Pleasant Hill School District 1Student Enrollment

This enrollment 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).Office Use Only Entry Date ___/___/_____ Birth Record Out of District Exchange

Advisor:_______________ Immunizations Open Enrollment

___________________________ __________________________ _________________________ Last First Middle

Grade (Current):________ Gender: Female MaleStudent's Home Address: Mailing Address: Same as home address____________________________________# _______ ____________________________________________Address Address (if different than home address)

___________________________________OR______ ___________________________ ______ _________City Zip City State Zip

Home Phone:________________________ Cell Phone:_________________________________Are there any restraining/court orders in place to protect your student? Yes NoIf YES, a copy of the restraining/court order must be provided for our school records.Home Language: 1. Which language did this student learn first? English Other:________________ 2. Which language does this student most often use at home? English Other:________________ 3. Which language do parents use most often at home? English Other:________________ 4. Has this student attended school in any other country? Yes:_________________________ a. If yes, when did this student begin school in the US? _____/_____/_________

Month Day Year

b. If yes, has this student been in an English Language Learner program in the US? Yes No c. If yes, when? ______/______/______ and where?____________________________________________

Birth Date:_____/_____/_____

Birth City:___________________________________________Birth State:__________________________________________Birth Country:________________________________________

Ethnicity: Hispanic Non-HispanicRace: White Asian Native Hawaiian or Pacific Islander(Mark all that apply) Black or African American American Indian or Alaska Native

Non-US Native American (ancestors from Mexico, Central America, South America Or Canada)Special Services/Circumstances: Please check all services needed by this student

ELL/LEP Section 504 SPED. IEP Suspended/Expelled from another district? Speech TAG Title VII Indian Ed (Native Program) Tribe:________________

Preferred Name:_________________________________Student's Legal Name:

First two contacts will receive automated emergency notifications. 1st ___________________________ _________________ _________________ ________________

Parent/Guardian Name Relationship to Student Phone Cell

2nd ___________________________ _________________ _________________ ________________Parent/Guardian Name Relationship to Student Phone Cell

3rd ___________________________ _________________ _________________ ________________Name Relationship to Student Phone Cell

4th ___________________________ _________________ _________________ ________________Name Relationship to Student Phone Cell

(Services contacts, if applicable)__________________________ _______________________ __________________________ (Case Worker) Supervisor Phone

___________________________ __________________ ___________ ______________________________Student Name Relationship to Student Grade School Enrolled

___________________________ __________________ ___________ ______________________________Student Name Relationship to Student Grade School Enrolled

___________________________ __________________ ___________ ______________________________Student Name Relationship to Student Grade School Enrolled

Other InformationEmergency Closure Transportation:

In an emergency closure my student will ride the bus. YES NOIn an emergency closure someone will pick up my student. YES NO

Permissions:

Field Trips: My student may participate in all school Field Trips. YES NOSchool Directory: My student's information may be printed in a school directory. YES NOSchool Website: My student may be mentioned, quoted or pictured on the school website. YES NONews Media: My student may be seen, interviewed or quoted on T.V., radio or newsprint. YES NOPhotographs: My student's picture may be taken during class or for class activities. YES NOVideo: My student may be videotaped during class or class assignments. YES NOHIV/AIDS Instruction: My student may be present during HIV/AIDS instruction times. YES NOHolidays: My student has permission to celebrate holidays. Exception:__________________ YES NOHigh School Only: School Year Book: My student may be mentioned or pictured in the School Year Book. YES NO

(By law the district must release to military recruiters the name, address and phone number of high school

students, unless your Student, Parent or Guardian notifies the district that they do not want the information released.)

I request my student's name/contact information NOT be given to Military Recruiters. YES NO

Emergency Contacts

Siblings (List all school age brothers, sisters, step/half brothers and sisters of this student living in district)

Student Name:____________________________________________________________

Health Information Student Name:_______________________________________________ D.O.B_______/_______/_______

Student's Doctor: _____________________________ Phone:_____________________________________Date of last Physical Exam:______/______/______

1. Does your student have a physical disability? No Yes_____________________________ 2. Has your student ever had an operation? No Yes_____________________________ 3. Has your student ever had a severe injury? No Yes_____________________________ 4. Does your student wear glasses? No Yes_____________________________ 5. Does your student have a current medical condition? No Yes_____________________________ 6. Is your student taking any medications? No Yes_____________________________ 7. Will your student take medication at school? No Yes_____________________________ a. If yes: Medication:________________________ for condition: ____________________________ 8. Is your student able to participate fully in activities at school? Yes No (if No, please explain)____________________________________________________________________________________________________ 9. Check if your student has any of the following?

