Student Enrollment Application Form

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STUDENT ENROLLMENT APPLICATION FORM

School Year 2021/2022

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Student's Name: Student's First Name* Student's Last Name* Date of Birth: Date of Birth* Age: * Grade: *

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PARENT INFORMATION

Mother/Female Guardian Information

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Name

First Name Last Name
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Phone Number
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Secondary Number
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Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Email
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PARENT INFORMATION Continued

Father/Male Guardian Information

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Name

First Name Last Name
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Phone Number
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Secondary Number
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Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Email
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EMERGENCY CONTACT INFORMATION

In the event of an emergency, please contact the following in the order listed below

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1 First Name Last Name Relationship to Child: Area Code Phone Number Secondary Number: Area Code Phone Number

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2 First Name Last Name Relationship to Child: Area Code Phone Number Secondary Number: Area Code Phone Number

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3 First Name Last Name Relationship to Child: Area Code Phone Number Secondary Number: Area Code Phone Number

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4 First Name Last Name Relationship to Child: Area Code Phone Number Secondary Number: Area Code Phone Number

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5 First Name Last Name Relationship to Child: Area Code Phone Number Secondary Number: Area Code Phone Number

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Please note that individuals other than the parent will be required to provide a picture identification card before the student is released to them. This is for safety and protection of your child. If custody issues exist, we will require documentation to support this in the form of a court order, restraining order, etc.

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TRANSPORTATION

Pick-up/Drop-off information if needed. (Please Type N/A if not applicable)

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Bus Pick-Up

First Name Last Name
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Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Bus Drop-Off

First Name Last Name
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Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Does the student walk to and /or from school?

Yes No
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Is the student dropped-off/Picked-up afterschool?

Yes No
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Does the student walk to any of the following?
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Is student picked up by POI Recreation Center?

Yes No
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I verify that the information contained in this document is true and correct to the best of my knowledge. First Name* Last Name* SIGNATURE: Signature* Date* Relationship to Student: *.

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STUDENT IDENTIFICATION

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Student's Full Name: First Name Middle Name Last Nmae

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Student's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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Student's Date of Birth

Month Day Year
Date
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Student's Place of Birth: blanks

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Sex

Male Female
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Tribal Affiliation: blanks Degree of Indian Blood Dominant Language Spoken in the home: blank

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Is the Student Hispanic/Latino?

yes No
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FAMILY INFORMATION

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Mother's/Female Guardian's Name

First Name Last Name
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Does Mother/Female Guardian live with Student?

Yes No
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Mother/Female Guardian Information:

	If not applicable please type N/A
Tribal Affiliation (if any):
Enrollment Number:
Occupation (optional):
Employer:
Work Phone:

Father's/Male Guardian's Name

First Name Last Name
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Does Father/Male Guardian live with Student?

Yes No
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Father/Male Guardian Information:

	If not applicable please type N/A
Tribal Affiliation (if any):
Enrollment Number:
Occupation (optional):
Employer:
Work Phone

Sibling(s) attending Isleta Elementary School

	Name	Teacher	Grade
1.
2.
3.
4.

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OTHER GUARDIAN INFORMATION

If applies to student (Foster Parent(s), etc.)

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First Name Last Name Street Address Address Line 2 City State Zip Area Code Phone Number Occupation (Optional) Employer Work Number Emergency Number Other (Specify)

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First Name Last Name Street Address Address Line 2 City State Zip Area Code Phone Number

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PREVIOUS SCHOOL INFORMATION

School(s) Previously Attended (if any)

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School Name: Year(s) Attended: Street Address Address Line 2 City State Zip

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Street Address Address Line 2 City State Zip

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I am legally responsible for this student and hereby apply for his/her admission to this school. I understand that addition information may be requested by the school before the student is enrolled. Signature Date

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STUDENT RESIDENCY VERIFICATION DOCUMENT

This document is intended to address the McKinney-Vento Act. Your answers will help the school determine residency documents necessary for enrollment of this student.

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SECTION A: Where is the student presently living?

In a shelter In a house or an apartment with more than one family In a motel, car or campsite With friends or family members (other than parent/guardian)
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SECTION B: Where is the student presently living?

Choices in SECTION A do not apply
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Signature of Parent/Legal Guardian: Signature* Date*

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This portion is for school use only

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If the parent has checked Section B above, completion of form is not required. For any choices in Section A, this form must be completed and provided to the School Registrar immediately after completion. Form will be kept separately from the Student's permanent Record for audit purposes during the school year.
Name and phone number of a School Contact Person who may know of the family's situation:
First Name Last Name Area Code Phone Number

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CONSENT FOR MEDICAL SERVICES

Pueblo of Isleta Elementary School and the Pueblo of Isleta health Center

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The Pueblo of Isleta Elementary School is asking you to complete this form in order to arrange for or provide health care services and education for your child/children while attending school. This includes medical, dental care and especially emergency services.
We understand that some children do not receive health care services from the Pueblo of Isleta Health Clinic. In the event of a medical emergency, the Pueblo of Isleta Emergency Medical Technicians are called and will administer first aid and possibly transport your child for medical care. In the event of an emergency, the parent or other emergency contact will be notified as soon as possible.
The Isleta Diabetes Program provides nutrition awareness to our students and tracks their fitness level. The Pueblo of Isleta Community Health Nurse and Health Educator provide health education to our students in a variety of topics such as nutrition, healthy lifestyle choices and puberty education.
Our Community Health Nurse also performs head lice checks routinely. Student immunization records are also reviewed to ensure that students are up to date with their shots. As a parent, you can specify exceptions or special instructions in the space provided below. This information is used for future promotion planning. The Pueblo of Isleta Health Clinic/Pueblo of Isleta Elementary School may provide the following services:
1. Emergency Health Care fo accidents or illness.
2. Transportation of the child to another health facility for these services.
3. Health education such as diabetes awareness, head lice, nutrition,etc.
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Student's Name: First Name Last Name Date of Birth:Date Grade:

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Please note any special instructions or exceptions:
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Parent/Guardian Signature: Signature* Date*

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MEDIA PERMISSION SLIP

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There are several events throughout the school year when the media will be invited to the Pueblo of Isleta Elementary School. We are asking for your permission for your child to be interviewed, photographed, videotaped, etc. Your child's teacher will notify you.

My child HAS my permission to participate in interviews, photography opportunities and may also be videotaped. My child DOES NOT have my permission to participate in interviews, photography opportunities and may also be videotaped.
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Name of Student

First Name Last Name
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Date of Birth

Month Day Year
Date
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Grade:

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Parent/Guardian Signature: Signature Date

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WALKING PERMISSION SLIP

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During the school year, your child's classroom may be involved in an activity at the Isleta Head Start or Isleta Health Clinic (located approximately ¼ mile down the street) away from school grounds with staff supervision. With your permission, your child may walk to the different offices within the Sunset Hills area. Once again, your child's teacher will notify you as to the date of the activity. This permission form does not allow your child to walk off campus after school without parent permission.

My child HAS my permission to walk to activities in the Sunset Hills area during the school year. My child DOES NOT have my permission to walk to activities in the Sunset Hills area during the school year.
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Name of Student

First Name Last Name
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Date of Birth

Month Day Year
Date
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Grade:

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Parent/Guardian Signature: Signature* Date*

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INTERNET, ELECTRONIC MAIL AND COMPUTER PERMISSION FORM FOR PUEBLO OF ISLETA ELEMENTARY SCHOOL STUDENTS

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he Pueblo of Isleta Elementary School is pleased to offer students access to a computer network for electronic mail ( e-mail) and the Internet, all students must obtain parental permission as verified by the signature on the attach form.

Pueblo of Isleta Elementary School Rules for Use of Computers, the Internet and Electronic (e-mail):
1. DO NOT use a computer to harm other people or their work.
2. DO NOT damage the computer or the network in any way. This includes not damaging the computer keyboard, mouse, mousepad or monitor. any student who damages computer equipment will lose the privilege to use school computers and will have to pay for repairs.
3. DO NOT create, view, send or display offensive, inappropriate messages or pictures - Profane, abusive, or impolite language should not be used to communicate, nor should materials be accessed which are not in line with the rules of school behavior.
4. DO NOT trespass in another's folder, work or files.
5. NOTIFY an adult immediately if you or another student encounter inappropriate materials or language.
6. BE PREPARED to be held accountable for your actions and for the loss of privileges if the Rule of Appropiate Use are violated.
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As a parent or guardian of a student at the Pueblo of Isleta Elementary School, I have read the above information about the appropriate use of computers and technology equipment at the school and I understand that this agreement will be kept on file at the school. (All questions should be directed to the Principal). Each child will be issued a set of headphones for use with computers during the school year. Should the headphones be damaged or lost, it will be the responsibility of the parent to pay for the headphones.

