DUNELAND SCHOOL CORPORATION New Student Information Packet 1. Complete New Student Online Application located at https://skyward.duneland.k12.in.us/scripts/wsisa.dll/WService=wsEAplus/skyenroll.w 2. Supply the following required documents listed below: • A legal birth certificate • Immunization record (requirements available at (https://www.in.gov/isdh/17094.htm) • Completed New Student Information Forms a. New Student Information Card b. Residency Affirmation and one (1) supporting document c. Home Language Survey d. Ethnicity Form e. Health Services Forms (H11/Health Services Questionnaire is required for all new students. For new Kindergarten students, forms H-17/Medical Form, H-17a/Dental Examination are highly recommended.) f. Children and Hoosiers Immunization Registry Program (CHIRP) Consent • If applicable, please bring these additional documents: a. Proof of guardianship if student is not living with natural parent(s). b. Legal custody instructions. (If custody documents are not on file, your student can be released to either natural parent.) c. Psychological evaluation, current IEP, GEI, 504 documents, and pertinent information if your student received services in Special Education, 504, English Language Learner, Response to Intervention or other support services. d. For those students transferring from another school, a Records Request form is available at each Duneland School and at the annual onsite registration. General information regarding the Programs and Services that Duneland School Corporation offers can be found at our website at www.duneland.k12.in.us
b. ResidencyAffirmationandone(1)supportingdocument
c. HomeLanguageSurvey
d. EthnicityForm
e. HealthServicesForms(H11/HealthServicesQuestionnaireisrequiredforallnewstudents.FornewKindergartenstudents,formsH-17/MedicalForm,H-17a/DentalExaminationarehighlyrecommended.)
f. ChildrenandHoosiersImmunizationRegistryProgram(CHIRP)Consent
a. Proofofguardianshipifstudentisnotlivingwithnaturalparent(s).
b. Legalcustodyinstructions.(Ifcustodydocumentsarenotonfile,yourstudentcanbereleasedtoeithernaturalparent.)
c. Psychologicalevaluation,currentIEP,GEI,504documents,andpertinentinformationifyourstudentreceivedservicesinSpecialEducation,504,EnglishLanguageLearner,ResponsetoInterventionorothersupportservices.
d. Forthosestudentstransferringfromanotherschool,aRecordsRequestformisavailableateachDunelandSchoolandattheannualonsiteregistration.
DUNELAND SCHOOL CORPORATION New Student Information Card
Student’s Legal Name (As shown on the Birth Certificate)
_________________________ ________ ___________________ ______________ Last Suffix First Middle
Date of Birth________________ Sex (Circle one) M F Birth Country________________
Date of Enrollment___________ Expected Grade_______________ School Year _________
Name of Primary Guardian (in household) __________________________________________ Last First Relationship to Student ____Father ___Mother ____Legal Guardian ____Other _________________ Specify Who does the student reside with? ____Mother ____Father ____Both Are there any court papers in regards to the student’s custody? Y or N Name of 2nd Guardian (in household)________________________________________________ Last First Relationship to Student _____ Father _____ Mother_____ Legal Guardian _____ Other_______________ Specify Home Address________________________________City/State/Zip_______________________ Primary Guardian Phone_________________________ Email____________________________ Has your student ever received any of the following services? (Check all that apply) ___ Spec Ed Classroom ___ Spec Ed Support (OT/PT/Speech/Social Work, Etc.) ___ Title I ____ELL ____504 ____ RTI ____Other (specify)_______________________ Name of Previous School__________________________________________________________ Is there any other information you would like to share with the school? ________________________________________________________________________________
This form MUST be completed in the presence of a Duneland School Corporation staff member when enrolling a NEW student. (Note: Students who reside in the same household and attend the same school may have their names entered on one form.) The parent(s) and/or legal guardian(s), or emancipated student, must provide acceptable documentation of “legal residence” within the boundaries of the Duneland School Corporation. In addition, an emancipated student must provide proof of emancipation. The term “legal residence” means the primary and principal place of habitation of the parent(s)/guardian(s), or emancipated student, meaning that residence where the parent(s)/guardian(s), or emancipated student in question eat their meals and sleep on a regular basis, receive their mail, and, if applicable, where the parent(s)/guardian(s) or emancipated student, are registered to vote. According to Indiana Code, ‘legal residence’ “…means a permanent and principal habitation that an individual uses for a home for a fixed or indefinite period, at which the individual remains when not called elsewhere for work, studies, recreation, or other temporary or special purpose. Student’s Name(s) _______________________________________________________ School ____________________________________ Grade Level(s) ___________ Parent’s Name (Please Print) _________________________________________________ Guardian’s Name (Please Print) _______________________________________________ The “Legal Residence” for the above named student(s) is: ___________________________________________________________________________ (Street Number and Street) (City) (State) (Zip Code) I AFFIRM, UNDER THE PENALTIES FOR PERJURY, THAT THE FOREGOING REPRESENTATIONS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. _____________________________ _____________ Signature(s) Date Source Document(s): ________________________________________________________ (Ex. Current mortgage statement or lease agreement and one of the following with the current address on it – paycheck stub, current utility bill, current bank statement, vehicle registration, EOB from health insurance, etc.) To be completed by school personnel. ________________________________________________ School Corporation Personnel – Signature
* * * * * * * * * * * * * NOTICE: READ CAREFULLY: Knowingly falsifying this document is a violation of Indiana Code (I.C. 35-44-2), which is a Class D Felony. Falsifying this document will result in the affiant being billed and prosecuted in court, if necessary, for all back tuition, which may be due. Providing inaccurate and/or false information will result in immediate exclusion or withdrawal of your child/children from the Duneland School Corporation. Approved – Board of School Trustees – 12.4.06 2020-2021
HLS
Home Language Survey (HLS)
The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 457 U.S. 202 (1982).
