____________ Work #: ______________ Cell #: _______________ Guardian’s Name #2 ___________________ Employer: ______________________ Home Phone: _____________ Work #: ______________ Cell #: _______________ Bus Route (Please Check student route) � William Mutchler: (HS/ELEM) Solen, (ELEM) Chairmans, Horseshoe, 8th Ave., N. CB � Blaine Hoffman: (HS) 1st Ave., 2nd Ave., 3rd Ave., 4th Ave., North CB � Blake Isbell: (HS) Horseshoe, Chairmans St., 8th Ave., South Big Lake Rd � Louis Decouteau Jr.: (ELEM) 1st Ave., 2nd Ave., 3rd Ave., 4th Ave., South Big Lake Rd

& Hwy 24 � Other: ____________________________________________________________

Person(s) and relationship to which we are authorized to release your child(ren) from the school buildings.

______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Solen Public School District #3 McKinney-Vento Act Survey

This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title 1 Part A, Title 1 Part C- Migrant, Individuals with Disabilities Education Act (IDEA) and/or Title X, Part C, Federal McKinney-Vento Assistance Act, 42 U.S.C. 11435. Eligibility can be determined by completing this questionnaire. It is illegal to knowingly make false statements on this form. If eligible, students are to be immediately enrolled in accordance with Bulletin 741, Section 341. Student Legal Name: _________________________________________________________________________________ Adult(s) Caring for Student: ____________________________________________________________________________ Relationship: __________Parent __________Other: __________________________ _________CPS / Court Placement 1.) Is this student’s address a temporary living arrangement? __________Yes __________No *Note: If this is a permanent living arrangement of the family you may skip the rest of the questions and sign the form on the bottom 2.) Is the temporary living arrangement due to the loss of housing or economic hardship? __________ Yes __________No 3.) Where is the student currently living? (Check all that apply)

� Temporarily with another family because we cannot afford or find affordable housing. � With an adult that is not a parent / legal guardian, or alone without an adult. � In a Hotel / Motel � In a vehicle of any kind, trailer park or campground without running water/electricity, abandoned building or

substandard housing. � Emergency housing (i.e. FEMA Trailer or Rental Assistance) � In an emergency / transition shelter � Other (Must provide specific information) ___________________________________________________________ _______________________________________________________________________________________________

4.) Does your child have a disability or receive any special services? __________Yes __________No 5.) Does your child exhibit behaviors that interfere with his/her academic performance? _________Yes ____________)_No 6.) Does your child have siblings? __________Yes If yes, List ages: ___________________)________ __________No The undersigned certifies that the information provided above is accurate __________________________________________________________________________________________________PRINT – Parent / Guardian Name(s) Signature Date __________________________________________________________________________________________________Phone # Physical Address City State Zip Code For School Homeless Liaison: Place check mark on the left of which setting was checked on No. #3

Doubled Up Doubled Up/ Unaccompanied Youth Hotel/Motel Unsheltered/FEMA Sheltered

Solen Public School District #3 Field Trip / Media Consent Form

I, ______________________ Parent / Guardian of ________________________ (Print Student Name) hereby give consent to the Solen Public School / Cannon Ball Elementary to provide him / her with the following services:

� LOCAL TRIPS ON THE RESERVATION (SIOUX COUNTY) � OFF THE RESERVATION TRIPS � OVERNIGHT TRIPS � EXTENDED TRIPS – FOR TWO OR MORE DAYS � EMERGENCY MEDICAL CARE (FIRST AID / CPR CERTIFIED STAFF

MEMBERS) � AFTER SCHOOL TUTORING – IF STUDENT(S) SIGNED UP

I also give my permission to transport my child to and from locations of localities where travel services are provided. I understand that my child will be chaperoned and all precautions taken to insure his/her return home. This consent is a blanket cover for all school trips from the Solen and Cannon Ball 2018-2019 school year. The Elementary, Solen Jr. High, and Solen High School will send Reminders, Notices of upcoming events or you can also check the Solen School District Webpage www.solen.k12.nd.us or Add the schools Facebook page at Solen Sioux for any changes of events or other notices that may have come up. You WILL NOT need to sign another consent for the school year.

� I hereby also allow Solen Public School District to use my child’s photographs as needed, e.g. Student of the Month, Honor Roll, Sports, Graduation events, School newspaper, etc.

Parent / Guardian Signature Date Telephone/ Cell. phone

Student Name: (Please Print) __________________________________________ Parent / Guardian Signature: __________________________________________ I understand and agree to adhere to the behaviors outlined in the Solen Public School District #3 – Acceptable Use Policy (AUP). I understand that any violation of this policy will result in the loss of Internet privileges. ______________________________________________________ Student Signature – Date (If student is 18 years of age or older) For students under the age of 18, the parent / guardian are required to complete the following section:

I have read and understood the Acceptable Use Policy for the Solen Public School #3 Internet use. I understand that the use of the internet is designed strictly for educational purposes. I also understand that the Solen Public School District #3 is taking measures to ensure that my child does not have access to any material deemed inappropriate. I agree that I WILL NOT hold the Solen Public School responsible for any access by my child of any inappropriate materials acquired ib the Internet. I hereby give my child permission to work on the Internet for school use. Parent / Guardian Signature: ____________________________ Date: ________

