Heavener Public Schools Enrollment Form For ... AWS
Heavener Public Schools Enrollment Form For Returning High School Student
The f ollowing e nrollment f orm i s f or RETURNING S TUDENTS O NLY . T he e nrollment f orm w ill n eed to b e f illed o ut, p rinted a nd s igned b efore r eturning i t a t t he d esignated e nrollment d ate i n A ugust.
A N EW S TUDENT i s d efined a s a s tudent w ho d id N OT a ttend s chool i n t he H eavener S chool D istrict o r l eft t he district a t s ome p oint l ast y ear. I f y ou f it t his d efinition y ou w ill n eed t o f ill o ut a N ew S tudent E nrollment F orm n ot this f orm.
Enrolling F reshman w ho a ttended H eavener i n t he 8 th g rade a re c onsidered R ETURNING S TUDENTS .
Enrollment Time is 8:30 to 11:30: ● August 1 , 2 017 S eniors (must h ave a ttended H HS l ast y ear) ● August 2 , 2 017 J uniors (must h ave a ttended H HS l ast y ear) ● August 3 , 2 017 S ophomores (must h ave a ttended H HS l ast y ear) ● August 4 , 2 017 F reshman a nd N ew S tudents ( Any S tudent w ho d id n ot a ttend H HS l ast y ear) All Students Must Be Accompanied By A Parent/Guardian.
You may use ONE FORM for all returning students living at the same residence who are enrolling in high school.
***Please n ote: E ach o f t he f ollowing f orms n eed t o b e f illed o ut p er s tudent*** ●
HEAVENER H IGH S CHOOL P ARENTSCHOOL C OMPACT
●
STUDENT E NROLLMENT Q UESTIONNAIRE
●
FORM A : H OME L ANGUAGE S URVEY F OR P REK12 S CHOOL D ISTRICTS
●
FORM C : T ITLE V I E D 5 06 I NDIAN S TUDENT E LIGIBILITY C ERTIFICATION F ORM
One o f e ach i s i ncluded i n t he f ollow f orm. For m ultiply s tudents ● The o ffice w ill p rovide f or y ou. ● You c an f ill o ut a dditional o nes a t http://www.heavenerschools.org/parentresources/returningstudentenrollmentforms
Heavener Public Schools Enrollment Form For Returning High School Student SCHOOL YEAR: 20172018
TODAY’S DATE : ____________
Student’s Full Name ( First, Middle and Last Name)
Entering Grade Level
☐ NO CHANGES TO A NY OF THE INFORMATION BELOW
Student(s) with NEW Medical Condition/Medication: ________________________________________________________ You M UST a lso f ill o ut t he a ppropriate f orm w ith t he S chool N urse.
Residency I nformation
Oklahoma State L egislature HB 1577 ( Effective July, 1 1997) L aw: $500.00 Penalty For T hose Providing False Residency I nformation To School.
Mailing Address:
STREET,Apt/Suite____________________________________CITY_________________STATE____ZIP______
Physical A ddress: (If different from mailing a ddress)
STREET,Apt/Suite:____________________________________CITY_________________STATE____ZIP______
Home Phone#: _____________________ Does your family live more than 1.5 miles from school? Yes ☐ No ☐ Transportation: How does your c hild(ren) get to a nd f rom school: ☐Walk ☐Car ☐Daycare ☐Bus#_____
Parent/Guardian I nformation Father/Male Guardian Living in the Home:_____________________________________ CELL #: ________________
Employer: ______________________ Work #:__________________Email:_______________________________
Mother/Female Guardian Living in the Home:___________________________________ CELL #: ________________
Employer: ______________________ Work #:__________________Email:_______________________________
Emergency C ontact I nformation : (Someone who will take responsibility for the student if the parent/guardian can not be reached.)
Contact #1 Name:_________________________________________Relation to Student:_____________________
Home #: __________________ Work#: __________________ Cell#: __________________
Contact #2 Name:_________________________________________Relation to Student:_____________________
Home #: __________________ Work#: __________________ Cell#: __________________
I Give the Following People Permission to take my c hild off school grounds:
Upon e nrollment of my child in Heavener Public School, I am giving my consent to ALL policies listed in the Student Handbook and certify that the above information is correct. I understand it is my responsibility to notify school officials of any changes in my legal residence and/or c ontact information.
Parent/Guardian Name (print): __________________________________________________________
Parent/Guardian Signature: __________________________________________________ Date: ___________________
ERate Program Heavener P ublic Schools p articipates i n the Erate program. This program is a Federal program which p rovides schools and l ibraries a cross t he c ountry w ith substantial discounts on t he c osts of t heir telephone service, internet service, internet a ccess, c omputer c onnections a nd m aintenance c osts. T he s ize o f this discounts is based on t he income l evel of our student’s families a nd e quates to s aving you, t he taxpayer, a s ubstantial a mount of money. Please, fill o ut t he survey. This information w ill remain c onfidential a nd will b e r eported only a s a total group, n ot by i ndividual f amilies, a nd will not be used for a ny purpose other than Erate. Head of Household Name: _ _____________________________________________________________ Family Mailing Address: STREET,Apt/Suite:_______________________________________CITY______________STATE____ZI P________ Circle the number of people in your household in the table below: Household Size*
Maximum I ncome Level ( Per Y ear)
Monthly
BiMonthly
Every 2 w eeks
Weekly
1
$21,978
$1,832
$916
$845
$423
2
$29,637
$2,470
$1,235
$1,140
$570
3
$37,296
$3,108
$1,554
$1,434
$717
4
$44,955
$3,746
$1,873
$1,729
$865
5
$52,614
$4,385
$2,192
$2,024
$1,012
6
$60,273
$5,023
$2,511
$2,318
$1,159
7
$67,950
$5,663
$2,831
$2,613
$1,307
8
$75,646
$6,304
$3,152
$2,909
$1,455
$7,696
$641
$321
$296
$148
For e ach a dditional m ember a dd:
Yes ⬜ No ⬜ Is your family’s income e qual to or less than a ny of the a mounts listed next to the number you c ircled? Yes ⬜ No ⬜ Are your c hildren e ligible for the NSLP (National School Lunch Program) which provides free or reduced lunches, breakfast, snacks or milk a t their school(s)? Yes ⬜ No ⬜ Is you family e ligible to receive food stamps?
Yes ⬜ No ⬜ Is you family e ligible for medical a ssistance under Medicaid?
Yes ⬜ No ⬜ Does y our family receive Temporary Assistance for Needy Families (TANF)? Yes ⬜ No ⬜ Does y our family receive Supplementary Security Income (SSI)? Yes ⬜ No ⬜ Does y our family receive housing a ssistance (section 8)?
Yes ⬜ No ⬜ Does y our family receive home e nergy a ssistance (LIHEAP)? If you answered YES to any of the preceding questions, please list the names of all school c hildren living in your home, including which school they attend. ( Attach a separate sheet if needed) Name of Child School Grade ____________________________ _______________________________ ______ ____________________________ _______________________________ ______ ____________________________ _______________________________ ______ ____________________________ _______________________________ ______ I certify that the above information is true and correct to the best of my knowledge:
Signature: _________________________________________
Date:_________________________
Heavener Public Schools Student Enrollment Questionnaire Student Name: Date of Birth:
Today’s Date: School:
Grade:
Your child may be eligible for additional educational services through Title X, Part C McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire. Where are you and your family currently living? Please check one of the boxes below. Section A ❑ Rent/own my own home or apartment STOP: If you checked the box that you rent/own your own home or apartment skip to the bottom of the page, sign the form, and then submit to school personnel. If you do not rent/own your own home or apartment, please continue to the next section. Section B ❑ Temporarily with another family member or friend until we can locate affordable housing ❑ In an emergency or transitional shelter ❑ In a vehicle, park, campground, or on the streets ❑ In a house, building, or trailer WITHOUT running water or electricity ❑ In a hotel or motel ❑ With an adult that is not a parent or legal guardian ❑ Alone or in different locations, without an adult serving as a caregiver ❑ Wherever I can find a place to stay at night ❑ Other Please Explain:
If you checked a box in section B, in the space below please list all children currently living with you who attend Heavener Public Schools. First and Last Name of Student
Male or Female
Date of Birth
Grade
School Name
Would you like to be contacted by an employee of the school to discuss additional educational services that may be available to your child? ❑YES ❑NO
The undersigned certifies that the information provided is correct and accurate. (Print) Parent/Guardian or Adult Caring for the Student: _____________________________________________ Relationship to the Student: _________________________ Signature: ___________________________________ _______________________________________________________________________________________________ Street Address City State Zip Phone Number: ________________________________ Email Address: __________________________________
FORM: A 17 18 20____20____
HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS STUDENT INFORMATION
Name of Student: ____________________________________________________________________ Last Name First Name Middle Name Date of Birth: __________________ MM/DD/YYYY
Grade:____________
School: _____________ Student ID # ___________________ Gender: Male_______ Female________
Is the student of Hispanic or Latino culture or origin? Yes________ No_________ Select one or more of the following races: ______ African American/Black ______ Native Hawaiian/Pacific Islander
______ American Indian/Alaskan Native ______ Caucasian/White
______ Asian
1.
What is the dominant language most often spoken by the student?
2.
What is the language routinely spoken in the home, regardless of the language spoken by the student?
3.
What language was first learned by the student?
4.
Does the parent/guardian need interpretation services? Yes _____ No _____ If so, what language? _______________________________
5.
Does the parent/guardian need translated materials? Yes _____ No _____ If so, what language?
6.
What was the date the student first enrolled in a school in the United States? ________________________ MM/YYYY
_______________________________
______________________________________________________________________________________________________________ Date (MM/DD/YYYY) Parent / Guardian Signature
SCHOOL USE ONLY Please have test score documentation available for the Regional Accreditation Officer to review. ☐ Other language than English indicated TWO OR MORE times on questions 1 – 3 above. The student is classified as “more often” and automatically qualifies as bilingual on the accreditation report. ☐ Other language than English indicated ONLY ONCE on questions 1 – 3 above. The student is classified as “less often” and only qualifies as bilingual on the accreditation report if he or she meets one of the following (any selection below REQUIRES appropriate documentation): ☐ 1. Designated English Learner on one of the Oklahoma English language proficiency assessments: ACCESS for ELLs 2.0, Alternate ACCESS for ELLs, WIDA Screener, WIDA MODEL, K-WAPT, W-APT or Oklahoma Pre-K Language Screening Tool. ☐ 2. Scored unsatisfactory or limited knowledge in Reading on the Oklahoma State Testing Program (OSTP). ☐ 3. Scored at or below the 35th percentile (or equivalent) composite reading score from spring of the previous school year on a state approved norm-referenced test (NRT). DOCUMENTATION OF A TEST RESULT FOR STUDENTS MARKED LESS OFTEN Date(s) of Kindergarten ACCESS, Score(s) on Kindergarten ACCESS, Date(s) of WIDA Screener or Score(s) on WIDA Screener or ACCESS for ELLs 2.0, or ACCESS for ELLs 2.0,or K-WAPT/WAPT or K-WAPT/WAPT or Alternate ACCESS Test Alternate ACCESS WIDA MODEL WIDA MODEL Composite Score Literacy Score Composite Score Literacy Score
Date(s) of Reading OSTP
Date(s) Norm Reference Test (NRT)
1.
2.
1.
2.
1.
Unsatisfactory
Score(s) on Reading OSTP Limited Knowledge Satisfactory
Advanced
Unsatisfactory
Limited Knowledge
Satisfactory
Advanced
Unsatisfactory
Limited Knowledge
Satisfactory
Advanced
Name of the NRT
Reading Total Composite Score(s) %
Date of the Oklahoma Pre-K Language Screening Tool
2.
Score on Pre-K Language Screening Tool
% From Above: Question 1: Reference WAVE code 1036 Question 2: Reference WAVE code 1037 Question 3: Reference WAVE code 1038
FORM: B Heavener Public Schools MIGRANT EDUCATION Family Work Status Survey HPS may qualify for special funding to help meet the educational needs of our students. To determine if we qualify, the information requested below is needed. Yes
No
Did your family move into this school district within the LAST THREE YEARS?
If YES, When? Year____________ Month______________ Day______ What city and state did you move from?_______________________________________
Yes
No Has any member of your family applied for work at a local meat processing plant? If YES, When? Year____________ Month______________ Day______
Yes
No When your family moved here, did any family member look for a job in our agriculture industry? If YES, Please check type of labor sought: ⬜ Farming ⬜ Food or Meat Processing ⬜ Ranching ⬜ Hauling Pulpwood ⬜ Fishing or Fishing Guiding ⬜ Production of Poultry, Swine, Cattle, Sheep, Hay ⬜ Clearing, Leveling, Watering or caring for land ⬜Others:_______________________________________________________________________
Name of all children in family from age 0-21 years Date of Birth
Parent/Guardian:
Address:
Birthplace
Gender Grade
Phone:
Parent/Guardian Signature: ___________________________________________________ Date: _____________________________
FORM: C
OMB Number: 1810-0021 Expiratin Date: 02/29/2020
FORM: D CHOCTAW NATION OF OKLAHOMA Johnson O’Malley Program
****FILL OUT ONLY IF YOUR FAMILY HAS A CDIB CARD**** SCHOOL DISTRICT: Heavener Public Schools
County: LeFlore
Head of Household Name:_________________________________________________________ 1.Tribe, Band or Group is: (check one) State Recognized? Yes⬜ No⬜ Federally Recognized? Yes⬜ No⬜ 2. Who is the CDIB card holder, if NOT t he child(ren): Name on Card:(Print)______________________________________________________ CDIB card holder:
Name of Student
1. 2. 3. 4. 5. 6. 7. 8. 9.
⬜ Child's Parent CDIB holder? Y/N
⬜Child's Grandparent
Date of Birth
Gender
Grade
Tribe
The f ollowing e nrollment f orm i s f or RETURNING S TUDENTS O NLY . T he e nrollment f orm w ill n eed to b e f illed o ut, p rinted a nd s igned b efore r eturning i t a t t he d esignated e nrollment d ate i n A ugust.
A N EW S TUDENT i s d efined a s a s tudent w ho d id N OT a ttend s chool i n t he H eavener S chool D istrict o r l eft t he district a t s ome p oint l ast y ear. I f y ou f it t his d efinition y ou w ill n eed t o f ill o ut a N ew S tudent E nrollment F orm n ot this f orm.
Enrolling F reshman w ho a ttended H eavener i n t he 8 th g rade a re c onsidered R ETURNING S TUDENTS .
Enrollment Time is 8:30 to 11:30: ● August 1 , 2 017 S eniors (must h ave a ttended H HS l ast y ear) ● August 2 , 2 017 J uniors (must h ave a ttended H HS l ast y ear) ● August 3 , 2 017 S ophomores (must h ave a ttended H HS l ast y ear) ● August 4 , 2 017 F reshman a nd N ew S tudents ( Any S tudent w ho d id n ot a ttend H HS l ast y ear) All Students Must Be Accompanied By A Parent/Guardian.
You may use ONE FORM for all returning students living at the same residence who are enrolling in high school.
***Please n ote: E ach o f t he f ollowing f orms n eed t o b e f illed o ut p er s tudent*** ●
HEAVENER H IGH S CHOOL P ARENTSCHOOL C OMPACT
●
STUDENT E NROLLMENT Q UESTIONNAIRE
●
FORM A : H OME L ANGUAGE S URVEY F OR P REK12 S CHOOL D ISTRICTS
●
FORM C : T ITLE V I E D 5 06 I NDIAN S TUDENT E LIGIBILITY C ERTIFICATION F ORM
One o f e ach i s i ncluded i n t he f ollow f orm. For m ultiply s tudents ● The o ffice w ill p rovide f or y ou. ● You c an f ill o ut a dditional o nes a t http://www.heavenerschools.org/parentresources/returningstudentenrollmentforms
Heavener Public Schools Enrollment Form For Returning High School Student SCHOOL YEAR: 20172018
TODAY’S DATE : ____________
Student’s Full Name ( First, Middle and Last Name)
Entering Grade Level
☐ NO CHANGES TO A NY OF THE INFORMATION BELOW
Student(s) with NEW Medical Condition/Medication: ________________________________________________________ You M UST a lso f ill o ut t he a ppropriate f orm w ith t he S chool N urse.
Residency I nformation
Oklahoma State L egislature HB 1577 ( Effective July, 1 1997) L aw: $500.00 Penalty For T hose Providing False Residency I nformation To School.
Mailing Address:
STREET,Apt/Suite____________________________________CITY_________________STATE____ZIP______
Physical A ddress: (If different from mailing a ddress)
STREET,Apt/Suite:____________________________________CITY_________________STATE____ZIP______
Home Phone#: _____________________ Does your family live more than 1.5 miles from school? Yes ☐ No ☐ Transportation: How does your c hild(ren) get to a nd f rom school: ☐Walk ☐Car ☐Daycare ☐Bus#_____
Parent/Guardian I nformation Father/Male Guardian Living in the Home:_____________________________________ CELL #: ________________
Employer: ______________________ Work #:__________________Email:_______________________________
Mother/Female Guardian Living in the Home:___________________________________ CELL #: ________________
Employer: ______________________ Work #:__________________Email:_______________________________
Emergency C ontact I nformation : (Someone who will take responsibility for the student if the parent/guardian can not be reached.)
Contact #1 Name:_________________________________________Relation to Student:_____________________
Home #: __________________ Work#: __________________ Cell#: __________________
Contact #2 Name:_________________________________________Relation to Student:_____________________
Home #: __________________ Work#: __________________ Cell#: __________________
I Give the Following People Permission to take my c hild off school grounds:
Upon e nrollment of my child in Heavener Public School, I am giving my consent to ALL policies listed in the Student Handbook and certify that the above information is correct. I understand it is my responsibility to notify school officials of any changes in my legal residence and/or c ontact information.
Parent/Guardian Name (print): __________________________________________________________
Parent/Guardian Signature: __________________________________________________ Date: ___________________
ERate Program Heavener P ublic Schools p articipates i n the Erate program. This program is a Federal program which p rovides schools and l ibraries a cross t he c ountry w ith substantial discounts on t he c osts of t heir telephone service, internet service, internet a ccess, c omputer c onnections a nd m aintenance c osts. T he s ize o f this discounts is based on t he income l evel of our student’s families a nd e quates to s aving you, t he taxpayer, a s ubstantial a mount of money. Please, fill o ut t he survey. This information w ill remain c onfidential a nd will b e r eported only a s a total group, n ot by i ndividual f amilies, a nd will not be used for a ny purpose other than Erate. Head of Household Name: _ _____________________________________________________________ Family Mailing Address: STREET,Apt/Suite:_______________________________________CITY______________STATE____ZI P________ Circle the number of people in your household in the table below: Household Size*
Maximum I ncome Level ( Per Y ear)
Monthly
BiMonthly
Every 2 w eeks
Weekly
1
$21,978
$1,832
$916
$845
$423
2
$29,637
$2,470
$1,235
$1,140
$570
3
$37,296
$3,108
$1,554
$1,434
$717
4
$44,955
$3,746
$1,873
$1,729
$865
5
$52,614
$4,385
$2,192
$2,024
$1,012
6
$60,273
$5,023
$2,511
$2,318
$1,159
7
$67,950
$5,663
$2,831
$2,613
$1,307
8
$75,646
$6,304
$3,152
$2,909
$1,455
$7,696
$641
$321
$296
$148
For e ach a dditional m ember a dd:
Yes ⬜ No ⬜ Is your family’s income e qual to or less than a ny of the a mounts listed next to the number you c ircled? Yes ⬜ No ⬜ Are your c hildren e ligible for the NSLP (National School Lunch Program) which provides free or reduced lunches, breakfast, snacks or milk a t their school(s)? Yes ⬜ No ⬜ Is you family e ligible to receive food stamps?
Yes ⬜ No ⬜ Is you family e ligible for medical a ssistance under Medicaid?
Yes ⬜ No ⬜ Does y our family receive Temporary Assistance for Needy Families (TANF)? Yes ⬜ No ⬜ Does y our family receive Supplementary Security Income (SSI)? Yes ⬜ No ⬜ Does y our family receive housing a ssistance (section 8)?
Yes ⬜ No ⬜ Does y our family receive home e nergy a ssistance (LIHEAP)? If you answered YES to any of the preceding questions, please list the names of all school c hildren living in your home, including which school they attend. ( Attach a separate sheet if needed) Name of Child School Grade ____________________________ _______________________________ ______ ____________________________ _______________________________ ______ ____________________________ _______________________________ ______ ____________________________ _______________________________ ______ I certify that the above information is true and correct to the best of my knowledge:
Signature: _________________________________________
Date:_________________________
Heavener Public Schools Student Enrollment Questionnaire Student Name: Date of Birth:
Today’s Date: School:
Grade:
Your child may be eligible for additional educational services through Title X, Part C McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire. Where are you and your family currently living? Please check one of the boxes below. Section A ❑ Rent/own my own home or apartment STOP: If you checked the box that you rent/own your own home or apartment skip to the bottom of the page, sign the form, and then submit to school personnel. If you do not rent/own your own home or apartment, please continue to the next section. Section B ❑ Temporarily with another family member or friend until we can locate affordable housing ❑ In an emergency or transitional shelter ❑ In a vehicle, park, campground, or on the streets ❑ In a house, building, or trailer WITHOUT running water or electricity ❑ In a hotel or motel ❑ With an adult that is not a parent or legal guardian ❑ Alone or in different locations, without an adult serving as a caregiver ❑ Wherever I can find a place to stay at night ❑ Other Please Explain:
If you checked a box in section B, in the space below please list all children currently living with you who attend Heavener Public Schools. First and Last Name of Student
Male or Female
Date of Birth
Grade
School Name
Would you like to be contacted by an employee of the school to discuss additional educational services that may be available to your child? ❑YES ❑NO
The undersigned certifies that the information provided is correct and accurate. (Print) Parent/Guardian or Adult Caring for the Student: _____________________________________________ Relationship to the Student: _________________________ Signature: ___________________________________ _______________________________________________________________________________________________ Street Address City State Zip Phone Number: ________________________________ Email Address: __________________________________
FORM: A 17 18 20____20____
HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS STUDENT INFORMATION
Name of Student: ____________________________________________________________________ Last Name First Name Middle Name Date of Birth: __________________ MM/DD/YYYY
Grade:____________
School: _____________ Student ID # ___________________ Gender: Male_______ Female________
Is the student of Hispanic or Latino culture or origin? Yes________ No_________ Select one or more of the following races: ______ African American/Black ______ Native Hawaiian/Pacific Islander
______ American Indian/Alaskan Native ______ Caucasian/White
______ Asian
1.
What is the dominant language most often spoken by the student?
2.
What is the language routinely spoken in the home, regardless of the language spoken by the student?
3.
What language was first learned by the student?
4.
Does the parent/guardian need interpretation services? Yes _____ No _____ If so, what language? _______________________________
5.
Does the parent/guardian need translated materials? Yes _____ No _____ If so, what language?
6.
What was the date the student first enrolled in a school in the United States? ________________________ MM/YYYY
_______________________________
______________________________________________________________________________________________________________ Date (MM/DD/YYYY) Parent / Guardian Signature
SCHOOL USE ONLY Please have test score documentation available for the Regional Accreditation Officer to review. ☐ Other language than English indicated TWO OR MORE times on questions 1 – 3 above. The student is classified as “more often” and automatically qualifies as bilingual on the accreditation report. ☐ Other language than English indicated ONLY ONCE on questions 1 – 3 above. The student is classified as “less often” and only qualifies as bilingual on the accreditation report if he or she meets one of the following (any selection below REQUIRES appropriate documentation): ☐ 1. Designated English Learner on one of the Oklahoma English language proficiency assessments: ACCESS for ELLs 2.0, Alternate ACCESS for ELLs, WIDA Screener, WIDA MODEL, K-WAPT, W-APT or Oklahoma Pre-K Language Screening Tool. ☐ 2. Scored unsatisfactory or limited knowledge in Reading on the Oklahoma State Testing Program (OSTP). ☐ 3. Scored at or below the 35th percentile (or equivalent) composite reading score from spring of the previous school year on a state approved norm-referenced test (NRT). DOCUMENTATION OF A TEST RESULT FOR STUDENTS MARKED LESS OFTEN Date(s) of Kindergarten ACCESS, Score(s) on Kindergarten ACCESS, Date(s) of WIDA Screener or Score(s) on WIDA Screener or ACCESS for ELLs 2.0, or ACCESS for ELLs 2.0,or K-WAPT/WAPT or K-WAPT/WAPT or Alternate ACCESS Test Alternate ACCESS WIDA MODEL WIDA MODEL Composite Score Literacy Score Composite Score Literacy Score
Date(s) of Reading OSTP
Date(s) Norm Reference Test (NRT)
1.
2.
1.
2.
1.
Unsatisfactory
Score(s) on Reading OSTP Limited Knowledge Satisfactory
Advanced
Unsatisfactory
Limited Knowledge
Satisfactory
Advanced
Unsatisfactory
Limited Knowledge
Satisfactory
Advanced
Name of the NRT
Reading Total Composite Score(s) %
Date of the Oklahoma Pre-K Language Screening Tool
2.
Score on Pre-K Language Screening Tool
% From Above: Question 1: Reference WAVE code 1036 Question 2: Reference WAVE code 1037 Question 3: Reference WAVE code 1038
FORM: B Heavener Public Schools MIGRANT EDUCATION Family Work Status Survey HPS may qualify for special funding to help meet the educational needs of our students. To determine if we qualify, the information requested below is needed. Yes
No
Did your family move into this school district within the LAST THREE YEARS?
If YES, When? Year____________ Month______________ Day______ What city and state did you move from?_______________________________________
Yes
No Has any member of your family applied for work at a local meat processing plant? If YES, When? Year____________ Month______________ Day______
Yes
No When your family moved here, did any family member look for a job in our agriculture industry? If YES, Please check type of labor sought: ⬜ Farming ⬜ Food or Meat Processing ⬜ Ranching ⬜ Hauling Pulpwood ⬜ Fishing or Fishing Guiding ⬜ Production of Poultry, Swine, Cattle, Sheep, Hay ⬜ Clearing, Leveling, Watering or caring for land ⬜Others:_______________________________________________________________________
Name of all children in family from age 0-21 years Date of Birth
Parent/Guardian:
Address:
Birthplace
Gender Grade
Phone:
Parent/Guardian Signature: ___________________________________________________ Date: _____________________________
FORM: C
OMB Number: 1810-0021 Expiratin Date: 02/29/2020
FORM: D CHOCTAW NATION OF OKLAHOMA Johnson O’Malley Program
****FILL OUT ONLY IF YOUR FAMILY HAS A CDIB CARD**** SCHOOL DISTRICT: Heavener Public Schools
County: LeFlore
Head of Household Name:_________________________________________________________ 1.Tribe, Band or Group is: (check one) State Recognized? Yes⬜ No⬜ Federally Recognized? Yes⬜ No⬜ 2. Who is the CDIB card holder, if NOT t he child(ren): Name on Card:(Print)______________________________________________________ CDIB card holder:
Name of Student
1. 2. 3. 4. 5. 6. 7. 8. 9.
⬜ Child's Parent CDIB holder? Y/N
⬜Child's Grandparent
Date of Birth
Gender
Grade
Tribe