Allergies- Food:________________________________________ Check if Life Threatening*Allergies- Insects:______________________________________ Check if Life Threatening*Allergies- Seasonal:____________________________________ Check if Life Threatening*Allergies- Misc.________________________________________ Check if Life Threatening*Asthma* Check if Life Threatening*Diabetes* Check if Life Threatening*Heart Problem* Check if Life Threatening*Seizure Disorder* Check if Life Threatening*Other:________________________________________________ Check if Life Threatening*

If your student has any of the above conditions with an asterisk*, please explain below.__________________________________________________________________________________________________________________________________________________________________________________

ADD/ADHD Fainting Hearing Loss Speech Disorder History of Ear Infections

Explain health conditions:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medical Emergency Transportation:I give my permission to have my student transported to a medical facility by YES NOemergency personnel.

Signature: I declare that the above information is true to the best of my knowledge and belief. I understand I commit the crime of false swearing if I 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 upon determination of a false address.

Parent/Guardian Name:__________________________________________ Date:_____________________ (Print)

Parent/Guardian Name:__________________________________________ Date:_____________________ (Signature)

I hereby give my consent for the release of permanent/confidential records to the school named on this document. I understand that I may review these records in accordance with the provisions of the Family Educational Rights and Privacy Act.

Pleasant Hill School District No. 1 36386 Highway 58, Pleasant Hill, OR 97455

Send records to:

□ Pleasant Hill Elementary □ Pleasant Hill High School 36386 Highway 58 36386 Highway 58 Pleasant Hill, Or 97455 Pleasant Hill, Or 97455 Fax: (541) 736-0446 Fax: (541) 744-3351 Phone: (541) 736-0400 Phone: (541) 747-4541

Student Birthdate Grade

Cumulative/Permanent Records (Attendance records, grade level, classroom test results, grades)

Health Records (Hearing, vision, Certificate of Immunizations)

Behavioral / Confidential Records

Special Education Records

Other special program records (TAG, Title 1, school lunch, ect.) __________________________________ ____________________________________ Signature of parent or guardian Date Signature of registrar/school designee Date Former School: Address: City, State, Zip: Phone: Fax:

For School use only:

Student Entry Date: _______________________ Date Faxed or request mailed: Date Records Received:___________

Student Information for Busing Child’s Name____________________________________________________

Grade (for planned school year)___________________________

� My child will NOT be riding the bus to school.

� My child will NOT be riding the bus home.

� My child will ride the bus in the morning.

Exact Address_________________________________________________

� My child will ride the bus in the afternoon.

� Same address as morning.

Afternoon Address_____________________________________________

Parent or Guardian Name______________________________________

Best phone number to reach you during the day________________

Email__________________________________________________________

If this information needs to be updated at any time before school starts, please email: michelle.banks@firstgroup.com or call 541-688-0454, ext. 307. Thanks!

mailto:michelle.banks@firstgroup.com

Billie News

Currently we send a hard copy of the Billie News out twice a month. We also post our Billie News newsletter on the Pleasant Hill School District website under the Elementary School tab www.pleasanthill.k12.or.us and PTO website www.phespto.org. They are published the first and third Mondays of the month. Please sign up below which way you would like to receive the newsletter or email Maria @ mskelton@pleasanthill.k12.or.us. Also, please follow us on twitter (@PHESBillies).

Student Name:__________________________________________

Yes! Please send me a hardcopy of the Billie News when it is available. I can’t receive it otherwise.

Name:___________________ Youngest Child’s Name:_____________________

Teacher:_________________

OR

We would like to receive an email copy!

