Granite Falls School District New Student Registration Checklist

Granite Falls School District
New Student Registration Checklist
 District Strategic Plan
 New Student Registration Form
 FERPA
 BECCA/Truancy Intervention Agreement
 Health Registration Form
 Immunization Form
 Ethnicity and Race Data Form
 Student Housing Questionnaire
 Home Language Survey
 Request for Records
 Field Trip/Medical Treatment Form
 Get to Know My Child Form
 Special Programs Registration
 Free/Reduced Lunch Form
 Birth Certificate/Verification of Birth (hospital copy, mid-wife)
Granite Falls School District does not discriminate in any programs or activities on the basis of sex, race, creed, religion, color, national origin,
age, veteran or military status, sexual orientation, gender expression or identity, disability, or the use of a trained dog guide or service animal
and provides equal access to the Boy Scouts and other designated youth groups. The following employee(s) has been designated to handle
questions and complaints of alleged discrimination:
CAROL PANAGOS, GRANITE FALLS SCHOOL DISTRICT, 205 NORTH ALDER AVE., GRANITE FALLS, WA 98252, (360) 691-7717,
[email protected]
GRANITE FALLS SCHOOL DISTRICT NO. 332
2014-2019 STRATEGIC PLAN
Adopted by the Granite Falls School District Board of Directors on December 4, 2013
Tag Line: “Every Student, Every Day, Every Classroom”
Mission Statement:
To inspire and facilitate a passion for life-long learning and the pursuit of excellence in every
student, every day.
Vision Statement:
Our students are passionate in pursuit of their goals and aspirations. To that end, they are
critical and inspired thinkers, adaptable, collaborative and committed to making a difference
in their communities and to the betterment of society.
Foundation of our District Beliefs:
1. Powerful teaching and learning.
2. District and Board communication with community and staff that is informing, encouraging,
intentional and collaborative.
3. Financial stewardship, assuring optimal use of district resources.
4. A district climate that emphasizes a positive school culture, focused on student safety, a
healthy lifestyle, and respect for other students and faculty.
District Goals:
1. Quality Learning. Engage and inspire every student through powerful and innovative
instruction, fostering development of critical-thinking skills and motivating academic
achievement through high expectations.
2. Positive Image. Strengthen our district by countering unfounded perceptions and
stereotypes of Granite Falls. Celebrate student successes and civic progress, working
collaboratively with district partners—including local government, the chamber of
commerce, and service organizations.
3. College- and Career-Ready. Ensure that every student transitions successfully between
grades and schools and graduates with the knowledge, skills and attitude to excel in diverse
post-secondary opportunities. Foster student achievement through active partnerships with
parents, families and our community.
DATE
GRANITE FALLS SCHOOL DISTRICT
NEW STUDENT REGISTRATION & STUDENT UPDATE FORM
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
 Yes  No
Has any member of your family ever been enrolled in the Granite Falls School District?
 Yes  No
Was this student ever enrolled an early learning program i.e. Preschool, ECEAP, etc?
STUDENT
NAME:
Legal Last Name
Legal First Name
Legal Last Name
BIRTHDATE (Month/Day/Year)
PRIMARY HOUSEHOLD
Last Name
GENDER (M/F)
City
(parent/guardian where student resides)
First Name
(parent/guardian where student resides)
First Name
Last Name
EMAIL ADDRESS
RESIDENT
ADDRESS
Street

MAILING
ADDRESS
(If different
from above)
Country
GRADE LEVEL
PHONE #1 (include area code)
 Home  Work  Cell
PHONE #2 (include area code)
 Home  Work  Cell
 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
STUDENT LIVES WITH
 Both parents
 Father only
 Father/Stepmother
 Mother/Stepfather
 Guardian
 Agency
Apt #
City
 Please check if unlisted
 Mother only
 Grandparents
 Self
State
 Stepfather/Stepmother
 Other
ZIP
Do not distribute
Street
Apt #
SECOND HOUSEHOLD (non-custodial parent/guardian not residing with student)
Last Name
First Name
Last Name
State
PRIMARY LANGUAGE
SPOKEN AT HOME:
 English
 Spanish
 Ukrainian
 Other _______
Prefers to be called:
Legal Middle Name
BIRTHPLACE:
PM
(non-custodial parent/guardian not residing with student)
First Name
P O Box
City
State
PHONE #1 (include area code)
 Home  Work  Cell
PHONE #2 (include area code)
 Home  Work  Cell
 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
 Both parents
 Father only
 Mother only
 Father/Stepmother
 Mother/Stepfather
 Grandparents  Stepfather/Stepmother
 Guardian
 Agency
 Self
 Other
(Street/PO Box, City, State, ZIP)
ADDITIONAL MAILINGS REQUESTED
EMAIL ADDRESS
SECOND HOUSEHOLD MAILING ADDRESS
 Yes
SCHOOL PREVIOUSLY ATTENDED
SCHOOL DISTRICT PREVIOUSLY ATTENDED
HAS STUDENT EVER ATTENDED GRANITE FALLS SCHOOLS?  Yes
IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT?
IS THERE A RESTRAINING ORDER IN EFFECT?
Restraining order is against:
 Mother
 Father
ZIP
 Yes
 No
 No
 Yes
PREVIOUS SCHOOL LOCATION (City and State)
IF YES, NAME OF SCHOOL ATTENDED
 No
(If yes, plan must be on file with the school)
(If yes, legal papers must be on file with the school)
 No
DATE ATTENDED (Month/Year)
 Copy Attached
 Copy Attached
 Other
 Please complete additional registration information on back…
HAS THE STUDENT HAD A BECCA/ATTENDANCE PETITION?
 Yes
 No
Date: ___________________________________
HAS THE STUDENT EVER BEEN SUSPENDED FOR A WEAPONS VIOLATION?
 Yes
 No
Date: ___________________________________
HAS THE STUDENT EVER BEEN LONG TERM SUSPENDED/EXPELLED?
 Yes
 No
Date: ___________________________________
HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL ED PROGRAM?
 Yes
 No
HAS YOUR CHILD EVER BEEN RETAINED?
HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN?
 Yes
 No
 Yes
HAS YOUR CHILD EVER PARTICPATED IN:  Title
 LAP
DOES STUDENT ATTEND CHILD CARE?
