For Office Use Only

Student ID # __________________

School ______________________

2017-2018 Transportation_________________

Student's Legal Name (as it appears on the Birth Certificate)

First Name ___________________________________________Middle Name ______________________ Last Name ________________________

Grade __________ Gender __________ Male __________ Female Date of Birth _____________ Age ______

Student's email (if any) ___________________________________ Nickname/Alias _____________________________________

Address ____________________________________________________ City __________________ Zip Code _____________

Apartment/Housing Addition ________________________________________ Home Phone ______________________________

Birth City ____________________________________________________ Birth State _____________________________________

If not born in the US:

Birth Country _____________________________ US Entry Date ________________ First Date in US Schools _____________

Indian Tribe _______________________________________________________________ CDIB Number ______________________

Transportation Parent Pick-Up _____ Bus Rider _____ Driver _____ Walker _____ Daycare (specify) ______________________

Has your child ever attended Mid-Del Schools? Yes _____ No ______ Start Date __________ End Date __________

Has your child ever been homeschooled? Yes _____ No ______ Start Date __________ End Date __________

Name of last school attended __________________________________________ City ________________________ State _____

Name of ALL high schools attended ____________________________________________________________________________________

School Phone _______________________________ School FAX _______________________ Withdrawal Date _____________

Does this student have a current IEP? Yes ____ No ____ Does this student have a current 504? Yes ____ No ____

Has this student ever participated in a Gifted and Talented Program? Yes _____ No ______

Is this student currently under suspension from another school? Yes _____ No _____

Does your student currently participate in the Oklahoma's Promise Program (OHLAP)? Yes ______ No ______

Siblings under the age of 18 living at home:

Name Grade Gender

Name Grade Gender

Name Grade Gender

Is any parent/legal guardian (including non-custodial) an active duty military member? Yes _____ No _____

Is any parent/legal guardian (including non-custodial) a military reserve member? Yes _____ No _____

Is any parent/legal guardian (including non-custodial) a National Guard member? Yes _____ No _____

School

Pursuant to the School Laws of Oklahoma, Mid-Del Public Schools prohibits the attendance of a student under suspension from another school, until such time as the terms of the

suspension have been met or the suspension has expired. The circumstances of an individual's suspension may be reviewed.

Mid-Del Public Schools

Student Enrollment Information

School

Birth date

Birth date

Birth date School

Parent/Guardian Contact InformationStudent resides with: Mother/Father Mother Father Mother/Step-Father Father/Step-Mother Other

List contacts in preference order for notification - legal guardians must be listed as first contacts. (Only one person per line)

Parent/Guardian #1

Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Work Phone

Employer Address

E-mail Address Relationship to student

Parent/Guardian #2

Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Work Phone

Employer Address

E-mail Address Relationship to student

Contact 3:

Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Relationship to student

Contact 4:

Last Name Middle

Address City State Zip Code

Home Phone Cell Phone Relationship to student

Specify any other individual that is eligible to pick up this student in addition to the contacts listed above:

Name Phone Name Phone

Custody alert Legal Documentation on file? Yes ______ No______

Are you the legal guardian of this student? Yes No

If no, explain below:

First Name

First Name

First Name

First Name

Student Name_____________________________________ Grade________ School__________________________

Health Information

Has this student been diagnosed with any of these conditions?

Diabetes Yes _____ No _____ Name of medications currently taking ___________________________

Asthma Yes _____ No _____ Name of medications currently taking ___________________________

Seizures Yes _____ No _____ Name of medications currently taking ___________________________

Does this student have a severe allergy that requires Epinephrine? Yes _____ No _____

Does this student have any other chronic health conditions? Yes _____ No _____

If yes, explain below:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Does this student have any medically documented food allergies? Yes _____ No _____

Parent/Guardian Signature_____________________________________ Date___________________

By signing this form I do hereby affirm that the student listed above is not currently under suspension from

another school district. I also affirm that the facts stated herein are true. Any false statement subjects the above

named student to immediate withdrawal.

