2016 – 2017 Initial Consultation

Document Checklist Students and parent can use this form the track all Phase I document submissions.

STUDENT NAME ____ Be sure to watch the Initial Consultation Tutorials I & II

Ensure you meet minimum qualifications Consultation Documents GPA above 2.0 NSHS disclaimer form

Junior showing a minimum of 11 credits GBC application

Senior showing a minimum of 17 credits NSHS graduation requirement agreement

Registration Documentation

FRL form (State Funding)

Print & sign online registration form from email Home Language Survey

Print, complete, & sign NSHS health form Residency Questionnaire

Copy of unofficial high school transcript

Online Enrollment (CSN/NSHE#)

Updated immunization records CSN Thank You Page (email w/ NSHE preferred)

Student birth certificate

Parent ID/guardianship forms

Sign up for MOODLE at NSHS http://registration.earlycollegeNV.com

IEP Documentation (if applicable) Username:

504 Documentation (if applicable) Password:

ELL Documentation (if applicable for spring only) Placement Test Prep (see Moodle Phase II)

NOTES: Directions Post NSHE Number Create a support ticket http://help.earlycollegenv.com

Include First & Last Name, NSHE #, and Accurate Email PLEASE BE ACCURATE

Get directions on placement testing prep and test

Next Steps:

1 . Turn in documents to NSHS – Start Now 2. Study for placement tests – Star t Now 3. Take placement tests @ NSHS – Start ing around March 4. Watch advisement videos on Moodle – Available in March

Sign if you agree to the terms and conditions of the referral program Date

It pays to ENROLL with friends

1 Friend = 50 points 10 Friends = 500 points

First & last name of your friend (REFERRING STUDENT)

MUST enroll at NSHS 2016-17 until 11/1/2016 for points Your first & last name (NEW STUDENT)

MUST enroll at NSHS 2016-17 until 11/1/2016 for points

REFERRAL PROGRAM

*All new and returning students receive 100 points distributed ½ during the fall and ½ during the spring semesters per terms and conditions.

REFERRAL POINTS USED FOR REIMBURSEMENT ON THE FOLLOWING:

REFERRING STUDENT Who referred you to NSHS?

(You) NEW STUDENT You enroll for 2016-17

The Referring Student gets

100 points*

All Students automatically get

50 points

ACT/SAT Books/class

supplies Extra/Summer

classes Transportation

Sign if you agree to the terms and conditions of the referral program Date

Buddy up Referral Program - Terms & Conditions

What is i t ? The Buddy up Refer ra l Program i s whe re s tudents can earn re fer ra l po in t s by recru i t ing New Studen ts to Nevada Sta te H igh Schoo l (N SHS) fo r the 2016 -17 schoo l year ;

Why the prog ram? NSHS’s budget is dependen t upon s tudents . The schoo l ’s ab i l i t y to pay fo r add i t i ona l benef i ts beyond co l l ege c lasses is dependent upon these numbers . Students are incent iv ized to rec ru i t o thers to have more f l ex ib i l i t y in choos ing the benef i t s t ha t f i t t he i r needs;

What can the re fer ra l po in ts pay fo r? NSHS wi l l p rov ide re fer ra l po in t s as re imbursement fo r the fo l lowing: ex terna l c red i ts , ex t ra co l l ege c lasses, summer c lasses, UNLV & NSC cos t d i f fe rences, ACT/SAT, co l l ege tex tbooks , c lass supp l ies , and t r anspor ta t ion costs ; NSHS admin is t ra t i ve s ta f f need to approve a l l o the r i tems in wr i t ing ;

Who i s e l ig ib le t o earn po in ts fo r re fer r i ng s tudents ? Re turn ing NSHS 11 t h g raders and new s tuden ts :

o El ig ib le : Must en ro l l a t NSHS fo r 2016 /17 and s tay enro l led th rough 11 /1 /2016; o Ine l ig ib le fo r any re fer ra l po in ts , f unds , o r r e imbursemen ts fo r the fo l lowing :

Student is t ruant o r owes NSHS f i nes ; Student d id no t comple te Income Ver i f i ca t ion or Res idency Form s 16/17 ; Student does not enro l l o r w i thdra ws f rom NSHS pr io r to 11 /1 /2016 fo r semes ter

on or 4 /1 /2017 fo r semester two ;

