IP Kindergarten Welcome Letter...Completed Certificate of Immunization Status (CIS), OR Certificate...

Grades6-8IslanderMiddleSchool

REGISTRATION PACKET

PLEASE PRINT 1-SIDED copies if you are printing this packet from your computer. Please type or print clearly when filling out the forms.

Some of the forms in this packet can be filled out on the computer. Download the packet and open it in Adobe Acrobat Reader for best results.

Please contact Marcy Berejka, IMS registrar, [email protected] for an appointment and questions. At the appointment please provide copy of a recent report card and the fully completed documents listed below.

Forachildtobeconsideredregistered,thesefullycompleteddocumentsmustbesubmitted:

❑ Student Enrollment Form❑ Student Health Forms❑ Proof of Residency (utility bill or closed bill of sale/rental lease agreement)❑ Completed Certificate of Immunization Status (CIS), OR Certificate of Exemption:

The CIS form must be filled out completely.❑ Home Language Survey❑ Ethnicity and Race Data❑ MISD Student Housing Questionnaire❑ Request for Transfer of Educational Records❑ IMS PTA New Families Form

Noexceptionsaremadeontheaboverequirements.Incompletepacketswillnotbeaccepted.

Schoolcalendarscanbefoundonthewebsiteatwww.mercerislandschools.org/StudentCalendar

Questions?Pleasecontact:IslanderMiddleSchool,Registrar744784thAve.SEMercerIsland,WA98040206-230-6160

Ifyouare completingyourregistrationpacketduringthesummerbeforetheschoolsreopeninearlytomid-August,pleasehold the packet. The IMS Registrar will be available for registration appointments starting August 15, 2017. Office hours will be 8:30 a.m. to 3:00 p.m. Please leave a message for Marcy Berejka at 206-230-6160 for a registration appointment.

VAdamsLearningServices/GR6-8RegPkt2016-17FrontPagerev/websiteStudentRegstorage/3-6-17

mailto:[email protected]

https://www.mercerislandschools.org/domain/32

mailto:[email protected]

Chi nese Tr ans l at i on f or Annual Non- di scr i mi nt at i on Not i ce 年度综合非歧视声明：默瑟岛学区，在学区的项目或活动中，保障任何人不得因性别、种族、

信仰、宗教、肤色、原国籍、年龄、退伍军人及军人身份、性取向、

性别表达及身份、残疾及缺陷、或使用受过训练的导盲犬或服务动物

而受到歧视。默瑟岛学区提供平等的机会参与童子军和其他指定的青

少年团体的项目和活动。在默瑟岛学区提供的许多大学和职业培训项

目的课程中，任何人的录取不受歧视。有限的英语能力不会是录取和

参与这些项目的障碍。以下人员负责处理有关非歧视政策的咨询：骚扰、恐吓和欺凌( HI B)协调员: Dr. Gary Plano, Superintendent,

(206) 236-‐3300 [email protected]

第九条权益合规协调员: Dean Mack, CFO/COO, (206) 236-‐4522 [email protected]

504条款及残障保护协调员: Lindsay Myatich, Director, (206) 236-‐3326 [email protected]

民权合规协调员: Mark Roschy, Director, (206) 236-‐3439 [email protected]

有关学区项目和活动的歧视投诉可根据区行政条例 3210P进行。













Comprehensive or Annual Nondiscrimination Statement:

The Mercer Island School District does not discriminate in any programs or activities on the basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender expression or identity, marital status, disability, or the use of a trained dog guide or service animal and provides equal access to the Boy Scouts and other designated youth groups. The Mercer Island School District offers classes in many College and Career Readiness Programs, admission to which is non-discriminatory. Lack of English-language proficiency will not be a barrier to admission and participation in those programs.

The following people have been designated to handle inquiries regarding the nondiscrimination policies:













SPANISH VERSION

Declaración completa de no discriminación El Distrito Escolar de Mercer Island no discrimina en los programas o actividades en base a sexo, raza, credo, religión, color, origen nacional, edad, veterano o estado militar, orientación sexual, expresión o identidad sexual, discapacidad, o el uso de un perro guía entrenado o animal de servicio y proporciona un acceso igualitario a los Boy Scouts y otros grupos de jóvenes designados. El Distrito Escolar de Mercer Island ofrece clases en muchos programas de preparación para la universidad y carreras, la admisión a dichos programas no es discriminatoria. La falta de dominio del idioma Inglés no será un obstáculo para la admisión y participación en esos programas. Las siguientes personas han sido designadas para atender las consultas relativas a las políticas de no discriminación:

Las quejas relativas a la discriminación en los programas del Distrito pueden ser hechas de acuerdo con el Procedimiento Administrativo del Distrito 3210P.

Coordinador de HIB (El acoso, la intimidación y el acoso escolar):

Dr. Gary Plano, Superintendente, (206) 236-‐3300

Coordinador del Cumplimiento del Título IX:

Dean Mack, CFO / Director de Operaciones, (206) 236-‐4522

Coordinadora de la Sección 504 y ADA:

Lindsay Myatich, Director, (206) 236-‐3326

Coordinador de Derechos Civiles:

Mark Roschy, Director, (206) 236-‐3439

Coordinador de Acción Afirmativa:


Erin C. Battersby(206) [email protected]

SPANISH VERSION

























Harassment, Intimidation and Bullying (HIB) Coordinator:

Title IX Compliance Coordinator:

Section 504 & ADA Coordinator:

SPANISH VERSION












Mark Roschy, Director, (206) 236-‐3439 Civil Rights Compliance Coordinator:

SPANISH VERSION

























SPANISH VERSION












Mark Roschy, Director, (206) 236-‐3439 Complaints regarding discrimination in District programs may be made in accordance with District Administrative Procedure 3210P.

SPANISH VERSION

























SPANISH VERSION















Dr. Lindsay Myatich, Director(206) [email protected]

(HIB)

:

SPANISH VERSION

Declaración completa de no discriminación El Distrito Escolar de Mercer Island no discrimina en los programas o actividades en base a sexo, raza, credo, religión, color, origen nacional, edad, veterano o estado militar, orientación sexual, expresión o identidad sexual, estado civil, discapacidad, o el uso de un perro guía entrenado o animal de servicio y proporciona un acceso igualitario a los Boy Scouts y otros grupos de jóvenes designados. El Distrito Escolar de Mercer Island ofrece clases en muchos programas de preparación para la universidad y carreras, la admisión a dichos programas no es discriminatoria. La falta de dominio del idioma Inglés no será un obstáculo para la admisión y participación en esos programas. Las siguientes personas han sido designadas para atender las consultas relativas a las políticas de no discriminación:

Las quejas relativas a la discriminación en los programas del

Distrito pueden ser hechas de acuerdo con el Procedimiento Administrativo del Distrito 3210P.