 Before school  After school
 Gifted
 ELL
 Other ______________________
CHILD CARE PROVIDER
Name
 No
If yes, at what grade level(s)____________________
Address
Phone Number
 Before and after school
ADDITIONAL CHILD CARE ARRANGEMENTS (Please provide information to school in writing)
PLEASE LIST OTHER SIBLINGS ATTENDING GRANITE FALLS 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 CONTACT (other than parent/guardian)
Last Name
First Name
PRIMARY CONTACT ADDRESS
Street
SECONDARY CONTACT (other than parent/guardian)
Last Name
First Name
SECONDARY CONTACT ADDRESS
Street
RELATIONSHIP TO CHILD
City
RELATIONSHIP TO CHILD
City
PHONE #1 (include area code)
 Home  Work  Cell
State
PHONE #1 (include area code)
 Home  Work  Cell
State
PHONE #2 (include area code)
 Home  Work  Cell
ZIP
PHONE #2 (include area code)
 Home  Work  Cell
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 ___________________________________________________ Date _____________________
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 ___________________________________________________ Date _____________________
VERIFICATION OF INFORMATION: The information on this form is true and accurate as of this date. I understand that
falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to
a school in the Granite Falls School District.
Legal Parent/Guardian Signature __________________________________________________ Date _____________________
revised 7/2014
ANNUAL AGREEMENT WITH GRANITE FALLS SCHOOL DISTRICT;
Notification of Rights under the Family Educational
Rights and Privacy Act (FERPA) & Protection of Pupil Rights Amendment (PPRA)
The Family Educational Rights and Privacy Act (FERPA) affords parents and students over 18 years of age (“eligible students”) certain
rights with respect to the student’s education records. They are:
1. The right to inspect and review the student’s education records within 45 days of the day the district receives a request for access.
2. The right to request the amendment of the student’s education records that the parent or eligible student believes is inaccurate or
misleading.
3. The right to consent to disclosure of personally identifiable information contained in the student’s education records, except to the
extent that FERPA authorizes disclosure without consent. (Upon request, the District discloses education records without the
consent to officials of another school district in which a student seeks or intends to enroll.)
4. The right to file a complaint with the US Department of Education concerning alleged failures by the District to comply with the
requirements of FERPA. The name and address of the Office that administers FERPA is:
Family Policy Compliance Office
US Department of Education
400 Maryland Ave, SW
Washington DC 20202-5901
FERPA also permits a school district to identify certain information that may be publicly released with permission of the parent or
eligible student. Directory Information is defined as the student’s name, photograph, dates of attendance, diplomas and awards received,
participation in officially recognized activities and sports, weight and height of members of athletic teams, and the most recent previous
school attended. Directory information is NOT released for commercial or other purposes not related to school business. If a
parent/guardian or eligible student chooses NOT to have directory information publicly released, written notification MUST be
presented to the District.
PLEASE READ THE BELOW TEXT THOROUGHLY, INDICATE YOUR PREFERENCE, SIGN, & RETURN TO SCHOOL.
I understand that once my student’s photograph, together with identifying information, is placed on the Internet, it can
be viewed by anyone who has access to the Internet. It is being requested of me to provide consent in order for my child
to receive recognition by the school in local media, yearbook, district website/Facebook page, etc.
_____________________________________________________________________________________________________
Child’s Name (please print)
Grade
PLEASE CHECK ALL THAT APPLY:
 I give permission for my child’s name and photograph to be printed on the Internet or in hard publication for schoolrelated achievements, accolades, yearbook, announcements, etc.
 I do NOT give permission for my child’s name and photograph to be used on the Internet or in any hard school
publication. This means your child’s name/picture will NOT be released for anything – i.e., for winning an educational award;
appearing on the honor roll; sports recognition or achievement; or any online forum such as the District website, or “School News”
emails. (We never release information for commercial purposes unless the company works in conjunction with the District, such
as the school picture company.)
 I do NOT give permission for my child’s name and photograph to be used or appear in the school YEARBOOK.
 Do not release any directory information about my student to the military/armed forces.
*** If you have any special or specific instructions/limitations, please contact the school directly. ***
________________________________________________
Parent/Guardian Name (please print)
(_________)______________________________________________________
Phone
X____________________________________________________________________________________________________________________________
Parent Signature
Date
If you have any questions or concerns regarding this agreement, please contact your child’s school directly.
Model Notification of Rights Under the Protection of Pupil Rights Amendment (PPRA)
PPRA affords parents certain rights regarding our conduct of surveys, collection and use of information for marketing purposes, and
certain physical exams. These include the right to:
 Consent before students are required to submit to a survey that concerns one or more of the following protected areas (“protected
information survey”) if the survey is funded in whole or in part by a program of the U.S. Department of Education (ED)–
1. Political affiliations or beliefs of the student or student’s parent;
2. Mental or psychological problems of the student or student’s family;
3. Sex behavior or attitudes;
4. Illegal, anti-social, self-incriminating, or demeaning behavior;
5. Critical appraisals of others with whom respondents have close family relationships;
6. Legally recognized privileged relationships, such as with lawyers, doctors, or ministers;
7. Religious practices, affiliations, or beliefs of the student or parents; or
8. Income, other than as required by law to determine program eligibility.
Receive notice and an opportunity to opt a student out of –
1. Any other protected information survey, regardless of funding;
2. Any non-emergency, invasive physical exam or screening required as a condition of attendance, administered by the school or
its agent, and not necessary to protect the immediate health and safety of a student, except for hearing, vision, or scoliosis
screenings, or any physical exam or screening permitted or required under State law; and
3. Activities involving collection, disclosure, or use of personal information obtained from students for marketing or to sell or
otherwise distribute the information to others.
Inspect, upon request and before administration or use –
1. Protected information surveys of students;
2. Instruments used to collect personal information from students for any of the above marketing, sales, or other distribution
purposes; and
3. Instructional material used as part of the educational curriculum.
These rights transfer to from the parents to a student who is 18 years old or an emancipated minor under State law.
The Granite Falls School District has adopted policy regarding these rights, as well as arrangements to protect student privacy in the
administration of protected information surveys and the collection, disclosure, or use of personal information for marketing, sales, or other
distribution purposes. The District will directly notify parents of this policy at least annually at the start of each school year and after any
substantive changes. The District will also directly notify, such as through U.S. Mail or email, parents of students who are scheduled to
participate in the specific activities or surveys noted below and will provide an opportunity for the parent to opt his or her child out of
participation of the specific activity or survey. The District will make this notification to parents at the beginning of the school year if the
District has identified the specific or approximate dates of the activities or surveys at that time. For surveys and activities scheduled after
the school year starts, parents will be provided reasonable notification of the planned activities and surveys listed below and be provided
an opportunity to opt their child out of such activities and surveys. Parents will also be provided an opportunity to review any pertinent
surveys. Following is a list of the specific activities and surveys covered under this requirement:
Collection, disclosure, or use of personal information for marketing, sales or other distribution.
Administration of any protected information survey not funded in whole or in part by ED.
