Crow Creek Admissions

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Application for Boarding 7th-12th & Day Students Grades K-12th

Dear Parent/Guardian of Student:

The enclosed packet of forms must be complete and returned to the school before your child will be considered officially enrolled at CCTS.

In order to get transportation arranged for your student, please complete all forms and send all documents needed. If you have any questions or concerns regarding the application process, please call our toll free number and our staff will assist you. JJJJJ

The first day of school is Sept. 8, 2015 to be considered for Perfect Attendance, Awards and Academic Honors then you must be present beginning Sept. 8th.

Crow Creek Admissions Packet - Check List

(Be sure you have completed, signed and provided copies of documents as indicated. Check as completed)

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qStudent Enrollment Form-Pages 1 & 2 Fill out and sign

qTranscript/Records Release Form Fill out and Sign (Both Parent/Guardian & Student)

qDay Student Check Out Form (Notarized/Mandatory)

qMedical Power of Attorney Fill out and sign

qLegal Custody Form (Notarized/Mandatory)

qHealth History Fill out include Medicaid #

qMedicaid Card(If on Medicaid) Include a copy with application

qPermission/Participants Consent Forms Fill out and sign ALL sections/pages

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qBIE McKinney-Vento Enrollment Form Fill out and sign

qParent Compact Read carefully and sign with your student

qCampus Parent/Portal Read, complete and sign (student/Parent/Guardian)

qPhoto Release Form Read, Complete and Sign

qFERPA Sign & Date

qTRIO Educational Talent Search Forms Added to Application Packet-fill out and sign

Other documents needed with this completed application:

qTribal Enrollment/Degree of Indian Blood MANDATORY-include a copy with application

qBirth Certificate (copy – not original) MANDATORY-include a copy with application

qSocial Security Card (copy – not original) MANDATORY-include a copy with application

qFree & Reduced Lunch Program Form MANDATORY-include a copy with application

qImmunization Records (copy is OK) MANDATORY-include a copy with application

q2012-13 S.D. Athletic Association Forms Not included-Get these (14 pages) from your local IHS office; parents/guardians are responsible for giving these form to your son/daughter’s doctor, and have their physical exam completed ASAP. These completed forms, requiring a doctor’s signature, should be sent with your application. (The other pages are for your information.)

OMB Control No. 1076-0122

Expires: 08/31/2016

STUDENT ENROLLMENT APPLICATION

FOR STUDENT ENROLLED IN BUREAU-FUNDED SCHOOLS

Name of School:
Type:
Day School ( )
Boarding School ( )
Peripheral Dormitory ( ) / Funding:
Pub. Law 100-297 Grant ( )
Pub. Law 93-638 Contract ( )
BIA Operated ( )
1.  IDENTIFICATION
Name of Student:
(Last) (First) (Middle)
Address: P.O. Box Street:
City: State: Zip Code
Miles from home to school:
Date of Birth: Place of Birth
Month Day Year
Sex: Male ( ) Female ( ) Verified By:
Tribal Affiliation: Degree of Indian:
Enrollment Number: Home Agency:
Dominant Language spoken in the home:
(1) (2)
FAMILY INFORMATION
Father:
Address:
Tribal Affiliation:
Home Agency:
Enrollment Number:
Living ( ) Dead ( )
Occupation (Optional):
Employer:
Telephone Home:
Work:
Emergency:
Other (Specify): / Mother:
Address:
Tribal Affiliation:
Home Agency:
Enrollment Number:
Living ( ) Dead ( )
Occupation (Optional):
Employer:
Telephone Home:
Work:
Emergency:
Other (Specify):

Page 1

OMB Control No. 1076-0122

Expires: 08/31/2016

Legal Guardian:
Address:
Tribal Affiliation:
Home Agency:
Enrollment Number:
Occupation (Optional):
Employer:
/ Other (group home, etc):
Address:
Telephone:
Student Lives With:
Telephone Home:
Work:
Emergency:
Other (specify)
4. CRITERIA FOR BORADING OR OUT OF BOUNDARY ENROLLMENT:
Favorable action is recommended upon this application because this case conforms to the following criteria for boarding school or out of boundary enrollment. If this application is for an off reservation boarding school and for social reasons, a social summary is to accompany this application.
Education Factors
Federal/Public schools near student’s home:
( )Do not offer grade lever
( )Are severely overcrowded
( )Do not offer student’s grade
( )Exceed 11/2 miles walking distance to school or bus route
( )Do not offer special vocational/preparatory training necessary for gainful employment
( )Do not offer adequate provisions to meet academic deficiencies or linguistic/cultural differences
( ) Receiving School offers special academic program needed by student.
Approved: Date:
In Boundary
(Signature & title of approving official)
Off-Reservation Boarding School
(Signature & title of approving official) / Social Factors
In his/her environment, the student:
( )Was rejected or neglected
( )Does not receive adequate parental supervision
( ) Well being was imperiled due to family behavioral problems
( )Has behavioral problems too difficult for solution by family or local resources
( )Has siblings or other close relative enrolled who would be adversely affected by separation
Approved: Date:
Out-of-Boundary
(Signature & title of approving official)