Chinese Translation for Annual Non-discrimintation Notice

年度综合非歧视声明：

默瑟岛学区，在学区的项目或活动中，保障任何人不得因性别、种族、


性别表达及身份、婚姻状况、残疾及缺陷、或使用受过训练的导盲犬

或服务动物而受到歧视。默瑟岛学区提供平等的机会参与童子军和其

他指定的青少年团体的项目和活动。在默瑟岛学区提供的许多大学和

职业培训项目的课程中，任何人的录取不受歧视。有限的英语能力不

会是录取和参与这些项目的障碍。

以下人员负责处理有关非歧视政策的咨询：

骚扰、恐吓和欺凌(HIB)协调员: Dr. Gary Plano, Superintendent, (206) 236-‐3300 [email protected]


504 条款及残障保护协调员: Lindsay Myatich, Director, (206) 236-‐3326 [email protected]


有关学区项目和活动的歧视投诉可根据区行政条例 3210P 进行。

Annual Nondiscrimination statement: Chinese

有关非歧视原则的声明：

默瑟岛学区不容许在任何项目或活动中，对如下情形有歧视行为：性别、种族、信仰、宗

教、肤色、国籍、年龄、退伍或现役军人身份、性取向、性别倾向或特征、残疾、导盲犬

或服務性動物的使用。学区向童子军和其他指定的青少年团体开放。对于学区提供的大学

预备和职业培训项目，录取标准和过程都遵循非歧视原则。英语能力不会成为录取和参与

这些项目的障碍。

以下人员负责处理有关非歧视政策的咨询：  

骚扰、恐吓和欺凌(HIB)协调员: Dr. Gary Plano, Superintendent, (206) 236-3300 [email protected]

第九条权益（反性别视法）合规协调员: Dean Mack, CFO/COO, (206) 236-4522 [email protected]

504条款（反残障歧视法）及残障保护协调员: Lindsay Myatich,  Director,  (206) 236-3326 [email protected]

民权合规协调员: Mark Roschy, Director, (206) 236-3439 [email protected]

对学区项目和活动的歧视投诉，应根据学区行政条例3210P进行。

VAdamsLearningServices/NondescriminationStatementStorage/5-10-16

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譯員服務或將文件翻譯成您使用的語言。

Waxaan kugu caawin karna Soomaaliga! Fadlan noo sheeg haddii aad u baahan tahay turjubaan ama in dokumeentiga laguugu turjubaano luqaddaada—iyadoo aanay wax kharash ah kaaga bixin.

Ми можемо надати вам інформацію українською мовою! Якщо вам потрібен перекладач або переклад того чи іншого документу українською мовою, просимо повідомити нам про це—послуга безкоштовна.

한국어 지원 서비스가 제공됩니다! 통역사가 필요하시거나 귀하의 언어로 번역된 문서

가 필요하시다면 저희에게 알려 주십시오. 부담하시

는 비용은 없습니다.

يمكننا مساعدتك باللغة ! العربية

يرجى إعالمنا إذا ما كنت بحاجة إلى مترجم فوري .أو إلى ترجمة مستند إلى لغتك، دون تكلفة عليك

Matutulungan ka namin sa Tagalog! Mangyaring ipaalam sa amin kung kailangan mo ng isang interpreter o ng isang dokumentong isinalin sa iyong wika—nang wala kang babayaran.

Russian

OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION | EQUITY AND CIVIL RIGHTS

안녕 xin chào

你好

Military Family Status

Mercer Island School District

Student Enrollment Form

Today’s Date: _______________ New Re-enrolling Entering Grade ________ Year of HS Graduation ____________ Counselor ____________________

Student Name: Legal Last Name Legal First Name Legal Middle Name Also known as:

Birthdate (Month/Day/Year) Gender Birthplace: City State Country M F

Primary Household Parent/Guardian #1 Phones and EmailPlease check primary phone; include area codeEmail Address: _________________________________________________________

Home phone: ( ) ______________________________________________

Cell phone ( ) ________________________________________________

Work phone ( ) _______________________________________________

Primary Household Parent/Guardian #1 (where student resides) Last name First Name

Primary Household Parent/Guardian #2 (where student resides) Last name First Name

Primary Household Information

ResidentAddress

Street Apt # City State Zip

Street Apt # PO Box City State Zip

Is there a joint custody or parenting plan in effect? Yes No (If yes, plan must be on file with the school for enforcement)

Is there a restraining order in effect? Yes No (If yes, legal papers must be on file with the school for enforcement)

Restraining order is against: Mother Father Other ___________________________________________________________________

Mailing Address(if different from above)

Secondary Household Parent/Guardian #1 Secondary Household Parent/Guardian #2 Last name First Name Last name First Name

Secondary Household Information Receive Mailings? Yes No

SecondaryAddress

Street Apt # City State Zip

Street Apt # PO Box City State ZipMailing Address(if different from above)

OFFICE USE ONLYAddress Verif. _________ Immuniz. _________Please Print

Clearly

Is this a temporary living situation? Yes No If Yes, please indicate where the student is living: ___ in a shelter ___ in a car ___ in a motel/hotel ___with more than one family

in a house or apartment ___with friends or a relative ___Other (please specify): ___________________________________________________________________________________

Does the living situation checked above result from a loss of housing or from economic hardship? Yes No Not sure

Primary Household Parent/Guardian #2 Phones and EmailPlease check primary phone; include area codeEmail Address: _________________________________________________________

Home phone: ( ) ______________________________________________

Cell phone ( ) ________________________________________________

Work phone ( ) _______________________________________________

Secondary Household Parent/Guardian #1 Phones and EmailPlease check primary phone; include area codeEmail Address: _________________________________________________________

Home phone: ( ) ______________________________________________

Cell phone ( ) ________________________________________________

Work phone ( ) _______________________________________________

Secondary Household Parent/Guardian #2 Phones and EmailPlease check primary phone; include area codeEmail Address: _________________________________________________________

Home phone: ( ) ______________________________________________

Cell phone ( ) ________________________________________________

Work phone ( ) _______________________________________________

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Is your child enrolled in a Special Ed Program? Yes No Does your child have a 504 Plan? Yes No Is your child participating in: Title I/LAP IEP Gifted OT/PT Speech Therapy Other ___________________________Is your child enrolled in English Language Learners Program? Yes No

Special Services

Parent/guardian currently serving in the military:

No affiliation U.S. Armed Forces active duty National Guard Member More than one member of U.S. Armed Forces reserves Refuse to stateArmed Forces/National Guard

Student lives with Both parents Father only Mother only Grandparents Father/Stepmother Mother/Stepfather Stepfather/Stepmother Foster Parent(s) Guardian Agency Emancipated Minor Self Other

Emergency Contacts— NOT parents or guardians. Local contacts only.(Fill in information for at least two contacts).

Preschool/Kindergarten Information

Has your child ever been suspended for a weapons violation? Yes No Date: ___________________

Last Name First Name School Grade

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Siblings Please list other siblings attending Mercer Island Public Schools:

Primary Contact (other than parent/guardian) Relationship to child Phone #1 (include area code) Phone #2 (include area code) Last name First Name Home Work Cell Home Work Cell

Second Contact (other than parent/guardian) Last name First Name Home Work Cell Home Work Cell

Third Contact (other than parent/guardian) Last name First Name Home Work Cell Home Work Cell

In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above.

Legal Parent/Guardian Signature __________________________________________________________________________________ Date _______________________________________

Notice: Only students who physically reside within the boundaries of the Mercer Island School District and nonresident students who have obtained a release from their resident districts and have been officially accepted by the Mercer Island School District may legally attend school within the Mercer Island School District. Recognizing this legal requirement, I hereby verify that the student named above physically resides within the Mercer Island School District boundaries or has obtained a release from his/her resident district and has been officially accepted by the Mercer Island School District.I certify the foregoing information to be true and recognize that falsification or omission of information could result in modification of the school or program placement for this student, including sending the student to his/her resident district.Legal Parent/Guardian Signature ________________________________________________________________________ Date ______________________________

Safety

Student Release Authorization

Previous Schooling Information

How many months (1 year = 10 months) has the student attended school in the US (K-12) before enrolling in the district?______________ How many months (1 year = 10 months) has the student received formal education in his/her native language (equivalent to K-12) before enrolling in the district? ______________

Did child attend Mercer Island School District Preschool? Yes No For kindergarten student, please indicate preschool attended ____________________________________________________________________________

Has your child ever attended Mercer Island School District? Yes No. Has your child been retained? Yes No . If yes, what grade? _____All previous schools attended, including Mercer Island (list most recent first): School Name Address City State From To Grade Levels Public Private

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Previous Schools Attended

please check

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Daycare/Childcare Provider Name Phone Number Cell Phone

Is Daycare/Childcare Provider authorized to remove student from school? Yes No

Daycare/Childcare Provider

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MISD Health Services Registration Information

VAdamsLearningServices/Health Info for Reg-2017-18/StudentRegistrationStorage/2016-17/1-30-17

MISD Health Services Website has information about communicable disease, immunization and medication law, district policy and procedure and, health forms that are required for school attendance including current year Immunization requirements, CIS, examples of Health Care Plans and Medication Authorization Request Forms. Visit our Health Services page at www.mercerislandschools.org/HealthServices for more information and to find your school nurse.

LIFE THREATENING Health Conditions A life threatening condition means a condition that will put a child in danger of death during the school day if a medication or treatment plan is not in place. Every child with a life-threatening health condition must have a Physician ordered medication or treatment order addressing the condition. The medication/treatment order must be submitted PRIOR to the child’s first day of school attendance.

Upon receipt of medication/treatment orders, a 504 IHP (Individualized Health Plan) will be developed by the School Nurse in-conjunction with the parent/guardian. Visit the MISD Health Services page for medication/treatment order and health care plans. Students who have a life threatening condition without medication/treatment orders in place shall be excluded from school. This is consistent with federal requirements for students with disabilities under the Disabilities Act and Section 504 of the Rehabilitation Act of 1973. New orders are required annually, consistent with Medication in School law. It is the parent/guardian responsibility to contact the School Nurse prior to their child attending school.

Immunization Compliance WA State Law and MISD Policy require full immunization compliance for Public School Attendance. Students may not be enrolled in school unless a Washington State Certificate of Immunization Status (CIS) is submitted. Washington State Law requires that any student entering a school district for the first time, must present to the school the dates (month, day, year) of immunization against Diphtheria, Pertussis, Tetanus, Polio, Measles, Mumps, and Rubella (MMR), Varicella and Hepatitis B. The CIS form must be completed and signed by the parent/guardian using personal records from the health care provider.

By WA State Law, you have 30 days from first day of school attendance to bring all immunizations into compliance. *Students will be excluded from attending school if immunizations are NOT in compliance after 30 days. If you wish to utilize a medical or personal exemption option, you must contact your medical provider for the form and submit that form to the school.

Parents can now download and print immunization records from the Department of Health's website. You can print your family members' records any time, for free! Go to www.mercerislandschools.org/DOHimmunizations for more information.

Medication at School MISD Policy requires authorization from both a licensed health care provider and parent/guardian for any and all medications at school (this includes over-the-counter, prescription and herbal medication). A written Medication Authorization Request (MAR) must be completed, signed by both the physician and parent/guardian and be on file with the school nurse prior to any medication being administered during school hours. Visit our Health Information and Forms page at www.mercerislandschools.org/HealthInfo to download a MAR form. Medication orders are good for the current school year only.

http://www.mercerislandschools.org/HealthServices

http://www.mercerislandschools.org/DOHimmunizations

http://www.mercerislandschools.org/HealthInfo

Mercer Island School District

Student Health Form (Confidential)Student Name: ______________________________________ Date of Birth: __________________ Male: _____ Female: _____

School: ____________________________________________________ Grade: _______________ Class of: _________________

LIFE THREATENING Medical Conditions (Check all that apply):

If your child has a life threatening medical condition, state law requires a medication/treatment order from a Health Care Provider, and a school nurse Health Care Plan before your child can attend school. The MISD medication form and school nurse contact information is available on the Health Services website: www.mercerislandschools.org/healthservicesDoes your child have any of the following conditions? Please explain:No ___ Yes ___ Severe allergic reaction (requiring epinephrine auto injector) to tree nuts, peanuts ___________________________________No ___ Yes ___ Severe allergic reaction (requiring epinephrine auto injector) to other foods ________________________________________ No ___ Yes ___ Severe allergic reaction (requiring epinephrine auto injector) to bee stings, other insects: _____________________________No ___ Yes ___ Other severe allergies (requiring epinephrine auto injector) - affecting school. Specify: _______________________________No ___ Yes ___ Severe asthma that requires emergency medication kept at school: _________________________________________________ No ___ Yes ___ Seizure disorder that requires emergency medication or device kept at school: ________________________________________ No ___ Yes ___ Diabetes: _______________________________________________________________________________________________ No ___ Yes ___ Heart condition: _________________________________________________________________________________________

Other Medical Conditions (If epinephrine auto injector is required, see LIFE THREATENING Medical conditions above). Does your child have any of the following OTHER conditions that would affect his/her classroom performance or P.E. activi-ties? (Check all that apply): Please explain:No ___ Yes___ Mild Allergies. Specify: ___________________________________________________________________________________No ___ Yes___ Asthma: Students self-carrying inhalers must have a Medication Authorization Form on file in the health room. No ___ Yes___ History of seizure disorder: ______________________ Type and date of last seizure: __________________________________No ___ Yes___ History of heart condition: _________________________________________________________________________________No ___ Yes___ Digestive, bowel or bladder problems: ________________________________________________________________________No ___ Yes___ Growth problems: _______________________________________________________________________________________ No ___ Yes___ Skeletal limitations: ______________________________________________________________________________________ No ___ Yes___ Cancer/Leukemia: _______________________________________________________________________________________No ___ Yes___ Neuromuscular problems: __________________________________________________________________________________No ___ Yes___ Other developmental disability: _____________________________________________________________________________ No ___ Yes___ AttentionDeficitDisorder: _________________________________________________________________________________ No ___ Yes___ Behavioral/Emotional concerns: _____________________________________________________________________________ No ___ Yes___ Tourette’s Syndrome: _____________________________________________________________________________________ No ___ Yes___ Migraine headaches: _____________________________________________________________________________________ No ___ Yes___ PE considerations: _______________________________________________________________________________________ No ___ Yes___ Visiondeficit: ___________________________________________________________________________________________ No ___ Yes___ Hearing loss: ___________________________________________________________________________________________No ___ Yes___ Routine medication: ______________________________________________________________________________________No ___ Yes___ Other (please explain): ____________________________________________________________________________________Medications: State law requires written permission from a Health Care Provider and parent before any medication (prescription or over-the-counter) can be given or carried by student at school. A form is available from the school nurse or MISD Health Services website: www.mercerislandschools.org/healthservices (under Health Information and Forms).Thisinformationisconsideredconfidential.Itwillbesharedwithschoolstaffonaneed-to-knowbasis.Iunderstand911maybecalledtoassistinamedicalemergencyduringschoolhours.Iunderstanditismyresponsibilitytonotifytheschoolofficeinwritingifthereareanychangesinmychild’shealth.

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Preferred Doctor: ________________________________________________ Phone number: _______________________________

Preferred Dentist: ________________________________________________ Phone number: _______________________________

Preferred Hospital: _______________________________________________ Phone number: _______________________________

Parent/Guardian Signature: _______________________________________ Date: ______________________________________

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CompletingtheImmunizationForms–Parents,pleaseread:

Priortofillingouttheimmunizationforms,hereareafewtipsofferedbyMISDnurses:TherearetwodifferentWAStateformsinthispacket:

•WAStateCertificateofImmunizationStatus(CIS)or•WAStateCertificateofExemptionWhicheverformyouchoose,youmustfillitoutcompletely.ManyWashingtonStatepediatricianshavetheCISformintheircomputersystems.Inquireiftheycangenerateaversionofthisformcustomizedforyourchild.

YoumayalsoregisterforMyIRandprinttheCISyourself.VisittheWashingtonStateDepartmentofHealthwebsiteatwww.doh.wa.gov/immsrecordsformoreinformation.YoumayfindmoreinformationandtranslationoptionsattheWashingtonStateDepartmentofHealthwebsite:www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization/VaccineRequirements

http://www.doh.wa.gov/YouandYourFamily/Immunization/ChildProfileHealthPromotion/ForParents/AccessyourFamilysImmunizationInformation

I want my family’s immunization records, right when I need them.

Inject more_______________into your family’s immunization records.

CONVENIENCE

Now you can review and print your family’s offi cial immunization records online from WA.MyIR.net. Getting started is easy.All you need to do is:

1. Request. Visit the Washington State Department of Health website at www.doh.wa.gov/immsrecords to download an Authorization to Release Immunization Records form. 2. Register. Complete the form, sign it, and return it by fax, mail, or email (preferred). 3. Review. You will be registered for MyIR and will receive an email with a temporary PIN and instructions on what to do next. Log in as soon as possible and activate your account.You’ll have immediate access to your family’s immunization records to view, download, or print as often as you need. Call or email for more information:

1-866-397-0337 [email protected]

If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY call 711).

DOH 348-519 Sept 2015

Quiero los registros de inmunización de mi familia justo cuando los necesito.

Ahora puede controlar e imprimir los registros de vacunación de su familia en línea a través del sitio Web WA.MyIR.net. Comenzar es sencillo solo siga estas instrucciones:

1. Solicite. Visite el sitio Web Child Profi le del Departamento de Salud del Estado de Washington en www.childprofi le.org para descargar un formulario de autorización para divulgar los registros de vacunación.

2. Inscribase. Complete el formulario, fírmelo y envíelo por fax, correo o correo electrónico (preferente).

3. Revise. Estará inscripto en MyIR y recibirá un correo electrónico con una contraseña/PIN temporal e instrucciones sobre lo que deberá hacer a continuación. Ingrese a su cuenta para activarla tan pronto como pueda. Podrá acceder de inmediato a los registros de vacunación de su familia para verlos, descargarlos o imprimirlos cada vez que lo necesite. Si desea más información, llame o envíe un correo electrónico:

1-866-397-0337 [email protected]

Ahora puede controlar e imprimir los registros de vacunación

Inyecte más_______________en los registros de inmunización de su familia.

CONVENIENCIA

Si usted tiene una discapacidad y necesita este documento en otro formato, por favor llame al 1-800-322-2588 o al 711 (teletexto TTY).

DOH 348-519 Sept 2015

Register with Washington’s MyIR.net Now you can register and print out your child’s Certificate of Immunization directly from the state. Registering on Washington’s MyIR.net website can save you time and help eliminate errors.

See back for translation in Mandarin Chinese

If y

ou

hav

e a

dis

abili

ty a

nd

ne

ed t

his

do

cum

en

t in

an

oth

er f

orm

at, p

leas

e ca

ll 1

‐80

0‐5

25

‐01

27

(TD

D/T

TY c

all 7

11

).

DO

H 3

48

-29

5 D

ecem

ber

20

16

P

are

nts

- A

re Y

ou

r K

ids

Re

ady

for

Sch

oo

l?

R

equ

ired

Imm

un

izat

ion

s fo

r Sc

ho

ol Y

ear

20

17

-20

18

He

pat

itis

B

DTa

P/T

d/T

dap

(D

iph

ther

ia, T

eta

nu

s,

Per

tuss

is)

Vac

cin

e d

ose

s re

qu

ired

may

b

e fe

wer

th

an li

sted

Po

lio

Vac

cin

e d

ose

s re

qu

ired

m

ay b

e fe

wer

th

an li

sted

MM

R

(Mea

sles

, Mu

mp

s,

Ru

bel

la)

Var

ice

lla

(Ch

icke

np

ox)

Kin

de

rgar

ten

–

5th

Gra

de

3 d

ose

s w

ith

in t

he

corr

ect

tim

efra

mes

5

do

ses

wit

hin

th

e co

rrec

t ti

mef

ram

es

4 d

ose

s w

ith

in t

he

corr

ect

tim

efra

mes

2

do

ses

wit

hin

th

e co

rrec

t ti

mef

ram

es

2 d

ose

s w

ith

in t

he

corr

ect

tim

efra

mes

O

R

Hea

lth

care

pro

vid

er

veri

fied

ch

ild h

ad d

ise

ase

6th

– 1

2th

Gra

de

3 d

ose

s w

ith

in t

he

corr

ect

tim

efra

mes

5

do

ses

DTa

P

A

ND

1 d

ose

Td

ap

, all

wit

hin

th

e co

rrec

t ti

mef

ram

es

4 d

ose

s w

ith

in t

he

corr

ect

tim

efra

mes

2

do

ses

wit

hin

th

e co

rrec

t ti

mef

ram

es

2 d

ose

s w

ith

in t

he

corr

ect

tim

efra

mes

O

R

Hea

lth

care

pro

vid

er

veri

fie

d

child

had

dis

eas

e (E

xcep

tio

ns

are

allo

wed

fo

r ce

rta

in s

tud

ents

)

Stu

de

nts

mu

st g

et

vacc

ine

do

ses

at c

orr

ect

tim

efr

ame

s to

be

in c

om

plia

nce

wit

h t

he

req

uir

em

en

ts. T

alk

to y

ou

r h

eal

thca

re p

rovi

de

r o

r sc

ho

ol s

taff

if

you

hav

e q

ue

stio

ns

abo

ut

sch

oo

l im

mu

niz

atio

n r

eq

uir

eme

nts

.

Fin

d in

form

atio

n o

n o

ther

rec

om

men

ded

vac

cin

es n

ot

req

uir

ed f

or

sch

oo

l: w

ww

.imm

un

ize.

org

/cd

c/sc

hed

ule

s/

Par

en

t/G

uar

dia

n I

nst

ruct

ion

s: T

o s

ee

wh

ich

vac

cin

es

are

req

uir

ed

fo

r sc

ho

ol,

fin

d y

ou

r ch

ild’s

gra

de

an

d lo

ok

on

ly a

t th

at r

ow

go

ing

acro

ss

to f

ind

th

e v

acci

ne

s an

d n

um

be

r o

f d

ose

s re

qu

ire

d.

C

ertif

icat

e of

Imm

uniz

atio

n St

atus

(CIS

)

Fo

r Kin

derg

arte

n-12

th G

rade

/ C

hild

Car

e En

try

Plea

se p

rint.

See

back

for i

nstr

uctio

ns o

n ho

w to

fill

out t

his

form

or g

et it

pri

nted

from

the

Was

hing

ton

Imm

uniz

atio

n In

form

atio

n Sy

stem

. C

hild

’s L

ast N

ame:

F

irst N

ame:

Mid

dle

Initi

al:

Birt

hdat

e (M

M/D

D/Y

Y):

S

ex:

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

I g

ive

perm

issi

on to

my

child

’s s

choo

l to

shar

e im

mun

izat

ion

info

rmat

ion

with

the

Imm

uniz

atio

n In

form

atio

n S

yste

m to

hel

p th

e sc

hool

mai

ntai

n m

y ch

ild’s

sch

ool

reco

rd.

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

__

Pare

nt/G

uard

ian

Sign

atur

e R

equi

red

D

ate

I cer

tify

that

the

info

rmat

ion

prov

ided

on

this

form

is c

orre

ct a

nd v

erifi

able

.

__

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Pa

rent

/Gua

rdia

n Si

gnat

ure

Req

uire

d

Dat

e

♦ R

equi

red

for S

choo

l and

Chi

ld C

are/

Pre

scho

ol

Dat

e M

M/D

D/Y

Y D

ate

MM

/DD

/YY

Dat

e M

M/D

D/Y

Y D

ate

MM

/DD

/YY

Dat

e M

M/D

D/Y

Y D

ate

MM

/DD

/YY

Doc

umen

tatio

n of

Dis

ease

Imm

unity

H

ealth

care

pro

vide

r use

onl

y If

the

child

nam

ed in

this

CIS

has

a h

isto

ry o

f Va

ricel

la (C

hick

enpo

x) o

r can

sho

w im

mun

ity

by b

lood

test

(tite

r) it

MU

ST b

e ve

rifie

d by

a

heal

thca

re p

rovi

der

I cer

tify

that

the

child

nam

ed o

n th

is C

IS h

as:

a v

erifi

ed h

isto

ry o

f Var

icel

la (C

hick

enpo

x).

lab

orat

ory

evid

ence

of i

mm

unity

(tite

r) to

dise

ase(

s) m

arke

d be

low

. Lab

repo

rt(s

)

fo

r tite

rs M

UST

als

o be

atta

ched

.

Dip

hthe

ria

M

umps

O

ther

:

Hep

atiti

s A

P

olio

__

____

____

Hep

atiti

s B

R

ubel

la

____

____

__

H

ib

T

etan

us

Mea

sles

Var

icel

la

Lice

nsed

hea

lthca

re p

rovi

der s

igna

ture

Dat

e (M

D, D

O, N

D, P

A, A

RN

P)

Prin

ted

Nam

e

● R

equi

red

Onl

y fo

r Chi

ld C

are/

Pre

scho

ol

Req

uire

d Va

ccin

es fo

r Sch

ool o

r Chi

ld C

are

Entr

y

♦ D

TaP,

DT

(Dip

hthe

ria, T

etan

us, P

ertu

ssis

)

♦ Td

ap (T

etan

us, D

ipht

heria

, Per

tuss

is)

♦ Td

(Tet

anus

, Dip

hthe

ria)

♦ H

epat

itis

B

2

-dos

e sc

hedu

le u

sed

betw

een

ages

11-

15

● H

ib (

Hae

mop

hilu

s in

fluen

zae

type

b)

♦ IP

V / O

PV (P

olio

)

♦ M

MR

(Mea

sles

, Mum

ps, R

ubel

la)

● P

CV

/ PPS

V (P

neum

ococ

cal)

♦ Va

ricel

la (C

hick

enpo

x)

H

isto

ry o

f dis

ease

ver

ified

by

IIS

Rec

omm

ende

d Va

ccin

es (N

ot R

equi

red

for S

choo

l or C

hild

Car

e En

try)

Flu

(Influ

enza

)

Hep

atiti

s A

HPV

(Hum

an P

apillo

mav

irus)

MC

V, M

PSV

(Men

ingo

cocc

al)

Men

B (M

enin

goco

ccal

)

Rot

aviru

s

Offi

ce U

se O

nly:

R

evie

wed

by:

D

ate:

S

igne

d C

ert.

of E

xem

ptio

n on

file

?

Y

es

N

o

vanessa adams

Highlight

vanessa adams

Highlight

vanessa adams

Highlight

vanessa adams

Highlight

To

prin

t with

imm

uniz

atio

n in

form

atio

n fil

led

in: A

sk if

you

r hea

lthca

re p

rovi

der’s

offi

ce e

nter

s im

mun

izat

ions

into

the

WA

Imm

uniz

atio

n In

form

atio

n S

yste

m (W

ashi

ngto

n’s

stat

ewid

e da

taba

se).

If th

ey d

o, a

sk th

em to

prin

t the

CIS

from

the

IIS a

nd y

our c

hild

’s im

mun

izat

ion

info

rmat

ion

will

fill

in a

utom

atic

ally

. You

can

als

o pr

int a

CIS

at h

ome

by s

igni

ng u

p an

d lo

ggin

g in

to M

yIR

at h

ttps:

//wa.

myi

r.net

. If y

our p

rovi

der d

oesn

’t us

e th

e IIS

, em

ail o

r cal

l the

Dep

artm

ent o

f Hea

lth to

get

a c

opy

of y

our c

hild

’s C

IS: w

aiis

reco

rds@

doh.

wa.

gov

or 1

-866

-39

7-03

37.

To fi

ll ou

t the

form

by

hand

: #1

Prin

t you

r chi

ld’s

nam

e, b

irthd

ate,

sex

, and

sig

n yo

ur n

ame

whe

re in

dica

ted

on p

age

one.

#2

Vac

cine

info

rmat

ion:

Writ

e th

e da

te o

f eac

h va

ccin

e do

se re

ceiv

ed in

the

date

col

umns

(as

MM

/DD

/YY)

. If y

our c

hild

rece

ives

a c

ombi

natio

n va

ccin

e (o

ne s

hot t

hat p

rote

cts

agai

nst

seve

ral d

isea

ses)

, use

the

Ref

eren

ce G

uide

bel

ow to

reco

rd e

ach

vacc

ine

corr

ectly

. For

exa

mpl

e, re

cord

Ped

iarix

und

er D

ipht

heria

, Tet

anus

, Per

tuss

is a

s D

TaP,

Hep

atiti

s B

as

Hep

B, a

nd

Pol

io a

s IP

V.

#3 H

isto

ry o

f Var

icel

la D

isea

se: I

f you

r chi

ld h

ad c

hick

enpo

x (v

aric

ella

) dis

ease

and

not

the

vacc

ine,

a h

ealth

car

e pr

ovid

er m

ust v

erify

chi

cken

pox

dise

ase

to m

eet s

choo

l re

quire

men

ts.

I

f you

r hea

lthca

re p

rovi

der c

an v

erify

that

you

r chi

ld h

ad c

hick

enpo

x, a

sk y

our p

rovi

der t

o ch

eck

the

box

in th

e D

ocum

enta

tion

of D

isea

se Im

mun

ity s

ectio

n an

d si

gn th

e fo

rm.

I

f sch

ool s

taff

acce

ss th

e IIS

and

see

ver

ifica

tion

that

you

r chi

ld h

ad c

hick

enpo

x, th

ey w

ill c

heck

the

box

unde

r Var

icel

la in

the

vacc

ines

sec

tion.

#4

Doc

umen

tatio

n of

Dis

ease

Imm

unity

: If y

our c

hild

can

sho

w p

ositi

ve im

mun

ity b

y bl

ood

test

(tite

r) a

nd h

as n

ot h

ad th

e va

ccin

e, h

ave

your

hea

lthca

re p

rovi

der

chec

k th

e bo

xes

for t

he

appr

opria

te d

isea

se in

the

Doc

umen

tatio

n of

Dis

ease

Imm

unity

box

, and

sig

n an

d da

te th

e fo

rm. Y

ou m

ust p

rovi

de la

b re

port

s w

ith th

is C

IS.

Ref

eren

ce g

uide

for v

acci

ne tr

ade

tam

es in

alp

habe

tical

ord

er

F

or u

pdat

ed li

st, v

isit

http

s://f

ortre

ss.w

a.go

v/do

h/cp

ir/iw

eb/h

omep

age/

com

plet

elis

tofv

acci

nena

mes

.pdf

Tr

ade

Nam

e Va

ccin

e Tr

ade

Nam

e Va

ccin

e Tr

ade

Nam

e Va

ccin

e Tr

ade

Nam

e Va

ccin

e Tr

ade

Nam

e Va

ccin

e

Act

HIB

®

Hib

Fl

uarix

®

Flu

Hav

rix®

Hep

A

Men

veo®

M

enin

goco

ccal

R

otar

ix®

Rot

aviru

s (R

V1)

Ada

cel®

Td

ap

Fluc

elva

x®

Flu

Hib

erix

®

Hib

P

edia

rix®

DTa

P +

Hep

B +

IP

V R

otaT

eq®

Rot

aviru

s (R

V5)

Aflu

ria®

Flu

FluL

aval

®

Flu

Hib

TITE

R®

Hib

P

edva

xHIB

®

Hib

Te

niva

c®

Td

Bex

sero

®

Men

B

FluM

ist®

Fl

u Ip

ol®

IPV

Pen

tace

l®

DTa

P +

Hib

+ IP

V

Trum

enba

®

Men

B

Boo

strix

®

Tdap

Fl

uviri

n®

Flu

Infa

nrix

®

DTa

P P

neum

ovax

®

PPS

V Tw

inrix

®

Hep

A +

Hep

B

Cer

varix

®

2vH

PV

Fl

uzon

e®

Flu

Kin

rix®

DTa

P +

IPV

Pre

vnar

®

PC

V

Vaq

ta®

Hep

A

Dap

tace

l®

DTa

P G

arda

sil®

4v

HP

V

Men

actra

®

MC

V o

r MC

V4

Pro

Qua

d®

MM

R +

Var

icel

la

Var

ivax

®

Var

icel

la

Eng

erix

-B®

Hep

B

Gar

dasi

l® 9

9v

HP

V

Men

omun

e®

MP

SV

4 R

ecom

biva

x H

B®

Hep

B

If yo

u ha

ve a

dis

abilit

y an

d ne

ed th

is d

ocum

ent i

n an

othe

r for

mat

, ple

ase

call

1-80

0-52

5-01

27 (T

DD

/TTY

cal

l 711

).

D

OH

348

-013

Dec

embe

r 201

6

Ref

eren

ce g

uide

for v

acci

ne a

bbre

viat

ions

in a

lpha

betic

al o

rder

For

upd

ated

list

, vis

it ht

tps:

//for

tress

.wa.

gov/

doh/

cpir/

iweb

/hom

epag

e/co

mpl

etel

isto

fvac

cine

nam

es.p

df

Abbr

evia

tions

Fu

ll Va

ccin

e N

ame

Abbr

evia

tions

Fu

ll Va

ccin

e N

ame

Abbr

evia

tions

Fu

ll Va

ccin

e N

ame

Abbr

evia

tions

Fu

ll Va

ccin

e N

ame

Abbr

evia

tions

Fu

ll Va

ccin

e N

ame

DT

Dip

hthe

ria, T

etan

us

Hep

A

Hep

atiti

s A

MC

V /

MC

V4

Men

ingo

cocc

al

Con

juga

te V

acci

ne

OP

V O

ral P

olio

viru

s V

acci

ne

Tdap

Te

tanu

s,

Dip

hthe

ria, a

cellu

lar

Per

tuss

is

DTa

P D

ipht

heria

, Te

tanu

s, a

cellu

lar

Per

tuss

is

Hep

B

Hep

atiti

s B

Men

B

Men

ingo

cocc

al B

P

CV

/ P

CV

7 /

PC

V13

P

neum

ococ

cal

Con

juga

te V

acci

ne

VA

R /

VZV

V

aric

ella

DTP

D

ipht

heria

, Te

tanu

s, P

ertu

ssis

H

ib

Hae

mop

hilu

s in

fluen

zae

type

b

MP

SV

/ MPS

V4

Men

ingo

cocc

al

Pol

ysac

char

ide

Vac

cine

P

PSV

/ PP

V23

P

neum

ococ

cal

Pol

ysac

char

ide

Vac

cine

Flu

(IIV

) In

fluen

za

HP

V (2

vHPV

/ 4v

HP

V /

9vH

PV

) H

uman

P

apill

omav

irus

MM

R

Mea

sles

, Mum

ps,

Rub

ella

R

ota

(RV

1 / R

V5)

R

otav

irus

HB

IG

Hep

atiti

s B

Imm

une

Glo

bulin

IP

V In

activ

ated

P

olio

viru

s V

acci

ne

MM

RV

M

easl

es, M

umps

, R

ubel

la w

ith

Var

icel

la

Td

Teta

nus,

D

ipht

heria

Inst

ruct

ions

for c

ompl

etin

g th

e C

ertif

icat

e of

Imm

uniz

atio

n St

atus

(CIS

): pr

intin

g it

from

the

Imm

uniz

atio

n In

form

atio

n Sy

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DOH 348-106 Jan 2015

Certificate of Exemption

PART 1: PARENT OR GUARDIAN INSTRUCTIONS

In order for this form to be valid for religious,

personal, philosophical, or medical reasons,

please: Step 1: Fill in your child’s information in Boxes 1-4

Step 2: Read the Parent/Guardian Declaration

Step 3: Provide your initials where indicated

Step 4: Print your name, sign, and date in Boxes 5-6

Step 5: Have a provider complete Part 2 of this

form

1. Child’s Last Name

2. Child’s First Name and Middle Initial

3. Birthdate (mm/dd/yyyy) 4. Gender

I am the parent or legal guardian of the above

named child. One or more required vaccines

are in conflict with my personal, philosophical,

or religious beliefs.

