Student Name: _______________________________

2017 – 2018 Registration Process: Checklist

233 North Stephanie Street // Henderson, NV 89074 update150202

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

300 N 13th St// Las Vegas, NV 89101 update150202

2201 W College Pkwy//Carson City, NV 89703 update150202

 Phase I Student Copy _______     Phase II Student Copy _______     Phase III Student Copy _______ 

Account Name Username Password

MOODLE Login

EdREADY Login

myCSN/myGBC login

NSHS Registration Checklist Phase I: Initial Consultation (est. 1 hr)

____ Logged on to EdREADy and MOODLE accounts and documented below

____ Completed Initial Consultation Phase I

Phase II: Placement Testing (est. 2 hr)

____ CSN Placement Scores Math Score: _______ English Score: _______ Reading Score: _______

____ GBC Placement Scores Math Score: _______ English Score: _______

____ Scheduled Advising with NSHS Date: _______ Time: _______

____ Submitted GBC online application

____ Completed Placement Testing Phase II

Phase III: Advising (est. 1.5 hr)

____ Confirmed myCSN login information and documented below

____ Completed NSHS Academic Plan Tutorial on MOODLE and COMPELTED form w/signatures

____ Completed CSN Enrollment Tutorial on MOODLE

____ Completed Advising Appointment Phase III

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

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

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

____ Completed the ENGAGE survey/receive start of school letter

____ Completed Course Enrollment Verification Phase IV

Be a Power User! Keep track of all your account logins in a safe place like your phone or computer!

2017 – 2018 Initial Consultation

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

STUDENT NAME

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

Ensure you meet minimum qualifications Consultation Documents GPA above 2.0 NSHS disclaimer form Junior showing a minimum of 11 credits GBC application Senior showing a minimum of 17 credits NSHS graduation requirement agreement Registration Documentation

FRL form (State Funding) Print & sign online registration form from email Home Language Survey Print, complete, & sign NSHS health form Residency Questionnaire BuddyUp Form

Copy of unofficial high school transcript

Online Enrollment (CSN/NSHE#)

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

Parent ID/guardianship forms

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

IEP Documentation (if applicable) Username: 504 Documentation (if applicable) Password: ELL Documentation (if applicable for spring only) Placement Test Prep (see Moodle Phase II)

NOTES: Directions Post NSHE Number Create a support ticket http://help.earlycollegenv.com Include First & Last Name, NSHE #, and Accurate Email PLEASE BE ACCURATE

Get directions on placement testing prep and test Next Steps:

1. Turn in documents to NSHS – Star t Now 2. Study for placement tes ts – Start Now 3. Take placement tes ts @ CSN or NSHS(by appointment) – Star ting around March 4. Watch advisement videos on Moodle – Available in March

Nevada State High School Student Name

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

_______ _______ 1. Student and parent/guardian understand and agree to follow the purpose and the mission of the school to support students in a college environment with personal, academic, and social skills and follow the academic plan _______ _______ 2. NSHS students are real college students and are treated as such by their college professors in regards to expectations, behavior, parent contact, and adult content. NSHS students must advocate for themselves when interacting with college professors and NSHS staff can assist if students have questions on how to do so. Parents are not to contact college professors for their children, and students should not seek attention for being in high school _______ _______ 3. If taking placement tests at CSN, students MUST indicate they are a CSN student testing for CSN classes or the student will incur any fees from the college that arise as a result of stating that they are a high school student _______ _______ 4. Students will receive information on purchasing textbooks during the Introduction to College and Study Skills courses.

