Application - Flandreau Indian School

The FlandreauIndian SchoolAdmissionsDepartmentconsistsof the Registrarand the
AdmissionsReview Committee.Applicationsare acceptedthroughoutthe schoolyear and
for the start of eachterm. The Registrarreviewsthe applicationsfor completeness.
The
Review Committeethen meetsto review eachapplicationfor acceptance.
After applications
arerevieweda letter is sentout regardingyour acceptanceor non-acceptance.The
acceptanceletterwill statethe term you are acceptedfor.
FLANDREAU INDIAN SCHOOL
lI32 N. Crescent
St.
Flandreau,SD 57028
(605)997-3773
ext.2ll4
(800)942-1647
ext.2ll4
www.fis.bia.edu
Dear Student:
Thank you for consideringthe FlandreauIndian Schoolfor advancingyour educational
opportunities.Pleasereadthe applicationand completeall requireddocumentationbefore
sendingto FlandreauIndian School.
FlandreauIndian Schoolis an off reservationboardinghigh schoolfor grades9 - 12.
Studentsare allowedto enroll prior to the beginningof a term. Contactthe Registrarif you
haveany questionsregardingadmissionsor the applicationprocessat the numberabove.
Here are answersto the most frequentlyaskedquestions:
1. What is the applicationdeadline?
The deadlinefor applicationsis tentativelyset for eachterm. We want to see
our studentsstart schoolon the first day. You may call the numberabovefor
thosedates.
2. When shouldthe applicationbe sent?
Our AdmissionsReview Committeewould like to havethe complete
applicationhere as soonas possibleoncethe studenthas completedtheir
currentschool year.
3. What happensif I don't senda completeapplication?
An incomplete application will not be reviewed.Parentsmust includeALL
requiredinformation with the applicationbefore sendingit. Sendingin an
incompleteapplicationdoesnot reservea slot for the student.
4. May I requestmy previousschoolto mail you my grades/transcripts?
Transcripts(official copy of schoolgrades)must be includedwith the
application.(Do not ask previousschoolto mail the transcriptdirectly to our
school.Pleaseattachthetranscriptto the application.)
5. May I sendmy applicationwith a releaseof information for FlandreauIndian Schoolto
requestmy transcripts?
FlandreauIndian SchoolWILL NOT REQUEST TRANSCRIPTS from
the applicant'sformer school(s).
6. May I get a physical after I am acceptedat the FlandreauIndian School?
Physicalexaminationsand immunizationsrecordmust be includedwith the
application.(A copy of a previousphysicalcan be sentif it is not older than one
year from the startdateof the schoolyear.We will also needa copy of the current
physicalto be sentto us oncethe studentis ableto schedulean appointmentat your
Indian Health ServiceClinic or other clinic.
7. When will I know if I am acceptedor denied?
Review Committeewill review applicationsand make selectionsthroughout
the year. An acceptanceor denialletterwill be sentafter your application
hasbeenreviewed.
8. Can a studentof legal age enroll themselvesat the FlandreauIndian School?
All forms mustbe completedand signedby parent/guardian; studentsmay
not sign their own applicationevenif they are 18 yearsof age or older.
FlandreauIndian SchoolAdmissionFacts
1. Behaviorcontractswill be requiredaspart of the approvalfor admissionfor students
having exhibiteda history of abusingschoolrules.
2. Specialapprovaland review will be requiredfor late applicationsand thereis not a
guaranteefor approval.
3. Studentswho havebeensuspendedor expelledwill receivecritical application
examinationby the AdmissionsReview Committeeand SchoolPrincipal.
4. Studentswho exhibit behaviorthat would endangerthemselvesor otherswill be denied
admission.
5. The FlandreauIndian Schoolis on a block schedule;therefore,26 creditsare required
to graduate.
6. Incompleteapplication packetswitl not be revieweduntil application is complete.
Your application must have the following to be consideredfor enrollment at
the Flandreau Indian School. Pleaseuse this list as a checkbefore vou mail
your application.
1. Parent/GuardianSignature
2. Social SecurityNumber (Copy of the Card)
3. Certificateof Indian Blood. You must be enrolledwith a US federally recognizedtribe or you must
be Yodegreeor more if not enrolled. Tribal EducationOffices cannotcertiff and sign blood degrees.
Tribal ID cards are not acceptable!
4. Physicalexamination. New one every year.
5. ImmunizationRecord.
6. Consentof parent/guardianfor medical care.Pg 10 CompletelySigned.
7. Parentalconsentform for Records,Field Trips, and Medication.
8. Copy of Birth Certificate. DO NOT SEND BAPTISMAL CERTIFICATE.
9. An ofhcial up-to-datehigh schooltranscriptmust be included. If you have not attendedschoolfor a
semesteror more, pleaseindicateso. Flandreau Indian Schoolwill not request transcripts.
10.If you are a new freshmanyou must provide proof of promotionto grade9. Pleasesubmit a copy of
your 8thgradereport card stating promoted to grade9.
11.Policy sign off sheet. Both Parent/Guardian
and student.
12.TrlbalResolution must accompanyapplicationif you resideoutsideof SouthDakota,North Dakota,
Montana,Wyoming, Iowa, Nebraska,Minnesota,Wisconsin,or Michigan.
13. ELO Signature(seepage 3 of the application)
14. Social Summary(seepage 3 of the application)
15.Free and ReducedLunch Form.
16.McKinney Ventro Form. Must be signedat the bottom.
lT.Letter from studentstating why they rvould like to attendFlandreauIndian School.
INCOMPLETE APPLICATIONS
WILL NOT BE CONSIDERED! ! t !
Completed applications can be mailed to: Flandreau Indian School
Attn: Registrar
1132N. CrescentSt.
Flandreau, SD 57028
Pleusedo not fsx upplications, we needoriginul signutuFes.
Page I
APPLICATION FOR
BUREAU FUNDED SCHOOLS&
FEDERAL BOARDING SCHOOLS
Attachedwith the applicationis an instructionsheetand accompanyingpapersto be completed.
TINITED STATESDEPARTMENT OF THE INTERIOR
Bureau of Indian Affairs
1076-0122Data Elements for Student Enrollment in Bureau Funded Schools: Expiration 0313112012
STUDENT ENROLLMENT APPLICATION
Name of School:
GradeApplying For:
FlandreauIndian
Irltltltrrtrrtllllllttttrrlrlrlllllttttatltttttlrrarrllllllllllrrrrlltrllltllllrllatllll
1. IDENTIFICATION:SOCIALSECURITYNUMBER:
NAME OF STUDENT
ADDRESS:POBOX
MIDDLE
FIRST
LAST
STREET
CITY:
STATE:
DATE OF BIRTH:
ZIP CODE:
DEGREEINDIAN:
S E X :M A L E ( ) F E M A L E ( )
PLACEOF BIRTH:
TRIBAL AFFILIATION:
ENROLLMENTNUMBER:
HOMEAGENCY:
(Must includecopy of Certificateof Indian Degreeof Blood)
:
RELIGIOUSAFFILIATION(optional)
DOMINANT LANGUAGE SPOKENIN HOME:
STUDENTATTENDEDFLANDREAUPREVIOUSLY?
YES
NO
NOTB: SocialSecurity Number must be included at the top of this page.
Page2
Student'sName:
NOTE: Pleaseinclude the area codewhen recording telephonenumbers. Pleaseprovide
documentation of legal guardianship if applicable.
ltlttrrllltttttrrlllltltttlllllltlllttltltrrllllllllllrllllltllltllllllllllllrllllllllll
2. FAMILY AND BACKGROTIND INFORMATION: Parentsor Legal Guardian (circle one)
Father
Mother:
Address:
Address:
Town:
Town:
Tribal Affrliation:
Tribal Affiliation:
Home Agency:
Home Agency:
Living: ( ) Deceased:( )
Living: ( ) Deceased:( )
Occupation:(opt.)
Occupation:(opt.)
Employer:
Employer:
Telephone: Home:
Telephone:Home:
Work:
Work:
Emergency:
Emergency:
Other:
Other:
Studentresideswith: Name
Address:
zip:
City, State
Telephone:
3. SCHOOL PREVIOUSLY ATTENDED: (Pleaseincludecompletemailing address)
SchoolName:
Address:
CitylStatelZip:
Telephone:
Dates Attended:
GradeCompleted:
I am legally responsiblefor this studentand hereby apply for his,4reradmissionto this school. Understandthat additional
information may be requestedby the school before the sfudentis enrolled.