Parent/Guardian Declaration

I understand that:

My child may not be allowed to attend school or

child care during an outbreak of the disease

that my child has not been fully vaccinated

against. ______ (initial)

Exempting my child from any or all required

vaccine(s) may result in serious illness, disability,

or death to my child or others. I understand the

risks and possible outcomes of my decision to exempt my child. ______ (initial)

The information provided on this form is

complete and correct. ______ (initial)

5. Print Parent/Guardian Name

6. Parent/Guardian Signature and Date

________ /________ /________________

____ /____ /____

FOR

OFFIC

E U

SE O

NLY

CH

ILD’S

LAST N

AM

E _

_________________________________________ F

IRST N

AM

E _

_______________________________________ M

.I. ______

___

1RCW 28A.210.080-090 “Before or on the first day of every child’s attendance at any public and private school or licensed child care center in Washington State, the parent or guardian must present proof of either: (1) full immunization, (2) the initiation of and compliance with a schedule of immunization, as required by rules

of the State Board of Health, or (3) a certificate of exemption signed by a parent or guardian and is either A) signed by a licensed healthcare provider or B)

demonstrates membership in a church or religious body that precludes healthcare practitioners from providing medical treatment to children.”

PART 2: HEALTHCARE PROVIDER INSTRUCTIONS

In order for this form to be valid, please:

Step 1: Mark which disease(s) and what type of

exemption is requested. If medical write a

T for Temporary or P for Permanent.

Step 2: Discuss the benefits and risks of

immunizations with the parent or guardian

Step 3: Read the Provider Declaration

Step 4: Print your name, credentials, sign, and date

in Boxes 7-8

**A provider may grant a medical exemption only if

there is a medical contraindication to a vaccine.

Provider Declaration

I declare that:

I have discussed the benefits and risks of

immunizations with the parent/legal guardian as a

condition for exempting their child.

I am a qualified MD, ND, DO, ARNP or PA

licensed under Title 18 RCW.

The information provided on this form is complete

and correct.

7. Print Provider Name and Credential (MD, ND, DO, ARNP, PA)

8. Provider Signature and Date

Vaccine Personal/

Philosophical Religious

Expiration

Date for

Temporary

Medical

Medical

(T/P)**

Diphtheria

Hepatitis B

Hib

Measles

Mumps

Pertussis

Pneumococcal

Polio

Rubella

Tetanus

Varicella

All

____ /____ /____

SIDE A: For Religious, Personal,

Philosophical, and Medical

Exemptions1

Male

Female

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I am the parent or legal guardian of the above named child and I am exempting my child from all

required vaccinations.

Parent/Guardian Declaration

I understand that:

My child may not be allowed to attend school or child care during an outbreak of the disease that my

child has not been fully vaccinated against. ______ (initial)

Exempting my child from all required vaccines may result in serious illness, disability, or death to my child or

others. I understand the risks and possible outcomes of my decision to exempt my child. ______ (initial)

The information provided on this form is complete and correct. ______ (initial)

Certificate of Exemption

NOTICE: Complete this side if you belong to a church or religion that objects to the use of

medical treatment.1

If you have a religious objection to vaccinations, but the beliefs or teachings of your church

or religion allow for your child to be treated by medical professionals such as doctors and

nurses, then you must use Side A of this Certificate of Exemption.

2. Child’s First Name and Middle Initial 1. Child’s Last Name

________ /________ /________________

3. Birthdate (mm/dd/yyyy) 4. Gender

PARENT OR GUARDIAN INSTRUCTIONS

In order for this form to be legally valid for religious membership reasons, please:

Step 1: Fill in your child’s information in Boxes 1-4

Step 2: Read the Parent/Guardian Declaration and provide your initials where indicated

Step 3: Provide the name of the church or religion of which you are a member, and print your

name, sign, and date in Boxes 5-7

FOR

OFFIC

E U

SE O

NLY

CH

ILD’S

LAST N

AM

E _

_________________________________________ F

IRST N

AM

E _

_______________________________________ M

.I. ______

___

5. Name of Church or Religion of Which You Are a Member 6. Print Parent/Guardian Name

I affirm that I am a member of a church or religion whose teachings preclude healthcare practitioners from

providing any medical treatment to my child.

_____/_____/_____

7. Parent/Guardian Signature and Date

SIDE B: For Religious Membership

Exemption ONLY

M F

1RCW 28A.210.090 “The parent of legal guardian demonstrates membership in a religious body or a church in which the religious beliefs or teachings of

the church preclude a health care practitioner from providing medical treatment to the child.”

If you have a disability and need this form in a different format please call 1-800-525-0127 (TDD/TTY Call 711)

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English

May 2014

The Purpose of the Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools. The following

information should help answer some of the questions you may have about this form.

What is the purpose of the Home Language Survey?

The primary purpose of the Home Language Survey is to help identify students who may qualify for

support to help them develop the English language skills necessary for success in the classroom and who

may qualify for other services. It is important that this information be correctly recorded since it can

affect the eligibility of students for services they need to be successful in school. Testing may be

necessary to determine whether or not additional language and academic supports are needed. No

student will be placed in an English language development program based solely on responses to this

form.

Why do you ask about the student’s first language and language(s) used in the home?

The two questions about the student’s language help us to determine:

if your student may be eligible for assistance with learning English, and

whether staff at the school should be aware of other languages being used by the student at home.

The language your child first learned may be different from the language your child uses for

communication at home now. The responses to both of these questions will assist the school in providing

instruction appropriate to the individual student’s needs as well as help with communication needs that

may arise. Students who first learned a language other than English may qualify for additional supports.

Even students who speak English well may still need support in developing the language skills needed to

be successful in school.

Why do you ask where the student was born?

This information helps the school district and the state determine if the student meets the definition of

immigrant for the purposes of federal funding. This applies even when the student’s parents are both US

citizens, but the student was born outside of the United States. This form is not used to identify students

who may be undocumented.

Why do you ask about my student’s previous education?

Information about a student’s education will help ensure that the student’s education both within and

outside of the United States is considered in any recommendations made for participation in programs and

district services. The student’s educational background is also important information to help determine if

the student is making adequate progress toward state standards based on their prior educational

background.

Thank you for providing the information needed on the Home Language Survey. Contact your school

district if you have further questions about this form or about services available at your child’s school.

English/November 2016

Office of Superintendent of Public Instruction (OSPI)

Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools.

Student Name: Grade: Date:

Parent/Guardian Name Parent/Guardian Signature

Right to Translation and

Interpretation Services

Indicate your language preference so

we can provide an interpreter or

translated documents, free of

charge, when you need them.

All parents have the right to information about their child’s

education in a language they understand.

1. In what language(s) would your family prefer to communicate

with the school?

__________________________________

Eligibility for Language

Development Support

Information about the student’s

language helps us identify students

who qualify for support to develop

the language skills necessary for

success in school. Testing may be

necessary to determine if language

supports are needed.

2. What language did your child learn first?

__________________________________

3. What language does your child use the most at home?

__________________________________

4. What is the primary language used in the home, regardless of

the language spoken by your child?

