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Bellaire High School Student Registration Part 2
School Year 2021-2022
Student's Legal Name
*
First Name
Middle Name
Last Name
Grade Level
9
10
11
12
Grade Level is subject to verification
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Student's Phone Number
-
Area Code
Phone Number
Student's Email Address
example@example.com
Student's Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the student currently at an HISD school?
Yes
No
Is your current address, listed above, what is on record for the current HISD school?
yes
no
N/A
Name of Primary Guardian (this is the legal guardian registering the student and/or the Adult Student)
*
First Name
Last Name
Are you the Primary guardian of the student?:
*
Yes. I am on the student's birth certificate or I have legal custody signed from a judge
No. I don't have a legal document stating I am the student's guardian.
If you are not the legal guardian, someone will contact you in August to complete the special enrollment and registration process.
Primary Guardian: Home or Cell Phone Number
*
-
Area Code
Phone Number
Primary Guardian: Work Phone Number
-
Area Code
Phone Number
Primary Guardian: Email Address
example@example.com
Upload 2nd proof of of residence, this should be different from what you uploaded on the HISD application.
*
Is the student coming from another HISD school or has the student been in an HISD school before?
*
Yes, returning Bellaire Student
Yes, coming from another HISD Campus
Yes, coming from another HISD Campus after completion of DAEP placement and met with BHS Administrator
Yes, previously attended an HISD School
No, student is coming from Out of the Country
No, Student is coming from Out of the state of TX
No, Student is coming from another TX Public School
No, student is coming from a Private or Charter School
No, Student is coming from a Charter School/JJAEP
If you are coming from another HISD campus, then please provide the student's ID# and the name of the school.
ID#
Previous HISD Campus Name
Please list all schools attended in the past 3 years.
*
Middle or High School
Name of the School
Address
Phone Number
Dates you were enrolled
2020-2021 school year
MS
HS
2019-2020 school year
MS
HS
2018-2019 school year
MS
HS
2017-2018 school year
MS
HS
2016-2017 school year
MS
HS
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1. Ethnicity Data Questionnaire - Is the student Hispanic/Latino?
*
Yes 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
2. Race Data Questionnaire - What is the student's race?
*
American Indian or Alaska Native - A person having origins in any of the peoples on 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 ex: 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.
1. Military Families Survey - Is the student a dependent of an active duty member of the US Army, Navy, Air Force, Marine Corps, or Coast Guard?
*
Yes
No
2. Military Families Survey - Is the student a dependent of a member of the Texas National Guard (Army, Air Guard, or State Guard)?
*
Yes
No
3. Military Families Survey - Is the student a dependent of a member of a reserve force in the US Military (Army, Navy, Air Force, Marine Corps, or Coast Guard)?
*
Yes
No
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1. Assistance Questionnaire - Is the student CURRENTLY in the conservator-ship of the Department of Family & Protective Services (Foster Care?)
*
Yes
No
If you answered YES to the previous questions; Name of DFPS Case manager
Phone Number of the DFPS Case manager
-
Area Code
Phone Number
2. Assistance Questionnaire - Where are you CURRENTLY living?
*
IN MY OWN HOME OR APARTMENT, or In section 8 housing, HUD Subsidized housing or in military housing with parent(s), legal guardian(s), or caregiver(s)
My home has NO electricity
My home has NO running water
I CURRENTLY LIVE IN A TRANSITIONAL HOUSING SITUATION
In a Shelter
In a Motel/Hotel
With more than one family in a house or Apartment (Doubled-up) due to economic hardship
UNSHELTERED
Moving from place to place
In a structure not usually used for housing
In a car, park, campsite, camper, or outside
3. Assistance Questionnaire - If you are currently living in a transitional housing situation, then please check any that may apply to your background situation.
Catastrophic Illness/Medical expenses/disability
New to town
Loss of Employment
Economic Hardship/low earnings
Evicted/Kicked out
House Fire or other Destruction
Natural Disaster/Evacuation
Domestic Issue
Migrant Work in Fishing or Agriculture
Awaiting Placement in Foster Care/CPS Custody
Parent(s) involved in Military Deployment
Parent Incarcerated/recently Released from Incarceration
4. Assistance Questionnaire - Check any that may apply to your situation's needs. An HISD Outreach Worker will contact you.
Enrollment Assistance
Free Lunch/Breakfast (child Nutrition)
Immunizations
Temporary Assistance for Need Families (TANF)
Transportation
School Supplies
Medicaid/CHIP Assistance
Emergency Clothing, Uniforms
Personal Hygiene Items
Food Stamps (SNAP) Assistance
Other
5.Assistance Questionnaire - Is the student an Unaccompanied Youth?
*
Yes, student is not in the physical custody of a parent or legal guardian, including living with non-custodial relatives or friends without a parent or legal guardian.
No, student lives with one or both parent legal guardian(s)
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Year Student Started School in USA?
*
Year Student Started 9th Grade?
*
Student's Birthplace:
*
City, State, Country
1. Home Language Survey - What Language is spoken in the child's home most of the time?
*
2. Home Language Survey - What Language does the child's speak most of the time?
*
1. Family Survey - Have you or anyone in your household moved within the last 3 yrs from one school district to another in TX or within the USA?
*
Yes
No
2. Family Survey - Were any of these moves made to find temporary/seasonal work in agriculture or fishing?
*
Yes (field work, canneries, dairy work, meat processing, fishery, poultry farm, plant nursery.
No
Has the student had any interruption of his/her academic years? ex: stopped attending school for several months or years?
*
Yes
No
If you answered yes to the previous question; type the grade level and at that time the age of the student
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HAVE ANY OF THE FOLLOWING EDUCATIONAL SERVICES PREVIOUSLY BEEN PROVIDED FOR STUDENT?
*
Yes
No
Special Education
504 Accomodations
Gifted/Talented
Free/Reduced Lunch
Transportation Provided
Coded as ESL (English as Second Language)
Please upload a copy of the student's last ARD or 504 Meeting paperwork. Name the documents 504 or ARD
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1. Student's Health Inventory - Have you ever been told by a doctor that your child had:
Age First Identified
Under Doctor's Care
Asthma
Yes
No
Allergies
Yes
No
Blood Disorder
Yes
No
Diabetes
Yes
No
Epilepsy/Seizures
Yes
No
Heart Disease
Yes
No
Kidney Disorder
Yes
No
Cancer
Yes
No
Bone/Joint Problem
Yes
No
Rheumatic Fever
Yes
No
Surgery/Fractures
Yes
No
T.B. Disease
Yes
No
Hearing Loss
Yes
No
Vision Loss
Yes
No
Severe Menstrual Cramps
Yes
No
Eating Disorder
Yes
No
2. Student's Health Inventory - Have you observed any of the following in your child?
Yes
No
Tires Easily
Frequent Headaches
Fainting
Earaches
Difficulty Making Friends
Coughs Frequently at Night
Wheezing, shortness of breath with exercise
Nail Biting
Restlessness
Has Your child been seen by a doctor for any of the above?
3. Student's Health Inventory - Is Your child on any kind of medication?
*
Yes
No
List Medications
Medications
Name
First Name
Last Name
List the medications your child is taking
For what condition is your child taking the above medications?
4. Student's Health Inventory - Let the school nurse or principal know if your child has other needs or is Pregnant or is a Parenting teen, and/or has a severe life-threatening food allergy or other condition for which they should be aware. Type N/A if there is no other condition to report.
*
5. Student's Health Inventory - What type of Medical Insurance do you carry for this child?
*
CHIP
Medicaid
HCHD
Private Insurance (through your work place)
NONE
6. Student's Health Inventory - In case of an emergency, please provide your family Physician's Name and Phone Number
Name
Phone Number
Please upload a legible copy of the Student's Immunization Record and any other medical records or documentation of medical condition(s) that the school nurse should be aware of. Please name the document, immunization record, or medical record 1, medical record 2, etc.
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PLEASE SIGN. Your electronic signature authorizes Bellaire High School to request student records and to verify any documents submitted in this application, including the verification of address. Falsification of documents: Presenting a false document or false record under TEC Section 25.002 is an offense under Section 37.10 Penal Code and may be prosecuted as a criminal offense and enrollment of a child under false documentation subjects the person to liability for tuition under Section 24.001(h). You hereby with your electronic signature ensure that the information stated in the enrollment application of your student is true and accurate.
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For Office Use Only
Student ID Number
PEIMS Number
Social Security Number
Should be Empty: