1. All new students entering Indianola Community School District must provide the proper
documentation to establish residency. The documents provided must always state the
student’s current physical address. A post office box is not an acceptable address
for the purpose of determining residency. If you do not know whether your residence is
within the Indianola Community School District, contact the Student Information
Management Assistant at 515.961.9500 or go to the Warren County Assessor site:
http://beacon.schneidercorp.com/?site=WarrenCountyIA.
You must provide proof of residency in order to enroll your child. Please submit a copy
of one of the following documents listing custodial parents’ current address:






Printed Verification Page from Assessor’s Web Page
Mortgage or Current Property Tax Document
Lease Agreement with Term listed
Settlement Statement or Warranty Deed from Closing on New Home
Purchase Contract with Possession/Closing Date
Current Utility Bill or Utility Deposit Receipt
2. Complete one of the following packets per child:
o
o
o
o
o
Purple and Gold Early Childhood Program (Early Childhood Special
Education or Preschool)
Kindergarten
Elementary (Grades 1-5)
Middle School (Grades 6-8)
High School (Grades 9-12)
3. You will need your child’s up-to-date immunization record, dental screening, lead
screening (preschool and kindergarten only) and proof of birth; i.e., a birth certificate.
*** It is the parents’ legal requirement to provide an up-to-date immunization record or
appropriate waiver for their child before their child can attend Indianola Schools. ***
4. Pay school fees or complete a fee waiver and free/reduced lunch application.
5. Bring any special needs documents if applicable. (Examples: Individualized Education
Plan (IEP), 504 Plan, Gifted and Talented/Enrichment Plan, Individualized Health Plan
(IHP), etc.)
6. Name, address and phone number of your child(ren)’s previous school.
Once you have gathered and completed the requirements above, please call
515.961.9500, Extension 1506, or email julie.ormsby@indianola.k12.ia.us to set up an
appointment with the Student Information Management Assistant. You must have all of the
documents with you before we can enroll your child(ren) in the Indianola Community
School District.
Office Use Only
Elementary Assignment
Local ID #
State ID #
Immunization: Y N
Today’s Date
Start Date
Start Code
Records Requested
Proof of Birth:
Y N
BC #
Dental: Y N
Elementary (Grades 1st -5th) Calendar Choice:
Traditional
Lead (K only):
Year Round Education (YRE)
Student’s Legal Name
Gender
Last Name
First Name
Y N
M
F
Middle
Nickname (to be used in the classroom)
Birth Date
Grade 2016-17
Birthplace
Date Entered US
City
State
Country (IF NOT USA)
(If not born in US)
Month
Day
Year
State
Zip
Primary Student Address and Phone
Address
Apt/Lot #
Home Phone (
City
)
Residency Verification: The residency information provided on this form is true and accurate as of this date. I understand that
falsification of an address or the use of any other fraudulent means to achieve an enrollment or assignment shall be cause for
revocation of the student’s enrollment and assignment to the school serving the home attendance area.
Signature of Parent/Guardian
Date
Parent/Guardian Residing with Student
Parent
Step-Parent
Name (first, middle, last)
Foster Parent
Other
Work Phone (
)
Cell Phone (
)
Email Address
Parent
Spouse of Parent/Guardian Residing with Student
Relationship
to Student
Name (first, middle, last)
Step-Parent
Fiancé(eé) of Parent
Other
Work Phone (
)
Cell Phone (
)
Email Address
ICSD (02.17.16)
H:/Registration/Elementary Student Registration
_____
1
Is there a Parent/Guardian Not Residing with Student (Non-Custodial Parent, etc.)? If yes,
Name
Relationship to Student
Home Phone (
)
Cell Phone (
Work Phone (
)
Spouse Name
)
Address
Email Address
Should school mailings be sent to this household also?
Yes
No
Yes
No
Former School Information
Did this student attend Indianola Community Schools last year?
Please list the last school attended (other than Indianola):
School Name
(
Address
City/State/Zip
County
Has this student ever attended Indianola schools before?
)
Phone Number
Yes
No
Year
Emergency Contact (someone not listed on the front in case you can’t be reached)
Name
Relationship to Student
Home Phone (
)
Work Phone (
)
Cell Phone (
)
Child Care Provider or Afterschool Program
Name
Work Phone (
Home Phone (
)
Cell Phone (
)
)
Household Information
School-Age Siblings
Grade/Age
Does this student qualify for special services;
i.e., Gifted and Talented, 504 Plan, ELL, Title I?
School-Age Siblings
Yes
If yes, please explain
Grade/Age
No
Does this student receive Special Education services and have an Individualized Education Plan
(IEP)?