My child MAY use school computers, the Internet and e-mail while at school according to the Rules of Appropriate Use. He/she may also post information about him/herself and personal work on school related web pages. I DO NOT want my child to use the school's computers (Internet, e-mail, etc.) to post about himself/herself on school related web pages.
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Parent Name: First Name* Last Name*
Parent Signature: Signature* Date*

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HOME LANGUAGE SURVEY

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Student's Name

First Name Last Name
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Grade:

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Dear Parents and Guardians:

In order to help your child, succeed in school, we ask that you please answer the following questions for each child in your family. Your answers will help us in creating the best possible educational program for your child's language development skills.

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What language was first learned by your child?
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What language(s) are commonly used in speaking with your child?
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Specify Tribal Language or Other
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What language(s) does your child use when speaking with you or family members?
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Specify Tribal Language or Other
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Do any family members or friends speak another language at home?
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Specify Tribal Language or Other
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The information in the below section is to be filled in by the person completing this form:

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Do parents need an interpreter?

Yes No
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Information was completed by: First Name Last Name
Parent Signature: Signature Date

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Relationship to child:

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This Document will be kept in the student's file per Family Educational Rights and Privacy Act Regulations. If you have any questions, please contact the front office 505-869-2321.

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SCREENING CONSENT FORM

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I give permission for my child to participate in the free vision, dental, and hearing screening programs provided at the school.

I understand the follwing regarding this program:

I. There is no charge for my child to participate in these screening programs.

II. The information obtained from this screening is preliminary only and does not constitute a diagnosis.

III. I will be contacted by the school or by my child's teacher, school administrators, or directors should my child be referred for further evaluations.

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Name of Parent/Guardian: First Name* Last Name*
Signature of Parent/Guardian: Signature* Date*

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LUNCH PROGRAM

Information Regarding The Pueblo of Isleta Elementary School Free Lunch Program

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HEALTH PLAN/MEDICATION ADMINISTRATION

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Child Information

First Name Last Name
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DOB:

Month Day Year
Date
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Classroom:

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Medical Condition/Diagnosis:
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Parent/Guardian Will:
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Health Assistant Will:
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Teaching Staff Will:
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What are the signs and symptoms of your Child's medical condition?
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Will your child require medication during program hours?

YES NO
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If YES, Please Enter the Name of Medication(s):
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Is this an over-the counter medication?:

YES NO
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Time of Administration:

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Dosage Amount:
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Date to Start Medication:

Month Day Year
Date
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Date to End Medication:

Month Day Year
Date
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Route (choose one):

Topical Oral Other
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Additional Instructions:
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Has your child experienced side effects or an allergic reaction while on this medication (explain):
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In case of an emergency, do we have permission to administer CPR and /or call EMS if necessary?

YES NO
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Prescriber's Information

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PERMISSION TO ADMINISTER MEDICATION

I hereby give permission to the Pueblo of Isleta Elementary School to administer medication as prescribed above. I have administered at least one does of medication to my child without any adverse effects.

Note: If your child refuses medication, parents will be notified. There is no medication disposal here at the Elementary School. Should medication run out or expire, parents will be notified to pick up medication.

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Parent/Guardian Signature: Signature Date Parent/Guardian Printed Name: First Name Last Name Area Code Phone Number Area Code Work Phone Area Code Cell Phone

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Health Assistant Signature: Signature Date

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Teaching Staff Signature(s):
Signature   Date
Signature   Date
Signature   Date

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FIELD TRIP MEDICATION RELEASE FORM

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Please download this fillable PDF and upload the completed document below. You can also download, print, scan, and upload, or send to the Elementary School.

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File Upload

Cancel of
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Should be Empty:

STUDENT ENROLLMENT APPLICATION FORM

PARENT INFORMATION

PARENT INFORMATION Continued

EMERGENCY CONTACT INFORMATION

TRANSPORTATION

STUDENT IDENTIFICATION

FAMILY INFORMATION

OTHER GUARDIAN INFORMATION

PREVIOUS SCHOOL INFORMATION

STUDENT RESIDENCY VERIFICATION DOCUMENT

This portion is for school use only

CONSENT FOR MEDICAL SERVICES

MEDIA PERMISSION SLIP

WALKING PERMISSION SLIP

INTERNET, ELECTRONIC MAIL AND COMPUTER PERMISSION FORM FOR PUEBLO OF ISLETA ELEMENTARY SCHOOL STUDENTS

HOME LANGUAGE SURVEY

SCREENING CONSENT FORM

LUNCH PROGRAM

HEALTH PLAN/MEDICATION ADMINISTRATION

FIELD TRIP MEDICATION RELEASE FORM