School Name: __________ _

STUDENT HEAL TH APPRAISAL: (Th1s information wi/1 be used by O1strict Health staffto help ourstudent

Student Legal Name:

Does yourstudenthave a physical disability? □ No □Yes---------------------------------

2 Doesyourstudentwearglassesorcontacts? □l'ilo □Yes--------------------------------

3 lsyourstudenttaking anymedication? □ No □Yes _______________________________ _

il Will yourstudenttake medicine atschool? □ No □Yes (list medicine and condition) ______________________ _

5 Is your student a ble to participate fully in activities al school? □Yes □ No (if no, please explain) ____________________ _

6 Check ifyourstudent hasanyof thefollowing?

□ Allergies-food: ____________ _

□ Allergies-insects: ___________ _

□ Allergies-seasonal: ___________ _

O Allergies-misc: ____________ _

□Asthma

O Check if Life Threatening

O Check if Life Threatening

O Check if Life Threatening

O Check if Life Threatening

□ Check if Life Threatening

□Diabetes

□ Heart Problem

□ Seizure Disorder

O Hearing Loss

O Speech Disorder

O Check if Life Threatening

O Check if Life Threatening

O Check if Life Threatening

Explain health conditions: (attach additional sheet if needed) _________________________________ _

Other: -------------------------------------------------

SIGNA TU RE: I declare that the abo ve information is true to the best of my knowledge and belief. I understand I commit the e rime of false swearing if J

make a false statement, knowing it to be false. (ORS 162.075). Further, I understand that my student could be returned to their neighborhood school

upan determination of a falseaddress.

Parent/Guardian Signature: __________________________________ Date: _______ _

School Name:

� Springfield i/¡11 Public Schools NEW STUDENT REOPEN ENROLLMENT FORM

2020-21 New Student Reopening Enrollment Form

/ School Use Only

School Year: ___ _ School: ___________________ _ Student ID# _______ 1'

This enroflment form is a legal document. The information you provide must be accurate and complete.

This information is protected by the Family Educational Rights and Privacy Act (FERPA).

SPECIAL SERVICES: (Please check al/ serv1ces needed by th1s student)

O Speech Se rvices □ Section 504 Plan

□Talented & Gifted Program

□ Special Ed IEP

□ELL/LEP Services □TitleVll lndianEd:Tribe __________ _

STUDENT'S LEGAL NAME:

Legal Last Name First Middle Suffix

Grade: (startingatthisschool) _______ _ Birthdate: __ / __ / __ Gender: □Female □ Male □ Non-Binary

Home Language Preferred First Name Last Name Goes By

First Language Spoken Student Cell Phone Number

Birth City Birth State Birth Country

ETHNICITY & RACE:

Federal Regulations require this information. Jf ethnicity and race fields are not entered, school staff must select for you.

ETHNICITY: O Hispanic □ Non-Hispanic

RACE: (Mark al/ that apply) □ White □ Asian

□Black/African American

O Non-US Native American

□ American lndian or Alaska Native

O Native Hawaiian or Pacific lslander

STUDENT'S HOME ADDRESS: MAILING ADDRESS:

Home Address Apt# Mailing Address (if different than home address)

City State Zip City

CountyofResidence: __________________ _

State

Apt#

Zip

Address Verification: (Provide Photo ID and One UtilityBi/1) Mustbe currentcopies-valid in the past 30days. Verifica/ion can be submittedthrough scannedorphoto copy as we/1 as mail-in documentation.