If yes, please explain
Signature of Parent/Guardian
ICSD (02.17.16)
H:/Registration/Elementary Student Registration
Date
_____
2
Indianola Community School District
HOME LANGUAGE SURVEY
Student Name: ____________________________________________ Birth Date: ___________________ Sex: ❏ Male
❏ Female
Parent/Guardian Name: ________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Home Telephone: __________________________________________ Work Telephone: ____________________________________
School: __________________________________________________ Grade: ______________________ Date: ________________
1.
2.
❏
Was your child born in the United States?
Yes
❏ No
If yes, in which state?
___________________________________
If no, in what other country?
___________________________________
Has your child attended any school in the United States
for any three years during their lifetime?
❏
If yes, please provide school name(s), state, and dates attended:
Name of School ____________________________________________
Name of School ____________________________________________
Name of School ____________________________________________
Yes
❏ No
State ________ Dates Attended________________
State ________ Dates Attended________________
State ________ Dates Attended________________
3.
What language is spoken by you and your family most of the time at home?
___________________________________
4.
If available, in what language would you prefer to receive
communication from the school?
___________________________________
5.
Is your child’s first-learned or home language anything other than English?
❏
Yes
❏ No
If you responded “Yes” to question number 5 above, please answer the following questions:
6.
What language did your child learn when he/she first began to talk?
___________________________________
7.
What language does your child most frequently speak at home?
___________________________________
8.
What language do you most frequently speak to your child?
(Father) ___________________________________
(Mother) ___________________________________
9.
Please describe the language understood by your child. (Check only one)
A. ❏
Understands only the home language and no English.
B. ❏
Understands mostly the home language and some English.
C. ❏
Understands the home language and English equally.
D. ❏
Understands mostly English and some of the home language.
E. ❏
Understands only English.
______________________________________________
Parent or Guardian's Signature
___________________________________
Date
OFFICE USE ONLY
Student ID #
Date Distributed
00NCLB-B1 (Rev. 04/13 - IA)
Date Received
© 2013 TransACT Communications, Inc.
253324
Indianola Community School District
Student Race and Ethnicity Reporting
Student Name: _____________________________________________ Date Form Completed: ___________________
Date of Birth: ______________________________________________ ❏ Male
Person Completing This Form:
❏
Parent/Guardian
❏
Student
❏
❏
Female
Other: __________________________
The U.S. Department of Education has implemented new standards for school districts to report student race and ethnicity.
Your answers to the following will be held strictly confidential and data will be used only in the aggregate.
1.
Is your child of Hispanic, Latino, or Spanish ethnicity:
❏ Yes
❏ No
Includes persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin.
If you answered “Yes” to question #1, you may also check one or more of the racial categories in question #2. If you
answered “No”, please check one or more of the following racial categories.
2. Racial Categories:
❏
American Indian or Alaska Native
Origins in any of the original peoples of North, Central, and South America who maintain a tribal
affiliation or community attachment.
❏
Asian
Origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent for
example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and
Vietnam.
❏
Black or African American
Origins in any of the black racial groups of Africa
❏
Native Hawaiian or Other Pacific Islander
Origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
❏
White
Origins in any of the original peoples of Europe, the Middle East, or North Africa.
Please complete the entire form and return it to:
Indianola Community Schools
515.961.9500
Name: __________________________________________________________
Phone Number: __________________
1304 East 2nd Avenue
Indianola
IA
50125
Address: ____________________________________
City: _______________
State: _____________
Zip: ________
00NCLB-B1 (04/13 - IA)
© 2013 TransACT Communications, Inc.
253324
Confidential
Student’s Name
Physician
Date of Birth
Gender
Grade
Physician’s Phone Number
Does the student have:
No
Yes
Dentist
Hospital Preference
Please explain “yes” answers
ADD/ADHD (please specify)
Allergies (food, environmental, medication)
Asthma/Reactive Airway Disease
Bone, joint, muscle concerns
Bowel problems
Has your child ever had a concussion? If
so, when (give ALL incidents)
Congenital birth defects
Depression
Diabetes
Emotional/Mental Health concerns
Glasses/contacts
Hearing aid(s)/concerns
Heart condition
Hepatitis
Herpes (cold sores)
Medical procedures needed at school
Medications to be given at school
For all medications given at school, please
complete the enclosed Request for Giving
Prescription and Nonprescription Medication at
School form.
Medications given at home (include name,
time needed, dosage and reason)
Migraines/headaches
Problems that would restrict PE involvement
Seizures/neurological disorder
Skin conditions
Speech concerns
Urinary problems
Other
Has your 7th grader received the
required Tdap immunization?
Date:
_____
H:/Registration/Student Health Update
(04.18.16)
1
No
Yes
Is the student covered by insurance:
Private Health Insurance
Type:
Title 19
Hawk-I Insurance
Dental Insurance
Has your child had the following health
intervention within the past 6 months?
Physical Exam
Date and Results:
Dental Exam
Date and Results:
Vision Exam
Date and Results:
TB Skin Test
Date and Results:
Hearing Test (not done at school)
Date and Results:
Emergency Room Visit
Date and Results:
Hospitalization
Date and Describe:
Surgery
Date and Describe:
Counseling
Date and Describe:
Has your child recently had a tetanus
shot?
Date:
Note to parents: Health information is shared with school staff having legitimate educational interest regarding
the student.
Parent/Guardian Signature
Date
Parent/Guardian Phone Number
The Indianola Community Schools believe that when children are healthy they are more competent in
their learning skills and more proficient in meeting their educational goals. If you DO NOT want your
child to receive any health screenings such as vision, dental and/or hearing, please provide your
refusal in writing to the health office at your child’s school.
Mental Health Screening Release
The Indianola Community Schools recognize mental health as a significant component to overall
health of the student. A mental health questionnaire is available to students who demonstrate a need.
I give consent for my child to be
for emotional/mental
I screened
give my permission
for my child to
health concerns.
participate
in these screenings.
Student’s Name
Parent/Guardian Signature
Date
_____
H:/Registration/Student Health Update
(04.18.16)
2
Confidential
Authorization and Parent Permission for
Administration of Medication
I request the following medication be given to
Student’s Name
Name of Medication:
Time to be Given:
Amount to be Given:
Doctor Who Prescribed Medication: _______________________________________________________
Additional Information:
School medications and health care services are administered following these guidelines:




Parent has signed and dated the authorization to administer the medication.
The medication must be in the original prescription container with pharmacy label
listing the student’s name, name of medication, directions for use, and date.
All over the counter medications must be in the manufacturer’s labeled container,
and be Children/Junior Strength. Adult Strength must be authorized in writing by
a physician.
Annual renewal of authorization and immediate notification, in writing, of changes.
I understand that I MUST provide my child’s medication to the school.
I understand that all class II narcotics such as Ritalin, Adderall, Dexedrine, etc. MUST be delivered to school
by an ADULT (parent/guardian or someone designated by parent).
I request the above student be given the medication at school by qualified staff, according to the prescription
or nonprescription instructions, and a record maintained. The student has experienced no previous side
effects from the medication. I further agree that school personnel may contact the doctor/prescriber as
needed and that medication information may be shared with school personnel who need to know.
I understand the law provides that there shall be no liability for civil damages as a result of the administration
of medication where the person administering the medication acts as an ordinarily reasonably, prudent
person would under the same or similar circumstances. I agree to provide safe delivery of medication and
equipment to and from school and to pick up remaining medication and equipment.
Parent’s Signature
Date
For more information refer to School Board Policy # 507.2 at www.indianola.k12.ia.us.
This form must be renewed at the beginning of each school year. Medication cannot be
given without parent/guardian written consent.
H:/Registration/Request for Giving Medication
(01.28.16)
Iowa Department of Public Health
CERTIFICATE OF DENTAL SCREENING
Note: Only needed
for Kindergarten
This certificate is not valid unless all fields are complete. and 9th grade
RETURN COMPLETED FORM TO CHILD’S SCHOOL.
students.
Student Information (please print)
Student Last Name:
Student First Name:
Parent or Guardian Name:
Birth Date (M/D/YYYY):
Telephone (home or mobile):
Street Address:
City:
Name of Elementary or High School:
County:
Grade Level:
Gender:
Male
Female
Screening Information (health care provider must complete this section)
Date of Dental Screening:
________________________________
Treatment Needs (check ONE only based on screening results, prior to treatment services provided):
No Obvious Problems – the child’s hard and soft tissues appear to be visually healthy and there
is no apparent reason for the child to be seen before the next routine dental checkup.
Requires Dental Care – tooth decay¹ or a white spot lesion² is suspected in one or more teeth, or
gum infection³ is suspected.
Requires Urgent Dental Care – obvious tooth decay¹ is present in one or more teeth, there is
evidence of injury or severe infection, or the child is experiencing pain.
¹ Tooth decay: A visible cavity or hole in a tooth with brown or black coloration, or a retained root.
² White spot lesion: A demineralized area of a tooth, usually appearing as a chalky, white spot or white line near the
gumline. A white spot lesion is considered an early indicator of tooth decay, especially in primary (baby) teeth.
³ Gum infection: Gum (gingival) tissue is red, bleeding, or swollen.
Screening Provider (check ONE only):
DDS/DMD
RDH
MD/DO
PA
Provider Name: (please print)
RN/ARNP (High school screen must be provided by DDS/DMD or RDH)
Phone:
Provider Business Address:
Signature and Credentials
of Provider or Recorder*:
Date:
*Recorder: An authorized provider (DDS/DMD, RDH, MD/DO, PA, or RN/ARNP) may transfer information onto this form from another
health document. The other health document should be attached to this form.
A screening does not replace an exam by a dentist.
Children should have a complete examination by a dentist at least once a year.
RETURN COMPLETED FORM TO CHILD’S SCHOOL.
Iowa Department of Public Health  Oral Health Center
515-242-6383  866-528-4020  www.idph.state.ia.us/ohds/OralHealth.aspx
A designee of the local board of health or Iowa Department of Public Health may review this certificate for survey purposes.
9/13/2012
Note: Form needed for
Kindergarten and 3rd
grade students only.
School Board Policy 506.2—Student Directory Information
During the school year your child may make headlines as a hero of the big game, or he or she might win an academic
honor. Often, stories about what is happening at school will feature students. We also might want to use your child’s name
or may get a great photograph or videotape of your child that we’d like to use in a school district publication or
presentation.
Student directory information is designed to be used internally within the school district. Directory information is defined in
the annual notice and may include:






Student's name, address, telephone number
Date and place of birth
E-mail address, grade level, enrollment status
Major field of study
Dates of attendance
Participation in officially recognized activities and
sports





Weight and height of members of athletic teams
Degrees and awards received
The most recent previous educational agency or
institution attended by the student
Student artwork, student photos and other likeness
Other similar information
Prior to developing a student directory or to giving general information to the public, parents will be given notice
annually of the intent to develop a directory or to give out general information and have the opportunity to deny
the inclusion of their child's information in the directory or in the general information about the students.
If you do NOT want the district to release “Directory Information” and/or publish your child’s photo, and/or release
videotape of your child, please complete and return the form below by the first day of school. OTHERWISE, IT IS NOT
NECESSARY TO TAKE ANY ACTION. If you have any questions, please call 515.961.9500; Ext. 1506.
Indianola Community School District
Directory Information and Photographs
(Return one form for each child.)
Directory Information
Do not release any “Directory Information” on my child.
or
Do not release “Directory Information” on my child, but you can include my child’s name in the school newsletter
and school directory.
Photograph/Videotape
Do not release my child’s photograph/videotape to the news media or use my child’s photograph in any Districtwide printed publication (such as the calendar).
Class Photograph
Do not release my child’s individual class photo for use in the school annual or yearbook.
Child’s Name:
School/Grade:
Parent/Guardian Printed Name:
Phone #:
Signature:
Date:
ICSD (01.27.15)
H:/Registration/Student Directory Info
Office Use Only
Records Requested:
Records Received:
I authorize the release of all school records and transcripts for the following student(s):
Name
Grade
Date of Birth
All records relating to the educational evaluation or placement of the above-named student(s)
are to be released. Please include cumulative record information, all case histories, medical
records (included but not limited to immunization card, dental screening and blood lead
screening (kindergarten only), proof of birth, social service reports, and any special education
placement to include the most recent psychological test, the latest IEP and speech and
language evaluations.
Please fax IEP information as soon as possible.
Return Information to:
Signature of Parent/Guardian
Date
Please list the last school attended:
School Name
Address
(
City
)
Phone Number
ICSD (04.20.16)
Registration / Release of Records
(
)
Fax Number
State
Zip
2016‐17 School Year Transportation Registration Please complete this form even if you do not wish to receive transportation services. All students at some time will ride a bus to an activity/field trip. This is the 2016‐17 registration form for all students. Please make sure information is current. Return to 1206 East Ashland Avenue or fax to 515‐961‐9504 regardless of your transportation needs. It is your responsibility to return this form ASAP. Incomplete and/or forms not returned will result in denial of transportation services. Student Name: Local ID: Grade: Gender: Parent/Guardian Name: Home Address: City:
Home Phone: State:
Zip: Cell Phone: Child Care Provider Name: Address: City:
Phone: State:
Zip: Your child’s transportation eligibility is determined by your home address. In‐town child care transportation is available at designated stops for child care addresses south of Highway 92. Child care transportation is available for rural addresses within the Indianola School District. All parents will be notified in writing of their bus route assignments approximately two weeks prior to the start of school. To receive a letter you must complete a transportation form. (If no, skip to the signature area located at Do you need school transportation? Yes No the bottom of letter)
Transportation From: Bus stop closest to my home Child Care Both (explain) Transportation To: Bus stop closest to my home Child Care Both (explain) If you need transportation to or from a child care, you must have the address in “Child Care Address” above. If you have questions regarding transportation, please contact Ron Swartz, Director, at 515‐961‐9592. Signature Date Printed Name For Office Use: Elementary Assignment: Is Eligible for transportation
Is Not Eligible for transportation