__________________________________

5. Has your child received English language development support

in a previous school? Yes___ No___ Don’t Know___

Prior Education

Your responses about your child’s

birth country and previous

education:

Give us information about the

knowledge and skills your child is

bringing to school.

May enable the school district to

receive additional federal funding

to provide support to your child.

This form is not used to identify

students’ immigration status.

6. In what country was your child born? ___________________

7. Has your child ever received formal education outside of the

United States? (Kindergarten – 12th grade) ____Yes ____No

If yes: Number of months: ______________

Language of instruction: ______________

8. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________

Month Day Year

Thank you for providing the information needed on the Home Language Survey. Contact your school

district if you have further questions about this form or about services available at your child’s school.

Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.

Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative

Commons Attribution 4.0 International License.

http://www.k12.wa.us/MigrantBilingual/TranslatedMaterial.aspx

http://www.k12.wa.us/

https://creativecommons.org/licenses/by/4.0/

https://creativecommons.org/licenses/by/4.0/

Student’s Legal Name: __________________________________ Date of Birth: _____________

Ethnicity and Race School districts in Washington State are required to report student data by ethnicity and race categories to the state’s Office of Superintendent of Public Instruction. Ethnicity and race categories used in our district are the same as used in all Washington school districts. They are set by the federal government, the Washington State Legislature, and the state Superintendent of Public Instruction. The new federal requirements state that Unknown, Multiracial and Not Provided are not valid responses to ethnicity or race identification questions. If parents, guardians, or students do not provide ethnicity and race information, districts are responsible for assigning categories based on observation.

Please complete the following: Is your child of Hispanic or Latino origin? q Yes, check all that apply in section 1 and 2. q No, check all that applies in section 2.

Section 1. Check all that apply.

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

Section 2. What race(s) do you consider your child? (check all that apply)

q African American or Black

q White or Caucasian

q Asian Indian q Cambodian q Chinese q Filipino q Hmong q Indonesian q Japanese q Korean q Laotian q Malaysian q Pakistani q Singaporean q Taiwanese

q Thai q Vietnamese q Other Asian q Native

Hawaiian q Fijian q Guamanian or

Chamorro q Mariana

Islander q Melanesian q Micronesian q Samoan q Tongan q Other Pacific

Islander q Alaska Native q Chehalis

q Colville q Cowlitz q Hoh q Jamestown q Kalispel q Lower Elwha q Lummi q Makah q Muckleshoot q Nisqually q Nooksack q Port Gamble

S’Klallam q Puyallup q Quileute q Quinault

q Samish q Sauk-Suiattle q Shoalwater q Skokomish q Snoqualmie q Spokane q Squaxin Island q Stillaguamish q Suquamish q Swinomish q Tulalip q Upper Skagit q Yakama q Other Washington

Indian Tribe q Other American

Indian Tribe/Alaska Native

Parent/Guardian Signature: _____________________________ Date: __________________

MercerIslandSchoolDistrictStudentHousingQuestionnaireFordistributiontoallfamilies/studentsannually

SchoolName:

StudentName:

Male Female First,Middle,Last

Birthdate:

Age:

Grade:

Month,Day,Year

ThisformisintendedtoaddressrequirementsoftheMcKinney-VentoAct,TitleX,PartCoftheNoChildLeftBehindAct.Youranswerstothesequestionswillhelpstaffwithschoolenrollmentandmayenablethestudenttoreceiveadditionalservices.

1. Isyourcurrentresidenceatemporarylivingarrangement? Yes No

2. Isyourlivingarrangementduetolossofhousingoreconomichardship? Yes No 3.Isyourcurrentresidenceinadequateformeetingphysicalandpsychologicalneeds? Yes No IfyouansweredYEStoanyofthequestions,pleasecompletetheremainderofthisform.IfyouansweredNOtoallofthequestions,youmaystophere.

Wheredoesthestudentstayatnight?(Pleasecheckonebox.) Inamotel/hotel InashelterWithmorethanonefamilyinahouse,mobilehome,orapartment(doubled-up) Inacar,park,campsite,orlocationnotusuallyusedforsleepingaccommodations(unsheltered)

Address:

Phone:

Street,City,Zip

Parent/LegalGuardianName:

IdeclareunderpenaltyofperjuryunderthelawsoftheStateofWashingtonthattheinformationprovidedhereistrueandcorrect:

Parent/GuardianSignature:

Date:

OR UnaccompaniedYouthSignature:

Date:

ForSchoolPersonnelUseOnlyIfstudentismissingenrollmentrecords,pleasecontactthestudent’spreviousschoolforrecords.Thefollowingrecordsarestillmissing:

Birthcertificate Immunizations Medicalrecords Prioracademicrecords

SchoolRegistrarSignature: Date:

IherebycertifythattheabovenamedstudentqualifiesforrightsandservicesundertheMcKinney-VentoAct.

McKinney-VentoLiaisonSignature: Date:

VAdamsLearning Services/MISDHousingQuestionnaire/StudentRegistration2017-18Storage/1-18-17

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VAdamsLearningServices/IMSRequestfortransferofstudentrecords/IMSStorage/9-7-16

Islander Middle School Request for Transfer of Educational Records

Daterequestfaxed:

Studentname: Birthdate:

Currentgrade:

Releasingschool: Phone: Fax:

Address: City/State/Zip:Pleasetransferthefollowingrecords:

Officialtranscript/reportcards IfthisstudentistransferringfromaWashingtonStateschoolandhassatisfiedtheWashingtonStatehistorygraduationrequirementin7thor8thgrade,pleasecheckhere.

Requirementmet

Signed:

Title:

Withdrawalgrades,ifapplicableImmunization/healthrecordsTestscores,includingMSPPsychologicalrecords/IEP504PlanAttendancehistory/recordsDisciplinehistory/recordsELLrecords

Parent Request: I request that all health/nurse school records of my child be transferred to the receiving school.

Parentsignature Date

Hasthisstudentbeensuspendedinthepast3years? Yes No

Ifyes,listreasonforsuspension:

Hasthisstudenthadattendanceissuesinthepast3years? Yes No

Doesthisstudenthavea504Plan? Yes No

HasthisstudentbeenenrolledinSpecialEducationinthepast3years? Yes No

Schoolofficialsignature Date

Pleasereturnthissheetalongwiththeaboverequestedinformation/recordsto:IslanderMiddleSchool,Registrar

8225SE72ndSt.,MercerIsland,WA98040Phone:206-230-6160•FAX:206-236-3408•email:[email protected]

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NewFamiliesTheIMSPTSAwelcomesyou!

TheGatorGreeterswouldliketocontactyouandhelporientyouandyourfamilytoourschool.

Pleasecontactme____ Noneedtocontact___

Studentname:______________________________________________________ Grade_______ Gender M F

Parentname(s)____________________________________________________________________________

____________________________________________________________________________

Currentphone:_______________________________________ Newphone:______________________________________

Emailaddress:_______________________________________________________

IgivepermissionforyoutosharemycontactinformationwiththePTSA:

Signature: ______________________________________________________Date:____________________________________

VAdamsLearningServices/IMSNewFamiliesform/StudentRegistrationStorage/10-26-16

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IP Kindergarten Welcome Letter...Completed Certificate of Immunization Status (CIS), OR Certificate...

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