2017-2018 Texas Education Data Standards Appendix 8.F – PEIMS Supplemental Information for Reporting Ethnicity and Race Data Reporting Final Version 2018.F.1.0
Exhibit 1A Student/Staff Ethnicity and Race Data Questionnaire in English Texas Education Agency Texas Public School Student/Staff Ethnicity and Race Data Questionnaire The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting. Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race. United States Federal Register (71 FR 44866) Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic/Latino Part 2. Race: What is the person’s race? (Choose one or more) American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment. Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Student/Staff Name (please print)
(Parent/Guardian)/(Staff) Signature
Student/Staff Identification Number
Date
This space reserved for Local school observer – upon completion and entering data in student software system, file this form in student’s permanent folder. Race – choose one or more: Ethnicity – choose only one: American Indian or Alaska Native Asian Hispanic / Latino Black or African American Native Hawaiian or Other Pacific Islander Not Hispanic/Latino White Observer signature:
Campus and Date: Texas Education Agency – March 2017 1
2017-2018 Texas Education Data Standards Appendix 8.F – PEIMS Supplemental Information for Reporting Ethnicity and Race Data Reporting Final Version 2018.F.1.0
Exhibit 1B Student/Staff Ethnicity and Race Data Questionnaire in Spanish Agencia de Educación de Texas Cuestionario de Información de Datos Raciales y de Etnicidad de Estudiantes/Miembros de Personal de las Escuelas Públicas de Texas El Departamento de Educación de Estados Unidos (USDE) requiere que todas las instituciones estatales y locales de educación, recopilen datos sobre etnicidad y raza de los estudiantes y de miembros de personal. Esta información es utilizada para los reportes estatales y federales así como para reportar a la Oficina de Derechos Civiles (OCR) y a la Comisión de Igualdad en el Empleo (EEOC). Al personal del distrito escolar y los padres o representante legal de estudiantes que deseen matricularse en la escuela, se le requiere proporcionar esta información. Si usted rehúsa proporcionarla, es importante que sepa que el USDE requiere que los distritos escolares usen la observación para identificación como último recurso para obtener estos datos utilizados para reportes federales. Favor de contestar ambas partes de las siguientes preguntas sobre la etnicidad y raza del estudiante así como del miembro de personal. Registro Federal de Estados Unidos (71 FR 44866). Parte 1. Etnicidad: ¿Es la persona Hispana/Latina? (Escoja solo una respuesta) Hispano/Latino – Una persona de origen cubano, mexicano, puertorriqueño, centro o sudamericano o de otra cultura u origen español, sin importar la raza. No Hispano/Latino Parte 2. Raza. ¿Cuál es la raza de la persona? (Escoja uno o más de uno) Indio Americano o Nativo de Alaska – Una persona con orígenes o de personas originarias de Norte y Sudamérica (incluyendo America Central), y que mantiene lazos o apego comunitario con una afiliación de alguna tribu. Asiático – Una persona con orígenes o de personas originarias del Lejano Este, Sureste de Asia o el subcontinente indio, incluyendo, por ejemplo a Cambodia, China, India, Japón, Corea, Malasia, Pakistán, las Islas Filipinas, Tailandia y Vietnam. Negro o Áfrico-Americano – Una persona con orígenes de cualquier grupo racial negro de África. Nativo de Hawai u otras islas del pacífico – Una persona con orígenes o de personas originarias de Hawai, Guam, Samoa u otras Islas del Pacífico. Blanco – Una persona con orígenes de personas originarias de Europa, el Medio Este o el Norte de África.
Nombre del Estudiante/Miembro de Personal (por favor use letra de imprenta)
Firma(Padre/Representante legal) /(Miembro de personal
Número de Identificación del Estudiante/Miembro del personal
Fecha
This space reserved for Local school observer – upon completion and entering data in student software system, file this form in student’s permanent folder. Ethnicity – choose only one: Race – choose one or more: Hispanic / Latino American Indian or Alaska Native Not Hispanic/Latino Asian Black or African American Native Hawaiian or Other Pacific Islander White Observer signature:
Campus and Date: Agencia de Educación de Texas – Marzo 2017 2
PREMONT INDEPENDENT SCHOOL DISTRICT Migrant Education Program 439 Southwest 4th Street Premont, TX 78375
2018-2019 (361)348-3915 ext. 2202
FAMILY SURVEY
Date:____________________ Dear Parents, In order to better serve your children, the Premont Independent School District would like to identify students who may qualify to receive additional educational services. The information provided below will be kept confidential. Please answer the following questions and return this survey form to your child’s school. Or, if you prefer, for more information, call: (361) 561-8615
Name of child____________________________________ Age______________ Grade________ 1. Have you moved within the last 3 years?
