Independent School District #181 Brainerd, MN 56401
SCHOOL ENROLLMENT FORM PLEASE PRINT CLEARLY
For Office Use Only Copy of Birth Certificate _____________ Copy of Immunization Record ________ MARSS #_________________________ Resident District ___________________ Date of Records Request_____________ Date Records Received______________
Today’s Date: ____________________ Student’s Legal Name ____________________________________________ Gender: Male Female (Last) (First) (Middle) Date of Birth ___________________________ Age ________ Grade ________ Graduation Year _________ City and State of Birth _________________________________ Is student Hispanic/Latino? Yes No Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Primary Home Language ____________ Student’s First Day of School will be _____________________ (month/day/year) Has student ever previously attended a school in Brainerd? Yes No Student Lives With: Both Parents Father only Mother only Other, relationship __________ Father and _____________________ Mother and ____________________ (relationship) (relationship) Current Living Situation: Own Home with relatives shelter hotel Vehicle/campground Other____________________ Student’s Address_______________________________________ _ Home Telephone # _________________
________________________________________
Father/Guardian LEGAL Name_________________________________ Email Address___________________
Address___________________________________________ City, State Zip ______________________
Employed at_________________________ Work #_________________ Cell #____________________
Mother/Guardian LEGAL Name________________________________ Email Address___________________
Address___________________________________________ City, State Zip ______________________
Employed at_________________________ Work #_________________ Cell #____________________
Siblings_____________________________________ Gender: M F Birthdate____________________
(Last) (First) (Middle) _____________________________________ Gender: M F Birthdate____________________ (Last) (First) (Middle) _____________________________________ Gender: M F Birthdate____________________ (Last) (First) (Middle) _____________________________________ Gender: M F Birthdate____________________ (Last) (First) (Middle)
Does your child have a current Individual Education Plan (IEP)? Yes No
Does your child have a 504 Accommodation Plan?
Yes No
Has the student ever attended a public school in Minnesota?
Yes No
Is your child up to date on his/her immunizations?
Yes
No
List any medications your child may be taking ____________________________________________________
Any other health concerns our school nurses need to be aware of? ___________________________________ Parent’s Signature __________________________________________________________________________
EMERGENCY CONTACT Other than those living with student
1. ________________________ _____________________ __________________ ___________________ Name Relationship Phone Other Phone Address____________________________________________ City, State Zip __________________________ 2. ________________________ _____________________ __________________ ___________________ Name Relationship Phone Other Phone Address____________________________________________ City, State Zip __________________________ Parent’s Signature _________________________________________________________________________
FOR KINDERGARTEN ENROLLMENTS ONLY This information will help us plan the Kindergarten school year. If you plans for kindergarten change, or if you have a change of address, please contac the ISD #181 Main Office at 454‐6900 or call the Early Childhood Center at 454‐5430. 1) My Child is eligible to start Kindergarten in ________ 2) My child will attend: ______ I plan to have my child start Kindergarten then ______ Brainerd Public Schools ______ I plan to have my child remain at home another year ______ Lake Region Christian School ______ I am undecided at this time ______ St. Francis Parochial School ______ Other _______________________ 3) ______ We may or will be moving out of the area.
Washington Educational Services Building 804 Oak Street Brainerd, MN 56401 Phone: (218) 454-6900 Fax: (281) 454-5549 ww.isd181..org
Request for Student Records Previous School Attended: _______________________________________________________________ Address: _____________________________________________________________________________ City ____________________________________________ State/Zip _____________________________ Phone # _________________________________________ Fax # ________________________________ ________________________________________ Student’s Name
________________ __________ Date of Birth Grade
has enrolled in our school district on _________________ and will start on __________________. Please release the following information for this student for scheduling purposes. - Transcript of Grades - Testing information including the MN Basic Standards Tests scores and MCA scores - MN High Standards Information (if applicable) - Attendance Record - Special Services Record - Health Records / Immunization Records / Physical forms - Psychological Assessments - Individualized Education Plan (IEP) and Evaluation Report - Current School Placement and Performance - Disciplinary Reports - Birth Certificate - Other information which may be helpful for placement Minnesota Schools: MARSS Number __________________________________________________ Signature of Parent/Guardian: __________________________________________________________ (Federal Law (Buckley amendment, Section 99.31) states that a written consent is not required for the release of educational records to another educational institution.)
SEND INFORMATION TO: Grades 5 – 8 Teri Osell Forestview Middle School 12149 Knollwood Dr. Baxter, MN 56425 Phone: 218-454-6067 Fax: 218-454-6688
[email protected]
Grade 9 Jenny Barnhart BHS So. Campus 400 Quince St Brainerd, MN 56401 Phone: 218-454-5202 Fax: 218-454-5201
[email protected]
Grades 10 – 12 Joy Ruzich Brainerd High School 702 5th St. S. Brainerd, MN 56401 Phone: 218-454-6298 Fax: 218-454-6325
[email protected]
Transportation Office 804 Oak Street Brainerd, MN 56401 (218)-454-6900
TRANSPORTATION REQUEST/INFORMATION CHANGE FORM Each student is allowed one stop for inbound and one stop for outbound. This includes daycare within the students elementary attendance boundary. If student lives in a split household, then each has one inbound and one outbound within the students elementary attendance boundary. Parents are responsible for making all temporary arrangements. There is NO busing for temporary stops. A.M. PICK-UP ADDRESS
CITY
P.M. DROP-OFF ADDRESS
ZIP
CITY
ZIP
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PARENT/FAMILY 1 NAME: ADDRESS CITY ZIP
HOME PHONE:
PARENT/FAMILY 2 NAME:
HOME PHONE:
DAYCARE CONTACT NAME:
CELL PHONE:
WORK PHONE:
ADDRESS
CITY
CELL PHONE:
WORK PHONE:
ADDRESS
HOME PHONE:
ZIP
CITY
CELL PHONE:
ZIP
WORK PHONE:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ STUDENT NAME/S: SCHOOL GRADE 1. 2. 3. 4.