Any non-emergency, invasive physical examination or screening as described above.
Parents who believe their rights have been violated may file a complaint with:
Family Policy Compliance Office
U.S. Department of Education
400 Maryland Avenue, SW
Washington, D.C. 20202-5901
Updated 8/14
Mountain Way Elementary
702 North Granite Ave * GraniteFalls * WA * 98252 * (360) 691- 7719 * Fax (360) 283 - 4416
Cheryl Larsen, Principal
BECCA Notification and Attendance Expectations
Under state law, students are required to attend school full-time until they reach the age of 18 (RCW 28A.225).
The BECCA Law requires schools to notify the juvenile court when students are in violation of this statute. As
a Granite Falls School District student I am aware of the following attendance expectations:
•
I will attend school every day and arrive on time.
•
If I am absent due to illness or other valid absence reasons, I understand parents must contact the school
either in writing or by phone in order for the absence to be excused.
•
I also understand that if I accumulate excessive absences, even if they are excused, a doctor’s note will
be required to excuse future absences. Without a doctor’s note, these absences will be considered
unexcused.
•
I understand that when I accumulate seven (7) days of unexcused absences in any month, or ten (10)
unexcused absences in a year, a BECCA Petition will be filed with juvenile court.
•
I understand that if I miss twenty (20) consecutive unexcused days of school, I will be withdrawn from
my school of attendance.
•
I understand that if I move, the Attendance Secretary or Registrar must receive a request for records
from my new school within ten (10) days or a BECCA petition will be filed with juvenile court.
•
Finally, I understand that in addition to the State Law requiring school attendance, Granite Falls School
District has its own attendance policy.
Return Signed Form Back to your Child’s School.
Print Student Name:_________________________________
Student Signature:___________________________
Parent Signature: __________________________________
Date: ____________________________________
Updated 5/14
About the Becca Bill
Becca’s Story
In 1993, a 13-year-old runaway named Rebecca Hedman was murdered in Spokane, Washington, far from her
home in Tacoma. A group of parents and Legislators came together and successfully pushed for legislation that
was passed in 1995, known as the “Becca” Bill. These laws were designed to prevent situations like Becca’s,
from happening again by confronting poor attendance, truancy, and the needs of at-risk youth.
What can parents/guardians do?
If you are concerned about your child’s attitude towards school and about his/her attendance record, contact
your child’s teacher, counselor and/or school principal. With the combined insights into your child’s needs
and interests, we can work together to design an individualized plan to help your child stay in school. If your
child is missing school due to a chronic health condition, we can arrange for you to meet with our district Nurse
to develop a plan to maximize school attendance.
Basic Guidelines for Mountain Way Elementary
Parent Contact: After one unexcused absence, the parent or guardian must be notified. An unexcused
absence means that the student has failed to attend the majority of the classes in an average school day and that
the parent has not excused the absence by providing a note or informing the school by phone within 48 hours.
Parent Contact: After two unexcused absences, the school must make contact with the parent or guardian
which is usually by letter. A parent conference will be done either by phone or in person to implement an
“Improvement Plan”.
File a Petition: According to district standard, filing a petition with the Juvenile Court alleging a violation is
done at the seventh unexcused absence in a month or the tenth unexcused absence in a school year.
Contempt: If a student has additional unexcused absences following a court order, they may be required to
appear and be found in contempt of court and may be sentenced to community service, juvenile detention or a
detention alternative. Parents who fail to get their children to school may be ordered to perform community
service or pay a fine of $25.00 a day for each unexcused absence.
Documentation: If a court assumes jurisdiction the school district shall regularly report to the court any
additional unexcused absences by the child.
Updated 5/14
Granite Falls School District
Student Health Registration Form
This questionnaire is designed to aid school staff in anticipating any health concerns that might affect your child’s safety or learning.
Student Name ______________________________________________Grade ____________Sex ______ Date of Birth ________________
MEDICAL
Does your child have a doctor or nurse practitioner? Yes ___ No ___
Name of child’s doctor or nurse practitioner _____________________________________________ phone number ____________________
In the past 12 months, did you have problems obtaining medical care for your child? Yes ___ No ___
DENTAL
Does your child have a dentist? Yes ___ No ___
Name of child’s dentist ______________________________________________________________ phone number ___________________
Did your child receive a dental exam in the last 12 months? Yes ___ No ___ Don’t know ___
Describe the condition of your child’s teeth? Good ___ Fair ___ Poor ___ Don’t know ____
In the past 12 months, did you have problems obtaining dental care for your child? Yes ___ No ___
INSURANCE
Does your child have medical insurance coverage? Yes ___ No ___ Don’t know ___ Name of provider ______________________________
Does your child have dental insurance coverage? Yes ___ No ___ Don’t know ___ Name of provider ________________________________
Does Medicaid insure him/her? (Apple Health for kids) Yes ___ No ___ Don’t know ___
MEDICAL HISTORY
Have you ever been told by a physician or health care professional that your child has:
___ Asthma
___ Seizure disorder
___ Bleeding disorder
___ Diabetes
___ Bone/muscle disease
___ Skin condition
___ Heart condition
___ Mental health condition (i.e., depression, anxiety, eating disorder)
_______________________
___ ADD/ADHD
___ Learning disability
___Other
Does your child experience any of the following?
___ Nose bleeds
___ Frequent ear aches
___ Overweight for age
___ Physical disability
___ Poor appetite
___ Frequent stomachaches
___ Frequent headaches
___ Fainting spells
___ Tires easily
___ Emotional concerns
___ Underweight for age
___ Other
_______________________
Do any of the above condition(s) limit/effect your child at school? _____________________________________
LIFE-THREATENING CONDITIONS
Does your child have a life-threatening health condition? Yes* ____ No ____ Describe: __________________________________________
*If yes, a meeting with the school nurse is required. Washington State Law requires medication or
treatment orders and a health care plan be in place prior to starting school.
ALLERGIES
Plants ________ Animals ________ Food ________ Molds ________ Drugs _________ Bees ________ Other _______________________
Please describe the allergic reaction and treatment for each checked allergy
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you plan for your child to receive school prepared meals? Yes* ___ No ____
*an additional form must be completed for food allergies
MEDICATION
Does your child take any medication? Yes ___ No ___ If yes, name of medication: ______________________________________________
Purpose _____________________________________ Will medication be needed at school? Yes* ___ No ___
*If your child needs to take medication at school, please contact the office for the necessary authorization form.
This form must be completed prior to any medication being brought to school.
HEARING/VISION
Do you have concerns about your child’s hearing? Yes ___ No ___ Does your child wear hearing aids?