Yes______ No_______ 2. If yes, have you done agricultural or fishing related work since your move? (e.g., field work, canneries, lumbering, dairy work, meat processing) Yes______ No_______
If you answered “yes” to both of the questions above, an education representative may contact you to find out whether your child is eligible for additional educational services. Please provide the following information: Parent/Guardian Name: Address: Telephone Number:
Alternate Phone Number:
Email Address:
Best Time to Contact You:
Schools: Please return this survey to the Federal Programs Office, ATTN: Gloria Garcia
PREMONT INDEPENDENT SCHOOL DISTRICT Migrant Office 439 Southwest 4th Street Premont, TX 78375
2018-2019
(361)348-3915 ext. 2202
ENCUESTA DE FAMILIA
Fecha:___________________ Estimados padres, Para mejorar los servicios educativos de sus hijos, el distrito escolar de Premont quisiera identificar estudiantes que puedan calificar para recibir servicios educativos adicionales. Toda la información proporcionada será mantenida confidencial. Favor de responder a las siguientes preguntas y devolver esta forma a la escuela de su niño/a. O, si prefiere, para más información, llame a: (361) 561-8615
Nombre de su Niño/a: _____________________________Edad _________ Grado ________ 1. ¿Ha cambiado de residencia usted o alguien en su familia dentro de los últimos tres años? Sí______ No _______ 2. Si usted contesto “sí” en la pregunta anterior, ¿ha trabajado usted en la agricultura o en la pesca? (por ejemplo, la labor, fábrica de conservas, explotación de bosques, trabajo en la lechería, el proceso de carne) Sí______ No _______
Si usted contestó "Sí," en las dos preguntas anteriores, un representante del distrito escolar quizás se vaya a comunicar con usted para averiguar si su niño/a califica para servicios educativos adicionales. Favor de completar la siguiente información: Nombre del Padre/Guardián: Número de teléfono:
Número Alterno:
Dirección: Dirección de correo electrónico:
La mejor hora para localizarlo:
Schools: Please return this survey to the Federal Programs Office, ATTN: Gloria Garcia
Premont Independent School District HOME LANGUAGE SURVEY-19TAC Chapter 89, Subchapter BB §89.1215 TO BE COMPLETED BY PARENT OR GUARDIAN (OR STUDENT IF GRADES 9-12): The state of Texas requires that the following information be completed for each student that enrolls for the first time in Texas public schools. This survey shall be kept in each student’s permanent record folder. NAME OF STUDENT______________________________________STUDENT ID#________________ ADDRESS_____________________________________TELEPHONE #_________________________ CAMPUS__________________________________________________________________________ 1. What language is spoken in your home most of the time? _____________________________ 2. What language does your child (do you) speak most of the time? _______________________ ___________________________________ Signature of Parent/Guardian ___________________________________ Signature of Student if Grades 9-12
_____________________________ Date _____________________________ Date
-------------------------------------------------------------------------------------------------------------------------------------
Distrito escolar independiente de Premont Cuestionario del idioma que se habla en el hogar DEBE DE COMPLETARSE POR EL PADRE/MADRE/ O REPRESENTANTE LEGAL: (O POR EL ESTUDIANTE SI ESTA EN LOS GRADOS 9-12): El estado de Texas requiere que la siguiente información se complete para cada estudiante que se matricula por primera vez en una escuela pública de Texas. Este cuestionario se archivará en el expediente del estudiante. NOMBRE DEL ESTUDIANTE_____________________________________ #ID__________________ DIRECCION ____________________________________ TELEFONO__________________________ ESCUELA __________________________________________________________________________ 1. ¿Qué idioma se habla en su hogar la mayoría del tiempo? _____________________________ 2. ¿Qué idioma habla su hijo/a (usted) la mayoría del tiempo? ___________________________ _______________________________________ Firma del Padre/Madre/ o Representante Legal _______________________________________ Firma del estudiante si está en los grados 9-12
____________________________ Fecha _____________________________ Fecha
Premont ISD Special Education Department 2018-2019 school year New Student Enrollment
Student Name: ____________________ Grade: ___________
D.O.B.__________
Enrollment of a NEW student to: Premont Early College Academy (Pre-K – 5th Grade) Premont Collegiate High School (6th – 12th Grade) Has your child received special education services or 504 services at the previous school he/she was attending?