PARENT/GUARDIAN SIGNATURE: FOR OFFICE USE ONLY: ❏
NEW ADDRESS
DATE ❏
BUSING NEEDED
❏
DAYCARE CHANGE
❏
SIF MESSAGE
INITIIALS ❏
PUSH
Dear Parent(s) or Guardian(s), Please review the following information regarding Bus Transportation, and School Bus Policy.
Bus Cards: All bus riders that live within the busing zone, and are receiving transportation need to carry their bus card with them when riding the school bus. Without proper identification a student may not be allowed to board a bus. If they misplace their card they can speak to the building secretary about replacement. Pickup and drop off locations: Students that live within the bus zone are allowed one pickup location and one drop off location. Students that attend an Elementary School may only be transported within their schools attendance boundary within the busing zone. If you move: Please contact the Student Enrollment Center at 218-454-6900, and they will make the address change. Please indicate to the Student Enrollment Center staff you will need transportation, and they will notify the Transportation Office. Transportation will send out new bus cards to your child’s school. The start date will be indicated on the bus card. We ask that your student does not start riding until they receive their bus card and do not start prior to the date listed on the card. This will ensure that Reicherts and the bus driver have been made aware of the changes. Daycare: If you have a change in daycare, you need to contact the Transportation Office at 218-454-6900. A bus card will be sent to your student’s school reflecting the change. All the bus information, as well as the start date will be indicated on the bus card. What if I decide I do not want transportation: The School District is required to report ridership to the State Department of Education. If you decide your will not need transportation services please contact the Transportation Office at 218-454-6900 and we will remove them from the bus route. What if something changes, and I later need transportation? If you decline transportation and later decide you would like your student to ride a bus, simply call 218-454-6900, and request transportation. A bus card will be sent to your child’s school. All the bus information as well as the start date will be listed on the bus card. Whom do I contact if? My child did not get off the bus: The Brainerd School District contracts with Reichert Bus Service for our service. You can contact them at 218-829-6955 extension 0. Driver concerns: If you need to contact your driver or have a driver concern, please contact management at Reichert Bus Service at 218-829-6955 extension 0. Late running morning buses: Reichert Bus Service will contact the Brainerd School District Transportation Office if a morning bus is running 15 minutes or more late. The Transportation Office will send out a Skylert to parents and guardians. Weather may also impact route time and buses may run behind on their schedule. Have your students dress appropriately for the possibility of longer waits at the bus stop. School closing information: Will be on all local radio stations. Bus Policies: You can find this policy in its entirety as well as all Transportation policies at http://www.isd181.org
Washington Educational Services Building 804 Oak Street Brainerd, MN 56401 Phone: (218) 454-6900 Fax: (281) 454-5549 ww.isd181..org
VERIFICATION OF (Non-Joint) CHILD CUSTODY Child(ren) Name______________________________________________ _____________________________________________________________ Non-Custodial Parent’s Name ____________________________________ __ Yes
__ No May the non–custodial parent have access to your child’s school records (report card, progress report, class work, IEP)?
__ Yes
__ No May the non–custodial parent discuss your child’s progress with his/her teacher?
__ Yes
__ No May the non-custodial parent visit your child at school?
__ Yes
__ No May the non-custodial parent telephone your child at School?
If you checked “No” to any of the above the Brainerd Public School District Policy 515 requires that you provide the court documentation to the District for our records. If court documentation is not provided and the non-custodial parent requests information regarding the child(ren), the information will be released to them upon their request. Custodial Parent’s Signature______________________________________ Date___________________
OMB Number: 1810-0021
Expiration Date: 05/03/2016 U.S. DEPARTMENT OF EDUCATION OFFICE OF INDIAN EDUCATION WASHINGTON, DC 20202 TITLE VII STUDENT ELIGIBILITY CERTIFICATION Elementary and Secondary Education Act, Title VII, Part A, Subpart 1
Parents: Please return this completed form to your child's school. In order to apply for a formula grant under the Indian Education Program, your child's school must determine the number of Indian children enrolled. Any child who meets the following definition may be counted for this purpose. You are not required to complete or submit this form to the school. However, if you choose not to submit a form, the school cannot count your child for funding under the program. This form will become part of your child's school record and will not need to be completed every year. This form will be maintained at the school and information on the form will not be released without your written approval. Definition: Indian means any individual who is (1) a member (as defined by the Indian tribe or band) of an Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized by the State in which the tribe or band reside; or (2) a descendent in the first or second degree (parent or grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994. NAME OF CHILD ____________________________________ (As shown on school enrollment records)
Date of Birth ___________________
School Name ___________________________________________
Grade _____________
NAME OF TRIBE, BAND OR GROUP________________________________________________________ Tribe, Band or Group is: (check one) Federally Recognized, State _____ Including Alaska Native _____ Recognized _____ Terminated
Organized Indian Group Meeting #5 of the _____ Definition Above
Name of individual with tribal membership: _____________________________________________ Individual named is (check one): _____ Child
_____ Child's Parent
_____ Child's Grandparent
Proof of membership, as defined by tribe, band, or group is: A. Membership or enrollment number (if readily available) _________________________ OR Other (explain) _____________________________________________
Name and address of organization maintaining membership data for the tribe, band or group: __________________________________________________________ I verify that the information provided above is accurate: PARENT'S SIGNATURE _______________________________________ DATE ____________________ Mailing Address _______________________________________________ Telephone _________________
Notice: Public Reporting Burden Notice on Reverse Side
PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3E200, Washington, D.C. 20202-6335.
