Student Name: Legal Last Name Legal First Name Legal Middle Name. If born outside U.S., when did student first attend school in the U.S.?
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1 P-134 EdCAP 4/2013 EDMONDS SCHOOL DISTRICT NO. 15 EdCAP Secondary Student Registration PLEASE PRINT CLEARLY Last School Attended Application Date STUDENT PERSONAL DATA Student : Legal Last Legal First Legal Middle Also or Previously Known As Age Birthdate (Month/Day/Year) Gender Country of Birth (if outside of U.S.) Student Address: If born outside U.S., when did student first attend school in the U.S.? Mo Year M F Student Cell Phone Number Student Home Phone Number Residential Address Street Apt / Unit City State & ZIP Current Grade Mailing Address Street Apt / Unit PO Box City State & ZIP Both questions must be completed.* QUESTION 1. Are you of Hispanic or Latino origin? (Check all that apply.) Not Hispanic / Latino (10) Spaniard (65) Central American (75) Latin American (85) Cuban (55) Puerto Rican (70) South American (80) Other Hispanic/Latino (90) Dominican (60) Mexican/ Mexican American/ Chicano (30) QUESTION 2. What race do you consider yourself? (Check all that apply.) African American/ Black (200) Native Hawaiian (605) Kalispel (424) Stillaguamish (478) Fijian (615) Lower Elwha (427) Suquamish (481) White (300) Guamanian or Chamorro (620) Lummi (430) Swinomish (484) Asian Indian (505) Mariana Islander (625) Makah (433) Tulalip (487) Cambodian (507) Melanesian (630) Muckleshoot (436) Yakama (490) Chinese (510) Micronesian (632) Nisqually (439) Other Washington Indian (495) Filipino (520) Samoan (635) Nooksack (442) Hmong (525) Tongan (640) Port Gamble Klallam (445) Other American Indian: Indonesian (530) Other Pacific Islander (699) Puyallup (448) The indigenous peoples Japanese (535) Quileute (451) of North, Central, South, Korean (540) or Latin America (those Alaska Native (405) Quinault (454) Laotian (545) not choosing one of the Chehalis (410) Samish (457) federally recognized Malaysian (550) Colville (413) Sauk-suiattle (460) state tribes). (499) Pakistani (555) Cowlitz (416) Shoalwater (463) Singaporean (560) Taiwanese (565) Thai (570) Vietnamese (575) Other Asian (599) Hoh (418) Jamestown (421) Skokomish (466) Snoqualmie (469) Spokane (472) Squaxin Island (475) * The information in both questions 1 and 2 is required to be in compliance with 2010 Federal and State Ethnicity Reporting Requirements. HOME LANGUAGE SURVEY: Is the student's first-learned or home language anything OTHER THAN English? Yes No If yes, what language? Have ELL services been provided in the school? Yes No If yes, are you willing to decline ELL services: Yes No
2 Parent / Guardian Parent / Guardian P-134 EdCAP PAGE 2 Student Grade School SIBLINGS (IF APPLICABLE) Please list all siblings attending an Edmonds School District program Grade School PRIMARY HOUSEHOLD INFORMATION - Students under 18 must complete parent/guardian information A student's primary residence is defined as the physical location where he/she lives for FOUR OR MORE nights per week. Legal Last Legal First Legal Middle Relationship to Student Birthdate (Month/Day/Year) Parent Address Home Phone Work Phone Cell Phone / Pager Residential Address Street Address Apt/Unit City State Zip Mailing Address Street Address Apt/Unit City State Zip SECONDARY HOUSEHOLD INFORMATION (IF APPLICABLE) Residence of non-custodial parents /guardians not living with the student OR location where the student lives LESS THAN FOUR nights per week Legal Last Legal First Legal Middle Relationship to Student Birthdate (Month/Day/Year) Student Address Home Phone Work Phone Cell Phone / Pager Residential Address Street Address Apt/Unit City State Zip Mailing Address Street Address Apt/Unit City State Zip EMERGENCY INFORMATION: List two local persons (other than yourself) usually available during the school day who have agreed to care for and provide transportation for student if they become ill or injured and emergency contact cannot be reached. Relationship to Student Address Daytime Phone Ext. Relationship to Student Address Daytime Phone Ext.
3 P-134 EdCAP PAGE 3 Student EDUCATIONAL BACKGROUND: Please list most recent high schools the student attended. Start with the most recent school. of Previous/Current School Location of School (City & State or Country) Grades Attended Entry Date Withdrawal Date of Previous School Location of School (City & State or Country) Grades Attended Entry Date Withdrawal Date Has the student applicant ever attended the Edmonds School District? Yes No If yes, school attended Year(s) Attended SPECIAL EDUCATION SERVICES Special Education services based on an IEP are NOT provided in EdCAP--including specialized state testing. Have you received Special Education services based on an IEP? No If yes: Are you currently eligible for these Special Education services? No Yes Yes (Your counselor can help answer this question.) If you are currently eligible for special education services and wish to enroll in the EdCAP program, you must choose to either revoke (officially discontinue) your IEP or be a shared student as explained on the Shared Student Application on page 4 of this application. To indicate your choice, follow the procedures below: In District Special Education Students must: Contact Shanelle Pfeiffer, ESD Secondary Special Education coordinator, to complete district paperwork to either revoke their IEP or request shared student status. No Yes I have contacted Shanelle Pfeiffer in order to complete district paperwork. Out-of District Special Education Students must: 1) Revoke their IEP at the last attended school and provide a signed copy of the revocation with their EdCAP application, OR 2) Apply to be a shared student by completing the Shared Student Application on page 4 of this Registration, attach the required documentation listed on the Shared Student Application, and contact Shanelle Pfeiffer, ESD Secondary Special Education coordinator, at Note: Applications for students currently eligible for special education services will not be considered without completion of the procedures above and inclusion of the following required documentation: A signed copy of your Revocation of Special Education Services from last school attended, OR The Shared Student Application and most recent IEP and Evaluation. APPLICANT AND PARENT/GUARDIAN SIGNATURES I attest that the information herein is complete, true, and accurate, and may be verified with the appropriate institution(s). I understand that providing false information may be grounds for revocation of enrollment in the Edmonds School District. Student Signature: Parent/Guardian Signature, IF student applicant is under 18: Date Date
4 P-134 EdCAP PAGE 4 FOR STUDENTS IN SPECIAL EDUCATION ONLY Worksheet for students applying to be a SHARED STUDENT in the Edmonds School District Edmonds School District #15 EdCAP Shared Student Application For Students Currently Eligible for Special Education Services Applicant Information (Student Responsibility) Full : Last First M.I. Age: Are you willing to attend both an assigned high school in the Edmonds School District and the YES NO EdCAP campus daily? You must provide your own transportation between the two campuses. Do you have or YES NO can you arrange transportation? Do you still want to be a Shared Student and attend an assigned high school campus for your YES NO special education services? If you answered NO to any of the questions on the left, you need to revoke your special education services with your last attended school district and submit a copy of your revocation with your EdCAP application. Note: If you do not attend your special education classes regularly, your absence will be recorded and potentially reported to BECCA. Address: Street Address Apartment/Unit # City State ZIP Code Phone: Attachments Required (Student Responsibility) To process your application and place you correctly in a high school special education program, the following are required to complete your application. 1. Please attach a copy of your most recent IEP. 2. Please attach a copy of your most recent Evaluation. Questions? If you have any questions or need more information regarding special education services, please contact: Shanelle Pfeiffer Secondary Special Education Coordinator Edmonds School District # pfeiffers@edmonds.wednet.edu FOR EDMONDS SCHOOL DISTRICT OFFICE USE ONLY Communication: Phone In-Person (Circle one) Date(s): Copy of Revocation Attached Applied to be Shared Student X Edmonds School District Staff
5 Student Date of Birth P-134 EdCAP PAGE 5 FOR SCHOOL/DISTRICT USE ONLY: BEHAVIOR & IEP VERIFICATION Please provide the following information to the Edmonds Career Access Program (EdCAP) and the Edmonds School District. Counselor/District Designee: If PRESENTLY ENROLLED, name of high school OR If NOT PRESENTLY ENROLLED, name of last high school Section 1: In accordance with Washington State law (RCW28A ), please answer the following questions: 1. Does the student applicant have any history of violent behavior? No Yes If yes, please explain 2. Does the student applicant have any past, current, or pending suspension or expulsion from a current or previous school? No Yes If yes, please explain 3. If high school is outside Edmonds District, discipline records are attached: No Yes 4. Is student currently under BECCA petition? No Yes If yes, which district? 5. Has student officially withdrawn from his/her previous school? No Yes If yes, date: 6. Did student receive any of these special services: 504 Plan ELL Other Section 2: Were Special Education services provided to student DURING HIGH SCHOOL? No Yes If yes: Is the student currently eligible for Special Education Services based on an IEP? No Yes If currently eligible, specify IEP Case Mgr. s name, phone, and high school: IEP Case Manager Phone High School Note to counselors of students with current IEP services: Special Education Services based on an IEP are not provided in EdCAP--including specialized state testing. In order to enroll in the program, students with a current IEP must choose to either revoke their IEP or be a shared student in the Edmonds School District & EdCAP as explained on the Shared Student Application on page 4 of their P-134 Registration. To indicate their choice, students need to complete the following procedures: In District students must contact Shanelle Pfeiffer, ESD Secondary Special Education coordinator, at to complete district paperwork to either revoke their IEP or request shared student status. Out of District students must either: 1. Revoke their IEP at the last attended school and provide a signed copy of their revocation with their EdCAP application (if student chooses to revoke, please assist with your school s process); OR 2. Apply to be a shared student by completing the Shared Student Application, attaching their most recent IEP and Evaluation, and contacting Shanelle Pfeiffer, ESD Secondary Special Education Coordinator, at Section 3: Enrollment Recommendation 1. Based on your association with this student, do you recommend student be allowed to enroll in reengagement programming? No Yes 2. Please briefly indicate the reason: (Use reverse if more space is needed.) Counselor/District Designee (please print) Title Signature Date Phone FOR EDMONDS SCHOOL DISTRICT OFFICE USE ONLY Yrs. Attended Credit Deficiency % Meets Cr. Def. No Yes Student Fees Owed: Other: Approved Denied Condition of Approval Reason Program Director Signature Date EdCAP Staff or
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