Walla Walla Public Schools Registration/Enrollment Form Revised March 2019

Office Use: ID#: Ent date: OE/OL/SP Proof of Age Rec'd

Bus Y - N Imm Current? Y - NLegal Middle Name Also Known As:

Gender BIRTHPLACE: City/ State/ Country Initial US enroll date Grade Level:

Male Female Education months outside US?

Student Lives With: (Circle) Students Language: Has this student ever attended WW Public Schools? Yes / No

Mom Only Dad Only Mom/Stepdad Dad/Stepmom Student's 1st Language: If yes, has his/her last name changed? No / Yes

Grandparent(s) Other:___________________________ Primary Lang at home: Student's Previous School and City: prev name

PRIMARY HOUSEHOLD (Where student resides the majority of the time)Primary Guardian Name: Last/First Guardian email address: Phone Numbers for Primary Guardian

Home: ( )

Relationship to Student: Cell: ( ) Work: ( )

Primary Guardian Address: Street address must be furnished Mailing Address: If different

Secondary Guardian Name (Same House): Last/First Guardian email address: Phone Numbers for Secondary Guardian

Cell: ( ) Work: ( )

Relationship to Student:

Secondary Household

Primary Guardian Name: Last/First Guardian email address: Phone Numbers for Primary Guardian

Home: ( )

Relationship to Student: Cell: ( ) Work: ( )

Primary Guardian Address: Street address must be furnished Mailing Address: If different

Secondary Guardian Name (Same House): Last/First Guardian email address: Phone Numbers for Secondary Guardian

Cell: ( ) Work: ( )

Relationship to Student:

IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? No Yes (if yes, plan must be on file with the school)

IS THERE A RESTRAINING ORDER IN EFFECT? No Yes (If yes, legal papers must be on file with the school)

Restraining order is against: Mother Father Other: ___________________________________________

1st Contact (other than parent/guardian)

Cell Phone:

( )

2nd Contact (other than parent/guardian)

Last Name First Name Cell Phone: Home Phone: Work Phone:

( ) ( ) ( )

Student Release Authorization: In the event that the school is unable to contact the parent or guardian(s) listed

above, I authorize that my child may be released to the person(s) listed above.

Parent/Guardian Signature _______________________________________________ Date _______________________

Did Parents/Guardians move within the past 3 years (36 Months) to work or seek work in agriculture, forestry industry, fishing or a related food processing activity?

yes no When?

PLEASE COMPLETE REVERSE SIDE

Birthdate:

____________________________________________________________________Apt#__________________

______________________________________________________________________________________

________________________

________________________

___________________________________________________________________Apt#___________________

______________________________________________

________________________

______________________________________________________________________________________

First Name

STUDENT INFORMATION: Legal Last Name (Please Print Legibly)

Both Parents

Legal First Name

Other

______________________________________________

_____________________________________________

________________________

_____________________________________________

Home Phone:

( )

Work Phone:

( )

Relationship to Child

OTHER CONTACTS: When injury illness or other non-emergency situations occur involving your child, we want to be able to quickly reach families or

other responsible adults. In the event we cannot reach a parent or guardian, please list persons you trust who are available during the day to provide

care for your child (local area only please).

Last Name Relationship to Child

Walla Walla Public Schools Registration/Enrollment Form Revised March 2019

STUDENT INFORMATION continued Grade?

Has your child ever been retained? 0 yes 0 no

Has your child ever qualified for or been enrolled in a Special Education Program? 0 yes 0 no

Does your child have a current Individual Education Plan (IEP) on file?   yes □ no Date ________

Please check any special/additional help your child has received: Title LAP

Gifted Resource Room Handicapped Self-Contained Reading/Math Speech Therapy

Audiology Occ Therapy Migrant Behavior Other_________________________________

Any health conditions that may affect education needs?____________________________________________________

Has your child ever been in a preschool program? Never Less than 1 year 1, 2, 3, 4, 5 years (circle #)

How many years did your child participate in: Childcare with Relative_____ Preschool/Private_____

List any other programs:_____________________ Preschool/Head Start ______ Early Head Start _______

Current Childcare provider: Name____________________ Address_________________ Phone__________________

Please list ALL other siblings and where they attend if enrolled in Walla Walla Public Schools including preschool

Last Name First Name School/Grade Received Free/Reduced Lunch?

YES NO

YES NO

YES NO

Yes No Comment:

Has your child been expelled or suspended for more than 10 consecutive days? Yes No Comment:

Yes No Comment:

Is a truancy petition filed or in the process of being filed for your student? Yes No Comment:

Does your child have any unpaid fines or fees from other schools? Yes No Comment:

ETHNICITY: Is your child of Hispanic or Latino origin? (mark all that apply) NOT Hispanic/Latino

Mexican/Mexican American/Chicano Other Hispanic/Latino Cuban Central American South American Spaniard Latin American Puerto Rican Dominican

RACE: What race(s) do you consider your child? (mark all that apply)

African American/Black White Alaska Native Snoqualmie

Asian Indian Pakistani Mariana Islander Chehalis Spokane

Cambodian Singaporean Melanesian Colville Squaxin Island

Chinese Taiwanese Micronesian Cowlitz

Filipino Thai Samoan Hoh Stillaguamish

Hmong Vietnamese Tongan Jamestown Suquamish

Indonesian Other Asian Fijian Kalispel Swinomish

Japanese Other American Indian/Alaska Native Lower Elwha Tulalip

Korean Native Hawaiian Lummi Yakama

Laotian Other Pacific Islander Makah

Malaysian Guamanian or Chamorro

VERIFICATION OF INFORMATION: The information on this form is true and accurate as of this date. I understand that

falsification of information to achieve enrollment or assignment may be cause for revocation of the student's enrollment

or assignment to a school in the Walla Walla Public Schools.

Parent/Guardian Signature_________________________________________________________________ Date_______________________

Other Wash. Indian

Skokomish

Quileute

Quinault

Samish

Sauk-Suiattle

Shoalwater

Muckleshoot

Nisqually

Nooksack

Port Gamble Klallam

Puyallup

Does your child have a record of conviction of crimes, violent or disruptive

behavior or gang membership?

Have you and/or your student had any formal meetings with school officials

regarding school attendance issues in the past two years?

ESL □ Bilingual

3/14/2019

RESIDENCY VERIFICATION

Parent/Guardian: You must sign this form upon initial student enrollment in WWPS or when your

residency information changes from what is currently on file with the district. Residency verification

must be one of the following types of documents and dated within the last 30 days:

Utility bill (gas, electric, water)

Rental agreement or current rent receipt

Residence insurance statement

Mortgage booklet, escrow papers, homeowner’s association receipt, property tax form

(Please present a copy of address verification to the school secretary)

Student Name / Grade School

Student Name / Grade School

Student Name / Grade School

Student Name / Grade School

Parent/Guardian Signature Date

School Secretary Signature Date

Student Housing Questionnaire

The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. If you own/rent your own home, you do not need to complete this form. If you do not own/rent your own home, please check all that apply below.

In a motel A car, park, campsite, or similar location In a shelter Transitional Housing Moving from place to place/couch surfing Other________________________________

In someone else’s house or apartment with another family In a residence with inadequate facilities (no water, heat, electricity, etc.)

Name of Student: First Middle Last

Name of School: Grade: Birthdate (Month/Day/Year): Age:

Gender: Student is unaccompanied (not living with a parent or legal guardian) Student is living with a parent or legal guardian

ADDRESS OF CURRENT RESIDENCE:

PHONE NUMBER OR CONTACT NUMBER: NAME OF CONTACT:

Print name of parent(s)/legal guardian(s)/unaccompanied youth:

*Signature parent(s)/legal guardian(s)/unaccompanied youth: Date:

*I declare under penalty of perjury under the laws of the State of Washington that the information provided here is trueand correct.

For School Personnel Only: For data collection purposes and student information system coding

(N) Not Homeless (A) Shelters (B) Doubled-Up (C) Unsheltered (D) Hotels/Motels

McKinney-Vento Act 42 U.S.C. 11435 SEC. 725. DEFINITIONS. For purposes of this subtitle:

(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities. (2) The term homeless children andyouths' —

(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1)); and(B) includes —(i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason;are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living inemergency or transitional shelters; are abandoned in hospitals;(ii) children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used asa regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C));(iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations,or similar settings; and(iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualifyas homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).

(3) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian.

Additional Resources: National Center for Homeless Education National Association for the Education of Homeless Children and Youth (NAEHCY) SchoolHouse Connection Revised March 2019

Certificate of Immunization Status (CIS) For Kindergarten-12th Grade / Child Care Entry

Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex: ____________________________________________________________________________________________________________________________________________________

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record. ______________________________________________________________ Parent/Guardian Signature Required Date

I certify that the information provided on this form is correct and verifiable.

______________________________________________________________ Parent/Guardian Signature Required Date

♦ Required for School and Child Care/Preschool Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Documentation of Disease Immunity Healthcare provider use only

If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider I certify that the child named on this CIS has: a verified history of Varicella (Chickenpox). laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. Diphtheria Mumps Other: Hepatitis A Polio __________ Hepatitis B Rubella __________ Hib Tetanus Measles Varicella

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name

● Required Only for Child Care/Preschool

Required Vaccines for School or Child Care Entry

♦ DTaP, DT (Diphtheria, Tetanus, Pertussis)

♦ Tdap (Tetanus, Diphtheria, Pertussis)

♦ Td (Tetanus, Diphtheria)

♦ Hepatitis B 2-dose schedule used between ages 11-15

● Hib ( Haemophilus influenzae type b)

♦ IPV / OPV (Polio)

♦ MMR (Measles, Mumps, Rubella)

● PCV / PPSV (Pneumococcal)

♦ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV, MPSV (Meningococcal)

MenB (Meningococcal)

Rotavirus

Office Use Only:

Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide

database). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: waiisrecords@doh.wa.gov or 1-866-397-0337.

To fill out the form by hand: #1 Print your child’s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against

several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.

If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.

#4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.

Reference guide for vaccine trade tames in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB® Hib Fluarix® Flu Havrix® Hep A Menveo® Meningococcal Rotarix® Rotavirus (RV1)

Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® DTaP + Hep B + IPV RotaTeq® Rotavirus (RV5)

Afluria® Flu FluLaval® Flu HibTITER® Hib PedvaxHIB® Hib Tenivac® Td

Bexsero® MenB FluMist® Flu Ipol® IPV Pentacel® DTaP + Hib + IPV Trumenba® MenB

Boostrix® Tdap Fluvirin® Flu Infanrix® DTaP Pneumovax® PPSV Twinrix® Hep A + Hep B

Cervarix® 2vHPV Fluzone® Flu Kinrix® DTaP + IPV Prevnar® PCV Vaqta® Hep A

Daptacel® DTaP Gardasil® 4vHPV Menactra® MCV or MCV4 ProQuad® MMR + Varicella Varivax® Varicella

Engerix-B® Hep B Gardasil® 9 9vHPV Menomune® MPSV4 Recombivax HB® Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 December 2016

Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 Meningococcal Conjugate Vaccine OPV Oral Poliovirus

Vaccine Tdap Tetanus, Diphtheria, acellular Pertussis

DTaP Diphtheria, Tetanus, acellular Pertussis

Hep B Hepatitis B MenB Meningococcal B PCV / PCV7 / PCV13

Pneumococcal Conjugate Vaccine VAR / VZV Varicella

DTP Diphtheria, Tetanus, Pertussis Hib Haemophilus

influenzae type b MPSV / MPSV4 Meningococcal Polysaccharide Vaccine

PPSV / PPV23 Pneumococcal Polysaccharide Vaccine

Flu (IIV) Influenza HPV (2vHPV / 4vHPV / 9vHPV)

Human Papillomavirus MMR Measles, Mumps,

Rubella Rota (RV1 / RV5) Rotavirus

HBIG Hepatitis B Immune Globulin IPV Inactivated

Poliovirus Vaccine MMRV Measles, Mumps, Rubella with Varicella

Td Tetanus, Diphtheria

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

2019 MARCH

Walla Walla Public School District

Student Health History To be completed by parent/guardian

Name of Student: ___________________________________Date of Birth: ________________ Sex: � Male � Female

� No � Yes Glasses/Contacts, Date of last eye evaluation: _______________________________________________

� No � Yes Hearing aids, Date of last hearing exam: ___________________________________________________

Primary Provider: Dentist: Date of last visit dental visit:

Daily Medications

State law RCW 28A.210.260 requires written permission from a Health Care Provider and parent before any

medication (prescription or over-the-counter) can be given at school. A form is available at your school

office or on Walla Walla Public Schools Health Services website.

� No � Yes Medication needed at school (list):________________________________________________________

� No � Yes Medication needed at home (list):_________________________________________________________

� No � Yes Allergies: (list)

Life Threatening Medical Conditions

Washington State law requires that students with life-threatening health conditions, where the condition would

“put the child in danger of death during the school day”, have medication/treatment orders and a nursing plan in

place at school before your child can attend school. Forms are available in your school office or on Walla Walla

Public Schools Health Services website.

