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<!-- [et_pb_line_break_holder] --><!DOCTYPE html><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><html xmlns="http://www.w3.org/1999/xhtml"><!-- [et_pb_line_break_holder] --><head><!-- [et_pb_line_break_holder] --><meta charset="utf-8"/><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1"/><!-- [et_pb_line_break_holder] --><link rel="stylesheet" href="base.min.css"/><!-- [et_pb_line_break_holder] --><link rel="stylesheet" href="fancy.min.css"/><!-- [et_pb_line_break_holder] --><link rel="stylesheet" href="main.css"/><!-- [et_pb_line_break_holder] --><script src="compatibility.min.js"></script><!-- [et_pb_line_break_holder] --><script src="theViewer.min.js"></script><!-- [et_pb_line_break_holder] --><script><!-- [et_pb_line_break_holder] -->try{<!-- [et_pb_line_break_holder] -->theViewer.defaultViewer = new theViewer.Viewer({});<!-- [et_pb_line_break_holder] -->}catch(e){}<!-- [et_pb_line_break_holder] --></script><!-- [et_pb_line_break_holder] --><title></title><!-- [et_pb_line_break_holder] --></head><!-- [et_pb_line_break_holder] --><body><!-- [et_pb_line_break_holder] --><div id="sidebar"><!-- [et_pb_line_break_holder] --><div id="outline"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div id="page-container"><!-- [et_pb_line_break_holder] --><div id="pf1" class="pf w0 h0" data-page-no="1"><div class="pc pc1 w0 h0"><img class="bi x0 y0 w1 h1" alt="" src="bg1.png"/><div class="t m0 x1 h2 y1 ff1 fs0 fc0 sc0 ls0 ws0">Dec. 2017 </div><div class="t m0 x2 h3 y2 ff2 fs0 fc0 sc0 ls0 ws0">LA CENTER SCHOOL DISTRICT NO. 101 </div><div class="t m0 x3 h4 y3 ff2 fs1 fc0 sc0 ls0 ws0">La Center Ele<span class="_ _0"></span>mentary School Reg<span class="_ _0"></span>istration </div><div class="t m0 x4 h4 y4 ff2 fs1 fc0 sc0 ls0 ws0">PO Box 1810 <span class="ff3 sc1"></span> 700 Eas<span class="_ _0"></span>t 4</div><div class="t m0 x5 h5 y5 ff2 fs2 fc0 sc0 ls1 ws0">th</div><div class="t m0 x6 h4 y4 ff2 fs1 fc0 sc0 ls0 ws0"> Avenue </div><div class="t m0 x7 h4 y6 ff2 fs1 fc0 sc0 ls0 ws0">La Center, WA 9862<span class="_ _0"></span>9 </div><div class="t m0 x8 h3 y7 ff2 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y8 ff1 fs0 fc0 sc0 ls0 ws0">Date: __________________________ </div><div class="t m0 x9 h2 y9 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 ya ff1 fs0 fc0 sc0 ls0 ws0">School Entry Date: _______________ Returning Student? Yes/No Date last attended: _________________ </div><div class="t m0 x9 h2 yb ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 yc ff1 fs0 fc0 sc0 ls0 ws0">Student's Legal Last Name: ________________ Legal First Name: ______________Middle: ______________ </div><div class="t m0 x9 h2 yd ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 ye ff1 fs0 fc0 sc0 ls0 ws0">Grade Level: ______Sex: ____ Home Phone: _______________________Birth Date: ___________________ </div><div class="t m0 x9 h2 yf ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h3 y10 ff2 fs0 fc0 sc0 ls0 ws0">PRIMARY HOUSEHOLD<span class="ff1"> </span></div><div class="t m0 x9 h2 y11 ff1 fs0 fc0 sc0 ls0 ws0">Guardian #1 Last Name: ___________________ First Name: ________________Relationship: ___________ </div><div class="t m0 x9 h2 y12 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y13 ff1 fs0 fc0 sc0 ls0 ws0">Cell phone #: ___________________ Work Phone #: _______________________ Ext __________________ </div><div class="t m0 x9 h2 y14 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y15 ff1 fs0 fc0 sc0 ls0 ws0">Guardian #2 Last Name: ___________________First Name: _________________Relationship: ___________ </div><div class="t m0 x9 h2 y16 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y17 ff1 fs0 fc0 sc0 ls0 ws0">Cell phone #: ___________________ Work Phone #: _______________________ Ext __________________ </div><div class="t m0 x9 h2 y18 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y19 ff1 fs0 fc0 sc0 ls0 ws0">Mailing Address: ___________________________City: _________________ Zip Code: ________________ </div><div class="t m0 x9 h2 y1a ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y1b ff1 fs0 fc0 sc0 ls0 ws0">Street Address: ____________________________ Cit<span class="_ _1"></span>y<span class="_ _0"></span>: _________________ Zip Code: ________________ </div><div class="t m0 x9 h2 y1c ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y1d ff1 fs3 fc0 sc0 ls0 ws0">Guardian 1 e-mail add<span class="_ _1"></span>ress:<span class="fs0"> ________________________ </span>Guardian 2<span class="_ _1"></span> e-mail addr<span class="_ _1"></span>ess: ___<span class="_ _1"></span>__________<span class="_ _1"></span>____________<span class="_ _1"></span>________ </div><div class="t m0 x9 h2 y1e ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h3 y1f ff2 fs0 fc0 sc0 ls0 ws0">ALTERNATE HOUSEHOLD <span class="ff1">(if applicable</span>) </div><div class="t m0 x9 h2 y20 ff1 fs0 fc0 sc0 ls0 ws0">Guardian #1 Last Name: ____________________First Name: _________________Relationship: ___________ </div><div class="t m0 x9 h2 y21 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y22 ff1 fs0 fc0 sc0 ls0 ws0">Primary phone: _______________________ Cell phone #: ___________________ Work Phone #: __________ </div><div class="t m0 x9 h2 y23 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y24 ff1 fs0 fc0 sc0 ls0 ws0">Guardian #2 Last Name: ____________________First Name: _________________Relationship: ___________ </div><div class="t m0 x9 h2 y25 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y26 ff1 fs0 fc0 sc0 ls0 ws0">Cell phone #: ________________________ Work Phone # ____________________ Ext #_________________ </div><div class="t m0 x9 h2 y27 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y28 ff1 fs0 fc0 sc0 ls0 ws0">Mailing address: ___________________________City: _________________________Zip Code: __________ </div><div class="t m0 x9 h2 y29 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y2a ff1 fs0 fc0 sc0 ls0 ws0">Home address: ____________________________City: _________________________Zip Code: ___________ </div><div class="t m0 x9 h2 y2b ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y2c ff1 fs3 fc0 sc0 ls0 ws0">Guardian 1 e-mail add<span class="_ _1"></span>ress:<span class="fs0"> ________________________ </span>Guardian 2<span class="_ _1"></span> e-mail addr<span class="_ _1"></span>ess: ___<span class="_ _1"></span>__________<span class="_ _1"></span>____________<span class="_ _1"></span>________<span class="fs0"> </span></div><div class="t m0 x9 h2 y2d ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y2e ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h3 y2f ff2 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y30 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y31 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y32 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y33 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h3 y34 ff2 fs0 fc0 sc0 ls0 ws0"> (Office use only) <span class="ff1">Student # __________________ Teacher: __________________ Bus #: _____________ </span></div><div class="t m0 x9 h2 y35 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="c x0 y36 w2 h6"><div class="t m0 xa h4 y37 ff2 fs1 fc0 sc0 ls0 ws0">Legal Restriction<span class="_ _0"></span>s: <span class="ff1">Are there any<span class="_ _0"></span> current Washing<span class="_ _0"></span>ton State restraining<span class="_ _0"></span> orders or leg<span class="_ _0"></span>al restrictions in e<span class="_ _0"></span>ffect prev<span class="_ _0"></span>enting a </span></div><div class="t m0 xa h7 y38 ff1 fs1 fc0 sc0 ls0 ws0">non-custodial perso<span class="_ _0"></span>n from<span class="_ _0"></span> visiting the schoo<span class="_ _0"></span>l, having access to sc<span class="_ _0"></span>hool repor<span class="_ _0"></span>ts/records or removing<span class="_ _0"></span> your student from </div><div class="t m0 xa h4 y39 ff1 fs1 fc0 sc0 ls0 ws0">school? Yes___ No__<span class="_ _0"></span>_ <span class="ff2">If yes, lega<span class="_ _0"></span>l papers <span class="_ _0"></span>must be on <span class="_ _0"></span>file with the school. </span></div><div class="t m0 xa h7 y3a ff1 fs1 fc0 sc0 ls0 ws0">If yes, who is <span class="_ _0"></span>the order against<span class="_ _0"></span>:__________________<span class="_ _0"></span>__________<span class="_ _0"></span>____________<span class="_ _0"></span>_ Relation<span class="_ _0"></span>ship to studen<span class="_ _0"></span>t:___________ </div></div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf2" class="pf w0 h0" data-page-no="2"><div class="pc pc2 w0 h0"><img class="bi xb y3b w3 h8" alt="" src="bg2.png"/><div class="t m0 x1 h2 y1 ff1 fs0 fc0 sc0 ls0 ws0">Dec. 2017 </div><div class="t m0 x9 h9 y3c ff1 fs4 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 ha y3d ff2 fs4 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 ha y3e ff2 fs4 fc0 sc0 ls0 ws0">Emergency cont<span class="_ _0"></span>acts are contacted <span class="_ _0"></span>in the event th<span class="_ _0"></span>at we ar<span class="_ _0"></span>e unable to re<span class="_ _0"></span>ach parent/<span class="_ _0"></span>guardian. Pleas<span class="_ _0"></span>e list ind<span class="_ _0"></span>ividuals t<span class="_ _1"></span>hat live in th<span class="_ _0"></span>e local area i<span class="_ _0"></span>f possible. </div><div class="t m0 x9 ha y3f ff2 fs4 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y40 ff1 fs3 fc0 sc0 ls0 ws0">Emergency Contact <span class="_ _1"></span> <span class="ls2">#1:</span><span class="fs0"> __________________ </span>Phone #:<span class="fs0"> ______________</span> Relati<span class="_ _1"></span>onship<span class="fs0">: ________</span>P<span class="_ _1"></span>ick up any time? Yes/No<span class="_ _1"></span> </div><div class="t m0 x9 hb y41 ff1 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y42 ff1 fs3 fc0 sc0 ls0 ws0">Emergency Contact #<span class="_ _1"></span>2:<span class="fs0"> __________________ </span>P<span class="_ _1"></span>hone #:<span class="fs0"> ______________</span> Relatio<span class="_ _1"></span>nship<span class="fs0">: ________</span>Pick up an<span class="_ _1"></span>y time? Yes/No<span class="_ _1"></span> </div><div class="t m0 x9 hb y43 ff1 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y44 ff1 fs3 fc0 sc0 ls0 ws0">Emergency Contact #<span class="_ _1"></span>3:<span class="fs0"> __________________ </span>P<span class="_ _1"></span>hone #:<span class="fs0"> ______________</span> Relatio<span class="_ _1"></span>nship<span class="fs0">: ________</span>Pick up an<span class="_ _1"></span>y time? Yes/No<span class="_ _1"></span> </div><div class="t m0 x9 hb y45 ff1 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y46 ff1 fs3 fc0 sc0 ls0 ws0">Will your child <span class="_ _1"></span>ride the bus to<span class="_ _1"></span> <span class="ls3">an</span> after school da<span class="_ _1"></span>ycare provider?<span class="_ _1"></span><span class="fs0"> Yes/No Daycare Provider: _______________________ </span></div><div class="t m0 x9 h2 y47 ff1 fs0 fc0 sc0 ls0 ws0">Phone #: _____________________Address:______________________________________________________ </div><div class="t m0 x9 h2 y48 ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h2 y49 ff1 fs0 fc0 sc0 ls0 ws0">Other siblings you are enrolling or that are enrolled in La Center School District: </div><div class="t m0 x9 h2 y4a ff1 fs0 fc0 sc0 ls0 ws0">Name <span class="_ _2"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span>Grade </div><div class="t m0 x9 h2 y4b ff1 fs0 fc0 sc0 ls0 ws0">__________________________________________________________________________________________ </div><div class="t m0 x9 h2 y4c ff1 fs0 fc0 sc0 ls0 ws0">__________________________________________________________________________________________ </div><div class="t m0 x9 h2 y4d ff1 fs0 fc0 sc0 ls0 ws0">__________________________________________________________________________________________ </div><div class="t m0 x9 h2 y4e ff1 fs0 fc0 sc0 ls0 ws0">__________________________________________________________________________________________ </div><div class="t m0 x9 h2 y4f ff1 fs0 fc0 sc0 ls0 ws0">For the past five (5) years, the student has attended the following<span class="_ _0"></span> schools:<span class="_ _1"></span> </div><div class="t m0 x9 h2 y50 ff1 fs0 fc0 sc0 ls0 ws0">Date entered <span class="_ _4"> </span> Name of School <span class="_ _5"> </span> <span class="_ _3"> </span> City, State <span class="_ _6"></span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> Date withdrawn </div><div class="t m0 x9 h2 y51 ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________</div><div class="t m0 x9 h2 y52 ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________</div><div class="t m0 x9 h2 y53 ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________</div><div class="t m0 x9 h2 y54 ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________ </div><div class="t m0 x9 h3 y55 ff2 fs0 fc0 sc0 ls0 ws0">Has student ever been enrolled in a special program? Yes/ No If yes, please indicate wh<span class="_ _1"></span>ich program<span class="_ _0"></span>: </div><div class="t m0 x9 h3 y56 ff2 fs0 fc0 sc0 ls0 ws0">Gifted/TAG ___ Remedial Math (LAP) ___ Remedial Reading (Title 1) ____ Special Ed.