Signatureof Parent/LegalGuardian
The FlandreauIndian School will follow the guidelines set forth in 62 BIAM 9.5
Page3
A. CRITERIA FOR BOARDING SCHOOL:
Favorableaction is recommendedupon this application becausethis caseconforms to the following criteria
for boardingschool. Ifthis applicationis for an off-reservationboardingschool and for socialreasons,a
social summarymust accompanythis application.
Check all applicablecriteria.
EDUCATION FACTORS
SOCIAL FACTORS (Must be accompanied
by social summary)
schoolsnearstudent'shome:
Federal/public
In hisftrer family environment, the student:
( ) Grade level not offered.
( ) Are severelyovercrowded.
( ) Exceed| % mile walking distanceto schoolor bus route.
(
(
(
( ) Do not offer specialvocational/preparatorytraining
necessaryfor gainful emPloYment.
( ) Do not offer adequateprovisionsto meet academic
deficienciesor linguistic/culturaldifferences.
( ) ReceivingSchooloffers specialacademicprogram
neededbv student.
OTHER FACTORS -
Parent Choice -
Was rejectedor neglected.
Does not receiveadequateparentalsupervision.
Well beingwas imperiled due to family
behavioral
( ) Was behavioralproblemstoo difficult for solution
by family or local resources.
( ) Was siblingsor other closerelativeenrolledwho
would be adverselyaffectedby separation.
Homeless -
Other
If you do not live in SouthDakota,North Dakota,Minnesota,Michigan, Wisconsin,Iowa, Nebraska,
Montanaor Wyoming, you will be requiredto submit a resolutionfrom your tribe to attendour school.
If you live outside the boundaries of the Flandreau Indian School,it is the parent's responsibility to
contact the Tribe to find out if your Tribe has a resolution'
.
If you shouldhavequestionsregardingresolutions,pleasefeel free to contactus at 1-800-942-1647
B. Out-of-Bounds ApProval:
ReceivingBIA EducationLine Officer
Date
Page4
(To aid studentin IntenseResidentialGuidance)
SUPPLEMENTALATTACHMENT FOR FIS BOARDING
SCHOOL APPLICATIONS
AN INTENSERESIDENTIALGUIDANCE(IRG)
FLANDREAUINDIAN SCHOOLOFFE,RS
PROGRAMTO ASSISTSTUDENTSWHO HAVE SEzuOUSPROBLEMSADJUSTINGTO SCHOOL,
OF THE INTENSERESIDENTIALGUIDANCE
OTHERPEOPLE,AND/OR SOCIETY.THE PURPOSE
IN
SUPPORTS
PROGRAMIS TO PROVIDECULTURALVALUE REINFORCEMENTS,
AND
SOCIAL
ABUSE
DRUG
IINDERSTANDINGAND COPINGWITH ALCOHOLAND
DEVELOPMENT,PLUSDEVELOPINGA PEERGROUPALL IINDER THE DIRECTIONOF
INDIVIDUAL ADVISORS.PLACEMENTOF ELIGIBLESTUDENTSIS KNOWN TO MAXIMIZE
THEIRSCHOOLRETENTIONRATE AND TO HELPRESOLVESOCIALPROBLEMSTHEY MIGHT
BE EXPERIENCING.
for IRG eligibility,we needa statement
In orderfor the studentapplicantto be considered
from a socialworkeror socialagencyofficial,officerof the court,
placement
recommending
Pleasemakea brief statement
or psychologist.
juvenileauthority,formerprincipal,counselor,
on thestudent'sapplication,further
if you checkedoneof the socialreasons
regardless
Programplacement.
Guidance
for IntenseResidential
will benecessary
explanation
for referringa studentto IRG mustbe from officialsotherthanparents.
Statements
REFERRAL STATEMENT/SOCIALHISTORY:
Recommendthe need for
Student'sName
To be placed in Flandreau Indian School's Intense Residential Guidance Program.
Name and Title
(Parentsor Legal Guardianscannot sign this form.)
Date
Page5
SOCIAL INFORMATION AND PROGRAM REFBRRAL
Has your studentmissedmore than 10 daysof schoolin the last year?
If yes, give nameof school:
No Yes
ol, dates'and reason
No -ff"or.t"a*t Ueensusperuledfrom schoolin the last year?Yes school.dates.and reason:
If so, explain:
No
Has studentever beenarrested?Yes
If yes, give nameof
What was the law violation? ExPlain:
Has studenteverbeenin jail or detention?Yes
If so, explam:
No --
If yes, give nameof probationofficer, address,and phonenumber:
Has your studentreceivedor beenreferredto treatment?Yes
No -
If yes,where?
If yes, pleaseidentify and describewhat kind and havethe Counseloror therapist
No _
senda reportto FlandreauIndian School.
yes
Type of Therapyor CounselingReceived:
Name & Title of Counseloror Therapist:
Address:
PhoneNumber:
Parent/ GuardianSignature
Date
NOT PROVIDING OR PROVIDING FALSE INFORMATION MAY RESULT IN YOUR CHILD'S
IMMEDIATE RELEASE FROM THE FLANDREAU INDIAN SCHOOL.
PLEASE FILL OUT THIS PAGE COMPLETELY.
Page6
MEDICAL INFORMATION
Does the studenthave any medical problems that may interfere with school attendanceand/or needsmedical
If yes,pleaseexplain:
No carewhile in school? Yes
Is the studenttaking medicationson a regularbasis? Yes -
No -
Is the studentallergicto any medicationsor foods? Yes -
No -
Has the studentreceivedthe HepatitisA injection? Yes
Has the studentreceivedthe HepatitisB injection? Yes
No -No --
If yes, list:
If yes, list:
No
Doesthe studenthave any medical insuranceor Medicaid? Yes
type?
What
If So,
Pleaseprovide a copy of the card with the application.
WhatNumber?
All FlandreauIndian School staff is authorizedto act in Loco Parentisfor the studentsat the Flandreau
Indian School. The FIS staff has authorityto sign all paperworkrequiredfor emergency,medical,or
hospital careat any medical facility.
FYI: Definition - In Loco Parentis:
In loco parentis is a term used in situations where another individual or agency is acting in place of a
parent on behalf of a minor. The tcrm is used in legal settingsto assign the rights, duties, and
responsibilitiesof a parent to another person or agency. Alternatively, the term has been used in less
formal referencesto describe the role played by an educational institution, such as a boarding school,
college,or university, in supervising minors and young adults.
NOT PROVIDING OR PROVIDING FALSE INFORMATION MAY RESULT IN YOUR CHILD'S
IMMEDIATE RELEASE FROM THE FLANDREAU INDIAN SCHOOL.
I. MEDICATION
With my full consent,the FlandreauIndian Schoolhasmy permissionto administermedicationto the
student.
I (we), as parent (s)/legal guardian (s), have read this consentform for the FlandreauIndian School and
fully understandand agreeto its content.
SIGNATURE OF PARENT/GUARDIAN
DATE
Page 7
FLANDRBAU INDIAN SCHOOL POLICIES
The FlandreauIndian School wants to provide positive leaming within a safe and healthy environment. Our
concernis to encouragestrong academicprogressin the classroomand dormitory situation. We have
adoptedthe following policies to improve our studentslearningand safety.
NO TOLERANCE POLICY
ON ALCOHOL, DRUGS, AND VIOLENT BEHAVIOR
The FlandreauIndian Schoolwill adopta policy on violence,use of alcohol,use of drugs,and any
administrativelydeterminedaction. Violencemeansviolent behaviorwhich might lead to insult, or injury
toward studentsor staff. Studentsmay be subjectto an immediate hearing, which could result in a referral to
the TransitionDorm, suspension,or expulsion.
Students,who are involved in any act of violence or exhibit violent behavior toward staff, students,or to the
generalpublic on or off campus,will be subjectto a mandatorycounselinginterventionprogramwithin the
TransitionDorm. (This will include disrespectfulbehaviorin the classroom,cafeteria,canteen,dormitory, at
the gate,or other areason campus.) This also includesan accumulationof majors,which might result in a
studint hearing. Examplesof the aboveare listed,but not limited to the following: Intimidation;threatsof
violence;participationin group violence,i.e., in a room where a fight may take place or groupsof students
intimidating others;verbal threats or written threats,or any such treatsto staff members,AWOL's that
would endangerhealth and safety, or any.thinglisted in Article X, SectionsA, B, and C of the Student
Handbookwhich definesstudentsstandardsof behaviorand conduct. If a studentcommits an act of violence
leading to seriousbodily harm to themselves,anotherstudent,or staff member, the studentmay be subjectto
a hearingfor suspensionor expulsionimmediately.
