Student Enrollment Form

Fields marked with an * are required

I. Student Information

1. (Legal Name Only) Last Name *

First Name *

Middle Name *

Suffix (Jr, II, III)

2. Other Name(s) used previously (AKA):

3. Nickname:

4. Grade *

5. Birthdate: *

6. Birth Place (city, state) *

7. Is student a US Citizen? *

8. Is student Hispanic or latino? *

9. Gender: *

Male
Female

10. Languages Spoken at Home *

Student's Primary Language *

11. Previously Enrolled in a Montana School *

If Yes Above: Date:

12. Race (Check all that apply): *

White
Pacific Islander or Native Hawaiian
Black or African American
Asian
American Indian or Alaska Native

Tribal Affiliation:

13. Home Address (Street, City, State, Zip Code) *

14. Mailing Address (Street, City, State, Zip Code) *

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II. Parent & Emergency Contact Information

15. Parent/Guardian (Check all that apply) *

Custody
Lives with Student
School Pickup
Emergency Contact
Receive Mail

Last Name

First Name

Relation to Student *

Email Address *

Place of Employment *

Home Address (If different than Box 13) (Street, City, State, Zip Code)

Mailing Address (If different than Box 14) (Street, City, State, Zip Code)

Primary Phone Number *

Type of Phone *

Cell
Home
Work
Accepts Texts

Alternate Phone Number *

Type of Phone *

Cell
Home
Work
Accepts Texts

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16. Parent/Guardian Other (Check all that apply) *

Custody
Lives with Student
School Pickup
Emergency Contact
Receive Mail

Last Name

First Name

Relation to Student *

Email Address *

Place of Employment *

Home Address (If different than Box 13) (Street, City, State, Zip Code)

Mailing Address (If different than Box 14) (Street, City, State, Zip Code)

Primary Phone Number *

Type of Phone *

Cell
Home
Work
Accepts Texts

Alternate Phone Number *

Type of Phone *

Cell
Home
Work
Accepts Texts

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17. Local Emergency Contact (Other than Parent/Guardian)

First Name *

Last Name *

Relation to Student *

Primary Phone Number *

Type of Phone *

Cell
Home
Work
Accepts Texts

Alternate Phone Number *

Type of Phone *

Cell
Home
Work
Accepts Texts

Home Address (Street, City, State, Zip Code) *

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18. Additional Contact

Last Name *

First Name *

Relation to Student *

Primary Phone Number *

Type of Phone *

Cell
Home
Work

Alternate Phone Number *

Type of Phone *

Cell
Home
Work

Home Address (Street, City, State, Zip Code) *

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III. Media Consent

19. Occasionally the newspaper or television will visit our school to report on one of our programs. They may want to interview or photograph students involved in school activities. In order for your students to participate, we need your consent. May your student participate in media coverage of a school activity or program? *

20. Occasionally our staff takes photographs and/or videos of our students engaged in school activities and their learning process. We then post these videos to our school Facebook page and/or monthly newsletter. In order for your student to particpate in need your consent. May your student have his/her photo taken and/or posted to our school media sites? *

IV. Previous Schools

21. Last Elementary School (Name of School, City, State, Grades) *

22. Last Middle School (Name of School, City, State, Grades)

23. Any additional schools attended in the past year (Names of Each School, City, State, Grades)

Office Use Only: Records Requested _______________/______/___________ Records Received _______________/______/___________ Copy

V. Transportation

24. Transportation to and from school: *

Walk
Parent Drives
School Bus
Other (Explain Below)
Friend/Relative (Explain Below)
Daycare (Explain Below)

Explain "Other"

Explain "Friend/Relative" Provide Name, Relationship and Phone Number:

Explain "Daycare" Name of Daycare and Phone Number:

VI. Questions For Parents

25. Has student ever received service from or been involved in: (Check all that apply): *

No
Special Education
Title 1
Speech Therapy
Section 504
English 2nd Language
Behavior Management
Counseling
Gifted Program

Other (Please Explain):

26. Student Residency (Helps identify students who may qualify to receive additional services) Where does the Student Stay at Night? *

In a Home You own or Rent
Temporarily with another family in a house, mobile home or apartment
Other

If "Other" Please Specify:

27. Has the student immigrated to the United States (Check one): *

*If yes: date first enrolled in US School:

28. Has the student ever been under long term suspension or been suspended from school? (Check one)

29. Legal Bindings: Please list any legal binding information, including restraining orders, custody agreements that are pertinent to this student and his/her safety: (copy of legal documenation is required).

30. Is there any other information that would help us better serve your student?

31. Dependent of Active Duty Military Member: Is this student the dependent of an active military member? *

If so: Name of Military Member

Relationship of Military Member (check one):

The US Military (Army, Navy, Air Force, Marines, or Coast Guard
Active Duty National Guard
Active Duty Reserve Force of the US Military
Transitioning out of Active Duty to National Guard or Reserve

All information provided in sections I to V are complete and accurate to the best of my knowledge. *

Type Your Full Name for Your Signature (Parent or Guardian Signature Required) *

Date of Signature *

Health And Medical Information

Allergies to (Check all that apply): *

None (False)
Bee Sting
Food
Environment
Latex
Medication
Other
Needs Medications at School
Takes Medications at Home

Describe Reaction and Intervention:

List Other Allergies

Asthma: *

No (False)
Yes

I Yes, name of Asthma Medication(s):

Asthma Medication Administration Copy

Needs Asthma medication at school
Takes Asthma medication at home
Carries Asthman inhaler on person
Inhaler for Asthman in school office

Attention Deficit Disorder: *

No (False)
Yes

I Yes, name of Attention Deficit Medication(s):

Asthma Attention Deficit Medication Administration

Needs Attention Deficit Medication medication at school
Takes Attention Deficit Medication medication at home
Diagnosed with Attention Deficit but no medication

Diabetes *

No (False)
Yes

If Yes to Diabetes:

Insulin Dependent / Needs Shool Program Set Up
Self Manages Snacks, Diet, Testing, Coverage

Headaches *

No (False)
Yes

If Yes, Name of Headache Medication(s):

Seizures: *

No (False)
Yes

If Yes to Seizures, Name of Medication(s):

If Yes to Seizures:

Needs Seizure Medication at School
Takes Seizure Medication at Home
History of Seizure but Not Currently on Medication

Takes Other Medications *

No (False)
Yes

Other Medications at School

Needs Other Medications at School
Takes Other Medications at Home

Diagnosis for Other Medications

Name of Other Medication(s):

Hearing Concerns: *

No (False)
Yes

Hearing Concerns: (Please Explain)

Vision Concerns: *

No (False)
Yes

If Yes, Please Explain Vision Concerns:

Physical Restrictions: *

No (False)
Uses Mobilty Aide (Wheelchair, Walker, Crutches, etc.)
Restricted Because of Something Other (Desribe Below)
Must Avoid Certain Activities (Describe Below)

If Yes to Restricted Activities or Needs to Avoid Certain Activities, Please Explain. (Doctor's letter is required for some P.E. Adaptations).

Other: Describe Health History (Operations, Serious Accidents, and Serious Illness):

Diseases/Conditions: If Known, Please Indicate the Year of the Disease/Condition when Applicable (Check All That Apply): *

None
Chicken Pox
Measles (Rubella)
Mumps
Rubella (3 Day)
Scarlet Fever
Sinusitis
Eczema
Whooping Cough
Heart Disease
Rheumatic Fever
Kidney/Bladder Disorder
Congenital Condition

Hospital Sign Off: In Case of Emergency, I authorize Medical/Dental Care: *

Billings Clinic
St. Vincents
Either

Doctor's Name: *

Dentist's Name: *

Note: All items will require notification of the school nurse. If medication is needed, a parent must complete a medication authorization form before the first dose of medication can be given at the school. The health concern information may be shared with school personnel as necessary to benefit the health and safety of this student and others. Please keep school staff informed as to changes to the information so the student's records can be updated as needed. *

Yes, I Understand and Will Notify the School Nurse

All information provided in this Medical Section are complete and accurate to the best of my knowledge. *

Type Your Full Name for Yor Signature (Parent or Guardian Signature Required) *

Date of Signature *

State of Montana Immunization Registry

I give permission for RiverStone Health (Yellowstone County Health Department) to enter my child's vaccination information into the state Health Department's immunization registry. This information is available to health care providers to help prevent over and under-immunization and to develop one consolidated vaccine record for the child. *

Child's Name (First and Last) *

Parent Signature *

Date of Parent Signature *

Home Language Survey

Student's Full Name *

Student's Birth Date *

Sex (Check One): *

Female
Male

Parent/Gaurdian Name *

1. Was Your Child Born in the United States? *

If Yes, which State?

If No, What Other Country?

2. Has your child attended any school in the United States for any three years during their lifetime? *

If Yes, Please Provide the Name of School(s), State(s) and Date(s) Attended:

3. What language is spoken by you and your family most of the time at home? *

4. If available, in what language would you prefer to receive communication from the school?

5. Please check if your child is:

Native American Indian
Alaska Native
Native Pacific Islander
Native U.S. Virgin Islander

6. Is your child's first-learned or home language anything other than English? *

If you responded "Yes" to question number 6 above, please answer the following questions:

7. What language did your child learn when he/she first began to talk?

8. What langauge does your child most frequently speak at home?

9. What language do you most frequently speak to your child? *

Mother Uses Language: *

Father Uses Language: *

10. Please describe the language understood by your child (check only one): *

Understands only the home language and no English
Understands mostly the home language and some English
Understands the home language and English equally
Understands mostly English and some of the home language
Understands only English

Does The Student Have Any Siblings? *

If Yes, Please List All Below

If Yes, please list all brother(s)/sister(s) (List every sibling from baby to 18 years of age WITH their birth dates whether living at home or not). Enter First Name, Last Name, and Date of Birth.

Sibling: First Name, Last Name, and Date of Birth.

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Type Your Full Name for Your Signature (Parent or Guardian Signature Required) *

Date of Parent/Guardian Signature *

Office Use Only: Student ID# ____________________ Date Distributed _______________/______/___________ Records Received _______________/______/___________

Signature Form

Student's Full Name (First and Last) *

Grade *

Parents and Guardians, Thank you.

Parents and Guardians, Thank you for assisting us in reviewing the expectations of our school with your child. Our partnership with you makes for a great relationship when all of us are on the same page. This year, we have developed a sign-off sheet. While summaries are brief, this serves as a guide as you review the student handbook with your child and reflect with special emphasis on some of the issues and concerns that have occurred within our school. Again, we thank you for taking the time to review these important issues.

A. Pioneer Elementary Handbook

A. Pioneer Elementary School's Handbook (available online at www.pioneerschool.us)

Our goal at Pioneer Elementary School

Our goal at Pioneer Elementary School is to provide a safe and successful learning environment for your child. Research on effective schools states that when children feel safe at school they are productive and successful. Please take a few minutes to review the expectations, rights, and responsibilities as outlined in the student handbook so that you and your child understand the District's behavior expectations and consequences for failure to meet those expectations.

Student Initials: I Have Reviewed and Understand the Handbook *

Parent Initials: I Have Reviewed the Student Handbook with My Child *

B. Attendance

Frequent Absencenses

Frequent absencenses and tardies from the regular classroom disrupts the student's education. Montana attendance laws and Pioneer Elementary School policies place the responsibility of regular attendance on the student and the parent/guardian.

Student Initials: I Have Reviewed the Attendance Policy *

Parent Intitials: I have Reviewed and Understand the Attendance Policy *

C. Media Coverage

There may be times during the school year when different media groups or staff will cover curricular activities at Pioneer Elementary School with articles, video, or still photography that may be published. In addition, Pioneer may want to include school-oriented articles, blogs, video or photography in their own publications and/or web-site. I give permission for media coverage as stated. Parent/Guardian Initials: *

D. Technology Policy

Tech Policy Defined

Pioneer Elementary School's technology policy is designed to 1) meet the academic and technological needs of our students as they become knowledgeable and productive citizens while 2) educating students on the appropriate use of technology. Because the field is expanding at such a rapid rate, this policy has global implications involving electronic devices. When students use such devices inappropriately, there will be school and possible legal consequences. It is required that before any student be allowed to use any of the school devices that parentand child review and sign off on the Technology Policy.

Student Intitials: I have Reviewed and Understand the Technology Policy *

Parent Intitials: I have Reviewed and Understand the Technology Policy with My Child *

E. Hazing/Harrassment

E. Hazing/Harrassment/Intimidation/Bullying/Menacing Policy and Weapon Policy

Text

The Hazing/Harassment/Intimidation/Bullying/Menacing Policy and Weapon Policy, respectively, are designed to halt any repeated negative verbal or physical behavior between two or more people where there is a real or perceived imbalance of power, and any possession of a weapon, actual or assumed, that is used to threatened to be used. Students who are found to be in violation of these policies shall be subject to appropriate sanctions.

Student Initials: I Have Reviewed the Hazing/Harrassment/Intimidation/Bullying/Menacing Policy and Weapon Policy *

Parent Initials: I Have Reviewed the the Hazing/Harrassment/Intimidation/Bullying/Menacing Policy and Weapon Policy with My Child *

F. Hearing Screening

Dental and Hearing Screening

Dental and Hearing Screening is conducted at certain grade levels during the year. Parent/Guardian initials give consent for your child to have hearing and/or dental screening conducted during the 2019-2020 school year.

(Hearing) Parental Initials Indicate Parent Permission is Granted

G. Bus Pick-up/Drop Off

The Student Name Below has my Permission to get off the Pioneer School Bus at the designated Location. *

Name and Address of Person, Place, and Address Where Student Needs to Get Off the Bus *

My Student will need to Get Off the Bus at the Above Address: *

Every Day
Only On The Following Days:
Monday
Tuesday
Wednesday
Thursday
Friday

Parent Initials *

Please Contact the School With Changes

Please Contact the School Office if There are Any Changes to This Schedule

H. In Case of Emergency

In The Event Of Illness

In the event my child is injured or becomes seriously ill, I hereby delgate school personnel to take emergency action as they believe necessary.

In the event of early dismissal due to an emergency my child is to go: *

I Authorize School Personnel to Take Emergency Action. (Parent Initials). *

Final Signatures

Final Signatures for Sign-Off Form REQUIRED

Student Signature *

Student Signature Date *

Parent Signature *

Parent Signature Date *

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Home » Student Enrollment Form

I. Student Information

II. Parent & Emergency Contact Information

17. Local Emergency Contact (Other than Parent/Guardian)

18. Additional Contact

III. Media Consent

IV. Previous Schools

V. Transportation

VI. Questions For Parents

Health And Medical Information

State of Montana Immunization Registry

Home Language Survey

If Yes, please list all brother(s)/sister(s) (List every sibling from baby to 18 years of age WITH their birth dates whether living at home or not). Enter First Name, Last Name, and Date of Birth.

Signature Form

B. Attendance

C. Media Coverage

D. Technology Policy

E. Hazing/Harrassment/Intimidation/Bullying/Menacing Policy and Weapon Policy

F. Hearing Screening

H. In Case of Emergency

Final Signatures for Sign-Off Form REQUIRED

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November 13th, 2023 Board Meeting Minutes

December 11, 2023 Board Meeting Agenda

October 16, 2023 Board Meeting Minutes