/ / M F Student's Legal Last Name First Name M.I. Birthdate (Month-Day-Yr) Gender. ( ) - ( ) - Student's Cellphone
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1 Please Print STUDENT INFORMATION PASCO SCHOOL DISTRICT STUDENT REGISTRATION FORM Important: A copy of the birth certificate and shot record must be included in the registration packet when it is returned. Student Number: For District Use Only / / M F Student's Legal Last Name First Name M.I. Birthdate (Month-Day-Yr) Gender ( ) - Home Phone Grade ( ) - Student's Cellphone Address (Physical Residence) Nickname (If any) Country of Birth Do student's parents/grandparents have tribal affiliation? YES NO Student Lives With: (Circle One) Both Parents Father Mother Father/Stepfather Mother/Stepmother Grandparent Foster Parent Host Family Spouse Alternates with Mother & Father Unaccompanied Youth Other(specify relationship) Is your current address a temporary living situation? If yes, please circle where this student is living: S-In a Shelter U-Unsheltered H/M-Hotel/Motel D-Doubled Up with more than one family in a house or apartment or with friends or a relative Other (please specify): Does the current living situation circled above result from economic hardship? Other Parent(s)/Guardian(s) NOT living with this student who require(s) information. Last Name First Name Address Apt# City State Zip Phone ( ) - Relationship Joint Custody? Release student to noncustodial parent? Babysitter Name: Address Phone ( ) - Language and Education Data: Language student first learned to speak? Student's language spoken most at home? Language used by parent/guardian to communicate with student? of initial enrollment in US schools (mm/yyyy): / How many months U. S. education prior to this enrollment? How many months education outside U.S. prior to this enrollment? (a typical school year is 0 months per year) School Experience Data: (Circle and enter the appropriate answer) HAS THIS STUDENT: Previously attended the Pasco School District? Ever attended a school in Washington State? If Yes, School Name Yr If Yes, School Name Yr Previous School Name City State Been enrolled in any special education program? If Yes, What program(s)? Been enrolled in ESL/Migrant programs? What year(s)? Had a history of violent or criminal behavior? Had any history of weapons possession? Ever been suspended or expelled for disciplinary reasons? I certify that all of the information I have provided is true, correct and complete. Ever attended a pre-school program? Parent/Guardian Signature SR- FOR OFFICE USE ONLY Enrollment Immunization Birth Certificate Interpreter Family ID 5
2 PSD ETHNICITY AND RACE DATA COLLECTION FORM FORMULARIO DE COLECCION DE DATOS SOBRE LA RAZA Y ETNICIDAD EN PSD ` Student Name / Nombre del estudiante Student Number / Numero del estudiante QUESTION : HISPANIC/LATINO? Is your child of Hispanic or Latino origin? (Mark if YES) PREGUNTA : HISPANIC/LATINO? Es su hijo de origen Hispano o Latino? (Marque SI) QUESTION A: HISPANIC/LATINO CULTURE? If YES above; which culture best describes your child? (You must check at least one.) PREGUNTA : Si contestó sí arriba, Cuál cultura describe mejor a su hijo? (Debe marcar por lo menos una) ` CUBAN / CUBANO ` DOMINICAN / DOMINICANO ` SPANIARD / ESPANOL ` PUERTO RICAN / PUERTORRIQUENO ` MEXICAN/MEXICAN AMERICAN/CHICANO/MEXICANO ` CENTRAL AMERICAN / CENTRO AMERICANO ` SOUTH AMERICAN / SUR AMERICANO ` LATIN AMERICAN / LATINO AMERICANO ` OTHER HISPANIC/LATINO / OTRO HISPANO/LATINO Question : RACE? What race(s) do you consider your child? Whether or not you marked YES to QUESTION, (Check all that apply. You must check at least one.) PREGUNTA : RAZA? De qué raza(s) usted considera que su hijo es? Aunque usted no haya marcado SÍ a la PREGUNTA, (Marque todas las que se aplican. Debe por lo menos marcar una.) AFRICAN AMERICAN/BLACK / NATIVE AMERICAN/AMERICAN INDIAN/ALASKA NATIVE / ` AFRO AMERICANO/NEGRO NATIVO AMERICANO/INDIO AMERICANO/NATIVO DE ALASKA ` WHITE / CAUCASICO ` ALASKA NATIVE ` CHEHALIS ASIA / ASIÁTICO ` COLVILLE ` COWLITZ ` ASIAN INDIAN ` HOH ` CAMBODIAN ` JAMESTOWN ` CHINESE ` KALISPEL ` FILIPINO ` LOWER ELWHA ` HMONG ` LUMMI ` INDONESIAN ` MAKAH ` JAPANESE ` MUCKLESHOOT ` KOREAN ` NISQUALLY ` LAOTIAN ` NOOKSACK ` MALAYSIAN ` PORT GAMBLE S KLALLAM ` PAKISTANI ` PUYALLUP ` SINGAPOREAN ` QUILEUTE ` TAIWANESE ` QUINAULT ` THAI ` SAMISH ` VIETNAMESE ` SAUK-SUIATTLE ` OTHER ASIAN ` SHOALWATER ` SKOKOMISH PACIFIC ISLANDER / ISLA DEL PACÍFICO ` SNOQUALMIE ` SPOKANE ` NATIVE HAWAIIAN ` SQUAXIN ISLAND ` FIJIAN ` STILLAGUAMISH ` GUAMANIAN or CHAMORRO ` SUQUAMISH ` MARIANA ISLANDER ` SWINOMISH ` MELANESIAN ` TULALIP ` MICRONESIAN ` UPPER SKAGIT ` SAMOAN ` YAKAMA ` TONGAN ` OTHER WASHINGTON INDIAN ` OTHER PACIFIC ISLANDER ` OTHER AMERICAN INDIAN / OTROS INDIAN AMERICANO Parent/Guardian Signature / Firma del Padre/Tutor / Fecha
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4 Certificate of Immunization Status (CIS) DOH 8-0 January 05 Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System. Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I give permission to my child s school to share immunization information with the Immunization Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only Recommended, but not required Dose Hepatitis B (Hep B) or Hep B - dose alternate schedule for teens Rotavirus (RV, RV5) Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 5 Tetanus, Diphtheria, Pertussis (Tdap) Tetanus, Diphtheria (Td) Haemophilus influenzae type b (Hib) Influenza (flu, most recent) I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Dose Pneumococcal (PCV, PPSV) 5 Polio (IPV, OPV) Measles, Mumps, Rubella (MMR) Varicella (chickenpox) Hepatitis A (Hep A) Human Papillomavirus (HPV) does not print from the IIS; write dates in by hand Meningococcal (MCV, MPSV) Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Information System to help the school maintain my child s school record. Parent/Guardian Signature Required If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option,, OR below (see # 5 on back) ) Chickenpox disease verified by printout from the Immunization Information System (IIS) Must be marked by printout (not by hand) to be valid. ) Chickenpox disease verified by healthcare provider (HCP) If you choose this box, mark A OR B below. A) Signed note from HCP attached OR B) HCP sign here and print name below: Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name: ) Chickenpox disease verified by school staff from the Immunization Information System 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 Other: Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name:
5 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. # To print with information filled in: First, ask if your healthcare provider s office puts vaccination history into the WA Immunization Information System (Washington s statewide database). If they do, ask them to print the CIS from the IIS and your child s information will fill in automatically. Be sure to review all the information, sign and date the CIS, and return it to school or child care. If your provider s office does not use the IIS, ask for a copy of your child s vaccine record so you can fill it in by hand using steps #-7 (below): # 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 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 # 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. EXAMPLE #5 If your child had chickenpox (varicella) disease and not the vaccine, use only one of these three options to record this on the CIS: ) If your child s CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box is automatically marked. To be valid, this box must be marked by the IIS printout (not by hand). ) If your healthcare provider can verify that your child had chickenpox, mark box. Then mark either A to attach a signed note from your provider, or B if your provider signs and dates in the space provided. Be sure your provider s full name is also printed. ) If school staff access the IIS and see verification that your child had chickenpox, they will mark box. #6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your healthcare provider fill in this box. Ask your provider 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, and return to the school or child care. Trade Names in alphabetical order (For updated lists, visit Trade Name Trade Name Trade Name Trade Name Trade Name ActHIB Hib FluLaval Flu Ipol IPV PedvaxHIB Hib Twinrix (Twnrx) Hep A + Hep B Adacel Tdap FluMist Flu Infanrix DTaP Pentacel (Pntcl) DTaP + Hib + IPV Vaqta Hep A Afluria Flu Fluvirin Flu Kinrix (Knrx) DTaP + IPV Pneumovax PPSV or PPV Varivax Varicella Boostrix Tdap Fluzone Flu Menactra MCV or MCV Prevnar PCV or PCV7 or PCV Cervarix HPV Gardasil HPV MenHibrix Meningococcal C/Y- (Mnhbrx) HIB-PRP ProQuad (PrQd) MMR + Varicella Daptacel DTaP Havrix Hep A Menomune MPSV or MPSV Recombivax HB Hep B Engerix-B Hep B Hiberix Hib Menveo Meningococcal Rotarix Rotavirus (RV) Fluarix Flu HibTITER Hib Pediarix (Pdrx) DTaP + Hep B + IPV RotaTeq Rotavirus (RV5) Abbreviations in alphabetical order (For updated lists, visit Abbreviations Full Name Abbreviations Full Name Abbreviations Full Name Abbreviations Full Name Hep A (HAV) Hepatitis A Meningococcal Rota DT Diphtheria, Tetanus MPSV or MPSV Rotavirus Hep B (HBV) Hepatitis B Polysaccharide (RV or RV5) Diphtheria, Tetanus, Haemophilus influenzae Measles, Mumps, Rubella / DTaP Hib MMR / MMRV Td Tetanus, Diphtheria acellular Pertussis type b with Varicella Diphtheria, Tetanus, Tetanus, Diphtheria, acellular DTP HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Pertussis Pertussis Flu (IIV or LAIV) HBIG Influenza Hepatitis B Immune Globulin IPV MCV or MCV Inactivated Poliovirus Meningococcal Conjugate PCV or PCV7 or PCV PPSV or PPV Pneumococcal Conjugate Pneumococcal Polysaccharide Dose Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 0 0 DTaP DTaP TIG VAR or VZV Tetanus immune globulin If you have a disability and need this document in another format, please call (TDD/TTY call 7). DOH 8-0 January 05 Varicella
/ / M F Student's Legal Last Name First Name M.I. Birthdate (Month-Day-Yr) Gender. ( ) - ( ) - Student's Cellphone
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