The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district / charter school. The HLS is administered one time, upon initial enrollment, and remains in the student's cumulative file.
Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the survey questions below, the W-APT will be administered to determine whether or not the student will qualify for additional English language development support.
Please answer the following questions regarding the language spoken by the student:
1. What is the native language of the student? _________________________________
2. What language(s) is spoken most often by the student? _________________________________
3. What language(s) is spoken by the student in the home? _________________________________
By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be
tested annually to determine their English language proficiency.
For School Use Only:
School personnel who administered and explained the HLS and the placement of a student into an English language development program if a language other than English was indicated:
El Decreto de los Derechos Civiles de 1964, Titulo VI, Cumplimiento de Normas para Minorías en Lenguaje, requiere a los distritos escolares y escuelas semi-autónomas que determinen el idioma o idiomas que se hablan en el hogar de cada estudiante. Esta información es esencial para que las escuelas puedan ofrecer instrucción útil a todos los estudiantes de acuerdo con Plyler v. Doe, 457 U.S. 202 (1982).
El propósito de esta encuesta es determinar el idioma principal de su hijo/a en el hogar. Esta encuesta (HLS) tiene que darse a todos los estudiantes en el distrito escolar / escuela semi-autónoma. Esta encuesta (HLS) es administrada una vez, durante la matrícula inicial, y permanece en el archivo acumulativo del estudiante.
Por favor tenga en cuenta que las respuestas a la encuesta corresponden solamente a su hijo/a. Si en alguna de las tres preguntas escritas abajo, usted identifica un idioma diferente al inglés, la escuela administrará la Prueba del Desarrollo del Inglés (LAS Links) para determinar si su hijo/a calificará para el programa de desarrollo del idioma inglés.
Por favor responda las siguientes preguntas acerca del idioma(s) hablado por su estudiante:
1. ¿Cuál es el idioma o el dialecto nativo de su hijo/hija? ________________________________
2. ¿Cuál es el idioma(s) más hablado por su hijo/hija? ________________________________
3. ¿Cuál idioma(s) habla su hijo/hija en casa? _____________________________
Nombre del Estudiante: ____________________________________________ Grado:_________________
Nombre del Padre, Madre o Guardián: _______________________________________________________
Firma del Padre, Madre o Guardián: __________________________________Fecha:__________________
Al firmar aquí, usted certifica que las respuestas a las tres preguntas mencionadas arriba corresponden a su hijo/a. Usted entiende que si se ha identificado un idioma diferente al inglés, su hijo/a tendrá un examen para determinar si él o ella califica para el programa de desarrollo del idioma
inglés, para ayudarlo/a a que sea fluente en inglés. Si entra en el programa de desarrollo del idioma inglés, su hijo/a, tendrá derecho a servicios que lo ayudarán a aprender el idioma inglés y tendrá un examen cada año para determinar su nivel de inglés.
For School Use Only / Para Uso de la Escuela Únicamente:
School personnel who administered and explained the HLS and the placement of a student into an English language development program if a language other than English was indicated:
Student’sFullName:______________________________________________________Date:_____________NeworReturningStudent(circleone) Grade:__________ Student’sDateofBirth:________________Doesthestudenthaveanyofthefollowinghealthconditions?HealthCondition: Comments:Includealldates,symptoms,andtreatmentsastheyapplyBirthAbnormalities Yes No Asthma* Yes No SeasonalAllergies Yes No FoodAllergies* Yes No
InsectAllergies* Yes No MedicationAllergies Yes No Diabetes* Yes No HeartProblems Yes No Kidney/UrinaryProblems Yes No Eye/VisionProblems Yes No WearGlasses/Contacts Yes No Lasteyeexamdate:FrequentEarInfections Yes No EarTubes Yes No Lasteartubesatage:HearingProblems Yes No WearsHearingAides Yes No HasCochlearImplant Yes No Eczema/SkinRashes Yes No Seizures/Fainting* Yes No BleedingTendencies Yes No i.e.,frequentnosebleeds:PhysicalHandicap Yes No Speech/LanguageDifficulties Yes No Speechtherapyfacility:SpecialDietaryNeeds** Yes No ADHD/ADD Yes No
*AdditionalFormRequired**Physician’sOrderRequired Hasthestudenteverhadthefollowing?HeadInjuries Yes No Ifyes,diditrequiremedicalintervention:HighFevers Yes No BrokenBones Yes No Surgeries Yes No Doesthestudenttakeanymedicationsonaregularbasis? Yes(listbelow) NoMedication Dose Time ReasonforGiving TakenatSchool Yes/No Yes/No Yes/NoNOTE:Ifyourchildwillbetakingmedicationatschool,whetherprescriptionorover-the-counter,pleasecompletetheschoolmedicationforms.Doesyourchildhaveanyrestrictionsatschool? YES NO (Ifso,aPhysician’snoteisrequired)