<span class="_ _1"></span>___ IEP ___ </div><div class="t m0 x9 h3 y57 ff2 fs0 fc0 sc0 ls0 ws0">Section 504 ___ ESL/ELL: ___ </div><div class="t m0 x9 h2 y58 ff1 fs0 fc0 sc0 ls0 ws0">Does the student have past, current or pending, disciplinary action? Yes/No </div><div class="t m0 x9 h2 y59 ff1 fs0 fc0 sc0 ls0 ws0">Is student currently suspended or expelled from the previous school district? Yes/<span class="ls4">No</span> </div><div class="t m0 x9 h2 y5a ff1 fs0 fc0 sc0 ls0 ws0">History of violent behavior: Yes/No If yes, please explain __________________________________________ </div><div class="t m0 x9 h2 y5b ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________</div><div class="t m0 x9 h2 y5c ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________</div><div class="t m0 x9 h2 y5d ff1 fs0 fc0 sc0 ls0 ws0">___________________________________________________________________________________________ </div><div class="t m0 x9 h2 y5e ff1 fs0 fc0 sc0 ls0 ws0">Unpaid fines or fees imposed by other schools: Yes/No </div><div class="t m0 x9 h2 y5f ff1 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 hc y60 ff2 fs3 fc0 sc0 ls0 ws0">Student Release Aut<span class="_ _1"></span>horizati<span class="_ _1"></span><span class="ls2">on</span><span class="ff1">: In the event that the sc<span class="_ _1"></span>hool is unable to contact p<span class="_ _1"></span>arent/guardia<span class="_ _1"></span>n, I authorize that <span class="_ _1"></span>my child may be </span></div><div class="t m0 x9 hb y61 ff1 fs3 fc0 sc0 ls0 ws0">released to the e<span class="_ _1"></span>mergency contacts listed<span class="_ _1"></span>. </div><div class="t m0 x9 hb y62 ff1 fs3 fc0 sc0 ls0 ws0">Parent/Legal Guard<span class="_ _1"></span>ian signature:<span class="_ _1"></span> ___________<span class="_ _1"></span>________________<span class="_ _1"></span>_____________________<span class="_ _1"></span>______________<span class="_ _7"></span> </div><div class="t m0 x9 hb y63 ff1 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 hc y64 ff2 fs3 fc0 sc0 ls0 ws0">Emergency M<span class="_ _1"></span>edical Authoriza<span class="_ _1"></span>tion<span class="ff1">: I<span class="_ _1"></span> understand that in the event o<span class="_ _1"></span>f accident or illness, <span class="_ _1"></span>every effort will b<span class="_ _1"></span>e made to contact the </span></div><div class="t m0 x9 hb y65 ff1 fs3 fc0 sc0 ls0 ws0">parent/guardian immediatel<span class="_ _1"></span>y. If parent/guardian ca<span class="_ _1"></span>nnot be reached, I<span class="_ _1"></span> authorize the school <span class="_ _1"></span>to obtain e<span class="_ _1"></span>mergency care for my ch<span class="_ _7"></span>ild. <span class="_ _1"></span> </div><div class="t m0 x9 hb y66 ff1 fs3 fc0 sc0 ls0 ws0">Parent/Legal Guard<span class="_ _1"></span>ian signature:<span class="_ _1"></span> ___________<span class="_ _1"></span>________________<span class="_ _1"></span>_____________________<span class="_ _1"></span>______________<span class="_ _7"></span> </div><div class="t m0 x9 hb y67 ff1 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 hc y68 ff2 fs3 fc0 sc0 ls0 ws0">Verification of<span class="_ _1"></span> Information<span class="ff1">: <span class="_ _1"></span>The information on this <span class="_ _1"></span>form is true<span class="_ _1"></span> and accurate as o<span class="_ _1"></span>f this date<span class="_ _1"></span> </span></div><div class="t m0 x9 hb y69 ff1 fs3 fc0 sc0 ls0 ws0">Parent/Legal G<span class="_ _1"></span>uardian Signature<span class="_ _1"></span>: ____<span class="_ _1"></span>___________________<span class="_ _1"></span>___________<span class="_ _1"></span>_Relatio<span class="_ _1"></span>nship to Child ___<span class="_ _1"></span>____<span class="_ _1"></span><span class="ls5">__</span>____<span class="_ _1"></span>__ </div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf3" class="pf w0 h0" data-page-no="3"><div class="pc pc3 w0 h0"><img class="bi xc y6a w4 hd" alt="" src="bg3.png"/><div class="t m0 xd he y6b ff4 fs1 fc0 sc0 ls0 ws0">Mexican/Mexi<span class="_ _0"></span>can American<span class="_ _0"></span>/Chicano<span class="ff5"> </span></div><div class="t m0 xd he y6c ff4 fs1 fc0 sc0 ls0 ws0">Central American<span class="ff5"> </span></div><div class="t m0 xd he y6d ff4 fs1 fc0 sc0 ls0 ws0">South American<span class="ff5"> </span></div><div class="t m0 xd he y6e ff4 fs1 fc0 sc0 ls0 ws0">Lan American<span class="_ _0"></span><span class="ff5"> </span></div><div class="t m0 xd he y6f ff4 fs1 fc0 sc0 ls0 ws0">Other Hispanic<span class="_ _0"></span>/Lano<span class="ff5"> </span></div><div class="t m0 xe hf y70 ff6 fs5 fc0 sc0 ls0 ws0">La Cent<span class="_ _0"></span>er School Dis<span class="_ _0"></span>trict —<span class="ff7"> </span>E<span class="_ _0"></span>thnicity & Race Dat<span class="_ _0"></span>a Collecon For<span class="_ _0"></span>m<span class="ff8"> </span></div><div class="t m0 xf h10 y3 ff4 fs0 fc0 sc0 ls0 ws0">STUDENT____________________________________________ SCHOO<span class="_ _0"></span>L___________________ GRADE ________<span class="_ _1"></span><span class="ff5"> </span></div><div class="t m0 xb h11 y71 ff6 fs0 fc0 sc0 ls0 ws0">Please ll out both Queson 1 and Queson 2<span class="ff8"> </span></div><div class="t m0 xb h11 y72 ff6 fs0 fc0 sc0 ls0 ws0">Queson 1. <span class="ff4">I<span class="_ _1"></span>s y<span class="_ _1"></span>ou<span class="_ _1"></span>r st<span class="_ _1"></span>ud<span class="_ _1"></span>ent<span class="_ _1"></span> o<span class="_ _1"></span>f Hi<span class="_ _1"></span>s<span class="_ _1"></span>pa<span class="_ _1"></span>ni<span class="_ _1"></span>c or<span class="_ _1"></span> La<span class="_ _1"></span>n<span class="_ _1"></span>o o<span class="_ _1"></span>ri<span class="_ _1"></span>gin<span class="_ _1"></span>? (<span class="_ _1"></span>Check<span class="_ _1"></span> al<span class="_ _1"></span>l<span class="_ _1"></span> th<span class="_ _1"></span>a<span class="_ _1"></span>t ap<span class="_ _1"></span>p<span class="_ _1"></span>l<span class="_ _1"></span>y)<span class="_ _8"></span><span class="ff5"> </span></span></div><div class="t m0 x10 he y6b ff4 fs1 fc0 sc0 ls0 ws0">Not Hispanic/Lano<span class="_ _0"></span><span class="ff5"> </span></div><div class="t m0 x10 he y6c ff4 fs1 fc0 sc0 ls0 ws0">Cuban<span class="ff5"> </span></div><div class="t m0 x10 he y6d ff4 fs1 fc0 sc0 ls0 ws0">Dominican<span class="ff5"> </span></div><div class="t m0 x10 he y6e ff4 fs1 fc0 sc0 ls0 ws0">Spaniard<span class="ff5"> </span></div><div class="t m0 x10 he y6f ff4 fs1 fc0 sc0 ls0 ws0">Puerto Rico<span class="ff5"> </span></div><div class="t m0 x11 h11 y73 ff6 fs0 fc0 sc0 ls0 ws0">Queson 2. <span class="ff4">W<span class="_ _1"></span>ha<span class="_ _1"></span>t r<span class="_ _1"></span>ace(s<span class="_ _1"></span>) d<span class="_ _1"></span>o <span class="_ _1"></span>yo<span class="_ _1"></span>u con<span class="_ _1"></span>si<span class="_ _1"></span>d<span class="_ _1"></span>er y<span class="_ _1"></span>ou<span class="_ _1"></span>r st<span class="_ _1"></span>ud<span class="_ _1"></span>en<span class="_ _1"></span>t? (Ch<span class="_ _1"></span>eck<span class="_ _1"></span> a<span class="_ _1"></span>ll<span class="_ _1"></span> th<span class="_ _1"></span>at<span class="_ _1"></span> ap<span class="_ _1"></span>p<span class="_ _1"></span>l<span class="_ _1"></span>y)<span class="_ _8"></span><span class="ff5"> </span></span></div><div class="t m0 x12 h12 y74 ff4 fs3 fc0 sc0 ls0 ws0">African American/Black<span class="_ _1"></span><span class="ff5"> </span></div><div class="t m0 x12 h12 y75 ff4 fs3 fc0 sc0 ls0 ws0">White<span class="ff5"> </span></div><div class="t m0 x12 h12 y76 ff4 fs3 fc0 sc0 ls0 ws0">Asian/Indian<span class="ff5"> </span></div><div class="t m0 x12 h12 y77 ff4 fs3 fc0 sc0 ls0 ws0">Cambodian<span class="ff5"> </span></div><div class="t m0 x12 h12 y78 ff4 fs3 fc0 sc0 ls0 ws0">Chinese<span class="ff5"> </span></div><div class="t m0 x12 h12 y79 ff4 fs3 fc0 sc0 ls0 ws0">Filipino<span class="ff5"> </span></div><div class="t m0 x12 h12 y7a ff4 fs3 fc0 sc0 ls0 ws0">Hmong<span class="ff5"> </span></div><div class="t m0 x12 h12 y7b ff4 fs3 fc0 sc0 ls0 ws0">Indonesian<span class="ff5"> </span></div><div class="t m0 x12 h12 y7c ff4 fs3 fc0 sc0 ls0 ws0">Japanese<span class="ff5"> </span></div><div class="t m0 x12 h12 y7d ff4 fs3 fc0 sc0 ls0 ws0">Korean<span class="ff5"> </span></div><div class="t m0 x12 h12 y7e ff4 fs3 fc0 sc0 ls0 ws0">Laoan<span class="ff5"> </span></div><div class="t m0 x12 h12 y7f ff4 fs3 fc0 sc0 ls0 ws0">Malaysian<span class="ff5"> </span></div><div class="t m0 x12 h12 y80 ff4 fs3 fc0 sc0 ls0 ws0">Pakistani<span class="ff5"> </span></div><div class="t m0 x12 h12 y81 ff4 fs3 fc0 sc0 ls0 ws0">Singaporean<span class="ff5"> </span></div><div class="t m0 x12 h12 y82 ff4 fs3 fc0 sc0 ls0 ws0">Taiwanese<span class="ff5"> </span></div><div class="t m0 x12 h12 y83 ff4 fs3 fc0 sc0 ls0 ws0">Thai<span class="ff5"> </span></div><div class="t m0 x12 h12 y84 ff4 fs3 fc0 sc0 ls0 ws0">Vietnamese<span class="ff5"> </span></div><div class="t m0 x12 h13 y85 ff4 fs6 fc0 sc0 ls0 ws0">Other Asian<span class="ff5"> </span></div><div class="t m0 x12 h12 y86 ff4 fs3 fc0 sc0 ls0 ws0">Nave Hawaiian<span class="ff5"> </span></div><div class="t m0 x12 h12 y87 ff4 fs3 fc0 sc0 ls0 ws0">Fijian<span class="ff5"> </span></div><div class="t m0 x12 h12 y88 ff4 fs3 fc0 sc0 ls0 ws0">Guamanian or Chamorro<span class="_ _1"></span><span class="ff5"> </span></div><div class="t m0 x12 h12 y89 ff4 fs3 fc0 sc0 ls0 ws0">Mariana Islander<span class="_ _1"></span><span class="ff5"> </span></div><div class="t m0 x12 h12 y8a ff4 fs3 fc0 sc0 ls0 ws0">Melanesian<span class="ff5"> </span></div><div class="t m0 x12 h12 y8b ff4 fs3 fc0 sc0 ls0 ws0">Micronesian<span class="ff5"> </span></div><div class="t m0 x12 h12 y8c ff4 fs3 fc0 sc0 ls0 ws0">Samoan<span class="ff5"> </span></div><div class="t m0 x12 h12 y8d ff4 fs3 fc0 sc0 ls0 ws0">Tongan<span class="ff5"> </span></div><div class="t m0 x12 h12 y8e ff4 fs3 fc0 sc0 ls0 ws0">Other Pacic Islander<span class="_ _1"></span><span class="ff5"> </span></div><div class="t m0 x13 h12 y8f ff4 fs3 fc0 sc0 ls0 ws0">Alaskan Nave<span class="_ _1"></span><span class="ff5"> </span></div><div class="t m0 x13 h12 y90 ff4 fs3 fc0 sc0 ls0 ws0">Chehalis<span class="ff5"> </span></div><div class="t m0 x13 he y91 ff4 fs1 fc0 sc0 ls0 ws0">Colville<span class="ff5"> </span></div><div class="t m0 x13 he y92 ff4 fs1 fc0 sc0 ls0 ws0">Cowlitz<span class="ff5"> </span></div><div class="t m0 x13 he y93 ff4 fs1 fc0 sc0 ls0 ws0">Hoh<span class="ff5"> </span></div><div class="t m0 x13 he y94 ff4 fs1 fc0 sc0 ls0 ws0">Jamestown<span class="ff5"> </span></div><div class="t m0 x13 he y95 ff4 fs1 fc0 sc0 ls0 ws0">Kalilspell<span class="ff5"> </span></div><div class="t m0 x13 h14 y96 ff4 fs7 fc0 sc0 ls0 ws0">Lower Elwha<span class="_ _0"></span><span class="ff5"> </span></div><div class="t m0 x13 he y97 ff4 fs1 fc0 sc0 ls0 ws0">Lummi<span class="ff5"> </span></div><div class="t m0 x13 he y98 ff4 fs1 fc0 sc0 ls0 ws0">Makah<span class="ff5"> </span></div><div class="t m0 x13 he y99 ff4 fs1 fc0 sc0 ls0 ws0">Muckleshoot<span class="ff5"> </span></div><div class="t m0 x13 he y24 ff4 fs1 fc0 sc0 ls0 ws0">Nisqually<span class="ff5"> </span></div><div class="t m0 x13 he y9a ff4 fs1 fc0 sc0 ls0 ws0">Nooksack<span class="ff5"> </span></div><div class="t m0 x13 he y9b ff4 fs1 fc0 sc0 ls0 ws0">Port Gamble Klella<span class="_ _0"></span>m<span class="ff5"> </span></div><div class="t m0 x13 he y9c ff4 fs1 fc0 sc0 ls0 ws0">Puyallup<span class="ff5"> </span></div><div class="t m0 x13 he y9d ff4 fs1 fc0 sc0 ls0 ws0">Quilleute<span class="ff5"> </span></div><div class="t m0 x13 he y9e ff4 fs1 fc0 sc0 ls0 ws0">Quinault<span class="ff5"> </span></div><div class="t m0 x13 he y9f ff4 fs1 fc0 sc0 ls0 ws0">Samish<span class="ff5"> </span></div><div class="t m0 x13 he ya0 ff4 fs1 fc0 sc0 ls0 ws0">Sauk<span class="ff5">-</span>Suiale<span class="ff5"> </span></div><div class="t m0 x13 he ya1 ff4 fs1 fc0 sc0 ls0 ws0">Shoalwater<span class="ff5"> </span></div><div class="t m0 x13 he ya2 ff4 fs1 fc0 sc0 ls0 ws0">Skokomish<span class="ff5"> </span></div><div class="t m0 x13 he ya3 ff4 fs1 fc0 sc0 ls0 ws0">Snoqualimie<span class="ff5"> </span></div><div class="t m0 x13 he ya4 ff4 fs1 fc0 sc0 ls0 ws0">Spokane<span class="ff5"> </span></div><div class="t m0 x13 he ya5 ff4 fs1 fc0 sc0 ls0 ws0">Squaxin Island<span class="ff5"> </span></div><div class="t m0 x13 h14 ya6 ff4 fs7 fc0 sc0 ls0 ws0">Sllaguamish<span class="_ _0"></span><span class="ff5"> </span></div><div class="t m0 x14 he ya7 ff4 fs1 fc0 sc0 ls0 ws0">Suquamish<span class="ff5"> </span></div><div class="t m0 x14 he ya8 ff4 fs1 fc0 sc0 ls0 ws0">Swinomish<span class="ff5"> </span></div><div class="t m0 x14 he ya9 ff4 fs1 fc0 sc0 ls0 ws0">Tulaup<span class="ff5"> </span></div><div class="t m0 x14 he yaa ff4 fs1 fc0 sc0 ls0 ws0">Yakima<span class="ff5"> </span></div><div