P-4s 0/ Please Print Clearly Edmonds School District Secondary Student Registration For Office Use Only Received: Time School Date Time STUDENT PERSONAL DATA Student Name: Also or Previously Known as Birthdate (Month/Day/Year) Gender M F Country of Birth (If outside of U.S.) Grade Entering When did your student first attend school in the USA? (Mo/Yr) Student Cell Phone Number Student Email Address Has the student ever been enrolled in the Edmonds School District? YES NO If so, which school(s)? Have any of the following services ever been provided to your student? ELL / ESL 504 Plan Highly Capable Other (Please specify): Special Education (IEP) Alternative School / Program Will the student be SIMULTANEOUSLY attending another school while enrolled in the Edmonds School District? Has your student ever been YES NO Advanced Grade(s): If so, what other school will the student be enrolling in? Retained Grade(s): Both questions must be completed.* QUESTION. Is your child of Hispanic or Latino origin? (Check all that apply.) Not Hispanic/ Latino (0) Mexican/ Mexican American/ Chicano (0) Cuban (55) Central American (75) Dominican (60) South American (80) Spaniard (65) Latin American (85) Puerto Rican (70) Other Hispanic/Latino (90) QUESTION. African American/ Black (00) White(00) Asian Indian (505) Cambodian (507) Chinese (50) Filipino (50) Hmong (55) Indonesian (50) Japanese (55) Korean (540) Laotian (545) Malaysian (550) Pakistani (555) Singaporean (560) Taiwanese (565) Thai (570) Vietnamese (575) Other Asian (599) What race do you consider your child? (Check all that apply.) Native Hawaiian (605) Fijian (65) Guamanian or Chamorro (60) Mariana Islander (65) Melanesian (60) Micronesian (6) Samoan (65) Tongan (640) Other Pacific Islander (699) Muckleshoot (46) Other American Indian: Nisqually (49) The indigenous peoples Nooksack (44) of North, Central, South, Port Gamble Klallam (445) or Latin America (those Puyallup (448) not choosing one of the Quileute (45) federally recognized state tribes). (499) Quinault (454) Samish (457) Sauk-suiattle (460) Shoalwater (46) Skokomish (466) Snoqualmie (469) Spokane (47) Squaxin Island (475) Stillaguamish (478) Suquamish (48) Swinomish (484) Tulalip (487) Yakama (490) Other Washington Indian (495) Alaska Native (405) Chehalis (40) Colville (4) Cowlitz (46) Hoh (48) Jamestown (4) Kalispel (44) Lower Elwha (47) Lummi (40) Makah (4) * The information, in both questions and, is required to be in compliance with 00 Federal and State Ethnicity Reporting Requirements.
Please Print Clearly P-4s Page Student Name School Has either parent ever been employed by or is currently employed by the Edmonds School District? Yes No If so, under what name? PRIMARY HOUSEHOLD INFORMATION A students primary residence is defined as the physical location where he/she lives for FOUR OR MORE nights per week Parent / Guardian Parent / Guardian Relationship to Student Birthdate (Month/Day/Year) Email Address Home Phone Unlisted Work Phone Unlisted Cell Phone Number Unlisted Relationship to Student Birthdate (Month/Day/Year) Email Address Home Phone Unlisted Work Phone Unlisted Cell Phone Number Unlisted Which telephone number should be listed as the primary contact number (please circle one) Home Phone Work Phone Cell Phone Residential Address Street Apt / Unit City State & ZIP Mailing Address Street Apt / Unit PO Box City State & ZIP (If different than above) RESIDENCY VERIFICATION: I affirm that the residency information provided on this form is true and accurate as of this date. I understand that falsification of an address, residence, or conditions of living arrangements, or the use of any other fraudulent means to obtain a school assignment shall be cause for revocation of this enrollment. Such falsification will also cause forfeiture of any future transfer rights through the highest grade level of the school. Proof of residency (PUD bill; homeowner s statement or insurance policy; lease or renter s statement or receipt of payment; renter s insurance policy) is required. Homeless Students: If an eligible student is homeless, the district shall not require proof of residency or any other information regarding an address and shall enroll the student at the request of the student or parent/guardian. Students enrolled in a district program without legal residence may continue in that school until the end of the academic year. Parent Signature: Date: SIBLINGS ( IF APPLICABLE) Please list all siblings attending an Edmonds School District program Name Grade School Name Grade School 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 Parent / Guardian Parent / Guardian Relationship to Student Birthdate (Month/Day/Year) Email Address Home Phone Unlisted Work Phone Unlisted Cell Phone Number Unlisted Relationship to Student Birthdate (Month/Day/Year) Email Address Home Phone Unlisted Work Phone Unlisted Cell Phone Number Unlisted Residential Address Street Apt / Unit City State & ZIP Mailing Address Street Apt / Unit PO Box City State & ZIP (If different than above)
P-4s Please Print Clearly Page Student Name School EMERGENCY CONTACT INFORMATION - Other Than Parents In case of an emergency, we will always attempt to contact parents or guardians first. Please list local persons other than yourself usually available during the school day who have agreed to care for and provide transportation for your student in an emergency situation or if they become ill or injured and you cannot be reached. Emergency Contact Relationship to Student Birthdate (Month/Day/Year) Residential Street Address City State Zip Home Phone Work Phone Cell Phone Number Emergency Contact Relationship to Student Birthdate (Month/Day/Year) Residential Street Address City State Zip Home Phone Work Phone Cell Phone Number Emergency Contact Doctor Relationship to Student Birthdate (Month/Day/Year) Residential Street Address City State Zip Home Phone Work Phone Cell Phone Number Last Name Preferred Hospital (Optional) First Name Contact Phone Number Health Insurance Company & Policy Number (Optional) EDUCATIONAL BACKGROUND Please list all schools the student attended in the LAST THREE YEARS. Start with the most recent school. Attach additional sheets if necessary. Name of Previous / Current School Grades Attended Location of School (City & State or Country) Entry Date: Withdrawal Date: Name of Previous School Grades Attended Location of school (City & State or Country) Entry Date: Withdrawal Date: Name of Previous School Grades Attended Location of school (City & State or Country) Entry Date: Withdrawal Date: Name of Previous School Grades Attended Location of school (City & State or Country) Entry Date: Withdrawal Date: Name of Previous School Grades Attended Location of school (City & State or Country) Entry Date: Withdrawal Date: Phone Number Phone Number Phone Number Phone Number Phone Number
P-4s Please Print Clearly Page 4 Student Name What language does the student currently speak? Is the student s first-learned language anything OTHER THAN English? YES NO Language NATIVE If yes, student must be referred for testing on the Washington Language Proficiency Placement Test Does the student speak a language OTHER THAN English in the home? YES NO Language Home Please describe the language understood by your child (check one only) Understands only the home language and no English. Understands mostly the home language and some English. Understands the home language and English equally. HOME LANGUAGE SURVEY (Please respond in English) School Understands mostly English and some of the home language. Understands only English. If available, in what language would you prefer to receive communication from the school? Office Use Skyward Box LANG In accordance with Washington State Law RCW 8A.5.0, please answer the following questions: Attach additional sheets if necessary Does your student have any history of violent behavior? YES NO If so, please explain. Does your student have any past, current, or pending suspension or expulsion from a current or previous school? YES NO If so, please explain. Has your student officially withdrawn from his/her current or Is your student currently under Becca Petition? previous school? YES NO Date: YES NO If so, from which district? ADDITIONAL INFORMATION Are one or both parents active military? Yes No Name of Parent: Do you reside in transitional housing? Yes No Is there a Court Order that restrains / curtails any parental rights? YES NO If so, please provide copy. Is there a Restraining Order in effect? YES NO If so, please provide copy. Please list and provide copies of any other legal documents that are pertinent to your student and his/her safety. Please provide additional comments to assist us in caring for your student. SIGNATURE 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. X Parent / Legal Guardian Signature Date Update your voter registration! The school office can assist you. FOR OFFICE USE ONLY
P-4 att. / EDMONDS PLEASE PRINT CLEARLY EDMONDS SCHOOL DISTRICT NO. 5 Registration Attachment SCHOOL D I S T R I C T School Grade Level Date Student Name Date of Birth Expected student school start date: Parent /Guardian Name (Print) The following information is important for your student's health and safety. It will be forwarded to the school nurse. I acknowledge that this information will be maintained in my student s school record and shared with staff on a need to know basis to provide a safe and healthy environment for my student. q I prefer to speak with a school nurse directly regarding my child s health information described below. Please contact me by telephone at this number: ( ) Health Information Does your child have a LIFE-THREATENING HEALTH CONDITION? q Yes q No A LIFE-THREATENING CONDITION is a health condition that will put the child in danger of death during the school day if a medication or treatment order and a nursing plan are not in place. Children with LIFE-THREATENING CONDITIONS such as severe bee sting or severe food allergies, severe asthma, diabetes, severe seizures, or other at-risk conditions are required to have a medication or treatment order and a nursing plan in place before they start school. Please notify office staff at registration; you will need to contact your school nurse before your student can attend school. Does your student have medical insurance? q Yes Has your child ever been hospitalized for a health condition? q Yes q No If so, what kind? q No If so, what kind? Check any of these conditions which your child has or has had: q ADD q Blood Disorder q Convulsions/Seizures q Hearing Problems q Orthopedic/Bone q ADHD q Bowel Concerns q In Counseling q Heart Disease q Social/Emotional/Behavioral q Autism q Cancer q Diabetes q Kidney/Bladder Disease q Vision Problems q Allergy to: Severe? q Yes q No q Asthma Severe? q Yes q No Hospitalized for asthma? q Yes q No What triggers your student's asthma (for example: exercise, upper respiratory infections, allergies, emotions, etc.)? q Other heath concerns: (please specify) Licensed health provider name: (e.g. M.D., D.O., A.R.N.P., P.A., etc.) Name: Contact phone number: ( ) What does this student do to manage his/her own condition? How can the nurse/teacher help with this at school? What symptoms should we report to you? List any medications taken by student. Medication Taken: For q At Home q At School Medication Taken: For q At Home q At School Students who have medication administered by school staff need an MEDICATION AUTHORIZATION form completed and signed by their attending health care provider and parent or legal guardian. You can obtain this form from the school office staff. Provide any information not included above which you think we should know about this student s physical, emotional, or mental health which might affect school performance or require special consideration (i.e. limitations in activities, major life events, etc.). Signature of Parent / Legal Guardian Date White: Nurse Yellow: File Permission for hearing test? q Yes q No
SS 58 (K-) EDMONDS SCHOOL DISTRICT NO. 5 TO: Parents of Edmonds School District Students FROM: Educational Health Services Department This Certificate of Immunization Status must be submitted on or before the first day of school in order for your child to attend school. Washington State Law (RCW 8A.0.060-70) requires certification of immunization for all school children. The minimum immunization requirements for the school attendance are listed on this form.. Complete the Certificate of Immunization Status by: Entering the month, day and year when each required dose of a vaccine was given. (If you do not know the specific day, the Health Services professional will assume the first of the month.) OR Notifying the school that a schedule of immunization has been started and will be completed in accord with your health care provider s recommended schedule. Immunizations are available from your private health care provider or you may obtain them from: Snohomish Health District South County Clinic Phone: 45-775-5 60 00th St. SW, Lynnwood, WA 9806 Please contact the clinic for an appointment Parent and/or Legal Guardian must accompany the child DSHS/Medicaid recipients should go to their assigned provider for immunization (Bring records of your child s immunization to Snohomish Health District to assure that your child receives the correct vaccine.) OR Complete a Certificate of Exemption (C.O.E.) in addition to the Certification of Immunization BE AWARE-- If there is an outbreak at school of any vaccine-preventable disease for which your student is exempted, your student will be excluded from school for the duration of the outbreak.. Sign the certificate(s) indicating your information is correct. Please contact your child s school if you need further assistance in completing the certificate.
Certificate of Immunization Status (CIS) DOH 48-0 January 00 Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Registry. Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I certify that the information provided on this form is correct and verifiable. Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only Vaccine Dose Hepatitis B (Hep B) Date Month Day Year or Hep B - dose alternate schedule for teens Rotavirus (RV, RV5) Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 4 5 Tetanus, Diphtheria, Pertussis (Tdap, Td) Haemophilus influenzae type b (Hib) 4 Pneumococcal (PCV, PPSV) 4 Vaccine Parent/Guardian Name (please print): Dose Polio (IPV, OPV) 4 Influenza (flu, most recent) Date Month Day Year Measles, Mumps, Rubella (MMR) Varicella (chickenpox) or verify disease -4 Hepatitis A (Hep A) Meningococcal (MCV, MPSV) Human Papillomavirus (HPV) Office Use Only: Immunization information updated and verified with parent/guardian permission: Printed Staff Name Date Printed Staff Name Date Printed Staff Name Date Printed Staff Name Date Office Use Only: Reviewed by: Date: Signed Cert. of Exemption on file? Yes No Parent/Guardian Signature Required Date If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option,,, OR 4 below see, back #5. ) Chickenpox disease verified by printout from CHILD Profile Immunization Registry Must be marked by printout (not by hand) to be valid. ) Chickenpox disease verified by Health Care Provider (HCP) If you choose this box, mark A OR B below. A) Signed note from HCP attached OR B) HCP signed here and print name below: Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP) HCP Printed Name: ) Chickenpox disease verified by school staff from CHILD Profile Immunization Registry If you choose this box, staff must initial that parent or guardian approves: (initial) (date) 4) Chickenpox disease verified by parent* If you choose this box, fill in the date or child s age when he or she had the disease: Age/Date of disease: *Can ONLY verify for some grades, see back #5 (4). If the child can show immunity by blood test (titer) and hasn t had the vaccine, ask your HCP to fill in this box. Documentation of Disease Immunity I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached. Diphtheria Hepatitis A Hepatitis B Hib Measles Mumps Polio Rubella Tetanus Varicella Other: Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP) HCP Printed Name:
Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand. # To print with info filled in: First, ask if your health care provider s office puts vaccination history into the CHILD Profile Immunization Registry (Washington s statewide database). If they do, ask them to print the CIS from CHILD Profile and your child s information will fill in automatically. Be sure to review all the information, sign and date the CIS in the upper right hand box, and return it to school or child care. If your provider s office does not use CHILD Profile, ask for a copy of your child s vaccine record so you can fill it in by hand using steps #-7 (below): EXAMPLE Vaccine Dose Date Month Day Year Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 0 0 DTaP 0 0 0 DTaP 06 0 0 # To fill in by hand: Print your child s name, birthdate, sex, and your own name in the top box. # Write each vaccine your child received under the correct disease. Write the vaccine type under the Vaccine column and the date each dose was received in the Month, Day, and Year columns (as mm/dd/yyyy). For example, if DTaP was received Jan, March 0, June,, fill in as shown here #4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS: ) If your child s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is found, box is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand). ) If your health care provider (HCP) can verify that your child has had chickenpox, mark box. Then mark either A to attach a signed note from your HCP, or B if your HCP signs and dates in the space provided. Be sure your HCP s full name is also printed. ) If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box. Then, they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS. 4) If your child started kindergarten in the 008-009 school year or later, you CANNOT use this box. If your child started kindergarten before the 08-09 school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox. To find out which grades require chickenpox vaccine (or history), visit: http://www.doh.wa.gov/cfh/immunize/schools/vaccine.htm #6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider (HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports. #7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care. #8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval. Vaccine Trade Names in alphabetical order (For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/us-vaccines-508.pdf) Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Engerix-B Hep B Ipol IPV Pentavalente DTaP + Hep B + Hib TriHIBit DTaP + Hib Adacel Tdap Fluarix Flu (TIV) Infanrix DTaP Pneumovax PPSV or PPV Tripedia DTaP Afluria Flu (TIV) FluLaval Flu (TIV) Kinrix (Knrx) DTaP + IPV Prevnar PCV or PCV7 or PCV Twinrix (Twnrx) Hep A + Hep B Boostrix Tdap FluMist Flu (LAIV) Menactra MCV or MCV4 ProQuad (PrQd) MMR + Varicella Vaqta Hep A Cervarix HPV Fluvirin Flu (TIV) Menomune MPSV or MPSV4 Quadracel (Qdrcl) DTaP + IPV Varivax Varicella Comvax (Cmvx) Hep B + Hib Fluzone Flu (TIV) Pediarix (Pdrx) DTaP + Hep B + IPV Recombivax HB Hep B Daptacel DTaP Gardasil HPV4 PedvaxHIB Hib Rotarix Rotavirus (RV) Decavac Td Havrix Hep A Pentacel (Pntcl) DTaP + Hib + IPV RotaTeq Rotavirus (RV5) Vaccine Abbreviations in alphabetical order (For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/us-vaccines-508.pdf) Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name DT Diphtheria, Tetanus Hep A (HAV) Hepatitis A Meningococcal Rota MPSV or MPSV4 Hep B (HBV) Hepatitis B Polysaccharide Vaccine (RV or RV5) Rotavirus DTaP Diphtheria, Tetanus, Haemophilus influenzae Measles, Mumps, Rubella / Hib MMR / MMRV acellular Pertussis type b with Varicella Td Tetanus, Diphtheria DTP Diphtheria, Tetanus, Tetanus, Diphtheria, acellular HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Pertussis Pertussis Flu (TIV or LAIV) HBIG Influenza Hepatitis B Immune Globulin IPV MCV or MCV4 Inactivated Poliovirus Vaccine Meningococcal Conjugate Vaccine PCV or PCV7 or PCV PPSV or PPV Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine TIG VAR or VZV Tetanus immune globulin If you have a disability and need this document in another format, please call -800-55-07 (TDD/TTY -800-8-688). DOH 48-0 January 00 Varicella
VACCINES REQUIRED FOR SCHOOL ATTENDANCE, GRADES K- July, 0 June 0, 04 VACCINE Kindergarten- nd Grade rd -5 th Grade 6 th Grade 7 th - th Grade Hepatitis B doses See minimum intervals on page Dose must be given >4 weeks of age doses See minimum intervals on page Dose must be given >4 months of age Diphtheria, Tetanus, and Pertussis (DTaP/DT/Td/Tdap) 5 doses (4 doses required IF 4 th dose given >4 th birthday) plus dose Tdap required for 6 th - th grade IF > years old Polio (IPV or OPV) 4 doses ( doses only IF rd dose given >4 th birthday) The final dose given on or after August 7, 009 must be given at a minimum of 4 years of age AND a minimum interval of 6 months from the previous dose. 4 doses ( doses only IF rd dose given >4 th birthday) Measles, Mumps, and Rubella doses doses dose Varicella OR OR Recommended, but not required. Healthcare provider verifies disease Parent verifies disease Look at the Minimum Age and Interval Table on page for recommended minimum age and spacing information. Review the Individual Vaccine Requirements Summary for more detailed information: www.doh.wa.gov/portals//documents/pubs/48-84- IndividualVaccineRequirements.pdf Page of
Hepatitis B HepB Minimum Age & Interval for Valid Vaccine Doses Vaccine Dose # Minimum Age Minimum Interval Between Doses Notes Diphtheria, Tetanus, and Pertussis DTaP/DT Tetanus, Diphtheria, and Pertussis Tdap Dose Birth 4 weeks between Dose & (K- th ) Dose 4 weeks 8 weeks between Dose & (K- th ) Dose 4 weeks (K-6 th ) 4 months (7 th - th ) 6 weeks between Dose & (K-6 th ) No minimum interval between Dose & (7 th - th ) Dose 6 weeks 4 weeks between Dose & Dose 0 weeks 4 weeks between Dose & Dose 4 weeks 6 months between Dose & 4 Dose 4 months 6 months between Dose 4 & 5 Dose 5 4 years Dose 0 years (minimum age depends on vaccine brand) Note minimum age and interval changes for 0-4 school year. doses valid if adult Recombivax HB given between ages and 5 and doses separated by >4 months. DTaP: for children through age 6. Recommended to have 6 months between Dose and Dose 4, but >4 months acceptable. Boostrix : licensed for >0 year olds; Adacel : licensed for > year olds. Can be given regardless of the interval between DTaP or Td. Students 7-0 years of age not fully immunized with DTaP or Td should get one Tdap followed by additional doses of Td if needed. Tetanus and Diphtheria Td Polio IPV or OPV Measles, Mumps, and Rubella MMR Dose 7 years 5 years Dose 6 weeks 4 weeks between Dose & Dose 0 weeks 4 weeks between Dose & Dose 4 weeks 6 months between Dose & 4 Dose 4 4 years Dose months 4 weeks between Dose & Dose months Td: for children >7 years of age. doses of Td required, if starting series >7 years, with a single dose of Tdap preferred as the first dose. Not required for students 8 years and older. If a student got all doses before August 7, 009: 4 week minimum interval must separate all doses and minimum age must be >8 weeks. MMRV (MMR + varicella) may be used instead of separate MMR and varicella vaccines. 4-day grace DOES apply between doses of the same live vaccine such as MMR/MMR or MMRV/MMRV. The 4 day grace period DOES NOT apply between Dose and Dose of different live vaccines, such as between MMR and Varicella or between MMR and live flu vaccine. Varicella (chickenpox) VAR Dose months Dose 5 months months between Dose & Recommended: months between varicella doses, but >8 days acceptable. Must get the same day as MMR OR > 8 days apart. (4-day grace DOES NOT apply). 4-day grace DOES apply between doses of the same live vaccine such as VAR and VAR). If you have a disability and need this document in another format, please call 800 55 07 (TDD/TTY call 7) DOH 48 05 January 0 Page of