Buddy Up reimbursements are available for those who complete the forms by the deadlines to offset the extra costs _______ _______ 5. Students who complete online enrollment with CSN or GBC and do not enroll with NSHS are subject to all college fees 6. The Income Verification packet needs to be completed to receive any reimbursement from NSHS. Federal qualification is not required

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

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

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

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

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

Student Signature Parent/Guardian Signature

Nevada State High School Nombre del Estudiante: ____________________________

La información de renuncia para nuevos estudiantes Fecha: _______________ NSHS es una escuela pública de elección y con destino a la intención de la carta de la escuela (NRS 386,500 a 386,610 inclusive). Es fundamental que todos los nuevos estudiantes y los padres estén de acuerdo en seguir las expectativas y entiende lo siguiente acerca de la escuela antes de completar el proceso de registro. El Manual del Estudiante NSHS estará disponible en agosto y tendrá información sobre los procedimientos de la escuela. Padre Estudiante _______ _______ 1.El estudiante y el padre/guardián entienden y están de acuerdo en seguir el propósito y la misión de la escuela para apoyar a los

estudiantes en un ambiente universitario con lo personal, académico y habilidades sociales y seguir el plan académico _______ _______ 2.Estudiantes de NSHS son estudiantes universitarios y son tratados como tales por sus profesores de la universidad con las

expectativas, comportamiento, comunicación con los padres, y el contenido para adultos. Padres no deben contactar a los profesores de sus hijos, y los estudiantes no deben buscar atención por ser estudiantes de preparatoria.

_______ _______ 3.Cuando el estudiante tome los exámenes en CSN el estudiante NO debe decir que es un estudiante de la preparatoria. Cualquier gasto que resulte en consecuencia por la universidad si dice que es estudiate le la preparatoria será la responsabilidad del estudiante.

_______ _______ 4.NSHS ayuda con algunos gastos de libros comprados o rentados para aquellos estudiantes que siguen el proceso de reembolso. Los estudiantes recibirán información sobre los libros durante el curso de introducción al Colegio.

_______ _______ 5.Estudiantes que no se inscriban con NSHS después de completar la inscripción con CSN o GBC serán sujetos a los gastos Universitarios. _______ _______ 6.La forma libre y almuerzo reducido (FRL) debe ser completado para recibir cualquier reembolso de NSHS. La cualificación federal no se requiere por NSHS sino:

a) La Forma FRL es requerido por la ley estatal y federal para auditar sumisiones del FRL. Las personas seleccionadas tendrán una semana para presentar una carta de su empleador y/o una copia de su documentación de impuestos más reciente para apoyar la forma FRL

b) Los estudiantes pueden contactarse con NSHS para cualquier información financiera adicional _______ _______ 7.El estudiante asistirá a una cita para escoger clases de la universidad. Padres/guardianes pueden asistir a la cita, y es la Responsabilidad del padre de verificar las clases. _______ _______ 8.Los estudiantes NO pueden retirarse de cursos universitarios sin el permiso de NSHS, sino serán responsables por los gastos _______ _______ 9.Los estudiantes deben seguir el plan académico y asistir a TODOS los siguientes cursos para mantener la inscripción:

a) Matemáticas cada semestre (nivel depende en los exámenes) b) Ingles cada semestre (nivel depende en los exámenes) c) Ciencias Sociales (historia HIST 101 & 102 o gobierno PSC 101 & 210) d) Curso de Introducción al Colegio (2 semanas, a mediados de agosto o en la primavera para estudiantes a mitad de

año) y un electivo el segundo semestre e) Curso de Habilidades de estudio cada semestre (dos días a la semana por dos horas) f) Curso de Transición cada semestre por el primer año (ocurre una vez al mes para los estudiantes de primer año)

_______ _______ 10.Es un requisito que los estudiantes completen servicio voluntario y actividades sociales cada semestre _______ _______ 11.Padre/guardián están de acuerdo en asistir a la reunión OBLIGATORIA para los padres en septiembre y revisar MOODLE _______ _______ 12.La actividad del estudiante en MOODLE es monitoreado por NSHS _______ _______ 13.NSHS tiene un evento de lavado de carros al año en agosto para recaudar fondos. Los estudiantes tienen diferentes opciones de participación. _______ _______ 14.La inscripción en NSHS no es garantizada. No se retire de su escuela anterior hasta que se verifique la inscripción con NSHS _______ _______ 15.Se requerirá a los estudiantes sin dominio que tengan que asistir a la preparación de exámenes de fin de curso _______ _______ 16.Los estudiantes/padres que retengan o falsifiquen información pueden ser retirados de la escuela o no serán inscritos _______ _______ 17.Los padres serán responsables de recoger las calificaciones de los estudiantes después de cada semestre _______ _______ 18.Los estudiantes deben mantener la inscripción en NSHS a través del semestre para ser elegible para el reembolso Cuando un estudiante asiste a una institución de educación superior, la Ley de los Derechos Educativos y Privacidad (FERPA) permiten la transferencia de los derechos de privacidad de los padres al estudiante independientemente de su edad. En NSHS, el padre y el estudiante deben ponerse de acuerdo para compartir información con los padres, estudiantes, NSHS y colegios del estudiante. El estudiante se compromete a permitir el acceso de cunetas universitarias a NSHS para la verificación de horario y calificaciones finales de todos los cursos. La ley de Nevada sobre expulsión y el ausentismo escolar es aplicada en NSHS. Al inscribirse a NSHS, el padre y el estudiante entienden que ya no están inscritos en una escuela pública, escuela privada, una escuela del Distrito del Condado de Clark, u otra escuela autónoma. NSHS tiene permiso para obtener los registros educativos de su escuela anterior(s) durante la inscripción final. * Nota: NSHS no tiene la capacidad de retirar a un estudiante de cualquier curso universitario en cualquier momento. En caso de que el estudiante deje su inscripción con NSHS, el estudiante es responsable de retirase de cualquier y todos los cursos universitarios, y será responsable de todas las multas de esos cursos. NSHS está disponible para ayudar con el proceso de retiro de clases, pero no puede llevar a cabo la retirada. __________________________________________________ _____________________________________________________ Firma del Estudiante Firma del Padre/Guardian

Nevada State High School Graduation Requirement Agreements

Nevada State High School has graduation requirements above and beyond the state requirements, and this agreement serves as a written notification to parents and students of these extra graduation requirements. The school will attempt and document interventions with students who are not meeting these requirements, but it is ultimately up to the student to meet these requirements and the parents to monitor their graduation progress. NSHS will have student transcripts for parent to pick up in person from the school each semester.

Standard Diploma State Graduation Requirements:

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

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

NSHS’s Extra Graduation Requirements: Nevada State High School is a very mission specific charter school. The school’s extra graduation requirements are not set up to be punitive, but to reinforce students’ commitment to achieving the school’s charter.

a. Fulfilling college remedial requirements by earning a C (not C-) in MATH 096, 097 ENG 098, or placing directly into MATH 126 with ACT/SAT or college placement tests

1. Math 120 and Math 124 do not fulfill this requirement ii. Students have until spring of their 12th grade year to meet these requirements

b. Passing Study Skills or the Study Skills exemption requirement all semesters c. Passing Transitions (1st year student) all semesters d. Passing COMPASS (2nd year student, not for credit, required for exemptions/graduation all semesters)

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

College Remedial Placement – take college summer and/or winter courses, take and retake the SAT/ACT for improved placement, retake the colleges’ placement tests, pass your classes with a C or better.

Study Skills/ Transitions/ COMPASS –retrieval courses will be held to allow students to make up failing these courses which may be offered over winter and summer. Customized plans may be developed for students who fail more than one course a semester. Fall failed courses may repeat in the winter, and spring failures may repeat in the summer.

o College remedial courses can be taken in the summer at the expense of the student o 12th graders who do not meet requirements for graduation may not participate in the graduation

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

By signing below, you are acknowledging that you understand the NSHS extra graduation requirements and that if these are not met, NSHS will not issue a high school diploma and the student will not participate in graduation.

Student Signature Date Parent Signature Date

I N S T R U C T I O N S F O R V E R I F I C A T I O N N E V A D A S T A T E H I G H S C H O O L

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

IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS: If all children in the household are foster children: Part 1: List all foster children and the school name for each child. Check the box indicating the child is a foster child. Part 2: Skip this part. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.

