LITTLE WOUND MIDDLE SCHOOL REGISTRATION

LITTLE WOUND MIDDLE SCHOOL REGISTRATION

Documents required for registration for new students include: Birth Certificate, Immunization Record, Tribal Enrollment, Custody Document, Test Scores
STUDENT AND FAMILY INFORMATION

Complete all questions.
1. Student's Grade *

Grade 6 Grade 7 Grade 8
2. Student's Full Name *

First Name Middle Name Last Name
3. Is student known by any other name? *

Yes, please enter other name below No
4. Student's also known as....

First Name Middle Name Last Name
5. Student's Date of Birth *
6. Place of Birth *
7. Tribal Agency Enrolled
8. Tribal Enrollment Number
9. Student's Father's Name

First Name Last Name
10. Father's Address
11. Father's Place of Employment
12. Student's Mother's Name

First Name Last Name
13. Mother's Address
14. Mother's Place of Employment
15. Who has custody of child while attending Little Wound School? *

Both Parents Above, go to question 19 Father Above, go to question 19 Mother Above, go to question 19 Other, complete questions 16-19
16. Name of person, other than parents, who will have custody of student while attending LWS?

First Name Last Name
17. Place of Employment of person who has custody
18. Relationship to Child? *
19. Bus Run (if known)
CONTACT INFORMATION

Complete all questions
20. MAILING Address where child will be residing while attending Little Wound School. *
20a. PHYSICAL Address where child will be residing while attending LWS. *
21. Home/Cell Phone Number: *
22. Employment Phone Number
23. Email address *
FORMER SCHOOL INFORMATION

Complete all questions
24. Previous School Attended *
25. Is student currently on an IEP for Special Education services? *

Yes No I do not know
26. Is student on a 504 Plan? *

Yes No I do not know
27. Did student participate in Gifted & Talented Program? *

Yes No I do not know
STUDENT HEALTH

Complete all questions
28. Is your child allergic to any Medicines? Foods? Bee Stings? *

Yes, list allergies below No
29. List allergies.
29a Has your child received the COVID 19 Vaccinations as follows: *

1st Vaccination 2nd vaccination Johnson & Johnson Vaccination Booster Vaccination
30. Does your child have any health problems? *

Yes, list health problems below No
31. Identify health problems
32. Who is the primary health provider for your child? *
33. In case of an emergency, name of person to contact: *
34. Telephone No. *
35. If 1st contact person cannot be reached, contact: *
36. Telephone No. *
List the first and last names of ALL the people who are allowed to check out your student from school.
McKinney-Vento Student Housing Form

Little Wound School may receive additional money from the Bureau of Indian Education to provide services to our students depending on the living situations of our students. Completing this form helps LWS apply for these resources.

All responses to the questions below are confidential.
This student living in a building without at least one of the following: Electricity, Heat, Running Water, Plumbing, Working Bathroom, Unsafe Living Conditions *

Yes No
This student living in a building with more than one family for reasons of economic hardship or lack of affordable housing options. *

Yes No
This student consistently moves from place to place with no long-term, fixed home. *

Yes No
This student resides in a temporary shelter or other tribal- or state-run residential facility. *

Yes No
This student is living in a location that is not ordinarily used for living. *

Yes No
This student is living in a car, park, motel, hotel, or campground. *

Yes No
If you have any questions regarding the McKinney Vento student housing form, please reach out to your building's principal at 455-6182.
Opta Ocanku Alcohol/Drug Screening Consent Form

Little Wound School received a 16 month SAMHSA Grant in response to COVID-19 pandemic’s impact on Native American Youth with substance use disorders. Our Goal is to decrease substance use through substance abuse education, screenings, assessments, outpatient services, treatment planning, referrals as well as Equine Therapy and culturally based counseling services along with Lakota Healing Ceremonies.

The alcohol/drug screening is the process by which a client is determined to be appropriate and eligible for admission to a particular program. Areas of focus are substance use disorders, substance-related riding/driving risk, and other risky behaviors among youth ages 12-21. Screening tools have been used as part of universal screening efforts in thousands of busy medical and community health settings, as it yields information that can serve as the basis for early intervention and patient-centered counseling.

In the event of a high screening score parent/guardian will be contacted for consent for further assessment and evaluation.

LWS Opta Ocanku Program staff are credentialed in their respective fields of Addiction and Mental Health with many years of experience and education to provide these services.

Statement of Agreement: I acknowledge that I fully understand what I have read. I give consent for my child to participate in counseling with the Opta Ocanku staff at the Little Wound School.
I give my consent for my child to be screened for alcohol/drug use. *

Yes No
I give my consent for my child to participate in Lakota ceremonies. *

Yes No
BIE Home Language Survey

Federal requirements direct schools to assess the English language proficiency of students. The process begins with determining the language(s) spoken in the home of each student. Students will be assessed using the WIDA assessment to provide English Learner Assessments and Supports identified in the Home Language Survey.

Purpose: The responses to the home language survey will assist in determining if a student's proficiency in English should be tested. This information is essential in order for the school to provide adequate instructional programs and services. As parents or guardians, your cooperation is requested in complying with these requirements.

For each question, write the name(s) of the language(s) that apply in the space provided. Please do not leave any question unanswered.

If you have any questions you have the right to share them before your student's English proficiency is assessed.
1. Which language did your child learn when they first began to talk? *
2. Which language does your child most frequently speak at home? *
3. Which language do you (the parents/guardians) use more often when speaking to your child? *
4. Which language is spoken more often by other adults in the home? *
5. Do you believe your child might need additional support learning the academic language for math, science, reading, or writing? *
Additional Information (Optional):
Attachments

Documents required for registration for new students include: Birth Certificate, Immunization Record, Tribal Enrollment, Custody Document, Test Scores. If you have any of these documents in an electronic format, please upload the document(s) below.
Upload documents here.

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AGREEMENTS

Please read and answer the individual agreements below. A copy of these agreements can be downloaded on the registration page. Also other school information for school health services, counseling information, and other important documents are available that we encourage you to download or read.
Participate in School Related Activities

I give my consent for my son/daughter to participate in all school related activities. The school personnel will do within their power to safeguard the health and well being of the student to participate in all school activities, but are not responsible for accidents beyond their control. In case of any accident or illness while the student is participating or in route to participate in a school activity, I give my permission and signed consent to emergency medical care, including emergency dental or minor surgery, if such procedures become necessary, while the studentis under jurisdiction of the Little Wound School.

Records Release

I give the proper authorities/personnel of Little Wound School the authority to acquire all necessary documents from various departments and agencies that are required to attend Little Wound School.

Counseling Services

I agree to the standard and normal practice that students are able to see a counselor, when it becomes necessary. for Little Wound School to provide any counseling session deemed necessary for my son/daughter.

Photo Release

All photographers taking photographs on school property or of school events or students work must obtain a signed release form from any student or staff member who is visibly recognizable in the photograph. Crowd scenes where no single person is the dominant feature are exempt.

These rules governs photographs intended for use in any school publication of marketing or a public relations nature, such as newsletters, brochures, yearbooks, promotional items, or other such material, including photographs used on the web. These rules are not in effect when photographs are taken of news events, but photographs taken for news purposes requires a release for reuse in marketing materials.

Internet User Agreement

I grant permission for my son or daughter to access networked computer services such as electronic mail on the Internet. I understand that individuals and families may be held liable for violations. I accept full responsibility for child’s use of the Internet.

Participate in Lakota Ceremonies

I give my consent for my child to participate in Lakota ceremonies; Inipi (sweat lodge), smudging/songs.

School-Parent Compact

Little Wound School, and the parents of the students participating in activities, services, and programs funded by Title I, Part A of the Elementary and Secondary Education Act (ESEA) (participating children), agree that this compact outlines how the parents, the entire school staff , and the students will share the responsibility for improved student academic achievement and the means by which the school and parents will build and develop a partnership that will help children achieve the State’s high standards. Working together, teachers, parents, and students will form a partnership to help each child achieve success in school. Our united effort will benefit your child by supporting their success in school.

School Responsibilities - Little Wound School will support our students in the following ways:

1. Providing high-quality curriculum and instruction in a supportive and effective learning environment that enables the participating children to meet the State’s student academic achievement standards as follows:

a. Providing a positive learning environment for all students.

b. Making our students aware of the expectations for his or her success in school.

c. Teaching strategies to help our students become better readers, writers, and thinkers.

d. Encouraging our students to read outside of school every day.

e. Developing, adopting, and delivering high-quality programs and curriculum, which are based on research and best practices, and are aligned with the State adopted standards.

2. Holding parent-teacher conferences, during which the strategies and practices within this compact will be discussed as they relate to the individual child’s achievement and continued progress.

a. Providing parents with frequent reports on their children’s progress.

b. Providing parents reasonable access to staff.

c. Provide materials and training to help parents work with their children

Parent Responsibilities - Parents are encouraged to support their children’s learning in the following ways:

a. Sending your children to school ready to learn.

b. Making your children aware of your expectations for their success in school

b. Providing a quiet place for your children to do homework; and checking to see that it is finished.

c. Encourage your children to read every day, outside of school.

d. Monitoring attendance.

e. Volunteering in your children’s classroom, to the extent able.

f. Participating, as appropriate, in decisions relating to your children’s education.

g. Staying informed about your children’s education and communicating with the school by reading all notices from the school, provided through electronic means, or received by mail, and responding, as appropriate.

Student Responsibilities - Students share the responsibility to improve their individual academic achievement and achieve the State’s high standards. Students are able to share in the responsibility for their learning by:

a. Coming to school ready to learn, and always doing your best in school.

b. Doing your homework every day and ask for help when we need to.

c. Reading for at least 30 minutes every day outside of school time.

d. Give parents, or guardians, all notices and information received from our school every day.
I agree to the "Participate in School Related Activities" *

Yes No
I agree to the "Records Release" *

Yes No
I agree to the "Counseling Release" *

Yes No
I agree to the "Photo Release" *

Yes No
I agree to the "Internet User Agreement" *

Yes No
I agree to the "Participate in Lakota Ceremonies" *

Yes No
I agree to the "School-Parent Compact" *

Yes No
Please type person completing this registration *
Please sign below: *

Clear
By submitting this registration form, you are assuring Little Wound School that you are the legal parent/guardian of the student and all responses to this registration are accurate.
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LITTLE WOUND MIDDLE SCHOOL REGISTRATION

STUDENT AND FAMILY INFORMATION

CONTACT INFORMATION

FORMER SCHOOL INFORMATION

STUDENT HEALTH

Attachments

AGREEMENTS