Descriptor code: ACEA

SOLEN PUBLIC SCHOOL DISTRICT #3 Student Contract for Internet use

Student Name:______________________________ DOB: _____________ Grade: _________ _____ Solen Jr/High School _____ Cannon Ball Elementary Date: _______________ The U.S. Office of Civil Rights requires that schools identify possible English Language Learner students during enrollment. This Home Language Survey will be used as a tool to determine if your child is eligible for language support services (ELL). If a language other than English is used by you or your child and your child meets the Limited English Proficiency (LEP) definition, the school may give your child an English Language Proficiency Assessment. The school will share the resuts of the assessment with you. The Limited English Proficient definition can be made available upon request. Native American or Alaskan Native student: Native American and Alaskan Native students are mentioned specifically in the LEP definition and may qualify for LEP services. Would your child be considered Native American or an Alaskan Native student?___Yes ___No What language(s) are spoken at home? ____________________________________________ If a second language is spoken at home, does it prevent your child from learning in an English speaking classroom? _______Yes _______No What language(s) do you use most to speak to your child? _____________________________ What language(s) does your child use the most at home? ______________________________ What language(s) did your child learn when he/she first began to talk? ___________________ List other language(s) that your child has used with a grandparent or caretaker: ___________ Have your child ever been in an English as a Second Language (ESL or ELL) Program? ________Yes ________No If Yes, Where and When? _______________________________________________________

SOLEN PUBLIC SCHOOL DISTRICT #3 Home Language Survey

2018-2019

Student Name: ________________________________________ Grade: ______ Parent / Guardian Name: ____________________________________________ Home Address/Physical: ____________________________________________ Home Phone: ______________________ Work Phone: ____________________ Cell Phone: _________________ Email Address: _______________________ Cannon Ball Community (in town) Primary Emergency Contact Name: ___________________________________________________________________ Relationship to student: _____________________________________________ Home Address/Physical: ____________________________________________ Home Phone: ______________________ Work Phone: ____________________ Cell Phone: _________________ Cannon Ball Community (in town) Secondary Emergency Contact Name: __________________________________________________________________ Relationship to student: _____________________________________________ Home Address/Physical: ____________________________________________ Home Phone: ______________________ Work Phone: ____________________ Cell Phone: _________________

SOLEN PUBLIC SCHOOL DISTRICT #3 EMERGENCY STORM CONTACT INFORMATION - MANDATORY

2018-2019

ANNUAL HEALTH HISTORY

Requires renewal at the beginning of each school year

School Year: ___________ Grade: ____________ Teacher: _______________________________ Birth Date: ___________ M or F __________

Student Name: ___________________________________________________________ Rides Bus: _______ Walks: ______ Brought by Car: _____

Address: ___________________________________________________ Home Phone: ______________________ Cell: _______________________

Name of Parent or Guardian (with whom student resides with):

Name: ______________________________________________________ Relationship: _________________________ Home Phone: ___________________________

Cell Phone: ________________________ Work Phone: _____________________ E-Mail: ______________________________________________________________

Name: _______________________________________________________Relationship: _________________________ Home Phone: __________________________

Cell Phone: ________________________ Work Phone: _____________________ E-Mail: ______________________________________________________________

Emergency Contacts (other than Parent/Guardian listed above) Local Contacts ONLY:

Name: _______________________________________ Relationship: _________ Home Phone: ____________ Work: _______________ Cell: ____________________

Name: _______________________________________ Relationship: _________ Home Phone: _____________ Work: _______________ Cell: ___________________

Allergic to (foods, insects, medicines, etc.): Type of Reaction (rash, difficulty breathing, etc.):

__________________________________________________________ ________________________________________________________________

__________________________________________________________ ________________________________________________________________

Current Medical Diagnosis or Disability- please circle if applicable:

ADD/ADHD Asthma Cancer/Leukemia Cardiac Cystic Fibrosis Cerebral Palsy

Diabetes Genetic High Blood Pressure Migraine Muscular Dystrophy Neurological

Seizures Urological Hearing Problems Psychiatric Issues Vision Problems Other

Please Explain:

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Medication Dosage Times Given Reason for Medication

Is there anything else we need to know about your child? Yes or No (If yes please explain)

Physician: _____________________________________________________________ Phone Number: _____________________________

I give permission for my child to be seen by the school nurse and give permission for the school nurse and or school administrator to

communicate with the above named physician and release information to the appropriate school personnel regarding my child’s medical

condition.

Parent/Guardian: ____________________________________________ Date: ________________ Insurance or Medicaid Number (if applicable)________________

OVER-THE-COUNTER/NON-PRESCRIPTION MEDICATION CONSENT FORM

Requires renewal at the beginning of each school year

Name of student_____________________________________________ D.O.B __________________________

Address: Physical and P.O. Box # _______________________________________________________________

__________________________________________________________________________________________

Parent / Guardian Name: _____________________________________________________________________

Home Phone: ____________________ Work Phone: ____________________ Cellular: ___________________

School Attending: ___________________________________________________________________________

Name of medication: ________________________________________________________________________

Dose: _____________________________________________________________________________________

Frequency: ________________________________________________________________________________

Reason to give medication: ___________________________________________________________________

Over-The-Counter-Medication

I authorize school staff to administer the above over-the-counter/non-prescription medication to my student

while at school and relieve the school district and personnel of all responsibility. I understand that the school

district and individuals involved will not be held liable for any adverse effects of the medication.

I further understand that the medication must be in the original container and the medication dose must be

according to the label on medication and MUST ALSO be delivered to the school AND picked up BY THE

Parent/Guardian. I also know that It is illegal for students to transport medications to and from school. (i.e..

cough drops, Tylenol, Ibuprofen, Tums, etc.. anything taken orally)

� We also understand that the school district can no longer supply these for the students, it is the

parent/ guardian responsibility.

Parent/ Guardian Signature: ____________________________________________ Date: _________________