class="t m0 x14 he yab ff4 fs1 fc0 sc0 ls0 ws0">Other Washington Indian<span class="_ _0"></span><span class="ff5"> </span></div><div class="t m0 x14 he yac ff4 fs1 fc0 sc0 ls0 ws0">Other American Indian/Alaska </div><div class="t m0 x14 he yad ff4 fs1 fc0 sc0 ls0 ws0">Nave<span class="ff5"> </span></div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf4" class="pf w0 h0" data-page-no="4"><div class="pc pc4 w0 h0"><img class="bi x15 yae w5 h15" alt="" src="bg4.png"/><div class="t m0 x16 he yaf ff9 fs1 fc0 sc0 ls0 ws0">Dec. 2017 </div><div class="t m0 x15 he yb0 ff9 fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 x4 h16 yb1 ff9 fs8 fc0 sc0 ls0 ws0">La Center School Dist<span class="_ _1"></span>rict </div><div class="t m0 x17 h17 yb2 ffa fs9 fc0 sc0 ls0 ws0">RESIDENCY VERI<span class="_ _0"></span>FICATION DECLARATION<span class="_ _0"></span> FORM </div><div class="t m0 x18 h12 yb3 ff9 fs3 fc0 sc0 ls0 ws0">(Please complete one <span class="_ _1"></span>form for each student)<span class="_ _1"></span> </div><div class="t m0 x10 h18 yb4 ffb fs4 fc0 sc0 ls0 ws0"> HOME O<span class="_ _0"></span>WNER <span class="_ _9"> </span> <span class="_ _a"> </span> </div><div class="t m0 x10 h18 yb5 ffb fs4 fc0 sc0 ls0 ws0"> RENTER </div><div class="t m0 x10 h18 yb6 ffb fs4 fc0 sc0 ls0 ws0"> OTHER (spe<span class="_ _0"></span>cify) _<span class="ls6">_______________________________________<span class="_ _1"></span>________________________<span class="_ _1"></span></span> </div><div class="t m0 x15 h18 yb7 ffb fs4 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h19 yb8 ffb fsa fc0 sc0 ls0 ws0">W<span class="_ _1"></span>ashington law<span class="_ _0"></span> requires schools to be open to the admission of all persons between the ages <span class="_ _1"></span><span class="ls7">of</span> 5 and 21 residing in that </div><div class="t m0 x15 h19 yb9 ffb fsa fc0 sc0 ls0 ws0">school district (RCW 28A.225.160). The La Center School District (District) is required to take appropriate steps to ensure that </div><div class="t m0 x15 h19 yba ffb fsa fc0 sc0 ls0 ws0">students attending its schools satisfy applicable laws. T<span class="_ _0"></span>his Residency Verification Form must be completed<span class="_ _1"></span>, <span class="_ _1"></span>signed, and </div><div class="t m0 x15 h19 ybb ffb fsa fc0 sc0 ls0 ws0">submitted with appropriate documentation demonstrating co<span class="_ _0"></span>mpliance with Washington residency laws. <span class="_ _1"></span> </div><div class="t m0 x15 h18 ybc ffb fs4 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h1a ybd ffc fs4 fc0 sc0 ls0 ws0">DO NOT SIGN<span class="_ _0"></span> THIS FOR<span class="_ _0"></span>M IF ANY OF THE STA<span class="_ _0"></span>TEMENTS A<span class="_ _0"></span>RE INCOR<span class="_ _0"></span>RECT<span class="ffb">. Evidence that<span class="_ _0"></span> false information<span class="_ _0"></span> was provide<span class="_ _0"></span>d may be cause </span></div><div class="t m0 x15 h18 ybe ffb fs4 fc0 sc0 ls0 ws0">for immediate re<span class="_ _0"></span>vocation of the<span class="_ _0"></span> student’s s<span class="_ _0"></span>chool assign<span class="_ _0"></span>ment and withdraw<span class="_ _0"></span>al from the District<span class="_ _0"></span>. </div><div class="t m0 x19 h1b ybf ffb fs3 fc0 sc0 ls8 ws0"> <span class="ls0">Current<span class="_ _1"></span> <span class="_ _1"></span> C<span class="_ _1"></span>urrent </span></div><div class="t m0 x15 h1b yc0 ffb fs3 fc0 sc0 ls0 ws0">Student: ________<span class="_ _1"></span>________________<span class="_ _1"></span>_____<span class="_ _1"></span>_______<span class="_ _1"></span> School: ______<span class="_ _1"></span>_________<span class="_ _1"></span>_____ Grad<span class="_ _1"></span>e: _______<span class="_ _1"></span> </div><div class="t m0 x15 h1b yc1 ffb fs3 fc0 sc0 ls0 ws0"> <span class="_ _b"> </span> <span class="_ _3"> </span><span class="fs2">Last <span class="_ _1"></span>Name <span class="_ _1"></span><span class="ls9"> <span class="_ _1"></span></span>First Name<span class="_ _1"></span> </span></div><div class="t m0 x15 h1b yc2 ffb fs3 fc0 sc0 ls0 ws0">Parent/Guardian: ____<span class="_ _1"></span>_______________<span class="_ _1"></span>__________<span class="_ _1"></span>____ Hom<span class="_ _1"></span>e Phone: ________________<span class="_ _1"></span>________<span class="_ _7"></span> </div><div class="t m0 x15 h1b yc3 ffb fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h1b y14 ffb fs3 fc0 sc0 ls0 ws0">Address<span class="ls8">: _</span>___<span class="_ _1"></span>______________<span class="_ _1"></span>______________<span class="_ _1"></span>_____________<span class="_ _7"></span>____________<span class="_ _1"></span>_____________<span class="_ _1"></span>______<span class="_ _1"></span> </div><div class="t m0 x15 h16 yc4 ff9 fs8 fc0 sc0 lsa ws0"> <span class="fs3 lsb"> <span class="ls0">Number</span> <span class="ls0">Stre<span class="_ _1"></span>et <span class="_ _c"> </span> <span class="_ _a"> </span> <span class="_ _a"> </span>City <span class="_ _1"></span> State <span class="_ _d"> </span> <span class="_ _a"> </span></span> <span class="_ _0"></span> <span class="ls0">Zip Code </span></span></div><div class="t m0 x15 h1b yc5 ffb fs3 fc0 sc0 ls0 ws0">Email Address<span class="_ _1"></span>: _____________<span class="_ _1"></span>______________<span class="_ _1"></span>___________<span class="_ _1"></span>___<span class="_ _1"></span> </div><div class="t m0 x15 h12 yc6 ff9 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h1c yc7 ff9 fsa fc0 sc0 ls0 ws0">NOTE: The District presumes that the person who enrolls a stude<span class="_ _0"></span>nt in school is the residential parent of<span class="_ _1"></span> the student. In circumstances in </div><div class="t m0 x15 h1c yc8 ff9 fsa fc0 sc0 ls0 ws0">which legal and physical custody of the student is shared between two parents, you must provide a certified copy of the court<span class="_ _0"></span> order </div><div class="t m0 x15 h1c yc9 ffd fsa fc0 sc0 ls0 ws0">identifying each parent’s respective legal and physical <span class="ff9">custody rights. You also must inform the District of any changes<span class="_ _0"></span> to the court <span class="_ _1"></span>order </span></div><div class="t m0 x15 h1c yca ff9 fsa fc0 sc0 ls0 ws0">within (5) days. </div><div class="t m0 x15 h1c ycb ff9 fsa fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 he y1c ff9 fs1 fc0 sc0 ls0 ws0">In compliance with <span class="_ _0"></span>WAC <span class="fs3 lsc">392<span class="ls0">-</span>137<span class="ls0">-115</span></span>, by signing below I acknowledge<span class="_ _0"></span> the followin<span class="_ _0"></span>g: </div><div class="t m0 x1a h1c ycc ffe fsa fc0 sc0 ls0 ws0"><span class="ffb"> <span class="_ _e"> </span><span class="ff9">My student (listed above) resides with me at leas<span class="_ _0"></span>t four (4) nights per week at the address listed abo<span class="_ _1"></span>ve which is my primary </span></span></div><div class="t m0 x1b h1c ycd ff9 fsa fc0 sc0 ls0 ws0">residence. </div><div class="t m0 x1a h1c yce ffe fsa fc0 sc0 ls0 ws0"><span class="ffb"> <span class="_ _e"> </span><span class="ff9">I agree to notify and provide updated proof of residency to the District/School with<span class="lsd">in</span> (5) da<span class="lse">ys</span> <span class="lsf">of</span> when I change my residence or </span></span></div><div class="t m0 x1b h1c ycf ff9 fsa fc0 sc0 ls0 ws0">that <span class="lsf">of</span> my student to a new address, either within<span class="_ _0"></span> or outside the District. <span class="_ _1"></span> </div><div class="t m0 x1a h1c yd0 ffe fsa fc0 sc0 ls0 ws0"><span class="ffb"> <span class="_ _e"> </span><span class="ff9">The District will investigate all cases where<span class="_ _0"></span> it has reason to believe that residency status has changed and/or false information has </span></span></div><div class="t m0 x1b h1c y98 ff9 fsa fc0 sc0 ls0 ws0">been provided, which may include home visits to verify residency. </div><div class="t m0 x1a h1c yd1 ffe fsa fc0 sc0 ls0 ws0"><span class="ffb"> <span class="_ _e"> </span><span class="ff9">Investigations that reveal students have enrolled<span class="_ _0"></span> on the basis of pro<span class="_ _1"></span>viding false information may result in the revocation of the </span></span></div><div class="t m0 x1b h1c yd2 ffd fsa fc0 sc0 ls0 ws0">student’s school assignment and <span class="ff9">withdrawal from the District. </span></div><div class="t m0 x1a h12 yd3 ffe fs3 fc0 sc0 ls0 ws0"><span class="ffb"> <span class="_ _f"> </span><span class="ff9 fsa">I have attached the following two (2) *Proof of Residency documents whi<span class="_ _0"></span>ch include my name and residential<span class="fs3"> ad<span class="_ _1"></span>dress.<span class="_ _1"></span> </span></span></span></div><div class="t m0 x15 h12 yd4 ff9 fs3 fc0 sc0 ls0 ws0"> <span class="_ _a"> </span> </div><div class="t m0 x1c h12 yd5 ff9 fs3 fc0 sc0 lsb ws0"> <span class="ls0">Current payroll check stub<span class="_ _1"></span> with name an<span class="_ _1"></span>d address<span class="_ _1"></span> <span class="_ _10"> </span><span class="ffa"> </span>Mortgage, rental or lea<span class="_ _1"></span>se documents<span class="_ _1"></span> </span></div><div class="t m0 x1c h12 yd6 ff9 fs3 fc0 sc0 lsb ws0"> <span class="ls0">Government issued check o<span class="_ _1"></span>r correspondence<span class="_ _1"></span> <span class="_ _11"> </span> <span class="_ _12"> </span><span class="ffa"> </span>Homeowners or Renters In<span class="_ _1"></span>surance Policy<span class="_ _1"></span> </span></div><div class="t m0 x1c h12 yd7 ff9 fs3 fc0 sc0 lsb ws0"> <span class="ls0">Public agency documents (D<span class="_ _1"></span>SHS, courts, etc.)<span class="_ _1"></span> <span class="_ _13"> </span> <span class="_ _12"> </span><span class="ffa"> </span>Utility bill(s) (water, se<span class="_ _1"></span>wer, gas, electric, cable, etc.<span class="_ _1"></span>)<span class="_ _1"></span> </span></div><div class="t m0 x15 h12 yd8 ff9 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h1c yd9 ff9 fsa fc0 sc0 ls0 ws0">*Personal correspondence or copies of envel<span class="_ _0"></span>op<span class="_ _1"></span>es are not acceptable Proof of Residency documents. </div><div class="t m0 x15 he yda ff9 fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h1d ydb ff9 fs4 fc0 sc0 ls0 ws0">I swear (or<span class="_ _0"></span> certify) unde<span class="_ _0"></span>r penalty of perjur<span class="_ _0"></span>y under the l<span class="_ _0"></span>aws of the State o<span class="_ _0"></span>f Washington that<span class="_ _0"></span> the foregoi<span class="_ _0"></span>ng is true and c<span class="_ _0"></span>orrect, and that any<span class="_ _0"></span> and all copies of </div><div class="t m0 x15 h1d ydc ff9 fs4 fc0 sc0 ls0 ws0">documents su<span class="_ _0"></span>bmitted t<span class="_ _0"></span>o verify my residenc<span class="_ _0"></span>y are true<span class="_ _0"></span> and correct c<span class="_ _0"></span>opies of the origina<span class="_ _0"></span>l documents, and that any and al<span class="_ _0"></span>l document<span class="_ _0"></span>s submitted hav<span class="_ _0"></span>e not been </div><div class="t m0 x15 h1d ydd ff9 fs4 fc0 sc0 ls0 ws0">altered <span class="_ _0"></span>except for the cr<span class="_ _0"></span>ossing out of dol<span class="_ _0"></span>lar amounts <span class="_ _0"></span>and account numbe<span class="_ _0"></span>rs (redacte<span class="_ _0"></span>d), which is permitt<span class="_ _0"></span>ed for the pur<span class="_ _0"></span>poses of this Residency Ver<span class="_ _0"></span>ification </div><div class="t m0 x15 h1d yde ff9 fs4 fc0 sc0 ls0 ws0">Declarat<span class="_ _0"></span>ion<span class="ls10">. </span> </div><div class="t m0 x15 h1d ydf ff9 fs4 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h12 ye0 ff9 fs3 fc0 sc0 ls0 ws0">__________________<span class="_ _1"></span>______________<span class="_ _1"></span>______<span class="_ _1"></span>________________<span class="_ _1"></span>______ </div><div class="t m0 x15 h12 ye1 ff9 fs3 fc0 sc0 ls0 ws0">Printed Name of Parent/<span class="_ _1"></span>Guardian<span class="_ _1"></span> <span class="_ _14"> </span><span class="lsb"> <span class="_ _0"></span> <span class="_ _0"></span> <span class="_ _0"></span> <span class="_ _0"></span> <span class="_ _0"></span> <span class="ls0"> </span></span></div><div class="t m0 x15 h12 ye2 ff9 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x15 h12 ye3 ff9 fs3 fc0 sc0 ls0 ws0">__________________<span class="_ _1"></span>________________<span class="_ _1"></span>__________________<span class="_ _1"></span>________ _______<span class="_ _1"></span>_____________<span class="_ _1"></span>____________<span class="_ _7"></span> </div><div class="t m0 x15 h12 ye4 ff9 fs3 fc0 sc0 ls0 ws0">Signature of Parent/<span class="_ _1"></span>Guardian<span class="_ _1"></span> <span class="_ _15"> </span><span class="lsb"> <span class="_ _0"></span> <span class="_ _0"></span> <span class="_ _0"></span> <span class="_ _0"></span> <span class="_ _0"></span> <span class="ls0">Date </span></span></div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf5" class="pf w0 h0" data-page-no="5"><div class="pc pc5 w0 h0"><img class="bi x9 ye5 w6 h1e" alt="" src="bg5.png"/><div class="t m0 x1d h1f ye6 fff fsa fc1 sc0 ls0 ws0"> </div><div class="t m0 x1e h1f ye7 fff fsa fc1 sc0 ls0 ws0">English/November 2016 </div><div class="t m0 x9 h20 ye8 fff fsb fc0 sc0 ls0 ws0"> </div><div class="t m0 x1f h21 ye9 ff10 fs3 fc0 sc0 ls0 ws0">Office of Super<span class="_ _1"></span>intende<span class="_ _1"></span>nt of Public <span class="_ _1"></span>Instruction (OSPI<span class="_ _1"></span>)<span class="_ _1"></span> </div><div class="t m0 x1f h21 yea ff10 fs3 fc0 sc0 ls0 ws0">Home Language<span class="_ _1"></span> Survey<span class="_ _1"></span> </div><div class="t m0 x1f h22 yeb fff fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 x1f h21 yec ff10 fs3 fc0 sc0 ls0 ws0">The Home Lang<span class="_ _1"></span>uage Surv<span class="_ _1"></span>ey is given to <span class="_ _1"></span><span class="ff11">all<span class="_ _1"></span></span> students<span class="_ _1"></span> enrolling in W<span class="_ _1"></span>ashington sc<span class="_ _1"></span>hools. <span class="_ _1"></span> </div><div class="c x9 yed w7 h23"><div class="t m0 x20 h21 yee ff10 fs3 fc0 sc0 ls0 ws0">Student Name:<span class="_ _1"></span> </div></div><div class="c x21 yed w8 h23"><div class="t m0 x20 h21 yee ff10 fs3 fc0 sc0 ls0 ws0">Grade: </div></div><div class="c x22 yed w9 h23"><div class="t m0 x20 h21 yee ff10 fs3 fc0 sc0 ls0 ws0">Date:</div><div class="t m0 x20 h21 yef ff10 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h21 yf0 ff10 fs3 fc0 sc0 ls0 ws0"> <span class="_ _16"> </span><span class="fff fsa"> </span></div></div><div class="c x9 yf1 wa h24"><div class="t m0 x20 h21 yf2 ff10 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 yf3 fff fs3 fc0 sc0 ls0 ws0">Parent/Guardi<span class="_ _1"></span>an Name <span class="_ _1"></span> <span class="_ _1"></span> Pa<span class="_ _1"></span>rent/Guardi<span class="_ _1"></span>an Signature </div><div class="t m0 x20 h26 yf4 ff10 fsc fc0 sc0 ls0 ws0"> </div></div><div class="c x9 yf5 wb h27"><div class="t m0 x20 h21 yf6 ff10 fs3 fc0 sc0 ls0 ws0">Right to Trans<span class="_ _1"></span>lation and </div><div class="t m0 x20 h21 yf7 ff10 fs3 fc0 sc0 ls0 ws0">Interpretation <span class="_ _1"></span>Services<span class="_ _1"></span> </div><div class="t m0 x20 h25 yf8 fff fs3 fc0 sc0 ls0 ws0">Indicate your lan<span class="_ _1"></span>guage preferenc<span class="_ _1"></span>e so </div><div class="t m0 x20 h25 yf9 fff fs3 fc0 sc0 ls0 ws0">we can provid<span class="_ _1"></span>e an interpret<span class="_ _1"></span>er or </div><div class="t m0 x20 h25 yfa fff fs3 fc0 sc0 ls0 ws0">translated docum<span class="_ _1"></span>ents, free of </div><div class="t m0 x20 h25 yfb fff fs3 fc0 sc0 ls0 ws0">charge, when you<span class="_ _1"></span> need them.<span class="_ _1"></span> </div></div><div class="c x23 yf5 wc h27"><div class="t m0 x20 h25 yfc fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h28 yfd ff12 fs3 fc0 sc0 ls0 ws0">All parents have<span class="_ _1"></span> the right to i<span class="_ _1"></span>nformation about <span class="_ _1"></span>their chil<span class="_ _1"></span>d’s </div><div class="t m0 x20 h25 yfe fff fs3 fc0 sc0 ls0 ws0">education i<span class="_ _1"></span>n a langu<span class="_ _1"></span>age they understand.<span class="_ _1"></span> </div><div class="t m0 x20 h25 yff fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y100 fff fsa fc0 sc0 ls7 ws0">1.<span class="ff13 ls0"> <span class="_ _17"> </span><span class="fff fs3">In what langu<span class="_ _1"></span>age(s) woul<span class="_ _1"></span>d your family prefer to commun<span class="_ _1"></span>icate </span></span></div><div class="t m0 x24 h25 y101 fff fs3 fc0 sc0 ls0 ws0">with th<span class="_ _1"></span>e school? </div><div class="t m0 x24 h25 y102 fff fs3 fc0 sc0 ls11 ws0">__________________________________<span class="ls0"> </span></div><div class="t m0 x20 h21 y103 ff10 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x9 y104 wb h29"><div class="t m0 x20 h21 y105 ff10 fs3 fc0 sc0 ls0 ws0">Eligibility for <span class="_ _1"></span>Language </div><div class="t m0 x20 h21 y106 ff10 fs3 fc0 sc0 ls0 ws0">Development <span class="_ _1"></span>Support<span class="_ _1"></span> </div><div class="t m0 x20 h28 y107 ff12 fs3 fc0 sc0 ls0 ws0">Information about the<span class="_ _1"></span> student’s </div><div class="t m0 x20 h25 y31 fff fs3 fc0 sc0 ls0 ws0">language hel<span class="_ _1"></span>ps us identify students </div><div class="t m0 x20 h25 y108 fff fs3 fc0 sc0 ls0 ws0">who quali<span class="_ _1"></span>fy for support to devel<span class="_ _1"></span>op </div><div class="t m0 x20 h25 y109 fff fs3 fc0 sc0 ls0 ws0">the langu<span class="_ _1"></span>age skills necessary for </div><div class="t m0 x20 h25 y10a fff fs3 fc0 sc0 ls0 ws0">success in<span class="_ _1"></span> school. Testing<span class="_ _1"></span> may be </div><div class="t m0 x20 h25 y10b fff fs3 fc0 sc0 ls0 ws0">necessary to determi<span class="_ _1"></span>ne if lan<span class="_ _1"></span>guage </div><div class="t m0 x20 h25 y10c fff fs3 fc0 sc0 ls0 ws0">supports are needed.<span class="_ _1"></span> </div></div><div class="c x23 y104 wc h29"><div class="t m0 x24 h25 y10d fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y10e fff fsa fc0 sc0 ls7 ws0">2.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">What lan<span class="_ _1"></span>guage did your chil<span class="_ _1"></span>d learn first?<span class="_ _1"></span> </span></span></div><div class="t m0 x24 h25 y10f fff fs3 fc0 sc0 ls11 ws0">__________________________________<span class="ls0"> </span></div><div class="t m0 x20 h25 y110 fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y111 fff fsa fc0 sc0 ls7 ws0">3.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">What lan<span class="_ _1"></span>guage does your chi<span class="_ _1"></span>ld use the most<span class="_ _1"></span> at home?<span class="_ _1"></span> </span></span></div><div class="t m0 x24 h25 y112 fff fs3 fc0 sc0 ls11 ws0">__________________________________<span class="ls0"> </span></div><div class="t m0 x20 h25 y113 fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y114 fff fsa fc0 sc0 ls7 ws0">4.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">What is the pri<span class="_ _1"></span>mary langu<span class="_ _1"></span>age used in<span class="_ _1"></span> the home, regardles<span class="_ _1"></span>s of </span></span></div><div class="t m0 x24 h25 y115 fff fs3 fc0 sc0 ls0 ws0">the lang<span class="_ _1"></span>uage spoken by you<span class="_ _1"></span>r chil<span class="_ _1"></span>d? </div><div class="t m0 x20 h25 y116 fff fs3 fc0 sc0 ls0 ws0"> <span class="ls11">__________________________________</span> </div><div class="t m0 x20 h25 y117 fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y118 fff fsa fc0 sc0 ls7 ws0">5.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">Has your chil<span class="_ _1"></span>d received Eng<span class="_ _1"></span>lish l<span class="_ _1"></span>anguage develop<span class="_ _1"></span>ment support </span></span></div><div class="t m0 x24 h25 y119 fff fs3 fc0 sc0 ls0 ws0">in a previous sch<span class="_ _1"></span>ool? Y<span class="_ _1"></span>es___ No__<span class="ff12">_ <span class="_ _1"></span>Don’t Kno<span class="_ _1"></span>w_</span>__ </div><div class="t m0 x24 h25 y11a fff fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x9 y11b wb h2a"><div class="t m0 x20 h21 y11c ff10 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h21 y11d ff10 fs3 fc0 sc0 ls0 ws0">Prior Education <span class="_ _1"></span><span class="fsd"> </span></div><div class="t m0 x20 h2b y11e fff fsd fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y11f fff fs3 fc0 sc0 ls0 ws0">Your responses <span class="ff12">ab<span class="_ _1"></span>out your chi<span class="_ _1"></span>ld’s </span></div><div class="t m0 x20 h25 y120 fff fs3 fc0 sc0 ls0 ws0">birth country and pr<span class="_ _1"></span>eviou<span class="_ _1"></span>s </div><div class="t m0 x20 h25 y121 fff fs3 fc0 sc0 ls0 ws0">education:<span class="_ _1"></span> </div><div class="t m0 x20 h25 y122 ff14 fs3 fc0 sc0 ls0 ws0"><span class="ff13"> <span class="_ _9"></span><span class="fff">Gi<span class="_ _1"></span>ve us informati<span class="_ _1"></span>on abou<span class="_ _1"></span>t the </span></span></div><div class="t m0 x25 h25 y123 fff fs3 fc0 sc0 ls0 ws0">knowledge and ski<span class="_ _1"></span>ll<span class="_ _1"></span>s your child i<span class="_ _1"></span>s </div><div class="t m0 x25 h25 y124 fff fs3 fc0 sc0 ls0 ws0">bringi<span class="_ _1"></span>ng to school.<span class="_ _1"></span> </div><div class="t m0 x20 h25 y125 ff14 fs3 fc0 sc0 ls0 ws0"><span class="ff13"> <span class="_ _9"></span><span class="fff">May <span class="_ _1"></span>enabl<span class="_ _1"></span>e the school di<span class="_ _1"></span>strict to </span></span></div><div class="t m0 x25 h25 y126 fff fs3 fc0 sc0 ls0 ws0">receive additi<span class="_ _1"></span>onal federal<span class="_ _1"></span> fundi<span class="_ _1"></span>ng </div><div class="t m0 x25 h25 y127 fff fs3 fc0 sc0 ls0 ws0">to provide support t<span class="_ _1"></span>o your chi<span class="_ _1"></span>ld.<span class="_ _1"></span> </div><div class="t m0 x20 h25 yf2 ff15 fs3 fc0 sc0 ls0 ws0">This form is not<span class="_ _1"></span> used to identify </div><div class="t m0 x20 h25 y128 ff16 fs3 fc0 sc0 ls0 ws0">students’ immig<span class="_ _1"></span>ration status<span class="_ _1"></span><span class="fff">. </span></div></div><div class="c x23 y11b wc h2a"><div class="t m0 x20 h25 y129 fff fsa fc0 sc0 ls7 ws0">6.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">In what country was<span class="_ _1"></span> your chi<span class="_ _1"></span>ld born? _____<span class="_ _1"></span>______<span class="_ _1"></span>________<span class="_ _1"></span> </span></span></div><div class="t m0 x24 h25 y12a fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y12b fff fsa fc0 sc0 ls7 ws0">7.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">Has your chil<span class="_ _1"></span>d ever recei<span class="_ _1"></span>ved formal educati<span class="_ _1"></span>on outsi<span class="_ _1"></span>de of the </span></span></div><div class="t m0 x24 h25 y12c fff fs3 fc0 sc0 ls0 ws0">United States? <span class="_ _1"></span><span class="fs2">(Kindergart<span class="_ _1"></span>en <span class="ff12">–</span> <span class="ls12">12</span></span></div><div class="t m0 x26 h2c y12d fff fse fc0 sc0 ls13 ws0">th</div><div class="t m0 x27 h25 y12c fff fs2 fc0 sc0 ls0 ws0"> grade) <span class="fs3"> ____Y<span class="_ _1"></span>es __<span class="_ _1"></span>__No </span></div><div class="t m0 x24 h25 y12e fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x24 h25 y12f fff fs3 fc0 sc0 ls0 ws0">If yes: Number of m<span class="_ _1"></span>onths:<span class="ls14"> <span class="ls11">______________<span class="_ _1"></span></span></span> </div><div class="t m0 x24 h25 y130 fff fs3 fc0 sc0 ls0 ws0"> Language of i<span class="_ _1"></span>nstructi<span class="_ _1"></span>on: <span class="ls11">______________ </span> </div><div class="t m0 x24 h25 y131 fff fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h25 y132 fff fsa fc0 sc0 ls7 ws0">8.<span class="ff13 ls0"> <span class="_ _18"> </span><span class="fff fs3">When did your chi<span class="_ _1"></span>ld fi<span class="_ _1"></span>rst attend a school<span class="_ _1"></span> in the Unit<span class="_ _1"></span>ed States? </span></span></div><div class="t m0 x24 h2d y133 fff fs2 fc0 sc0 ls0 ws0">(Kindergarten <span class="ff12">–<span class="_ _1"></span></span> <span class="ls12">12</span></div><div class="t m0 x1f h2c y134 fff fse fc0 sc0 ls13 ws0">th</div><div class="t m0 x28 h2d y133 fff fs2 fc0 sc0 ls0 ws0"> grade) </div><div class="t m0 x24 h25 y135 fff fs3 fc0 sc0 ls11 ws0">_______________________<span class="ls0"> </span></div><div class="t m0 x24 h25 y136 fff fs3 fc0 sc0 ls0 ws0">Month Day Y<span class="_ _1"></span>ear<span class="fs2"> </span></div></div><div class="t m0 x9 h2e y137 ff10 fsd fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h25 y138 fff fs3 fc0 sc0 ls0 ws0">Thank you for provi<span class="_ _1"></span>din<span class="_ _1"></span>g the information need<span class="_ _1"></span>ed on the Home<span class="_ _1"></span> Language Surv<span class="_ _1"></span>ey. Contact you<span class="_ _1"></span>r school </div><div class="t m0 x9 h25 y139 ff12 fs3 fc0 sc0 ls0 ws0">district i<span class="_ _1"></span>f you have further qu<span class="_ _1"></span>estions about<span class="_ _1"></span> this form or ab<span class="_ _1"></span>out services avai<span class="_ _1"></span>labl<span class="_ _1"></span>e at your child’s school<span class="_ _1"></span>. <span class="_ _7"></span><span class="fff"> </span></div><div class="t m0 x9 h2f y13a ff17 fsa fc0 sc0 ls0 ws0">Note to district:<span class="ff18"> This form is available in multiple languages on <span class="fc2">http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx</span><span class="ls15">. </span>A response that </span></div><div class="t m0 x9 h2f y13b ff18 fsa fc0 sc0 ls0 ws0">includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to </div><div class="t m0 x9 h2f y13c ff18 fsa fc0 sc0 ls0 ws0">questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #<span class="_ _1"></span>3 were clearly </div><div class="t m0 x9 h2f y13d ff18 fsa fc0 sc0 ls0 ws0">understood. <span class="ff19">”Formal education”</span> in #7 does not include refugee camps or other unaccredited <span class="_ _1"></span>educatio<span class="_ _0"></span>nal programs for children.<span class="fsd"> </span></div><div class="t m0 x29 h30 y13e ff18 fsc fc0 sc0 ls0 ws0"> </div><div class="t m0 x29 h31 y13f ff1a fsf fc2 sc0 ls0 ws0">Forms and Tran<span class="_ _0"></span>slated Mate<span class="_ _0"></span>rial<span class="fc3"> from the<span class="_ _0"></span> Bi<span class="_ _0"></span>lingual Educati<span class="_ _0"></span>on Office of <span class="_ _0"></span>the <span class="fc2">Offi<span class="_ _0"></span>ce of Superinte<span class="_ _0"></span>ndent of Pu<span class="_ _0"></span>blic Instructi<span class="_ _0"></span>on<span class="fc3"> are l<span class="_ _0"></span>icensed under <span class="_ _0"></span>a <span class="fc2">Creativ<span class="_ _0"></span>e </span></span></span></span></div><div class="t m0 x29 h32 y140 ff1a fsf fc2 sc0 ls0 ws0">Commons A<span class="_ _0"></span>ttribution 4.0 I<span class="_ _0"></span>nternatio<span class="_ _0"></span>nal License<span class="fc3">.<span class="_ _0"></span><span class="fs1 fc4"> </span></span></div><a class="l" href="http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx"><div class="d m1" style="border-style:none;position:absolute;left:264.690000px;bottom:82.331000px;width:232.500000px;height:10.986000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://www.k12.wa.us/MigrantBilingual/TranslatedMaterial.aspx"><div class="d m1" style="border-style:none;position:absolute;left:107.200000px;bottom:35.181000px;width:98.130000px;height:10.528000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://www.k12.wa.us/"><div class="d m1" style="border-style:none;position:absolute;left:330.430000px;bottom:35.181000px;width:142.780000px;height:10.528000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://creativecommons.org/licenses/by/4.0/"><div class="d m1" style="border-style:none;position:absolute;left:533.780000px;bottom:35.181000px;width:44.470000px;height:10.528000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://creativecommons.org/licenses/by/4.0/"><div class="d m1" style="border-style:none;position:absolute;left:107.200000px;bottom:14.652000px;width:147.300000px;height:20.529000px;background-color:rgba(255,255,255,0.000001);"></div></a></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf6" class="pf w0 h0" data-page-no="6"><div class="pc pc6 w0 h0"><img class="bi x2a y141 w0 h0" alt="" src="bg6.png"/><div class="t m0 x2b h33 y142 ff1b fs10 fc5 sc0 ls0 ws0"> </div><div class="t m0 x18 h33 y143 ff1b fs10 fc0 sc0 ls0 ws0">La Center School District #101 </div><div class="t m0 x2b h33 y144 ff1b fs10 fc0 sc0 ls0 ws0"> 725 Highland Road La Center, WA 98629<span class="fs11"> </span></div><div class="t m0 x2c h33 y145 ff1b fs10 fc0 sc0 ls0 ws0">Student Housing Questionnaire </div><div class="t m0 x9 h34 y146 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y147 ff1c fs11 fc0 sc0 ls0 ws0">The answers to the following questions can help determine the services this student may be eligible to receive under the </div><div class="t m0 x9 h34 y148 ff1c fs11 fc0 sc0 ls0 ws0">McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth </div><div class="t m0 x9 h34 y149 ff1c fs11 fc0 sc0 ls0 ws0">experiencing homelessness or housing instability. (Please see reverse side for more information.) </div><div class="t m0 x9 h34 y14a ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h35 y14b ff1b fs12 fc0 sc0 ls0 ws0">If you own/rent your own home, you do not need to complete this form. </div><div class="t m0 x9 h35 y14c ff1b fs12 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y14d ff1c fs11 fc0 sc0 ls0 ws0">Please check which box reflects your current living situation: </div><div class="t m0 x9 h36 y14e ff1d fs11 fc0 sc0 ls0 ws0">☐<span class="_ _4"> </span><span class="ff1c">In a motel<span class="_ _19"> </span></span>☐<span class="_ _4"> </span><span class="ff1c">A car, park, campsite, or similar location </span></div><div class="t m0 x9 h36 y14f ff1d fs11 fc0 sc0 ls0 ws0">☐<span class="_ _4"> </span><span class="ff1c">In a shelter<span class="_ _1a"> </span></span>☐<span class="_ _4"> </span><span class="ff1c">Transitional Housing </span></div><div class="t m0 x9 h36 y150 ff1d fs11 fc0 sc0 ls0 ws0">☐<span class="_ _4"> </span><span class="ff1c">Moving from place to place/couchsurfing </span>☐<span class="ff1c"> Other ________________________________ </span></div><div class="t m0 x9 h36 y151 ff1d fs11 fc0 sc0 ls0 ws0">☐<span class="ff1c"> In someone else’s house or apartment with another family </span></div><div class="t m0 x9 h36 y152 ff1d fs11 fc0 sc0 ls0 ws0">☐<span class="_ _4"> </span><span class="ff1c">In a residence with inadequate facilities (no water, heat, electricity, etc.) </span></div><div class="t m0 x1d h34 y153 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y154 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y155 ff1c fs11 fc0 sc0 ls0 ws0">Name of Student: <span class="ff1e"></span>_________________________________________________________________________________ </div><div class="t m0 x2d h34 y156 ff1c fs11 fc0 sc0 ls0 ws0">First<span class="_ _1b"> </span>Middle<span class="_ _1c"> </span>Last </div><div class="t m0 x9 h34 y157 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y158 ff1c fs11 fc0 sc0 ls0 ws0">Name of School: <span class="ff1e"></span>____________________________<span class="ff1e"></span>Grade:<span class="ff1e"></span>________<span class="_ _1d"> </span><span class="ff1e"></span>Birthdate: <span class="ff1e"></span>______________<span class="_ _1e"> </span>Age: <span class="ff1e"></span>____<span class="_ _1f"> </span> </div><div class="t m0 x2e h34 y159 ff1c fs11 fc0 sc0 ls0 ws0"> Month/Day/Year </div><div class="t m0 x9 h36 y15a ff1c fs11 fc0 sc0 ls0 ws0">Gender: <span class="ff1e"></span>________<span class="_ _20"> </span><span class="ff1d">☐<span class="_ _4"> </span></span>Student is unaccompanied (not living with a parent or legal guardian) </div><div class="t m0 x9 h36 y15b ff1c fs11 fc0 sc0 ls0 ws0"> <span class="ff1d">☐</span> Student is living with a parent or legal guardian </div><div class="t m0 x9 h34 y15c ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y15d ff1c fs11 fc0 sc0 ls0 ws0">Address or Current Residence: : <span class="ff1e"></span>_____________________________________________________________________<span class="_ _21"> </span> </div><div class="t m0 x9 h34 y15e ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y15f ff1c fs11 fc0 sc0 ls0 ws0">Phone Number or Contact Number: : <span class="ff1e"></span>_______________________<span class="_ _22"> </span> </div><div class="t m0 x9 h34 y160 ff1c fs11 fc0 sc0 ls0 ws0">Name of Contact:: <span class="ff1e"></span>________________________<span class="_ _23"> </span> </div><div class="t m0 x9 h34 y161 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y162 ff1c fs11 fc0 sc0 ls0 ws0">Print name of Parent(s)/Legal Guardian(s): <span class="ff1e"></span>_____________________________________________________________ </div><div class="t m0 x9 h34 y163 ff1c fs11 fc0 sc0 ls0 ws0">(Or Unaccompanied Youth) </div><div class="t m0 x9 h34 y164 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y165 ff1c fs11 fc0 sc0 ls0 ws0">*Signature of Parent/Legal Guardian: <span class="ff1e"></span>________________________________________<span class="ff1e"></span> Date: <span class="ff1e"></span>_______________<span class="_ _24"> </span> </div><div class="t m0 x9 h34 y166 ff1c fs11 fc0 sc0 ls0 ws0">(Or Unaccompanied Youth) </div><div class="t m0 x9 h34 y167 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y168 ff1c fs11 fc0 sc0 ls0 ws0">*I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true </div><div class="t m0 x9 h34 y169 ff1c fs11 fc0 sc0 ls0 ws0">and correct. </div><div class="t m0 x9 h34 y16a ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y16b ff1b fs11 fc0 sc0 ls0 ws0">McKinney-Vento Building Liaison Signature<span class="ff1e sc1"></span><span class="ff1c">____________________________________ Date_______________ </span></div><div class="t m0 x9 h34 y16c ff1c fs11 fc0 sc0 ls0 ws0">I hereby certify that the above named student qualifies for rights and services under the McKinney-Vento Act. </div><div class="t m0 x9 h34 y16d ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h37 y16e ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y16f ff1b fs11 fc0 sc0 ls0 ws0">McKinney-Vento District Liaison Signature<span class="ff1e sc1"></span><span class="ff1c">____________________________________ Date_______________ </span></div><div class="t m0 x2f h34 y170 ff1c fs11 fc0 sc0 ls0 ws0"> La Center School District 360-263-2136 </div><div class="t m0 x9 h37 y171 ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x30 h37 y172 ff1b fs11 fc0 sc0 ls0 ws0"> <span class="ff1e sc1"></span><span class="ff1c fs13">Rev 10/2016 </span></div><div class="t m0 x9 h37 y173 ff1b fs11 fc0 sc0 ls0 ws0"> </div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf7" class="pf w0 h0" data-page-no="7"><div class="pc pc7 w0 h0"><img class="bi x2a y141 w0 h0" alt="" src="bg7.png"/><div class="t m0 x9 h37 y174 ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h37 y175 ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h37 y176 ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h37 y177 ff1b fs11 fc0 sc0 ls0 ws0">McKinney-Vento Act 42 U.S.C. 11435 </div><div class="t m0 x9 h37 y178 ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h37 y179 ff1b fs11 fc0 sc0 ls0 ws0">SEC. 725. DEFINITIONS. </div><div class="t m0 x31 h34 y17a ff1c fs11 fc0 sc0 ls0 ws0">For purposes of this subtitle: </div><div class="t m0 x32 h34 y17b ff1c fs11 fc0 sc0 ls0 ws0">(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities. </div><div class="t m0 x32 h34 y17c ff1c fs11 fc0 sc0 ls0 ws0">(2) The term homeless children and youths' — </div><div class="t m0 x33 h34 y14c ff1c fs11 fc0 sc0 ls0 ws0">(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the </div><div class="t m0 x33 h34 y17d ff1c fs11 fc0 sc0 ls0 ws0">meaning of section 103(a)(1)); and </div><div class="t m0 x33 h34 y17e ff1c fs11 fc0 sc0 ls0 ws0">(B) includes — </div><div class="t m0 x34 h34 y17f ff1c fs11 fc0 sc0 ls0 ws0">(i) children and youths who are sharing the housing of other persons due to loss of </div><div class="t m0 x34 h34 y180 ff1c fs11 fc0 sc0 ls0 ws0">housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, </div><div class="t m0 x34 h34 y181 ff1c fs11 fc0 sc0 ls0 ws0">or camping grounds due to the lack of alternative adequate accommodations; are living in </div><div class="t m0 x34 h34 y182 ff1c fs11 fc0 sc0 ls0 ws0">emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster </div><div class="t m0 x34 h34 y183 ff1c fs11 fc0 sc0 ls0 ws0">care placement; </div><div class="t m0 x34 h34 y184 ff1c fs11 fc0 sc0 ls0 ws0">(ii) children and youths who have a primary nighttime residence that is a public or private </div><div class="t m0 x34 h34 y185 ff1c fs11 fc0 sc0 ls0 ws0">place not designed for or ordinarily used as a regular sleeping accommodation for human </div><div class="t m0 x34 h34 y186 ff1c fs11 fc0 sc0 ls0 ws0">beings (within the meaning of section 103(a)(2)(C)); </div><div class="t m0 x34 h34 y187 ff1c fs11 fc0 sc0 ls0 ws0">(iii) children and youths who are living in cars, parks, public spaces, abandoned buildings, </div><div class="t m0 x34 h34 y188 ff1c fs11 fc0 sc0 ls0 ws0">substandard housing, bus or train stations, or similar settings; and </div><div class="t m0 x34 h34 y189 ff1c fs11 fc0 sc0 ls0 ws0">(iv) migratory children (as such term is defined in section 1309 of the Elementary and </div><div class="t m0 x34 h34 y18a ff1c fs11 fc0 sc0 ls0 ws0">Secondary Education Act of 1965) who qualify as homeless for the purposes of this </div><div class="t m0 x34 h34 y18b ff1c fs11 fc0 sc0 ls0 ws0">subtitle because the children are living in circumstances described in clauses (i) through </div><div class="t m0 x34 h34 y18c ff1c fs11 fc0 sc0 ls0 ws0">(iii). </div><div class="t m0 x32 h34 y18d ff1c fs11 fc0 sc0 ls0 ws0">(6) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian. </div><div class="t m0 x9 h37 y18e ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h37 y18f ff1b fs11 fc0 sc0 ls0 ws0">Additional Resources </div><div class="t m0 x9 h37 y190 ff1b fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y191 ff1c fs11 fc0 sc0 ls0 ws0">Parent information and resources can be found at the following: </div><div class="t m0 x9 h34 y192 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y193 ff1c fs11 fc6 sc0 ls0 ws0">http://center.serve.org/nche/ibt/parent_res.php<span class="fc0"> </span></div><div class="t m0 x9 h34 y194 ff1c fs11 fc6 sc0 ls0 ws0">http://naehcy.org/educational-resources/naehcy-publications<span class="fc0"> </span></div><div class="t m0 x9 h34 y195 ff1c fs11 fc0 sc0 ls0 ws0"> </div><div class="t m0 x9 h34 y196 ff1c fs11 fc0 sc0 ls0 ws0"> </div><a class="l" href="http://naehcy.org/educational-resources/naehcy-publications"><div class="d m1" style="border-style:none;position:absolute;left:36.000000px;bottom:171.750000px;width:6.000000px;height:12.000000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://naehcy.org/educational-resources/naehcy-publications"><div class="d m1" style="border-style:none;position:absolute;left:36.000000px;bottom:185.250000px;width:267.000000px;height:12.000000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://naehcy.org/educational-resources/naehcy-publications"><div class="d m1" style="border-style:none;position:absolute;left:36.000000px;bottom:158.250000px;width:6.000000px;height:12.000000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://center.serve.org/nche/ibt/parent_res.php"><div class="d m1" style="border-style:none;position:absolute;left:240.750000px;bottom:198.750000px;width:6.000000px;height:12.000000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://center.serve.org/nche/ibt/parent_res.php"><div class="d m1" style="border-style:none;position:absolute;left:36.000000px;bottom:198.750000px;width:205.500000px;height:12.000000px;background-color:rgba(255,255,255,0.000001);"></div></a><a class="l" href="http://naehcy.org/educational-resources/naehcy-publications"><div class="d m1" style="border-style:none;position:absolute;left:302.250000px;bottom:185.250000px;width:6.000000px;height:12.000000px;background-color:rgba(255,255,255,0.000001);"></div></a></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf8" class="pf w0 h0" data-page-no="8"><div class="pc pc8 w0 h0"><img class="bi x35 y197 wd h38" alt="" src="bg8.png"/><div class="t m0 x4 h16 y198 ff1f fs8 fc0 sc0 ls0 ws0">La Center School Dist<span class="_ _1"></span>rict </div><div class="t m0 x36 h39 y199 ff1f fs9 fc0 sc0 ls0 ws0">Clark County,<span class="_ _0"></span> Washington </div><div class="t m0 x37 h39 y19a ff1f fs9 fc0 sc0 ls0 ws0">La Cente<span class="_ _0"></span>r Elementary School </div><div class="t m0 x38 h10 y19b ff1f fs0 fc0 sc0 ls0 ws0">Phone (360) 263-2134 <span class="ls16"> </span> Fax (360) 263<span class="_ _1"></span>-<span class="ls7">2133</span> </div><div class="t m0 x39 he y19c ff1f fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h10 y19d ff1f fs0 fc0 sc0 ls0 ws0">Requested_____________ </div><div class="t m0 x31 h10 y19e ff1f fs0 fc0 sc0 ls0 ws0">Received______________ </div><div class="t m0 x31 h10 y19f ff1f fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x3a h3a y1a0 ff20 fs14 fc0 sc0 ls0 ws0">REQUEST FOR SENDI<span class="_ _1"></span>NG PERSON<span class="_ _1"></span>ALLY IDENTI<span class="_ _1"></span>FIABLE RECORDS<span class="_ _1"></span> </div><div class="t m0 x39 h3a y1a1 ff20 fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x39 h3a y1a2 ff20 fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1a3 ff1f fs14 fc0 sc0 ls0 ws0">STUDENT__________<span class="_ _1"></span>____________<span class="_ _1"></span>___<span class="_ _1"></span>__________________<span class="_ _1"></span>____DATE_____________<span class="_ _7"></span> </div><div class="t m0 x31 h3b y1a4 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1a5 ff1f fs14 fc0 sc0 ls0 ws0">BIRTHDATE________<span class="_ _1"></span>____________<span class="_ _1"></span>___________________<span class="_ _1"></span>______GRADE___________<span class="_ _1"></span>_<span class="_ _7"></span> </div><div class="t m0 x31 h3b y1a6 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1a7 ff1f fs14 fc0 sc0 ls0 ws0">I request an exchange<span class="_ _1"></span> of records for the following<span class="_ _1"></span> reason: </div><div class="t m0 x31 h3b y1a8 ff1f fs14 fc0 sc0 ls17 ws0">______________________________________________________<span class="_ _0"></span>__________________<span class="ls0"> </span></div><div class="t m0 x31 h3b y1a9 ff1f fs14 fc0 sc0 ls0 ws0">Please send: </div><div class="t m0 x1f h3c y1aa ff21 fs14 fc0 sc0 ls0 ws0"><span class="ff22"> <span class="_ _18"> </span><span class="ff1f">Perman<span class="_ _1"></span>ent records </span></span></div><div class="t m0 x1f h3c y1ab ff21 fs14 fc0 sc0 ls0 ws0"><span class="ff22"> <span class="_ _18"> </span><span class="ff1f">Health rec<span class="_ _1"></span>ords </span></span></div><div class="t m0 x1f h3c y1ac ff21 fs14 fc0 sc0 ls0 ws0"><span class="ff22"> <span class="_ _18"> </span><span class="ff1f">Spe<span class="_ _1"></span>cial Education records (Includ<span class="_ _1"></span>ing speech and<span class="_ _1"></span> language record<span class="_ _1"></span>s)<span class="_ _1"></span> </span></span></div><div class="t m0 x1f h3c y1ad ff21 fs14 fc0 sc0 ls0 ws0"><span class="ff22"> <span class="_ _18"> </span><span class="ff1f">Othe<span class="_ _1"></span>r ______________<span class="_ _1"></span>____________<span class="_ _1"></span>______________<span class="_ _1"></span> </span></span></div><div class="t m0 x32 h3b y1ae ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1af ff1f fs14 fc0 sc0 ls0 ws0">This information is to b<span class="_ _1"></span>e exchanged between:<span class="_ _1"></span> <span class="_ _4"> </span> <span class="_ _3"> </span> </div><div class="t m0 x32 h3b y1b0 ff1f fs14 fc0 sc0 ls0 ws0">the new school <span class="_ _1"></span> <span class="_ _15"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span>and the prev<span class="_ _1"></span>ious school<span class="_ _1"></span> </div><div class="t m0 x31 h3b y1b1 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1b2 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1b3 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1b4 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1b5 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h3b y1b6 ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h12 y1b7 ff1f fs3 fc0 sc0 ls0 ws0">As pr<span class="ff23">ovided under the Fa<span class="_ _1"></span>mily Rights and Privacy Act o<span class="_ _1"></span>f 1974, I u<span class="_ _1"></span>nderstand that<span class="_ _1"></span> I may obtain a copy o<span class="_ _1"></span>f my child’s </span></div><div class="t m0 x31 h12 y1b8 ff1f fs3 fc0 sc0 ls0 ws0">personally identifiable record<span class="_ _1"></span>s. I am aware that<span class="_ _1"></span> I may chall<span class="_ _1"></span>enge the content of the<span class="_ _1"></span>se records. I a<span class="_ _1"></span>lso understand </div><div class="t m0 x31 h12 y1b9 ff1f fs3 fc0 sc0 ls0 ws0">that the school will treat the<span class="_ _1"></span>se <span class="_ _1"></span>records confidentially.<span class="_ _1"></span> Finally, n<span class="_ _1"></span>o one will send these reco<span class="_ _1"></span>rds to a non<span class="_ _7"></span>-public </div><div class="t m0 x31 h12 y1ba ff1f fs3 fc0 sc0 ls0 ws0">school agency without my wri<span class="_ _1"></span>tten consent. <span class="_ _1"></span> </div><div class="t m0 x3b h3b y1bb ff1f fs14 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span> </div><div class="t m0 x19 h3b y1bc ff1f fs14 fc0 sc0 ls0 ws0">Signature:____<span class="_ _1"></span>__________________<span class="_ _1"></span>____________<span class="_ _1"></span> </div><div class="t m0 x3c h3b y1bd ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x3d h3b y1be ff1f fs14 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span>Relationship:<span class="_ _1"></span><span class="ls17">___</span>_________________<span class="_ _1"></span>____________<span class="_ _1"></span> </div><div class="t m0 x3c h3b y1bf ff1f fs14 fc0 sc0 ls0 ws0"> </div><div class="t m0 x3e h3b y1c0 ff1f fs14 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span>Address:<span class="ls17">___________________________________</span> </div><div class="t m0 x31 h3b y1c1 ff1f fs14 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span> </div><div class="t m0 x3f h3b y1c2 ff1f fs14 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span>Phone:_____<span class="_ _1"></span>__________________<span class="_ _1"></span>_____________<span class="_ _1"></span> </div><div class="t m0 x40 h3b y1c3 ff1f fs14 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _3"> </span> </div><div class="c x35 y1c4 we h3d"><div class="t m0 xa he y1c5 ff1f fs1 fc0 sc0 ls0 ws0">La Center Ele<span class="_ _0"></span>mentary Scho<span class="_ _0"></span>ol </div><div class="t m0 xa he y1c6 ff1f fs1 fc0 sc0 ls0 ws0">PO Box 1810 <span class="_ _0"></span>/ 700 E. 4</div><div class="t m0 x32 h3e y1c7 ff1f fs2 fc0 sc0 ls18 ws0">th</div><div class="t m0 x41 he y1c6 ff1f fs1 fc0 sc0 ls0 ws0"> Street </div><div class="t m0 xa he y1c8 ff1f fs1 fc0 sc0 ls0 ws0">La Center, WA 98<span class="_ _0"></span>629 </div></div><div class="c x42 y1c4 wf h3f"><div class="t m0 xa he y1c9 ff1f fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 xa he y1ca ff1f fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 xa he y1cb ff1f fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 xa he y1cc ff1f fs1 fc0 sc0 ls0 ws0"> </div></div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pf9" class="pf w0 h0" data-page-no="9"><div class="pc pc9 w0 h0"><img class="bi x43 y1cd w10 h40" alt="" src="bg9.png"/><div class="t m0 x44 h41 y1ce ff24 fs0 fc0 sc0 ls0 ws0">Parent/guardian signature: ________________________________Date:__________________ </div><div class="t m0 x38 h42 y1cf ff25 fs8 fc0 sc0 ls19 ws0">La<span class="ls0"> Center Schoo<span class="_ _1"></span>l District </span></div><div class="t m0 x45 h42 y1d0 ff25 fs8 fc0 sc0 ls0 ws0">Student Health H<span class="_ _1"></span>istory 201<span class="_ _1"></span>7-18 </div><div class="t m0 x46 h21 y1d1 ff25 fs3 fc0 sc0 ls0 ws0">To be completed b<span class="_ _1"></span>y parent/gu<span class="_ _1"></span>ardian<span class="_ _1"></span> </div><div class="t m0 x8 h43 y1d2 ff25 fs0 fc0 sc0 ls0 ws0"> <span class="ff26 fs4"> </span></div><div class="t m0 x11 h22 y1d3 ff26 fs1 fc0 sc0 ls0 ws0">Student Name<span class="ff24">: _<span class="_ _0"></span>______________<span class="_ _0"></span>___________ <span class="ff26">D<span class="_ _0"></span>ate of Bi<span class="_ _0"></span>rth<span class="ff24">: _________</span><span class="ls1a">Grade</span><span class="ff24">: ____ <span class="ff27 fs9"></span> </span><span class="fs3">Male</span><span class="ff24"> <span class="ff27 fs9"></span> Fem<span class="_ _0"></span>ale </span></span></span></div><div class="t m0 x11 h44 y1d4 ff24 fs1 fc0 sc0 ls0 ws0"> </div><div class="t m0 x11 h22 y1d5 ff26 fs1 fc0 sc0 ls0 ws0">Parent Nam<span class="_ _0"></span>e<span class="ff24">: _________________<span class="_ _0"></span>______<span class="ff26">Phone</span> <span class="_ _0"></span>#: ________________<span class="_ _0"></span>___<span class="ff26 ls1b">Te<span class="ls0">acher</span></span>: __________<span class="ff26">Bus<span class="_ _0"></span><span class="ff24">#____ <span class="_ _0"></span> <span class="_ _0"></span> </span></span></span></div><div class="t m0 x44 h44 y1d6 ff24 fs1 fc0 sc0 ls0 ws0"> <span class="_ _3"> </span> <span class="_ _b"> </span> <span class="_ _b"> </span> <span class="_ _b"> </span> <span class="_ _b"> </span> </div><div class="t m0 x11 h21 y1d7 ff25 fs3 fc0 sc0 ls0 ws0">INDICATE IF ST<span class="_ _1"></span>UDENT HAS <span class="_ _1"></span>BEEN DIAGNO<span class="_ _1"></span>SED BY A LICE<span class="_ _1"></span>NSED H<span class="_ _1"></span>EALTHCARE PRO<span class="_ _1"></span>VIDER WITH </div><div class="t m0 x44 h45 y1d8 ff25 fs3 fc0 sc0 ls0 ws0">ANY OF THE FOLLOW<span class="_ _1"></span>ING<span class="_ _1"></span><span class="ff28 fs1">: </span></div><div class="c x43 y1d9 w11 h46"><div class="t m0 x20 h25 y1da ff29 fs3 fc0 sc0 ls0 ws0">If your child has a lif<span class="_ _1"></span>e-threatening c<span class="_ _1"></span>ondition, state law <span class="_ _1"></span>requires a me<span class="_ _1"></span>di<span class="_ _1"></span>cation and/o<span class="_ _1"></span>r treatment orde<span class="_ _1"></span>rs from a<span class="_ _1"></span> </div></div><div class="c x43 y1db w11 h47"><div class="t m0 x20 h25 y1dc ff29 fs3 fc0 sc0 ls0 ws0"> Licensed Health P<span class="_ _1"></span>rofessional and an<span class="_ _1"></span> Emergency plan<span class="_ _1"></span> must be in place bef<span class="_ _1"></span>ore your child can att<span class="_ _1"></span>end school.<span class="_ _8"></span> </div><div class="t m0 x20 h25 y1dd ff29 fs3 fc0 sc0 ls0 ws0">See office for forms.