YES ---please list their disability/disabilities: Condition 1: __________________________________ Condition 2: _______________________________ Condition 3: _______________________________
NO ***** Parent / Guardian: If you selected yes that you child was receiving special
education or 504 services at a previous district please fill out and sign the next page (Notice of Release / Consent to Request Confidential Information). This will enable Premont ISD to obtain you child’s Special Education / 504 Records in a timely manner.
Office Information Only: If YES was selected by parent…please ensure that a copy of the enrollment/registration sheet, SPED form, and Notice of Release / Consent to Request Confidential Information sheet is submitted to Premont ISD SPED Department immediately.
Premont ISD
Notice of Release / Consent to Request Confidential Information Student ID
Student Name
Academic Year
Campus Enrolling In
2018-2019
Age
Premont Early College Academy
Explanation of Procedural Safeguards was provided Yes
Gender Grade
(Please Check Appropriate Box)
Premont Collegiate High School
Date Sent
Date of Birth
No
Method of Delivery Sent
Mailed
Given
E-mailed
We are asking that you authorize the disclosure of confidential information regarding your child. Information to be released by:___________________________ (Please put information from previous school district/school) Name of person / Agency: Address Line 1: Address Line 2: City/State/Zip: Phone Number ( ) -
(
To: Premont ISD Name of person / Agency: Ashley Cantu / Premont ISD Special Education Director Address Line 1: P.O. Box 530 Address Line 2: 439 S.W. 4th Street City/State/Zip: Premont, Tx 78375 Fax Number Phone Number
Fax Number ) -
(361) 348 - 3915 ext. 2015
Records to Be Released / Requested
(361) 348 - 4022
Purpose of Disclosure
1.) Academic Records (e.g., attendance, grades, Home Language Survey, state assessment information, etc.)
1.) Determine appropriate programming and placement
2.) Annual IEP, related notices, supplements, and subsequent Briefs and/or Amendments
3.) Assist in transition planning
2.) Update student information
3.) Full and Individual Evaluation / Psychological Evaluation 4.) Individualized Education Program Meeting (IEP) 5.) IEP goals, objectives, progress reports For more information, please contact
Phone Number
Email
Ashley Cantu
(361) 348 - 3915 ext 2015
[email protected]
Yes
No
I have been full informed and understand the school's request for my consent as described above. This information will be released upon receipt of my written consent.
Yes
No
I understand that my consent is voluntary and may be revoked in writing at any time.
Yes
No
I understand that I will be notified in writing of each release of educationally related information.
Your rights were explained to you when your child was initially referred for special education assessment. Federal requlations require that parents and adult students be provided a full explanation of all procedural safeguards in you Procedural Safeguards native language or other mode of communnication at least once a year. Please contact Ashley Cantu at (361) 348-3915 ext Statement 2015 if you have any questions or need names of other individuals to assist you in understanding this document. I understand that the individually identifiable health records disclosed persuant to this authorization form may include information relating to communicable diseases such as Human Immunodeficiency Virus (HIV) infection or Acquired Immunodeficiency Syndrome (AIDS); medical history; laboratory test results; treatment progress; treatment for or history of drug or alcohol abuse; or mental or behavioral health or psychiatric care.
Signature of Parent / Guardian / Surrogate Parent / Adult Student:
Signature Date
Please note: 1) Required only when a school district does not include in its policy a notice that education records are forwarded to other agencies or instituations that have requested the records and in which the student seeks or intends to enroll. 2 )The student's current and previous school districts are not required to obtain parental consent for release of information before requesting or sending the student's records if the disclosure is conducted in accordance with 34 CFR, 99.31 (a)(2) and 99.34.
Please return this form to: Ashley Cantu
Department: Special Education
Premont ISD
Notificacion de deivulgacion/consentimeiento para solicitar informacion confidencial N.o de identificacion
Nombre del estudiante
Edad
Ano escolar
Fecha de nacimiento Sexo Grado
Escuela
2018-2019
Premont Collegiate High School
Date Sent
Premont Early College Academy
Explanation of Procedural Safeguards was provided
Method of Delivery Correo Postal
Enviado Correo electronico Entregado Le estamos pidiendo que usted autorice la divulgacion del la informacion confidencial relacionada con __________ Si
No
La informacion sera divulgada por:___________________________ (Please put information from previous school district/school) Nobre del la Persona/Agencia: Lina 1 Domicilio: Lina 2 Domicilio: Ciudad/Estado/Codigo Postal: Telefono ( ) -
(
Para: Premont ISD Nobre del la Persona/Agencia: Ashley Cantu / Premont ISD Special Education Director Lina 1 Domicilio: P.O. Box 530 Lina 2 Domicilio: 439 S.W. 4th Street Ciudad/Estado/Codigo Postal: Premont, Tx 78375 Fax Number Telefono
Fax Number ) -
(361) 348 - 3915 ext. 2015
Expedientes que se daran a conocer
(361) 348 - 4022
Proposito de la divulgacion
1.) Academic Records (e.g., attendance, grades, Home Language Survey, state assessment information, etc.)
1.) Determine appropriate programming and placement
2.) Annual IEP, related notices, supplements, and subsequent Briefs and/or Amendments
3.) Assist in transition planning
2.) Update student information
3.) Full and Individual Evaluation / Psychological Evaluation 4.) Individualized Education Program Meeting (IEP) 5.) IEP goals, objectives, progress reports Para obtener informacion, pongase en contacto con:
Numero de telefono
Correo electronico
Ashley Cantu
(361) 348 - 3915 ext 2015
[email protected]
Yes
No
Se me ha informado plenamente y entiendo la solicitud de la escuela para obtener mi consentimiento sequn se describe anteriormente. La infromacion sera divulgada cuando se reciba mi consentimiento por escrito.
Yes
No
Entiendo que mi consentimiento es coluntario y puede ser revocado en cualquier momento pro escrito.
Yes
No
Entiendo que se me notificara por escrito cada vez que se divulgue informacion relacionada con la educacion.
Your rights were explained to you when your child was initially referred for special education assessment. Federal requlations require that parents and adult students be provided a full explanation of all procedural safeguards in you Procedural Safeguards native language or other mode of communnication at least once a year. Please contact Ashley Cantu at (361) 348-3915 ext Statement 2015 if you have any questions or need names of other individuals to assist you in understanding this document. Entiendo que los registros de salud de identificacion personal dados a conocer de acuerdo con este formulario de autorizacion pueden incluir informacion relacionada con enfermedades contagiosas como el virus de inmunodeficiencia humana (VIH) o sindromen de inmunodeficiencia adquirida (SIDA), la historia clinica, los resultados de analisis de laboratorio, el progreso del tratamiento, el tratamiento o antecedented de abuso de drogas o alchol, o la salud mental o de comportamiento o atencion psiquiatrica.
Firma del padre/tutor/estudiante adulto:
Fecha en que se firmo
Por favor tome en cuenta: 1) Solo es necesario cuando un distrito escolar no incluye en su politica una notificacion de que el expendiente academico se envia a otras agencias o instituciones que lo han solicitado y en las cuales el estudiante quiera o intente inscribirse. 2.) Los distritos escolares precios ye actuales del estudiante no tienen la onligacion de obtener el consentimiento del padre para divulgar informacion antes de solicitar o enviar el expediente del estudiante si la divulgacion se realiza de conformidad con 34 CFR 99,31 (2)(2) y 99,34.
Por favor regrese este formulario a: Ashley Cantu
Department: Special Education
Premont Independent School District Emergency & Health Data
Parent/Guardian: To serve your child in case of ACCIDENT OR SUDDEN ILLNESS It is necessary that you furnish the following information annually. 2018-2019 Student’s Name ____________________________Birth Date_____/_____/_____ Grade _________ A Med at School Form must be signed by the Dr. and both parents before the Nurse will administer medications at school. A Food Allergy Action Plan must be filed separately with the Nurse. Please designate the student’s Doctor in case an emergency arises. Doctor___________________________________PH#______________________________Address__________________________ List any Health/Medical conditions that the student may have:
Heart kidney Epilepsy Asthma
Does your child carry an inhaler
eye or ear problems low blood sugar or diabetes Severe allergies Other _________________________
yes
no
List any surgeries that the student may have had: 1. 2. 3.
Please list your child’s allergies: 1. 2. 3.
• • •
• • •
• •
Your child’s vision, hearing, weight, height, spine (visual assessment for abnormal curvature), and blood pressure will be screened in selected grades as required by law and school policy. I, do hereby authorize officials of PISD to contact the person(s) named on this form, and do authorize the physician listed to render such treatment necessary in the event of an emergency to the child. In the event that the physician, other person’s on this form, or parent cannot be contacted, the school officials (Principal or Appointed designee) are hereby authorized to take whatever action is necessary in their judgment, for the health of the child. I will not hold the school district financially responsible for the emergency care and or transportation for the said child. The undersigned, legal custodian of ________________________ a minor, hereby authorize the Principal or Appointed Designee into whose care the aforementioned minor pupil has been entrusted, to consent to any emergency x-rays, treatment, or hospital care. It is understood that this authority is given in advance of any required diagnosis, treatment or hospital care and provides power to the aforementioned agent to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist might deem necessary. The authorization is given for the full school year unless revoked in writing and delivered to said agents. Understand that PISD, its officers, and its employees assume no liability of any nature in relation to the transportation of the child.
Signature of Parent or Guardian____________________________________ Date ____________________
PREMONT INDEPENDENT SCHOOL DISTRICT P.O. Box 530 PREMONT, TEXAS 78375 (361)348-3915
REQUEST FOR MEDICAL-PROFESSIONAL RECORDS Dear Parent/Guardian: We feel that it is necessary to request information concerning your child’s medical/health history so that we may meet his/her needs in the school setting. Your signature on the following release form will give us your permission to request this information. _ Date
Principal’s Signature
REQUEST FOR RELEASE OF MEDICAL-PROFESSIONAL RECORDS I do hereby give my consent for the release and exchange of information contained in the Medical or professional record.
Child’s Name Name and Address of Professional to be contacted for information
Birth Date Information needed by School
Send information to School Contact
Telephone Number Date
Signature of Parent/Guardian Relationship to Child
Premont Independent School District P.O. Box 530 Premont, Texas 78375 Phone # (361)-348-3915 Ext.2003
Fax #(361)-348-2882
Name of Student: _______________________________________________ Birth Date ___/___/___ Age:____ Social Security #____________________ This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student maybe eligible to receive. 1. Is your address a temporary living arrangement? _____Yes _____No 2. Is this temporary living arrangement due to loss of housing or economic hardship? _____Yes _____No If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here.
Where is the student presently living? (Check one box) ____ In a motel ____ In a shelter ____Moving from place to place ____ With more than one family in a house or apartment ____ In a place not designed for ordinary sleeping accommodations such as a car, park, or Campsite. Name of Parent (s) Legal Guardian (s) ___________________________________________ Address________________________________ Zip_____________ Phone______________ Presenting a false record or falsifying is a offense under Section 37.10, Penal Code, and enrollment of the child under false documents subjects the person to liability For tuition or other costs. TEC Sec.25.002 (3) (d) Signature of Parent/Legal Guardian__________________________________ Date___________ Please send a copy to Premont ISD at the Central Office or Fax a copy to (361)348-2882
Distrito escolar independiente de Premont P.O. Box 530 Premont, Texas 78375
Teléfono # (361) - 348 - 3915 Ext.2003
Fax # (361)-348-2882
Nombre del estudiante: ________________________________________ Fecha de nacimiento ___ / ___ / ___ edad: _____________previsionales #_________________ Este cuestionario es destinada a cumplir con el acto de McKinney-Vento 42 U.S.C. 11435. Las respuestas a esta información de residencia ayudan a determinar los servicios al estudiante tal vez elegible para recibir.
1. Es su dirección en un arreglo de vivienda temporal? ___Si ___No 2. Es este arreglo de vivienda temporal debido a la pérdida de penurias económicas o vivienda? ___Si ___No Si usted contestó sí a las preguntas anteriores, por favor complete el resto de esta forma. Si su respuesta es NO, usted puede dejar aquí.
Dónde está actualmente viviendo el estudiante? (Marque una casilla) ___ En un motel ___ en un refugio ___Moving de sitio a otro ___ Con más de una familia en una casa o apartamento ___ En un lugar no diseñado para ordinario plazas como un coche, aparcar, o Camping. Nombre del padre (s) encargado (s) ___ Address________________________________ Zip_____________ Phone______________ Presentar un registro falso o la falsificación es una ofensa bajo la sección 37.10, Código Penal, y la inscripción del niño bajo documentos falsos somete a la persona a responsabilidad Por matrícula u otros costos. TEC Sec.25.002 (3) (d) Firma del padre/Legal Guardian______________________________Date________________ Por favor, envíe una copia a Premont ISD en la Oficina Central o Fax una copia a (361) 348-2882
Premont Independent School District Military Connected Student Form 2018-2019 PLEASE RETURN THIS FORM TO YOUR CHILD’S CAMPUS ONLY IF YOUR CHILD MEETS ONE OF THE CRITERIA BELOW In 2009 The Texas Legislature adopted the Interstate Compact on Educational Opportunity for Military Students – Texas Education Code Chapter 162. This legislation requires schools to recognize and extend certain privileges to students who are military dependents and to assist military dependent students in the transition process of changing schools when their military parents are reassigned and forced to relocate. Parent Name: Student Name:
Date of Birth:
Grade:
Campus:
Please check one box below to indicate if your child is a dependent of a member of: For all students: Active Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard [This includes Missing in Action (MIA)] Texas National Guard Reserve Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard For Pre-Kindergarten students ONLY: Armed forces or reserved forces of the United States (Army, Navy, Air Force, Marine Corps, or Coast Guard) or Texas National Guard who has been injured or killed while on active duty
PREMONT ISD 2018-2019 School/Parent/Student COMPACT Student Name ___________________________________ Grade___________ TEACHER/PRINCIPAL AGREEMENT It is important that all students achieve to their greatest potential . Therefore, we shall strive to do the following: • Communicate and work with families to support quality student learning. • Care about all students and their success. • Provide relevant assignments that are appropriate for students. • Provide an enjoyable, supportive, learning environment. • Maintain high expectations for all students, parents, and educators. Teacher’s Signature: ______________________________________________________ Principal’s Signature: _____________________________________________________
PARENT/GUARDIAN AGREEMENT I want my child to achieve to his/her greatest potential. Therefore, I shall strive to do the following: • Be actively involved in the education of my child including attending parent/teacher conferences • See that my child is punctual and attends school regularly, • Encourage my child’s efforts. • Provide uninterrupted time (without TV) for reading, homework, and other learning activities. • Support the school in its effort to maintain proper discipline. Parent’s/Guardian’s Signature: _______________________________________________
STUDENT AGREEMENT It is important that I get the best education possible. Therefore, I shall strive do the following: • Attend school regularly and on time. • Come to school each day with the necessary material for learning. • Follow school and classroom rules • Complete and return school assignments to the best ability. • Respect self, others, and community. Student’s Signature: ______________________________________________________
Field Trips for Premont ISD The students of PREMONT ISD will have the opportunity to go on a number of educational field trips during the year. As always, parental consent must be granted in order for your child to attend/participate. YES, I give permission for _______________________________ to attend field trips. Name
Grade
NO, I do not give permission for ___________________________ to attend field trips. Name
Grade
I understand and realize that the Premont Independent School District is not legally liable under Texas Laws for injuries of any nature at any time or any place to any person(s), pupils, teachers, other employees, or any other person whatsoever. Chaperone(s) for the conference, meeting, activity, will expect all students who are participating in the program/activity to give them their complete cooperation and to comply with all requests governing their conduct and activities. PARENT/GUARDIAN SIGNATURE
DATE
Phone Number: ___________________
Emergency Information In case of an emergency I give permission for my child to receive emergency medical treatment. In case of such emergency please contact:
PARENT/GUARDIAN SIGNATURE
DATE
