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Enrollment Packet

408 Cherry St * P.O. Box 1210

Warren, AR 71671

870-226-6738

870-226-8531-Fax

Website: www.warrensd.org

Enrollment Requirements for Warren School District

Prior to a child’s admission to an Arkansas public school, the parent, guardian, or other responsible personal shall provide the school with the following:

Copy of child’s Social Security card or request that the school district assign a nine-digit number designated by the Arkansas Department of Education. (In July 2005 the district began assigning a student identification number to every student in the district to be used on documents that are public.)

The district must have one of the following to verify the child’s age:

Birth Certificate
A statement by the local registrar or a county recorder certifying the child’s date of birth.
An attested baptismal certificate
A passport
An affidavit of the date and pace birth by the child’s parent or guardian
Previous school records
Military ID

Immunizations are up-to-date

Proof of Residency (Ex. current utility bill, real estate contract or rental agreement, etc)

Students who have previously attended school in another district should bring their latest report card, if available.

Students receiving special education services should bring a copy of the current Individualized Education Program (IEP).

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STATEMENT OF VERIFICATION OF LEGAL RIGHT TO BE ENROLLED AS A STUDENT IN THE WARREN SCHOOL DISTRICT

Student’s Name_______________________ Grade_________________

El nombre del estudiante

I attest that my child has a legal right to be enrolled the Warren School District because:

Certifico que mi hijo tiene el derecho legal de estar inscrito en el Distrito Escolar Warren porque:

I am a resident of Warren School District.

Soy residente del Distrito Escolar de Warren.

My current address is: _____________________________________________________________

Mi dirección actual es:

My child has been granted a legal transfer from____________________School District into the Warren School District.�A mi hijo se le ha concedido una transferencia Del: distrito escolar al distrito escolar de Warren.

Other (Describe any other circumstances which would make a child eligible to attend Warren School District.) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________�Otro (Describa cualquier otra circunstancia que haría que un niño sea elegible en el Distrito Escolar de Warren.)

______________________________ ____________________________

Parent’s Name (please print) Parent’s Signature

Nombre del Padre (por favor escriba) Firma de los padres

Date_________________

Fetcha

Note: This information is required by section 6-18-202 of the School Laws of Arkansas. Falsification of information will result in the student's removal from the school. Such falsification is a misdemeanor and is punishable by a fine of up to $500.

Note: La falsificación de información resultará en la expulsión del estudiante de la escuela. Tal falsificación es un delito menor y se castiga con una multa de hasta $500.

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Student Information Form

First Name:	Middle Name:	Last Name:
Birthdate:	Nickname:	Gender: Female Male
Grade:	SSN (Optional):	Hispanic or Latino Ethnicity: Yes No

𛲠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 tribal affiliation or community attachment.)
𛲠Asian (A person having origins in any of the original peoples of 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, Middle East or North Africa)
Additional Races (check all that apply): 𛲠American Indian/Alaska Native 𛲠 Asian 𛲠Black 𛲠 Natice Hawaiian/Other Pacific Islander 𛲠White
Language Spoken at Home:
Student Email Address:

RACE Please answer the following in accordance with standards issued by the US Department of Education.

Student Physical /911 Address Address: _________________________ City: _____________________________ State: __________ Zip Code:_______	Student Mailing Address Address: _________________________ City: _____________________________ State: __________ Zip Code:_______
Student Home Phone:_______________	Student Cell Phone:________________

Parent/Guardian 1 Name: _________________________________ Relationship to Student:____________________ Language of Correspondence:_______________ Mailing Address: _________________________ City:___________________________________ State:____________ Zip Code:______________ Email:__________________________________ Home Phone:____________________________ Cell Phone:______________________________ Alert Phone:_____________________________ Alert Phone is used by the district’s automated phone message system. Employer: _______________________________ 𛲠Student Primarily Resides with this Guardian.	Parent/Guardian 2 Name: _________________________________ Relationship to Student:____________________ Language of Correspondence:_______________ Mailing Address: _________________________ City:___________________________________ State:____________ Zip Code:______________ Email:__________________________________ Home Phone:____________________________ Cell Phone:______________________________ Alert Phone:_____________________________ Alert Phone is used by the district’s automated phone message system. Employer: _______________________________ 𛲠Student Primarily Resides with this Guardian.

