New Student ENROLLING AT CROSSROADS

New Student
ENROLLING AT CROSSROADS
Student Name __________________________________________ Date __________
Cell phone ________________________ email _______________________________
1. MAKE AN APPOINTMENT
 Call or email the Crossroads Registrar to schedule an appointment for registration
360-283-4012
[email protected]
Student and Parent/Guardian must attend.
2. WHAT TO BRING WITH YOU TO YOUR MEETING
 Completed Registration Packet
 Copy of Immunizations
 Copy of Birth Certificate
 Copy of State Test Scores
 Copy of IEP/504
 Copy of Community Service Hours
 Copy of Transcript
 This Form
3. THINGS YOU NEED TO DO PRIOR TO THE FIRST DAY OF SCHOOL
 Attend 3 day Orientation prior to being enrolled in Block – MANDATORY
 Get Portfolio from previous school if not from Granite Falls High School
 Withdraw from previous school / RETURN ALL BOOKS / PAY FINES
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]
3/2016
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CROSSROADS HIGH SCHOOL
205 N ALDER AVE
GRANITE FALLS, WA 98252
360-283-4407 FAX 360-283-4307
BLOCK PROGRAM _____ RE-ENTRY_____ NIGHT SCHOOL _____
Last Name __________________________________ First Name _____________________________ Middle Name _______________
Student Cell # ________________________ Home Phone # _________________________ Email ______________________________
Gender _____ Age _____ Birthdate ______________ Graduation Year _________ Grade ______Today’s Date ____________________
Birth City __________________________ Birth State ______________________________ Birth Country ________________________
Do you live at home? ________ Social Security # ___________________________ Home Phone _______________________________
Are you currently enrolled in school? _____ IF YES: What School? _______________________________________________________
City _______________________ State __________________ Phone _____________________
IF NO: What was your last school of attendance? ____________________________________
City _______________________ State __________________ Phone _____________________
Have you ever been suspended for a weapons violation? Yes _____ No ______ Date _____________
Have you ever qualified for or had a 504 Plan? Yes _____ No ______ When ____________________
Have you ever participated in: Title _____ LAP _____ Gifted _____ ELL ______ Unknown _____ Other
_______________________
Have you ever been retained? Yes _____ No ______ If yes, what grade level(s) ____________________
Has any member of your family ever been enrolled in Granite Falls Schools? If yes, who? ____________________________________
____________________________________________________________________________________________________________
SPECIAL NEEDS:
Has your child ever been enrolled in a Special Education Program?
Yes _____ No ______
Is your child currently on an IEP?
Case Manager ____________________________________________
Yes _____ No ______
Attach a copy of IEP and evaluation.
PARENT/GUARDIAN PERMISSION
I have discussed the alternative school program with ______________________________________________________________________
Student’s Name
I support his/her decision to participate in this program ____________________________________________________________________
Parent Signature
Date
CROSSROADS HIGH SCHOOL
Family / Emergency Information
PRIMARY HOUSEHOLD (parent / guardian where student lives)
Last Name
Phone 1
First Name
Last Name
First Name
Phone 2
Home
Work
Cell
Home
Work
Cell
Phone 1
Cell
Home
Work
Cell
Father
Mother
Agency
Guardian
Self
Both Parents
Mother/Stepfather
Stepfather/Stepmother
Grandparents
Other
Resident Address
Mailing Address (if different)
Work
Phone 2
Student Lives with:
Father/Stepmother
Email Address
Home
PO Box
Apt. #
City
State
Zip
Apt. #
City
State
Zip
SECOND HOUSEHOLD
Last Name
First Name
Phone 1
Phone 2
Home
Last Name
First Name
Work
Cell
Phone 1
Home
Work
Cell
Home
Work
Cell
Phone 2
Home
Work
Cell
Email Address
Second Household Mailing Address
Would you like to receive Mailings?
Yes
No
IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT?
Yes
No (If yes, plan must be on file with the school)
IS THERE A RESTRAINING ORDER IN EFFECT?
