Premont ISD Registration Checklist 2018-2019 Returning Students Please have each item checked before leaving. Items in Registration Packet  Registration Form o Handbook/Code of Conduct Acknowledgement o Bus Information  Ethnicity Race Questionnaire  Migrant Survey  Emergency and Health Data  Request for Medical Records  McKinney Vento Homeless Form  Connected Military Form  Student Compact  Field Trip Permission  Computer Acceptable Use/Chrome Contract

 Income Verification – Only one form needed per family.  Immunization Records  Transfer Form – for any student who resides outside of PISD boundaries.

2017-2018 Texas Education Data Standards Appendix 8.F – PEIMS Supplemental Information for Reporting Ethnicity and Race Data Reporting Final Version 2018.F.1.0

Exhibit 1A Student/Staff Ethnicity and Race Data Questionnaire in English Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data Questionnaire The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race. United States Federal Register (71 FR 44866) Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic/Latino Part 2. Race: What is the person’s race? (Choose one or more) American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment. Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Student/Staff Name (please print)

(Parent/Guardian)/(Staff) Signature

Student/Staff Identification Number

Date

This space reserved for Local school observer – upon completion and entering data in student software system, file this form in student’s permanent folder. Race – choose one or more: Ethnicity – choose only one: American Indian or Alaska Native Asian Hispanic / Latino Black or African American Native Hawaiian or Other Pacific Islander Not Hispanic/Latino White Observer signature:

Campus and Date: Texas Education Agency – March 2017 1

2017-2018 Texas Education Data Standards Appendix 8.F – PEIMS Supplemental Information for Reporting Ethnicity and Race Data Reporting Final Version 2018.F.1.0

Exhibit 1B Student/Staff Ethnicity and Race Data Questionnaire in Spanish Agencia de Educación de Texas Cuestionario de Información de Datos Raciales y de Etnicidad de Estudiantes/Miembros de Personal de las Escuelas Públicas de Texas El Departamento de Educación de Estados Unidos (USDE) requiere que todas las instituciones estatales y locales de educación, recopilen datos sobre etnicidad y raza de los estudiantes y de miembros de personal. Esta información es utilizada para los reportes estatales y federales así como para reportar a la Oficina de Derechos Civiles (OCR) y a la Comisión de Igualdad en el Empleo (EEOC). Al personal del distrito escolar y los padres o representante legal de estudiantes que deseen matricularse en la escuela, se le requiere proporcionar esta información. Si usted rehúsa proporcionarla, es importante que sepa que el USDE requiere que los distritos escolares usen la observación para identificación como último recurso para obtener estos datos utilizados para reportes federales. Favor de contestar ambas partes de las siguientes preguntas sobre la etnicidad y raza del estudiante así como del miembro de personal. Registro Federal de Estados Unidos (71 FR 44866). Parte 1. Etnicidad: ¿Es la persona Hispana/Latina? (Escoja solo una respuesta) Hispano/Latino – Una persona de origen cubano, mexicano, puertorriqueño, centro o sudamericano o de otra cultura u origen español, sin importar la raza. No Hispano/Latino Parte 2. Raza. ¿Cuál es la raza de la persona? (Escoja uno o más de uno) Indio Americano o Nativo de Alaska – Una persona con orígenes o de personas originarias de Norte y Sudamérica (incluyendo America Central), y que mantiene lazos o apego comunitario con una afiliación de alguna tribu. Asiático – Una persona con orígenes o de personas originarias del Lejano Este, Sureste de Asia o el subcontinente indio, incluyendo, por ejemplo a Cambodia, China, India, Japón, Corea, Malasia, Pakistán, las Islas Filipinas, Tailandia y Vietnam. Negro o Áfrico-Americano – Una persona con orígenes de cualquier grupo racial negro de África. Nativo de Hawai u otras islas del pacífico – Una persona con orígenes o de personas originarias de Hawai, Guam, Samoa u otras Islas del Pacífico. Blanco – Una persona con orígenes de personas originarias de Europa, el Medio Este o el Norte de África.

Nombre del Estudiante/Miembro de Personal (por favor use letra de imprenta)

Firma(Padre/Representante legal) /(Miembro de personal

Número de Identificación del Estudiante/Miembro del personal

Fecha

This space reserved for Local school observer – upon completion and entering data in student software system, file this form in student’s permanent folder. Ethnicity – choose only one: Race – choose one or more: Hispanic / Latino American Indian or Alaska Native Not Hispanic/Latino Asian Black or African American Native Hawaiian or Other Pacific Islander White Observer signature:

Campus and Date: Agencia de Educación de Texas – Marzo 2017 2

PREMONT INDEPENDENT SCHOOL DISTRICT Migrant Education Program 439 Southwest 4th Street Premont, TX 78375

2018-2019 (361)348-3915 ext. 2202

FAMILY SURVEY

Date:____________________ Dear Parents, In order to better serve your children, the Premont Independent School District would like to identify students who may qualify to receive additional educational services. The information provided below will be kept confidential. Please answer the following questions and return this survey form to your child’s school. Or, if you prefer, for more information, call: (361) 561-8615

Name of child____________________________________ Age______________ Grade________ 1. Have you moved within the last 3 years?

Yes______ No_______ 2. If yes, have you done agricultural or fishing related work since your move? (e.g., field work, canneries, lumbering, dairy work, meat processing) Yes______ No_______

If you answered “yes” to both of the questions above, an education representative may contact you to find out whether your child is eligible for additional educational services. Please provide the following information: Parent/Guardian Name: Address: Telephone Number:

Alternate Phone Number:

Email Address:

Best Time to Contact You:

Schools: Please return this survey to the Federal Programs Office, ATTN: Gloria Garcia

PREMONT INDEPENDENT SCHOOL DISTRICT Migrant Office 439 Southwest 4th Street Premont, TX 78375

2018-2019

(361)348-3915 ext. 2202

ENCUESTA DE FAMILIA

Fecha:___________________ Estimados padres, Para mejorar los servicios educativos de sus hijos, el distrito escolar de Premont quisiera identificar estudiantes que puedan calificar para recibir servicios educativos adicionales. Toda la información proporcionada será mantenida confidencial. Favor de responder a las siguientes preguntas y devolver esta forma a la escuela de su niño/a. O, si prefiere, para más información, llame a: (361) 561-8615

Nombre de su Niño/a: _____________________________Edad _________ Grado ________ 1. ¿Ha cambiado de residencia usted o alguien en su familia dentro de los últimos tres años? Sí______ No _______ 2. Si usted contesto “sí” en la pregunta anterior, ¿ha trabajado usted en la agricultura o en la pesca? (por ejemplo, la labor, fábrica de conservas, explotación de bosques, trabajo en la lechería, el proceso de carne) Sí______ No _______

Si usted contestó "Sí," en las dos preguntas anteriores, un representante del distrito escolar quizás se vaya a comunicar con usted para averiguar si su niño/a califica para servicios educativos adicionales. Favor de completar la siguiente información: Nombre del Padre/Guardián: Número de teléfono:

Número Alterno:

Dirección: Dirección de correo electrónico:

La mejor hora para localizarlo:

Schools: Please return this survey to the Federal Programs Office, ATTN: Gloria Garcia

Premont Independent School District Emergency & Health Data

Parent/Guardian: To serve your child in case of ACCIDENT OR SUDDEN ILLNESS It is necessary that you furnish the following information annually. 2018-2019 Student’s Name ____________________________Birth Date_____/_____/_____ Grade _________ A Med at School Form must be signed by the Dr. and both parents before the Nurse will administer medications at school. A Food Allergy Action Plan must be filed separately with the Nurse. Please designate the student’s Doctor in case an emergency arises. Doctor___________________________________PH#______________________________Address__________________________ List any Health/Medical conditions that the student may have:

Heart kidney Epilepsy Asthma

Does your child carry an inhaler

eye or ear problems low blood sugar or diabetes Severe allergies Other _________________________

yes

no

List any surgeries that the student may have had: 1. 2. 3.

Please list your child’s allergies: 1. 2. 3.

• • •

• • •

• •

Your child’s vision, hearing, weight, height, spine (visual assessment for abnormal curvature), and blood pressure will be screened in selected grades as required by law and school policy. I, do hereby authorize officials of PISD to contact the person(s) named on this form, and do authorize the physician listed to render such treatment necessary in the event of an emergency to the child. In the event that the physician, other person’s on this form, or parent cannot be contacted, the school officials (Principal or Appointed designee) are hereby authorized to take whatever action is necessary in their judgment, for the health of the child. I will not hold the school district financially responsible for the emergency care and or transportation for the said child. The undersigned, legal custodian of ________________________ a minor, hereby authorize the Principal or Appointed Designee into whose care the aforementioned minor pupil has been entrusted, to consent to any emergency x-rays, treatment, or hospital care. It is understood that this authority is given in advance of any required diagnosis, treatment or hospital care and provides power to the aforementioned agent to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist might deem necessary. The authorization is given for the full school year unless revoked in writing and delivered to said agents. Understand that PISD, its officers, and its employees assume no liability of any nature in relation to the transportation of the child.

Signature of Parent or Guardian____________________________________ Date ____________________

PREMONT INDEPENDENT SCHOOL DISTRICT P.O. Box 530 PREMONT, TEXAS 78375 (361)348-3915

REQUEST FOR MEDICAL-PROFESSIONAL RECORDS Dear Parent/Guardian: We feel that it is necessary to request information concerning your child’s medical/health history so that we may meet his/her needs in the school setting. Your signature on the following release form will give us your permission to request this information. _ Date

Principal’s Signature

REQUEST FOR RELEASE OF MEDICAL-PROFESSIONAL RECORDS I do hereby give my consent for the release and exchange of information contained in the Medical or professional record.

Child’s Name Name and Address of Professional to be contacted for information

Birth Date Information needed by School

Send information to School Contact

Telephone Number Date

Signature of Parent/Guardian Relationship to Child

Premont Independent School District P.O. Box 530 Premont, Texas 78375 Phone # (361)-348-3915 Ext.2003

Fax #(361)-348-2882

Name of Student: _______________________________________________ Birth Date ___/___/___ Age:____ Social Security #____________________ This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student maybe eligible to receive. 1. Is your address a temporary living arrangement? _____Yes _____No 2. Is this temporary living arrangement due to loss of housing or economic hardship? _____Yes _____No If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here.

Where is the student presently living? (Check one box) ____ In a motel ____ In a shelter ____Moving from place to place ____ With more than one family in a house or apartment ____ In a place not designed for ordinary sleeping accommodations such as a car, park, or Campsite. Name of Parent (s) Legal Guardian (s) ___________________________________________ Address________________________________ Zip_____________ Phone______________ Presenting a false record or falsifying is a offense under Section 37.10, Penal Code, and enrollment of the child under false documents subjects the person to liability For tuition or other costs. TEC Sec.25.002 (3) (d) Signature of Parent/Legal Guardian__________________________________ Date___________ Please send a copy to Premont ISD at the Central Office or Fax a copy to (361)348-2882

Distrito escolar independiente de Premont P.O. Box 530 Premont, Texas 78375

Teléfono # (361) - 348 - 3915 Ext.2003

Fax # (361)-348-2882

Nombre del estudiante: ________________________________________ Fecha de nacimiento ___ / ___ / ___ edad: _____________previsionales #_________________ Este cuestionario es destinada a cumplir con el acto de McKinney-Vento 42 U.S.C. 11435. Las respuestas a esta información de residencia ayudan a determinar los servicios al estudiante tal vez elegible para recibir.

1. Es su dirección en un arreglo de vivienda temporal? ___Si ___No 2. Es este arreglo de vivienda temporal debido a la pérdida de penurias económicas o vivienda? ___Si ___No Si usted contestó sí a las preguntas anteriores, por favor complete el resto de esta forma. Si su respuesta es NO, usted puede dejar aquí.

Dónde está actualmente viviendo el estudiante? (Marque una casilla) ___ En un motel ___ en un refugio ___Moving de sitio a otro ___ Con más de una familia en una casa o apartamento ___ En un lugar no diseñado para ordinario plazas como un coche, aparcar, o Camping. Nombre del padre (s) encargado (s) ___ Address________________________________ Zip_____________ Phone______________ Presentar un registro falso o la falsificación es una ofensa bajo la sección 37.10, Código Penal, y la inscripción del niño bajo documentos falsos somete a la persona a responsabilidad Por matrícula u otros costos. TEC Sec.25.002 (3) (d) Firma del padre/Legal Guardian______________________________Date________________ Por favor, envíe una copia a Premont ISD en la Oficina Central o Fax una copia a (361) 348-2882

Premont Independent School District Military Connected Student Form 2018-2019 PLEASE RETURN THIS FORM TO YOUR CHILD’S CAMPUS ONLY IF YOUR CHILD MEETS ONE OF THE CRITERIA BELOW In 2009 The Texas Legislature adopted the Interstate Compact on Educational Opportunity for Military Students – Texas Education Code Chapter 162. This legislation requires schools to recognize and extend certain privileges to students who are military dependents and to assist military dependent students in the transition process of changing schools when their military parents are reassigned and forced to relocate. Parent Name: Student Name:

Date of Birth:

Grade:

Campus:

Please check one box below to indicate if your child is a dependent of a member of: For all students: Active Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard [This includes Missing in Action (MIA)] Texas National Guard Reserve Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard For Pre-Kindergarten students ONLY: Armed forces or reserved forces of the United States (Army, Navy, Air Force, Marine Corps, or Coast Guard) or Texas National Guard who has been injured or killed while on active duty

PREMONT ISD 2018-2019 School/Parent/Student COMPACT Student Name ___________________________________ Grade___________ TEACHER/PRINCIPAL AGREEMENT It is important that all students achieve to their greatest potential . Therefore, we shall strive to do the following: • Communicate and work with families to support quality student learning. • Care about all students and their success. • Provide relevant assignments that are appropriate for students. • Provide an enjoyable, supportive, learning environment. • Maintain high expectations for all students, parents, and educators. Teacher’s Signature: ______________________________________________________ Principal’s Signature: _____________________________________________________

PARENT/GUARDIAN AGREEMENT I want my child to achieve to his/her greatest potential. Therefore, I shall strive to do the following: • Be actively involved in the education of my child including attending parent/teacher conferences • See that my child is punctual and attends school regularly, • Encourage my child’s efforts. • Provide uninterrupted time (without TV) for reading, homework, and other learning activities. • Support the school in its effort to maintain proper discipline. Parent’s/Guardian’s Signature: _______________________________________________

STUDENT AGREEMENT It is important that I get the best education possible. Therefore, I shall strive do the following: • Attend school regularly and on time. • Come to school each day with the necessary material for learning. • Follow school and classroom rules • Complete and return school assignments to the best ability. • Respect self, others, and community. Student’s Signature: ______________________________________________________

Field Trips for Premont ISD The students of PREMONT ISD will have the opportunity to go on a number of educational field trips during the year. As always, parental consent must be granted in order for your child to attend/participate. YES, I give permission for _______________________________ to attend field trips. Name

Grade

NO, I do not give permission for ___________________________ to attend field trips. Name

Grade

I understand and realize that the Premont Independent School District is not legally liable under Texas Laws for injuries of any nature at any time or any place to any person(s), pupils, teachers, other employees, or any other person whatsoever. Chaperone(s) for the conference, meeting, activity, will expect all students who are participating in the program/activity to give them their complete cooperation and to comply with all requests governing their conduct and activities. PARENT/GUARDIAN SIGNATURE

DATE

Phone Number: ___________________

Emergency Information In case of an emergency I give permission for my child to receive emergency medical treatment. In case of such emergency please contact:

PARENT/GUARDIAN SIGNATURE

DATE

______________________________ Emergency Contact Person

____________________ Phone Number

Computer Acceptable Usage and Chromebook Checkout Premont ISD 2018-2019 Acceptable Use Policy I agree to abide by the conditions set forth by Premont ISD. I understand that I am responsible for my actions while using the school network and while using the internet. I have read (copy available on the district website) and understand the Acceptable Use Policy. I realize that if I violate any part of the AUP, it may result in the suspension or revoking of my privileges. _____________________________ Please Print Student Name

________________________ Student Signature

Grade ____

_____________________________ Please Print Parent/Guardian Name

________________________ Parent/Guardian Signature

Date:______________

Permission for the Publication of Classroom Work/Pictures on School Webpages ____Yes, my child’s photo, artwork, projects etc. can be used online. ____No, my child’s photo, artwork, projects etc. cannot be used online. Students in grades 3rd through 12th have Google accounts for use with their Chromebooks. _____ Yes, I give my student permission to have a google account for educational purposes. _____ No, I do not give my student permission to have a google account for educational purposes. Premont ISD issues Chromebooks for Student Usage - For Grades 3 – 12 only I agree to abide by the conditions set forth by Premont ISD. I understand that I am responsible for my actions while using the school equipment and while using the internet. I have read (copy available on the district website) and understand the Premont ISD Chromebook Policy. _____ I agree to have my student check out a Chromebook device from Premont ISD and take responsibility for the any damages to the device. _____ I do not wish to have my student check out a device from Premont ISD. I understand that at times a computing device will be needed for class work. Damage Charges – Lost or Stolen Device $225, Broken Screen or Keyboard $40, Lost Charger $35. Premont ISD Asset Tag #________ Serial Number:_____________________

PREMONT INDEPENDENT SCHOOL DISTRICT

439 SW 4TH STREET, PREMONT, TX 78375 361-348-3915, FAX 361-348-2882 www.premotisd.net

STUDENT:

CAMPUS:

GRADE LEVEL: STUDENT:

CAMPUS:

GRADE LEVEL: STUDENT:

CAMPUS:

GRADE LEVEL:

HOUSEHOLD – INCOME VERIFICATION 2018-2019 The Household –Income information provided will assist the Premont ISD in completing audit requirements and reviews set forth by the Texas Education Agency. It is very important that we have the most accurate information about your child. All information will remain confidential.

PLEASE COMPLETE THE INFORMATION NEEDED BELOW. Please select the number of family members

Family Size Gross Income

Weekly$ Bi-Weekly$ Monthly$ Please check the program(s) that apply

Assistance Programs

__

TANF-Temporary Assistance to Needy Family __AFDC __Food Stamps __Other OFFICE USE ONLY

00-Not Identified Econ. Disadv.

99-Other Econ. Disadv.

Code Reference: PEIMS Standards Section 4 p4.116 I certify that all the information on this verification form is true and that all income is reported. I understand that the school will receive funds based on the information provided. I understand that I decline the disclosure of household income information. Parent/Guardian Signature:

Date

PREMONT INDEPENDENT SCHOOL DISTRICT TH

439 SW 4 STREET, PREMONT, Tx 78375 361-348-3915, FAX 361-348-2882 www.premontisd.net

Estudiante: ___________________________________________ Nivel de Grado: ___________

Escuela: ___________________

Estudiante: ___________________________________________ Nivel de Grado: ___________

Escuela: ___________________

Estudiante: ___________________________________________ Nivel de Grado: ___________

Escuela: ___________________

VERIFICACION DE INGRESOS 2018-2019 – HOGAR La información proporcionada -Ingresos del hogar ayudará a Premont ISD para completar los requisitos de auditoría yrevisión establecidos por la Agencia de Educación de Texas. Es muy importante que tengamos la información más precisa acerca de su hijo. Toda la información será confidencial.

COMPLETE LA INFORMACION NECESARIA ABAJO

Por favor, seleccione el número de miembros en la familia Tamaño de Familia Ingresos Brutos

Programas de Asistencia

___________________ Por Semana $ ________________ Quincenal $ ________________ Mensual $ ________________ Por favor, compruebe el programa (s) que se aplican ___ TANF – Asistencia Temporal para Familia Necesitados ___ AFDC ____ ESTAMPILLAS PARA COMIDA ____ OTRO

SÓLO USO DE OFICINA 00-Not Identified Econ. Disadv. Econ. Disadv.

99 – Other Econ. Disadv.

Código de Referencia: Sección de Normas PEIMS 4 p4.116 Certifico que toda la información en este formulario de verificación es verdadera y que he reportado todos los ingresos. Yo entiendo que la escuela recibirá fondos sobre la base de la información proporcionada. Yo entiendo que no acepta la divulgación de información sobre los ingresos de los hogares.

Firma de Padre / Guardián: ______________________________________________

Fecha: __________