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

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

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

ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the “No Income” box. Part 2: If the household does not have a case number, skip this part. Part 3: If any child is homeless, migrant, or a runaway check the appropriate box and call Wendi Hawk, homeless liaison; migrant coordinator. If not, skip this part. Part 4: Follow these instructions to report total household income from this month or last month. • Box 1–Name: List all household members with income. • Box 2 –Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how

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

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

2017-2018 FAMILY INCOME VERIFICATION

PART 1. ALL HOUSEHOLD MEMBERS

Names of ALL people living in household (First, Middle Initial, Last)

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

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

Check if NO income

PART 2. IF ANY CHILD IS HOMELESS, MIGRANT, OR A RUNAWAY CHECK THE APPROPRIATE BOX AND CALL Wendi Hawk, homeless liaison; migrant coordinator at phone 702-953-2600 HOMELESS MIGRANT RUNAWAY

PART 3. FOSTER CHILD IF YOU LIST A CHILD(REN) WHO IS(ARE) THE LEGAL RESPONSIBILITY OF A WELFARE AGENCY OR COURT, CHECK THIS BOX AND THEN LIST THE AMOUNT OF EACH CHILD’S PERSONAL USE MONTHLY INCOME: $____________________. SKIP TO PART 5.

PART 4. TOTAL HOUSEHOLD GROSS INCOME. You must tell us how much and how often. 1. NAME (List ONLY household members with income) 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED

Earnings From Work before deductions Welfare, child support, alimony

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

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

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

$______/________ $______/________ $______/________ $______/_______

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

DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12

Total Income: _________________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: ________ Eligibility: Free Reduced _ Paid __________ Verifying Official’s Signature: _______________________________Date: ________________________

Privacy Act Statement: This explains how we will use the information you give us. Nevada State High School requires the information on this document to apply for grant applications. You do not have to give the information, but if you do not, we cannot include your child for our statistics. You must include the social security number of the adult household member who signs this document. The social security number is not required when you fill out information on behalf of a foster child or you list a Food Stamp Program, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDRIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number.

BUDDYUP WAIVER/INCOME VERIFICATION OPT-OUT – FY1718

Students:

If your parents choose to opt out of filling out the income verification information, you will automatically be required to fill out this income verification waiver form.

This form is required to be filled out during the registration process- should you change your mind about opting out, you may submit a complete income verification packet no later than September 15th.

Note: In order to receive any reimbursements from Nevada State High School, parents must fill out the income verification form. This opt out form nullifies their eligibility to receive possible reimbursements that can assist in the cost of textbooks, ACT/SAT testing, and transportation.

Any questions and concerns can be directed to your school site administrator at 702-953-2600 or through the help ticket system at help.earlycollegenv.com

OPT OUT: I wish to opt out of filling out the Income Verification Form.

Reverse OPT OUT: If you initially filed to opt out, you may reverse by checking this box. (If reversing OPT out, you must also submit a copy of a filled income verification form)

Signature of Parent: Date:

Printed Name:

2017 – 2018 Registration Process: Home Language Survey

233 North Stephanie Street // Henderson, NV 89074 update150202

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

300 N 13th St// Las Vegas, NV 89101 update150202

2201 W College Pkwy//Carson City, NV 89703 update150202

Home Language Survey

LAST NAME FIRST NAME M.I. DATE

The law requires the school to ask quest ions about students’ language backgrounds to make sure that all s tudents receive educat ion services they need. The three quest ions below wil l tel l the school if the student’s profic iency in English must be evaluated and ensures that programs and services are offered to qual if ied students. The Parent/Guardian information below will help us communicate with you. Direc t ions: Plea se ind ica t e the correct response for each o f th e fo l lowing ques t ions and speci f y wh ere ap propria te . Student Language Information: 1. What is the pr imary language used in the home, regardless of the language spoken by the student?