Yes
Restraining order is against:
Other ___________________________________________________________________________
Mother
Father
No (If yes, legal papers must be on file with the school)
Copy Attached
Copy Attached
PLEASE LIST OTHER SIBLINGS ATTENDING GRANITE FALLS SCHOOLS
Last Name
First Name
School
Grade
STUDENT RELEASE AUTHORIZATION
When injury, illness or other non-emergency situation(s) 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 the person you trust who are available during the day to provide care for your child.
PRIMARY CONTACT
(Other than parent/guardian)____________________________________________________
PRIMARY CONTACT
(Other than parent/guardian)____________________________________________________
Relationship ____________________ Phone 1 ______________ Phone 2 _________________
Relationship ____________________ Phone 1 ______________ Phone 2 _________________
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 case 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 to achieve enrollment or
assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Granite Falls Schools.
Legal Parent/Guardian signature _________________________________________________________ Date ____________________
12/2014
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
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
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
Student _________________________________________________
Date _______________
PARENT/GUARDIAN PERMISSION: ANALYSIS OF FILM AND TELEVISION
In the Crossroads program a few of the films we watch will be rated “R”, and we are asking for a “cover all” permission to allow your
son/daughter to watch those films. The “R” rating permission would cover films that contain profane language, adult situations, brief
nudity, violence, and sexual content. However, our pledge to you is that all materials in the Crossroads Program have high artistic
value and educational merit.
Signature of Student ______________________________________________
Signature of Parent/Guardian ________________________________________
Cell Phones
The use of cell phones is prohibited during class time. Any noise from these devices is considered disruptive to the school
environment. Teachers will expect such devises to be put away and turned off during class. Failure to comply with this will result
in the cell phone being confiscated for the period. Students will be asked, by their teachers to leave cellular devices with them
when leaving the classroom for any reason. Failure to relinquish a cell phone will result in a referral to the office where the phone
will be turned in and may result in disciplinary action. If you are sent out of class to the office you will be required to relinquish
your phone. It will be returned by the end of the day.
Signature of Student ______________________________________________
Signature of Parent/Guardian ________________________________________
Drug and Alcohol Contract
The staff at CROSSROADS is glad that you have chosen to become a student here. We are dedicated to providing each student with
a quality education. It is difficult, if not impossible, to benefit from this education if you are using drugs and/or alcohol.
Also, any student involved with drugs and/or alcohol can have a very negative effect on other students. We need you and this school
to be free from the damaging effects of drug and alcohol use. We, therefore, expect you to agree to and follow this contract.
1. I agree to take a urinalysis (UAA) if suspected of using alcohol and other drugs or academic progress remains unsatisfactory.
2. I agree that, if at any time the UA results indicate drug use, I will: (a) have an assessment by an outside treatment agency; (b)
follow the health care recommendations; and (c) sign any necessary releases.
3. I agree to be responsible for all costs, excluding US’s associated with this contract;
4. If at any time I refuse a UA, I may be immediately withdrawn from CROSSROADS. Refusal will be viewed as admitting to use.
5. If I fail to follow this contract, I will be withdrawn from CROSSROADS until I meet the requirements and participate in an intake
interview.
6. I understand that the school may share my UA results with my parent/guardian.
7. Any “Party” talk is not tolerated at CROSSROADS and will result in an automatic search.
Signature of Student ______________________________________________
Signature of Parent/Guardian ________________________________________
12/2014
Drug Use Policy
Crossroads High School
Student receives “Unsatisfactory” or reasonable
suspicion of drug use
U.A. GIVEN
POSITIVE UA, ADMITTED USE, or REFUSAL
Allowed to return to classes if determined safe, parent
call, conference scheduled with school counselor or
principal.
ONE MONTH FOLLOW-UP
With individualized “intervention plan” in place. End of
month period – another UA given.
NEGATIVE:
No action or possible referral to
counselor for follow-up.
