North Bend School District #13

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North Bend School District #13

Student Registration/Enrollment Form

For Office Use Only
Student ID # / Grade/Grad Year
/ School Name and Building #
/ SSID #
ENR: / Date of ENR: M /D / Y / RES: Yes No / IDT: Yes No / FTE: 1.0 .50

Please Print/Type

Enrollment Status
Has this Student Previously Attended North Bend Public Schools?Yes No
Student Information
Legal Last Name:
/ Legal First Name:
/ Legal Middle Name:
Preferred Name:
/ Teacher/Advisor:
Gender: M F / Date of Birth: M /D /Y / Birth Place: City , State
Ethnicity (optional): Hispanic Asian/Pacific Islander White American Indian, Alaskan Native Black Multi-Racial
Social Security Number: (see page 2) *000-00-0000 / Main Language Spoken at Home:
* Providing your child’s social security number (SSN) is voluntary. If you provide it, the school district will use the SSN for record keeping, research, and reporting purposes only. The school district will not use the SSN to make any decision directly affecting you or any other persons. The SSN will not be given to the general public. If you choose not to provide the SSN, your child will not be denied any rights as a student.
Address Information
Physical Address:
City:North Bend / State:OR / Zip:97459
Mailing: (if different) / City:North Bend / State: OR / Zip:97459
Family/Guardian Information
Student Lives With: Parents Mother Father Guardian Other (explain):
Father’s Full Name:
/ Mother’s Full Name:
Relationship:  Father Stepfather Guardian Other / Relationship:  Mother Stepmother Guardian Other
Mailing Address: (if different than above) / Mailing Address: (if different than above)
City:North Bend / State:OR / Zip:97459 / City:North Bend / State:OR / Zip:97459
Home Phone:541-000-0000 / Cell Phone:541-000-0000 / Home Phone:541-000-0000 / Cell Phone:541-000-0000
Father’s Place of Employment: / Mother’s Place of Employment:
Work Phone / Extension:541-000-0000 x000 / Work Phone / Extension:541-000-0000 x000
Responsible Party/Main Contact Person:
Additional Guardian Information
Guardian Name: / Relationship:
Mailing Address: / City:North Bend / State:OR / Zip:97459
Home Phone:
541-000-0000 / Cell Phone:
541-000-0000
Guardian’s Place of Employment:
/ Work Phone / Extension:
541-000-0000 x000
Guardian Name:
/ Relationship:
Mailing Address:
/ City:
North Bend / State:OR / Zip:97459
Home Phone:
541-000-0000 / Cell Phone:
541-000-0000
Guardian’s Place of Employment:
/ Work Phone / Extension:
541-000-0000 x000
Emergency Information
(person to be contacted when parents cannot be reached)
Name of Physician:
/ Clinic Name:
/ Phone/Extension:541-000-0000 x000
Emergency Contact Name:
/ Relationship: / Phone/Extension:
541-000-0000 x000 / Cell Phone:
541-000-0000
Emergency Contact Name:
/ Relationship: / Phone/Extension:
541-000-0000 x000 / Cell Phone:
541-000-0000
Emergency Contact Name:
/ Relationship: / Phone/Extension:
541-000-0000 x000 / Cell Phone:
541-000-0000
Name(s) and Date(s) of Birth Brother(s) and Sister(s)
Name:
/ Date of Birth:
M /D / Y / Name: / Date of Birth:
M /D / Y
Name: / Date of Birth:
M /D / Y / Name: / Date of Birth:
M /D / Y
Name: / Date of Birth:
M /D / Y / Name: / Date of Birth:
M /D / Y
Name: / Date of Birth:
M /D / Y / Name: / Date of Birth:
M /D / Y
Miscellaneous information
Last School Attended:
Address: / City: / State: / Zip:
Retained ? Yes No / Grade Retained:
Prior Special Program Participation
To provide continuity in your child’s educational program, it is important that we be made aware of any special help he/she may have received at previous schools. Please check any of the following that pertain to your child:
Student has an IEP
Student has been identified as TAG
Student is currently participating in a Title I program
* Social Security Information
OAR 581-21-225 authorizes school districts to ask for parents/guardians to provide their child's social security number (SSN). The SSN will be used by the district for reporting, research, and record keeping. It will also be given to the Oregon Department of Education. The Oregon Department of Education gathers information about students and programs to meet state and federal statistical reporting requirements. It also helps school districts and the state research, plan, and develop educational programs. This information supports the evaluation of educational programs and student success in the workplace.
The school district and Oregon Department of Education may also match the SSN with records from other agencies as follows:
The Oregon Department of Education uses information gathered from the Oregon Employment Division to learn about
education, training, and job market trends. The information is also used for planning, research, and program improvement.