Life Threatening Conditions (Requires Health Care Provider Orders) Please check all that apply:

� No � Yes Severe Allergic reaction to Nuts (list): ____________________________________________________

� No � Yes Severe Allergic reaction to Bee Stings requiring emergency medication: _______________________

� No � Yes Other Severe Allergies-affecting school. Specify: __________________________________________

� No � Yes Severe Asthma: regularly takes medication for asthmatic condition and/or hospitalized within the

last 5 years for asthmatic condition

� No � Yes Diabetes

� No � Yes Seizure Disorder that requires an emergency medication: ___________________________________

Health Concerns: (which may potentially be a life threatening conditions that may require Health Care Provider orders)

Please check all that apply and explain:

� No � Yes Asthma: takes medication only when needed: ____________________________________________

� No � Yes Seizure: Type of Seizures and date of last Seizure: _________________________________________

� No � Yes Heart Condition: _____________________________________________________________________

� No � Yes Behavioral/Emotional Concerns: _______________________________________________________

� No � Yes Other Health Concerns: _______________________________________________________________

� No � Yes Any Chronic or recurring illness: _______________________________________________________

Does your child have any other condition that would affect his/her classroom performance or P.E. activities?

� No �Yes if yes, explain: _______________________________________________________________________

All health information is considered confidential. It will be shared electronically with staff as needed during the time your child is enrolled

in Walla Walla School District in order to ensure the health and safety of your child, unless otherwise requested by you in writing.

Parent/guardian signature

_____________________________________________Date_________________________________________

Grade: ______________

Teacher: ____________

School: _____________

The Walla Walla Public Schools is an Equal Opportunity Employer and compiles with all requirement of the ADA

421 S. Fourth Street, Walla Walla WA 99362-3293 * (509) 526-8507 * Fax (509) 526-8508

Health Services

Walla Walla Public SchoolsWalla Walla Public SchoolsWalla Walla Public Schools

Dear Parent or Guardian:

The Walla Walla School District school clinic staff is proud to be part of the team effort that supports student

success in our county. We hope this letter will explain some of the things we do and how we can help you and

your child have a successful school experience. This parent letter, Immunization Information, the Medication at

School Policy 3416, Authorization for Administration of Medication at School, and Health Care Plans are

available at the schools.

IMMUNIZATION CERTIFICATES

All students entering or attending preschool through 12th grade are required to have a complete Washington

Certificate of Immunization Status in accordance with Washington State law (RCW 28A.210.160). All students

must be immunized against disease as specified by the Washington Department of Health or have medical or

religious exemption on file at school. Please see attached immunization chart.

SCHOOL MEDICATION ADMINISTRATION

Walla Walla Public School’s Medication at School Policy 3416 will be followed for all medications given during

school hours.

• The parent or legal guardian and health care provider(s) must complete and sign an Authorization for

Administration of Medication at School form for all medications (prescription and over-the-counter) given at

school. Copies of the form are available in most health care provider clinics and can be obtained from your

school clinic.

• A parent/legal guardian or other designated adult must bring all medication, accompanied by the

Authorization for Administration of Medication at School, to the school clinic unless special permission is

given by the principal or clinic staff.

• All over-the-counter and prescription medications must be in their original containers with unexpired dates.

Prescription medications must be clearly labeled with the physician’s name, medication’s name, strength,

dosage, date, time for administration and dispensing pharmacy. The parent/guardian must provide over-the-

counter medications to the clinic.

• If your child has a life-threatening condition (i.e. asthma, diabetes, or allergic reaction), permission may be

granted to carry the medication (such as inhaler, glucose tablet, Epi-pen, or internal Insulin pump) on his or

her person from the child’s physician and parent/guardian on the School Medication Authorization.

HEALTH PLANS/SERIOUS HEALTH CONDITIONS

Parents/guardians of children with life-threatening health conditions must notify the school and complete the

required paperwork before your child can start school. If your child has an allergy, asthma, diabetes, seizures or

other chronic health condition which may require medication, treatment order or Health Plan, make an

appointment with your healthcare provider. Addressing the health condition that may require medical services to

be performed at the school assists us in caring for your child during the school day. Forms are available from

your school clinic staff. See Washington state law RCW 28A.210.320 regarding life-threatening health conditions.

Please contact your school clinic if you have any questions or concerns. Working together, we can promote the

health and well-being of your child and ensure s/he obtain the maximum educational benefit while at school.

If you have any questions or concerns, please contact your school's clinic.