Privacy Act Statement: This information is collected as provided by 5 U.S.C. 552A. The Office of Indian Education Programs is authorized to collect this information I accordance with Public Law 95-561; 98-511: 99-89; ad 100-297. The information will be used to determine the level of funding to be distributed by formula to BIA funded elementary and secondary schools. Weighted student units, the value of basic and specialized instructional and residential programs, are used to calculate the distribution of funds. The information may be disclosed to appropriate Department of the Interior and Congressional Offices for policy and budgetary purposes.

OMB Control No. 1076-0122

Expires: 08/31/2016

2.  FAMILY AND BACKGROUND INFORMATION
Parent’s Name
Father’s
Address: / Enter father’s address if different from student’s
Tribal Affiliation: / Enter father’s Tribe
Home Agency: / Enter Agency where father is enrolled
Census Number: / Enter father’s census number
Living/
Deceased: / Indicate whether father is alive or deceased entering date if deceased.
Occupation
(Optional) / Enter father’s occupation
Employer / Enter the name of father’s employer or where he works
Telephone
Numbers: / Please list father’s home telephone, work number, and emergency number or other numbers where father can be reached in case of an emergency. If other, indicate friend, aunt, uncle, etc.
Mother: / Same instruction as above.
Legal Guardian: / Same instruction as above
3.  SCHOOLS P-REVIOUSLY ATTENDED: List the names, addresses, dates, grades completed and reasons for leaving all the schools the student previously attended.
Please fill out as accurately as possible.
4.  FOR BUREAU USE ONLY: Self-Explanatory

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Crow Creek Tribal Schools/Transcripts/Records Release

High School/Middle School

101 Crow Creek Loop

Stephan, SD 57346

1-800-370-7908 Fax: Registrar 605-852-2573

Middle School: 605-852-2541

High School: 605-852-2401

*Please complete and submit to the last school the student has attended. These records need to be sent to Crow Creek High School immediately.

Student Name: ______

Last First MI

Address:______City:______State:______Zip______

Home Phone:______Cell or emergency #______

I authorize the Principal, Counselor, Registrar and Special Education staff at:

Name of Previous School attended: ______

Address of Previous School:______City:______State:______Zip______

Dates Attended: ______to ______

Month/Year Month/Year

To release the following information: Crow Creek Tribal Schools

·  Transfer Grades, Last Report Card, Transcripts, Attendance

·  Behavior Report-MANDTORY

·  Standard Test Results, English Language Proficiency

·  504 Plan, Talented and Gifted Records

·  Immunizations, Birth Certificate, Degree of Indian Blood-ALL MANDATORY

·  Special Education Records-please include: current or last IEP, Parental Consent, Team Summary, Evaluation Report, Current Psychological Evaluation Report

·  Other if any:______

______

Student Signature Parent/Guardian Signature Date

School Official: ______Date:______

FEDERAL LAW 99-31-*THERE IS NO PARENT SIGNATURE REQUIRED FOR EDUCATION RESOURCES TO BE SENT TO ANOTHER AGENCY.*

Crow Creek Tribal Schools

Day Students Check out Form 2015/2016

(Dorm Students must use the Dorm Check-Out Form when checking out during school)

It is very important the Parent/Legal Guardian have this form complete and notarized for the safety of our students. Students will not be allowed to check out of the dormitory or school unless they are released to a person whose name appears on this permission form. Any other special circumstances will have to be referred to a Principal, Dormitory Supervisor or Superintendent.

______

Student Name Home Reservation

______

Parent/Legal Guardian Phone # you can be reached at immediately

______

PO Box/Address City State Zip

·  I hereby give the following adults permission to check out my son/daughter for week-ends or holidays.

·  I understand that these adults must personally pick up the student and sign him/her out from the school (if during school hours) and from the dormitory.

·  I understand that off reservation students may not check out to Ft. Thompson and surrounding communities for overnight unless with parents or legal guardian.

(Handwriting must correspond to notarized signatures at bottom of the page)

______

______

______

______

I also give the school permission to seek out adequate housing and transportation for my son/daughter during emergencies.

______

Signature of Parent/Legal Guardian Verified by Notary of the Public

______

My Commission Expires on

**Confidential-for School/Dormitory Counselor and Indian Health Service Counselor**

Medical Power of Attorney

For Care of Minor Child

I affirm that I am the parent and/or legal guardian of the minor child named below:

______

Child’s FULL Name Date of Birth

I hereby, give consent to the Crow Creek Tribal School Nursing staff to seek and obtain routine medical and dental care for this child at the Fort Thompson Indian Health Care Center (Dormitory or school staff may take students under special circumstances).