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

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

English ______ Spanish ______ Other (please specify) ________________ Parent/Guardian Information: To bet ter ass is t parents in communicat ing effectively with the school , NSHS has staff available who speak Spanish. For registrat ion information or quest ions, contact 702-953-2600 or contact www.help.earlycollegenv.com.

English ___Spanish ___ Other (specify)______________

Student Signature Parent/Guardian Signature

OFFICIAL USE ONLY Home Language Survey Phase 1 Status

Complete: Yes No

Entered into Data System: Yes No

By:______________ Date:_______

DATE

Encuesta sobre el idioma hablado en el hogar

Al inscribirse, cada estudiante necesita contestar una encuesta sobre el idioma que se habla en el hogar. Esta encuesta será usada para determinar si el estudiante debe ser evaluado sobre su aptitud en el idioma de inglés. El conocimiento de o la exposición a otro idioma no es necesario de reportar. Si un idioma distinto del inglés se indica en cualquiera de las 3 preguntas siguientes, el estudiante será evaluado para determinar si es elegible para servicios adicionales. Si los resultados de la evaluación determinan que el estudiante no es hábil en cualquier do los dominios del idioma (en escuchar, leer, o hablar inglés), el estudiante calificará para servicios adicionales.

Instrucciones: Por favor indique la respuesta correcta para cada una de las siguientes preguntas e indique otros idiomas si son aplicable.

1. Primer idioma que aprendió el estudiante:

Inglés _______ Español _______ Otro (por favor especifique) ___________ 2. Idioma hablado más frecuente con los amigos:

Inglés _______ Español _______ Otro (por favor especifique) ___________ 3. Idioma(s) que se habla en el hogar:

Inglés _______ Español _______ Otro (por favor especifique) ___________

Información para el Padre/Tutor:

Para asistir a nuestros padres en comunicar efectivamente con la escuela sobre información importante, NSHS tiene empleados que ofrecen ayuda en español durante el proceso de matriculación y durante el año escolar, asegurando que los padres entienden cómo funciona nuestro programa y las expectativas de la escuela. Para información sobre el proceso de matriculación, llame al 702-953-2600. Si tiene preguntas o si necesita asistencia de nuestro enlace entre los padres y la escuela, envié un correo electrónico a PiP@earlycollegenv.com.

Idioma más frecuente usado por el padre/tutor:

Inglés _______ Español _______ Otro (por favor especifique) ___________

______________________________________ ______________________________________ Firma del Estudiante Fecha Firma del Padre/Tutor Fecha

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

documents necessary to enroll your child quickly.

Student: ____________________________________________ (Male ___ Female___) Birthdate: ___________________________ Grade: ____________ 1. Do you and your student live in a fixed, regular, adequate nighttime residence? Yes___ No___ (If you circled “NO”, please continue with this form. If you circled “YES”, then skip to the signature portion of this page) 2. Do you and the student live in:

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

3. The student lives with:

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

4. I am:

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

I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own personal knowledge. Parent Signature: ______________________________________ Date: __________________ Print Your Name: _______________________________________________________________ Residence: ____________________________________________________________________ Street City Zip Mailing Address: _____________________________________________________________________________ Street City Zip Telephone: (_____) _____________________ Cell Phone: (_____) _______________________

CUESTIONARIO DE RESIDENCIA ESTUDIANTIL/DECLARACIÓN JURADA Este documento tiene por objeto abordar la Ley de Asistencia McKinney-Vento. Sus respuestas le ayudarán

a determinar los documentos necesarios para inscribir a su hijo rápidamente. Estudiante: ____________________________________________ (Femenino ___ Femenina___) Fecha de nacimiento: ___________________________ Grado: ____________ 1. ¿Usted y su estudiante viven en una residencia nocturna fija, regular, adecuada? Si___ No___ (Si selecciono “NO”, porfavor continue con esta forma. Si selecciono “SI”, proceda a la parte de la firma de esta página) 2. Usted y el estudiante viven en:

