SNOHOMISH SCHOOL DISTRICT 201 NEW STUDENT REGISTRATION FORM

Transcription

1 SNOHOMISH SCHOOL DISTRICT 201 NEW STUDENT REGISTRATION FORM 3111F3 SCHOOL: DATE: DO NOT WRITE IN SHADED AREA FOR OFFICE USE ONLY STUDENT SCHOOL NUMBER SCHOOL ENTRY DATE MEDICAL ALERT HOMEROOM NUMBER LOCKER NUMBER BUS ROUTE AM PM Has any member of your family ever been enrolled in the Snohomish School District? Yes No STUDENT NAME: Legal Last Name Legal First Name Legal Middle Name Also Known As: BIRTHDATE (Month/Day/Year) DISTRICT RESIDENT? Yes Resident District: GENDER F M No BIRTHPLACE: City County State Country Grade Level: Military Family Status (circle) A U.S. Armed Forces active duty G National Guard member M More than one member of Armed Forces/National Guard N No affiliation R U.S. Armed Forces reserves Z Do not wish to state PRIMARY LANGUAGE SPOKEN AT HOME English Other PRIMARY HOUSEHOLD (primary parent/guardian where student resides) Legal Last Name (of primary contact) Legal First Name Middle Name PRIMARY CONTACT # (include area code) Home Work Cell PRIMARY CONTACT PH #2 (area code) Home Work Cell RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self Please check if unlisted Legal Last Name Legal First Name Middle Name PHONE #1 (include area code) Home Work Cell Please check if unlisted PHONE #2 (include area code) Home Work Cell RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self FAMILY ADDRESS Please check if unlisted ADDITIONAL ADDRESS Please check if unlisted RESIDENT ADDRESS Street Apt # City State ZIP Street Apt # P O Box City State ZIP MAILING ADDRESS (If different from above) SECOND HOUSEHOLD (Non custodial parent/guardian not residing with student) Legal Last Name Legal First Name Middle Name PHONE #1 (include area code) Home Work Cell PHONE #2 (include area code) Home Work Cell RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self (Non custodial parent/guardian not residing with student) Legal Last Name Legal First Name Middle Name Please check if unlisted PHONE #1 (include area code) Home Work Cell Please check if unlisted PHONE #2 (include area code) Home Work Cell Please check if unlisted Please check if unlisted RELATIONSHIP TO STUDENT Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self FAMILY ADDRESS RELATIONSHIP TO STUDENT: Father Mother Stepfather Stepmother Guardian Grandfather Grandmother Uncle Aunt Agency Friend Self SECOND HOUSEHOLD MAILING ADDRESS (Street/PO Box, City, State, ZIP) ADDITIONAL MAILINGS REQUESTED Yes No SCHOOL PREVIOUSLY ATTENDED SCHOOL DISTRICT PREVIOUSLY ATTENDED PREVIOUS SCHOOL LOCATION (City and State) HAS STUDENT EVER ATTENDED SNOHOMISH PUBLIC SCHOOLS? Yes No IF YES, NAME OF SCHOOL(S) ATTENDED DATE ATTENDED (Month/Year) IS THERE A JOINT CUSTODY OR PARENTING PLAN IN EFFECT? Yes No (If yes, plan must be on file with the school) Copy Attached IS THERE A RESTRAINING ORDER IN EFFECT? Yes No (If yes, legal papers must be on file with the school) Copy Attached Restraining order is against: Mother Father Other Please complete additionalregistration informationonback 01/2017

2 3111F1 HAS THE STUDENT EVER BEEN SUSPENDED FOR A WEAPONS VIOLATION? Yes No : HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL EDUCATION PROGRAM? Yes No HAS YOUR CHILD EVER BEEN ON AN IEP? (Individualized Education Program) Yes HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN? Yes No No HAS YOUR CHILD EVER BEEN RETAINED? Yes No If yes, at what grade level(s) HAS YOUR CHILD EVER PARTICPATED IN: Title Title 1 Services LAP Learning Assistance Program Gifted Accelerated Learning Program ELL English Language Learner DOES STUDENT ATTEND CHILD CARE? Before school After school Before and after school CHILD CARE PROVIDER Name Address Phone Number ADDITIONAL CHILD CARE ARRANGEMENTS (Please provide information to school in writing) PLEASE LIST OTHER SIBLINGS ATTENDING SNOHOMISH PUBLIC SCHOOLS Last Name First Name School Grade SPECIAL INSTRUCTIONS REGARDING RELIGIOUS BELIEFS (Please provide information to school in writing) STUDENT RELEASE AUTHORIZATION When injury, illness or other non emergency situations occur involving your child, we want to be able to quickly reach families or other responsible adults. In the event we cannot reach a parent/guardian, please list persons you trust who are available during the day to provide care for your child. PRIMARY EMERGENCY CONTACT (after parent/guardian contact) Legal Last Name Legal First Name RELATIONSHIP TO CHILD PHONE #1 (include area code) Home Work Cell PHONE #2 (include area code) Home Work Cell PRIMARY CONTACT ADDRESS Street City State ZIP SECONDARY EMERGENCY CONTACT (after parent/guardian contact) Legal Last Name Legal First Name RELATIONSHIP TO CHILD PHONE #1 (include area code) Home Work Cell PHONE #2 (include area code) Home Work Cell SECONDARY CONTACT ADDRESS Street City State ZIP STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above. Legal Parent/Guardian Signature EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child. Legal Parent/Guardian Signature Continue to next page for Ethnicity & Race Information 01/2017

3 SNOHOMISHSCHOOL DISTRICTNO. 201 Ethnicity and Race Collection Form State and Federally Required Information QUESTION 1. Is your child of Hispanic or Latino origin? (Check all that apply) 3111F1 NOT HISPANIC/LATINO CUBAN DOMINICAN SPANIARD MEXICAN/ MEXICAN AMERICAN/ CHICANO CENTRAL AMERICAN SOUTH AMERICAN LATIN AMERICAN OTHER HISPANIC/LATINO QUESTION 2. What race(s) 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 OTHER ASIAN NATIVE HAWAIIAN FIJIAN GUAMANIAN or CHAMORRO MARIANA ISLANDER MALANESIAN MICRONESIAN SAMOAN TONGAN OTHER PACIFIC ISLANDER ALASKA NATIVE CHEHALIS COLVILLE COWLITZ HOH JAMESTOWN KALISPEL LOWER ELWHA LUMMI MAKAH MUCKLESHOOT NISQUALLY NOOKSACK PORT GAMBLE KLALLAM PUYALLUP QUILEUTE SAMISH SAUK SUIATTLE SHOALWATER SKOKOMISH SNOQUALMIE SPOKANE SQUAXIN ISLAND STILLAGUAMISH SUQUAMISH SWINOMISH TULALIP YAKIMA OTHER WASHINGTON INDIAN OTHER AMERICAN INDIAN QUESTION 3. What local race do you consider your child? (Choose one only, please) ASIAN BLACK, NON HISPANIC HISPANIC AMERICAN INDIAN/ALASKAN NATIVE MULTIRACIAL PACIFIC ISLANDER WHITE, NON HISPANIC NOT PROVIDED REQUIRED INFORMATION: If born in a country other than the United States, please answer these questions: How many months have you been in US? How many years? Has your child had any formal education outside the US? Where and how long? Legal Parent/Guardian Signature of Verification: 02/2018

4 EMERGENCY INFORMATION Snohomish School District No. 201, Snohomish, WA F1 Please print student s last name In order to provide immediate and safe care for your child and carry out your wishes in case of injury or illness at school, we require the following information. Please fill out completely. Please Print. Student Name Last First Initial Birth date Grad Year_ Home Address City Zip Home Phone Mailing Address if different from home address: City Zip Lives with: Parents Mother only Mother/Stepfather Guardian Father only Father/Stepmother Other_ Parent/Guardian Name 1. E mail Address Employer Work Phone Cell Phone Bus # Parent/Guardian Name 2. E mail Address Employer Work Phone Cell Phone Primary language spoken at home: English Spanish Other Day Care Provider (if applicable) Please complete the following if student has a non custodial parent who can make emergency decisions for the student and receive copies of records involving this student, including newsletters, grade reports, correspondence, etc. Phone Home Address City Zip Home Phone Parent/Guardian Name 1. E mail Address _ Place of business Work Phone Cell Phone Parent/Guardian Name 2. E mail Address Place of business Work Phone Cell Phone In addition to the parent/guardian, if you cannot be reached, the school may call and release your child to any of the following: Name 1. Relationship Phone Work Phone Cell Phone 2. Relationship Phone Work Phone Cell Phone 3. Relationship Phone Work Phone Cell Phone Please list all children in Snohomish School District this year. (Please list students in this school first.) Last Name First Name School Grade Signature of Parent or Legal Guardian Please check here if any information on this form is new. ***THIS FORM MUST BE RETURNED AT REGISTRATION 1/2017

5 Health History 3431 F3 To be completed by parent/guardian (Last, First): DOB: M F Grade: ID #: Student Name This information is needed to plan an appropriate program for your student and to prepare for an emergency, should one arise. Your building nurse will contact you if there are any additional questions. MEDICAL HISTORY (check all that apply) OR no health concerns at this time (please sign form). Congenital Conditions A_ Please List Hematology (Blood) BB *Hemophilia BC Sickle Cell Anemia BD Other Blood Condition Cardiovascular/Heart Conditions C_ Please List Endocrine, Allergy, Immune System, Metabolic, and Nutritional ED Allergy-Food EE Allergy Insect E- Other Allergy EG *Anaphylactic Condition (Epi-Pen) EJ Cystic Fibrosis EK/L*Diabetes Type 1 *Diabetes Type 2 EN Eating Disorder EU Thyroid Disorder E_ Other Endocrine, Immune, or Metabolic Disorder Gastrointestinal, Dental, and Oral Conditions GA/J/K Celiac Disease Crohn s Irritable Bowel GH/LGastroesophageal Reflux Lactose Intolerance GI Other GMLiver Disease GD Dental Condition GNOral Condition Musculoskeletal and Connective Tissue MC Juvenile Idiopathic Arthritis MD Muscular Dystrophy MFOsgood-Schlatter MH Scoliosis M_ Other Hospital preference Health insurance NO YES Name of Company Dental insurance NO YES Name of Company Nervous System NA Autism Spectrum Disorder ADHD-Inattentive ADHD-Hyperactive/Impulsive NB ADHD-Combined Diagnosed by: NE Cerebral Palsy NF Developmental Delay NH/I/J Migraines Headaches Shunt NL Intellectually Disabled NN Paralysis NP Seizure Disorder NQ Sensory Condition NS Spina Bifida NT Spinal Cord Injury NU Traumatic Brain Injury Behavioral Health Conditions PH Sleep Disorder PI Tourette Syndrome P_ Other Respiratory RA Exercise-Induced Bronchospasm *Inhaler RB/C/DAsthma Mild *Moderate *Severe *Inhaler RE Reactive Airway Disease RF Other Skin and Subcutaneous Tissue SB Contact Dermatitis (Eczema) S_ Other Neoplasms (Cancer/Tumors) T_ Please List Renal and Genitourinary UB/U- Chronic Urinary Tract Infection Urinary Reflux UC Dysmenorrhea (painful periods) U_ Other Eye and Ear YB Hearing Impaired YA/YC Chronic Ear Infections Ear Condition YD Visually Impaired YE Eye Condition Wears Glasses Family doctor Phone of last physical exam of last vision exam Specialist Phone of last exam Dentist Phone of last dental exam Is medication needed at home? NO YES Please List Is medication needed at school? NO YES Please List State law requires written permission from parent and/or a health care provider before any medications, prescription or over-the-counter medication may be taken at school. Forms are available from the school health rooms or school office. * Law requires that life threatening conditions such as anaphylaxis, asthma, or diabetes have a care plan completed prior to the first day of school. Please contact the building nurse as soon as possible to insure the paper work is complete. If parent/guardian or authorized emergency contact cannot be reached at the time of a medical emergency, and if immediate care is urgent in the judgment of school authorities. I authorize and direct the school authorities to send the student to the hospital or doctor most accessible. I understand that I will assume full responsibility for the payment of any services rendered. I understand that the information given above will be shared with appropriate school staff that needs to know in order to provide for the health and safety of my student. I understand that SSD staff may obtain immunization info from Washington State Immunization Information System to update my student s immunization status. If I do NOT want SSD staff to obtain info from Washington State Immunization Information System I will check here. Signature Relationship Phone 1/2018

6 Student Transportation Input Form Will your student ride the school bus during the school year? Yes No Student's name (first and last) Student's ID number (please provide if known) Student address (home address and city) School student will attend during the school year Cathcart Elementary Centennial Middle School Central Primary Center Valley View Middle School Cascade View Elementary Glacier Peak High School Dutch Hill Elementary Snohomish High School Emerson Elementary Aim High School Little Cedars Elementary Machias Elementary Riverview Elementary Seattle Hill Elementary Totem Falls Elementary Grade student will be in during the school year Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade A.M pick-up location Home Student does not plan to ride the bus Other P.M. drop-off location Home Student does not plan to ride the bus Other Will student be making a request for a permanent bus pass at the beginning of the year for alternative pick-up or drop-off location? If so, to where? Parent's name (printed) Parent's signature address Contact phone number The form will need to be completed for every student in your household who will attend a Snohomish School District School in the school year. Please return this completed form to your student s school. Please contact the Transportation Dept. at (360) if you have any questions or concerns.

7 1601 Avenue D, Snohomish, WA Fax School Attendance form School attendance is required by state law. State law requires children from age 8 to 17 to attend school. Children that are 6- or 7-years-old, who are enrolled in school, must also attend school. Youth who are 16 or older may be excused from attending school if they meet certain requirements per state law (RCW 28A ). If your child is going to be absent, please contact the school office. School s duties upon a student s absences: If your child has two unexcused absences in one month, state law (RCW 28A ) requires we schedule a conference with you and your child. In elementary school after five excused absences in any month, or ten or more excused absences in the school year, the school district is required to contact you to schedule a conference. A conference is not required if your child has provided a doctor s note, or pre-arranged the absence in writing, and plans are in place so your child does not fall behind academically. If your child has seven unexcused absences in any month or ten unexcused absences within the school year, we are required to file a petition with the juvenile court, alleging a violation of RCW 28A , the mandatory attendance laws. You and your child may need to appear in juvenile court. By 6th grade, absenteeism is one of three signs that a student may drop out of high school. Absences can be a sign that a student is losing interest in school, struggling with school work, dealing with a bully or facing some other potentially serious difficulty. By 9th grade, regular attendance is a better predictor of high school graduation rates than 8th grade test scores. What you can do: Don t let your child stay home unless they are truly sick, such as fever, vomiting, diarrhea, or a contagious rash. Avoid appointments and travel when school is in session. Keep track of your child s attendance. Missing more than nine days, excused or unexcused, could put your child at risk of falling behind. Set a regular bedtime and morning routine as well as finishing homework and packing backpacks the night before. Have a back-up plan in place with family members, neighbors, or other parents for getting your child to school in case something comes up. If you are struggling to get your child to school for any reason, we are here to support you and work with you towards possible solutions. Please do not hesitate to contact the school office to schedule an appointment to discuss your child s attendance. Did you know? Attending school on-time, all day, every day will give your child the best chance of graduating from high school. Starting in kindergarten, missing on average just two days a month, whether excused or unexcused, makes it more likely that your child will not meet academic standards in math and reading by third grade.

8 I acknowledge that I have read (or I have had someone read this to me) and I understand this document. Student Name: First Middle Last of Birth: Age: Grade: Name of School: Current address: Street City Zip Phone/Contact Number: Do you have other children that attend a school in the Snohomish School District? Name: of Birth: Age: Grade: School: Name: of Birth: Age: Grade: School: Name: of Birth: Age: Grade: School: I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate. Print name of person completing form: Signature: : Relationship to student(s): Parent Guardian Self Other Please read and complete this form and return to your child's school office by the end of September.

9 1601 Avenue D, Snohomish, WA Fax Student Housing questionnaire The answers to the following questions help determine educational services your child(ren) may be eligible to receive through the McKinney-Vento Homeless Assistance Act. Are you doubled up with another family due to a loss of housing or economic hardship? Yes No Are you living in a motel/hotel due to lack of housing? Yes No Are you living in a shelter? Yes No Are you living in a car, park, campsite or location not usually used for sleeping accommodations? Yes No As a student, are you living with someone other than your parent? Yes No If you answered YES to any of the above questions, please complete the remainder of this form and return it to your child s school. If you answered NO to all of the above questions, you may stop here. Student Name: First Middle Last of Birth: Age: Grade: Name of School: Current address: Street City Zip Phone/Contact Number: Do you have other children that attend a school in the Snohomish School District? Name: of Birth: Age: Grade: School: Name: of Birth: Age: Grade: School: Name: of Birth: Age: Grade: School: I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate. Print name of person completing form: Signature: : Relationship to student(s): Parent Guardian Self Other For School Staff Only: If Yes is checked for any question above, please give this form to the School Counselor or Administrator

10 3600F3 Photos/Recordings Opt Out Form There are times during the year when photographs or audio visual recordings of students may be taken for school or district use. When possible, we will alert parents in advance, but this is not always possible. It is important that you know that student family members, community members, and attendees at school events may take and publish photos and other recordings of students without coordinating such with school district personnel, and it is possible that your student could appear in a third party's photos and other recordings. Snohomish School District is not responsible for the use of any of your student s likeness (photo, voice, etc.) that appears in those photos and recordings. You may choose to opt out of allowing your student to appear in photos or other recordings taken by or on behalf of the Snohomish School District by checking and signing below. I do NOT want my student to appear in photos or audio visual recordings taken by or on behalf of the Snohomish School District. (By checking this box your student will NOT appear in ANY photos and recordings taken for yearbook, classroom/school/district presentations, parent club/classroom/school/district newsletters, media, etc.) Please note Opt out restrictions must be renewed at the beginning of each school year. Student Last Name First Name Parent Last Name First Name Parent Signature Contact Phone F o r O f f i c e U s e O n l y 1. Enter opt out date in Skyward student record custom forms/internet opt out. 2. From WS/ST/TB/CF web student/student tabs/custom forms 3. Check photo opt out box and enter date of opt out. 4. Retain this signed form at the school for the duration of school year. 01/2017

11 Parents - Are Your Kids Ready for School? Required Immunizations for School Year Parent/Guardian Instructions: To see which vaccines are required for school, find your child s grade and look only at that row going across to find the vaccines and number of doses required. Hepatitis B DTaP/Tdap (Diphtheria, Tetanus, Pertussis) Vaccine doses required may be fewer than listed Polio Vaccine doses required may be fewer than listed MMR (Measles, Mumps, Rubella) Varicella (Chickenpox) Kindergarten 5 th Grade 3 doses within the correct timeframes 5 doses within the correct timeframes 4 doses within the correct timeframes 2 doses within the correct timeframes 2 doses within the correct timeframes OR Healthcare provider verified child had disease 6 th 12 th Grade 3 doses within the correct timeframes 5 doses DTaP AND 1 dose Tdap, all within the correct timeframes 4 doses within the correct timeframes 2 doses within the correct timeframes 2 doses within the correct timeframes OR Healthcare provider verified child had disease (Exceptions are allowed for certain students) Students must get vaccine doses at correct timeframes to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements. Find information on other recommended vaccines not required for school: If you have a disability and need this document in another format, please call (TDD/TTY call 711). DOH November 2017

12 Certificate of Immunization Status (CIS) For Kindergarten-12 th Grade / Child Care Entry Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System. Child s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex: I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my child s school record. Parent/Guardian Signature Required I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Required for School and Child Care/Preschool Required Only for Child Care/Preschool DTaP / DT (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) MM/DD/YY MM/DD/YY MM/DD/YY Required Vaccines for School or Child Care Entry MM/DD/YY MM/DD/YY MM/DD/YY Documentation of Disease Immunity Healthcare provider use only If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages a verified history of Varicella (Chickenpox). Hib (Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. MMR (Measles, Mumps, Rubella) PCV / PPSV (Pneumococcal) Varicella (Chickenpox) History of disease verified by IIS Recommended Vaccines (Not Required for School or Child Care Entry) Diphtheria Mumps Other: Hepatitis A Polio Hepatitis B Rubella Hib Measles Tetanus Varicella Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV / MPSV (Meningococcal) MenB (Meningococcal) Rotavirus Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name

13 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 immunization information filled in: Ask if your healthcare provider s office enters immunizations 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 immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at If your provider doesn t use the IIS, or call the Department of Health to get a copy of your child s CIS: waiisrecords@doh.wa.gov or To fill out the form by hand: #1 Print your child s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides 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. #3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. #4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS. Reference guide for vaccine abbreviations in alphabetical order Full Vaccine Full Vaccine Abbreviations Abbreviations Name Name DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 DTaP DTP Flu (IIV) HBIG Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Influenza Hepatitis B Immune Globulin Reference guide for vaccine trade names in alphabetical order For updated list, visit Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1) Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix For updated list, visit Full Vaccine Full Vaccine Abbreviations Abbreviations Abbreviations Full Vaccine Name Name Name Meningococcal Conjugate Vaccine Hep B Hepatitis B MenB Meningococcal B Hib HPV (2vHPV / 4vHPV / 9vHPV) IPV Haemophilus influenzae type b Human Papillomavirus Inactivated Poliovirus Vaccine MPSV / MPSV4 DTaP + Hep B + IPV RotaTeq Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib + IPV Trumenba MenB Rotavirus (RV5) Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B MMR MMRV Meningococcal Polysaccharide Vaccine Measles, Mumps, Rubella Measles, Mumps, Rubella with Varicella If you have a disability and need this document in another format, please call (TDD/TTY call 711). DOH December 2016 OPV PCV / PCV7 / PCV13 PPSV / PPV23 Oral Poliovirus Vaccine Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine Rota (RV1 / RV5) Rotavirus Td Tetanus, Diphtheria Tdap VAR / VZV Tetanus, Diphtheria, acellular Pertussis Varicella

14 Certificate of Exemption - Personal/Religious From School, Childcare, and Preschool Immunization Requirements Complete the box for the desired exemption type Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Gender: NOTICE: A parent or guardian may exempt their child from some or all vaccinations listed below by submitting this completed form to the child s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. Exempted children/students may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. The diseases vaccines can protect against still exist, and can spread quickly in school and child care settings. Immunizations are one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death. Personal/Philosophical or Religious Exemption Exemption Type: Personal/Philosophical Religious I am exempting my child from the requirement that my child be vaccinated against the following diseases to attend school or child care: Diphtheria Hepatitis B Hib Measles Mumps Pertussis (whooping cough) Pneumococcal Polio Rubella Tetanus Varicella (chickenpox) Parent/Guardian Declaration One or more of the required vaccines are in conflict with my personal, philosophical or religious beliefs. I have discussed the benefits and risks of immunizations with the health care practitioner below. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature Health Care Practitioner Declaration I have discussed the benefits and risks of immunizations with the parent/legal guardian as a condition for exempting their child. I am a qualified MD, ND, DO, ARNP or PA licensed under Title 18 RCW, and the information provided on this form is complete and correct. Licensed Health Care Practitioner Name (print) MD ND DO ARNP PA Licensed Health Care Practitioner Signature Religious Membership Exemption Complete this section ONLY if you belong to a church or religion that objects to the use of medical treatment. Use the section above if you have a religious objection to vaccinations but the beliefs or teachings of your church or religion allow for your child to be treated by medical professionals such as doctors and nurses. Parent/Guardian Declaration I am the parent or legal guardian of the above named child. I affirm that I am a member of a church or religion whose teaching preclude health care practitioners from providing medical treatment to my child. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature Name of Church or Religion of which you are a member: If you have a disability and need this form in a different format please call (TDD/TTY Call 711) DOH January 2018

15 Certificate of Exemption - Medical From School, Childcare, and Preschool Immunization Requirements Complete the box for the desired exemption type Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Gender: NOTICE: A parent or guardian may exempt their child from some or all vaccinations listed below by submitting this completed form to the child s school and/or child care. A person who has been exempted from a vaccination is considered at risk for the disease or diseases for which the vaccination offers protection. Exempted children/students may be excluded from school or child care settings and activities during an outbreak of the disease that they have not been fully vaccinated against. The diseases that vaccines can protect against still exist, and can spread quickly in school and child care settings. Immunizations are one of the best ways to protect people from getting and spreading diseases that may result in serious illness, disability, or death. Medical Exemption Licensed Health Care Practitioner (MD, ND, DO, ARNP, PA) completes this section. A health care practitioner may grant a medical exemption to a vaccine antigen required by rule of the state board of health only if in his or her medical judgment, the vaccine antigen is not advisable for the child. When it is determined that this particular vaccine antigen is no longer contraindicated, the child will be required to have the vaccine (RCW 28A ). Guidance for medical exemptions for vaccination can be obtained from the contraindications, indications, and precautions described in the vaccine manufacturer s package insert and by the most recent recommendations of the Advisory Committee on Immunization Practices (ACIP) available in the Centers for Disease Control and Prevention publication, Guide to Vaccine Contraindications and Precautions. This guide can be found at the following website: Please indicate which vaccine antigen(s) the medical exemption is referring to: Disease Permanent Temporary Expiration for Temporary Medical Diphtheria Hepatitis B Hib Measles Mumps Pertussis Pneumococcal Polio Rubella Tetanus Varicella I declare that vaccination for the disease/s checked above is not advisable for this child. I have discussed the benefits and risks of immunizations with the parent/legal guardian as a condition for exempting their child. I am a qualified MD, ND, DO, ARNP or PA licensed under Title 18 RCW, and the information provided on this form is complete and correct. Licensed Health Care Practitioner Name (print) MD ND DO ARNP PA Licensed Health Care Practitioner Signature Parent/Guardian Declaration I have discussed the benefits and risks of immunizations with the health care practitioner granting this medical exemption. I have received notice that if an outbreak of vaccine-preventable disease for which my child is exempted occurs, my child may be excluded from the school or child care center for the duration of the outbreak. The information on this form is complete and correct. Parent/Guardian Name (print) Parent/Guardian Signature If you have a disability and need this form in a different format please call (TDD/TTY Call 711) DOH January 2018

16 Office of Superintendent of Public Instruction (OSPI) Home Language Survey English/November 2016 The Home Language Survey is given to all students enrolling in Washington schools. Student Name: Grade: : Parent/Guardian Name Parent/Guardian Signature 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. All parents have the right to information about their child s education in a language they understand. 1. In what language(s) would your family prefer to communicate with the school? 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. 2. What language did your child learn first? 3. What language does your child use the most at home? 4. What is the primary language used in the home, regardless of the language spoken by your child? 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. 6. In what country was your child born? 7. Has your child ever received formal education outside of the United States? (Kindergarten 12 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 12 th grade) Month Day Year This form is not used to identify students immigration status. 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 #2 OR question #3 triggers English language proficiency placement testing. Responses to questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 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.

17 SNOHOMISH SCHOOL DISTRICT NO. 201 Snohomish, Washington CONSENT TO RELEASE EDUCATIONAL RECORDS Student Birth date Last First Middle School For the purpose of gathering data relevant to educational programming, I authorize the release of information regarding the above named student between the Snohomish School District and: Name/Agency Phone Address City/State Zip Name/Agency Phone Address City/State Zip I acknowledge notification of this transfer of records as required by the Family Educational Rights and Privacy Act of 1974 and understand that I have a right to receive a copy at my own expense, if requested, and have an opportunity for a hearing to challenge the content of the records. I understand that the information transferred will be treated in a confidential manner and will not be transmitted to a third party without my consent, except as allowed by WAC Signature Parent, guardian or adult student Address City/State Zip Phone Responding agency please address information regarding this student to: Snohomish School District No. 201 Attention School/Department Phone address Fax Number Address City/State Zip 3600F1 1/2017