NEGATIVE:
No action or possible referral to
counselor for follow-up. Parent
notified
nd
2 POSITIVE UA OFFENSE
Assessment with Treatment Facility and necessary
follow-up will be required. After one month period,
follow-up compliance check will be ongoing with
treatment provider.
IF NON-COMPLIANT
Meeting with principal to review possible suspension,
program change and/or further action.
PARENT ___________________________________________ DATE ________________
STUDENT __________________________________________ DATE ________________
12/2014
Declaration of Understanding
The purpose of this declaration is to clarify the three legal choices of education available to children in Washington State; public, private, and home-based (home
schooling) instruction. Students are considered either one or the other.
Home Based Instruction is authorized under RCW 28A.225. Where the parent has filed an annual Declaration of Intent with the district and is meeting the
requirements stated in Chapter 28A.225, the student is eligible to receive Home Based Instruction. Students receiving Home Based Instruction are not enrolled in
public education, they do not have to comply with the rules and regulations regarding public schools RCW 28A.200.010 (3). Because the student is not registered or
enrolled in the public school, the school district is under no obligation to provide instruction or instructional materials for classes. Home Based Instruction students
are not required to participate in any district or State assessments RCW 28A.200.0101 (3). Additionally, Home Based Instruction students are not eligible for
graduation through a public high school unless they meet all of the graduation requirements established by state, district and local high school, including earning the
Certificate of Academic Achievement.
Private School Students are students enrolled in an approved private school in the State of Washington. Students receiving private school instruction are not
enrolled in public education; they do not have to comply with the rules and regulations regarding public schools. The school district is under no obligation to provide
instruction or instructional materials for classes the student is not registered or enrolled in public schools. Students enrolled in private schools are not required to
participate in all district and State assessments. However, private school students are eligible for graduation through a public high school until they meet all of the
graduation requirements established by state, district and local high school, including earning the Certificate of Academic Achievement.
Private School or Home Based Instruction students may have access to ancillary services, and may enroll in public school course on a part-time basis where space is
available. Part-time enrollment is defined as being less than full-time enrollment. In these cases, the student is responsible for maintaining acceptable attendance
and meeting all course and school requirements. The student is considered to be a Private School or Home Based Instruction student, when enrolled part-time in a
public school setting. Public school courses and classes in which the student is enrolled are under the direct control of the District and the certified teacher
supervising the course. Other classes, taught by the parent or the private school, are not part of the public school’s responsibility. Therefore, all classes in which a
student is enrolled in a public school, individual class requirements, school and district attendance rules, and school behavior policies; must be followed. For classes
taken under home-based instruction or as a private school student, the limitations and restrictions noted in paragraphs one and two above are in force.
Students enrolling in a public school as a full-time student are neither Private School students nor Home Based Instruction students – they are considered public
school students and are subject to the rules and regulations governing the actions of all public school students. This includes, but is not limited to, attendance,
meeting course requirements, graduation requirements, and assessment requirements. Full-time students are eligible for graduation from a public school upon
meeting all of the school, district and state requirements.
All instructional materials used for public school instruction must meet the standards set forth by the local school district and must be free from sectarian control or
influence.
I am enrolling as a
Full-time student
Part-time student
I understand that I must meet applicable state, district, school and course requirements.
I have read and understand the above declaration _____________________________________________________________ __________________________
Signature of Parent/Guardian or Student
Date
The Role of Each Participant in the Program
Certificated Staff Responsibilities:
Identify appropriate essential learning for the student.
Develop the ALP together with parent and student.
Identify and help to provide appropriate instructional materials.
Provide guidance in regard to graduation requirements where high school graduation is a goal.
Ensure that work reflected in the ALP and completed for High School credit is of sufficient scope and depth and represents District and Washington State curriculum
goals.
Assess the success of the ALP and student achievement in accordance with state rules as adopted by the Office of Superintendent of Public Instruction.
Refer students not substantially successful to other courses of study.
Document contact sheet required by state rules.
Parent Responsibilities:
Supervise and assess daily progress.
Document time spent on ALP activities, attend the monthly review meeting and sign the monthly review sheet.
Keep records and samples of work completed.
Take primary responsibility for the student’s education and provide instruction in accordance with the ALP.
Attend all monthly meetings.
Assure appropriate behavior for students attending all activities.
Pick up students immediately following supervised activities.
Accompany students on field trips.
Student Responsibilities:
Ask questions so the staff can assist you.
Keep school materials in good condition.
Bring current work and books to each meeting.
Master the essential learnings associated with the Alternative Learning Plan in a timely manner.
Complete and document sufficient hours of schoolwork each week to maintain adequate progress toward the fulfillment of course contracts.
Attend scheduled meetings.
Demonstrate appropriate behavior during activities.
12/2014
CROSSROADS HIGH SCHOOL
TRUANCY INTERVENTION AGREEMENT
Under state law, students are required to attend school full-time until they reach the age of 18.
(RCW 28A.225). The BECCA state law requires schools to notify the Juvenile Court when
students are in violation of this statute. As a Crossroads High School/Granite Falls School
District student, I am aware of the following attendance expectations:
•
I will attend scheduled classes every day, on time, all period long
•
I understand that when I accumulate five (5) unexcused absences in any month (one
unexcused day consists of more than half the school day) the school may file a petition
to the Juvenile Court. However, the school MUST file a petition after seven (7)
unexcused absences in a month or ten (10) unexcused absences in a school year.
•
I also understand that depending upon the number of absences, a doctor’s note may be
required for every two days absent in order for those absences to be considered
excused. Without a doctor’s note, the absences will be considered unexcused.
•
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 in addition to the state law require school attendance, Crossroads
High School has its own attendance policy. An accumulation of five (5) or more
absences, excused or unexcused, in any single class may result in loss of credit for that
course during that quarter.
_______________________________
Printed Student Name
________________________________
Student Signature
_______________________________
Parent Signature
________________________________
School Staff Signature
________________________________
Date
12/2014
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
McKINNEY-VENTO HOMELESS
ASSISTANCE ACT
205 N Alder Avenue, Granite Falls, WA 98252
360-691-7717 Fax 360-925-6477
INTAKE AND REFERRAL
Send completed form to McKinney-Vento Liaison (Carol Panagos, Director of Special Programs)
Date: _______________
Student Name: ____________________________________________________________
First
Middle
Unaccompanied youth? Yes  No
Last
Date of Birth: ___________
Age: ___ Grade: ___ Name of School: ______________________
Information obtained by: ______________________________________________________________________
Parent/Guardian Name: __________________________________________________________________________________
(Leave blank if student is unaccompanied)
Nighttime address: ______________________________________________________________________________________
Street
City
Zip
Contact phone: __________________________ Email: _______________________________________________________
Where does the student stay at night? (Please check one box.)
“Doubled Up” with another family due to a loss of housing or economic hardship;
A motel/hotel;
At an emergency or transitional shelter;
Student is awaiting foster care placement;
In a location not usually used for sleeping accommodations; (cars, parks, campsite, public places, abandoned buildings,
substandard housing, transportation stations or similar settings)
Are there other children/siblings in the family who are also homeless? (names, ages, grade/school)
_______________________________________________________________________________________________
Are there programs the student(s) has been participating in or is in need of? (i.e., gifted, bilingual, special education
(IEP), 504, Title I/LAP, band, athletics, clubs) ____________________________________________________________
What school did the student(s) attend when permanently housed? _______________________________________
Is there any other information we need to know? ____________________________________________________
_______________________________________________________________________________________________
Does the student need assistance with any of the following?