<span class="_ _1"></span> Please che<span class="_ _1"></span>ck appropriate b<span class="_ _1"></span>oxes below and expl<span class="_ _1"></span>ain if needed<span class="_ _7"></span> </div><div class="t m0 x20 h25 y1de ff26 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x20 h21 y1df ff25 fs3 fc0 sc0 ls1c ws0"> <span class="ls0">Health<span class="_ _1"></span> Condition <span class="_ _1"></span>Yes <span class="ff2a">No <span class="_ _1"></span> Explanation if “<span class="_ _1"></span>Yes” check<span class="_ _1"></span>ed<span class="_ _1"></span><span class="ff2b"> </span></span></span></div></div><div class="c x43 y1e0 w12 h48"><div class="t m0 x20 h21 y1e1 ff25 fs3 fc0 sc0 ls0 ws0">Food Allergies<span class="_ _1"></span> </div></div><div class="c x47 y1e0 w13 h49"><div class="t m0 x20 h21 y1e1 ff25 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x47 y1e2 w14 h4a"><div class="t m0 x20 h21 y1e3 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1e0 w13 h49"><div class="t m0 x20 h21 y1e1 ff25 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x48 y1e2 w14 h4a"><div class="t m0 x20 h21 y1e3 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1e0 w15 h49"><div class="t m0 x20 h21 y1e4 ff25 fs3 fc0 sc0 ls0 ws0">Food(S): <span class="ff27 sc1"><span class="_ _1"></span></span> peanut <span class="_ _1"></span><span class="ff27 sc1"></span> tree nut <span class="ff27 sc1"><span class="_ _1"></span></span> dairy <span class="ff27 sc1"><span class="_ _1"></span></span> eggs <span class="ff27 sc1"></span> oth<span class="_ _1"></span>er_________<span class="_ _1"></span> </div></div><div class="c x49 y1e2 w15 h4a"><div class="t m0 x20 h21 y1de ff25 fs3 fc0 sc0 ls0 ws0">Rate the reaction<span class="_ _1"></span>: <span class="ff27 sc1"></span><span class="ls1d"> </span>mild <span class="ff27 sc1"><span class="_ _1"></span></span><span class="ls1d"> </span>moderate <span class="ff27 sc1"><span class="_ _1"></span></span> life-thre<span class="_ _1"></span>atening </div><div class="t m0 x20 h21 y1e5 ff25 fs3 fc0 sc0 ls0 ws0">Does your child<span class="_ _1"></span> require an EpiPen<span class="_ _1"></span>? <span class="_ _1"></span><span class="ff27 sc1"></span> yes <span class="ff27 sc1"><span class="_ _1"></span></span> <span class="ls1e">no<span class="_ _1"></span></span> </div></div><div class="c x43 y1e6 w12 h4b"><div class="t m0 x20 h21 y119 ff25 fs3 fc0 sc0 ls0 ws0">Allergy to Bee Sti<span class="_ _1"></span>ngs<span class="_ _1"></span> </div></div><div class="c x47 y1e6 w16 h4b"><div class="t m0 x20 h21 y1e7 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1e6 w16 h4b"><div class="t m0 x20 h21 y1e7 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1e6 w15 h4b"><div class="t m0 x20 h21 y1e8 ff25 fs3 fc0 sc0 ls0 ws0">Rate the reaction<span class="_ _1"></span>: <span class="ff27 sc1"></span> <span class="_ _1"></span>mild <span class="ff27 sc1"></span> mod<span class="_ _1"></span>erate <span class="ff27 sc1"><span class="_ _1"></span></span> life-threaten<span class="_ _1"></span>ing<span class="_ _1"></span> </div><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">Does your child<span class="_ _1"></span> require an EpiPen<span class="_ _1"></span>? <span class="_ _1"></span><span class="ff27 sc1"></span> yes <span class="ff27 sc1"></span> <span class="_ _1"></span><span class="ls1e">no</span> </div></div><div class="c x43 y1e9 w12 h4c"><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">Medication Allerg<span class="_ _1"></span>ies </div></div><div class="c x47 y1e9 w16 h4c"><div class="t m0 x20 h21 y1ea ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1e9 w16 h4c"><div class="t m0 x20 h21 y1ea ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1e9 w15 h4c"><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">List: </div></div><div class="c x43 y90 w12 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Allergies (other)<span class="_ _1"></span> </div></div><div class="c x47 y90 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y90 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y90 w15 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">List: </div></div><div class="c x43 y1ed w12 h4a"><div class="t m0 x20 h21 y1e1 ff25 fs3 fc0 sc0 ls0 ws0">Asthma </div></div><div class="c x47 y1ed w13 h4e"><div class="t m0 x20 h21 y1e1 ff25 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x47 y1ed w14 h4a"><div class="t m0 x20 h21 y1e7 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1ed w13 h4e"><div class="t m0 x20 h21 y1e1 ff25 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x48 y1ed w14 h4a"><div class="t m0 x20 h21 y1e7 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1ed w15 h4e"><div class="t m0 x20 h21 y1e4 ff25 fs3 fc0 sc0 ls0 ws0">Rate the severity<span class="_ _1"></span>: <span class="ff27 sc1"></span> <span class="_ _1"></span>mild <span class="ff27 sc1"></span>mod<span class="_ _1"></span>erate <span class="_ _1"></span><span class="ff27 sc1"></span> life-thre<span class="_ _1"></span>atening<span class="_ _1"></span> </div></div><div class="c x49 y1ed w15 h4a"><div class="t m0 x20 h21 y1ee ff25 fs3 fc0 sc0 ls0 ws0">Asthma medic<span class="_ _1"></span>ation taken at ho<span class="_ _1"></span>me:_____<span class="_ _1"></span>__________<span class="_ _1"></span>____________<span class="_ _7"></span> </div><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Medication requi<span class="_ _1"></span>red at school:<span class="_ _1"></span> </div></div><div class="c x43 y1ef w12 h4f"><div class="t m0 x20 h21 y119 ff25 fs3 fc0 sc0 ls0 ws0">Diabetes<span class="_ _1"></span> </div></div><div class="c x47 y1ef w16 h4f"><div class="t m0 x20 h21 y1e7 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1ef w16 h4f"><div class="t m0 x20 h21 y1e7 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1ef w15 h50"><div class="t m0 x20 h21 y1e8 ff25 fs3 fc0 sc0 ls1c ws0"> <span class="ff27 sc1 ls0"></span><span class="ls0">Type 1 (<span class="_ _1"></span>insulin Depend<span class="_ _1"></span>ent) <span class="_ _1"></span><span class="ff27 sc1"></span>Type 2<span class="_ _1"></span> </span></div></div><div class="c x49 y1ef w15 h4f"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Diabetes medicat<span class="_ _1"></span>ions(s)<span class="_ _1"></span> taken at home<span class="_ _1"></span>:<span class="_ _1"></span> </div></div><div class="c x43 y1f0 w12 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Seizure Disorder<span class="_ _1"></span> </div></div><div class="c x47 y1f0 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1f0 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1f0 w15 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Type of seizure<span class="_ _1"></span>: Medic<span class="_ _1"></span>ations:<span class="_ _7"></span> </div></div><div class="c x43 y1f1 w12 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Heart Condition<span class="_ _1"></span> </div></div><div class="c x47 y1f1 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1f1 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1f1 w15 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Specify: <span class="_ _1"></span> <span class="_ _1"></span> </div></div><div class="c x43 y1f2 w12 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Cancer </div></div><div class="c x47 y1f2 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1f2 w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1f2 w15 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Specify: </div></div><div class="c x43 y1f3 w12 h4c"><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">Blood Disorder<span class="_ _1"></span> </div></div><div class="c x47 y1f3 w16 h4c"><div class="t m0 x20 h21 y1ea ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1f3 w16 h4c"><div class="t m0 x20 h21 y1ea ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1f3 w15 h4c"><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">Specify: <span class="_ _1"></span> Treatment<span class="_ _1"></span>:<span class="_ _7"></span> </div></div><div class="c x43 y1f4 w12 h51"><div class="t m0 x20 h21 y1f5 ff25 fs3 fc0 sc0 ls0 ws0">ADD/ADHD<span class="_ _1"></span> </div></div><div class="c x47 y1f4 w16 h51"><div class="t m0 x20 h21 y1f6 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1f4 w16 h51"><div class="t m0 x20 h21 y1f6 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1f4 w15 h51"><div class="t m0 x20 h21 y1f5 ff25 fs3 fc0 sc0 ls0 ws0">Medication for A<span class="_ _1"></span>DD/ADHD<span class="_ _1"></span>: </div></div><div class="c x43 y1f7 w12 h52"><div class="t m0 x20 h21 y119 ff25 fs3 fc0 sc0 ls0 ws0">Mental Health /<span class="_ _1"></span> </div></div><div class="c x43 y1f8 w17 h53"><div class="t m0 x20 h21 y1df ff25 fs3 fc0 sc0 ls0 ws0">Behavioral Issues<span class="_ _1"></span> </div></div><div class="c x47 y1f7 w13 h52"><div class="t m0 x20 h21 y119 ff25 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x47 y1f8 w14 h53"><div class="t m0 x20 h21 y1f9 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1f7 w13 h52"><div class="t m0 x20 h21 y119 ff25 fs3 fc0 sc0 ls0 ws0"> </div></div><div class="c x48 y1f8 w14 h53"><div class="t m0 x20 h21 y1f9 ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1f7 w15 h52"><div class="t m0 x20 h21 y119 ff25 fs3 fc0 sc0 ls0 ws0">Specify: </div></div><div class="c x49 y1f8 w15 h53"><div class="t m0 x20 h21 y1df ff25 fs3 fc0 sc0 ls0 ws0">Treatment/Med<span class="_ _1"></span>ication:<span class="_ _1"></span> </div></div><div class="c x43 y1fa w12 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Orthopedic Condit<span class="_ _1"></span>ion </div></div><div class="c x47 y1fa w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1fa w16 h4d"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1fa w15 h4d"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Specify: </div></div><div class="c x43 y1fb w12 h4c"><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">Wears glasses<span class="_ _1"></span> </div></div><div class="c x47 y1fb w16 h4c"><div class="t m0 x20 h21 y1ea ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1fb w16 h4c"><div class="t m0 x20 h21 y1ea ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1fb w15 h4c"><div class="t m0 x20 h21 y1fc ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> For Distanc<span class="_ _1"></span>e <span class="_ _1"></span></span><span class="_ _1"></span><span class="ff25 sc0"> For Reading<span class="_ _1"></span> </span></div></div><div class="c x43 y1fd w12 h51"><div class="t m0 x20 h21 y1eb ff25 fs3 fc0 sc0 ls0 ws0">Hearing Loss<span class="_ _1"></span> </div></div><div class="c x47 y1fd w16 h51"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x48 y1fd w16 h51"><div class="t m0 x20 h21 y1ec ff27 fs3 fc0 sc1 ls0 ws0"><span class="ff25 sc0"> </span></div></div><div class="c x49 y1fd w15 h51"><div class="t m0 x20 h21 y11a ff25 fs3 fc0 sc0 ls0 ws0">Hearing Loss <span class="_ _1"></span><span class="ff27 sc1"></span> Right E<span class="_ _1"></span>ar <span class="ff27 sc1"></span> Left Ea<span class="_ _1"></span>r <span class="ff27 sc1"></span> He<span class="_ _1"></span>aring Aid<span class="_ _1"></span>s </div></div><div class="t m0 x11 h21 y1fe ff25 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x11 h21 y1ff ff25 fs3 fc0 sc0 ls0 ws0">Does your child<span class="_ _1"></span> have any oth<span class="_ _1"></span>er condition t<span class="_ _1"></span>hat would affect<span class="_ _1"></span> his/her<span class="_ _1"></span> classroom perf<span class="_ _1"></span>ormance or </div><div class="t m0 x44 h21 y200 ff25 fs3 fc0 sc0 ls0 ws0">P.E. activities<span class="ff26">? </span></div><div class="t m0 x11 h25 y201 ff27 fs3 fc0 sc0 ls0 ws0"><span class="ff26"> No </span><span class="ff26"> Yes i<span class="_ _1"></span>f yes, expl<span class="_ _1"></span>ain: <span class="ls11">_________________________________________________________</span> </span></div><div class="t m0 x11 h25 y202 ff26 fs3 fc0 sc0 ls0 ws0"> </div><div class="c xb y203 w18 h54"><div class="t m0 x20 h55 y204 ff25 fs1 fc0 sc0 ls0 ws0">Daily <span class="_ _0"></span>Medication </div></div><div class="c xb y203 w18 h56"><div class="t m0 x20 h25 y1ee ff26 fs3 fc0 sc0 ls0 ws0">State law requi<span class="_ _1"></span>res writ<span class="_ _1"></span>ten permissi<span class="_ _1"></span>on from a Licensed <span class="_ _1"></span>Health Pro<span class="_ _1"></span>fession<span class="_ _1"></span>al and<span class="_ _1"></span> parent before any<span class="_ _1"></span> medicati<span class="_ _1"></span>on </div><div class="t m0 x20 h57 y1eb ff26 fs3 fc0 sc0 ls0 ws0">(prescripti<span class="_ _1"></span>on or over-the-counte<span class="_ _1"></span>r) can be gi<span class="_ _1"></span>ven at school<span class="_ _1"></span>. A form is avai<span class="_ _1"></span>labl<span class="_ _1"></span>e from the s<span class="_ _1"></span>chool offi<span class="_ _1"></span>ce.<span class="fs0"> </span></div></div><div class="t m0 x11 h25 y205 ff26 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x11 h21 y2c ff27 fs3 fc0 sc0 ls0 ws0"><span class="ff26"> No </span><span class="ff26"> Yes <span class="ls14"> </span>M<span class="_ _1"></span>edicati<span class="_ _1"></span>on<span class="ff25"> </span>needed at school<span class="_ _1"></span>- spe<span class="_ _1"></span>cify: <span class="ls11">______________________</span>__<span class="ls11">___</span> </span></div><div class="t m0 x11 h25 y206 ff27 fs3 fc0 sc0 ls0 ws0"><span class="ff26"> No </span><span class="ff26"> Yes <span class="ls14"> </span>M<span class="_ _1"></span>edicati<span class="_ _1"></span>on needed at home<span class="_ _1"></span>- spec<span class="_ _1"></span>ify: _<span class="ls11">___________________________</span> </span></div><div class="t m0 x11 h25 y207 ff27 fs3 fc0 sc0 ls0 ws0"><span class="ff26"> No </span><span class="ff26"> Yes Fo<span class="_ _1"></span>r dail<span class="_ _1"></span>y medicati<span class="_ _1"></span>on taken at home, woul<span class="_ _1"></span>d mi<span class="_ _1"></span>ssing <span class="_ _1"></span><span class="ls11">24</span> hours of thi<span class="_ _1"></span>s medicati<span class="_ _1"></span>on </span></div><div class="t m0 x11 h25 y208 ff26 fs3 fc0 sc0 ls0 ws0">pose a heal<span class="_ _1"></span>th risk to yo<span class="_ _1"></span>ur child or othe<span class="_ _1"></span>rs? If yes, a th<span class="_ _1"></span>ree-d<span class="_ _1"></span>ay suppl<span class="_ _1"></span>y of medi<span class="_ _1"></span>cation woul<span class="_ _1"></span>d need to </div><div class="t m0 x11 h25 y209 ff26 fs3 fc0 sc0 ls0 ws0">be suppli<span class="_ _1"></span>ed to the school<span class="_ _1"></span> in case of an emergen<span class="_ _1"></span>cy (<span class="_ _1"></span>eg. dai<span class="_ _1"></span>ly asthma<span class="_ _1"></span>, diabetes, seizu<span class="_ _1"></span>re, allergy or </div><div class="t m0 x11 h25 y20a ff26 fs3 fc0 sc0 ls0 ws0">ADD/ADHD medi<span class="_ _1"></span>cation). </div><div class="t m0 x11 h25 y20b ff26 fs3 fc0 sc0 ls0 ws0"> </div><div class="t m0 x11 h58 y20c ff2c fs3 fc0 sc0 ls0 ws0">This information is co<span class="_ _1"></span>nsidered con<span class="_ _1"></span>fidential. It will be sha<span class="_ _1"></span>red with school staff a<span class="_ _1"></span>nd emergency respo<span class="_ _1"></span>nders as need<span class="_ _8"></span>ed during </div><div class="t m0 x11 h58 y20d ff2c fs3 fc0 sc0 ls0 ws0">the time your ch<span class="_ _1"></span>ild is enrolled in <span class="_ _1"></span><span class="ls1f">La</span> Center <span class="_ _1"></span>School District in o<span class="_ _1"></span>rder to ensure th<span class="_ _1"></span>e health and safety o<span class="_ _1"></span>f your child, unless </div><div class="t m0 x11 h58 y20e ff2c fs3 fc0 sc0 ls0 ws0">otherwise requested by <span class="_ _1"></span>you in writing. <span class="_ _1"></span> </div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pfa" class="pf w0 h0" data-page-no="a"><div class="pc pca w0 h0"><img class="bi x4a y20f w19 h59" alt="" src="bga.png"/><div class="t m0 x4b h5a y210 ff2d fs9 fc0 sc0 ls0 ws0">LA CENTER ELE<span class="_ _0"></span>MENTARY SC<span class="_ _0"></span>HOOL<span class="ff2e"> </span></div><div class="t m0 x1f h5b y211 ff2f fs0 fc0 sc0 ls0 ws0">______________________________________________________________________________ </div><div class="t m0 x4c h41 y212 ff30 fs0 fc0 sc0 ls0 ws0">700 East 4</div><div class="t m0 x4d h5c y213 ff30 fs4 fc0 sc0 ls20 ws0">th</div><div class="t m0 x4e h41 y212 ff30 fs0 fc0 sc0 ls0 ws0"> St, La Ce<span class="_ _0"></span>nter, WA 98629 360.263.2134 </div><div class="t m0 x4f h41 y214 ff30 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x50 h5b y215 ff2f fs0 fc0 sc0 ls0 ws0">FAMILY EMERGENCY PLAN </div><div class="t m0 x31 h41 y216 ff30 fs0 fc0 sc0 ls0 ws0">Should <span class="_ _21"></span>an <span class="_ _9"></span>emergency <span class="_ _9"></span>closure <span class="_ _21"></span>of <span class="_ _9"></span>school <span class="_ _21"></span>be <span class="_ _9"></span>necessar<span class="_ _1"></span>y, <span class="_ _9"></span>each <span class="_ _21"></span>family<span class="_ _0"></span> <span class="_ _21"></span>needs <span class="_ _9"></span>to <span class="_ _21"></span>hav<span class="_ _1"></span>e <span class="_ _21"></span>pre<span class="_ _0"></span>pared <span class="_ _9"></span>a <span class="_ _21"></span>plan <span class="_ _21"></span>for </div><div class="t m0 x31 h41 y217 ff30 fs0 fc0 sc0 ls0 ws0">supervision <span class="_ _8"></span>of <span class="_ _8"></span>y<span class="_ _0"></span>our <span class="_ _8"></span>child <span class="_ _7"></span>(ren). <span class="_ _8"></span>Please <span class="_ _7"></span>discuss <span class="_ _8"></span>with <span class="_ _9"></span>y<span class="_ _0"></span>our <span class="_ _7"></span>child <span class="_ _8"></span>(ren) <span class="_ _7"></span>to <span class="_ _8"></span>whom <span class="_ _8"></span>the<span class="_ _1"></span>y<span class="_ _0"></span> <span class="_ _7"></span>should <span class="_ _8"></span>report <span class="_ _8"></span>if <span class="_ _8"></span>you </div><div class="t m0 x31 h41 y218 ff30 fs0 fc0 sc0 ls0 ws0">are <span class="_ _8"></span>not <span class="_ _25"></span>home <span class="_ _25"></span>when <span class="_ _8"></span>th<span class="_ _1"></span>ey <span class="_ _8"></span>arrive. <span class="_ _9"></span>It <span class="_ _8"></span>is <span class="_ _25"></span>especially <span class="_ _8"></span>h<span class="_ _1"></span>elpful <span class="_ _8"></span>to <span class="_ _25"></span>children <span class="_ _8"></span>to <span class="_ _25"></span>h<span class="_ _1"></span>ave <span class="_ _8"></span>at <span class="_ _25"></span>least <span class="_ _25"></span>two <span class="_ _25"></span>alternatives <span class="_ _25"></span>for </div><div class="t m0 x31 h41 y219 ff30 fs0 fc0 sc0 ls0 ws0">safe <span class="_ _8"></span>supervision. <span class="_ _8"></span>Also, <span class="_ _8"></span>in <span class="_ _8"></span>an <span class="_ _8"></span>emergency, <span class="_ _8"></span>the<span class="_ _1"></span>y<span class="_ _0"></span> <span class="_ _8"></span>are <span class="_ _8"></span>more <span class="_ _8"></span>assured <span class="_ _8"></span>if <span class="_ _8"></span>the <span class="_ _8"></span>fami<span class="_ _1"></span>ly <span class="_ _7"></span>has <span class="_ _8"></span>a<span class="_ _1"></span>ctually <span class="_ _7"></span>pr<span class="_ _1"></span>acticed <span class="_ _8"></span>the </div><div class="t m0 x31 h41 y21a ff30 fs0 fc0 sc0 ls0 ws0">routine of <span class="_ _7"></span>what to <span class="_ _1"></span>do <span class="_ _1"></span>if <span class="_ _1"></span>p<span class="_ _1"></span>arents <span class="_ _1"></span>are not <span class="_ _1"></span>home <span class="_ _1"></span>to<span class="_ _1"></span> <span class="_ _1"></span>meet them. <span class="_ _1"></span>Em<span class="_ _1"></span>ergency clo<span class="_ _1"></span>sures of<span class="_ _1"></span> school <span class="_ _7"></span>are ex<span class="_ _1"></span>tremely </div><div class="t m0 x31 h41 y21b ff30 fs0 fc0 sc0 ls0 ws0">rare. Ho<span class="_ _1"></span>wever, <span class="_ _1"></span>we <span class="_ _1"></span>need <span class="_ _1"></span>to <span class="_ _7"></span>prepare our <span class="_ _7"></span>children fo<span class="_ _1"></span>r <span class="_ _1"></span>a <span class="_ _1"></span>safe <span class="_ _1"></span>experience <span class="_ _1"></span>shou<span class="_ _1"></span>ld <span class="_ _7"></span>the <span class="_ _1"></span>need <span class="_ _1"></span>arise. <span class="_ _1"></span>If <span class="_ _1"></span>we <span class="_ _7"></span>do <span class="_ _1"></span>not </div><div class="t m0 x31 h41 y21c ff30 fs0 fc0 sc0 ls0 ws0">have an alternative plan, we will send your c<span class="_ _0"></span>hild home according to their regular routine.<span class="_ _1"></span> </div><div class="t m0 x31 h41 y21d ff30 fs0 fc0 sc0 ls0 ws0">Please <span class="_ _7"></span>specify <span class="_ _7"></span>below <span class="_ _7"></span>any <span class="_ _7"></span>specific <span class="_ _7"></span>instructions <span class="_ _7"></span>fo<span class="_ _1"></span>r <span class="_ _7"></span>the <span class="_ _7"></span>school <span class="_ _7"></span>staff <span class="_ _7"></span>in <span class="_ _8"></span>the <span class="_ _7"></span>e<span class="_ _1"></span>vent <span class="_ _7"></span>of <span class="_ _7"></span>an <span class="_ _7"></span>unannounced <span class="_ _7"></span>earl<span class="_ _1"></span>y </div><div class="t m0 x31 h41 y21e ff30 fs0 fc0 sc0 ls0 ws0">dismissal. </div><div class="t m0 x51 h5b y21f ff2f fs0 fc0 sc0 ls0 ws0">PHONE CALLS FROM SCHOOL CANNOT BE A PART OF THIS PLAN </div><div class="t m0 x4f h5b y220 ff2f fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h41 y221 ff30 fs0 fc0 sc0 ls0 ws0">Student Name: ________________________________________________________________ </div><div class="t m0 x31 h41 y222 ff30 fs0 fc0 sc0 ls0 ws0">Grade: __________________ Teacher: _____________________________________________ </div><div class="t m0 x31 h41 y223 ff30 fs0 fc0 sc0 ls0 ws0">Sibling grade level(s): </div><div class="t m0 x31 h41 y224 ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________</div><div class="t m0 x31 h41 y225 ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________</div><div class="t m0 x31 h41 y226 ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________</div><div class="t m0 x31 h41 y227 ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________ </div><div class="t m0 x31 h41 y228 ff30 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h5b y229 ff30 fs0 fc0 sc0 ls0 ws0"> <span class="ff2f">Ride the bus home as usual. </span></div><div class="t m0 x31 h41 y22a ff30 fs0 fc0 sc0 ls0 ws0">Special instructions- please include any alternate bus numbers: </div><div class="t m0 x31 h41 y22b ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________</div><div class="t m0 x31 h41 y22c ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________</div><div class="t m0 x31 h41 y22d ff30 fs0 fc0 sc0 ls0 ws0">____________________________________________________________________________________ </div><div class="t m0 x31 h41 y22e ff30 fs0 fc0 sc0 ls0 ws0"> </div><div class="t m0 x31 h41 y22f ff30 fs0 fc0 sc0 ls0 ws0">Parent signature: ___________________________________________ </div><div class="t m0 x31 h41 y230 ff30 fs0 fc0 sc0 ls0 ws0">Date: _____________________________ <span class="_ _26"> </span>Phone: _________________________________ </div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --><div id="pfb" class="pf w0 h0" data-page-no="b"><div class="pc pcb w0 h0"><img class="bi x1c y231 w1a h5d" alt="" src="bgb.png"/><div class="t m0 x52 h5e y232 ff31 fs15 fc0 sc0 ls0 ws0">Military P<span class="_ _0"></span>ar<span class="_ _0"></span>e<span class="_ _0"></span>nt <span class="_ _0"></span>or Guardia<span class="_ _0"></span>n Alia<span class="_ _0"></span>on<span class="ff32"> </span></div><div class="t m0 x53 h5f y233 ff31 fs5 fc0 sc0 ls0 ws0">(Please mark all that apply)<span class="ff32"> </span></div><div class="t m0 xe h12 y234 ff33 fs3 fc0 sc0 ls0 ws0"> <span class="_ _27"> </span><span class="ff34">N—No parent or <span class="_ _1"></span>guardian of the above children i<span class="_ _1"></span>s currently serving as a m<span class="_ _1"></span>ember of the ac<span class="_ _1"></span>ve duty U.S. </span></div><div class="t m0 x54 h12 y235 ff34 fs3 fc0 sc0 ls0 ws0">Armed Forces, Reserve<span class="_ _1"></span>s of the U.S. Armed Force<span class="_ _1"></span>s or Washingto<span class="_ _1"></span>n Naonal Guard<span class="_ _7"></span><span class="ff33"> </span></div><div class="t m0 xe h12 y236 ff33 fs3 fc0 sc0 ls0 ws0"> <span class="_ _27"> </span><span class="ff34">A—A parent or <span class="_ _1"></span>guardian of the children ab<span class="_ _1"></span>ove is a current <span class="_ _1"></span>member of the acve d<span class="_ _1"></span>uty U.S. Armed Force<span class="_ _1"></span>s<span class="_ _7"></span></span> </div><div class="t m0 xe h12 y237 ff33 fs3 fc0 sc0 ls0 ws0"> <span class="_ _27"> </span><span class="ff34">R—A parent or <span class="_ _1"></span>guardian of the children ab<span class="_ _1"></span>ove is a current <span class="_ _1"></span>member of the reserves o<span class="_ _1"></span>f the U.S. Armed </span></div><div class="t m0 x54 h12 y238 ff34 fs3 fc0 sc0 ls0 ws0">Forces<span class="ff33"> </span></div><div class="t m0 xe h12 y239 ff33 fs3 fc0 sc0 ls0 ws0"> <span class="_ _27"> </span><span class="ff34">G—A parent or gu<span class="_ _1"></span>ardian of the children above i<span class="_ _1"></span>s a current <span class="_ _1"></span>member of the Washington<span class="_ _1"></span> Naonal Guard<span class="_ _7"></span></span> </div><div class="t m0 xe h12 y23a ff33 fs3 fc0 sc0 ls0 ws0"> <span class="_ _27"> </span><span class="ff34">Z—No response/Refused t<span class="_ _1"></span>o state<span class="_ _1"></span></span> </div><div class="t m0 xe h12 y23b ff34 fs3 fc0 sc0 ls0 ws0">Parent/Guardian(s) Na<span class="_ _1"></span>me(s):<span class="_ _1"></span><span class="ff33"> <span class="_ _28"> </span></span>Student Name(s):<span class="_ _1"></span><span class="ff33"> </span></div></div><div class="pi" data-data='{"ctm":[1.000000,0.000000,0.000000,1.000000,0.000000,0.000000]}'></div></div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="loading-indicator"><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --></body><!-- [et_pb_line_break_holder] 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