New Student Enrollment Packet (English)

CHPA New Student Registration
Enrollment Year
Student Information:
Last Name
First Name
Middle Name
Student Date of Birth (mm/dd/yyyy):

MonthDayYear
Date
Student Gender
Incoming Grade Level:
Student ID (From Previous District 60 School):
Primary Contact Information:
Primary Contact Phone Number (XXX-XXX-XXXX):
Type (cell, home, work, etc.)
Primary Contact Name:
Relationship to Student
Residential and Mailing Information:
Primary Student Address:
City:
State:
Zip:
Mailing Address (if different from above):
Mailing City (if different from above):
Mailing State (if different from above):
Mailing Zip (if different from above):
Is this an Active Military Family?
Father/Male Guardian Name (Last, First)
Father/Male Guardian Relationship to student:
Father/Male Guardian Address (if different from primary student address)

Address (if different from primary student address)

Street Address Line 2

CityState

Zip
Mother/Female Guardian (Last, First):
Mother/Female Guardian Relationship to student:
Mother/Female Guardian Address (if different from primary student address)

Address (if different from primary student address)

Street Address Line 2

CityState

Zip
Previous School and Program Enrollment:
School currently attending, or attended most recently:
School Name
Grade
School year
City
State
Has student EVER attended Pueblo City Schools before?
If Yes, which school(s)?
Is student presently under an EXPULSION order from any school district?
If Yes, Date of Expulsion (mm/dd/yyyy):

MonthDayYear
Date
If Yes, Length of Expulsion - Days:
Has student been enrolled in a Colorado public school for the past 3 years? (Do not count the years enrolled in Preschool or Kindergarten)
Has student been enrolled in the Pueblo City School district for at least the past year?
Student Ethnicity and Race:
Is student Hispanic/Latino (of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin) regardless of race?
Race: (Must select at least one)
Signature (Parent/Guardian):

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date:

MonthDayYear
Date
Relationship to Student:
Guardianship

Other
Primary Phone & Email Contacts

Starred (*) Items will be used for All-Call messages, automated attendance call and announcements, etc. - ONLY ENTER REGULAR CONTACTS - Emergency Contacts are to be entered in a separate area.
Primary Contact Phone Number (XXX-XXX-XXXX)
Primary Contact Phone Type (Cell, home, work, etc.)
Primary Contact Full Name
Primary Contact Relationship to Student
Alternate Phone Number 1 (XXX-XXX-XXXX)
Alternate Phone Number 1 Type (Cell, home, work, etc.)
Alternate Phone Number 1 Full Name
Alternate Phone 1 Relationship to Student
Alternate Phone Number 2 (XXX-XXX-XXXX)
Alternate Phone Number 2 Type (Cell, home, work, etc.)
Alternate Phone Number 2 Full Name
Alternate Phone Number 2 Relationship to Student
Alternate Phone Number 3 (XXX-XXX-XXXX)
Alternate Phone Number 3 Type (Cell, home, work, etc.)
Alternate Phone Number 3 Full Name
Alternate Phone Number 3 Relationship to Student
Student Cell Phone - (XXX-XXX-XXXX)
Name of student's legal guardian(s):
Relationship to student:
Primary Guardian Email (email@domain.com)
Alternate Email 1 (email@domain.com)
Alternate Email 2 (email@domain.com)
Emergency Contacts (to be called if regular contacts are not available - List in order of preferred contact)
Contact 1

Name(s)

Street Address Line 2

Relationship to StudentPhone Number(s) (XXX-XXX-XXXX)

Zip
Contact 2

Name(s)

Street Address Line 2

Relationship to StudentPhone Number(s) (XXX-XXX-XXXX)

Zip
Contact 3

Name(s)

Street Address Line 2

Relationship to StudentPhone Number(s) (XXX-XXX-XXXX)

Zip
Does the student have siblings attending CCA, ECMS or DHPH?
If Yes, please list names below:
Do you wish to also have information sent to a parent or guardian not living at the student's address?
If Yes, Full Name:
If Yes, Guardian's relationship to student:
If Yes, Guardian's Full Mailing Address:
Do you wish to also have information sent to a parent or guardian not living at the student's address?
Phone:
Type (cell, home, work, etc.):
Email:
example@example.com
Parent Permission and Release Form
School
Student Name
Parent Permission for Excursions:
On occasion, students will be given the opportunity to participate in field trips. On excursions, children take school buses, walk or use some other means of transportation. If you sign in the space below, your child will be allowed to join in these field trips during the current school year. CCA/DHPH will send information home before each excursion – by note, newsletter, school’s monthly calendar or some other means – to provide information on the place to be visited and the date of the excursion. At that time, you may revoke your permission for your child to go on a specific excursion. Neither CCA/DHPH nor Pueblo City Schools is responsible for student injury sustained on an excursion or field trip. I have read the foregoing information and consent to my child’s being taken on field trips or excursions during the school year.
Parent/Guardian Signature:

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Today's Date:

MonthDayYear
Date
Parent Permission for Media:
Throughout the school year CCA/DHPH may produce a variety of informational publications and other materials. These may include brochures, pamphlets, website postings, posters, and news releases. Additionally, the news media or an educational promotional/informational organization may request to cover a story at CCA or DHPH. In these and other instances where your student may be identified in the public, CCA/DHPH must have your written permission. I understand that CCA/DHPH shall not be liable for royalties, commissions, or payments of any nature to me or my child(ren) in connection with such filming, photographing, and/or interviewing. CCA/DHPH assumes no liability of any nature in connection with such filming and/or interviewing.
I hearby __________ my permission to PCS to allow my child to be filmed/photographed and interviewed by media.
Parent/Guardian Signature:

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date:

MonthDayYear
Date
Parent Permission for Internet and Technology Use:
As the parent or guardian of a CCA/DHPH student I have read the Acceptable Use Agreement in the Student Handbook, understand its contents, and agree that my child will abide by it. I am fully aware that the school technology system is administered by CCA/DHPH and is intended for official CCA/DHPH business and educational use only. Should my child commit any violation of the Acceptable Use Agreement, his/her access privileges may be revoked, and other disciplinary action may be taken.
I hearby __________ my permission to issue Internet access for my child.
Parent/Guardian Signature:

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date:

MonthDayYear
Date
Parent Permission for PowerSchool Parent/Guardian and Student Portal:
The PowerSchool Parent/Guardian Portal and Student Portal are available for parents and DHPH students to have real-time access to grades, attendance, and student information. I hereby acknowledge that I am fully aware that access to student information from the Internet is a privilege not a right, and I understand that this system uses a secure Internet site to enable access to only my student’s information. I will practice proper and ethical use when accessing my student’s data. If I discover information that is not related to my student(s) I will notify the school immediately.
Parent/Guardian Signature:

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date:

MonthDayYear
Date
Home Language Survey

To be completed by a parent/guardian
Student Name
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Parent/Guardian Name(s)
Phone
Home Address
School
1. What is your child's first/native language?

Other
2. What language does your child speak with you at home?

Other
If, Other:
3. What language do you speak with your child?

Other
If, Other:
4. Do other adult family members speak to each other in a language other than English?

Other
If Other, Does your child understand the conversations?
If Other, Does your child participate in the conversations?
If Other, are these extended family members able to speak English?
5. In what language does your child read?
6. In what language does your child write?
7. Has your child ever attended school in another country?
If Yes; what country?
Parent/Guardian Signature

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date

MonthDayYear
Date
MCKINNEY-VENTO (TITLE IX-A)

Verification Form
Student 1 Information:
Student FIRST Name
Student MIDDLE Name
Student LAST Name
Student's Gender
Date of Birth:

MonthDayYear
Date
School Name
Grade:
ID#:
Student 2 Information:

(If Applicable)
Student FIRST Name
Student MIDDLE Name
Student LAST Name
Student's Gender
Date of Birth:

MonthDayYear
Date
School Name
Grade:
ID#:
Student 3 Information:

(If Applicable)
Student FIRST Name
Student MIDDLE Name
Student LAST Name
Student's Gender
Date of Birth:

MonthDayYear
Date
School Name
Grade:
ID#:
Address:
Phone:
Emergency Phone:
THIS INFORMATION IS NOT SHARED WITH ANY OUTSIDE AGENCY

This document is intended to address the requirement of McKinney-Vento Act, Title IX part A of ESSA. Please answer questions below to help determine if the student meets the definition of home-lessness.
Unaccompanied Youth Check Box
If you selected yes above, please answer the complete the following fields:
Student Signature Only:

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date:

MonthDayYear
Date
As a student, are you living with someone other than your parent or legal guardian?
Where does the student stay at night?
Please check all that apply:

Other
Please list non-school age children below

(Children not in school yet)
Child 1

Name

Street Address Line 2

Birthday (MM/DD/YYYY)Reason(s) for medication

Zip
Child 2

Name

Street Address Line 2

Birthday (MM/DD/YYYY)Reason(s) for medication

Zip
Child 3

Name

Street Address Line 2

Birthday (MM/DD/YYYY)Reason(s) for medication

Zip
I verify the above information is correct and agree to services for my child.
Print Parent or Guardian Name:
Parent or Guardian Signature

Please sign using mouse cursor on desktop & finger for mobile/tablet.
Date

MonthDayYear
Date
How Did You Hear About Us/Why Did You Choose CHPA?
How did you hear about us?

Other
Why did you choose CHPA?

Other
Should be Empty:

CHPA New Student Registration

Student Information:

Primary Contact Information:

Residential and Mailing Information:

Previous School and Program Enrollment:

Student Ethnicity and Race:

Primary Phone & Email Contacts

Emergency Contacts (to be called if regular contacts are not available - List in order of preferred contact)

Parent Permission and Release Form

Parent Permission for Excursions:

Parent Permission for Media:

Parent Permission for Internet and Technology Use:

Parent Permission for PowerSchool Parent/Guardian and Student Portal:

Home Language Survey

MCKINNEY-VENTO (TITLE IX-A)

Student 1 Information:

Student 2 Information:

Student 3 Information:

If you selected yes above, please answer the complete the following fields:

Please list non-school age children below

I verify the above information is correct and agree to services for my child.

How Did You Hear About Us/Why Did You Choose CHPA?