Assistance acquiring previous school records
School Supplies
ECEAP for preschoolers
Medical/Dental
Other _________________________________
School Fees
Housing
BELOW FOR USE BY McKINNEY-VENTO HOMELESS LIAISON ONLY
Skyward
Unaccompanied Youth
Meals
Notify Admin/Counselor
____________________
Signature of School District
Liaison:__________________
Transportation:
E-Mail Transportation Department
ORCA Card
“In Lieu Of Agreement” & Expense Statement
Cooperating District
__________________________________
Correspondence:
Welcome Letter
National School Meal Program Eligibility Letter
Parent “In Lieu Of Agreement” and Letter
o Expense Statement forms
Re-Verification Letter for new school year
o Follow up telephone contact
Denial Letter and Appeals Disclosure
GRANITE FALLS SCHOOL DISTRICT #332
INTER-DISTRICT SCHOOL TRANSFER REQUEST
___________________________________________ ____________________________
Student Name
Birthdate
___________________________________________ ____________________________
Address
City
Home Telephone
My child will be a _____ grade student designated to attend __________________ school.
I hereby request that my child be permitted to attend _____________________________
school for the following reasons:
□ A financial, educational, safety, or health condition-please explain:
_______________________________________________________________________
□ There is some other special hardship or detrimental condition- please explain:
_______________________________________________________________________
□ Student has been suspended/expelled from previous school
□ Other________________________________________________________________
Check any needed services ESL___ Special Education ___ 504 ____ Hi-Cap___OT____
Title I____Speech____Counseling___Other____________________________________
I understand that:
1.
Approval of this application is for the specified year only;
2.
Approval is granted only if it does not create classroom overcrowding;
3.
Approval may be revoked if the student develops a pattern of disruptive behavior, nonattendance, tardiness.
______________________________________________ _________________________
Parent or Student Signature (if 18 years old)
Date
This section to be completed by transferring schools
□ Crossroads packet has been completed and approved
This transfer request is ____approved for the ____________school year.
This transfer request is ____ denied for the ___________school year for the following reason(s):
________________________________________________________________________
______________________________________________ ________________________
Receiving School
Date
______________________________________________ ________________________
Releasing School
Date
CROSSROADS HIGH SCHOOL
REGISTRAR’S OFFICE
Connie Workman
Phone 360-283-4012
Fax 360-283-4307
Crossroads High School
205 North Alder Avenue
Granite Falls, WA 98252
REQUEST FOR STUDENT RECORDS
DATE: _________________________________________
NAME AND ADDRESS OF LAST SCHOOL OF ATTENDANCE:
____________________________________________________________ PHONE _________________________
____________________________________________________________ FAX ____________________________
_____________________________________________________________________________________________
STUDENT NAME: ______________________________________________________________________________
GRADE: ____________________
BIRTHDATE: __________________________
Request for Transfer of Educational, Psychological, Medical, and Other Confidential Records between Schools:
PLEASE FAX:
1. Official Transcript of grades and credits.
2. Withdrawal grades to date of leaving for work in progress.
(Please include attendance record to date of withdrawal.)
3. WASL, HSPE, EOC, and any other Standard tests.
4. Student portfolio project.
5. BECCA petition information/applicable truancy files.
6. Immunization and health records.
7. Psychological, Special Service, and other confidential records.
8. Community service hours and documentation.
PLEASE MAIL:
Entire CUM file (to include all of the above.)
REGISTRAR ___________________________________________________________________________________
PARENT OR GUARDIAN SIGNATURE _____________________________________________ DATE _____________
12/2014
Granite Falls School District Electronic Network Use Agreement
(Revised 8-21-2000)
As a condition of my right to use the electronic data network in the Granite Falls School District, the K-20 network and the Internet, I understand and agree to the following:
1.
The use of electronic networks in the Granite Falls School District is a privilege that may be revoked by the Granite Falls School District, the Washington School Information Processing Cooperative
(WSIPC), or other administrators of the K-20 network at any time for violation of the following conditions of use.
a.
Abusive conduct is prohibited. Abusive conduct includes but is not limited to:
-
Placing unlawful information on the network
Damaging computers, computer systems, or computer networks
Improperly accessing or misusing the files for other users
Harassing, insulting or attacking others
Using obscene, abusive or otherwise offensive or objectionable language in public or private messages.
b.
Communication intended to facilitate commercial, political, religious, or illegal activities is prohibited.
c.