Who can dec la re a re fer ra l? On ly New Students can comp le te a re fer ra l fo rm and dec lare a Refer r i ng S tudent who re fer red them to NSHS . Dec lara t ions mus t be made a t the t ime o f the in i t i a l consu l ta t ion o f reg i s t ra t ion (un less o the rw ise approved by NSHS Admin is t ra t ion) ;

What is the t ime f rame for the p rog ram: 3 /1 /16-11/1 /16 ;

How are re fer ra l po in t s awarded? A Refer r ing Student earns po in ts when a New Student dec lares the fu l l name o f t he Refer r i ng S tudent i n wr i t i ng on the Buddy up Refe r ra l Program form a t t he in i t ia l consu l ta t ion dur ing reg is t ra t ion . The New Student must enro l l and s tay enro l led th rough 11/1 /2016 fo r re fe r ra l po in t s t o be awarded:

o New Students can on ly comple te one re fer ra l fo rm and des ig nate on ly one Re fer r ing Student who made the re fer ra l to Nevada S ta te High Schoo l ;

o Refer ra ls a re vo id where a New S tudent and Refer r i ng Studen t a re one and the same; o I f a New Studen t l i s ts more than one Refer r ing Student , the n the re fer ra l w i l l be vo ided ;

There i s no l im i t to the number o f t imes a Re fer r ing Student is des igna ted , ye t the Refer r ing Student and New Studen ts mak ing the dec lara t ion must mee t e l ig ib i l i t y requ i rements fo r po in t s ;

Al l 2016/17 enro l led s tudents th rough 11/1 /2016 w i l l au tomat ica l ly rece ive 100 po in ts ;

NSHS w i l l t a l ly a l l r e fe r ra l po in t s and award s tudents ½ o f the amount o f po in t s by December 1 , 2016 and the o ther ½ o f t he remain ing amount o r any new ba lances earned by May 1 , 2017;

Respect ing your p r i vacy is a pr io r i t y f o r us : o REFERRING STUDENT: NSHS w i l l keep a scoreboard on the schoo l in te rna l por ta l

(MOODLE) o f re fer ra ls and ma in ta in documen ta t ion fo r aud i t i ng and va l ida t i on ; o NEW STUDENT: R efer ra l s must be va l ida ted . By accep t ing the te rms and cond i t ions , you

g ive NSHS permiss ion to d isc lose your name as the New Student who l i s ted the Refer r i ng Student . Wi thout th is au thor i ty , you acknow ledge tha t you r re fer ra l is i nva l id and w i l l be exc luded f rom the Buddy up Refer ra l Program;

NSHS reserves the r i gh t t o aud i t a min imum of 3 % o f the s tuden t rece ip t s fo r p rogram expend i tu res . I f you are randomly se lec ted, you have two weeks to prov ide documen ta t ion va l ida t i ng your educat iona l expend i tu res as ou t l ined above or you may not be e l ig ib le to rece ive awarded po in ts fo r re imbursement ;

The te rms and cond i t i ons o f t h i s p rogram are sub jec t to change a t any t ime w i thout no t i ce . Th is p rogram may te rminate a t Nevada Sta te H igh Schoo l ’s d iscre t ion . For f u r ther i n fo rmat ion , p lease emai l jhawk@ear lyco l legenv.com o r ca l l a t 70 2 -3 32 -2 59 3 .

Health Card NEVADA STATE HIGH SCHOOL

Last Name

First Name MI Student Number Grade Birthdate Sex

Guardian Last Name

Guardian First Name MI Home Phone Work Phone Other Phone School Year

CURRENT HEALTH PROBLEMS (Please Check Any That Apply) (*Must have a medical diagnosis)

Asthma/Airway Disorder*

Visual Impairment* Explain any health problems checked:

Blood Disorder*

Hearing Aid (R) or (L)

Food Allergy To:

Hearing Loss

Medication Allergy To:

ADD/ADHD*

Potentially Severe Reaction To:

Cancer

Environmentally Hypersensitive To:

Neurological Disease*

Diabetes*:

Muscular Disease*

Seizures/Type*:

Orthopedic Problem

Genetic Syndrome*:

Heart Problem*

Glasses/Contacts*:

Other or exempt from screening:

Able to take P.E.? (Circle One) Yes or No (Must provide medical documentation regarding limitations) Is your child under a doctor’s care for any circled problem? (Circle One) Yes or No If yes, Doctor’s Name__________________ Last School Attended:________________________________ Is your child receiving Medications? (Circle One) Yes or No If yes, list medications:___________________________________________________________________________ ________________________________________________________________________________________________________ Is medication needed at school? Circle One) Yes or No Parent Signature Date

Nevada State High School Student Name

New Student Information Disclaimer Date:   NSHS is a public school of choice and bound to the intent of the school’s charter (NRS 386.500 to 386.610 inclusive). It is crucial that all new students and parents agree to follow the charter and understands the following about the school prior to completing the registration process. The NSHS Student Handbook will be available in August and will detail information on school procedures. Parent Student

_______ _______ 1. Student and parent/guardian understand and agree to follow the purpose and the mission of the school to support students in a college environment with personal, academic, and social skills and follow the academic plan _______ _______ 2. NSHS students are real college students and are treated as such by their college professors in regards to expectations, behavior, parent contact, and adult content. NSHS students must advocate for themselves when interacting with college professors and staff _______ _______ 3. If taking placement tests at CSN, students MUST indicate they are a CSN student testing for CSN classes or the student will incur any fees from the college that arise as a result of stating that they are a high school student _______ _______ 4. NSHS provides support for textbook rentals or purchases for students who follow the school’s textbook reimbursement

process. Students will receive information on textbooks during the Introduction to College and Study Skills courses. _______ _______ 5. NSHS will reimburse a student’s monthly bus pass if they use it to attend their high school and college classes. The reimbursement process is outlined in the NSHS student handbook and taught at the two-week course 6. The Free and Reduced Lunch (FRL) form needs to be completed to receive any reimbursement from NSHS. Federal qualification is not required

a) NSHS is required by state and federal law to audit FRL submissions. Those randomly selected will have one week to submit letter from an employer and/or a copy of their most recent tax documentation to support the FRL form

b) Students may contact NSHS for any additional financial information _______ _______ 7. Student will attend an advising appointment to set up college classes. Parent/Guardians may attend, and it is their responsibility to verify their child’s classes _______ _______ 8. Students may NOT drop classes without written permission from NSHS, and they are responsible for all fees _______ _______ 9. Students must follow the academic plan schedule and attend ALL of the following courses to maintain enrollment:

a) College math every semester (level dependent on placement) b) College English every semester (level dependent on placement) c) Social Studies (history HIST 101 & 102 or government PSC 101 & 210) d) Intro to College Course (2-weeks long, in mid-August or in spring for mid-year students) and elective 2nd semester e) Study Skills every semester (twice a week for two hours) f) Transition Course every semester for 1st year (occurs once a month for first year students)

_______ _______ 10. Students are required to complete volunteer service and social activities each semester _______ _______ 11. Parent/Guardian agree to attend the MANDATORY Parent Meeting in September and check MOODLE regularly _______ _______ 12. Student activity on MOODLE is monitored by NSHS _______ _______ 13. NSHS holds one carwash fundraiser a year in August. Students have a variety of options for required participation _______ _______ 14. Enrollment at NSHS is not guaranteed. Do not withdraw from your previous school until NSHS enrollment is verified _______ _______ 15. Non-proficient students will be required to attend End-of-Course exam preparation _______ _______ 16. Students/parents who withhold or falsify information may be removed from the school or may not be enrolled _______ _______ 17. Parents will be responsible for picking up student’s grades after each semester during posted times _______ _______ 18. Students must maintain enrollment at NSHS through the semester to be eligible for any reimbursement _______ _______ 19. Students who complete with online enrollment with CSN or GBC and do not enroll with NSHS are subject to all fees When a student attends a post-secondary institution, the Family Educational Rights and Privacy Act (FERPA) allow transfer of privacy rights from the parent to the student regardless of their age. At NSHS, the parent and student must agree to share information with the parent, student, NSHS, and the student’s colleges. Student agrees to give NSHS access to college student accounts for schedule verification and final grades. Nevada Law regarding expulsion and truancy are enforced at NSHS. By enrolling at NSHS, parent and student understand that they are no longer enrolled at a home school, private school, Clark County School District School, or other charter school. NSHS has permission to obtain educational records from your previous school(s) upon final enrollment.

*Please Note: NSHS does not have the ability to withdraw a student from any college courses at any time. Should the student discontinue enrollment with NSHS, the student is ultimately responsible for withdrawing from any and all scheduled college courses, and they will be responsible for all fees. NSHS is available to assist with the processes of course withdrawal, but cannot conduct the withdrawal.

Student Signature Parent/Guardian Signature

Student Name: _______________________________

2016 – 2017 Registration Process: Checklist

233 North Stephanie Street // Henderson, NV 89074 update150202

850 S. Durango Drive; Suite 100 // Las Vegas, NV 89145 update150202

Be a power user!  Keep track of login information is a safe place! Phase I Student Copy _______     Phase II Student Copy _______     Phase III Student Copy _______ 

Account Name Username Password

MOODLE Login

myCSN/myGBC login

NSHS Registration Checklist NOTE: All video tutorial may be viewed from home to assist with completing forms to expedite registration. Parents and students are accountable for tutorial information and will be allowed to view at NSHS site if forms are incomplete or if assistance is needed.

Phase I: Initial Consultation (est. 1.5 hr)

____ Logged on to MOODLE account and documented below

____ Completed Initial Consultation I and II Tutorials on MOODLE

____ Completed Initial Consultation Phase I

Phase II: Placement Testing (est. 2 hr)

____ Received NSHE# from CSN and reported it to NSHS through ticket or in person

____ Took CSN math and English placement tests Math Score: _______ English Score: _______

____ Took GBC math and English placement tests Math Score: _______ English Score: _______

____ Scheduled Advising Appointment with NSHS Staff Date: _______ Time: _______

____ Completed Placement Testing Phase II

Phase III: Advising (est. 1.5 hr)

____ Confirmed myCSN login information and documented below

____ Completed NSHS Academic Plan Tutorial on MOODLE

____ Completed CSN Enrollment Tutorial on MOODLE

____ Printed college class schedule for verification

____ Completed Advising Appointment Phase III

Phase IV: Course Enrollment Verification (est. 30 min)

____ Submitted final transcript with final spring grades and updated proficiency scores or end of course scores

____ Returned completed/signed course enrollment verification with final college class schedule to NSHS by Aug. 1(student and parent MUST sign Course Enrollment Verification Contract)

____ Completed the ENGAGE survey

____ Provided start of school letter

____ Completed Course Enrollment Verification Phase IV with final proof of course validation

08/05/2015

SPECIAL ADMISSIONS FORM FOR HIGH

SCHOOL STUDENTS

Admissions & Records Office 1500 College Parkway Elko, Nevada 89801

Phone: 775.753.2102 Fax: 775.753.2311 Email: mygbc@gbcnv.edu

Date:_______________________ Semester: Fall Spring Summer

________________________________________________________________________ Name of High School

Name: ________________________________________________________________________________________

First Middle Last Address: _________________________________________________________________ Mail Address City State Zip

Phone: SS# (optional): _______________________

HS Grade Level:____________________ GBC Student ID:______________________

Expected High School Graduation Date: _______________________

I understand that when a student attends a post-secondary institution, the Family Educational Rights Privacy

Act states that parents do not have access to their student’s educational records. I understand that I am

enrolled in a dual credit course at Great Basin College that may be paid for by my high school.

I further understand that I may be responsible for all fees associated with this class if any of the following

situations occur:

a) I am no longer enrolled with the high school and I do not drop the class before the 100% refund

period ends

b) I no longer want to be enrolled in the class and I do not drop the class before the

100% refund period ends

c) I receive a ‘W’ (withdrawn) grade in the class

Parents must have written permission from the student before information will be released, and

information will not be given over the phone. (Contact Admissions and Records for further information).

I realize that academic freedom is zealously guarded in college classrooms and as such, topics and ideas of a

controversial or sensitive nature may be discussed. If taking academic courses, it is important to meet with a

GBC advisor to clarify enrollment and academic progress. Continued enrollment is contingent upon review

of academic progress each semester.

Student Signature: _______________________________ Date Signed: _______________ Parent or Guardian Signature: Date Signed: _______________

07/30/2015

RELEASE OF STUDENT INFORMATION

TO HIGH SCHOOL

Admissions & Records Office

1500 College Parkway

Elko, Nevada 89801

Phone: 775.753.2102 Fax: 775.753.2311 Email: mygbc@gbcnv.edu

Student’s Name (please print): ____________________________________________

Student’s Signature: ____________________________________________________

Date of Birth or GBC Student ID: _________________________________

My signature indicates my permission for Great Basin College to release my academic

records to the high school listed below until further notice, and allows them direct contact

with my instructor(s) and the Admissions & Records Office.

Name of High School: ___________________________________________________

Notice to Party Receiving Records: This information is intended only for the

institution listed above. It may contain information that is privileged, confidential, or

otherwise protected from use and third party disclosure. You are hereby notified that any

review, disclosure, copying, or dissemination of this information, or the taking of any

action reliant on the contents, or other use, is strictly prohibited.

Nevada State High School  

Graduation Requirement Agreements  Nevada State High School has a graduation requirements above and beyond the state requirements. This agreement serves as a written 

notification to parents and students that NSHS has informed them of these extra graduation requirements.  The school will attempt and 

document its attempts to intervene with students who are not meeting these requirements, yet it is up to the students to meet these 

requirements and the parents to monitor the graduation progress.  NSHS will have student transcripts for parent to pick up in person from the 

school each semester.   

 

Standard Diploma State Graduation Requirements:   

The total number of credits required to graduate is 22.5.   4 credits of English  3 credits of mathematics, including Algebra I or above  2 credits of science  3 credits of social studies, including American government, American history, and world history  2 credits in PE (physical education)  ½ credit in health education  ½ credit in computers  7.5 elective credits  State Exams:  All students must pass the required Nevada High School Proficiency Exams (HSPE) 

in reading and/or writing (ELA), math, and science. This includes the End‐of Course exams.  

NSHS’s Extra Graduation Requirements: 

Nevada State High School is a very mission specific charter school.  The school’s extra graduation requirements are 

not set up to be punitive, but to reinforce students’ commitment to achieving the school’s charter.   

a. Fulfilling college remedial requirements by earning a C (not C‐) in MATH 096, 097 ENG 098, or placing 

directly into the college level with ACT/SAT or college placement tests 

i. Students have until spring of their 12th grade year to meet these requirements 

b. Passing Study Skills or the  Study Skills exemption requirement all semesters  

c. Passing Transitions (1st year student) all semesters 

d. Passing COMPASS (2nd year student, not for credit, required to meet exemptions all semesters) 

 

Remediation: 

NSHS will provide students with the opportunity to remediate deficiencies in these extra requirements.   

College Remedial Placement – take college summer and/or winter courses, take and retake the SAT/ACT 

for improved placement, retake the colleges’ placement tests, pass your classes with a C or better. 

Study Skills/ Transitions/ COMPASS – 2‐week long/6 hour a day grade retrieval courses will be held over 

winter and summer.  Customized plans may be developed for students who fail more than one course a 

semester.  Fall failed courses may repeat in the winter, and spring failures may repeat in the summer.   

o College remedial courses can be taken in the summer, and students may be reimbursed for these 

costs by following the reimbursement process (does not apply to 12th graders who do not graduate) 

o Please review the NSHS Student Handbook for the current year for details 

o 12th graders who do not meet requirements for graduation may not participate in the graduation 

ceremony, but may still attend the summer session to earn their diploma from NSHS  

 

By signing below, you are acknowledging that you understand the NSHS extra graduation requirements and that 

if these are not met, NSHS will not issue a high school diploma and the student will not participate in graduation. 

