Juanita High School NE 132 nd Street Kirkland, WA (425)

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1 Juanita High School 060 NE nd Street Kirkland, WA 9804 (45) Welcome to Juanita High School for the school year. Please complete and return to the Juanita Counseling Office the following required documentation for enrollment. Proof of Residency (please submit one of the following) o Utility bill o Closing papers o Rental agreement Birth Certificate Immunization Record Unofficial Transcript from previous school o Unofficial transcript for incoming 0 th, th and th graders. Counselors must have this at the time of enrollment to help with credit check and scheduling classes. o Report card or academic history for incoming 9 th graders. Withdrawal from previous school o Make sure you inform the school your student would have attended in 08-9 that your student will not be attending for the school year. Proof of Guardianship (if applicable) Special Needs (if applicable): Please provide a current copy of an IEP Individual Education Plan, 504 Plan, or ELL English Language Learner documentation. Completed Juanita High School Enrollment Forms

2 Lake Washington School District Student Registration Form School Today s Date Student Information Legal Last Name Legal First Name Legal Middle Name Also known as Birthdate (M/D/Y) Gender (M/F) Birthplace: City State Country Grade Level Has your child ever been in programs such as: Highly Capable Special Education 504 Accommodation English Language Learner Occupational Therapy Speech/Language Is the student s parent/guardian currently in the military? No Yes: Number of parents/guardians currently in the military: If Yes: Ethnic Code: The district is required to report the following information to the state. (Categories are determined by the state and federal government). Question : Is your child of Hispanic or Latino origin? (Check all that apply) Physical Therapy Armed Forces, Active Duty Armed Forces, Reserves Washington National Guard Not Hispanic/Latino Cuban Dominican Spaniard Puerto Rican Mexican/Mexican American/ Chicano Central American South American Latin American Hispanic/Latino Question : What race do you consider your child? (Check all that apply) African American/Black White Asian Indian Cambodian Chinese Filipino Hmong Indonesian Japanese Korean Laotian Malaysian Pakistani Singaporean Taiwanese Thai Vietnamese Asian Native Hawaiian Fijian Guamanian or Chamorro Mariana Islander Melanesian Micronesian Samoan Tongan Pacific Islander Alaska Native Chehalis Colville Cowlitz Hoh Jamestown Kalispel Lower Elwha Lummi Makah Muckleshoot Nisqually Nooksack Port Gamble Klallam Puyallup Quileute Quinault Samish Sauk-Suiattle Shoalwater Skokomish Snoqualmie Spokane Squaxin Island Stillaguamish Suquamish Swinomish Tulalip Yakama Washington Indian American Indian Previous School Information Number of previous schools attended: Last school student attended (include year, grade and address of former school): Has your child ever enrolled in a school or schools in Washington state? Yes No If yes, what school(s) and year(s) attended? Has your child ever attended Lake Washington School District (including Headstart, Readystart or Pre-school)? Yes No If yes, what school and year(s) attended? _ For Office Use Only School Entry Date Advisor Name Student ID # B/D Verified (initial) SS-008 /07

3 Primary Household Information Resident Address where student resides Street Apt # For Office Use Only City State Zip Housing Development (if applicable) Mailing Address (if different from above) Street PO Box Apt # City State Zip Address Verified (initial) Primary Phone: ( )_ Check if unlisted Home Cell Work Parent/Guardian # Last Name Parent/Guardian # Last Name Phone : ( ) Home Cell Work Home Cell Work Phone : ( ) Home Cell Work Home Cell Work Second Household Mailing Information Street Apt # City State Zip Housing Development (if applicable) Mailing Address (if different from above) Street PO Box Apt # City State Zip Primary Phone: ( )_ Check if unlisted Home Cell Work Parent/Guardian # Last Name Phone : ( ) Home Cell Work Home Cell Work Parent/Guardian #4 Last Name Phone : ( ) Home Cell Work Home Cell Work Verification of Information: The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student s enrollment or assignment to a school in Lake Washington School District. Legal Parent/Guardian Signature Date SS-008 /07

4 Lake Washington School District Emergency Notification - Secondary Student Name: Last First Middle Grade Level Birthdate (MM/DD/YYYY) Gender (M/F) Teacher (Advisor/Counselor): Primary Household Information Resident Address where student resides Street Apt # City State Zip Housing Development (if applicable) Mailing Address (if different from above) Street PO Box Apt # City State Zip Primary Phone: ( )_ Check if unlisted Home Cell* Work Parent/Guardian # Last Name Parent/Guardian # Last Name Phone : ( ) Home Cell* Work Home Cell* Work Phone : ( ) Home Cell* Work Home Cell* Work * I grant LWSD permission to use the SchoolMessenger auto-dialer system to contact me on all of the cell phones listed in the Primary Household Information section of this form. (Please note: LWSD will use SchoolMessenger to contact you with emergency messages, even if you do not check this box.) Second Household Information (if a parent lives at an address different from primary) Street Apt # City State Zip Housing Development (if applicable) Mailing Address (if different from above) Street PO Box Apt # City State Zip Primary Phone: ( )_ Check if unlisted Home Cell** Work Parent/Guardian # Last Name Parent/Guardian #4 Last Name Phone : ( ) Home Cell** Work Home Cell** Work Phone : ( ) Home Cell** Work Home Cell** Work **Please note: The Second Household will use an online process through Parent Access to confirm permission to call cell phones using the SchoolMessenger auto-dialer system. Please fill out other side

5 Emergency Contacts When injury or illness involving your child occurs, we want to be able to quickly reach families or other responsible adults. In the event we cannot reach a parent/guardian, please list person(s) you trust who are available during the day to provide care for your child. We suggest at least one local contact and one out of state contact. Please be sure to list anyone who may need to pick your child up from school (i.e., carpool drivers).. Name: Relationship: Phone: ( ). Name: Relationship: Phone: ( ). Name: Relationship: Phone: ( ) Student Release Authorization: In the event the school is unable to contact the parent/guardian, I authorize the school to release my student to the person(s) listed above. For grades 6-8, in the event of an unanticipated dismissal of school we will attempt to contact parents/guardians. If we are unable to reach you, please indicate if your student has permission to: bus home (if buses run early) walk home Siblings in District Name: Name: Name: School: School: School: Verification of Information: The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student s enrollment or assignment to a school in Lake Washington School District. Legal Parent/Guardian Signature Date Please notify your student s school if any of the information on this form changes during the school year. 8A Revised 6/06

6 Office of Superintendent of Public Instruction (OSPI) Home Language Survey English/February 07 The Home Language Survey is given to all students enrolling in Washington schools. Student Name: Birthdate: Grade: Date: Parent/ Guardian Name Right to Translation and Interpretation Services Indicate your language preference so we can provide an interpreter or translated documents, free of charge, when you need them. Eligibility for Language Development Support Information about the student s language helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed. Parent/ Guardian Signature All parents have the right to information about their child s education in a language they understand.. In what language(s) would your family prefer to communicate with the school?. What is the primary language used in the home, regardless of the language spoken by your child? (Language Field). What language did your child learn first? (Native Language Field) 4. What language does your child use the most at home? (Home Language Field) 5. Has your child received English language development support in a previous school? Yes No Don t Know Prior Education Your responses about your child s birth country and previous education: Give us information about the knowledge and skills your child is bringing to school. May enable the school district to receive additional federal funding to provide support to your child. This form is not used to identify students immigration status. 6. In what country was your child born? 7. Has your child ever received formal education outside of the United States? (Kindergarten th grade) Yes No If yes: Number of months: Language of instruction: 8. When did your child first attend a school in the United States? (Kindergarten th grade) Month Day Year Thank you for providing the information needed on the Home Language Survey. Contact your school district if you have further questions about this form or about services available at your child s school. Note to district: This form is available in multiple languages on A response that includes a language other than English to question # OR question #4 triggers English language proficiency placement testing. Responses to questions # or # of a language other than English could prompt further conversation with the family to ensure that # and #4 were clearly understood. Formal education in #7 does not include refugee camps or other unaccredited educational programs for children. Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative Commons Attribution 4.0 International License.

7 Certificate of Immunization Status (CIS) DOH 48-0 January 00 Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Registry. Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I certify that the information provided on this form is correct and verifiable. Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only Vaccine Dose Hepatitis B (Hep B) Date Month Day Year or Hep B - dose alternate schedule for teens Rotavirus (RV, RV5) Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 4 5 Tetanus, Diphtheria, Pertussis (Tdap, Td) Haemophilus influenzae type b (Hib) 4 Pneumococcal (PCV, PPSV) 4 Vaccine Parent/Guardian Name (please print): Dose Polio (IPV, OPV) 4 Influenza (flu, most recent) Date Month Day Year Measles, Mumps, Rubella (MMR) Varicella (chickenpox) or verify disease -4 Hepatitis A (Hep A) Meningococcal (MCV, MPSV) Human Papillomavirus (HPV) Office Use Only: Immunization information updated and verified with parent/guardian permission: Printed Staff Name Date Printed Staff Name Date Printed Staff Name Date Printed Staff Name Date Office Use Only: Reviewed by: Date: Signed Cert. of Exemption on file? Yes No Parent/Guardian Signature Required Date If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option,,, OR 4 below see, back #5. ) Chickenpox disease verified by printout from CHILD Profile Immunization Registry Must be marked by printout (not by hand) to be valid. ) Chickenpox disease verified by Health Care Provider (HCP) If you choose this box, mark A OR B below. A) Signed note from HCP attached OR B) HCP signed here and print name below: Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP) HCP Printed Name: ) Chickenpox disease verified by school staff from CHILD Profile Immunization Registry If you choose this box, staff must initial that parent or guardian approves: (initial) (date) 4) Chickenpox disease verified by parent* If you choose this box, fill in the date or child s age when he or she had the disease: Age/Date of disease: *Can ONLY verify for some grades, see back #5 (4). If the child can show immunity by blood test (titer) and hasn t had the vaccine, ask your HCP to fill in this box. Documentation of Disease Immunity I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached. Diphtheria Hepatitis A Hepatitis B Hib Measles Mumps Polio Rubella Tetanus Varicella : Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP) HCP Printed Name:

8 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand. # To print with info filled in: First, ask if your health care provider s office puts vaccination history into the CHILD Profile Immunization Registry (Washington s statewide database). If they do, ask them to print the CIS from CHILD Profile and your child s information will fill in automatically. Be sure to review all the information, sign and date the CIS in the upper right hand box, and return it to school or child care. If your provider s office does not use CHILD Profile, ask for a copy of your child s vaccine record so you can fill it in by hand using steps #-7 (below): EAMPLE Vaccine Dose Date Month Day Year Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 0 0 DTaP DTaP # To fill in by hand: Print your child s name, birthdate, sex, and your own name in the top box. # Write each vaccine your child received under the correct disease. Write the vaccine type under the Vaccine column and the date each dose was received in the Month, Day, and Year columns (as mm/dd/yyyy). For example, if DTaP was received Jan, March 0, June,, fill in as shown here #4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS: ) If your child s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is found, box is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand). ) If your health care provider (HCP) can verify that your child has had chickenpox, mark box. Then mark either A to attach a signed note from your HCP, or B if your HCP signs and dates in the space provided. Be sure your HCP s full name is also printed. ) If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box. Then, they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS. 4) If your child started kindergarten in the school year or later, you CANNOT use this box. If your child started kindergarten before the school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox. To find out which grades require chickenpox vaccine (or history), visit: #6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider (HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports. #7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care. #8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval. Vaccine Trade Names in alphabetical order (For updated lists, visit Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Engerix-B Hep B Ipol IPV Pentavalente DTaP + Hep B + Hib TriHIBit DTaP + Hib Adacel Tdap Fluarix Flu (TIV) Infanrix DTaP Pneumovax PPSV or PPV Tripedia DTaP Afluria Flu (TIV) FluLaval Flu (TIV) Kinrix (Knrx) DTaP + IPV Prevnar PCV or PCV7 or PCV Twinrix (Twnrx) Hep A + Hep B Boostrix Tdap FluMist Flu (LAIV) Menactra MCV or MCV4 ProQuad (PrQd) MMR + Varicella Vaqta Hep A Cervarix HPV Fluvirin Flu (TIV) Menomune MPSV or MPSV4 Quadracel (Qdrcl) DTaP + IPV Varivax Varicella Comvax (Cmvx) Hep B + Hib Fluzone Flu (TIV) Pediarix (Pdrx) DTaP + Hep B + IPV Recombivax HB Hep B Daptacel DTaP Gardasil HPV4 PedvaxHIB Hib Rotarix Rotavirus (RV) Decavac Td Havrix Hep A Pentacel (Pntcl) DTaP + Hib + IPV RotaTeq Rotavirus (RV5) Vaccine Abbreviations in alphabetical order (For updated lists, visit Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name DT Diphtheria, Tetanus Hep A (HAV) Hepatitis A Meningococcal Rota MPSV or MPSV4 Hep B (HBV) Hepatitis B Polysaccharide Vaccine (RV or RV5) Rotavirus DTaP Diphtheria, Tetanus, Haemophilus influenzae Measles, Mumps, Rubella / Hib MMR / MMRV acellular Pertussis type b with Varicella Td Tetanus, Diphtheria DTP Diphtheria, Tetanus, Tetanus, Diphtheria, acellular HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Pertussis Pertussis Flu (TIV or LAIV) HBIG Influenza Hepatitis B Immune Globulin IPV MCV or MCV4 Inactivated Poliovirus Vaccine Meningococcal Conjugate Vaccine PCV or PCV7 or PCV PPSV or PPV Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine TIG VAR or VZV Tetanus immune globulin If you have a disability and need this document in another format, please call (TDD/TTY ). DOH 48-0 January 00 Varicella

9 * *** DUE ON WEDNESDAY, FEBRUARY 4, 08 *** Final FRESHMAN JUANITA HIGH SCHOOL COURSE SELECTION WORKSHEET Student Name: THIS IS THE FINAL COPY OF YOUR COURSE SELECTION WORKSHEET AND MUST BE TURNED IN FOR REGISTRATION FOR NET SCHOOL YEAR. PLEASE BE SURE THAT ALL SIGNATURES HAVE BEEN OBTAINED. REVIEW YOUR REQUESTS CAREFULLY AND READ THE STATEMENT IN THE BO BELOW BEFORE SUBMITTING THIS WORKSHEET. NOTE THAT YOU MUST SIGN UP FOR 7 CLASSES EACH SEMESTER. SEMESTER : SEMESTER : Teacher INITIAL TITLE OF COURSE TITLE OF COURSE ENGLISH: Honors English 9 ENGLISH: Honors English 9 (choose one) English 9 English 9 SOCIAL STUDIES: Hon World History (year) ELECTIVE: (choose one) World History ( semester) MATH: MATH: Honors World History (year) ( semester) Teacher INITIAL SCIENCE: PE:* ELECTIVE: ELECTIVE: Biology in the Earth System Physical Education SCIENCE: Biology in the Earth System HEALTH:* Health ELECTIVE: ELECTIVE: * PE and Health are recommended classes for all 9 th graders and fulfill specific graduation requirements. See back of this sheet for a list of all classes available to freshmen. ELECTIVE above includes any class listed on the back. ALTERNATES: You must choose 6 different ELECTIVE alternates. Please note: There is no priority ranking to the alternate choices. Title of Alternate ELECTIVE Course: Title of Alternate ELECTIVE Course: Parents and Students, Please note that teachers will be assigned to specific classes at JHS based on student requests for courses. Students should select courses carefully. Requests for schedule changes that deviate from the courses selected on this Course Selection Worksheet cannot be granted. I have reviewed my graduation requirements and request the above courses for next year. Student Signature Parent Signature Date / / Date / / 0/8

10 COURSES AVAILABLE TO FRESHMEN (See the JHS Course Catalog for course descriptions, pre-requisites and requirements) REQUIRED 9 TH GRADE CLASSES: SEMESTER ENGLISH English 9 Honors English 9 SEMESTER SOCIAL STUDIES World History Honors World History MATH (depends on previous math level): SEMESTER YEAR YEAR YEAR Algebra (follows 8 th grade math) Geometry (follows Algebra ) Algebra (follows Geometry) SEMESTER YEAR SCIENCE: Biology in the Earth System (Integrated Honors option available) HIGHLY RECOMMENDED FOR ALL 9 TH GRADERS: Health Physical Education OTHER COURSES OPEN TO 9 TH GRADERS: D Design American Sign Language* AP Music Theory Architecture & Construction Foundation Art Ceramics/Pottery Ceramics/Pottery Child Development Chorus Concert Band Digital Design Drama Drama Production Workshop Fitness & Conditioning Food Science Foods Gourmet Foods International Foods French* COURSES OPEN TO 9 TH GRADERS CONTINUED SEMESTER YEAR Guitar Guitar Improvisation Intro to Computer Science Japanese* Jazz Ensemble (audition) Leadership Leadership Marketing Materials Science Technology Mechanical Engineering Microsoft Imagine Academy Music Theory Musical Theatre Orchestra Photography Piano Piano Psychology Recreational Sports Spanish* Theatre Costume/Scenic Design Theatre Lighting/Sound Vocal Jazz Ensemble (audition) Walking & Yoga * It is not necessary to begin a World Language in 9 th grade, unless you want to complete 4 years of study in the same language. The JHS World Language department recommends beginning a World Language in the 0 th grade to give yourself time to acclimate to the academic rigor of high school.

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