Medications that are prescribed to be taken during the school day must be brought to the office by an adult.

List medications to be given at school: Parental Authority to Administer Medication form must be on file for each

prescribed medication.

If yes, you must provide information from the student's physician explaining each allergy the child has. This

documentation must be provided by October 1 of each school year.

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I-22 R-1

Mid-Del Schools Internet Safety Policy Family Consent Form

Student Section

Student Name __________________________________________ Grade ____________________

School

I have read the Mid-Del District Policy, “Use of the Wide Area Network, The Internet, and

Other Technological Resources”. I agree to follow the rules contained in the Policy and any additional

rules provided by school staff. I understand that if I violate the rules my access privileges may be

revoked and school disciplinary and/or appropriate legal action may be taken.

Student Signature _________________________________________Date___________________

Parent or Guardian Section

I am the parent/guardian of _________________________, the minor student who has signed

the district’s agreement for student use of computerized information resources. I have been provided

with a copy and I have read the district’s Acceptable Use Policy and am aware that additional

guidelines and regulations concerning use of the district computer system are posted for students and

are available at my school for further examination.

I also acknowledge receiving notice that, unlike most traditional or library media materials, the

district computer system will potentially allow my son/daughter student access to external computer

networks not controlled by the school district. I understand that some materials available may be

inappropriate and objectionable; however, I acknowledge that it is impossible for the district to screen

or review all of the available materials. I accept responsibility to set and convey standards for

appropriate and acceptable use to my child when using the district computer system or any other

electronic media or communications.

I also acknowledge that my child will be allowed to post tasks or assignments they have

completed on the Internet. The Board has ensured that the requirements of the Children’s Internet

Protection Act (CIPA) have been addressed.

I hereby release the District, its personnel, and any institutions with which it is affiliated, from

any and all claims and damages of any nature arising from my child’s use of, or inability to use, the

District system, including, but not limited to claims that may arise from the unauthorized use of the

system to purchase products or services.

Please select one and return to the school.

No, I do not give permission for my child to have personal access to electronic communications.

Yes, I agree that my child may have access to electronic communications for educational purposes

only.

________________________________________________ __________________________

Parent or Guardian Signature Date

IF AT ANY TIME, YOU WISH TO CHANGE YOUR ELECTION ABOVE TO THE OTHER

CHOICE, YOU MUST NOTIFY THE PRINCIPAL OF YOUR CHILD’S SCHOOL IN WRITING.

(See Internet Safety Policy on back)

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I-22 R-1

Use of the Wide Area Network, The Internet, and Other Technological Resources

Internet Safety Policy (ISP)

The Board of Education provides the wide area network, local area networks, Internet access, and other technological

resources for the purpose of supporting and enhancing learning and teaching. The Board recognizes that guidelines must

be established to assure that these technologies are used to provide activities that are appropriate to the learning

environment.

Some material accessible via the Internet may contain items that are illegal, defamatory, inaccurate or potentially

offensive. The Board cannot guarantee that a student will not encounter questionable material on the Internet. This policy

addresses the following as required by CIPA:

A. Access by minors to inappropriate matter on the Internet and World Wide Web;

B. The safety and security of minors when using electronic mail, chat rooms, and other forms of direct electronic

communications;

C. Unauthorized access, including so-called “hacking,” and other unlawful activities by minors online;

D. Unauthorized disclosure, use, and dissemination of personal information regarding minors;

E. Measures designed to restrict minors’ access to materials harmful to minors; and

F. Educating minors about appropriate online behavior, including interacting with other individuals on social

networking websites and in chat rooms and cyber bullying awareness and response.

Acceptable uses of the network and Internet are activities resulting from specific tasks and assignments which support

learning and teaching and promote the district’s mission and goals.