□ refugio □ motel/hotel

□ temporarlmente con otra familia en una casa, casa móvil o apartamento □ en un coche o RV □ en un campamento □ vivienda de transición □ otra locación ________________________________________________________

3. El estudiante vive vo:

□ un padre □ ambos padres □ un relative cualificaso □ amigo(s) □ un adulto que no es tutor legal □ solo sin adultos

4. Yo soy:

□ El padre / tutor legal del estudiante mencionado anteriormente □ Un pariente adulto cualificado del estudiante mencionado anteriormente (Relacion: _______________________________________________________)

Declaro bajo pena de perjurio bajo las leyes de este estado que la información proporcionada aquí es verdadera y correcta y de mi propio conocimiento personal. Firma del padre: ______________________________________ Fecha: __________________ Imprima su nombre: _______________________________________________________________ Dirección ____________________________________________________________________ Calle Ciudad Codigo postal Dirección de envio de correo _____________________________________________________________________________ Street City Zip Teléfono: (_____) _____________________ Teléfono móvil: (_____) _______________________

08/05/2015

SPECIAL ADMISSIONS FORM FOR HIGH

SCHOOL STUDENTS

Admissions & Records Office 1500 College Parkway Elko, Nevada 89801

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

Date:_______________________ Semester: Fall Spring Summer

________________________________________________________________________ Name of High School

Name: ________________________________________________________________________________________

First Middle Last Address: _________________________________________________________________ Mail Address City State Zip

Phone: SS# (optional): _______________________

HS Grade Level:____________________ GBC Student ID:______________________

Expected High School Graduation Date: _______________________

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

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

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

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

situations occur:

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

period ends

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

100% refund period ends

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

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

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

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

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

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

of academic progress each semester.

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

07/30/2015

RELEASE OF STUDENT INFORMATION

TO HIGH SCHOOL

Admissions & Records Office

1500 College Parkway

Elko, Nevada 89801

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

Student’s Name (please print): ____________________________________________

Student’s Signature: ____________________________________________________

Date of Birth or GBC Student ID: _________________________________

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

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

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

Name of High School: ___________________________________________________

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

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

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

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

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

Untested High School End of Course Exam Disclaimer

Student Name: Date:

Grade Level: 11th

All students starting with the graduating class of 2018 in the State of Nevada must pass the End of Course Exams (EOC’s) in math and language arts. Typically, these tests are completed at the end of their 9th and 10th grade years. For various reasons, students may have not tested including, late enrollment, absences, being from out of state or being a private or home school student. NSHS is mandated by law to test all students if they have not passed these exams or have never tested.

This document is for parents/students to provide a written statement that the above named student has never tested in one or more of these exams. ONLY check the box for the test(s) that have NEVER BEEN TAKEN. In the space provided, write the school where the student attended in which the proficiency tests were supposed to be administered, and explain the reason why you have not taken the test selected.

Math I Previous school Reason

Language Arts I Previous school Reason

Math II Previous school Reason

Language Arts II Previous school Reason

Parents and students also understand that the student will be scheduled for the test prep sessions at a later determined time and location.

Student Signature: Date:

Parent Signature:

Health Card NEVADA STATE HIGH SCHOOL

Last Name

First Name MI Student Number Grade Birthdate Sex

Guardian Last Name

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

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

□ Asthma/Airway Disorder*

□ Visual Impairment* Explain any health problems checked:

□ Blood Disorder*

□ Hearing Aid (R) or (L)

□ Food Allergy To:

□ Hearing Loss

□ Medication Allergy To:

□ ADD/ADHD*

□ Potentially Severe Reaction To:

□ Cancer

□ Environmentally Hypersensitive To:

□ Neurological Disease*

□ Diabetes*:

□ Muscular Disease*

□ Seizures/Type*:

□ Orthopedic Problem

□ Genetic Syndrome*:

□ Heart Problem*

□ Glasses/Contacts*:

□ Other or exempt from screening:

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