In addition, I hereby give consent for the following adults to seek and obtain routine medical or dental care for this child at Fort Thompson Indian Health Center.

SCHOOL STAFF

88888 School Year 2015 - 2016

SCHOOL NURSE

I understand that I or one of the above persons must accompany the child each time medical or dental care is sought; otherwise care will not be given until I (or the child’s other parent) have been contacted and give consent for care.

I further understand that this consent applies only to routine medical and dental care that I must give additional consent for more complicated or difficult procedures. Written consent is not required for care during a serious emergency.

THIS CONSENT EXPIRES AT THE END OF THE SCHOOL YEAR: MAY 20, 2016

______

Signature Relationship Date

______

Signature Relationship Date

Crow Creek Tribal Schools

High School/Middle School

101 Crow Creek Loop

Stephan, SD 57346

LEGAL CUSTODY FORM

Is child currently under custody of the ICWA (Indian Child Welfare Act) or State or Tribal Social Services, Department of Corrections or Other?

______Yes ______No

If yes, please provide a copy of custody documents. (MUST SHOW LEGAL COURT PAPERS)

I, ______have legal custody of

(Print Parent/Guardian)

______as set forth by:

(Print Student Name)

Birth

Divorce Decree

Tribal Court

Other

Please attach a copy of one of the above named documents and return with application.

Is there a restraining order in place? Yes No

If yes, please give name of person:______

______

Signature of Parent/Legal Guardian Verified by Notary of the Public

______

My Commission Expires on

Crow Creek Tribal Schools

Health History

Student Name______Sex: Male or Female

Social Security Number ______-______-______Age______

Date of Birth______Birth Place______

Allergies______

Is student on any medication? ______Yes ______No

List Medications______

School Last Attended______

Name of Indian Health Service Unit______

Address______City______State______Zip______

Are your students covered by Health Insurance? _____Yes _____No *If yes Insurance#______

Name of Company______Effective Date______Group#______

Name of Insured______

Is the student covered by Medicaid? ______Yes ______No *If yes Medicaid#______

**Please attach copy of Medicaid Card**

-Make sure ALL information is complete-

Nurse_____ Dorm_____

Does your family have a state or tribal social worker? ___Yes ___No

If yes, Name: ______Ph. #:______

Address: ______City:______State:______Zip:______

Does Student have a Primary Care Provider? ___Yes ___No

If yes, Name of Primary Doctor:______

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Accident Prone
Depression
Headaches(frequent)
Hyperactivity
Nervous Behavior
Problems With Eating
Sleeping Problems
Stuttering
Other:

List any comments or concerns that we should be aware of:

______

Please check any concerns which apply:

Family Health History-Please check all that apply:

Alcohol
Birth Defects
Cancer
Dental Problems
Diabetes
Drugs
Ear Infections
Epilepsy
Hearing Problems
Heart Attack
Hepatitis
High Blood Pressure
Impetigo
Pneumonia
Scoliosis
Smoking
Tuberculosis
Urinary/Kidney Problem
Vision Problems

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If your child is taken to the clinic, do you wish to be notified by: _____Phone _____Mail _____E-mail

Please list CORRECT information:______

Does student wear glasses or contact lenses _____Yes _____No *** If your child needs glasses and is eligible to obtain them from your local Indian Health Service Unit or with your private insurance, you are encouraged to make the appointment to get the glasses on your own to avoid a long delay.

Crow Creek Tribal Schools

Ø  Permission Form for Internet Usage in Classroom and Dormitory

Ø  General Consent for Field Trip

Ø  Religion of Choice Consent

Ø  Participation in Talented & Gifted Program in a Previous School

Ø  Internet Usage

Students at CCTS have access to the internet in computer related classes, as well as in the dormitory

ü  There are strict rules for Internet usage by students. As a school system we attempt to block out as many inappropriate sites as possible, but as you may have read or heard, this can be difficult at times.

ü  In order for your child to be allowed any contact on the internet, we need to have your permission. Please understand that due to certain circumstances your student may access an inappropriate site. We will not be held liable for any such occurrences.

ü  If it is proved that a student has misused the internet or e-mail services, their privileges may be revoked for the remainder of the school year.

Please check on of the following:

_____ I Do Not Give Permission for my child to be on the internet.

_____ I Do Give Permission for my child to be on the internet.

I also give permission to use my child’s picture on your website. I understand that staff will monitor student use of the internet and agree not to hold the school liable for any unintentional incident of my child viewing an inappropriate site.

Student:______Parent:______Date______

Signature Signature

******************************************************************************

Ø  General Consent for Field Trip

I, _____Give _____Do No Give, permission for my child to go on off-campus activities and events sponsored by Crow Creek Tribal School (including middle school, high school, dormitories, Counselor and recreation programs.)