Studentswho are involved in consumptionof alcoholor useof drugswill be subjectto a mandatory
counselingintervention program within the Transition Dorm. A studentmust attend the mandatory
counselinginterventionsessionsassignedby the staff immediately. When the studenthas successfully
completedthe programin the TransitionDorm and then receivesanothermajorriclating the zero tolerance
policy, that studentmay be subjectto a hearingfor suspensionor expulsionimmediately.
GANG-RELATED CLOTHING
Any wearing of apparelthat signifies gang membership,items with gang connection such as handkerchiefs,
"rag", necklaces,and/or"colors", and clothesdepictingany tobacco,liquor, or explicit/implied sexual
connotation are viewed as inappropriate. Any clothing items the school administration deemsto be gangrelatedwill be banned. Studentswho may participatein anyway in gang related activities may be subjectto
immediatesuspensionor expulsion. Activities suchas the abovemay be considereda health and safety
issue.
We have readand agreeto the abovepolicies:
Parent/GuardianSi gnature
Date
StudentSignature
Date
Page8
VANDALISM POLICY
The FlandreauIndian Schoolhas adopteda policy on vandalism. The policy statesthat vandalismwill result
in a major infraction and that the studentwill be expectedto pay for damages,such as but not limited to:
brokenwindows; defacing;of ID cards;destructionof heatvents,furniture, or textbooks;damageto walls;
graffiti on any FIS property; or tampering with the sprinkler system. However, if the destructionis the result
of u d"lib.tately setfire ordeliberatedamageto property,law enforcementwill be notified and the FBI may
alsobe involved.
All students,upon enrolling at the FlandreauIndian School,will be required to sign a contract statingthat
they agreeto keeptheir dormitory room in good condition. This policy may include all buildings locatedon
When vandalismis discoveredin a dormitory room, all studentswho occupythat room will be
"*p,rr.
chargedwith vandalism or destruction of federal property. Parentswill be notified and the student(s)will be
given five days to arrangefor payment of damages. The student(s)involved will also be citied with a major
ior vandalism. Any studentin the room where the vandalismhas taken place, who can prove he/shewas not
involved,will be exemptfrom the vandalismcharges'
SEARCH AND SEIZURB POLICY
It is the inherentright of schoolboardsand schooladministratorsto inspectlockers,desks,and/orstorage
spaces.Theselockers,desks,and/orother storagespacesremainthe property of the school;and school
&ficials have the right to accessat anytime for any reason. School officials have the authority to conduct
searchesof individual studentsand studentproperty. Authority for thesesearchesmay be exercisedas
neededin the interestofsafeguardingstudents,staff, studentproperty,staffproperty, and schoolproperty.
Schoolofficials may searcha locker, desk,or other storageplace wheneverthere is reasonablesuspicionto
believea locker, desk,or other storageplace may containarticleswhich are illegal or constitutea violation
of schoolpolicies or regulations. Reasonablesuspicionprovidesthat school officials are not underthe more
stringentconditionsof probablecauseas are law enforcementofficials. School liaison ofltcers are also
coveredunder the conditionsof reasonablesuspicionwhen directedby a school administrator.
If an actual student searchis deemednecessary,it must be done by a staff member of the samesex as the
studentand with the samesex witness. If probablecauseexists,law enforcementwill decideif a strip search
is required.
Schoolofficials may grant law enforcementofficials permissionto usedrug dogs on propertyownedand/or
controlledby the FlandreauIndian School.
We haveread and agreeto the abovepolicies:
Parent/Guardian Si gnature
Date
StudentSignature
Date
Page9
PARENTAL CONSENT
DOB
STUDENT'SNAME:
RECORDS
1.
Family EducationRights and Privacy Act (FERPA)
34 CFR Part99
SubpartD - May an Educational Agency or Institution disclosepersonally identifiable information from
educationrecords?
Sec.99.31 Under what conditionsis prior consentnot requiredto discloseinformation? (readsin paa)
(a)
An educationalagencyor institution may disclosepersonallyidentifiable information from an
educationrecordof a studentwithout the consentrequiredby Sec.99.30if the disclosuremeetsone or more
of the following conditions:
(1)
The disclosureis to other schoolofficials, including teachers,within the agencyor institutionwhom
the agencyor institution has determinedto have legitimate educationalinterests.
(2)
The disclosureis, subjectto the requirementsof Sec.99.34,to officials of anotherschool,school
system,or institutionof postsecondaryeducationwherethe studentseeksor intendsto enroll.
Releaseto:
SCHOLASTIC
ASSESSMENT
TRANSCRIPTS
HEALTH
IMMUNIZATION
OTHER(specify)
Registrar
FlandreauIndian School
1132N. Crescent
Flandreau.SD 57028
Purpose:For Enrollment
2.
EXCEPTIONAL EDUCATION
Releaseto: ExceptionalEducation
FlandreauIndian School
1132N. Crescent
Flandreau.SD 57028
IEP
FIELD TRIPS
3.
I (we) hereby grant permission for studentto participatein an organizedschool sponsoredactivity trip as
approvedby FlandreauIndian School. I understandthe studentswill be properly chaperonedand alL
precautionswill be taken to insure his/her safety.
(Check only those appropriate)
Recreational
SchoolClubs
Camping
Interscholastic
Sports
Parent/GuardianSignature
Town Trips
Reli gious/Traditional
On-Reservation
Off-Reservation
Extracurricular
Date
Overnight
Out-of-State
Home Visits
Swimming
Other
Pase10
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
CONSENTOF PARENT OR LEGAL GUARDIAN OR OTHER PERSONWITH PRIMARY
RESPONSIBILITY FOR THE CARE OF THE CHILD
SSN
Date of Birth
Name of Student
have read the ConsentForm for the Indian Health
I (We),
to arrangefor or to provide the following health servicesfor this child:
1. Health careincluding medical examinations,routinelaboratorystudies,x-ray procedures,and skin tests.
2. Dental careincluding dentalexaminations,preventativeuseof fluorides and necessaryemergencydental
care.
3. Mental healthservicesincluding evaluationand treatmentnecessary.
4. Emergencyhealthcarefor accidentsor illness.
5. Transportationof the child to andlor from anotherhealth facility for these services.
I herebygive consentfor all of the aboveservices'
Exceptionsor SpecialInstructions:
Signed
Address
City & State
Relationship
Date
ValidUntil
IF YOU HAVE INSURANCE, PLEASE PROVIDE A COPY OF THE CARD WITH
APPLICATION.
YOUR
Personis defined as one who in the absenceof the parent or legal guardianprovides a home for the child
suchas next ofkin.
All FlandreauIndian School staff is authorizedto act in Loco Parentisfor the studentsat the Flandreau
Indian School.
Page1I
FLANDREAU INDIAN SCHOOL
PHYSICAL EXAMINATION
Other names
NAME:
Date of Birth:
Parentor Legal
Guardian:
Not Evaluated
Abnormal
Normal
Eyes
Iars.
Teeth
Glands
Heart
Lungs
Abdomen
Genitals
Posture
Physical findings which are of
significanceto the School:
BloodPressure
Pulse
Recommendationsand Restrictions:
List allergies:
Significantfamily/personal& socialhistory:
(List seriousillnesses,hospitalizations,etc.)
Pleaseinclude history of chicken pox or vaccine for Chicken pox #l & #2.