Prohibited uses are those which violate the right to privacy or access to materials, information or files of another

individual or organization without permission; violate the copyright laws; spread computer viruses; deliberately attempt to

vandalize, damage, disable or disrupt the property of the District, another individual, organization or the network; or any

effort to locate, receive, transmit, store or print files or messages that are profane, obscene, sexually explicit or use

language that is offensive or degrading to others. Use for commercial activities, product advertisement or political

lobbying is also prohibited. Staff will be provided a school email account to be used for school purposes. Students may be

provided an email account to be used for school purposes. Electronic communications may be used for educational

purposes only. Supervision by an adult is required for students in Kindergarten through grade 12.

The District is responsible for protecting its networks in a reasonable manner against unauthorized access and/or

abuse, while making them accessible for authorized and legitimate users. This responsibility includes informing users of

expected standards of conduct and the punitive measures for violating them.

Before a student may access the Internet, parental permission will be required. In those cases involving adult student

training, business and industry training, or 18 year-old students, a signed statement declaring the participant’s intent to

comply with district policy and guidelines will be required. Students’ directory information may be referenced in the

Student Expectations Policies, Procedures and Safety Guidelines Handbook. (See Policy J-18)

The Superintendent or designee shall be responsible for developing guidelines to govern the use of these technologies

in the District.

For students to remain eligible as users, student use must be in support of and consistent with the educational

objectives of the District. Access requires responsibility. Students and all other users of the district’s networks and other

technological resources are responsible for respecting and adhering to local, state, federal and international laws and

guidelines governing use of information and the available technologies. Any attempt to violate the guidelines, terms and

conditions for use of technology, the network or the Internet may result in revocation of user privileges, other disciplinary

actions consistent with Board of Education policy and existing practice regarding inappropriate language or behavior,

including, but not limited to, suspension from school, termination of employment and/or appropriate legal action.

The District makes no warranties of any kind, either expressed or implied, for the Internet access it is providing. The

District will not be responsible for any damages users suffer, including, but not limited to, loss of data; delays or

interruptions in service; accuracy, nature or quality of information stored on District diskettes, hard drives or servers; and

accuracy, nature or quality of information gathered through district-provided Internet access.

The District will not be responsible for unauthorized financial obligations resulting from district-provided access to

the Internet.

Mid-Del Schools

Child Nutrition

Program 2017-2018

It is the goal of the Mid-Del Schools Child Nutrition Program to make available to every

student a nutritious, well-prepared breakfast and/or lunch every day. A computerized

cash register system is used in the school cafeterias and an account has been created for

each child’s use. Students will be issued a personal identification number to access their

account. You may pre-pay into this account with cash and/or personal checks.

Check Writing Policy

Personal checks made payables to the school Child Nutrition Program are accepted. In

the event that a returned check is received on your child’s account, the school cafeteria

supervisor will notify you. Payment must be made within ten (10) days after notification

in the form of cash, cashiers check or money order.

No Charge Policy

It is the responsibility of each student’s parent/guardian to maintain sufficient funds in

his/her account. If a child has a zero balance in his/her account, they will be expected to

pay at the cash register. Mid-Del Schools has had a NO CHARGE policy since 1983 –

there are no exceptions. A student who does not have money to purchase a lunch will

receive a cheese sandwich, fruit, and milk paid for by the Child Nutrition Program for no

more than three (3) consecutive days. Parents are encouraged to have a plan with their

child regarding what to do if lunch money is forgotten, i.e. a relative to call to bring

money, etc.

If you have any questions, please feel free to contact the Child Nutrition Department at

739-1611.

I have read, understand and agree to the above Check Writing and No Charge Policies.

_________________________________________

Student Name

_________________________________________ ________________________

Parent/Guardian Signature Date

Parent Notification System Parents Must Sign Form Each School Year

Each year, parents much sign an authorization form to receive communication from Mid-Del Schools. For more information, please visit the link below for more information about the Telephone Consumer Protection Act (TCPA): http://transition.fcc.gov/cgb/policy/TCPA-Rules.pdf

I agree that Mid-Del Public Schools will contact me by phone, email, and text through the parent notification system unless I opt-out of this service, which I may do at any time. By agreeing to this service, I will receive notifications from the school including school closings, upcoming events and other important messages from the school. By signing this form, you agree to allow Mid-Del to use its parent notification system to contact you throughout the 2017-2018 school year.

Print Student Name: _______________________________________________________________________

Parent/Guardian Signature: _________________________________________________________________

No, I want to Opt-Out of ALL Messages.

HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

Name of Student: ____________________________________________________________________ Grade:____________ Last Name First Name Middle Name Date of Birth: __________________ School: _____________ Student ID # ___________________ Gender: Male_______ Female________ MM/DD/YYYY Is the student of Hispanic or Latino culture or origin? Yes________ No_________ Select one or more of the following races: ______ African American/Black ______ American Indian/Alaskan Native ______ Asian ______ Native Hawaiian/Pacific Islander ______ Caucasian/White

1. What is the dominant language most often spoken by the student?

2. What is the language routinely spoken in the home, regardless of the language spoken by the student?

3. What language was first learned by the student?

4. Does the parent/guardian need interpretation services? Yes _____ No _____ If so, what language? _______________________________

5. Does the parent/guardian need translated materials? Yes _____ No _____ If so, what language? _______________________________ 6. What was the date the student first enrolled in a school in the United States? ________________________

MM/YYYY

______________________________________________________________________________________________________________

☐ Other language than English indicated TWO OR MORE times on questions 1 – 3 above. The student is classified as “more often” and automatically qualifies as bilingual on

the accreditation report.

☐ Other language than English indicated ONLY ONCE on questions 1 – 3 above. The student is classified as “less often” and only qualifies as bilingual on the accreditation

report if he or she meets one of the following (any selection below REQUIRES appropriate documentation):

☐ 1. Designated English Learner on one of the Oklahoma English language proficiency assessments: ACCESS for ELLs 2.0, Alternate ACCESS for ELLs,

WIDA Screener, WIDA MODEL, K-WAPT, W-APT or Oklahoma Pre-K Language Screening Tool.

☐ 2. Scored unsatisfactory or limited knowledge in Reading on the Oklahoma State Testing Program (OSTP).

☐ 3. Scored at or below the 35th percentile (or equivalent) composite reading score from spring of the previous school year on a state approved norm-referenced test (NRT).

DOCUMENTATION OF A TEST RESULT FOR STUDENTS MARKED LESS OFTEN

Date(s) of Kindergarten ACCESS, ACCESS for ELLs 2.0, or Alternate ACCESS Test

Score(s) on Kindergarten ACCESS, ACCESS for ELLs 2.0,or

Alternate ACCESS

Date(s) of WIDA Screener or K-WAPT/WAPT or

WIDA MODEL

Score(s) on WIDA Screener or K-WAPT/WAPT or

WIDA MODEL Composite Score Literacy Score Composite Score Literacy Score

1. 2. 1. 2.

1. 2.

Date(s) of Reading OSTP Score(s) on Reading OSTP

Unsatisfactory Limited Knowledge Satisfactory Advanced

Unsatisfactory Limited Knowledge Satisfactory Advanced

Unsatisfactory Limited Knowledge Satisfactory Advanced

Date(s) Norm Reference Test (NRT) Name of the NRT Reading Total Composite Score(s) %

Date of the Oklahoma Pre-K Language Screening Tool

Score on Pre-K Language Screening Tool

%

20____- 20____

SCHOOL USE ONLY Please have test score documentation available for the Regional Accreditation Officer to review.

STUDENT INFORMATION

Revised: January, 2017 5

Date (MM/DD/YYYY) Parent / Guardian Signature

From Above: Question 1: Reference WAVE code 1036 Question 2: Reference WAVE code 1037 Question 3: Reference WAVE code 1038

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