* * * T E S T T R A N S A C T I O N * * *
1. Student
Demo Ed Georgetown Elementary
STUDENT REGISTRATION
SCHOOL YEAR 2017-2018
Grade Level: Pre-K3
Application No.: ms_3-3
Family Unit Name: ms_3-3
Student First Name: Middle Name: Last Name: Suffix:River Melody Pond Song
Student Residence Street Address: / Apt #: / City: / State: / Zip Code:
221B Baker St / London / TX / 77777
Student Mailing Street Address: / Apt #: / City: / State: / Zip Code:
221B Baker St / London / TX / 77777
Student Phone: Phone Unlisted? Student Cell #: Student Email Address: Yes No
Student Social Security No.: Date of Birth: Age: Place of Birth City: State: 03/03/2014 3 Waco TX
Gender Ethnicity Race (check all that apply)
Male Hispanic/Latino American Indian or Alaska Native
Female Not Hispanic/Latino Asian
Black/African American Hawaiian/Pacific Islander White
2. Contacts
• Primary Contact
• Student Household Information
• Emergency Contact
• Other Home Residents
List other people living in household that are not listed above:Name Age Grade Level School
3. Academic Background
Special Education/504 / Yes / NoEarly Childhood Program / Yes / No
Bilingual / Yes / No
Speech Therapy / Yes / No
English as a Second Language / Yes / No
Gifted and Talented/AP Honors / Yes / No
4. Person Enrolling Student
Student Last Name: Song
First Name: River
Middle Name: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for student and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights and the Equal Employment Opportunity Commission.
School district parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires schools districts to use observer identification as a last resort of collect the data for federal reporting.
Please answer both parts of the following questions on the student’s ethnicity and race. United States Federal Register (71 FR 44866)
PART 1. ETHNICITY. Is the person Hispanic/Latino? (Choose only one)
Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic/Latino
PART 2. RACE. What is the person’s race? (Choose one or more)
American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Parent/Guardian Signature:
Amy Pond
Date:
03/03/2017
Student Last Name: Song
First Name: River
Middle Name: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
The Texas Education Agency requires all local education agencies to collect specific data for state reporting. Please check the appropriate box in each category.
Military Connectedness
Not a military connected student.
Student is a dependent of a member the Army , Navy, Air Force, Marine Crops, or Coast Guard on Active Duty. Student is a dependent of the Texas National Guard (Army, Air Guard, or State Guard)
Student is a dependent of a member of the reserve force in the United States military (Army, Navy, Air Force, Marine Corps, or Coast Guard)
Pre-Kindergarten student is a dependent of 1) active duty uniformed member of the Army, Navy, Air Force, Marine Corps, or Coast Guard, 2) activated/mobilized uniformed member of the Texas National Guard (Army, Air Guard, or State Guard), or
3) activated/mobilized members of the Reserve components of the Army, Navy, Air Force, Marine Corps, or Coast Guard, who are currently on active duty or who were injured or killed while serving on active duty.
Foster Care
Student is not currently in the conservatorship of the Department of Family and Protective Services. Student is currently in the conservatorship of the Department of Family and Protective Services.
Pre-Kindergarten student was previously in the conservatorship of the Department of Family and Protective Services following an adversary hearing help as provided by Section 262.201, Family Code.
Parent/Guardian Signature:
Amy Pond
Date:
03/03/2017
Student Last Name: Song
First Name: River
Middle: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
The information on this form is required by the McKinney-Vento Act 42 U.S.C which is part of the No Child Left Behind Act. The answers you provide will help the school determine the services the student may be eligible to receive.
Presenting a false record of falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs. (TEC Sec. 25.022(3)(d))
1. Is the student’s current address a temporary living arrangement? Yes No
Is this temporary living arrangement due to loss of housing or economic hardship? Yes No
2. Is the student currently in the conservatorship of the Department of Family and Protective Services (DFPS)? Yes No If yes, please provide a copy of the DFPS Form 2085, DFPS Form E-2085, or the court order.
3. If you answered 'Yes' to either 1 or 2 above, please answer the following two questions.
Where is the student presently living?
In the home of a friend/relative due to loss of housing (loss of housing, economic hardship)
Shelter (family shelter, domestic violence shelter, children/youth shelter)
Motel (loss of housing, do not have ‘fixed’ nighttime residence)
Unsheltered (car, tent, van, abandoned building, on the street, campground, in the park)
Other - Please describe: home is mobile
The student lives with:
Parent Legal Guardian
Adult/relative who is not a legal guardian Alone with no adult(s)
4. I am:
The parent/legal guardian of this student. The student (Unaccompanied Youth) A qualified adult/relative of this student
Parent/Guardian Signature:
Amy Pond
Date:
03/03/2017
For Office Use Only
Campus Homeless Liaison Signature
Date
I certify that above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act. District Food and Nutrition Coordinator Signature Date
Student Last Name: Song
First Name: River
Middle Name: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
Schools are required by Texas law to determine the following for all students. Please help us meet this requirement by answering every question. A parent, guardian or student may sign when the student in in the ninth grade or higher; otherwise a parent or guardian must sign.