ENTBNDATE (MO/DAYiYR) EACH IMMUNIZATION WAS GIVEN
a|v
5'"
4'n
J
2^'
10'
VaccineType
DTAP/DTP/DT
Td
OPV/IPV
Measles
Or date child had disease
Rubella
Historv of d sease not acceptable
History of disease not accePtable
Mumps
Hib
Hep. B
Hep.A
Tuberculin Test
(Mantoux recommended;
Induration (In mm):
Other
Signatureof Examining Physician
Date
Page 12
INDIVIDUAL EDUCATIONAL PROGRAMS
Studentparticipatedin SpecialEducation: Yes
Studentparticipatedin Gifted & Talented: Yes
No
No
Has your studentever beenon an IndividualizedEducationPlan (IEP) for SpecialEducation? If yes,please
indicateyour child's disabilitY:
Cognitive Impairment
Emotional Disturbance
Leaming Disability
Speechor LanguageImPairment
Other Health Impairment
pleasecontactthe schoolthat last implementedyour child's IEP and havethem forward the Special
EducationRecordsto the FlandreauIndian School. This is extremelyimportant. It will assistthe staff in
planning an appropriateprogram for your student.
I am legally responsiblefor this studentand herebyunderstandthat additional information may be requested
by the ExceptionalEducationDepartmentconcerningmy child's Individual EducationProgram.
Parent/LegalGuardian Signature
The FlandreauIndian School, in cooperationwith the Bureauof Indian Affairs funded schools,will ensure
that a free and appropriateeducationand a full educationalopportunity is provided in the least restrictive
environmentto all childrenwith disabilities,grades9 through 12.
PHYSICAL EXAMINATION INSTRUCTIONS
I.
Requirementof SchoolBoards.
A. Each governing board shall decide if the exam is to be repeatedon an annual basis, on a
biennial basisor triennial basis.
B. Each goveming board shall decide whether they want the doctors to evaluate sexual
maturity based upon the Tanner Maturation Index. Please white-out item 13 on the
PhysicalExam form if the decisionis NOT to usethe TannerMaturationIndex.
TI. Requirementsof Member Schools.
A. Each member school shall make copies of the forms that must be completed by the
parentsandlordoctorsin sufficientquantitiesto meetyour needs.
B . Member schoolsmust keep on file the following:
1. A copy of the PARENT PERMIT FORM. This form must be submittedannually.
2. A copy of the INITIAL PRE-PARTICIPATION HISTORY report for each student
who takes the comprehensiveexam for the first time. This form must be made available
to the medical examiner at the time the studenttakes his/her first physical exam.
3, A copy of the INTERIM PRE-PARTICIPATION HISTORY for eachstudentmust be
submitted annually by the parents except on the very first occasion when the INITIAL
PRE-PARTICIPATION HISTORY is required.
All questionson the INTERIM PRE-PARTICIPATION HISTORY form should be
answeredwith the following in mind: IN THE PAST YEAR: Pleaseexplain any yes
answersin the spaceprovided on the form. Any yes answersmay require a re-visit to the
medical provider for re-certification of health. The parent/guardiansignaturedenotesthat
the student is physically able to participate.
signed by either a
4. A copy of the comprehensivePHYSICAL EXAMINATION
Doctor of Medicine, Doctor of Osteopathy,Doctor of Chiropractic,PhysicianAssistant
or NursePractitioner.
C. Member schools may commence schedulingphysical exams as early as April i for the
ensuingschool year.
III.
Role of Doctors, Physician Assistant and Nurse Practitioners.
A. The certificatiorVsigningof the physical exam form is reserved for only a Doctor of
Medicine, Doctor of Osteopathy,Doctor of Chiropractic, a Physician Assistant or Nurse
Practitioner.Stampingthe name of a medical clinic or a medical associationas a substitute
for the authorized signatureis unacceptable.All examsmust be signed by authorizedmedical
personnelas listed in paragraphtwo above.
B . The examiner shall receive a copy of Instructions for conducting the orthopedic screening
and other portions of the exam. The instruction sheet follows the other forms located in
this section of this publication.
C . The medical history form must be made availableto the person(s),conductingthe physical
exam at the time the examinationtakesplace.
Revised07-09
PHYS - #1
SOUTH DAKOTA HIGH SCHOOL ACTIVITIES ASSOCIATION
PHYSICAL EXAMINATION
ITEMS TO BE EVALUATED
Station I - Individual History
All \'ES items in the history are reviewed in detail to determineif they constitute a risk to participation by the athlete,or need
additionalevaluation.
Station2 - Blood Pressure
Right arm,sitting.Valuesneedingrecheckandpossiblefurtherevaluationare:
Under11Years130175
12yearsandolder140185
Station 3 - Vision (Snellen)
corrected
visionlessthan20l40requiresfurtherevaluation.
visionlessthan201200,
Uncorrected
Station 4 - Skin, Mouth, Eyes, Ears
severecaries,pupil inequality,contacts,ear
Pustularacne,herpesor otherinfections,athlete'sfoot; braces,dentalprostheses,
drainage,malformation.
Station 5 - Chest
pulse discrepancy,murmurs,abnormalrhythm, forced expiratory
history. Heart enlargement,
Review of cardiac-related
maneuver,evidenceof latentbronchospasm.
Station 6 - Lymphatics' Abdomen, Genitalia
of testicles,hemia,andTannermaturationindex.
absence
organomegaly,
Cervicalor axillaryadenopathy,
Station 7 - Orthopedic
rangeof motionor strength
Asymmetry,scoliosis,swellingor deformity,decreased
Station 8 - Review
that applY.
Checkall categories
other)
Sports(collision,contact/endutance,
-All
-Contact/Endurance Sportsonly dueto
-Other SportsOnlYdueto
-sports
dueto
ParticipationNot Recommended,
ApprovalWittrheldPendirigevaluationfor
CrossCountry'
Sports=Basketball,
and Wrestling];[Contact/Endurance
Definition:[Collision=Football
Track, Volteybatl,CompetitiveCheerand CompetitiveDance];[Other Sports=Golll
GymnasticsiTennis,
Revised07-09
PHYS _ 1A
SOUTH DAKOTA HIGH SCHOOL ACTIVITIES ASSOCIATION
ORTHOPEDICSCREENINGGUIDE
Athletic A
Generalhabitus;acromioclavicularjoints
StandFacins Examiner
Look at ceiling, floor, over both
shoulders;touch earsto shoulders
Cervical spine motion
Shrug shoulders(examiner resists)
Trapezius strength
Abductshoulder90 degrees
(examinerresistsat 90 degrees)
Deltoid strength
Full external rotation of arms
Shouldermotion
Flex and extend elbows
Elbow motion
Arms at sides,elbow 90 degrees
flexed, pronate and suPinatewrists
Elbow and wrist motion
Spreadfingers;make fist
Hand or finser motion and deformities
Tighten (contact) quadriceps;relax
quadriceps
Symmetryandkneeeffusion;
ankleeffusion
"Duck walk" four steps(awayfrom the
examinerwith buttockson heels)
Hip, knee and ankle motion
Back to examiner; knees shaight,
touch toes
Shouldersymmetry;scoliosis,
hip motion,hamshingtightness
Calf symmetry,leg strength
Raise up on toes, raise heels
uire reflex hammer, ta
measure, n, and examination table.
SOUTH DAKOTA HIGH SCHOOL ACTIVITIES ASSOCIATION
ANNUAL PARENT OR GUARDIAN PERMIT
I herebygivemy consentfor
who was bom at
GRADE
2 0 0 9 - 1 0S c h o o lY e a r
Name (PleasePrint)
City, Town, County, State
High School
to compete in SDHSAA approved athletics for
Date of Birth
duringthe2009-2010schoolYear.
to participatein organizedhigh schoolathletics,realizingthat suchactivity
INVegive our permissionfor our son/daughter
involvesthepotentialfor injury which is inherentin all sports'
Signed
Parent or Legal Guardian
INSPECTIONAT THE SCHOOL'
THIS FORM MUST BE COMPLETED ANNUALLY AND MUST BE AVAILABLE FOR
INITIAL PRE-PARTICIPATION HISTORY
SEEREVERSESIDE FOR
TIEALTH HISTORY QUESTIONNAIRE
Revised07-09
PHYS- 1B
INITIAL PRE-PARTICIPATIONHISTORY
(This form must be completedprior to the taking of a physical examination.)
GRADE
NAME
DATE OF BIRTH
,2009-10SchoolYear)
YES NO
YES NO
I
2.
3
Has a doctor ever deniedor restrictedyour
oarticipation in sports for any reason?
Do you have an ongoing medical condition (like
diabetesor asthma)?
Are you cunently taking any prescription or nonnrescriotion(over-the-counter)medicinesor pills?
Do you have allergiesto medicines,pollens,
foods.or stinging insects?
Have you ever passedout or nearly passedout
A
5
DUzuNG exercise?
6.
7
8
9.
t0,
Have you ever passedout or nearly passedout
AFTER exercise?
Have you ever had discomfort,pain, or pressuretn
vour chestduring exercise?
Doesvour heartrace or skip beatsduring exercise:
Has a doctor ever told you that you have a heart
murrnur,high blood pressure,high cholesterol,or
a heart infection?
Has a doctor ever ordered a test for your heart?
(for example:ECG, echocardiogram)
l1
Has anyonein your family died for no apparent
reason?
12
Doesanyonein your family huue4!"44,plq!&nll
ll.
Has any family member or relative died of heart
nroblemsor ofsudden deathbefore age 50?
t4.
Does anyone in your family have Marfan
Svndrome?
l5
H a v ey o u e v e rs p e n it h e n i g h t i n a h o s p i t a l ?
16.
Have you ever had surgery?
ln
Have you ever had an injury, like a sprain,muscle
or ligamenttear,or tendonitis,that causedyou to
miss a oracticeor game?
l8
19.
Have you had any broken or fracturedbonesor
dislocatedioints?
Have you had a bone orjoint injury that required
x-rays,MRI, CT, surgery.injections,
rehabilitation,physical therapy,a brace,a cast,or
crutches?
20.
Have vou ever had a stressfiacture?
11
Have you beentold that you have or have you had
an x-ray for atlantoaxial (neck) instability?
Do vou regularlvuse a braceor assistivedevice?
22.
ZJ
24.
25.
26.
Has a doctor ever told you that you have asthma
or allereies?
3 0 . Have you had a herpesskin infection?
3 l Have you ever had a headinjury or
concussion?
you beenhit in the headand been
Have
32.
confusedor lost your memory?
Have you ever had a seizure?
JJ.
3 4 . Do you have headacheswith exercise?
3 5 . Have you ever had numbness,tingling, or
weaknessin your armsor legs after being hit or
falline?
JO.
Have you ever beenunableto move your arms
or less after being hit or falling?
3 7 When exercisingin the heat,do you have
severemusclecrampsor becomeill?
3 8 . Has a doctor told you that you or someonein
39.
40.
41
42.
43.
44.
45.
your family has sickle cell trait or sickle cell
anemia?
Have you had any problemswith your eyesor
vision?
Do vou wear glassesor contactlenses?
Do you wear protectiveeyewear,such as
eosslesor a faceshield?
Are vou [6ppy with vour weight?
Are vou tryins to gain or loseweight?
Has anyonerecommendedyou changeyour
weisht or eatinghabits?
Do you limit or carefully control what you eat?
Do you have any concernsthat you would like
to discusswith a doctor?
4'7. Are thereother sportsthat you would like to
participatein that were not approvedat a
oreviousexamination?
4().
FEMALES ONLY:
4 8 . Have you ever had a menstrualperiod?
49. How old were you when you had your first
menstrualperiod?
50. How many periodshaveyou had in the
last l2 months?
Explain "Yes" answers here:
Do you cough, wheeze, or have difficulty
breathingduring or after exercise?
Is there anyone in you family who has asthma?
Have you ever used an inhaler or taken asthma
medicine?
27. Were you bom without or areyou mlsslnga
kidney, an eye, a testicle,or any other organ?
28. Haveyou had infectiousmononucleosis
(continueon frontsideof this form if necessary)
(mono)within the last month?
29. Do you have any rashes,pressrresores,or
other skin problems?
in interscholasticathletics' I
I do not know of any additional health reasonwhich should keep this studentfrom participating
certiry that the answersto the above questionsare true.
DATE
SIGNED
Sisnature ofParent or Guardian
Revised07-09
PIIYS _ 1B
@
NAME
CHECKONE:
SOUTH DAKOTA HIGH SCHOOI,
ACTIVITIES ASSOCIATION
PHYSICAL EXAMINATION FORM
Date Exam Expires:
Check Appropriate Physical Exam Term:
Triennial
Biennial
Annual
OF BIRTH-
GRADE-DATE
MALE
FEMALE
(2009-10SchoolYear)
Repeatin 5 minutes, if elevated
l. Blood pressure(sitting)
2. Height
3. Weight
4. Vision 201-(L)
Normal
Abnormal
YES
YES
YES
NO
NO
NO
YES
YES
NO
NO
YES
NONE-
COMMENTS
20l-(R)
5. Head
6. Mouth (dentures,braces?)
7. Eyes (contacts?)
8. ChesUlung
9. Heart
a. HearLsounds
b. Murmurs
c. pulsediscrepancy(rad. vs fem.)
'
d. abnormalrhythm
10.Abdomen
a. liver or spleen enlargement
b. masses
I l. Genitalia
a. hernias
b. testes
12. Orthopedic
a. cervical spine
b. shoulder shrug
c. deltoid
d. arms/elbow
e. hands
f. hips
g..knees
h. ankles
i. Scoliosis
13.TannerMaturationIndex(Optional)
Circle: I
II .III
IV V
SPORTSPARTICIPATION RECOMMENDED FOR:
other
All Sports:collision,contacVendurance,
Contact/EnduranceSports only due to
Other Sports Only due to
Sports Participation Not Recommended,due to
Approval Wittrheld Pending evaluation for
Definition: [Collision=Ftiotball and Wrestling]; [Contact/Endurance Sports=Basketball, Cross Country,
Gymnastics, Tennis, Track, Volleyball, Competitive Cheer and Competitive Dancel; [Other Sports=Golf]
NAME OF EXAMINER
DATE
and certify the health ofthe student athlete: Doctor of
NorE: The following licensed medical personnel are qualified to perform the examination
and licensedNurse Practitioner'
Medicine, Doctor of Osteopathy, Doctor of Chiropractic, licensedPhysician Assistant
Revised 07-09
PIIYS - lC
SOUTH DAKOTA HIGH SCHOOL ACTIVITIES ASSOCIATION
ANNUAL PARENT OR GUARDIAN PERMIT
GRADE
I hereby give my consentfor
SCHOOLYEAR
2OO9-10
Name (PleasePrint)
who was bom at
Date of Birth
City, Town, County, State
to competein SDHSAA approvedathleticsfor
High School during the 2009-2010 school year
IiWe give our permissionfor our son/daughterto participatein organizedhigh school athletics,realizing that such activity involves the
potential for injury which is inherent in all sports.
Date
Sigaed
Parent or Legal Guardian
THIS FORM MUST BE COMPLETED ANNUALLY AND MUST BE AVAILABLE FOR INSPECTIONAT THE SCHOOL.
INTERIM PRE-PARTICIPATIONHISTORY
(Used in conjunction with the BienniaUTriennial examination.)
SEEREVERSESIDE FOR
TIEALTH HISTORY QUESTIONNAIRE
Revised07-09
PHYS - #2
INTERTM PRE-PARTICIPATIONHISTORY
(Used in conjunction with the BienniaUTriennial examination.)
GRADE
NAI\M
IN THE PAST YEAR:
1
2.
J.
A
5.
6.
1.
DATE OF BIRTH
(2009-I 0 SchoolYear)
YES NO
YES NO
Has a doctor denied yow participation
in sports for any reason?
Do you have a new ongoing medical
condition 0ike diabetesor asthmaX
Are you currently taking anY new
prescription or non-prescription (overthe-counter)medicines or Pills?
Do you have new allergiesto medicines,
pollens, foods, or stinging insects?
Have you passedout or nearly passed
out DURING exercise?
Have you passedout or nearly passed
out AFTER exercise?
Haveyou had discomfort,Pain,or
Dressurein vour chest durine exercise?
Has your heart raced or skipped beats
durins exercise?
9 . Has a doctor told you that you have a
heart murmur, high blood pressure,high
cholesterol"or a heart infection?
1 0 . Has a doctor ordered a test for Your
heart?(for example: ECG,
echocardiogram)
Has anyone in your family died for no
ll
aDDarentreason?
t 2 . Have you spentthe night in a hospital?
1 7 . Havevou hada stressfracture?
1 8 . Did a doctor tell you that you have
t9.
20.
21
22.
z)-
24.
8.
Have vou had sureerv?
14. Have you had an injury, like a sPrain,
muscle or ligament tear, or tendonitis,
that required medical attention?
1 5 . Have you had any broken or fractured
bonesor dislocatedioints?
1 6 . Haveyou hada boneor joint injury that
requiredx-rays,MR[, CT, surgery,
injections,rehabilitation,physical
therapv.a brace.a cast,or crutches?
25.
asthmaor allergies?
Have you startedto cough, wheeze,or
have difficulty breathing during or after
exercise?
Have you used an inhaler or taken
asthmamedicine?
Have you lost a kidney, an eye, a
testicle, or any other organ?
Do you have any new rashes,pressure
sores.or other skin oroblems?
Have you had a new herpes skin
infection?
Have you had a head injury or
concussion?
Have you been hit in the head and been
confusedor lost your memory?
26. Have vou had a seizure?
21. Have you experiencedheadacheswith
exercise?
28. Have you had numbness,tingling, or
weaknessin your arms or legs after
beins hit or falline?
29. Have you been unable to move Your
arrnsor legs after beine hit or falling?
30. When exercising in the heat, did You
have severemusclecrampsor become
ill?
Explain "Yes" answershere:
(continueon front sideof this form if necessary)
RECERTIFICATIONOF HEALTH
As the parenyguardian, I herewith affix my signature and certify that the above named student is
physicatiy fit to participate in interscholasticathletics for the culrent school year insofar as all "Yes"
fesponsesare concerned.
Date
Revised07-09
Sisnature ofParent
PHYS - #2
This is the form that the South Dakota High School Activities Association recommends to those
for
member schools that feel it is important to get consent from parents and/or legal guardians
be
should
form
This
medical treatment when away from home on road trips for various activities.
kept on file at the school and another copy should travel with each team on which the athlete
competes.
CONSENTFOR MEDICAL TREATMENT
(Mother-Father-Legal Guardian)
I am the
who participatesin co-curricularactivities
of
High School. I hereby consent to any
for
medicalservicesthat may be requiredwhile saidchild is underthe supervisionof an employeeof
School District while on a school-sponsored
from
activity and hereby appoint said employeeto act on behalf in securingnecessarymedical services
any duly licensedmedical provider.
Datedthis
)o
day of
Parent'sSignature:
CONSENTOF CHILD
have read the above Consent form signed by
I,
(Mother-Father-Legal Guardian) and join
my
(himlher) in the consent'
with
Datedthis
day of
20
Student'sSignature:
Revised07-09
PHYS.#3
SOUTHDAKOTA HIGH SCHOOLACTIVITIES ASSOCIATION
ANNUAL PARENT AND STUDENT CONSENTFORM
SchoolYear:
Name of High School:
Name of Student:
Placeof Birth:
Date of Birth:
The Parentand StudentherebY:
part
1. Understandand agreethat participationin SDHSAA sponsoredactivities is voluntaryon the
of the studentand is considereda privilege.
to
2. Understandand agree that (a) by this ConsentForm the SDHSAA has provided notification
participation;
athletic
with
the parent and student of the existenceof potential dangersassociated
(b) participation in any athletic activity may involve injury of some type; (c) the severity of such
injuries .in ,ung" from minor cuts,bruises,sprains,and muscle strainsor more seriousinjuries
the
such as the boJy's bones,joints, ligaments,tendons,or muscles,to catastrophicinjuries to
disability,
total
result
in
to
as
head,neck and ipinal cord, or on rare occasions,injuries so severe
paralysisand death; and (d) even with the best coaching,use of the best protectiveequipment,
ind strict observanceofrules, injuries are still a possibility
3. Consentand agreeto participationof the studentin SDHSAA activities subjectto all SDHSAA
the
bylaws and rJes interpretationsfor participation in SDHSAA sponsoredactivities, and
activities rules of the SDHSAA memberschoolfor which the studentis participating;and
the
4. Consentand agreethat personallyidentifrabledirectory information may be disclosedabout
student as a rEsult of his/her participation in SDHSAA sponsoredactivities. Such directory
information may include, butls notlimited to, the student's photograph, name, grade level'
height, weight, and participation in officially recognizedactivities and sports. If I do not wish to
have any o, oit such information ilisclosed,L"nust notify the sbove mentioned high school, in
writing, of our refusal to allow disclosure of any or all such information prior to the student's
p articip atio n in sp on sor ed uctiv itie sterms
I acknowledge that I have read paragraphs(1) through (4) .above, understand and agree to the
thereof, including the warning of potential risk of injury inherent in participating in activities.
DATED this
,20
day of
Name of Student(Print Name)
Student Signature
(4) above,
I am the student's parentlguardian. I acknowledgethat I have read paragraphs(1) through
in
understandand agree to the terms thereof, including the warning of potential risk of injury inherent
for
permission
give
my
hereby
I
activities.
athletic
i"
participation
name) to practice and competefor the
,,;h;ltlf
DATED this
day of
20
Signature
ParenVGuardian
THIS FORM MUST BE COMPLETED ANNUALLY AND MUST BE AVAILABLE FOR
INSPECTIONAT THE SCHOOL
Revised07-09
PHYS-#4
CONSBNTFOR RELEASE OF MEDICAL INFORMATION FORM (HIPAA)
Date of Birth
StudentsName
1. I authorizethe use or disclosureof the above named individual's health information including
the Initial and Interim Pre-ParticipationHistory and Physical Exam information pertaining to a
student'sability to participate in South Dakota High School Activities Association sponsored
activities. Such disclosure may be made by any Health Care Provider generatingor maintaining
such information.
2. The information identified above may be used by or disclosed to the school nurse, athletic
trainer, coaches,medical providers and other school personnel involved in the care of this
student.
3. This information for which I am authorizing disclosure will be used for the purpose of
determining the student's eligibility to participate in extracurricular activities, any limitations on
suchparticipation and any treatmentneedsof the student.
4. I understandthat I have a right to revoke this authorization at any time. I understandthat if I
revoke this authorization,I must do so in writing and presentmy written revocation to the school
administration. I understandthat the revocation will not apply to information that has already
been releasedin responseto this authorization. I understandthat the revocation will not apply to
my insurancecompany when the law provides my insurer with the right to contesta claim under
my policy.
5. This authorizatronwill expire on July 1,20-.
6. I understandthat once the aboveinformationis disclosed,it may be redisclosedby the recipient
and the information may not be protectedby federal privacy laws or regulations'
7. I understandauthorizing the use or disclosure of the information identified above is voluntary.
However, a student's eligibility to participate in extracurricular activities dependson such
authorization. I need not sign this form to ensurehealthcaretreatment.
Signatureof Parent
Date
This form must be completed annually and must be available for inspection at the school
Revised07-09
PHYS- #5
United $tatesDepartmentof {:heInterior
BUREAU OF INDIAN AFFAIRS
FI.AN DRI,dU INDIAN SCHOOL
FI.ANNREAU, SOTJTHDAKOTA 57028
IN REPLY REfERTO:
ircbrualy2007
ans:
DearParentsiGuar:di
referraltbrmsfor theB.l.E (Burcauof Indian
received
inclianScrhoolhas
TheFlantlreau
of the progriunis to
Thc purpclsc
Eru:ollnrent.
N{cKinneyVcntroStuclent
Bducation)
youthrvhotnavbc ltomcless
ot
andunaccompaniecl
assistfanliliesof students
Thesefornrsrvill becotnepartof the cnrollrlcnt
tentporaryhourslessncss.
expcricncirrg
IndianSchoolmay bettersen/ethe
packct.This fonn is rcquiredso thattheFlandreau
filesalongwitir
will bekeptin contldential
needsof ourstudents.Yourinlbnrration
y"oL'rr
child'seducation.
otherfilesconcernittg
yourstudcntto tireFlanrjreau
IndianSchool.
l'hankyou for sencling
Sincerelv.
4"qE'-u*"*
tJettyBelkham
Chief SchoolAdministrator
$sF.EElgq4r
rr{ftMERlcA:'
la
.l ..i;
I
BIE McKinney-VentoEnrollment/ReferralForm
of this formis to addieeathe requirdmenlsof tha Mc(innay-Vonto
Thep*urpese
Act l-rtleX ParfC of the No ChlldL6ngeninO
providershav€thenecsssary
Act. Thisdooumentwill
beusedtoshar€withsohool
staffandparfner{ngagenoiesteensofeall
informstion
to support
ihe childendhivherhmily,
a temporarylivin!
1. lr yourcurfentaddrBEA
arangement?Yes_
No_
Yes - No2, lsyouriertrporaryaddressdueiolosso{housingoreconomlchardship?
lf answerto both questionsis. "YES'],otorsc6ntlnue, othefwieedoo here. Thank\bu.
Studenllnformetion
StudentNam{s)
Age(s)
FarenVGuardianName(s)
School Site(s)
GradeLevel(s)
phonenurnberl
ParenVGusrqian_/V'qvth
fl cellularphons n WofkPhone E ShalterPhone tr FrmllyiFrien&Residence
Resldenc)I lnformdion
No*
Are yorJa hlgh school studen{who is currenflylivfng on your own? Yes_
Wheredoesthe studentstayat night?
trothed
trShelter trTemporaryHousing
Address/Diredions
ShellerContactPersqn
The larnilyfouth has besn residlngwithin the school districtboundariesand intendto stay. ---.--
(pleaseinitial)
f rigin? O Yes D No
D o o c t h 6s l u d e n t w i s h t o c o n t i n l o a t s c h o o l o o
.
ls schoololorigin a boardingschool? Yeq
No-*
r|fpresentschoo|isaboardingschool.wi||sfudenlbeenro||edinresidentialdorm?Yes-NoI
Agnod Upon Soryrbes
EducaiionalSeivices
Description:
AfterschoolServlces
' DescriFtion:
SeMces
Transportation
Pick-up Location
Drop-offLocalfon(if different)
HealthServices
lmmpnizations
Dental
F
Fres Lunch
Counseling
undErstEnd
dayandwill
thatthe qgreeduBqt',gervlcelaresupplemenla{
to theregularinshuctiqnal
Tho perenVguardiarrfodh
v*richneedto be oontinued.Inthc went thatthc famlly/yor.fth
residoncychanges,it is their
be ro.analuated
to determino
immediately.
to notifi SchoolLiaisory'Deslgnee
rosponsibility
ParenUGuardianffouth
- -- -
---EF-'Rrr
7h-rt4-
SchoolLiaisonrDesignde
Dat€
United StatesDepartrrent of the Interior
BUREAU OF'{NDIAN AFFATRS
FLANDREAU INDIAN SCHOOL
FI,ANDREAU, SOUTH DAKOTA 57028
INREPLYREFERN);
:
March5,2007
DearParenVGuardian:
from the stateof SouthDakota
We operateour food programthrougha re-imbursement
to supplythebestfood from SouthDakotaChild & Adult Nutrition. In orderto continue
would you pleasesigrrthe form
operationwith the statethroughthesere-imbursements
for FreeandReducedlunchesandreturnit to the FlandreauIndian School. Your
responsibilityin signingthe formswill allow your child to participatein bettermealsat
tle FlandreauIndian School. Thankyou for your cooperationin this matter.
Sincerely,
E-unA^oa*"-'
s.ft,re.lkfuChief SchoolAdministrator
T+FF.EEI;1EtF+.
rx[MERrc.A={
INSTRUCTIONSFOR APPLYING
LIsea separate
application
for eachfosterchild.List otherchildrentogether.
If your householdgetsSNAP (fbrmerly FOOD STAMPS), FDPIR, OR TANF fbr all ot'the children listed,fbllow these
instructions:
Part lA: List eachchild's name.scl.rool/cenLcr,
age,and/orgrade.
Part 1B: List the SNAP (lbrmerlyFood S.tamps).
FDPIR. and/orTANF c:ase
number.
P a r t 2 : S k i p t h i sp a r t .
Part 3: Skip this part.
Part 4: Srenthe form. A SocialSecurityNumber is not necessar
If you are applying for a FOSTER CHILD, follow theseinstructions:
Part 1A: List eachchild's name.school/center.
agc, and/orgrade.
Part lB: Skip this part.
Part 2: I-ist the child's personalusemonthlyincome,if any.
Part 3: Skip this part.
Part 4: Sisn the tbrm. A SocialSecuriryNumberis nor neccssar
Part2B.If you are applying lbr a homeless,migrant, or a runaway check the appropriate box and call your school's homeless
Iiaison,or migrant coordinator.
ALL OTHER HOUSEHOLDS and f'or children the householddoesnot get benelits fbr, fbllow theseinstructions:
Part lA: List eachchild's name.school/center.
ageand/orgrade,
Part 2: Skip this part.
Part 3: Follow theseinstmctionsto reporttotal houscholdincomefrom last montn.
Column A-Name: List the tirst and last nameol eachpersonliving in your household.rclatedor not (suchas erandparents,
otherrclatives.or liicnds).You must inc:ludeyoursclfand all children.Collcgestudcntsawayat schoolrnly still be palt o1'the
householdin somecircumstances.
Iithc studentis countedin thc householdthat stLrdcnt's
ir.rcorne
mustalso be included.
Attachanothersl-reet
of paperil'you needto.
Column ll-Last month's incomeand how of'tenit was received:List the typesof incorneyour hor-rschrilri
got last monthand
how oiien you eot tlrcn. Enplovntenlinconre:List thegrossincomeeachpersoncfrned lastmnnth.lt is not thc samcas takc
homepay.Gross income is the amount earned belbretaxesand deductions.It shouldbc listcdon yorrrpay stub.or your
bosscan tell you. Ncxt to the amourtt.writc how oftenyou got it (wcekly.cvcly otherweek.twrcer month.or rnonthly).Otlrcr
lncctrne:
List thc total anrounteachpersongot lastmonthlrornall other sources.lncludewclllre. child support.alimony,
pcnsiotls.retircment.SocialSecurity,Worker'sCornpensation,
unemployment.
strikebeneiits.Sr-rpplemental
Sccuritylncome
(SSI).Veteran'sbeneilts(VA bcnetits),disabilitybenefits,resLrlarcontributions
fl'ompeoplewho do not live in your
household.and ANY OTHER INCOME. Seesamplebclow.For farm income,seethe exampleon thc back of the applicarion.
Next to the amount,write how often the persongot it.
Column C-Check ifno income:Ifthe persondoesnot haveany income,checkthe box.
Part 4: An adulthouseholdmembcrmustsign thc lbrm and list his or her SocialSecurityNumber.or mark thc box if he or shedoesnot
haveone.
Part 3. T6tal Household Incirme from Last Month-You
l. Name
(List everyone
in houschold)
must tell us how much and how often
2. t,ast month's income and how often it was received
Excntple: $lO1hnonthlt $1))/tv,iceamonth $10)/evervotherv,cek $t))/wcektt
3. Check
if No
income
Non-discriminationStatement:This explainswhat to do il'you believeyou have beentreatedunfairl5,.Iu accgrdance
with Federallaw and U.S.
Dcpartmentol'Agriculturepolicy. this institutionis prohibitedl'romdiscriminatingon rhebasisof race.color.narionirlorigin. scx.age.or disability.
Totl|eacomplainto|discrimination.writetJSDA,Director'Of|iceo'fCiviIRight'\,t400IndepandenceAl,enlte,
or calt (800) 795-3277(voice)or (202) 120-6382(TTY). USDA is an equplopporrunirypro,vider
and employcr..
Privacy Act Statement: This explains how we will use the infbrmation you give us.
The NationalSchoolLunch Act requiresthe informationon this application.You do not havcto give the infbrmrtion.but if you do not. we
cannotapprovechildrenfor tiee or reducedpricemeals.The SocialSecurityNumber of the adulthouseholdmemhclwho signsthe applicationis
requiredunlessyoulist SNAP (fbrmerlyFood Stamps).FDPIR,oTTANF casenunbers for all chilclrenyou areapplyingibr, OR if you are
applyingfor a fosterchild. You mustcheckthe "l do not havea SocialSecurityNumber"box if the adult householdmernbersigningthe
applicationdoesnot havea SocialSecurityNumber.We WILL useyour intbrmatjonto sceif childrenareeligiblelbr free or reducedprice
meals.to mn the program.and to entbrcethe mles of the proglam.We MAY shareyour eligibilityinformationwith education,health.and
nutlition programsto help them evaluate,fund, or determinebenefitsfor their programs,auditols for programreviews.and law enforcement
officialsto help themlook into misuseof programrules.CONFIDENTIALITY: Section9 (b) (2) (C) (iii) of the NationalSchoolLunch Act, as
amendedby section | 08 of Public Law 10 I -448, authorizesreleaseof free and reducedprice schoolmeal eligibil ity statusfor certainprograms.
suchas Title I, administeredby the South Dakota Deparrmentof Education.
Attachments-- oaoe 16
INCOMEGUIDE,LINES
( E l ' l i ' c t i vJct r l y| . 1 0 0 9l h r o t t g hJ u n d. J Uj.U l o )
20.036
1.670
Weekly
386
2
26.955
2.24'l
-519
3
13.874
2.821
652
4
40,79-l
3,400
785
5
41.112
3.9'/6
HouseholdSize
may
Participants
or
for
free
qualify
reducedpricemeals
if yourhousehold
incomeis at or
belowthelimits on
this chart.
Yearly
b
54.611
1
61.550
Monthly
9r8
1.051
5.r30
I. 1 8 4
8
68,469
5,106
1. 3 1 7
For eachadditional
member.add
6.919
511
1.14
and all
incluclingparcnts.cllildrcrr,grandparents.
Look at the IncomeGuidelilcs chart.Find your householdsizc.HOUSEHOLD is all persons.
HoUSEHol.l)
income.
TOTAL
your
household
Find
total
living
expenscs.
your
and
share
home
who
live
in
unrelated
peoplerelatedor
unemployment.
INCOME is the incomecachhouscholclmembergot last monthbefbrctaxes.Tliis includeswages.socialsccr:rity.pension'
price meals
f'ree
and
reduced
are
eligible
tbl
chilclren
tbstcr
In
certain
cases,
income.
cash
welfarechild support.alimony.and any other
us.
please
contact
want
to
apply
for
thcrn,
you
with
ancl
living
foster
children
you
If
have
income.
ol'your
regardless
DETERMINING INCOME
weeklyincomc
If a householdreportsincomesourcesat morc than one fiequcncy,the prefcrredmcthodis to annualizcall incorrteby rnLtltiplying
b v 5 2 . i n c o m e r e c c i v e d c v c r y 2 w e e k s b y 2 6 , i n c o m e r e c e i v e d t w i c e a m o n t h b y 2 4 . a n d i n c o m e r e c e i v e d1l 2
n .o n t h l y b y
Do not round the values resulting Jrom eaclt conversiott.
Thc inlbrrnationto ligurc incomelrorn privatebusincssoperationis to bc takenfionr your
To figure monthlyincomefor farmiself'-employed:
tax fbrrn lincs in the spaccsbelow.Divide thc total
U.S.lndividual lncomcTax lleturn Form 1040.Write the numbersfrom the corresponding
write it ls zcro on the applicatiorl.All other
nurtber,
ncgative
it
is
a
column.
If
earnirrgs
monthli,
in
the
the
application
by l2 and write rt on
fbr the personwho earncdit. Nct losscarrvovercannotbe usedto decrease
incomeon lines7 through22 ol'the tax lbrm must be listedseparately
the houselroldincome.
Proplietorship[ncorttc
Farrn lncorne
P a r t n e r s h i lpn c o t n e
Line 12 $
Linc 13 $
Line 13 li
Line ll $
Line14 $
Line 14 $
Line 14 $
Line l7 .$
TOTAL $
Linc 18 $
Line 17 $
TOTAL $
TOTAL $
INCOME TO REPORT
Earnings fiorn Work
Wages/salaries/tips
Strike benefits
UnenrploynrcntcomPensation
W o r k e r ' sc o m P e n s a t i o n
Net income fronr self:owned business.
day care businessor farrrl
Children's Incomc
Do not include income fiom a child's occasional
work such as lawn mowing. babysitting.cleaning
walks, etc. A child's income from regularly
scheduledjobs must be incltlded.
Attachments -- Page 14
P e n s i o n s / Ricr e
t m c n t / S o c i aSl e c r r r i t y
Pensions
SupplementalSecuritylnconre
Veteran'spaylnents
S o c i a lS e c u r i t y
Welf are/Child Support/Alimony
Public assistancepayments
Alimony/child supportpayments
Othcl Mont hly Inconre/Self-entployment
D i s a b i l i t yb e n c f i t s
C a s hr v i t h d r a w nf l o m s a v i n g s
lntorcst/di v idends
lncome 1l'onrcstates/trusts/investments
Regular contributionslrom personsnot living
in the samehousc'hold
rental income
Net royalties/annuities/net
A n y o l h e ri n c o m e
\,/
n NewAPPlicant
APPlicant
D Previous
PRICE MBALS
APPLICATIONFOR FREEAND REDUCBD
, refer to next Page.)
(For comPleteinstntctions
To apply for free ot recluced
Part I A.
Child's Name
meals,fill otlt thls
for each fbsterchild
l i c a t i o na n d
S c l r o o lo r C e n t e r
Child's Namc
S c h o o lo r C e n t e r
Grade
I,
b.
Programon lnclian
--------..-----3
fb*GdyE-ili." (T.qnF] u t'oodDistribution
str.t* trs), ternR^._r111a.1siston."
r...iuing sNAF@il"'[Ru,.
part r I]. Househords
3 and4 Thcapplication
Sections
Rescrvations(cor-rrmoditiesr.o-pn):lfyotrrhorrseholoist.ttiw.rceluingSNAP
yeumustalsocomplete
thesebenefits,
receive
l, i and4. If notail oi thenbouenairedchildren
cAsE NUMBIlR.Fi' oursccrions
e 1 ' a na d u l t
M U S T h a v ct h e s i g n a t u r o
SNAPClse Number:
FI)PIR Case Number:
T A N F C a s eN u m b e r :
income:
monthrv
ttst'
personrr
orthechir'r's
risttheamoun(
orcoun.
agencv
illii;,ii1ill,iljli;1"i,:ill$iflliliilJlJi l$iXl'til",,ora*criare
.$D
S
" -k
' _i rp- t' -o P a r t 4
'......-
^ . - L ^ ^ r . " k , . m a r o c cr i r i e . n o r m r p r a n t
2B.lfthechilclyoLrarelpplyingforislrorneless,mrgrant.orarunawaychecktheappropriateboxanc|cirllJoui.::H',1,:!t'*'a--u*ffiij
Purt 3Jot"t
Househoidlncome
itwasreceived
ffiften
$/Oi)i|eck/r'
$100/evetloth(rH't'cA
$100/twkenntonth
fr",ritr, $1O0/nutntlt
P e n s i o n sr.e t i r c t n e n lS' o c t a l FarnVOther
Secunty
S/
Earnings fl'orrtwork belbre
$/
!_
$/
$/
!-
$,/
s;/
!_
$/
n
tr
n
tr
tr
I
$/
s_
t_
L
$
!_
i_
!
$/
l_
$/
_q
!
$,/
!
$/
$_
3i/
x
$/
$
-sign)
(Adult
must
Number
r"-*-"'- "- ",-"-'-- "- - -P a r t 4 . S l 8 r l & f , u f €a n u o u c r a r o s r u r r r J " : : " ' " "
r : r l r , rl i s t h i s o r h c r S o c i a lS c c L r r i t y
Anadulthousehol<lmcmbermustsigntl.,"oppli.atiolbrmmrrstaIsolisthisorhcrSocil
Nurnberortnarkthe..ldonothaveaSocialsecurityNr.rmber''box'(SeePrivacyActStatementontheback"|'|'',|11..],.,'^|,',)t|..tIi,'.!,'r
I certify (Promise)
basetlottrheinJbtlntiottIgive,Iwtclerstarltlntst:lnolfr:ial'smayverif(t:lrck)tlte
I mav be prosecuted'
iribrmatiort, tie chiklren,iot'Iose nteaLbene.fits'and
Sign here:X
S o c i a lS e c u n t YN u m b e r :
I
t a o n o t h a v ea S o c i a lS c c u r i t yN u m b e r '
PrintedNamc:
Home Addless:
Mailing Address:
FOR SCHOOL/CENTER USE ONLY
No
categoricallyeligible free: n Yes I
sNAp / FDPIR / TANI. or orner eligible programhousehold
f] paia
ReducedPrice
Free
!
I
Eligibility Classification:
Total monthly rncome: -hcontplete information
fl Over income I
Not Eligible:
.
HouseholclSize: ---Until:
Free
fl Re<iucedPrice
!
TemporaryEligibility:
Date Withdrawn:
Changein StatusDate:
Dats NotificationSenl
Date:
Signatureof DeterminingOtficial
Attachments-- Page15