www.wenatcheevalleytech.com
Programs Available
Please place “1” in the box beside your first choice and “2” beside the second choice.
*Current Tech Prep Articulation Agreement in place ** Dress Code required for this program
AM Class 8:10 to 10:50 PM Class 12:10 to 2:40
Equivalency Credits Available
Please place a check mark or an X in the box(s) under the equivalency credit title you would like to receive while you
are attending the class to its left.
Program Choices
AM
PM
Math 2Applied orGeometry
Technical
English Fine Arts American History Phys Ed
Technical or Lab Science
Automotive Technology
*See Dress Code**
Applied Math 20.5/SEM 0.5/year
-
-
-
0.5/yearCinematography & Production
-
0.5/SEM 0.5/year-
-
-Collision Repair Technology
*See Dress Code**
Applied Math 20.5/SEM
-
0.5/year-
-
-Computer Technology plus Robotics
*
NO PMSession
Applied Math 2
0.5/SEM 0.5/year
-
-
-
0.5/yearConstruction Trades
Applied Math 20.5/SEM
-
-
-
-
-Cosmetology
-
0.5/SEM-
-
-
-Criminal Justice/Police Science
*See Dress Code**-
-
-
0.5/year 0.5/year-Culinary Arts
*See Dress Code**
Applied Math 20.5/SEM 0.5/year 0.5/year
-
-
0.5/yearFire Science
NOW located at the TECH CENTER Applied Math 2 0.5/SEM-
-
-
0.5/year-Video Game Programming
*
NO AMSession
Geometry
0.5/SEM
-
0.5/year-
-
-Revised 1.20.18 by emc
Visit our website for further information on our courses: www.wenatcheevalleytech.com
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All of the Tech Center programs are preparatory in nature. They lead to industry certification, post secondary education and are designed to prepare students to enter the workforce. Classes are not designed as basic, introductory, or “life skills”. Each Tech Center class period is equivalent to 3-4 class periods at the sending high school. If students do not show adequate progress, have poor attendance and/or lack motivation, we reserve the right to re-evaluate placement, move students to a different program or direct them to work with their school counselor to reschedule classes at their home high school. The final and continued placement of each student attending WVTSC is at the discretion of the Dean of Students and/or the Director and the Tech Center.
Please enroll me in the course listed above at the Wenatchee Valley Technical Skills Center.
I understand that completing this application form does not guarantee that I will be admitted to Wenatchee Valley Technical Skills
Center. I authorize the release of any information from the student file at my home high school to the Wenatchee Valley Technical Skills Center as part of this application (including all IEP, medical, vaccination, discipline, food service, etc.)
Student Printed Name: _________________________________________________________
Student Signature:
Parent/Legal Guardian Signature: Date:
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Our classes are open to all high school students in North Central Washington**
Student Application 2018-19
WENATCHEE VALLEY TECHNICAL SKILLS CENTER
327 East Penny Road, Wenatchee, WA 98801, Phone 509.662.8827, Fax 509.662.5993
**Dress Code:
In some of the Tech Center programs, students are required to wear industry related attire at all times. Auto shop shirts will be available to purchase from us or online. Detailed information regarding this attire can be found on our website at www.wenatcheevalleytech.com or by contacting us at 509.662.8827. NB: Please let us know if the purchase of the required shirts would be a barrier for your student to attend the Tech Center.
For Your Information:
The Tech Center class listed on your home high school schedule does not guarantee that you are actually enrolled at the Tech Center. Please call 662-8827, before August 25, to ensure that you are actually registered to attend a class at WVTSC.EQUIVALENCY CREDITS:
These credits are not automatically included when you register for a Tech Center program…you must identify your desired equivalencies by checking the box adjacent to the program name.
**Serving families in:
Cascade School District
Cashmere School District
Eastmont School District
Entiat School District
Lake Chelan School District
Manson School District
Pateros School District
Quincy School District
Waterville School District
Wenatchee School District
TO BE COMPLETED BY SENDING HIGH SCHOOL COUNSELOR Previously attended WVTSC? YES NO (please circle one) Sending High School _____________________________________
Resident School District ___________________________________
Current Grade Level __________ Graduation Year ______________ Current GPA ________________ Credits Completed ____________
State Secure Student ID #: District Student ID#:
Is this student enrolled in I.E.P. Program?
(Circle One) Yes No
Is this student enrolled in 504 Plan?
(Circle One) Yes No
Is this student enrolled in E.L.L. Program?
(Circle One) Yes No
If Yes, please attach documentation: I.E.P. Voc Goals/Objectives, Behavior Plan, 504 Accommodations Plan, etc. Medical Alert (ie asthma inhaler, epipen, allergies, etc) YES NO (circle one)
Is this student required by court order to attend school? YES NO (circle one) If known, please provide name and contact for PO:
PO Name_________________________________________________________________________ Phone ________________________
Counselor/Case Manager Signature (Required)______________________________________________________________________ Counselor/Case Manager Name Printed Date:
Please use this checklist to ensure your
application is complete.
To be complete, your application package
must include:
1. Application Form - all four pages, which must be signed &
dated by your parent/guardian in four different places
highlighted in yellow, as well as your high school counselor.
2. Proof of your current immunization status, signed & dated by
parent/guardian -
blank forms enclosed, or ask your doctor for an
updated report…be sure to sign that report too.
3. A completed Health Form - blank form enclosed.
4. A completed Opt Out Student Info Form - blank enclosed.
5. A completed Housing Questionnaire - blank enclosed.
6. A completed Military Family Status Form - blank enclosed.
7. A completed WVTSC Transportation Form - blank enclosed.
Visit
www.wenatcheevalleytech.com
for more information
on all of our courses.
Transportation to the Tech Center is provided from Wenatchee High School, WestSide High School &
Eastmont High School. Wenatchee Valley Tech will provide free LINK bus passes to out-of-town students
upon request. For more information, please inquire at our main office…509.662.8827.
327 East Penny Road, Wenatchee, WA 98801 Phone: (509) 662.8827
2018-19 Program BELL Schedule
MORNING SESSION (Mon-Fri): Passing 7:55 to 8:10,
Class 8:10 to 10:50
, Passing 10:50 to 11:05
AFTERNOON SESSION (Mon-Fri): Passing 11:55 to 12:10,
Class 12:10 to 2:40
, Passing 2:40 to 2:55
Please contact your home high school to identify any potential scheduling conflicts.
The Tech Center follows the Wenatchee School District schedule.
We
DO NOT
have late start on Monday.
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NEW STUDENT REGISTRATION FORM
DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY
SCHOOL ENTRY DATE STUDENT SCHOOL NUMBER STUDENT DISTRICT NUMBER HEALTH ALERT FTE TEACHER
STUDENT NAME: Legal Last Name Legal First Name Legal Middle Name Also known as:
BIRTHDATE (Month/Day/Year)
GENDER (M/F) BIRTHPLACE: City State Country GRADE LEVEL
Number of months attended school outside of the U.S.? _______ Initial date of U.S. enrollment _______________
WHAT LANGUAGE DID YOUR CHILD FIRST LEARN TO SPEAK? (NATIVE LANGUAGE)__________________ WHAT LANGUAGE DOES YOUR CHILD USE MOST AT HOME? ___________________________
PRIMARY HOUSEHOLD (parent/guardian where student resides) Last Name First Name M.I.
STUDENT LIVES WITH ! Both parents ! Father only ! Mother only ! Grandparents ! Father/Stepmother ! Mother/Stepfather ! Stepfather/Stepmother ! Guardian ! Agency ! Self ! Other _________ PRIMARY HOUSEHOLD Home Phone #1 (include area code)
Please check if unlisted !
PHONE #2 (include area code) Work
PHONE #3 (include area code) Cell
PRIMARY HOUSEHOLD (2nd Adult where student resides)
Last Name First Name M.I.
PHONE #2 (2nd Adult)
Work
PHONE #3 (2nd Adult)
Cell parent/guardian email:
RESIDENT ADDRESS Street Apt # City State ZIP
MAILING ADDRESS (If different from above)
Street Apt # P O Box City State ZIP
SECOND HOUSEHOLD ( parent not residing with student) Last Name First Name M.I.
RELATIONSHIP ! Both parents ! Father only ! Mother only ! Grandparents ! Father/Stepmother ! Mother/Stepfather ! Stepfather/Stepmother ! Guardian ! Agency ! Self ! Other _________ SECOND HOUSEHOLD Home Phone #1 (include area code)
Please check if unlisted !
PHONE #2 (include area code) Work
PHONE #3 (include area code) Cell
SECOND HOUSEHOLD (2nd Adult)
Last Name First Name M.I.
PHONE #2 (2nd Adult)
Work
PHONE #3 (2nd Adult)
Cell parent/guardian Email:
SECOND HOUSEHOLD MAILING ADDRESS (Street/PO Box, City, State, ZIP) ADDITIONAL MAILINGS REQUESTED ! Yes ! No
Is your child of Hispanic or Latino origin? (Check all that apply.)
! NOT HISPANIC/LATINO ! DOMINICAN ! PUERTO RICAN ! CENTRAL AMERICAN ! SOUTH AMERICAN
! CUBAN ! SPANIARD ! LATIN AMERICAN ! OTHER HISPANIC/LATINO ! MEXICAN / MEXICAN AMERICAN/ CHICANO What race(s) do you consider your child? (Check all that apply.)
! AFRICAN AMERICAN/ BLACK ! WHITE ! ALASKA NATIVE ! NISQUALLY ! SPOKANE ! CHEHALIS ! NOOKSACK ! SQUAXIN ISLAND ! ASIAN INDIAN ! LAOTIAN ! NATIVE HAWAIIAN ! COLVILLE ! PORT GAMBLE KLALLAM ! STILLAGUAMISH ! CAMBODIAN ! MALAYSIAN ! FIJIAN ! COWLITZ ! PUYALLUP ! SUQUAMISH ! CHINESE ! PAKISTANI ! GUAMANIAN or CHAMORRO ! HOH ! OUILEUTE ! SWINOMISH ! FILIPINO ! SINGAPOREAN ! MARIANA ISLANDER ! JAMESTOWN ! OUINAULT ! TULALIP ! HMONG ! TAIWANESE ! MELANESIAN ! KALISPEL ! SAMISH ! UPPER SKAGIT ! INDONESIAN ! THAI ! MICRONESIAN ! LOWER ELWHA ! SAUK-SUIATTLE ! YAKIMA
! JAPANESE ! VIETNAMESE ! SAMOAN ! LUMMI ! SHOALWATER ! OTHER WASHINGTON INDIAN
! KOREAN ! OTHER ASIAN ! TONGAN ! MAKAH ! SKOKOMISH ! OTHER AMERICAN INDIAN/ALASKA NATIVE ! OTHER PACIFIC ISLANDER ! MUCKLESHOOT ! SNOQUALMIE
! Yes ! No Did guardian move to area to work or seek work in Agriculture, Fishing, or related Food Processing? HAS STUDENT EVER BEEN SUSPENDED?! Yes ! No Date: Reason/School:
IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? ! Yes ! No (If yes, plan must be on file with the school for enforcement) IS THERE A RESTRAINING ORDER IN EFFECT? ! Yes ! No (If yes, legal papers must be on file with the school for enforcement) Restraining order is against: ! Mother ! Father ! Other
HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL ED PROGRAM? ! Yes ! No HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN? ! Yes ! No HAS YOUR CHILD EVER PARTICPATED IN: ! Title ! LAP ! Gifted ! ESL ! Other _______________________
HAS YOUR CHILD EVER BEEN RETAINED? ! Yes ! No
If yes, at what grade level(s)____________________
VERIFICATION OF INFORMATION: The information on this form is true and accurate as of this date. I understand that
falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Wenatchee School District.
Legal Parent/Guardian Signature __________________________________________________ Date _____________________ Additional registration information on back…
03/02/2018
Please Type or Print Clearly
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Parent/Legal Guardian Signature: Date:
Parent/Legal Guardian Email Address:
DOES STUDENT ATTEND CHILD CARE?
! Before school ! After school ! Before and after school
CHILD CARE PROVIDER Name Address Phone Number
ADDITIONAL CHILD CARE ARRANGEMENTS (Please provide information to school in writing)
PLEASE LIST OTHER SIBLINGS ATTENDING WENATCHEE SCHOOL DISTRICT
Last Name First Name School Grade
EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to
contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for
my child.
Legal Parent/Guardian Signature ___________________________________________________ Date _____________________
When injury, illness or other non-emergency situations occur involving your child, we want to be able to quickly reach families or other
responsible adults. In the event we cannot reach a parent/guardian, please list persons you trust who are available during the day to
provide care for your child.
1ST EMERGENCY CONTACT (other than parent/guardian)
Last Name First Name M.I. RELATIONSHIP TO CHILD HOME PHONE (include area code) PHONE #2 (include area code) Work PHONE #3 (include area code) Cell
1ST EMERGENCY RESIDENT ADDRESS Street City, State ZIP
2ND
EMERGENCY CONTACT (other than parent/guardian)
Last Name First Name M.I. RELATIONSHIP TO CHILD HOME PHONE (include area code) PHONE #2 (include area code) Work PHONE #3 (include area code) Cell
2ND EMERGENCY RESIDENT ADDRESS Street City, State ZIP
STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/guardian, I authorize that my
child may be released to the person(s) listed above.
Legal Parent/Guardian Signature ________________________________________________
Date _____________________
SCHOOL PREVIOUSLY ATTENDED SCHOOL DISTRICT PREVIOUSLY ATTENDED PREVIOUS SCHOOL LOCATION (City and State)
HAS STUDENT EVER ATTENDED WENATCHEE SCHOOL DISTRICT? ! Yes ! No IF YES, NAME OF SCHOOL ATTENDED DATE ATTENDED (Month/Year)
DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY
BUS ROUTE
AM PM
DATE RECORDS REQUESTED SHARED STUDENT OTHER SCHOOL IMMUN ON FILE RES AREA BIRTH VER ROOM
The Wenatchee School District complies with all federal and state rules and regulations and does not discriminate on the basis of race, color, national origin, creed, sex, sexual orientation, including gender identity, disability, familial status, marital status or age. This holds true for all staff and for students who are interested in participating in educational programs and/or extracurricular school activities. Inquiries regarding compliance and/or grievance procedures may be directed to RCW Officer and ADA Coordinator Chet Harum. Issues related to 504 should be directed to the Administrator for Student and Support Services. Rev.0828/09
03/02/2018
radio friend HS counselor teacher/principal family member
site visit summer school presentation in the Mail Fast Furious Futures
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The Wenatchee School District complies with all federal and state rules and regulations and does not discriminate on the basis of sex, race, creed, religion, color, national origin, age, honorably discharged veteran or military status, sexual orientation including gender expression or identity, the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal by a person with a disability in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. This holds true for all staff and for students who are interested in participating in educational programs and/or extracurricular school activities. Inquiries may be directed to RCW Officer, Title IX and ADA Coordinator Lisa Turner. Issues related to 504 should be directed to Chet Harum, Executive Director of Student & Support Services.
Where did you hear about the Tech Center?
(check the box by all that apply)
Be sure to have the sending high school counselor complete page 2 of this form.
Parent/Legal Guardian Signature: Date:
Parent/Legal Guardian Signature: Date:
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Certificate of Immunization Status (CIS)
For Kindergarten-12th Grade / Child Care Entry
Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.
Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY):
Sex:
____________________________________________________________________________________________________________________________________________________
I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record.
______________________________________________________________
Parent/Guardian Signature Required Date
I certify that the information provided on this form is correct and verifiable.
______________________________________________________________
Parent/Guardian Signature Required Date ♦ Required for School and Child Care/Preschool Date
MM/DD/YY MM/DD/YY Date MM/DD/YY Date MM/DD/YY Date MM/DD/YY Date MM/DD/YY Date Documentation of Disease Immunity Healthcare provider use only
If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider
I certify that the child named on this CIS has: a verified history of Varicella (Chickenpox).
laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s)
for titers MUST also be attached. Diphtheria Mumps Other: Hepatitis A Polio __________ Hepatitis B Rubella __________
Hib Tetanus
Measles Varicella
Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP)
Printed Name
● Required Only for Child Care/Preschool
Required Vaccines for School or Child Care Entry ♦ DTaP, DT (Diphtheria, Tetanus, Pertussis)
♦ Tdap (Tetanus, Diphtheria, Pertussis) ♦ Td (Tetanus, Diphtheria)
♦ Hepatitis B
2-dose schedule used between ages 11-15 ● Hib ( Haemophilus influenzae type b) ♦ IPV / OPV (Polio)
♦ MMR (Measles, Mumps, Rubella) ● PCV / PPSV (Pneumococcal) ♦ Varicella (Chickenpox)
History of disease verified by IIS
Recommended Vaccines (Not Required for School or Child Care Entry) Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV, MPSV (Meningococcal) MenB (Meningococcal) Rotavirus
Office Use Only:
Reviewed by: Date: Signed Cert. of Exemption on file? Yes No
DOH 348-106 Jan 2015
Certificate of Exemption
PART 1: PARENT OR GUARDIAN INSTRUCTIONS
In order for this form to be valid for religious,
personal, philosophical, or medical reasons,
please:
Step 1: Fill in your child’s information in Boxes 1-4 Step 2: Read the Parent/Guardian Declaration Step 3: Provide your initials where indicated
Step 4: Print your name, sign, and date in Boxes 5-6 Step 5: Have a provider complete Part 2 of this form
1. Child’s Last Name
2. Child’s First Name and Middle Initial
3. Birthdate (mm/dd/yyyy)
4. Gender
I am the parent or legal guardian of the above
named child. One or more required vaccines
are in conflict with my personal, philosophical,
or religious beliefs.
Parent/Guardian Declaration
I understand that:
My child may not be allowed to attend school or
child care during an outbreak of the disease that my child has not been fully vaccinated against. ______ (initial)
Exempting my child from any or all required
vaccine(s) may result in serious illness, disability, or death to my child or others. I understand the risks and possible outcomes of my decision to exempt my child. ______ (initial)
The information provided on this form is
complete and correct. ______ (initial)
5. Print Parent/Guardian Name
6. Parent/Guardian Signature and Date
________
/
________/
____________________ /____ /____
FO R O FF IC E US E O N LY C H ILD ’S LA ST N A M E ___ ___ ___ ___ ___ ____ ___ ___ ____ __ ___ ___ ___ __ FIRST N A M E ___ ___ ___ ___ ___ ___ ____ ___ ___ ____ ___ ___ __ M .I. ___ ___ ___1RCW 28A.210.080-090 “Before or on the first day of every child’s attendance at any public and private school or licensed child care center in Washington State,
the parent or guardian must present proof of either: (1) full immunization, (2) the initiation of and compliance with a schedule of immunization, as required by rules of the State Board of Health, or (3) a certificate of exemption signed by a parent or guardian and is either A) signed by a licensed healthcare provider or B) demonstrates membership in a church or religious body that precludes healthcare practitioners from providing medical treatment to children.”
PART 2: HEALTHCARE PROVIDER INSTRUCTIONS
In order for this form to be valid, please:
Step 1: Mark which disease(s) and what type of
exemption is requested. If medical write a
T for Temporary or P for Permanent. Step 2: Discuss the benefits and risks of
immunizations with the parent or guardian
Step 3: Read the Provider Declaration
Step 4: Print your name, credentials, sign, and date
in Boxes 7-8
**A provider may grant a medical exemption only if there is a medical contraindication to a vaccine.
Provider Declaration
I declare that:
I have discussed the benefits and risks of
immunizations with the parent/legal guardian as a condition for exempting their child.
I am a qualified MD, ND, DO, ARNP or PA
licensed under Title 18 RCW.
The information provided on this form is complete
and correct.
7. Print Provider Name and Credential (MD, ND, DO, ARNP, PA) 8. Provider Signature and Date
Vaccine Philosophical Personal/ Religious
Expiration Date for Temporary Medical Medical (T/P)** Diphtheria Hepatitis B Hib Measles Mumps Pertussis Pneumococcal Polio Rubella Tetanus Varicella All
____ /____ /____
SIDE A:
For Religious, Personal, Philosophical, and Medical
Exemptions1
Male Female
I am the parent or legal guardian of the above named child and I am exempting my child from all
required vaccinations.
Parent/Guardian Declaration
I understand that:
My child may not be allowed to attend school or child care during an outbreak of the disease that my
child has not been fully vaccinated against. ______ (initial)
Exempting my child from all required vaccines may result in serious illness, disability, or death to my child or
others. I understand the risks and possible outcomes of my decision to exempt my child. ______ (initial)
The information provided on this form is complete and correct. ______ (initial)
Certificate of Exemption
NOTICE: Complete this side if you belong to a church or religion that objects to the use of
medical treatment.
1If you have a religious objection to vaccinations, but the beliefs or teachings of your church
or religion allow for your child to be treated by medical professionals such as doctors and
nurses, then you must use Side A of this Certificate of Exemption.
2. Child’s First Name and Middle Initial
1. Child’s Last Name
________
/
________/
________________3. Birthdate (mm/dd/yyyy)
4. Gender
PARENT OR GUARDIAN INSTRUCTIONS
In order for this form to be legally valid for religious membership reasons, please:
Step 1: Fill in your child’s information in Boxes 1-4
Step 2: Read the Parent/Guardian Declaration and provide your initials where indicated
Step 3: Provide the name of the church or religion of which you are a member, and print your
name, sign, and date in Boxes 5-7
FO R O FF IC E US E O N LY C H ILD ’S LA ST N A M E ___ ___ ___ ___ ___ ____ ___ ___ ____ __ ___ ___ ___ __ FIRST N A M E ___ ___ ___ ___ ___ ___ ____ ___ ___ ____ ___ ___ __ M .I. ___ ___ ___
5. Name of Church or Religion of Which You Are a Member 6. Print Parent/Guardian Name
I affirm that I am a member of a church or religion whose teachings preclude healthcare practitioners from providing any medical treatment to my child.
_____/_____/_____
7. Parent/Guardian Signature and Date
SIDE B:
For Religious Membership Exemption ONLY
M F
1RCW 28A.210.090 “The parent of legal guardian demonstrates membership in a religious body or a church in which the religious beliefs or teachings of
the church preclude a health care practitioner from providing medical treatment to the child.”
Certificado de Estado de Vacunación
Para asistir a la guardería, el preescolar y los grados escolares K – 12
Encuentre instrucciones al reverso para imprimir y llenar esta forma a mano con letra de molde o imprimirla con todos los datos desde Sistema Informático de Vacunación del estado de Washington.
Apellido/s del niño/a: Primer nombre: Inicial del otro nombre: Fecha de nacimiento (mes/día/año):
Sexo:
____________________________________________________________________________________________________________________________________________________
Le doy permiso a la escuela de compartir la información en el registro de
vacunación de mi hijo/a con el Sistema Informático de Vacunación del estado para ayudar a la escuela a mantener el registro de vacunación de mi hijo/a vigente. ______________________________________________________________
Firma requerida del padre, madre o tutor legal Fecha
Certifico que la información en esta forma es correcta y verificable.
______________________________________________________________
Firma requerida del padre, madre o tutor legal Fecha ♦ Requisito para guardería, preescolar y escuela Fecha
mes/día/año Fecha mes/día/año Fecha mes/día/año Fecha mes/día/año Fecha mes/día/año Fecha
mes/día/año Documentation of Disease Immunity Healthcare provider use only
If the child named in this form has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider.
I certify that the child named on this form has: a verified history of Varicella (Chickenpox).
laboratory evidence of immunity (titer) to Disease/s marked below. Lab report(s) for
titers MUST also be attached.
Diphtheria Mumps Other:
Hepatitis A Polio __________
Hepatitis B Rubella __________
Hib Tetanus
Measles Varicella
Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP)
Printed Name
● Requisito único para guardería y preescolar
Vacunas requeridas para la entrada a guardería, preescolar o escuela ♦ DTaP, DT (Difteria, Tétanos, Tos ferina)
♦ Tdap (Tétanos, Difteria, Tos ferina) ♦ Td (Tétanos, Difteria)
♦ Hepatitis B
2-dosis entre las edades de 11-15 años ● Hib (Haemophilus influenzae tipo b) ♦ IPV / OPV (Polio)
♦ MMR (Sarampión, Paperas, Rubéola) ● PCV / PPSV (Neumocócica)
♦ Varicela
Inmunidad verificada por el Sistema
Vacunas recomendadas pero no requeridas para la entrada a guardería, preescolar o escuela
Gripe (Influenza)
Hepatitis A
HPV (Virus del Papiloma Humano o VPH)
MCV, MPSV (Meningocócica)
MenB (Meningocócica)
Rotavirus
Office Use Only:
Reviewed by: Date: Signed Cert. of Exemption on file? Yes No
Para imprimir con todos los datos: pregunte en la oficina de su proveedor médico si ellos ingresan los antecedentes de vacunación en el Sistema Informático de Vacunación (base de datos estatal). Si le dicen que sí, pídales imprimir el Certificado de Estado de Vacunación desde el Sistema y así la información de su hijo/a será llenada automáticamente con todos los datos. Usted también puede imprimirlo desde la comodidad de su hogar, solo necesita visitar https://wa.myir.net y abrir una cuenta en MyIR. Si su médico no usa el Sistema,
comuníquese con el Departamento de Salud del estado por email: [email protected] o teléfono: 1-866-397-0337, para recibir una copia del Certificado de su hijo/a.
Para llenar esta forma a mano:
#1 En la primera página de esta forma, proporcione los datos de su hijo/a: nombre, fecha de nacimiento y sexo. Firme su nombre en la parte indicada.
#2 Información sobre vacunas: bajo cada una de las columnas, proporcione las fechas en que las vacunas fueron administradas de la siguiente forma: mes/día/año. Si su hijo/a recibió una vacuna en forma combinada (una inyección que protege contra varias enfermedades), use las guías de referencia de abajo para proporcionar la información correcta. Por ejemplo: escriba Pediarix bajo Difteria, Tétanos, Tos ferina como DTaP, Hepatitis B como Hep B, y Polio como IPV.
#3 Inmunidad a la varicela a causa de la enfermedad: si su hijo/a tuvo varicela y desarrolló inmunidad a la enfermedad sin haber recibido la vacuna, un proveedor médico debe dar testimonio o verificar dicha inmunidad para cumplir con el requisito escolar.
Si su proveedor médico puede verificar que su hijo/a tuvo varicela, pídale que firme y marque el cuadrito en la sección titulada “Documentation of Disease Immunity”. Si el personal escolar tiene acceso al Sistema y puede ver la sección que indica que su hijo/a tuvo inmunidad a la varicela, ellos pueden marcar el cuadrito bajo esa sección. #4 Documentación de inmunidad a diferentes enfermedades: Si se puede verificar por medio de un estudio de sangre que su hijo/a es inmune a varias enfermedades aunque no haya
sido vacunado, pídale a su proveedor médico que: marque los cuadritos correspondientes a esas enfermedades en la sección titulada “Documentation of Disease Immunity”, firme y ponga la fecha en la forma. Junto con esta forma usted debe proporcionar copias de los estudios de sangre que muestran que su hijo/a tiene inmunidad.
Guía de referencia para marcas comerciales de vacunas en orden alfabético
Marca comercial Vacuna Marca comercial Vacuna Marca comercial Vacuna Marca comercial Vacuna Marca comercial Vacuna
ActHIB® Hib Fluarix® Influenza Havrix® Hep A Menveo® Meningocócica Rotarix® Rotavirus (RV1)
Adacel® Tdap Flucelvax® Influenza Hiberix® Hib Pediarix® DTaP + Hep B +
IPV RotaTeq
® Rotavirus (RV5)
Afluria® Influenza FluLaval® Influenza HibTITER® Hib PedvaxHIB® Hib Tenivac® Td
Bexsero® MenB FluMist® Influenza Ipol® IPV Pentacel® DTaP + Hib + IPV Trumenba® MenB
Boostrix® Tdap Fluvirin® Influenza Infanrix® DTaP Pneumovax® PPSV Twinrix® Hep A + Hep B
Cervarix® 2vHPV Fluzone® Influenza Kinrix® DTaP + IPV Prevnar® PCV Vaqta® Hep A
Daptacel® DTaP Gardasil® 4vHPV Menactra® MCV o MCV4 ProQuad® MMR + Varicela Varivax® Varicela
Engerix-B® Hep B Gardasil® 9 9vHPV Menomune® MPSV4 Recombivax HB® Hep B
Si tiene alguna discapacidad y necesita este documento en otro formato, por favor llame al 1-800-525-0127 (servicio TDD/TTY, llame al 711). DOH 348-013 Spanish December 2016
Guía de referencia para abreviaciones de vacunas en orden alfabético
Abreviaciones Nombre completo
de la vacuna Abreviaciones Nombre completo de la vacuna Abreviaciones Nombre completo de la vacuna Abreviaciones Nombre completo de la vacuna Abreviaciones Nombre completo de la vacuna
DT Difteria, Tétanos Hep A Hepatitis A MCV / MCV4 Meningocócica
conjugada OPV
Vacuna oral contra
la polio Tdap
Difteria, Tétanos, Tos ferina
DTaP Difteria, Tétanos,
Tos ferina Hep B Hepatitis B MenB Meningocócica B
PCV / PCV7 / PCV13
Neumocócica
conjugada VAR / VZV Varicela
DTP Difteria, Tétanos,
Tos ferina Hib
Haemophilus influenzae tipo b MPSV / MPSV4 Meningocócica polisacárida PPSV / PPV23 Neumocócica polisacárida
Gripe (IIV) Influenza HPV (2vHPV /
4vHPV / 9vHPV)
Virus del papiloma
humano (VPH) MMR
Sarampión,
Paperas, Rubéola Rota (RV1 / RV5) Rotavirus
HBIG Inmunoglobulina de Hepatitis B IPV Vacuna inactivada contra la polio MMRV Sarampión, Paperas, Rubéola, Varicela Td Tétanos, Difteria
To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide database). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: [email protected] or 1-866-397-0337.
To fill out the form by hand:
#1 Print your child’s name, birthdate, sex, and sign your name where indicated on page one.
#2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.
#3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.
If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.
#4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.
Reference guide for vaccine trade tames in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf
Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine
ActHIB® Hib Fluarix® Flu Havrix® Hep A Menveo® Meningococcal Rotarix® Rotavirus (RV1)
Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® DTaP + Hep B +
IPV RotaTeq® Rotavirus (RV5)
Afluria® Flu FluLaval® Flu HibTITER® Hib PedvaxHIB® Hib Tenivac® Td
Bexsero® MenB FluMist® Flu Ipol® IPV Pentacel® DTaP + Hib + IPV Trumenba® MenB
Boostrix® Tdap Fluvirin® Flu Infanrix® DTaP Pneumovax® PPSV Twinrix® Hep A + Hep B
Cervarix® 2vHPV Fluzone® Flu Kinrix® DTaP + IPV Prevnar® PCV Vaqta® Hep A
Daptacel® DTaP Gardasil® 4vHPV Menactra® MCV or MCV4 ProQuad® MMR + Varicella Varivax® Varicella
Engerix-B® Hep B Gardasil® 9 9vHPV Menomune® MPSV4 Recombivax HB® Hep B
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 December 2016
Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name
DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 Meningococcal Conjugate Vaccine OPV Oral Poliovirus Vaccine Tdap Tetanus, Diphtheria, acellular Pertussis
DTaP Diphtheria, Tetanus, acellular
Pertussis Hep B Hepatitis B MenB Meningococcal B
PCV / PCV7 /
PCV13 Pneumococcal Conjugate Vaccine VAR / VZV Varicella DTP Diphtheria, Tetanus, Pertussis Hib Haemophilusinfluenzae type b MPSV / MPSV4 Meningococcal Polysaccharide
Vaccine PPSV / PPV23
Pneumococcal Polysaccharide Vaccine Flu (IIV) Influenza HPV (2vHPV / 4vHPV / 9vHPV) Human Papillomavirus MMR Measles, Mumps, Rubella Rota (RV1 / RV5) Rotavirus HBIG Hepatitis B Immune Globulin IPV Inactivated Poliovirus Vaccine MMRV Measles, Mumps, Rubella with
Varicella Td
Tetanus, Diphtheria
SN-11-13 Wenatchee School District #246 Student Health Information Form Entered____
Section 1 Health Conditions
Section 2 Life-Threatening Information
Section 3 Medication Information
Male Female
Legal Last Name of Student Legal First Name (Please circle) Grade Date of Birth
Please complete sections 1, 2, and 3, date and sign this form, and return to the school office. Please keep the school informed of changes in your child’s health or medication during the school year.
Please place an
on all health conditions which apply to your student.
My child has no known health problems
Please indicate below ALL CURRENT ACTIVE health conditions which
MAY IMPACT YOUR STUDENT AT SCHOOL:
Are any of the above checked conditions life-threatening?
Yes No
As parent/guardian, I agree to contact the school nurse to create an individualized health care plan for my child with a life threatening condition. State law requires all students with life threatening conditions to have both medical authorization and necessary medication at school before that student will be allowed to attend school. Medications that may be required under this law include, but are not limited to: meter-dose inhalers, Epi-pens, Insulin, and medication for seizures (per RCW 28A.210 Sec.1).
For school staff to administer or store any prescription or over-the-counter medication, an
Authorization for Medication Administration #SN-02 form (AMA) must be signed by a
parent/guardian and the physician, and must be on file in the school office. A new AMA form is required at the beginning of each school year, or whenever there has been a change in medication or dose. For students who carry and self-administer emergency rescue medications we strongly encourage parents to provide a backup rescue medication to store at the school office. A completed AMA form is required to store medications at school. The Authorization for Medication
Administration #SN-02 form is available at your child’s school, and the district’s Student Health Services webpage
Parents and guardians may wish to share information about medications their child may take while at home, which may influence how their child learns at school.
If you would like to share this information, please list any medications your child takes while at home:
Consent: I authorize and give my consent to the authorities of Wenatchee School District to obtain emergency medical treatment. I also authorize medical authorities to perform upon or administer necessary emergency medical or surgical treatment to the above named student. District authorities are not excused from attempting to contact me before relying upon this authorization. I also authorize that the information listed above may be shared with school personnel on a need-to-know basis to facilitate the school district in providing a safe environment for my child. If there are any health changes to the above listed
information, it will be the parent/guardian’s responsibility to inform the school on the yearly update student information form.
Signature of Parent/Guardian Relationship to Student __ Date__ _____
Allergies:
Bee / Insect sting: Please describe reaction:
(AB)
Foods: Please list foods and type of allergic reaction:
(AF)
Other significant allergies likely to
affect student at school: Please list
allergy and type of reaction:
(AO)
Epi Pen needed for allergy above (AEP)
Asthma (R)
Heart Condition (HC)
Activity Restrictions Yes No (HCR)
Seizures: (S)
Known hearing loss (H)
Wears glasses
Distance Reading
(Vg)
Diabetes (D)
Physical or birth defect (PBD) ADD/ADHD
Medication Yes No
(ADH) Other (Mental Health, Cancer, Autism, etc) (O)
SN-11-13-S Wenatchee School District #246 Student Health Information Form Entered____
Sección 1 Condiciones de Salud
Sección 2 Información que Amenaza la Vida
Sección 3 Información del Tratamiento
Masculino Femenino
Apellido Legal del Estudiante Nombre Legal (Por favor circule uno) Grado Fecha de
Nacimiento Por favor complete las secciones 1, 2, y 3, firme la forma y ponga la fecha, y regrésela a la oficina de la escuela. Por favor mantenga a la escuela infomada de cualquier cambio en la salud o tratamiento de su niño(a) durante el año escolar.
Por favor marque con una
todos los problemas de salud que aplican a su estudiante.
Mi hijo(a) no tiene problemas conocidos de salud
Por favor indicar abajo todas las condiciones actuales activos de salud que
pueden afectar a su estudiante en la escuela:
Alguno de los problemas antes marcados amenaza la vida? Si No
Como padre/guardián, Estoy de acuerdo en contactar a la enfermera de la escuela para crear un plan de salud individualizado para mi hijo(a) que tiene un problema de salud que amenaza su vida. La ley estatal require que todos los estudiantes que tengan un problema de salud que amenaza su vida tengan ambos una autorización médica y el medicamento necesario en la escuela antes que se le permita al estudiante asistir a la escuela. Los medicamentos que pueden ser requeridos bajo ésta ley incluyen, pero no se limitan a: inhaladores de dosis medida, Epi-pens, Insulina, y medicamentos para los ataques o crisis (por RCW 28A.210 Sec.1).
Para que el personal administre u almacene cualquer medicamento recetado o adquirido sin receta, el padre/guardián debe firmar una forma de Autorización para la Administración de Medicamentos
(AMA) #SN-02 y la información del doctor debe estar en el archivo en la oficina de la escuela. Se require
una nueva forma AMA al inicio de cada año escolar, o cuando ha habido cambios en la dosis del medicamento. A los estudiantes que llevan consigo medicamentos y ellos mismos se administrant los medicamentos de emergencia les recomendamos a los padres que provean los medicamantos para ser almacenados en la oficina de la escuela y ser usados en caso de emergencia. Se require completar una forma AMA para almacenar los medicamentos en la escuela. La forma de Autorización para la Admisnistración de Madicamentos #SN-02 está disponible en la escuela de su hijo(a), y en la página del internet del distrito bajo los Servicios de Salud del Estudiante.
Los padres y guardianes que deseen informar de medicamentos que su hijo(a) toma en casa, y que pueden interferir en el aprendizaje de su hijo(a) en la escuela. Si
les gustaría dar ésta información, por favor enliste cualquier medicamento que su hijo(a) toma en su casa:
Consentimiento: Yo autorizo y doy mi consentimiento a las autoridades del Distrito Escolar de Wenatchee para obtener tratamiento de emergencia. Yo también autorizo a las autoridades médicas que actuen o administren el tratamiento de emergencia o el tratamiento quirúrgico necesario al estudiante arriba mencionado. Las autoridades del Distrito no tienen excusa y deben intentar contactarme antes que dependan de ésta autorización.Yo también autorizo para que la información antes mencionada se comparta si es necesarios con el personal de la escuela para facilitar al distrito escolar proveer un ambiente seguro para mi niño(a). Si hay algún
cambio en la información de salud antes mencionada, es la responsabilidad del padre/guardián de informar a la escuela en la forma de información anual actualizada del estudiante.
Firma del Padre/Guardián Relación con el Estudiante __ Fecha________
Alergias:
Piquete de abeja/ Insecto: Por favor describa la reacción:
(AB)
Comidas: Por favor enliste las comidas y y el tipo de reacción alérgica:
(AF)
Otras alergias significativas que puedan afectar a los estudiantes en la escuela: Por favor enliste las alergias y el tipo de reacción:
(AO)
Epi Pen es necesario para la reacción antes mencionada (AEP) Asma (R) Condiciones Cardiacas: (HC) Actividad Restringida Si No (HCR) Ataques o Crisis: (S)
Pérdida de la audición conocida (H)
Tiene lentes
Distancia Lectura
(Vg)
Diabetes (D)
Defectos Físicos o de Nacimiento (PBD)
TDAH
Medicamento Si No
(ADH) Otros : (Salud Mental, Cancer, Autismo,
etc.)
1/31/17-BL
School Year:
WENATCHEE SCHOOL DISTRICT #246
DO NOT Release Directory Information Request
If you DO NOT want photos (including class picture, yearbook and newsletter) or student directory information released about your student please complete and return this form to the student’s school office within ten school days of this form being provided to you.
Directory Information: Directory information can be made public without the consent of parents/guardians or the
student, according to the Federal Family Educational Rights and Privacy Act (FERPA). Directory information is defined as the student's name, photograph, address, telephone number, date and place of birth, dates of attendance, participation in officially recognized activities and sports, weight and height of members of athletic teams, diplomas and awards received and the most recent previous school attended. Wenatchee School District will release directory information upon request to Law Enforcement and Child Protective Services without the consent of parents when the law requires it.
Directory information is primarily used in school (local) publications. Examples include:
• Annual yearbook; school or district newsletter; a playbill showing your student's role in a drama production • Graduation programs; honor roll or other recognition lists
• Sports activity sheets such as wrestling, showing weight and height of team members
uu
If you fail to return this completed form to the student’s school office
within ten school days, then directory information will be released.
uuHIGH SCHOOL ONLY ALL STUDENTS
***
Check only when you DO NOT want directory information released***
☐ Military ☐Higher Education ☐Community ☐District ☐School
Military Higher Education (College, Tech) Beyond School Families Broad Public Audience Internal Use Only School Families are the Primary Audience, but Accessible by General Public Examples include
but are not limited to… • Army • Air Force • Navy • Marines • Coast Guard Examples include but are not limited to…
• Colleges • Universities • Technical Schools • Trade Schools
Examples include but are not limited to…
• Newspapers & Other Media • Publications to General Public • Other Agencies' Websites or Publications • Child's Former Teachers Examples include but are not limited to…
• Signs/Posters in District Buildings • Videos used in
School/District
Examples include but are not limited to…
• Yearbooks • Rosters
• Programs/Sport Activity Sheets • Newsletters
• District Website, including social media sites
• Student Handbooks
• For Release to District/ School Selected Vendors & Event Planners like Photographers, Trip Organizers, Alumni Assn, etc.
Student Name: Grade:
School:
Signature of Parent/Guardian of Student (students who are 18 must sign request)
Date:
UPON COMPLETION OF THIS FORM, PLEASE RETURN IT TO YOUR STUDENT’S SCHOOL OFFICE
FOR OFFICE USE ONLY
8/17/15-BL
Año Escolar:
DISTRITO ESCOLAR DE WENATCHEE #246
Petición de NO Liberación de la Información del Directorio
Complete y regrese ésta forma solamente si usted NO quiere que se liberen fotos (incluyendo la fotografía de la clase, anuario y boletín informativo) o la información del directorio estudiantil de su estudiante para propósitos específicos.
Información del Directorio: La información del Directorio se puede hacer pública sin el consentimiento de los padres/tutores legales, de acuerdo
al Acta Federal de Privacidad y los Derechos Familiares Educacionales (FERPA). La Información del Directorio es definida como el nombre del estudiante, fotografía, domicilio, número de teléfono, fecha y lugar de nacimiento fechas de asistencia, participación en organizaciones y deportes reconocidos oficialmente, peso y estatura de los miembros del equipo deportivo, diplomas y reconocimientos recibidos y la escuela más reciente a la que asistió. El Distrito Escolar de Wenatchee liberará la información del directorio cuando lo requiera las Agencias del Orden Público y Los Servicios de Protección Infantil sin el consentimiento de los padres. El Distrito Escolar de Wenatchee no libera el directorio de información para uso comercial. Para información adicional vea la Póliza de la Mesa Directiva 3231.
El directorio de información se usa principalmente en las publicaciones escolares (local). Los ejemplos incluyen:
• Anuario; boletín informativo del distrito o de la escuela; en póster publicitario que muestra el rol de su estudiante en una producción de drama • Programas de graduación, listas de honor u otras listas de reconocimiento
• Hojas de actividad deportiva como lucha greco-romana, mostrando peso y estatura los miembros del equipo
!!
Si no hay documentación en el expediente, se asumirá que el permiso para
la liberación de la información del directorio ha sido concedido
.
!!SOLAMENTE ESCUELA PREPARATORIA TODOS LOS ESTUDIANTES
***Marque solamente cuando usted NO QUIERE que se libere la información del directorio***
☐ Militar Educación Superior Comunidad Distrito Escuela
Militar Educación Superior (Colegio, Técnico) Varias Audiencias Públicas Además de Familias de la Escuela
Solamente Uso Interno
Las Familias de la Escuela son la Audiencia Primaria, pero accesible al
Público en General
Ejemplos incluye pero no se limita a…
• Ejército • Fuerza Aérea • La Marina • Guardia Costera
Ejemplos incluye pero no se limita a…
• Colegios • Escuelas Técnicas • Escuelas de Oficios
Ejemplos incluye pero no se limita a… • Periódicos y otros Medios de Comunicación • Publicaciones para el Público en General • Otras Agencias, Sitios
de la Red Cibernética o Publicaciones • Maestros previos de
su hijo
Ejemplos incluye pero no se limita a… • Anuncios/pósters en las Instalaciones del Distrito • Uso de Videos en la Escuela/Distrito
Ejemplos incluye pero no se limita a… • Anuarios
• Listas
• Programas/Hojas de Actividad Deportiva
• Boletín Informativo para las familia de la Escuela
• Página del Internet del Distrito • Manuales para la Estudiantes • Para liberarse a comerciantes selectos
y Organizadores de Eventos como Fotógrafos, Organizadores de Viajes, Asociación de Alumnos, etc.
Nombre del Estudiante: Grado:
Escuela:
Firma del Padre/Tutor Legal del Estudiante (Los estudiantes que son 18 deben firmar la petición)
Fecha:
AL COMPLETAR ESTE FORMULARIO, POR FAVOR DE REGRESAR A LA OFICINA DE LA ESCUELA DE SU HIJO/A.
SÓLO PARA USO DE OFICINA
8/12/16-BL
Student Housing Questionnaire
McKinney-Vento Program
It is illegal to knowingly make false statements on this form
___
Disclaimer: This questionnaire is intended to address the McKinney-Vento Act. Student may be eligible for additional educational services through Title X, Part C, Federal McKinney-Vento Assistance Act 42, U.S.C. 11435.
The answers to the following questions can help determine the services this student may be
eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act
provides services and support for children and youth experiencing homelessness.
Name of parent/legal guardian (Print)
(or unaccompanied youth)
Signature of parent/legal guardian Date:
(or unaccompanied youth)
Please list all of your children currently living with you.
Student Legal Name School Grade Birth Date Age
First Middle Last Month/Day/Year
Student Legal Name School Grade Birth Date Age
First Middle Last Month/Day/Year
Student Legal Name School Grade Birth Date Age
First Middle Last Month/Day/Year
Student Legal Name School Grade Birth Date Age
First Middle Last Month/Day/Year
If you own or rent the place you now live, you do not need to complete this form.
Where is this student currently living? (check 1 box)
☐ Motel/Hotel name ☐ Emergency/transitional shelter - Bruce Hotel, Haven of Hope, SAGE (DSV) Shelter, Grace House, etc. ☐ Living with more than your own family in a house/apartment but your signature is not on the lease
☐ Moving from place to place in search of affordable and adequate housing due to an eviction notice or other reason
☐ Tenant/Based Rent Assistance (T-BRA-Community Action Council, Women’s Resource Center) ☐ In a location not designated for sleeping accommodations such as a car, park or campsite
☐ Substandard housing (problems with heat, electrical and/or plumbing, or lack of bathroom and/or kitchen facilities)
☐ Unaccompanied Youth ☐ Other (please explain):
Address of current residence:
Primary phone/message #: Name of message contact:
8/12/16-BL
Teléfono
Cuestionario de la Residencia del Estudiante
Programa McKinney-Vento
Es ilegal hacer declaraciones falsas conscientemente en ésta forma
____
Declaración: Se intenta con éste cuestionario tomar en cuenta el Acta McKinney-Vento. Los estudiantes pueden ser elegibles para servicios educativos adicionales a través del Título IX, Parte C, Acta 42 de Asistencia Federal McKinney-Vento, U.S.C. 11435.
La respuesta a las siguientes preguntas pueden ayudar a determinar los servicios que el estudiante
pueda ser elegible para recibir bajo el Acta McKenney-Vento 42 U.S.C.11435. El Acta
McKenney-Vento provee servicios y apoyo para los niños y jóvenes que están experimentando
indigencia.
Si es dueño o renta el lugar en el que vive ahora, no necesita completar esta forma
Dónde está actualmente viviendo el estudiante? (marque 1 cuadro)
☐ Motel/Nombre del Motel ☐ Albergue de Emergencia/transición - Bruce Hotel, Haven of Hope, SAGE (DSV) Shelter, Grace House, etc.
☐ Viviendo con alguien mas además de su familia en una casa/apartamento, pero su firma no esta en el contrato de renta
☐ Moviéndose de lugar en lugar en busca de una casa adecuada y económica debido a un aviso de desalojo u otro motivo.
☐ Asistencia de Renta/Huésped (T-BRA - Consejo de Acción Comunitaria, Centros de Recursos de la Mujer) ☐ En un sitio no asignado para dormir como un auto, parque o un campamento al aire libre
☐ Casa por abajo de los estándares de vivienda (problemas con la calefacción, eléctricos y/o plomería, o ausencia de baño y/o cocina)
☐
Juventud Sola
☐ Otro (Explique por favor):
Domicilio de la residencia actual:
# de teléfono principal /mensaje:
Nombre del contacto para mensaje:
Nombre del padre/tutor legal(Letra)
(o joven no acompañado)
Firma de guarda paternal/legal Fecha:
(o joven no acompañado)
Por favor enliste todos sus hijos que están viviendo actualmente con usted.
Nombre Legal Escuela Grado Fecha de Nacimiento Edad
Primero Medio Último Mes/Día/Año
Nombre Legal Escuela Grado Fecha de Nacimiento Edad
Primero Medio Último Mes/Día/Año
Nombre Legal Escuela Grado Fecha de Nacimiento Edad
Primero Medio Último Mes/Día/Año
Nombre Legal Escuela Grado Fecha de Nacimiento Edad
3/7/18-BL
MILITARY FAMILY STATUS
Please check the box by the letter that applies to your family:
(A) US Armed Forces Active Duty
(G) National Guard Member
(M) More than one member of Armed Forces/National Guard
(N) No affiliation
(R) US Armed Forces Reserves
(F) *Former Military / Branch
Student Name
Grade
Date
Parent Name
Date
Parent/Guardian Signature
Date
3/7/18-BL
MILITARES DENTRO DE LA FAMILIA
Por favor marque el cuadro adjunto a la letra que aplica a su familia:
☐
(A) Servicio Activo de Fuerzas Armadas Estadounidense
☐
(G) Miembro de Guardia Nacional
☐
(M) Más de un miembro en las Fuerzas Armadas/Guardia Nacional
☐
(N) Ninguna afiliación
☐
(R) Reserva de las Fuerzas Armadas Estadounidenses
☐
(F) *Fuerza Militar / Anterior
Nombre del estudiante
Grado
Fecha
Nombre del padre
Fecha
Firma de Padre/Tutor Legal
Fecha
October 31, 2016
Dear Parents/Guardians:
We appreciate the opportunity to work with your student. Due to the uniqueness of the
Wenatchee Valley Tech Center, we want to pass on information regarding transportation to and
from your student’s home high school. Currently, for students whose home high school is
Wenatchee High School or Eastmont High School, we have school buses that provide
transportation. For other schools, we are able to provide Link Transit Bus Passes so that the
students may utilize public bus transportation.
The Wenatchee Valley Tech Center strongly encourages students to use the provided
bus transportation. However, it has come to our attention that some students do not use the
provided bus transportation.
The Wenatchee School District (“District”) does not authorize the use of private
transportation to transport students to or from their home high school. The District is unable and
has no duty to supervise a student when the student uses private transportation, and the District
has no control over the private transportation. As a result, please sign this form and return it to
the Wenatchee Valley Tech Center at your earliest convenience.
By signing this form, the undersigned agrees to indemnify and hold the District, their
officers, employees, volunteers, and agents harmless from all losses, costs, damage, injury,
liability, claims and causes of action whatsoever, arising out of or related to their student’s use of
private transportation to and from the student’s home high school and the Wenatchee Valley
Technical Skills Center.
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Parent/Guardian Printed Name Student name attending Wenatchee Valley Tech
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Parent/Guardian Signature
Date
If you have questions please contact us:
509-662-8827
327 East Penny Road, Wenatchee, WA 98801
OUR MISSION:
• To provide industry standard technical training and employability skills.
• To personally assist students in a pathway to successful career opportunities and/or postsecondary education. • To commit our professional efforts to the success of students.
OUR VISION:
Wenatchee Valley Tech is a school providing career and technical education. Students and staff are equipped with current industry standard tools, technology and physical space. Our programs offer a class schedule and size that provides an environment enabling students to focus on their chosen career and/or technical field while completing academic requirements. Motivated, ambitious students can experience a nurturing and challenging education, beginning with core competencies and progressing to an industry setting. Opportunities are available to receive industry certification and college articulation credit.