______________________________ Emergency Contact Person
____________________ Phone Number
Computer Acceptable Usage and Chromebook Checkout Premont ISD 2018-2019 Acceptable Use Policy I agree to abide by the conditions set forth by Premont ISD. I understand that I am responsible for my actions while using the school network and while using the internet. I have read (copy available on the district website) and understand the Acceptable Use Policy. I realize that if I violate any part of the AUP, it may result in the suspension or revoking of my privileges. _____________________________ Please Print Student Name
________________________ Student Signature
Grade ____
_____________________________ Please Print Parent/Guardian Name
________________________ Parent/Guardian Signature
Date:______________
Permission for the Publication of Classroom Work/Pictures on School Webpages ____Yes, my child’s photo, artwork, projects etc. can be used online. ____No, my child’s photo, artwork, projects etc. cannot be used online. Students in grades 3rd through 12th have Google accounts for use with their Chromebooks. _____ Yes, I give my student permission to have a google account for educational purposes. _____ No, I do not give my student permission to have a google account for educational purposes. Premont ISD issues Chromebooks for Student Usage - For Grades 3 – 12 only I agree to abide by the conditions set forth by Premont ISD. I understand that I am responsible for my actions while using the school equipment and while using the internet. I have read (copy available on the district website) and understand the Premont ISD Chromebook Policy. _____ I agree to have my student check out a Chromebook device from Premont ISD and take responsibility for the any damages to the device. _____ I do not wish to have my student check out a device from Premont ISD. I understand that at times a computing device will be needed for class work. Damage Charges – Lost or Stolen Device $225, Broken Screen or Keyboard $40, Lost Charger $35. Premont ISD Asset Tag #________ Serial Number:_____________________
PREMONT INDEPENDENT SCHOOL DISTRICT
439 SW 4TH STREET, PREMONT, TX 78375 361-348-3915, FAX 361-348-2882 www.premotisd.net
STUDENT:
CAMPUS:
GRADE LEVEL: STUDENT:
CAMPUS:
GRADE LEVEL: STUDENT:
CAMPUS:
GRADE LEVEL:
HOUSEHOLD – INCOME VERIFICATION 2018-2019 The Household –Income information provided will assist the Premont ISD in completing audit requirements and reviews set forth by the Texas Education Agency. It is very important that we have the most accurate information about your child. All information will remain confidential.
PLEASE COMPLETE THE INFORMATION NEEDED BELOW. Please select the number of family members
Family Size Gross Income
Weekly$ Bi-Weekly$ Monthly$ Please check the program(s) that apply
Assistance Programs
__
TANF-Temporary Assistance to Needy Family __AFDC __Food Stamps __Other OFFICE USE ONLY
00-Not Identified Econ. Disadv.
99-Other Econ. Disadv.
Code Reference: PEIMS Standards Section 4 p4.116 I certify that all the information on this verification form is true and that all income is reported. I understand that the school will receive funds based on the information provided. I understand that I decline the disclosure of household income information. Parent/Guardian Signature:
Date
PREMONT INDEPENDENT SCHOOL DISTRICT TH
439 SW 4 STREET, PREMONT, Tx 78375 361-348-3915, FAX 361-348-2882 www.premontisd.net
Estudiante: ___________________________________________ Nivel de Grado: ___________
Escuela: ___________________
Estudiante: ___________________________________________ Nivel de Grado: ___________
Escuela: ___________________
Estudiante: ___________________________________________ Nivel de Grado: ___________
Escuela: ___________________
VERIFICACION DE INGRESOS 2018-2019 – HOGAR La información proporcionada -Ingresos del hogar ayudará a Premont ISD para completar los requisitos de auditoría yrevisión establecidos por la Agencia de Educación de Texas. Es muy importante que tengamos la información más precisa acerca de su hijo. Toda la información será confidencial.
COMPLETE LA INFORMACION NECESARIA ABAJO
Por favor, seleccione el número de miembros en la familia Tamaño de Familia Ingresos Brutos
Programas de Asistencia
___________________ Por Semana $ ________________ Quincenal $ ________________ Mensual $ ________________ Por favor, compruebe el programa (s) que se aplican ___ TANF – Asistencia Temporal para Familia Necesitados ___ AFDC ____ ESTAMPILLAS PARA COMIDA ____ OTRO
SÓLO USO DE OFICINA 00-Not Identified Econ. Disadv. Econ. Disadv.
99 – Other Econ. Disadv.
Código de Referencia: Sección de Normas PEIMS 4 p4.116 Certifico que toda la información en este formulario de verificación es verdadera y que he reportado todos los ingresos. Yo entiendo que la escuela recibirá fondos sobre la base de la información proporcionada. Yo entiendo que no acepta la divulgación de información sobre los ingresos de los hogares.
Firma de Padre / Guardián: ______________________________________________
Fecha: __________