 

 

Student Signature    Date              Parent Signature    Date 

I N S T R U C T I O N S F O R V E R I F I C A T I O N N E V A D A S T A T E H I G H S C H O O L A HOUSEHOLD MEMBER IS ANY CHILD OR ADULT LIVING WITH YOU. IF YOUR HOUSEHOLD RECEIVES BENEFITS FROM NEVADA SNAP, OR NEVADA TANF OR THE FOOD DISTRIBUTION PROGRAM

ON INDIAN RESERVATIONS (FDPIR), FOLLOW THESE INSTRUCTIONS: Part 1: List all household members and the name of school for each child.  Part 2: List the case number for any household member (including adults) receiving NEVADA SNAP or NEVADA TANF or FDPIR benefits. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. The last four digits of a Social Security Number are not necessary. IF NO ONE IN YOUR HOUSEHOLD GETS Nevada SNAP OR Nevada TANF BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY, FOLLOW THESE INSTRUCTIONS: Part 1: List all household members and the name of school for each child. Part 2: Skip this part. Part 3: If any child is homeless, migrant, or a runaway check the appropriate box and call Wendi Hawk, homeless liaison; migrant coordinator. Part 4: Complete only if a child in your household isn’t eligible under Part 3. See instructions for All Other Households. Part 5: Sign the form. The last four digits of a Social Security Number are not necessary if you didn’t need to fill in Part 4.  IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: If all children in the household are foster children:   Part 1: List all foster children and the school name for each child.  Check the box indicating the child is a foster child.   Part 2: Skip this part. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.  

If some of the children in the household are foster children:   Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the               “No Income” box.  Check the box if the child is a foster child.   Part 2: If the household does not have a case number, skip this part.   Part 3: If any child is homeless, migrant, or a runaway check the appropriate box and call Wendi Hawk, homeless liaison; migrant coordinator. If not, skip this part. Part 4: Follow these instructions to report total household income from this month or last month.  

Box 1–Name: List all household members with income.  

Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take‐home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self‐employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. 

Part 5: Adult household member must sign the form and list the last four digits of the Social Security Number (or mark the box if s/he doesn’t have one).  ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the               “No Income” box.    Part 2: If the household does not have a case number, skip this part.   Part 3: If any child is homeless, migrant, or a runaway check the appropriate box and call Wendi Hawk, homeless liaison; migrant coordinator. If not, skip this part. Part 4: Follow these instructions to report total household income from this month or last month.  

Box 1–Name: List all household members with income.  

Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly.  For earnings, be sure to list the gross income, not the take‐home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency.  For ONLY the self‐employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits.  If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. 

Part 5: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one). 

2016-2017 FAMILY INCOME VERIFICATION PART 1. ALL HOUSEHOLD MEMBERS Names of ALL people living in household (First, Middle Initial, Last) 

Name of school and current grade level for each child/or indicate  “NA” if child is not in school 

Check if a foster child (legal responsibility of welfare agency or court)   * If all children listed below are foster children, skip to Part 3 then Part 5 to sign this form.   Food Stamp or TANF case # (if any).  Skip to Part 5 if you list a Food Stamp or TANF case # 

Check if NO income 

PART 2. IF ANY CHILD IS HOMELESS, MIGRANT, OR A RUNAWAY CHECK THE APPROPRIATE BOX AND CALL Wendi Hawk, homeless liaison; 

migrant coordinator at phone 702‐953‐2600                                                         HOMELESS MIGRANT RUNAWAY PART 3. FOSTER CHILD IF YOU LIST A CHILD(REN) WHO IS(ARE) THE LEGAL RESPONSIBILITY OF A WELFARE AGENCY OR COURT, CHECK THIS BOX AND THEN LIST THE AMOUNT OF EACH CHILD’S PERSONAL USE MONTHLY INCOME: $____________________. SKIP TO PART 5. PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often. 1. NAME (List ONLY household members with income)  

2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED 

Earnings From Work before deductions  Welfare, child support, alimony 

Pensions, retirement, Social Security, SSI, VA benefits  All Other Income 

(Example)  Jane Smith  $199.99/weekly $149.99/every other week $99.99/monthly $50.00/monthly $______/________ $______/________ $______/________ $______/_______ $______/________ $______/________ $______/________ $______/_______ $______/________ $______/________ $______/________ $______/_______ $______/________ $______/________ $______/________ $______/_______ $______/________ $______/________ $______/________ $______/_______ $______/________ $______/________ $______/________ $______/_______

PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN) An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement below.)  I certify (promise) that all information on this document is true and that all income is reported. I understand that the school will possibly get Federal funds based on the information I give. I understand that school officials may verify (check) the information. Sign here: ______________________________________________________________________Print name:_____________________________ Date: ____________________________ Address:_____________________________________________________________________________________Phone Number:______________ City:___________________________________________________________________________State:__________________Zip Code:___________ Last four digits of Social Security Number: * * * - * * - __ __ __ __ I do not have a Social Security Number

DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 Total Income: _________________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: ________ Eligibility: Free Reduced _ Paid __________ Verifying Official’s Signature: _______________________________Date: ________________________ Privacy Act Statement: This explains how we will use the information you give us. Nevada State High School requires the information on this document to apply for grant applications. You do not have to give the information, but if you do not, we cannot include your child for our statistics. You must include the social security number of the adult household member who signs this document. The social security number is not required when you fill out information on behalf of a foster child or you list a Food Stamp Program, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDRIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. SHARING INFORMATION WITH MEDICAID/SCHIP Dear Parent/Guardian: If your income verification meets certain levels of income, then your child may also be able to get free or low-cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP). Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness. Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children. If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send in. No! I DO NOT want information from my Income Verification Document shared with Medicaid or the State Children's Health Insurance Program. If you checked no, fill out the form below to ensure that your information is NOT shared for the child(ren) listed below: Child's Name: ___________________________________________School:___________________________________________ Child's Name: ___________________________________________School:___________________________________________ Child's Name: ___________________________________________School:___________________________________________ Child's Name: ___________________________________________School:___________________________________________ Signature of Parent/Guardian: ______________________________________________Date: ______________ Printed Name:________________________________________________________________________________ Address:_____________________________________________________________________________________

2016 – 2017 Registration Process: Home Language Survey

233 North Stephanie Street // Henderson, NV 89074 update150202

850 S. Durango Drive; Suite 100 // Las Vegas, NV 89145 update150202

Home Language Survey

LAST NAME FIRST NAME M.I. DATE

The law requires the school to ask quest ions about s tudents’ language backgrounds to make sure that a l l s tudents receive education services they need. The three quest ions below wil l tel l the school i f the s tudents’ proficiency in English must be evaluated and ensures that programs and services are offered to quali f ied students . The Parent/Guardian Information below wil l help us communicate with you. Direc t ions: P lease ind ica te the correc t response for each o f the fo l lowing ques t ions and spec i fy where appropria te . Student Language Information: 1 . What is the primary language used in the home, regardless of the language spoken by the student?

English ______ Spanish ______ Other (please specify) ________________ 2 . What is the language most often spoken by the student?

English ______ Spanish ______ Other (please specify) ________________ 3 . What is the language that the student f i rst acquired?

English ______ Spanish ______ Other (please specify) ________________ Parent/Guardian Information: To better assist parents in communicat ing effect ively with the school , NSHS has staff available who speak Spanish. For regist rat ion information or quest ions, contact 702-953-2600 or contact www.help.earlycollegenv.com.

English ___Spanish ___ Other (specify)______________

Student Signature Parent/Guardian Signature

OFFICIAL USE ONLY Home Language Survey Phase 1 Status

Complete:  Yes    No  

Entered into Data System:  Yes    No

By:______________  Date:_______  

DATE

STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT This document is intended to address the McKinney-Vento Assistance Act. Your answers will help

determine documents necessary to enroll your child quickly.

Student: ___________________________________________ (M/F) Birthdate: _______________ Grade:____________ 1. Do you and your student live in a fixed, regular, adequate nighttime residence? Yes No (If you circled “NO”, please continue with this form.) 2. Do you and the student live in:

□ shelter □ motel/hotel □ temporarily with another family in a house, mobile home, or apartment □ in a car or RV □ at a campsite □ transitional housing □ other location __________________________________________________

3. The student lives with:

□ one parent □ two parents □ a qualified relative □ friend(s) □ an adult that is not the legal guardian □ alone with no adult(s)

4. I am:

□ the parent/legal guardian of the above-named student □ a qualified adult relative of the above-named student (Relationship: _______________________________)

I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own personal knowledge. Signature: __________________________________________ Date: _________ Print Your Name: ___________________________________ Residence: ________________________________________________________________ Street City Zip Mailing Address: ________________________________________________________________ Street City Zip Telephone #: ( ) ___________________ Cell Phone #: ( ) __________________