State and private universities, colleges, community colleges, and vocational schools use the information to find out how many students go on with their education and their level of success.
Other state agencies use the information to help state and local agencies plan education training services to help Oregon
citizens get the best jobs available.
The SSN will be used only for statistical purposes as listed above. State and federal law protects the privacy of student records.
Field Trip Permission
As a student in the North Bend School District, your son/daughter may go on a limited number of educational field trips as part of North Bend School’s curriculum. The time, date, and purpose of the field trip will be sent to you in writing from your child's teacher prior to the field trip.
I give permission for my child to attend the educational field trips, unless I specifically request in writing that he/she be excused.
Parent/Guardian Signature:______Date: ______
Personally Identifiable Information
The 1995 Oregon Legislature directed the Oregon Department of Education to develop new guidelines for school records. These regulations have been made to ensure the confidentiality of school records and protect the student’s privacy.
The North Bend School District may use your child’s name and photograph, address or telephone number in the following school activities while he/she is in our district: annual; school newsletter; district publications, school displays; bulletin boards; class video projects; school programs and activities (music, athletics, plays); and PTA/PTO functions (chili feed, carnival, etc.).
I DO NOT Give Permission for my child’s name and photograph to be used in the activities listed above.
Parent/Guardian Signature:______Date: ______
Internet Publishing Guidelines
The North Bend School District (NBSD) maintains web sites for all schools. North Bend School District Web Publishing Guidelines state that parent permission is required to place a student’s picture, artwork, or writing on District web sites. Basically, the guidelines state:
Any student work published on the Internet by NBSD Net will be identified by the student's first name only.
Student artwork and writing will be published with parent permission.
NBSD will not give any other entity permission to publish student work without a separate parent permission.
Publishing of Student Photos:
Photos of school activities and projects may be included within a web document. Care will be given to avoid publishing personal information about subjects in photos.
Pictures will illustrate the activity and not be individual student portraits. Individual staff portraits can be published with the employees’ permission.
Picture captions will identify the activity or class but not identify students by name.
Pictures may only be published with written and dated permission of students' parents.
Accompanying web page text will not include the students' full name, address, phone number, or any other identifying personal information.
No posed class photographs will be published.
Please mark your preference for your child in regards to the web publishing policies of NBSD.
If you have any questions call Suzy Callery at 751-0857.
Please check one.
I agree to let the North Bend School District publish my
child’s photo online according to the above guidelines. Yes No
I agree to let the North Bend School District publish my
child’s artwork online according to the above guidelines. Yes No
I agreeto let the North Bend School District publish my
child’s writing online according to the above guidelines. Yes No
Parent/Guardian Signature: ______Date: ______

Home Language Survey

Student Name Grade
Please complete this survey. It is a legal requirement for schools to determine the language(s) spoken at home.
This information is necessary in order for schools to provide meaningful instruction to all students.
Thank you for your cooperation.
English is the only language spoken in the home.
If so, no further information is necessary. Please sign and date at the bottom of the survey.
English is not the only language spoken in the home.
If so please complete the following questions below:
Which language did your son or daughter learn when he or she first began to speak?
What language does your son or daughter most frequently use at home?
What language do you most frequently use to speak to your son or daughter?
Name the language most often spoken by the adults at home.
Was your child ever in an English as a Second Language program? Yes No
Parent/Guardian Signature: ______Date: ______
Registration Form CA/bw 10/9/03 Title VI Civil Rights Act
Equal Educational Opportunities Act 1974
Oregon Statutory Requirements

Registration Form 4-28-05 JM.bw