Email:______________________

http://www.pleasanthill.k12.or.us/http://www.phespto.org/mailto:mskelton@pleasanthill.k12.or.us

Pleasant Hill School District No. 1

Volunteer Information Packet

We are pleased that you have expressed an interest in volunteering to work in the classroom, on field trips or coaching in our schools this year. As educators, we value and encourage parent participation in the educational process. It is always best for kids when staff and parents work in a collaborative relationship to support learning. It is important for you to become familiar with the District’s policies and procedures that facilitate positive parent-school relationships. There is a need to keep the school campus safe and secure so learning can take place. The Pleasant Hill School District has school board adopted policy concerning both volunteers and visitors. After you complete the survey and the criminal background form, return it to our district office personnel, Sheri Longobardo, 541-736-0794, or the building secretaries to forward to the district office. Your information will be processed and you will be notified by letter once completed. The school secretaries will be maintaining a current list of approved volunteers. If you are interested in volunteering in the classroom, you may contact the teacher after you receive your approval letter. When you volunteer it is important to follow the agreements and schedule you have made with the teacher including maintaining confidentiality. Any information you learn, read, hear or overhear regarding a student is confidential. It is not to be shared with anyone except the classroom teacher. If you have a concern about a classroom procedure, be sure to discuss it with the classroom teacher in private. Questions asked by other parents or neighbors about a specific student or incident should be referred to the teacher or principal. All volunteers (and visitors) are required to check into the main office in either the elementary or middle/high school buildings. You will sign in and be given a volunteer pass to wear while you are volunteering. Visitors also need to check in. When you leave campus, please sign out and return the pass. All staff has been trained and will look for these passes to ensure that adults in the building have a purpose and have been cleared to work with students. Again, thank you for expressing an interest in volunteering in Pleasant Hill. Return the completed survey and Criminal History Form to either your school office. Before you volunteer, we encourage you to read a copy of the student handbook; it provides a great deal of information that will help you become familiar with our school and procedures.

Form 581-2282-M (Rev. 4/13) This Form may be reproduced locally without change.

Oregon Department of Education Public Service Building 255 Capitol Street NE Salem, Oregon 97310

CRIMINAL HISTORY VERIFICATION OF APPLICANTS

Office of Finance and Administration Pupil Transportation and Fingerprinting

503-947-5887

THIS FORM MUST BE ENCLOSED WITH THE 581-2281-N SCHOOL/DISTRICT COVER FORMCANT. ALL DOCUMENTS MUST BE MAILED TOGETHER TO THE DEPARTMENT OF EDUCATION.

Please type or print clearly. As Appears on License

Name: ______________________________ _________________________ _________________________ Date of Birth:______________ Sex: (Last Name) (First Name) (Middle Name) MM/DD/YY List Other Names Previously Used: (includes Maiden Name) Social Security No.: Driver License/Identification Card No.: Providing your social security number on this form is voluntary. If you choose not to disclose the social security number, this will not be a basis for denial of employment or any rights, services or benefits to which you are otherwise entitled. If you do provide the number the Oregon State Police will use it as an additional identifier to search for any criminal record you may have. Your social security number will be used as stated above. State and federal laws protect the privacy of your records.

Mailing Address: Full Street Address/Post Office Box

City: State: Zip + 4:

A. Have you EVER been convicted of a sex-related crime? Yes No

If yes, was the conviction in Oregon or another state? (Please specify if another state.) State:

If yes, did the crime involve force or minors? Yes No

B. Have you EVER been convicted of a crime involving violence or threat of violence? Yes No

If yes, was the conviction in Oregon or another state? (Please specify if another state.) State:

C. Have you EVER been convicted of a crime involving criminal activity in drugs or alcoholic beverages? Yes No

If yes, was the conviction in Oregon or another state? (Please specify if another state.) State:

D. Have you EVER been convicted of any other crime except a minor traffic violation?(Includes Traffic Crimes) Yes No E. Have you been arrested within the last three years for a crime for which there has not yet been an acquittal or dismissal? Yes No

Advisory: A check of the applicant's criminal history will be made by the Oregon Department of Education to verify the responses to the preceding questions. I hereby grant to the Oregon Department of Education permission to check civil or criminal records to verify any statement made on this form. Regardless of whether the applicant grants consent, the Oregon Department of Education will conduct a criminal offender record check of applicants for the position of school bus driver, volunteer, or other prospective school employees working with or around children. The applicant is entitled to review his/her criminal history for inaccurate or incomplete information. Discrimination by an employer on the basis of arrest records alone may violate federal civil rights law. The applicant may obtain further information concerning the applicant's rights by contacting the Bureau of Labor and Industries, Civil Rights Division, State Office Building, Suite 1070, Portland, Oregon 97232, telephone (503) 731-4075. I acknowledge reading and the receipt of this notice. Applicant's Signature: Date:

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Pleasant Hill School District No. 1 VOLUNTEER SIGN UP SHEET

Parent Name _____________________________________________________ Date____________ Address_____________________________________________________City/Zip_______________ Phone______________Cell______________Email_______________________________________

Would you like to receive updates via email: YES □ NO □ Children’s Name (s)________________________________________ Grade (Current)________ Children’s Name (s)________________________________________ Grade (Current)________ Children’s Name (s)________________________________________ Grade (Current)________ Children’s Name (s)________________________________________ Grade (Current)________ I am interested in volunteering in the following areas. Please check all that apply. ___Head Room Parent (PHES) ___Room Support Parent (PHES) ___Volunteer in Classroom ___I’d like to work on projects I can do at home ___Field Trips ___Chaperone school-sponsored events or dances (PHHS) ___Help in workroom making copies, preparing materials ___Library Days you could help M___Tu___W___Th___F___ ___Lunch Room M___Tu___W___Th___F___ ___Lunch Room Sub list M___Tu___W___Th___F___ ___Jog-A-Thon (PHES) ___Activity Thon (PHHS) ___Health Screening (PHES) ___Teacher/Staff Appreciations Week ___All-school last day event (PHES) ___Book fairs ___CBM Progress monitoring / Universal screening in reading and math (PHES) ___Assemblies ___Assist on the playground or during lunch with small group activities. (PHES) ___Carnival planning committee (PHES) ___OBOB discussion group leader grades 3-6 (PHES) ___Other List_________________________________ The school often looks for people to help with special events or programs. We know many of our parents have unique talents, expertise or perhaps travel experiences that they would like to share with a class. If you wish to volunteer in this way, please indicate below. Your career___________________________________Hobby_______________________________ Musical Talents____________________________ Arts/Crafts______________________________ Other____________________________________________________________________________

We look forward to you being an active participant in your child’s education.

Resv 4.8.12 Criminal background check completed , approved and on file ____ Yes (Checked off by Secretary)

Updated: 3/18/2016

Oregon Title 1C Migrant Education Program Eligibility Survey

Student’s Name:__________________________________________ _________________ Last First Date The Oregon Migrant Education Program helps children and young adults ages 0-21 who move (on their own or with their parents/guardians) in order to seek or obtain temporary or seasonal work in agriculture, forestry or fishing activities. Free services may include summer school, transfer of school records, 24-hour accident insurance, Free Lunch, prekinder & graduation support, and referrals to community resources. We would appreciate your cooperation in answering the following questions:

1. Has your family moved within the last three years? Yes No 2. Has a person in your family ever worked in or planned to work in agriculture, forestry and/or fishing?

Yes No If yes, type of work: _____________________________________________________

Please fill out the rest of this from if you feel you might qualify for the program or if you are interested in finding out more information about the programs’ services.

With my signature, I authorize personnel from the Migrant Education Program to contact me

for the purpose of determining if we qualify for services.

Please return this form to your school office.

Thank you! Migrant Education Program: Planting Seeds of Education!

School Official: Please send ALL completed forms by courier to Lane ESD Attn: Migrant Education Program For Questions in Lane County call: 541-461-8283 For Questions in Douglas County call: 541-817-4348

Student’s School: Date of Birth: Grade:

Full name(s) of Parent/Guardian(s):

Street Address: City: State/Zip:

Home Phone: Cell: Other:

Signature of Parent / Guardian: Date:

School Distrcit

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PHESenrollmentpkt17-18Sheet1Sheet2Sheet3Sheet4

revised records request 17-18Student Information for BusingBillie News sign-upvolunteer packet cov lt 2017-18Criminal History Application 2282-M 050113Volunteer Sign Up Sheet 2017-18Title X Eligibility SurveyTitle 1C Survey

Name: First Name: Middle Name: Date of Birth: Sex: List Other Names Previously Used: Social Security No: Driver LicenseIdentification Card No: Mailing Address: City: State: Zip 4: If yes was the conviction in Oregon or another state Please specify if another state State: Radio Button1: OffIf yes was the conviction in Oregon or another state Please specify if another state State_2: Radio Button2: OffIf yes was the conviction in Oregon or another state Please specify if another state State_3: Radio Button3: OffRadio Button4: OffRadio Button5: OffRadio Button6: OffDate: