Students - Registration_Forms

Sinton ISD
Registration Packet
2016-2017
Student Name ______________________________
Grade ___________
ID__________
2016-2017
YR _____________
AcknowledgmentofElectronicDistributionof
StudentHandbook
My child and I have been offered the option to receive a paper copy of or to electronically access
at www.sintonisd.net the Sinton ISD Student Handbook, Student Code of Conduct and the
Electronic Acceptable Use Policy.
I have chosen to:
Receive a paper copy of the Student Handbook, Student Code of Conduct and the
Electronic Acceptable Use Policy.
Accept responsibility for accessing the Student Handbook, Student Code of Conduct
and the Electronic Acceptable Use Policy by visiting the Web address listed above.
I understand that the handbook contains information that my child and I may need during the
school year and that all students will be held accountable for their behavior and will be subject to
the disciplinary consequences outlined in the Student Code of Conduct. If I have any questions,
I should direct those questions to the campus principal.
Campus: _________________________________________
Signature of student:
Signature of parent:
Date:
Office Use Only: Retain on campus
Centralized file
Student Name ______________________________
Grade ___________
ID__________
2016-2017
YR _____________
Notice Regarding Directory Information
Parent’s Response Regarding Release of Student Information
State law requires the district to give you the following information:
Certain information about district students is considered directory information and
will be released to anyone who follows the procedures for requesting the
information unless the parent or guardian objects to the release of the directory
information about the student. If you do not want Sinton ISD to disclose directory
information from your child’s education records without your prior written
consent, you must notify the district in writing within ten school days of child’s
first day of instruction for this school year.
This means that the district must give certain personal information (called “directory information”) about your child
to any person who requests it, unless you have told the district in writing not to do so. In addition, you have the
right to tell the district that it may, or may not, use certain personal information about your child for specific schoolsponsored purposes. The district is providing you this form so you can communicate your wishes about these issues.
[See Directory Information]
For all purposes, Sinton ISD has designated the following information as directory information:
 Student’s name
 Address
 Telephone listing
 E-mail address
 Photograph
 Date and place of birth
 Major field of study
 Degrees, honors, and awards received
 Dates of attendance
 Grade level
 Most recent school previously attended
 Participation in officially recognized activities and sports
 Weight and height, if a member of an athletic team
Directory information identified only for limited school-sponsored purposes remains otherwise confidential and will
not be released to the public without the consent of the parent or eligible student.
Parent: Please select one of the choices below:
(do give)
(do not give) the district
I, parent of ______________________________ (student’s name),
permission to use the information in the above list for the specified school-sponsored purposes.
Parent signature
Date
Please note that if this form is not returned within the specified timeframe above, the district will assume that
permission has been granted for the release of this information.
I, parent of ______________________________ (student’s name),
(do give)
(do not give) the district
permission to use the information in this list in response to a request unrelated to school-sponsored purposes.
Parent signature
Date
Please note that if this form is not returned within the specified timeframe above, the district will assume that
permission has been granted for the release of this information.
Office Use Only: Retain on campus
Student Name ______________________________
Grade ___________
ID__________
YR _____________
2016-2017
Release Form for Display of Student Work and Personal Information
Occasionally, Sinton ISD wishes to display or publish original student work, which may include
personally identifiable student information as defined in the Student Handbook, to promote
student academic and extracurricular activities on the district’s Web site, a Web site affiliated or
sponsored by the district, such as a campus or classroom Web site, and in district publications.
Original student work includes artwork, projects, photos taken by the student, or other academic
or creative work. The district may also wish to publish or display original video and voice
recordings.
The district agrees to use these student works and information only in the manner described
above.
Parent: Please circle one of the choices below and check the applicable boxes:
I, parent of ______________________________ (student’s name), give my permission for the
following to be displayed or published by the District:
Original student work
Voice recordings
Video recordings
Parent signature:
Date:
Office Use Only: Retain on campus
Student Name ______________________________
Grade ___________
ID__________
2016-2017
YR _____________
Parent’sObjectiontotheReleaseofStudentInformationtoMilitaryRecruiters
andInstitutionsofHigherEducation
(TobecompletedforHighSchoolStudentsOnly)
Federal law requires that the district release to military recruiters and institutions of higher
education, upon request, the name, address, and phone number of secondary school students
enrolled in the district, unless the parent or eligible student directs the district not to release
information to these types of requestors without prior written consent. [See Objecting to the
Release of Student Information to Military recruiters and Institutions of Higher Education
for more information.]
Parent: Please complete the following only if you do not want your child’s information
released to a military recruiter or an institution of higher education without your prior consent.
I, parent of ______________________________ (student’s name), request that the district not
a military recruiter or
release my child’s name, address, and telephone number to
institutions of higher education upon their request without my prior written consent.
Parent signature
Date
Please note that if this form is not returned with the other materials identifying what the district
considers directory information, the district will assume that permission has been granted for the
release of this information.
Office Use Only: Retain on campus
Student Name ______________________________
Grade ___________
ID__________
2016-2017
YR _____________
Sinton Independent School District
Military Connected Student Form
In 2009 The Texas Legislature adopted the Interstate Compact on Educational
Opportunity for Military Students – Texas Education Code Chapter 162. This legislation
requires schools to recognize and extend certain privileges to students who are military
dependents and to assist military dependent students in the transition process of
changing schools when their military parents are reassigned and forced to relocate.
Parent Name: _____________________________
Student Name: ________________________ Date of Birth: _________
If Known: Student ID: _______ Grade: ____
Campus: _____________
Please check one box below to indicate if your child is a dependent of a member of:
For all students:
No Military Connection
Active Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard
[This includes Missing in Action (MIA)]
Texas National Guard
Reserve Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard
For Pre-Kindergarten students ONLY:
Armed forces or reserved forces of the United States (Army, Navy, Air Force,
Marine Corps, or Coast Guard) or Texas National Guard who has been injured or
killed while on active duty
Office Use Only: Retain on campus
Student Name ______________________________
Grade ___________
ID__________
2016-2017
YR _____________
Drug Testing Consent Form
(To be completed for Middle School & High School Students Only)
Participation in school activities
Participation in school sponsored extra-curricular activities is a privilege. Extra-curricular activities include all clubs and
organizations, band, athletic programs, cheerleading, literary activities, One Act Play, choir, robotics including
performances, contests, demonstrations, and other events of these mentioned activities. Co-curricular activities are those
activities that take place with a class including, but not limited to, working outside the classroom in work study and
observing and helping in elementary classrooms.
Participants of Drug Testing
Each student in grades 7-12 participating in extra-curricular activities, co-curricular and/or U.I.L. events, will be subject
to random drug and alcohol testing through the school year. Eligible 6th grade students shall be tested for the presence of
illegal drugs and alcohol during the last week of their sixth grade year (this will be their initial test) and prior to joining an
extracurricular program any time during the school year. No student shall be allowed to practice or participate in any
extra-curricular, co-curricular or UIL activity until the student has returned the properly signed “Drug and Alcohol
Testing Consent Form.” No student shall be allowed to compete or perform in any of the before mentioned activities until
the student has been drug tested.
Drug Testing Procedures
Testing will be conducted by licensed professionals and lab work will be tested at a government certified lab.
Participants will be required to produce a urine sample in an Integrated E-Z Split Key Cup. Seventh graders new
to the district, all other eligible students new to the district and students who did not participate in any
activity the previous year will take a mandatory drug test. All participants, grades seven through twelve, will be
involved in random drug testing periodically through the school year. All drug testing will be arranged by the district
testing coordinator prior to students participating in their first eligible competition or performance.
A complete copy of the District Drug Policy is available at the Sinton ISD Administration Office at 322 S. Archer
and in the campus offices at Sinton High School and Smith Middle School
By signing this form the parent/guardian is giving their consent for their child to participate in the district drug
testing.
__________________________________________
Name of Student (Please Print)
_____________________________________
ID #
__________________________________________
Parent/guardian signature
_____________________________________
Date
Select the school that student attends and indicate grade level.
E. Merle Smith Middle School
Grade ______
Sinton High School
Grade _____
Office Use Only: Retain on campus
Centralized file
Student Name ______________________________
Grade ___________
ID__________
YR _____________
2016-2017
REQUEST FOR FOOD ALLERGY INFORMATION
Dear Parent:
This form allows you to disclose whether your child has a food allergy or severe food allergy that you believe
should be disclosed to the District in order to enable the District to take necessary precautions for your child's
safety.
"Severe food allergy" means a dangerous or life-threatening reaction of the human body to a food-borne
allergen introduced by inhalation, ingestion, or skin contact that requires immediate medical attention.
Please list any foods to which your child is allergic or severely allergic, as well as the nature of your child's
allergic reaction to the food.
No information to report
Food:
Nature of allergic reaction to the
food:
Is reaction mild, moderate or severe?
Please note any other allergies & include severity of reaction(s) that your child has:
_________________________________________________________________________________________
_________________________________________________________________________________________
If your child requires the use of an Epi-pen for anaphylactic (severe) reactions, please be sure to contact the
campus nurse. Parent will be required to furnish the district with a prescribed Epi-pen along with a doctor's
order for Epi-pen administration.
The District will maintain the confidentiality of the information provided above and may disclose the
information to teachers, school counselors, school nurses, and other appropriate school personnel only within
the limitations of the Family Educational Rights and Privacy Act and District policy.
Student name:
__________________________________
Grade:
____________
Parent/Guardian name:
Date of birth: _____________________
_________________________________________________________________
Work phone: ___________________________________
Home phone: ________________
Parent/Guardian Signature: ___________________________________ Date:
_________________
Date form was received by the school: __________________________
Office Use Only: Return to Campus Nurse
Student Name ______________________________
Grade ___________
ID__________
2016-2017
YR _____________
EMERGENCY MEDICAL TREATMENT FORM
In the event of a medical emergency at school, the school will first try to contact the child's parents. If the parent
cannot be reached, and the child needs immediate medical treatment, the form below would be given to the
hospital or clinic. The purpose of the Emergency Medical Treatment Form is to obtain medical treatment for your
child in the event you cannot be contacted.
Please complete and return this with the signed accountability form.
I hereby authorize the staff member(s) at
emergency medical treatment for:
School to consent to


Student's First/Last Name (Printed)




Birth Date




Grade
I understand in granting this authorization that:
•
•
•
•
•
•
My child will be taken to a hospital or clinic nearest to the school or activity he or she is attending so that
emergency medical treatment can be obtained.
School staff members will attempt to contact me before consenting to emergency medical treatment for
my child.
I will be responsible for all expenses incurred by virtue of the emergency medical treatment of my child and
for the transportation to the emergency medical treatment facility.
I release Sinton ISD staff members and trustees from any and all claims or actions from liabilities for the
injuries that occur to my child as a result of his or her receipt of emergency medical care.
The staff members of the Sinton ISD, its trustees and agents are not waiving any sovereign or
governmental immunity by requesting the execution of this document.
I understand the provisions of this document and execute it voluntarily.

Signature of Parent or Guardian

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

Home/Work Phone (include area code)




Date
IMPORTANT MEDICAL INFORMATION
List any medical problems your child has which medical personnel need to be aware of in an emergency:
(example—diabetes, asthma, seizures, heart problems, pregnancy, ADHD, mental health concerns, etc)
Medication(s) your child takes daily (either at home or school)
Any severe allergies to food?
Yes
No
If yes, which food(s)
Treatment:
?
Any severe allergies to insect bites?
Treatment:
Yes
No
If yes, what insect:
?
Family physician name
Phone Number
Health Insurance (
CHIP
Medicaid
_Private Insurance
_None)
Emergency Contact #1
Phone Number
Emergency Contact #2
Phone Number
Office Use Only: Return to Campus Nurse
Student Name ______________________________
2016-2017
ID__________ YR ___________
Grade ___________
SINTON ISD STUDENT HEALTH INFORMATION-TO BE COMPLETED BY PARENT OR GUARDIAN
Home Address
Birth Date
City
Zip Code
Sex
M
F
Home Phone
EMERGENCY CONTACTS (PERSONS WHO HAVE PERMISSION TO PICK UP STUDENT OR BRING MEDS)
Mother/Guardian Name
Cell Phone
(circle one)
Place of Employment
Work Phone
Father/Guardian Name
EXT
Cell Phone
(circle one)
Place of Employment
EXT
Work Phone
Others: Name
Relationship
Phone: Home
Work
EXT
Others: Name
Cell
Relationship
Phone: Home
Work
EXT
General Physician
Phone
Physician Specialist
Phone
Cell
HEALTH PROBLEMS
Students are not allowed to carry medications while at school. No medication will be given at school without written permission.
Refer to the student handbook or school nurse for proper medication procedures and special circumstances.
Medication not picked up at the end of the year will be destroyed.
Students with a fever above 100 o F before taking medication should remain at home.
CONTACT NURSE DIRECTLY EACH YEAR REGARDING ALL SERIOUS MEDICAL
CONDITIONS
Check yes or no to the following conditions as they apply to your student.
Chronic medical conditions such as asthma, seizures and diabetes require yearly management plans to be completed.
Explain symptoms, history, and treatment of other health problems in lines below, or on additional pages.
(Circle specific problem when indicated.)
HEALTH PROBLEM
YES
ADD/ADHD (Med Y / N )
Arthritis- Juvenile
Asthma (Med at school Y / N )
Autism
Birth Defects/Congenital
Blackouts/Fainting
Bladder Problems
Bowel Problems
Cancer/Malignancy
Cerebral Palsy
Cystic Fibrosis
Diabetes
NO
HEALTH PROBLEM
Down Syndrome
Eating Disorder
Headaches- Frequent/Severe
YES
NO
HEALTH PROBLEM
Orthopedic Problems
Pregnant (Due Date
_)
YES
NO
Psychological/Emotional Problems
Hearing Loss-Permanent/Aides
Seizures/Convulsions/Epilepsy
Heart Problems
Hemophilia
Sickle Cell Anemia/Trait (Circle 1)
Hypertension/High Blood Pressure
TB skin test ever showed Positive
Substance Abuse
Kidney/Renal Problems
Intellectual Disability
Migraines per Dr. Diagnosis
Muscular Dystrophy
Nosebleeds-Frequent/Severe
Vision Loss-Permanent
Glasses/Contacts -Last exam
Hx of Chicken Pox (Must sign form)
Other Serious Medical Problems
Specify below
SIGNIFICANT ALLERGIES (Food/Drug/Insect/Other)
Symptoms
Treatment
Epipen
Yes
No
List All Medications and Treatments Required at School
Additional comments: ______________________________________
I give permission for school nurse or designated staff to contact the student’s physician regarding health needs.
Parent/Guardian Signature
Date
Office Use Only: Return to Campus Nurse
Student Name ______________________________
Grade ___________
2016-2017
ID__________ YR ___________
SINTON INDEPENDENT SCHOOL DISTRICT
Family Survey
In order to better serve your children, the Sinton Independent School District is helping the
state of Texas identify students who may qualify to receive additional educational services.
The information provided below will be kept confidential. Please fill in all blanks
(including date) and answer the following questions and return this form to your child’s school.
Date: _______________
Name of your child: _________________________ Age _______ Grade ______
Date of Birth: ____________________
1. Have you moved within the last 3 years? Yes
No
2. If yes, have you done agricultural or fishing related work since your move? (e.g., field work,
No . If you answered “yes”,
canneries, lumbering, dairy work, meat processing) Yes
please mark appropriate boxes.
Planting or harvesting
(for example beans, corn, chili, cotton, etc.)
Farm (or ranch) irrigation, etc.
Orchards
Packing of eggs, fruits,
vegetables, etc.
Repair/build fences
Dairies
Animal Farming/Ranching
Meat packing plants, slaughter house
or transport of animals
Plant nurseries/sod farms.
Baling hay
Other _________________________
If you answered “yes” to both of the questions above, an education representative may contact
you to find out whether your child is eligible for additional educational services. Also, please
provide the following information:
Do you have a child under the age of 22 who lacks a U.S. issued high school diploma or GED
No
and is currently NOT enrolled in school? Yes
Name of Parent/Guardian: ___________________________________________
Address: _________________________________________________________
Telephone: ____________________ Best Time to Contact You: _____________
Number of Children in your Family: ____
Office Use Only: Return to Federal & Special Programs
Student Name ______________________________
Grade ___________
2016-2017
ID__________ YR ___________
SINTON INDEPENDENT SCHOOL DISTRICT
Family Survey
Para mejorar los servicios educacionales de sus hijos, el distrito de la escuela de Sinton
Independent School District está colaborando con el estado de Texas para identificar a
aquellos estudiantes que pueden calificar para recibir servicios educativos adicionales.
Toda información proporcionada será mantenida confidencial. Favor de responder a las
siguientes preguntas y devolver esta forma a la escuela de su niño. (Si usted recibe más de una
encuesta, complete sólo una forma y enliste abajo los nombres de todos sus hijos.)
Nombre de su Niño: _________________________ Edad _____ Grado ______
Fecha de Nacimiento:_________________
1. ¿Ha cambiado de residencia usted o alguien en su familia dentro de los últimos tres años?
Sí
No
2. Si usted contesto “sí” en la pregunta anterior, ¿ha trabajado usted en la agricultura o en la
pesca? (por ejemplo, la labor, fábrica de conservas, explotación de bosques, trabajo en la
No
lechería, el proceso de carne) Sí
Cosecha o siembra
(por ejemplo: fríjol, maíz, algodon,etc.)
Riego en granjas, ranchos, etc.
Huertos
Empacadora de huevos,
frutas, vegetales
Reparar/construer cercas
Lecherías
Granja de animales
Matanza/empacadoras de carne o
transporte de animales
Invernaderos o granjas de césped
Otro _________________________
Si usted contestó "Sí," en las dos preguntas anteriores, un representante del distrito escolar
quizás se vaya a comunicar con usted para averiguar si su niño/a califica para servicios
educativos adicionales. Favor de completar la siguiente información:
¿Tiene un niño menor de 22 años que carece de un Estados Unidos emitió diploma de escuela
No
secundaria o GED y actualmente no está inscrito en la escuela? Sí
Nombre del Padre/Guardián: ________________________________________
Dirección: _______________________________________________________
Teléfono: ___________________La Mejor Hora para Localizarlo: __________
Número de Niños en su Familia: __________________
Office Use Only: Return to Federal & Special Programs
Sinton ISD
Student Residency Questionnaire/Foster Care
The information on this form is required to meet the law known as the McKinney-Vento Act 42 U.S.C. 11434A(2),
which is also known as Title X, Part C, of the No Child Left Behind Act. The answers you give will help the school
determine the services the student may be eligible to receive.
Name of Student: ______________________________________________Gender: _____Male _____Female
Birth Date: _____/_____/_____
Grade: ___________
Social Security #: ________________________________
(or student identification number)
Name of the school where student is enrolled or in which student is attempting to enroll: ____________________
Last District Attended:__________________________Last School Attended:_______________________________
FOSTER CARE: THE LEGISLATURE OF THE STATE OF TEXAS has enacted an amendment on SECTION 1 Section 7.029,
Education Code to include the following: The legislation requires schools to recognize and collect data as to the
foster care status of all students. Please check one box below to indicate if the following applies to your child:
For all students:
□
Student is currently in the conservatorship of the Department of Family and Protective Services.
For Pre-Kindergarten students ONLY:
□
Pre-kindergarten student was previously in the conservatorship of the Department of Family and Protective
Services.
STUDENT RESIDENCY QUESTIONNAIRE Check the box that best describes with whom the student resides. (Please
note: legal guardianship may be granted only by a court; students living on their own or with friends or relatives who do
not have legal guardianship are allowed to enroll in and attend school. The school cannot require proof of guardianship
for enrollment or continued attendance.)
□
□
□
□
□
Parent(s)
Legal Guardian(s)
Caregiver(s) who are not legal guardian(s) (Examples: friends, relatives, parents of friends, etc.)
Transitional housing (Only available for a specific length of time or partly or completely
Other:_____________________________________________________________________________________
Name of person with whom student resides: ________________________________________________________
Address: ______________________________________________________________________________________
Current Phone #: ______________________
Email Address: __________________________________________
Please check only one box that best describes where the student sleeps at night:
□
□
□
□
□
□
□
□
□
□
In a home or apartment with self/parent/legal guardian
In a home or apartment with more than one family
□ The home/apartment does NOT have electricity
□ The home/apartment does NOT have running water
Section 8 housing, military housing
In the home of a friend or relative
In a shelter
In a motel
Moving from place to place
In a place not designed for ordinary sleeping accommodations such as car, park or campsite
In a place that does not have windows, doors, running water, heat, electricity or is overcrowded
Other: ____________________________________________________________________________
Office Use Only: Return to Federal & Special Programs
Is the student’s current address a temporary living arrangement? _____ Yes
Could the student be asked to leave at any time? _____ Yes
_____ No
_____No
Did the student move here because they would be on the streets or in another dangerous situation otherwise?
_____ Yes _____No
If students living conditions are temporary due to loss of housing or economic hardship, please check all the
following boxes that contribute to the student’s current living situation:
□
□
□
Natural Disaster
□ Tornado, storm, flood, etc.
□ Hurricane, Name: _______________
□ Fire: prairie, forest, grass, lightning strike, etc.
Family issues such as divorce, domestic violence, kicked out by parents, student left due to family conflict, etc.
Home issues such as lack of electricity, water, heat, adequate home repair due to lack of funds, overcrowding,
g
mold, etc.
□ Military: Parent/guardian deployed, injured or killed in action
□ Incarceration of parent/guardian
□ Incapacitation of parent /guardian due to health, mental health, drugs/alcohol, or other factors
□ Home fire not due to natural causes (i.e., faulty equipment/appliances/wiring, furnace, stove, fireplace, etc)
□ Economic hardship:
□ Loss of job resulting in inability to pay rent or mortgage
□ Income from part-time or low paying job does not cover cost of housing in the area
□ Loss of mortgage, including loss of mortgage of landlord if student/student’s family is renting
□ Eviction record and/or inability to produce deposits for rent or utilities
□ High medical bills that leave little or no money for housing
□ Lack of affordable housing in the area
□ Minor student unable to afford housing on my own
□ None of the above describe the main reasons for my present living situation. Briefly explain the contributing
factors: _______________________________________________________________________________________
_____________________________________________________________________________________________
Please provide the following information of school-age siblings (brothers and/or sisters) of the student:
Name
Grade Level
School
District
___________________________________________________________________________
Signature of Parent/Legal Guardian/Caregiver/Unaccompanied Student
________________
Date
For office use only
I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinneyVento Act.
___________________________________________________________________
McKinney-Vent o Liaison Signature
New Student
Clear All Pages
________________________
Date
Office Use Only: Return to Federal & Special Programs