Yes ___ No ___
Do you have concerns about your child’s vision? Yes ___ No ___ Does your child wear glasses or contacts? Yes ___ No ___
SPEECH/LANGUAGE
Do you have concerns about your child’s speech and/or language? Yes ___ No ___ Do others have difficulty understanding your child?
Yes ___ No ___ If yes, please explain __________________________________________________________________________________
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
I understand the information given above will be shared with appropriate school staff to provide for the health and safety of my child. If either I or an
authorized emergency contact person cannot be reached at the time of a medical emergency, I authorize and direct school staff to send my child to the most
easily accessible hospital or physician. I understand I will assume full responsibility for payment of any transport or emergency medical services rendered.
Parent/Guardian Signature ____________________________________________________________________ Date __________________
Revised 02/2014
Kindergarten – 5th
Grade
6th Grade
7th – 12th Grade
Parents - Are Your Kids Ready for School?
(Measles, Mumps,
Rubella)
2 doses
Recommended, but
not required.
2 doses
OR
Healthcare provider
verifies child had
disease
2 doses
OR
Healthcare provider
verifies child had
disease
(Chickenpox)
Varicella
Parent/Guardian Resource
Required Immunizations for School Year 2014-2015
Polio*
MMR
(Diphtheria, Tetanus,
Pertussis)
2 doses
DTaP/Td/Tdap*
Hepatitis B
4 doses
4 doses
2 doses
5 doses
5 doses DTaP
AND
1 dose Tdap
5 doses DTaP
AND
4 doses
3 doses
3 doses
3 doses
1 dose Tdap
DOH 348-295 December 2013
*Vaccine doses required may be fewer than listed.

Students must meet minimum intervals and ages 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: www.immunize.org/cdc/schedules/

If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711).
Certificate of Immunization Status (CIS)
DOH 348-013 January 2015
Office Use Only:
Reviewed by:
Date:
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 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
Information System to help the school maintain my
I certify that the information provided on this
Symbols below:  Required for School and Child Care/Preschool
child’s school record.
form is correct and verifiable.
 Required for Child Care/Preschool Only
■ Recommended, but not required
Parent/Guardian Signature Required
Date Parent/Guardian Signature Required
Date
Vaccine
Dose
Date
Month
Day
Year
 Hepatitis B (Hep B)
1
2
3
or Hep B - 2 dose alternate schedule for teens
1
2
■ Rotavirus (RV1, RV5)
1
2
3
 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
1
2
3
4
5
 Tetanus, Diphtheria, Pertussis (Tdap)
1
■ Tetanus, Diphtheria (Td)
1
2
 Haemophilus influenzae type b (Hib)
1
2
3
4
■ Influenza (flu, most recent)
Vaccine
Dose
Date
Month
Day
Year
 Pneumococcal (PCV, PPSV)
1
2
3
4
5
 Polio (IPV, OPV)
1
2
3
4
 Measles, Mumps, Rubella (MMR)
1
2
 Varicella (chickenpox)
1
2
■ Hepatitis A (Hep A)
1
2
■ Human Papillomavirus (HPV) – does not
print from the IIS; write dates in by hand
1
2
3
■ Meningococcal (MCV, MPSV)
1
2
If the child named on this CIS had chickenpox
disease (and not the vaccine), disease history
must be verified.
Mark option 1, 2, OR 3 below (see # 5 on back)
1)  Chickenpox disease verified by printout from
the Immunization Information System (IIS)
Must be marked by printout (not by hand) to be valid.
2)  Chickenpox disease verified by healthcare
provider (HCP)
If you choose this box, mark 2A OR 2B below.
2A) Signed note from HCP attached OR
2B) HCP sign here and print name below:
Licensed healthcare provider signature
(MD, DO, ND, PA, ARNP)
Date
Printed Name:
3)  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:
Date
Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization
Information System (IIS) or filling it in by hand.
#1 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 #2-7 (below):
EXAMPLE
#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box.
#3 Write each vaccine your child received under the correct disease. Write the vaccine type under the
Vaccine
Dose
Month
Date
Day
Year
 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
“Vaccine” column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as
DTaP
01
12
2011
1
mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here 
DTaP
03
20
2011
2
#4 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,
DTaP
06
01
2011
3
Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.
#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:
1)  If your child’s CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box 1 is automatically
marked. To be valid, this box must be marked by the IIS printout (not by hand).
2)  If your healthcare provider can verify that your child had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your provider, or
2B if your provider signs and dates in the space provided. Be sure your provider’s full name is also printed.
3)  If school staff access the IIS and see verification that your child had chickenpox, they will mark box 3.
#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.
Vaccine Trade Names in alphabetical order
Trade Name
Vaccine
(For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)
Trade
Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Ipol
Infanrix
Kinrix (Knrx)
Menactra
MenHibrix
(Mnhbrx)
Menomune
Menveo
Pediarix (Pdrx)
IPV
DTaP
DTaP + IPV
MCV or MCV4
Meningococcal C/YHIB-PRP
MPSV or MPSV4
Meningococcal
DTaP + Hep B + IPV
PedvaxHIB
Pentacel (Pntcl)
Pneumovax
Prevnar
Hib
DTaP + Hib + IPV
PPSV or PPV23
PCV or PCV7 or PCV13
Twinrix (Twnrx)
Vaqta
Varivax
Hep A + Hep B
Hep A
Varicella
ProQuad (PrQd)
MMR + Varicella
Recombivax HB
Rotarix
RotaTeq
Hep B
Rotavirus (RV1)
Rotavirus (RV5)
ActHIB
Adacel
Afluria
Boostrix
Hib
Tdap
Flu
Tdap
FluLaval
FluMist
Fluvirin
Fluzone
Flu
Flu
Flu
Flu
Cervarix
HPV2
Gardasil
HPV4
Daptacel
Engerix-B
Fluarix
DTaP
Hep B
Flu
Havrix
Hiberix
HibTITER
Hep A
Hib
Hib
Vaccine Abbreviations in alphabetical order
Abbreviations
Full Vaccine Name
DT
Diphtheria, Tetanus
DTaP
DTP
Flu
(IIV or LAIV)
Diphtheria, Tetanus,
acellular Pertussis
Diphtheria, Tetanus,
Pertussis
Abbreviations
Hep A (HAV)
Hep B (HBV)
Hib
HPV
(For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)
Full Vaccine Name
Hepatitis A
Hepatitis B
Haemophilus influenzae
type b
Abbreviations
Human Papillomavirus
OPV
MPSV or MPSV4
MMR / MMRV
Full Vaccine Name
Meningococcal
Polysaccharide Vaccine
Measles, Mumps, Rubella /
with Varicella
Abbreviations
Rota
(RV1 or RV5)
Full Vaccine Name
Td
Tetanus, Diphtheria
Oral Poliovirus Vccine
Tdap
Tetanus, Diphtheria, acellular
Pertussis
TIG
Tetanus immune globulin
VAR or VZV
Varicella
Inactivated Poliovirus
PCV or PCV7 or
Pneumococcal Conjugate
Vaccine
PCV13
Vaccine
Hepatitis B Immune
Meningococcal
Pneumococcal Polysaccharide
HBIG
MCV or MCV4
PPSV or PPV23
Globulin
Conjugate Vaccine
Vaccine
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711).
Influenza
IPV
Rotavirus
DOH 348-013 January 2015
Washington State
Ethnicity and Race Data Collection Form
The new Federal requirements state that Unknown, Multiracial, and Not Provided are not valid responses to ethnicity or race identification questions. If
parents, guardians, or students do not provide ethnicity and race information, districts are responsible for assigning categories based on observation.
Student Legal Last Name _______________________________________ Legal First Name ________________________________
Is your child of Hispanic or Latino origin?  Yes, check all that apply in section 1 and 2.  No, check all that applies in section 2.
Section 1. Check all that apply.
 Cuban
 Central American
 Dominican
 South American
 Spaniard
 Latin American
 Puerto Rican
 Other Hispanic/Latino
 Mexican/Mexican American/Chicano
Section 2. What race(s) do you consider your child? (check all that apply)
 African American/Black
 White
Asian
 Asian Indian
 Cambodian
 Chinese
 Filipino
 Hmong
 Indonesian
 Japanese
 Korean
 Laotian
 Malaysian
 Pakistani
 Singaporean
 Taiwanese
 Thai
 Vietnamese
 Other Asian
Native Hawaiian or Other Pacific Islander
 Native Hawaiian
 Fijian
 Guamanian or Chamorro
 Mariana Islander
 Melanesian
 Micronesian
 Samoan
 Tongan
 Other Pacific Islander
American Indian or Alaskan Native
 Alaska Native
 Chehalis
 Colville
 Cowlitz
 Hoh
 Jamestown
 Kalispel
 Lower Elwha
 Lummi
 Makah
 Muckleshoot
 Nisqually
 Nooksack
 Port Gamble Klallam
 Puyallup
 Quileute
 Quinault
 Samish
 Sauk-Suiattle
 Shoalwater
 Skokomish
 Snoqualmie
 Spokane
 Squaxin Island
 Stillaguamish
 Suquamish
 Swinomish
 Tulalip
 Yakama
 Other Washington Indian
 Other American Indian/Alaska Native
Parent/Guardian Signature ______________________________________________
Date ________________________________
FOR OFFICE USE ONLY
Received by
B/10/201-B
Date
Revised January 2010
Superintendent’s Office
205 N. Alder Ave
Granite Falls School District
Re. Ethnicity and Race Data Collection
Dear families,
There was a change in federal and state law that effects how student ethnicity/race data is collected.
This change, which occurred in 2010, now requires schools to have this data recorded and eliminates the
options of “Unknown”, “Multi racial” and “Not Provided.”
For many years, school districts in Washington have been required to report student data by ethnicity
and race categories to the state’s Office of Superintendent of Public Instruction (OSPI). No individual
student data is provided to the federal government. Federal law requires the state to report the total
number of students in various categories in each school to the federal government. These reports help
keep track of changes in student enrollment and various statistics such as graduation rates to ensure
that all students receive the educational programs and services to which they are entitled.
Ethnicity and race categories found on the back of this letter are the same as those used in all
Washington school districts. The categories are set by the federal government, the state Legislature,
and state Office of the Superintendent of Public Instruction (OSPI).
In 2010, the federal government and OSPI changed the reporting categories. As a result of the new
categories, we remain required to ask you to identify your child as either Hispanic/Latina or not
Hispanic/Latino and by one or more of the 57 racial groups. If your family is Asian, you will now be able
to list your child as Chinese or Japanese, or belonging to one or more of the other Asian groups. If your
family is Native American, you will be able to list your child’s tribal affiliation. If one parent identifies
with one race and the other with another, you will be able to check both races for your child.
While families are not required to respond, the federal government is now requiring schools to have
this information. Since September 2010, all public schools in Washington must have an ethnicity or race
categories identified for each student. If there is no response, schools are required to make the
selection. Granite Falls’ staff will not “observe” students for this selection. Without your input, the
selections will be marked “Not Hispanic/Latina” and “White.” Families objecting to offering this data
may also request in writing to “opt out” and the ethnicity/race data for those children will also default
to “Not Hispanic/Latina” and “White.”
Please complete the Form on the BACK. For more information about the student data reporting
categories for ethnicity and race, you may visit the OSPI link,
http://www.k12.wa.us/cedars/CEDARSDataFormQA.aspx or call the Communications Office at
360.691.7717.
Sincerely,
Linda Hall
Superintendent
STUDENT HOUSING
QUESTIONNAIRE
205 N Alder Avenue, Granite Falls, WA 98252
360-691-7717 Fax 360-691-6477
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?
Are you living in a motel/hotel due to lack of housing?
Are you living in a shelter?
Are you living in a car, park, campsite or location not usually used for sleeping accommodations?
Is this student awaiting foster care?
As a student, are you living with someone other than your parent?






Yes
Yes
Yes
Yes
Yes
Yes






No
No
No
No
No
No
 If you answered YES to any of the above questions, please complete the remainder of this form.
 If you answered NO to all of the above questions, you may stop here.
Student Name: _____________________________________________________________________________
First
Middle
Last
Date 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 Granite Falls School District?
Name ________________________ Date of Birth: _____________Age ___ Grade ___ School ______________
Name ________________________ Date of Birth: _____________Age ___ Grade ___ School ______________
Name ________________________ Date 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.
Signature of person completing form: _________________________________ Date: ____________________
Relationship to the 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
Rev. February 2014
English
Office of Superintendent of Public Instruction (OSPI)
Home Language Survey
Student Name:
Birth Date:
Date:
Gender:
Grade:
Form Completed by:
Parent/Guardian Name
Relationship to Student
Parent/Guardian Signature
If available, in what language would you prefer to receive communication from the school?
Did your child receive English language development support through the Transitional
Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__
1. In what country was your child born?
____________________
2. What language did your child first learn to speak?*
__________________
3. What language does YOUR CHILD use the most at home?*
____________________
4. What language(s) do parent/guardians use the most when you speak
_____________________
_____________________
to your child?
5. Has your child ever received formal education* outside of the United
States?
(Kindergarten – 12th grade)
_____Yes
_____No
If yes, in what language(s)
was instruction given?
_____________________
For how many months? ____
”Formal education” does not include refugee camps or other unaccredited
programs for children.
6. When did your child first attend a school in the United States?
(Kindergarten – 12th grade)
_______________________
Month
Day
Year
7. Do grandparent(s) or parent(s) have a Native American tribal
affiliation?
_____Yes
_____No
*WAC
392-160-005: "Primary language" means the language most often used by a student (not necessarily by
parents, guardians, or others) for communication in the student's place of residence.
Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing
May 2014
English
The Purpose of the Home Language Survey
The Home Language Survey is given to all students enrolling in Washington schools. The following
information should help answer some of the questions you may have about this form.
What is the purpose of the Home Language Survey?
The primary purpose of the Home Language Survey is to help identify students who may qualify for
support to help them develop the English language skills necessary for success in the classroom and who
may qualify for other services. It is important that this information be correctly recorded since it can
affect the eligibility of students for services they need to be successful in school. Testing may be
necessary to determine whether or not additional language and academic supports are needed. No
student will be placed in an English language development program based solely on responses to this
form.
Why do you ask about the student’s first language and language(s) used in the home?
The two questions about the student’s language help us to determine:
 if your student may be eligible for assistance with learning English, and
 whether staff at the school should be aware of other languages being used by the student at home.
The language your child first learned may be different from the language your child uses for
communication at home now. The responses to both of these questions will assist the school in providing
instruction appropriate to the individual student’s needs as well as help with communication needs that
may arise. Students who first learned a language other than English may qualify for additional supports.
Even students who speak English well may still need support in developing the language skills needed to
be successful in school.
Why do you ask where the student was born?
This information helps the school district and the state determine if the student meets the definition of
immigrant for the purposes of federal funding. This applies even when the student’s parents are both US
citizens, but the student was born outside of the United States. This form is not used to identify students
who may be undocumented.
Why do you ask about my student’s previous education?
Information about a student’s education will help ensure that the student’s education both within and
outside of the United States is considered in any recommendations made for participation in programs and
district services. The student’s educational background is also important information to help determine if
the student is making adequate progress toward state standards based on their prior educational
background.
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.
May 2014
Mountain Way Elementary
702 N Granite Ave
Granite Falls, Washington 98252
Phone: 360.691.7719 Fax: 360.283.4416
REQUEST TO PRINCIPAL /REGISTRAR FOR STUDENT RECORDS
_______________________________________________________________
Name of School
_______________________________________________________________
Mailing Address
______________________________________________________________
City
State
Zip Code
Please forward all school records, including health information, Special Education records, and all
previous achievement/test scores, for the following students:
1. ________________________________________ Birthdate _______________ Grade _______
2. ________________________________________ Birthdate _______________ Grade _______
3. ________________________________________ Birthdate _______________ Grade _______
4. ________________________________________ Birthdate _______________ Grade _______
Request for Transfer of Educational, Psychological, Medical and Other Confidential Records Between
Schools:
PLEASE FORWARD:
•
•
•
•
•
•
•
•
Official Transcripts of grades and credits
Withdrawal grades to date of leaving for work in progress (Please include attendance record to
date of withdrawal)
WASL results (WA State), other Standard Tests and student portfolio packet
BECCA petition information/applicable truancy files
Immunization and health records
Psychological, Special Services, and other confidential records
Entire CUMULATIVE file (to include all of the above)
Any and all discipline files
The Granite Falls School District is in full compliance with all aspects of Federal and State laws regarding
student records. The Federal Family Rights and Privacy Act of 1974 does not require the school
forwarding pupil records to obtain parent permission prior to release of records to another school.
______________________________________
Parent/Guardian Signature
March 2011
_______________________________________
Secretary Signature
General Field Trip Permission Form
I hereby give my permission for __________________________________________________
to take school field trips during the 20__-20__ school year.
Parent Consent
I understand that extended learning experiences present fun and exciting opportunities for
student learning, as well as heightened exposure to risk of injury – ranging from minor to
serious – not normally encountered in the classroom. Such exposure may be in the form of
transportation to/from the activity, or participation in experiences such as walking on trails,
playing in parks, riding amusement rides, etc.
Further, I understand that every reasonable effort will be made to safeguard the health and
safety of all participants. Accidents can occur however, and I agree to hold harmless the
Granite Falls School District, its elected and appointed officials, employees, agents, and staff
from any and all claims, liabilities, damages, expenses, or rights of action, directly or indirectly
attributed to my child’s participation in these field trip activities, except for the sole negligence
of the District.
Parent/Guardian Signature
Date
X
_____________________________________________________________________________
Medical Treatment Information and Consent
In the event that my child should need medical attention during the trip and I am unavailable for
consultation, the supervisor has my permission to acquire medical attention. Known medical
problems, allergies, or medications needed are described below.
Medical Information: ___________________________________________________
Allergies: _____________________________________________________________
Medications: ___________________________________________________________
Parent/Guardian Signature
Date
X ___________________________________________________________________________
Telephone Numbers:
Home: ________________________________ Work: ________________________________
Emergency Contact 1: __________________________________________________________
Emergency Contact 1: __________________________________________________________
11/2014
Please help me get to know your child….
As your child’s teacher, I’d like this school year to be the best your child has ever had. That’s why I’m
asking for your help. I’ve found that the more I know about my students, the easier it is for me to help
meet their needs. For that reason, I would appreciate it if you could take time to answer the questions
below. If you don’t feel comfortable answering a question, just skip it. Thank you for your time.
Child’s Name ______________________________________ Nickname ___________________
1.
Please list all the adults living in your child’s household.
Name
Relationship
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Please list all the children in the family, along with their ages and gender.
Name
Age
Sex
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3. Does your child speak or understand a language other than English? YES
If so, what language? ______________________________________
NO
4. What are your child’s major strengths?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. Tell me about your child’s interests and after school activities.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Describe your child’s feelings about school.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
11/2014
7. How does your child get along with other children?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
8. Does your child have any problems with learning?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
9. Please describe recent family events or changes (ie: death, divorce, new sibling, moving).
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
10. How do you feel the teacher can best help your child this year?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
11. Is there anything else you think your child would like the teacher to know about him/her?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. Would you like to become involved in the classroom or school? Are you interested in helping any
particular area?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please attach any additional comments or suggestions on a separate page.
These questions were answered by: ___________________________________ Date: ________________
Thanks for your help!
11/2014
GRANITE
FALLS
SCHOOL
DISTRICT
GRANITE
FALLS
SCHOOL
DISTRICT
ELEMENTARY
REGISTRATION
ELEMENTARY REGISTRATION
SPECIAL
PROGRAMS
SPECIAL
PROGRAMS
Student Name: __________________________________ Room: _____
M
F
Birthdate: ____________________ Age: _____ Date Entering: _______________
Does your child have any history of violent behavior or discipline problems?
 Yes
 No
If yes, please describe:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Does your child have any health conditions affecting their educational needs?
 Yes
 No
Has your child been in a special program?








LAP
Title I
Special Education
Speech
Occupational Therapy
Gifted
Counseling
English as a Second Language
Subject areas covered in the program:
 Reading
 Math
 Language
Previous School: _________________________________
Location: _______________________________________
Has your child ever been retained?
 Yes
 No
Does your child have any unpaid fines or fees imposed by other schools?
 Yes
 No
11/2014
2015–16
Letter to Households (Public Schools)
National School Lunch Program/School Breakfast Program
Exhibit 3
(use w/ Exhibit 2)
Dear Parent/Guardian:
This letter tells how your children can get free or reduced-price meals, as well as information on other benefits. The cost of school meals is
shown below.
Breakfast will be served at no cost to those children who qualify for free and reduced-price meals. Lunches will be served at no cost to
rd
children who qualify for free meals and to those who qualify for reduced-price meals in kindergarten through 3 grade. All other students
th
th
(preschool and 4 – 12 grades) will be charged the rates shown below.
REGULAR
REDUCED-PRICE
Grade Level
Breakfast
Lunch
Snack
Breakfast
K-3
Lunch
All Other Students
$ .40
Snack
K-5
$ 1.75
$ 3.00
$
$ 0.00
$ 0.00
6-12
$ 1.75
$ 3.25
$
$ 0.00
$
$ .40
$
$
$
$
$
$
$
$
$
WHO SHOULD FILL OUT AN APPLICATION?
Fill out the application if:

Total household income is the SAME or LESS than the amount on the chart

You receive Basic Food, take part in the Food Distribution Program on Indian Reservations (FDPIR), or receive Temporary
Assistance for Needy Families (TANF) for your children

You are applying for foster children that are under the legal responsibility of a foster care agency or court
Turn in the application to your child's school or Food Service office. Questions? Contact Viki Perrault 360 283 4310
Be sure to submit ONLY ONE application per household. We will notify you if the application is approved or denied. If any child you are
applying for is homeless (McKinney-Vento), or migrant, check the appropriate box.
.
WHAT COUNTS AS INCOME? WHO IS CONSIDERED A MEMBER OF MY HOUSEHOLD?
Look at the income chart below. Find your household size. Find your total household income. If members in the household are paid at
different times during the month and you are unsure if your household is eligible, fill out an application and we will determine your income
eligibility for you. The information you give will be used to determine your child's eligibility for free or reduced-price meals.
Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals regardless of personal use
income. If you have questions about applying for meal benefits for foster children, please contact us at
.
INCOME CHART
Effective from
July 1, 2015 to June 30, 2016
Household
Size
Annual
Monthly
Twice Per
Month
Every Two
Weeks
1
2
3
4
5
6
7
8
$21,775
29,471
37,167
44,863
52,559
60,255
67,951
75,647
$1,815
2,456
3,098
3,739
4,380
5,022
5,663
6,304
$ 908
1,228
1,549
1,870
2,190
2,511
2,832
3,152
$ 838
1,134
1,430
1,726
2,022
2,318
2,614
2,910
$ 419
567
715
863
1,011
1,159
1,307
1,455
+7,696
+642
+321
+296
+148
For each
additional
member add:
Weekly
HOUSEHOLD is defined as all persons, including parents,
children, grandparents, and all people related or unrelated
who live in your home and share living expenses. If applying for a
household with a foster child, you may include the foster child in
the total household size.
HOUSEHOLD INCOME is considered to be the income each
household member received before taxes. This includes
wages, social security, pension, unemployment, welfare,
child support, alimony, and any other cash income. If including a
foster child as part of the household, you must also include the
foster child’s personal income. Do not report foster payments as
income.
WHAT MUST BE ON THE APPLICATION?
A. For households not getting any assistance:
• Student’s name
• Names of all household members
• Income by source for all household members
• Adult household member's signature
• Last 4 digits of social security number of the adult household
member who signs the application, (or check the "I do not have
a social security number" box if the adult signing does not
have a social security number)
Complete Parts 1, 2, 3, and 4. Parts 5 and 6 are optional.
B. For a household with only a foster child(ren):
• Student’s name
• Adult household member's signature
Complete Parts 1 and 4. Parts 5 and 6 are optional. You may also send
the school a copy of the court documentation showing the foster child(ren)
was placed with you instead of filling out an application form.
C. For household with a foster child(ren) and other children:
Apply as a household and include foster children. Follow the
directions for “A. Households not getting any assistance” and include the
foster child’s personal use income.
D. For a family getting Basic Food/TANF/FDPIR:
• List all student names and case number where appropriate
• If the student is not the one with a case number, enter the household
member’s name and their case number
• Adult household member's signature
Complete Parts 1 and 4. Parts 5 and 6 are optional.
FORM SPI NSLP Exhibit 3 (Rev. 6/15)
Page 1
Bulletin 016-15 OSPI/Child Nutrition Services
May 2015
Exhibit 3
WHAT IF I’M NOT RECEIVING BASIC FOOD DOLLARS?
If you have been approved for Basic Food but do not actually receive Basic Food dollars, you must apply for free and reduced-price meal
benefits by filling out a meal application and returning it to your child’s school.
DO MY CHILDREN AUTOMATICALLY QUALIFY IF THEY HAVE A CASE NUMBER?
Yes. Children on TANF or Basic Food may get free meals without the household having to complete an application. These children are
identified by the school using a data matching process. This matched list is then made available to your child’s school food service staff. The
students on this list get free meals if their schools have the free and reduced-price breakfast and/or lunch program (not all schools do). Please
contact us immediately if you feel your children should be receiving free meals and are not. If you do not want your child to participate in the
free meal programs using this method, please notify the school.
IF ANYONE IN MY HOUSEHOLD HAS A CASE NUMBER, WILL ALL CHILDREN QUALIFY FOR FREE MEALS?
Yes. If someone else in the household has a case number, other than a student or a foster child, you must fill out an application and send it to
your student’s school. Please contact us immediately if you feel other children in your household should be receiving free meals and are not.
BASIC FOOD – CAN I QUALIFY FOR ASSISTANCE IN BUYING FOOD?
Basic Food is the state’s food stamp program. It helps households make ends meet by providing monthly benefits to buy food. Getting Basic
Food is easy! You can apply in person at the local DSHS Community Service Office, by mail, or online. There are other benefits too. You
can learn about Basic Food by calling 1-877-501-2233 or by logging on to http://www.foodhelp.wa.gov/basic_food.htm.
WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY?
Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or
receive Family Subsistence Supplemental Allowance payments, it must also be included as income. However, if your housing is part of the
Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from
deployment is also excluded from income.
MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE?
Yes. Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application
unless the school told you that your child is eligible for the new school year.
WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT?
Household members may not receive some types of income we ask you to report on the application, or may not receive income at all.
Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as
zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.
HEALTH COVERAGE
To inquire about or apply for health care coverage for kids in your family, please visit http://www.wahealthplanfinder.org or you may call
Washington Health Plan Finder at 1-855-923-4633.
WHAT IF MY CHILD NEEDS SPECIAL FOODS?
All meals served meet the federal food guidelines. Students who are identified as disabled by their doctor may need different foods. These
substitute foods will be made available at no extra charge if your child’s doctor fills out the necessary paperwork. If your child needs this
assistance, please contact us.
PROOF OF ELIGIBILITY
The information you provide may be verified at any time. You may be asked to send additional information to prove your child is eligible to
receive free and reduced-price meals.
FAIR HEARING
If you do not agree with the decision on your child's application or the process used to prove income eligibility, you may talk with
Linda Hall - Superintendent
, the fair hearing official. You have the right to a fair hearing which may be arranged by calling
the school/school district at this number 360 691 7717
.
REAPPLICATION
You may apply for benefits any time during the school year. If you should have a decrease in household income, an increase in household size,
or become unemployed, or receive Basic Food, TANF, or FDPIR, you may be eligible for benefits and may fill out an application at that time.
NONDISCRIMINATION
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the
bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political beliefs, marital status,
familial or parental status, sexual orientation, or if all or part of any individual’s income is derived from any public assistance program, or
protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases
will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the
USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or
call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your
completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Ave
S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at mailto:[email protected]. Individuals who are deaf, hard of
hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
USDA is an equal opportunity provider and employer.
FORM SPI NSLP Exhibit 3 (Rev. 6/15)
Page 2
Bulletin 016-15 OSPI/Child Nutrition Services
May 2015
Granite Falls School District
Check here if you received
meal benefits
last year.
2015–16 HOUSEHOLD APPLICATION FOR FREE AND REDUCED-PRICE MEALS
your child's school or Food Service Office
Complete, sign and return this application to
Grade
Monthly
School
Student
Income
2X Month
MI
Date of
Birth
Every 2
weeks
Student’s Last Name
Student’s First
Name
Weekly
List all students living with you that are attending school. If the student is a foster child, indicate this by placing an “x” in the appropriate box. Include any personal income received by
the student and make an “x” in the correct box for how often it is received. If you have written a case number for any of your children, skip to Section 4. However, if you have written a
case number only for the foster child and want to apply for all students in the household, you must proceed to Section 2.
If any child you are applying for is homeless (McKinney-Vento), or migrant, check the appropriate box.
Homeless
Migrant
Foster
Child
1.
Exhibit 2
Does the student receive Basic Food, TANF, or FDPIR?
If YES, you must list a case number and check the
appropriate box.
Basic Food TANF FDPIR
$
Case #
$
Case #
$
Case #
$
Case #
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Monthly
2X Month
Every 2 weeks
Any Other
Income Not
Already
Listed
Weekly
Monthly
2X Month
Weekly
Pensions,
Retirement,
Social
Security
(SSI)
Every 2 weeks
Monthly
2X Month
Every 2 weeks
Child Support,
Alimony
Weekly
Monthly
2X Month
Weekly
Names of ALL other household members
(do not include names of students listed
above)
Earnings
from work
(before any
deductions)
Every 2 weeks
Case #
List the names of all other household members - Enter income (in whole dollars) and CHECK how often it is received. If any household member does not receive income,
write 0. If you enter 0 or leave income sections blank, you are promising that there is no income to report. If you write a case number for another household member, skip
to Section 4. However, if the case number is only for the foster child(ren), you must proceed to Section 3.
Foster Child
2.
Does any household
member receive Basic
Food, TANF, or FDPIR? If
YES, you must list a case
number and check the
appropriate box.
Basic Food TANF FDPIR
Case #
Case #
Case #
Case #
Case #
3.
4.
Total Household Members (include all people living in your household):
Signature and Social Security Number – I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal
funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose
meal benefits, and I may be prosecuted. I understand my child’s eligibility status may be shared as allowed by law.
Last 4 digits of your social security number:
OR, if you do not have a social security number, check the box:
Printed Name of Adult Household Member
Mailing Address
City & Zip Code
FORM SPI NSLP Exhibit 2 (Rev. 6/15)
Street Address (if available)
Home Phone
Adult Household Member Signature
Work/Cell Phone
Date
Email Address
Page 1
Bulletin No. 016-15 OSPI/Child Nutrition Services
May 2015
Exhibit 2
5.
Children’s Racial and Ethnic Identities (Optional)
Mark one or more racial identities:
Asian
White
Black, or African American
6.
Mark one ethnic identity:
Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Other Benefits – Please check the box in front of the programs that you wish to share your child’s free or reduced price meal status with in order to qualify for a reduction
in fees:
Scholarships
Advanced Placement Testing
By signing below, I allow the information contained on this application to be shared with the other program(s) I have indicated.
Parent/Guardian Signature
Date
This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the
information, but if you do not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult household
member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition
Assistance Program (Basic Food), Temporary Assistance for Needy Families (TANF) Program, or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR
identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if
your child is eligible for free or reduced-price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education,
health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into
violations of program rules.
SCHOOL USE ONLY
DO NOT WRITE BELOW THIS LINE
ANNUAL INCOME CONVERSION: Weekly x 52; Every Two Weeks x 26; Twice a Month x 24; Monthly x 12. Do NOT convert to annual income unless household reports multiple pay frequencies.
LEA APPROVAL/DENIAL
Basic Food/TANF/FDPIR Household
Income Household
Foster Child (categorically free)
APPLICATION APPROVED FOR:
Free Meals
Reduced-Price Meals
Date Notice Sent
FORM SPI NSLP Exhibit 2 (Rev. 6/15)
Total Household Size
Total Household Income $
Income Approved by (check one):
weekly
every two weeks
2 times a month
monthly
annual
APPLICATION DENIED BECAUSE:
Income Over Allowed Amount
Incomplete/Missing Information
Other:
Signature of Approving Official
Date
Page 2
Bulletin No. 016-15 OSPI/Child Nutrition Services
May 2015