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City of Birth:	State of Birth:	Birth Country:

Travel To School (Please check one) 𛲠Bus (Bus Number_________) 𛲠Drives Self 𛲠 Parent .Guardian (includes walkers, child care vans, etc.) 𛲠District Paid Transportation	Travel From School (Please check one) 𛲠Bus (Bus Number________) 𛲠 Drives Self 𛲠 Parent .Guardian (includes walkers, child care vans, etc.) 𛲠District Paid Transportation
Distance from Home to School (miles) One Way:__________________

A- Arkansas Better Chance E-Even Start EC-Early Childhood	H- Headstart NA-Not Applicable C-21st Century	O-Other P-Private Pre-School PS-Public Pre-School

Pre-School Participation: _____

Birth Certificate #:	Resident County:
Is this child a dependent of an active or reserve member of a branch of the United States Armed Services? Yes No
If this child resides in a household with an active or reserved member of a branch f the United States Armed Services, please select the branch below:

__Active Duty-US Army __Active Duty- US Coast Guard __Reserves- US Marines	__Active Duty- US Air Force __Reserves-US Army __National Guard- US Army	__Active Duty-US Navy __Reserves-US Air Force __National Guard-US Air Force	__Active Duty-US Marines __Reserves-US Navy __Parents serve in Multiple Branches

Is this student a twin (or triplet, quadruplet, etc.)? 𛲠Yes 𛲠No
Additional Contact Information: Additional Guardian Contact Name: _________________________________ Email:__________________________________ Relationship to Student:____________________ Home Phone:____________________________ Language of Correspondence:_______________ Cell Phone:______________________________ Mailing Address: _________________________ Alert Phone:_____________________________ City:_____________State:___Zip Code:_______ Alert Phone is used by the district’s automated phone message system. Employer: ______________________________ Student Primarily Resides with this Guardian.

Contact Order	Name	Relationship to Child	Phone #	Phone Type (home, cell, etc.)
1
2
3
4
5

Emergency Information (Contacts other than Guardians to be called in case of an Emergency)

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Office Use Only Entry Date:________ Entry Code:________ Curriculum:________	Meal ST:___________ M/V Act:___________ 504:______________	ESL:_____________ SP:______________ MIG:_____________	IMMG:____________ GT:_______________ Homeroom:________	Residency:_________ Choice LEA:________ P/T ADM %:________

Last School Attended:	Phone #:	Address:
Has this child been expelled from school in any other school district or is the child a party to an expulsion proceeding? 𛲠 Yes 𛲠 No
Has this child been retained? 𛲠 Yes 𛲠No
Has this child me the requirements of the Arkansas State Health Laws necessary to enter school? 𛲠Yes 𛲠No

Physician:	Physician Phone Number:	Please list any medical concerns and /or medication for this child:
Physician:	Physician Phone Number:

Print Parent Name__________________________________

Parent Signature____________________________________ Date___________

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Warren School District

Families In Transition

Living Conditions Survey

The deral definition of homeless means individuals who lack a fixed regular, and adequate nighttime residence.

Please indicate if your child qualifies for homeless services due to any of the following conditions. Please check any/all that apply to your child.

_____ Shares the housing of other personal due to loss of housing economic hardship or a

similar reason

_____ Lives in motel, hotel, or camping grounds due to the lack f alternative adequate

accommodations

_____ Lives in emergency or transitional shelters

_____ Is abandoned in a hospital

_____ Is awaiting foster care placement

_____ Has a primary nighttime residence that is a public or private place NOT ordinarily

used a a regular sleeping accommodation for human beings

_____ Lives in a car, park public space, abandoned building, substandard housing, bus or

train station, or similar setting

_____ Is migratory because he or she is living in circumstances described above

Child name_________________________________ Grade ______________________

Parent/Guardian name________________________ Date_______________________

Address _______________________________ Home/cell phone number___________

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Heath and Emergency Update

Date of birth:	Grade/Homeroom:
Student Name:	Bus #:
Parent/Guardian Name:
Current Health Concerns and/or Limitations:

Significant Illnesses

Diabetes/Diagnosis Date:	Significant Allergies:
Seizures:	Date of last seizure:
Hypoglycemia/Treatment
Asthma medication:	Asthma Triggers
Major Illness (Specify)
Other Health related information: physical and/or emotional:

Current Physician	Telephone Number
Current Dentist	Telephone Number
Glasses	Contact Lenses

We stress the IMPORTANCE of giving the school several options to reach you in case of an emergency. If the phone is disconnected, phone number changed, or job changed PLEASE NOTIFY THE SCHOOL IMMEDIATELY!

Parent’s email address:
Home Phone Number:
Cell Phone Number:
Father’s name, work phone number and place of employment:
Mother’s name, work phone number and place of employment:
Relative’s name, work phone number and place of employment:
Neighbor’s name, work phone number and place of employment:

IN CASE OF EMERGENCY OR SERIOUS ILLNESS, I GIVE THE SCHOOL PERMISSION TO OBTAIN MEDICAL CARE FOR MY CHILD.

SIGNATURE OF PARENT/GUARDIAN_____________________________________DATE____________

Dear Parent/Guardian this is notification the District may provide your student’s vision and hearing screening and personally identifiable information to a Third Party Billing Agent for the purpose of billing Medicaid if you have provided written consent. You may withdraw consent at any time.

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Race and Ethnicity Information�(Información de raza y etnia)

Form #102 (revised 2/15)

School districts in Arkansas are required to report to the Arkansas Department of Education each year race and ethnicity categories set by the federal government. No individual student data/names are reported. Please answer the following questions.

(Los distritos escolares de Arkansas deben informar al Departamento de Educación de Arkansas cada año sobre las categorías de raza y etnia establecidas por el gobierno federal. No se informan datos / nombres de estudiantes individuales. Por favor, conteste a las siguientes preguntas.)

Student’s Name _______________________________ Date__________________

(Nombre del Estudiante) (Fecha)

Is this student Hispanic or Latino? (Choose only one)�¿Este estudiante es hispano o latino? (Seleccione solamente una)

▢ No, not Hispanic or Latino (No, no hispano o latino)

▢Yes, Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, South or Central American, or

other Spanish culture or origin, regardless of race.)�(Sí, hispano o latino Una persona de cultura u origen mexicano, puertorriqueno, cubano, sur o centroamericano, u otro origen o cultura española, sin importar la raza.)

What is the student’s race? (Regardless of how you answered the first question, choose one or more.) �(¿Cuál es la raza del estudiante? (Escoja una o más alternativas independientemente de cómo contestó en la primera pregunta.) Por favor indique la raza primaria con el número 1.)

𛲠 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 tribal affiliation or community attachment.)�(Amerindio o Nativo de Alaska (Una persona con origen en cualquiera de los pueblos orginales de América del Norte o del Sur, incluyendo América Central, y que mantiene afiliación tribal o relaciones de comunidad.)

𛲠 Asian (A person having origins in any of the original peoples of Far East, Southeast Asia,

or the Indian subcontinent, including for example, Cambodia, China, India, Japan, Korea,

Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam)� (Asiatico (Una persona que tiene origen en cualquiera de los pueblos orginales del

Extremo Oriente, Sureste de Asia, o el Subcontinente India incluyendo, por ejemplo, Camboya, China, India, Japón, Corea, Malasia, Pakistán, las Islas Filipinas, Tailandia y Vietnam.)

𛲠 Black or African American (A person having origins in any of the black racial groups of Africa)� (Negro o Afroamericano (Una persona conorigen en cualquiera de los grupos raciales

negros de 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)� (Hawaiano Naativo u otro Isleno del Pacifico (Una persona con origen en cualquiera de los

pueblos originales de Hawai, Guam, Samoa, u otra Islas del Pacifico.)

𛲠 White (A person having origins in any of the original peoples of Europe, Middle East or

North Africa) (Blanco (Una persona con origen en cualquiera de los pueblos orginales de Europa,

Medio Oeste, i África del Norte.)

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Student Electronic Device, Acceptable Use Policy

and Internet Use Agreement

4.29F—STUDENT ELECTRONIC DEVICE AND INTERNET USE AGREEMENT

The Warren School District agrees to allow the student identified below (“Student”) to use the district’s technology to access the Internet under the following terms and conditions which apply whether the access is through a District or student-owned technology device:

The Warren School District agrees to allow the student identified above (“Student”) to use the district’s technology to access the Internet under the following terms and conditions which apply whether the access is through a District or student-owned electronic device (as used in this Agreement, “electronic device” means anything that can be used to transmit or capture images, sound, or data):

1. Conditional Privilege: The Student’s use of the district’s access to the Internet is a privilege conditioned on the Student’s abiding by this agreement. No student may use the district’s access to the Internet whether through a District or student-owned electronic device unless the Student and his/her parent or guardian have read and signed this agreement.

2. Acceptable Use: The Student agrees that he/she will use the District’s Internet access for educational purposes only. In using the Internet, the Student agrees to obey all federal and state laws and regulations. The Student also agrees to abide by any Internet use rules instituted at the Student’s school or class, whether those rules are written or oral.

3. Penalties for Improper Use: If the Student violates this agreement and misuses the Internet, the Student shall be subject to disciplinary action. Any violations of this Policy may result in loss of access as well as other possible disciplinary and/or legal actions. Any disciplinary action taken will be in accordance with the Student Policy Handbook and at the discretion of the Building Principal.

4. “Misuse of the District’s access to the Internet” includes, but is not limited to, the following:

using the Internet for other than educational purposes;
gaining intentional access or maintaining access to materials which are “harmful to minors” as defined by Arkansas
law;
using the Internet for any illegal activity, including computer hacking and copyright or intellectual property law violations;
making unauthorized copies of the software;
accessing “chat lines” unless authorized by the instructor for a class activity directly supervised by a staff member;
using abusive or profane language in private messages on the system; or using the system to harass, insult, or verbally attack others;
posting anonymous messages on the system;
using encryption software;
wasteful use of limited resources provided by the school;
causing congestion of the network through lengthy downloads of files;
vandalizing data of another user;
obtaining or sending information which could be used to make destructive devices such as guns, weapons, bombs, explosives, or fireworks;
gaining or attempting to gain unauthorized access to resources or files;
identifying oneself with another person’s name or password or using an account or password of another user without proper authorization;
invading the privacy of individuals;
divulging personally identifying information about himself/herself or anyone else either on the Internet or in an email unless it is a necessary and integral part of the student’s academic endeavor. Personally identifying information includes full names, addresses, and phone numbers.
using the network for financial or commercial gain without district permission;
theft or vandalism of data, equipment, or intellectual property;

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attempting to gain access or gaining access to student records, grades, or files;
introducing a virus to, or otherwise improperly tampering with the system;
degrading or disrupting equipment or system performance;
creating a web page or associating a web page with the school or school district without proper authorization;
providing access to the District’s Internet Access to unauthorized individuals;
failing to obey school or classroom Internet use rules; or
taking part in any activity related to Internet use which creates a clear and present danger of the substantial disruption of the orderly operation of the district or any of its schools.
Installing or downloading software on district computers without prior approval of the technology director or his/her designee.

5. Liability for debts: Students and their co-signers shall be liable for any and all costs (debts) incurred through the student’s use of the computers or access to the Internet including penalties for copyright violations.

6. No Expectation of Privacy: The Student and parent/guardian signing below agree that if the Student uses the Internet through the District’s access, that the Student waives any right to privacy the Student may have for such use. The Student and the parent/guardian agree that the district may monitor the Student’s use of the District’s Internet Access and may also examine all system activities the Student participates in, including but not limited to email, voice, and video transmissions, to ensure proper use of the system. The District may share such transmissions with the Student’s parents/guardians.

7. No Guarantees: The District will make good faith efforts to protect children from improper or harmful matters which may be on the Internet. Even though the District uses a filtering system, either by itself or in combination with Arkansas Department of Information Systems (DIS), to block as many of the sites as possible, no filtering system is capable of blocking 100% of the inappropriate, obscene, or potentially harmful material available on the Internet. At the same time, in signing this agreement, the parent and Student recognize that the District makes no guarantees about preventing improper access to such materials on the part of the Student.

8. Signatures: We, the persons who have signed below, have read this agreement and agree to be bound by its terms and conditions of this agreement.

Student Name (Please Print) _____________________________________________ Grade Level ______________

Student Signature______________________________________________________ Date ____________________

Parent/Guardian Signature _______________________________________________ Date ____________________

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Student Media Consent

and Release Form

Throughout the school year, students may be highlighted in efforts to promote WSD

activities and achievements. For example, students may be featured in materials to train teachers and/or increase public awareness of our schools through newspapers, radio, TV, the web, DVDs, displays, brochures, and other types of media.

I, as the parent or guardian of ______________________________________, hereby give WSD and its employees, representatives, and authorized media organizations permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital and printed media.

This is with the understanding that neither WSD nor its representatives will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation.

I further release and relieve, WSD its Board of Trustees, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material.

I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions.

Please understand that failure to return this release form within ten (10) school days from the date of the distribution will constitute approval of the above requests.

Name of Child (Please Print)_______________________________________________ Grade_______________________

Address________________________________________________________________________________________________

City, State, Zip __________________________________________________________________________________________

Signature of Parent/Guardian ___________________________________________________________________________

Date ____________________________________________ Phone Number _______________________________________

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Warren Public School’s Parental/Guardian Consent to Access Public Insurance and the Release Personally Identifiable Information

Is your child covered by Medicaid or ARKids Insurance? ▢YES ▢ NO

Student Full Name _______________________________________________________

Student Date of Birth _______________________________ Grade _________________

With parental consent, the school district can seek federal Medicaid reimbursement for the cost of the health services the school district provides.

This consent grants the school district the ability to release student information for the purpose of billing Medicaid for these services.

Information released typically includes the following: student's name, date of birth, and the date and time of the hearing/vision screens conducted in the present school year.

You may revoke your consent at any time by notifying the school district in writing.

____________________________________________ ___________________

Parent or Guardian Signature Date

Medicaid Release Form