□ Oregon Drivers License □ UtilityBill□ Oregon ID O Cable/Satellite Bill

Primary Phone: !..__

__ .,_\ ________ (U sed for Attendance & Emergency Calling)

200113-0820

Are there custody issues that the school should be made aware of? □Yes □ No

Aretherecustodypapers? □Yes □No

Relationship to Student: □Father □ Mother □ Guardian (mustprovidelegalguardianshipdocumentation) □Other: (specify) _______ _Living with student? □Yes □No

Paren! Legal Las! Name Legal First Name

Mark ali that apply: □ Contact allowed □Ed. Rights □ Has Custody □ Mailings Allowed □ Release To □ Deceased

Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _

Employer: _____________________ _ Job Tille: ______________________ _

Home Address (if differentfrom student's) City State Zip

HomePhone: ( __ ) ________ Work: ('-___________ Cell: '-----' ________ _ Primary Phone (preferred contact): □ Home □Work □ Cell Active Military? □ Yes □ No

Relationship to Student: □Father □ Mother □Guardian (mustprovidelega/guardianship documentation) □Other: (specify) _______ _Living with student? □Yes □No

ParentLegalLastName Legal First Name

Mark ali that apply: □ Contact allowed □Ed. Rights □ Has Custody □ Mailings Allowed □ Release To □ Deceased

Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _

Employer: _____________________ _ Job Tille: _____________________ _

Home Address (if different from student's) City State Zip

Home Phone: ( __ ) ________ Work: ! _____________ Cell: ( __________ _

Primary Phone (preferred contact): □ Home □Work □Cell Active Military? □ Yes □ No

Relationship to Student: □Father □ Mother □Guardian (mustprovidelegalguardianshipdocumentation) □Other: (specify) _______ _Living with student? □Yes □No

ParentLegal Las!Name Legal First Name

Mark ali that apply: □ Contact allowed □Ed. Rights □ Has Custody □ Mailings Allowed □ Release To □ Deceased

Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _

Employer: _____________________ _ Job Tille: ______________________ _

Home Address (if differentfrom student's) City State Zip

HomePhone: ( __ ) ________ Work: '--- ________ Cell: �--� ________ _ Primary Phone (preferred contact): □ Home □Work □Cell Active Military? □ Yes □ No

Relationship to Student: □Father □ Mother □Guardian (mustprovidelegalguardianshipdocumentation) □Other: (specify) _______ _Living with student? □Yes □No

Paren! Legal Last Name Legal First Name

Mark ali !ha! apply: □ Contact allowed □Ed. Rights □ Has Custody □Mailings Allowed □ Release To □ Deceased

Primary Language: ____________ Dlnterpreter needed Email Address: _____________________ _

Employer: _____________________ _ Job Tille: ______________________ _

Home Address (if different from student's) City State Zip

Home Phone: ( __ ) ________ Work: '--- ________ Cell: '--- _______ _ Primary Phone (preferred contact): □ Home □Work □Cell Active Military? □ Yes □ No

In an emergency, Parents/Guardians Jisted on page 2 with "Contact Allowed" checked, will be called befare Other Emergency Contacts listed below. Líst on/y !hose authorized to pickup your student. lndividua/s listed below wi/1 be contacted to pickup your student in the event of an emergency e/asure.

1st (__ ) □ Home

Name Relationship to Student Phone

Address City State Zip

2nd (__ ) □ Home

Name Relationship to Student Phone

Address City State Zip

3rd (__

) □ Home

Name Relationship to Student Phone

Address City State Zip

4th (__

) □ HomeName Relationship to Student Phone

Address City State Zip

EMERGENCYSCHOOLCLOSURE

To prepare for an unexpected early school dismissal, please assist us by establishing a plan with your child and indicating your choice below:

□ My child will ride !he bus and has been instructed by me about what to do.□ 1 will make arrangements for my child to be picked up al school within an hour of emergency closure.□ My child may be released towalk and has been instructed by me aboutwhat todo.

SIBLINGS: (Líst ali brothers, sisters, step and half brothers and sisters of this student attendmg Springfield Pubilc Schools )

Student Name Relationship to Student Grade

Student Name Relationship to Student Grade

Student Name Relationship to Student Grade

Student Name Relationship to Student Grade

Student Name Relationship to Student Grade

OTHER INFORMATION:

School Enrolled

School Enrolled

School Enrolled

School Enrolled

School Enrolled

□ Cell

□ Cell

□ Cell

□ Cell

PreviousSchool: ________________________________ _ Phone: ( __ ) _______ _

Address City State Zip

Special Circumstances:

lsthisstudentcurrentlysuspended? □ No □Yes, from (name ofschool) ____________________________ _ lsthisstudentcurrentlyexpelled? □ No □Yes, from (name ofschool) _____________________________ _

SchoolAddress, City and State: -------------------------------------------

Permissions:

My student may participate in all school field trips. □Yes □No

SERVICES AND PROGRAMS Checklist for New Students

Student’s Name:

If your student had services or was involved in certain programs in the past year, we want to know in order to better serve your child. Please check those that apply.

Home Language:

No English

Both another language and English

Migrant Education

Native Youth. Tribe, Band or Group:

McKinney-Vento Program/Foster Care Student

Talented and Gifted

Title I

Reading

Math

Individualized Education Plan (I.E.P.)

Reading

Math

Written Language

Speech/Language Services

Emotional Disturbed

Physical/Occupational Therapy

Adaptive P.E.

English Language Learner (ELL/ESL)

Behavior Support

Hearing

Vision

Counseling

Head Start/EC Cares/Preschool Promise

Other (please describe):

PERMISSION TO RELEASE STUDENT RECORDS TO SPRINGFIELD SCHOOL DISTRICT,OREGON

Previous School Phone

City/State/Zip Fax

Student Name Grade Enrolling

Date of Birth Phone

Parent Signature

1st Request 2nd Request Fax # Initial

Please FAX the following: Transcript/Immunizatons

Copy of IEP/Eligibility if applicable

Withdraw Grades if applicable

Please forward the following records in their entirety to the school checked below:

•All permanent Records •Current Official Transcript •Health Records

•All Special Education Recofrds (IEP and 504 accommodations)

•Behavioral Records (including attendance, suspensions and expulsions)

Centennial Elementary School 1315 Aspen St., Springfield OR 97477 Attn: Registrar

Douglas Gardens Elementary School 3680 Jasper Rd., Springfield OR 97478 Attn: Registrar

Guy Lee Elementary School 755 Harlow Rd., Springfield OR 97477 Attn: Registrar

Maple Elementary School 2109 J St., Springfield OR 97477 Attn: Registrar

Mt Vernon Elementary School 935 Filbert Ln., Springfield OR 97478 Attn: Registrar

Page Elementary School 1300 Hayden Br Rd., Springfield OR 97477 Attn: Registrar

Ridgeview Elementary School 526 66th St., Springfield OR 97478 Attn: Registrar

Riverbend Elementary School 320 51st St., Springfield OR 97478 Attn: Registrar

Thurston Elementary School 7345 Thurston Rd., Springfield OR 97478 Attn: Registrar

Two Rivers Elementary School 1084 G St., Springfield OR 97477 Attn: Registrar

Walterville Elementary School 40589 McKenzie Hwy., Springfield OR 97478 Attn: Registrar

Yolanda Elementary School 2350 Yolanda Ave., Springfield OR 97477 Attn: Registrar

Agnes Stewart Middle School 900 S 32nd St., Springfield OR 97478 Attn: Registrar

Briggs Middle School 2355 Yolanda Ave., Springfield OR 97477 Attn: Registrar

Hamlin Middle School 326 Centennial Blvd., Springfield OR 97477 Attn: Registrar

Thurston Middle School 6300 Thurston Rd., Springfield OR 97478 Attn: Registrar

Academy of Arts and Academics 615 Main St., Springfield OR 97477 Attn: Records/Counseling

Gateways High School 425 10th St., Springfield OR 97477 Attn: Records/Counseling

Springfield High School 875 7th St., Springfield OR 97477 Attn: Records/Counseling

SPS OnLine (K-12) 425 10th St., Springfield OR 97477 Attn: Records/Counseling

Thurston High School 333 58th St., Springfield OR 97478 Attn: Records/Counseling

Received Records On: Checked In by:

Federal Law 99.31 Requires No Parent Signature for educational records sent to another agency. Permission is required for transfer of Special Education records.