Violating copyright and trademark laws is prohibited.
d.
Transmitting or intentionally receiving sexually explicit or other material generally considered inappropriate for use in school is prohibited.
e.
Revealing any user’s personal details to users outside the Granite Falls School District network is prohibited. This includes, but is not limited to, phone number, address, or
physical description.
f.
Any user identified as a security risk or having a history of problems with other computer systems may be denied network access.
g.
If a user can identify a security problem on the local District network, or elsewhere on the Internet, the user must notify the System Administrator. Any user found exploiting a security
problem, or demonstrating a security problem to users other than the System Administrator will lose network access.
h.
Individual accounts are issued to one and only one user. The use of another user’s account or allowing others to use one’s own account is strictly prohibited. The user is liable for any
use of the account. Only the user and System Administrators will have access to users’ accounts. Passwords will conform to security guidelines and remain confidential.
i.
Installing unauthorized software for use on district computers is prohibited.
j.
Vandalism will result in loss of access. Vandalism is defined as any malicious attempt to harm or destroy data. This includes, but is not limited to, the uploading or creation of software with
malicious intent (viruses, etc.). Vandalism also includes the altering or reconfiguring of any network hardware, except under supervision of the System Administrator.
k.
Resale, lease, or intentionally wasting of the local District network or K-20 shared bandwidth, electronics, or other equipment is strictly prohibited.
2.
The Granite Falls School District and/or WSIPC will be the sole arbiter(s) of what constitutes abusive conduct or violation of Granite Falls School District or K-20 policies.
3.
WSIPC and/or the Granite Falls School District staff has the right to review any material stored on the network and to remove any materials which they, in their sole discretion, believe may be unlawful,
obscene, abusive, or otherwise objectionable, and I hereby waive any right to privacy which I may otherwise have in and to such material.
4.
The Granite Falls School District has the right to monitor storage disk space utilization by users and limit it as necessary.
5.
That all information and services contained on the network is placed there for general information purposes and is, in no way intended to refer to, or be applicable to, any specific person, case or
situation.
6.
The Granite Falls School District and/or WSIPC will not be liable for any damages due to information gained and/or obtained via use of the Granite Falls School District electronic network, including
without limitation access to public networks.
7.
The Granite Falls School District does not guarantee that the network will be error free and that services will be uninterruptible. The Granite Falls School District and/or WSIPC will not be liable for
any loss of data or inability to use the network.
8.
The user will abide by such rules and regulations of usage as may be promulgated from time to time by WSIPC and/or the administrators of K-20, including, without limitation, K-20
Acceptable Use Policy.
9.
In consideration for the privilege of using the K-20 network and in consideration for having access to public networks, I hereby release WSIPC and/or the Granite Falls School District, its operators,
and any institutions with which they are affiliated from any and all claims and damages of any nature arising from my use, or inability to use, K-20, including, without limitation, the types of damages
identified in paragraphs 4 and 5 above.
10.
The Granite Fall School District reserves the right to revoke and deny access at its discretion.
I understand and will abide by the above Use Agreement. I further understand that any violation of the regulations above is unethical and may constitute a criminal offense. Should I commit any violation of the
terms and conditions herein, my access privileges may be revoked, school disciplinary action and/or appropriate legal action may be taken.
(Please Print) First Name
User Signature
Last Name
Middle Initial
Date
PARENT OR GUARDIAN
*(If the user is under the age of 18, a parent or guardian must also read and sign this agreement.)
As the parent or guardian of this student, I have read the Electronic Network User Agreement. I understand that this access is designed for educational purposes. Granite Falls School District has taken
precautions to eliminate sexually explicit material. However, I also recognize it is impossible for the Granite Falls School District to completely prevent access to these and other controversial materials and I
will not hold them responsible for materials acquired on the network. Further, I accept full responsibility for supervision if and when my child’s use is not in a school setting. I hereby give permission to issue
an account for my child and certify that the information contained on this form is correct.
(Please Print) Parent or Guardian’s Name
Parent or Guardian Signature
Date
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