1. In what month and year did the student first enroll in a school in the United States? 08/2017
2. In what city, state, and country was the student born? City: Waco State: TX Country: USA
3. What language is spoken in your home most of the time? English
4. What language does the student speak most of the time? English
5. Does the parent or guardian need to communicate with the school in a language other than English? Yes No If yes, what language would need to be spoken to communicate with the parent or guardian? English
6. Has your child ever participated in an ESL (English as a Second Language) or Bilingual Education Program? Yes No If yes, please provide the schools that provided service?
Parent/Guardian Signature:
Amy Pond
Date:
03/03/2017
Student Last Name: Song
First Name: River
Middle Name: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
Immigrant Status
Student born outside of the U.S., schooled outside of the U.S. or who have lived outside of the U.S. may be identified as immigrants. Immigrant students may be eligible to receive extra academic support in reading and writing English through English language learning services, extra classroom help, before or after school tutoring, summer school, and/or receive special consideration toward exemption from state exams for up to 3 years.
1. Where was your child born? City: Waco State: TX Country: USA
2. Has your child attended school outside of the United States for at least 2 consecutive years? Yes No
Migrant Status
Migrant students have moved independently or with their families in search of work in agriculture or fishing and may be eligible to receive extra academic support in reading and writing English through English language learning services, extra classroom help, before or after school tutoring and summer school.
1. Have you or your family moved from one school district to another in the last three years in search of agricultural/fishing work? Yes No
If Yes, please mark the type of employment and NGS Number:
a. Farming / f. Picking fruit or vegetables / l. Plant nurseryb. Ranching / g. Cotton farming/ginning / m. Poultry production
c. Fencing / h. Combining/harvesting grain / n. Clearing land
d. Dairying / i. Driving tractors, machinery / o. Picking pecans, etc
e. Fishing / j. Tree growing or harvesting / p. Bailing hay
k. Food porcessing in plants / q. Other similar work
Parent/Guardian Signature:
Amy Pond
Date:
03/03/2017
Student Last Name: Song
First Name: River
Middle Name: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
All students are at risk of dropping out school and identifying students that are at a higher risk of dropping out of school will allow schools to work and encourage at-risk students to remain in school and graduate. Please answers the following questions either Yes or No as to how it applies to your student.
Was or is your student:
Yes / No / 1. not advanced from one grade level to the next for one or more school years; (excludes pre-kindergarten or kindergarten students who were not advanced because of a documented request by the student’s parent underTEC 29.081 (D-10)?
Yes / No / 2. in grades 7, 8, 9, 10, 11, or 12 and did not maintain an average equal to 70 on a scale of 100 in two or more subjects in the foundation curriculum during a semester in the previous or current school year or is not maintaining such an average in two or more subjects in the foundation curriculum in the current semester?
Yes / No / 3. not performing satisfactorily on an assessment administered to the student under TEC Subchapter B, Chapter 39, and who has not in the previous or current school year scored equal to 110 percent of the level of satisfactory performance on that assessment or another appropriate assessment?
Yes / No / 4. in pre-kindergarten, kindergarten or grade 1, 2, or 3 and did not perform satisfactorily on a readiness test or assessment instrument administered during the current school year?
Yes / No / 5. pregnant or is a parent?
Yes / No / 6. been placed in an alternative education program in accordance with TEC 37.006 during the previous or current school year?
Yes / No / 7. been expelled in accordance with TEC 37.007 during the previous or current school year?
Yes / No / 8. currently on parole, probation, deferred prosecution or other conditional release?
Yes / No / 9. previously reported through the Public Education Information Management System (PEIMS) to have dropped out of school?
Yes / No / 10. a student of limited English proficiency, as defined by TEC 29.052?
Yes / No / 11. in the custody or care of the Department of Protective and Regulatory Services or has, during the current school year, been referred to the department by a school official, officer of the juvenile court, or law enforcement official?
Yes / No / 12. homeless, as defined by 42 U.S.C. Section 11302, and its subsequent amendments?
Yes / No / 13. resided in the previous school year or resides in the current school year in a residential placement facility, emergency shelter, or psychiatric facility?
Parent/Guardian Signature:
Amy Pond
Date:
03/03/2017
Student Last Name: Song
First Name: River
Middle Name: Melody Pond
Date of Birth: 03/03/2014
Grade Entering: Pre-K3
Demo Ed shall maintain a record of parents and other authorized persons to whom the child may be released. Each parent shall provide Demo Ed with the final four digits of their social security number, for purposes of security in emergency conditions.
NORMAL RELEASE PROCEDURES:
Children will be released only to the authorized persons you list on this form. Please inform the school office in writing promptly of any changes.
EMERGENCY PICK-UP PROCEDURE:
When emergency conditions require that a child be released to a person not identified in the release authorization records, the School shall require the parent’s prior approval, which may be submitted by telephone. The parent, identified for security purposes by the last four digits of their social security number, shall designate the person to whom the child may be released. The person to whom the child is to be released must in turn provide the parent’s four digit number as identification, present their driver’s license for the number to be recorded, and sign the “Child Pick-Up Authorization” form which shall be retained by Demo Ed.