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Central African Other (B31East African Burundian (B32) Comoran (B33) Djiboutian (B34) Eritrean (B35) Ethiopian (B36) Kenya (B37) Malagasy (Madagascar(B38) Malawian (B39) Mauritian (Mauritius) (B40) Mahoran (Mayotte) (B41) Mozambican (B42) Reunionese (B43) Rwandan (B44) Seychellois/Seychelloise(B45) Somali (B46) South Sudanese (B47) Ugandan (B49) Tanzanian (United Republicof Tanzania) (B50) Zambian (B51) Zimbabwean (B52) East African Other (B53)White White (W00)Eastern European Bosnian (W01) Herzegovinian (W02) Polish (W03) Romanian (W04) Russian (W05) Ukrainian (W06) Eastern European Other(W07)Latin American Argentine (B54) Belizean (B55) Bolivian (B56) Brazilian (B57) Chilean (B58) Colombian (B59) Costa Rican (B60) Ecuadorian (B61) El Salvadoran (B62) Falkland Islander (B63) French Guianese (B64) Guatemalan (B65) Guyanese (B66) Honduran (B67) Mexican (B68) Nicaraguan (B69) Panamanian (B70) Paraguayan (B71) Peruvian (B72) South Georgia and theSouth Sandwich Islands(B73) Surinamese (B74) Uruguayan (B75) Venezuelan (B76) Latin American Other(B77)South African Botswanan (B78) Mosotho (Lesotho) (B79) Namibian (B80) South African (B81) Swazi (B82) South African Other (B83)West African Beninese (B84) Bissau-Guinean (B85) Burkinabé (Burkina Faso)(B86) Cabo Verdean (B87) Ivorian (Cote d’lvoire)(B88) Gambian (B89) Ghanaian (B90) Liberian (B91) Malian (B92) Mauritanian (B93) Nigerien (Niger) (B94) Nigerian (Nigeria) (B95) Saint Helenian (B96) Senegalese (B97) Sierra Leonean (B98) Togolese (B99) West African Other (C01) Black Write in (C02)Middle Eastern and NorthAfrican Algerian (W08) Amazigh or Berber (W09) Arab or Arabic (W10) Assyrian (W11) Bahraini (W12) Bedouin (W13) Chaldean (W14) Copt (W15) Druze (W16) Egyptian (W17) Jordanian (W22) Kurdish Kuwaiti (W23) Lebanes (W24) Libyan (W25) Moroccan (W26) Omani (W27) Palestinian (W28) Qatari (W29) Saudi Arabian (W30) Syrian (W31) Tunisian (W32) Yemeni (W33)Ethnicity and Race Data Collection FormDF-101A-13

Emirati (W18) Iranian (W19) Iraqi (W20) Israeli (W21)American Indian/Alaskan Native American Indian/Alaskan Makah Indian Tribe of theNative (N00)Makah Indian ReservationWashington State Tribe(N13) Chinook Tribe (N01) Marietta Band ofNooksack Tribe (N14) Confederated Tribes and Muckleshoot Indian TribeBands of the Yakama Nation(N02)(N15) Confederated Tribes of the Nisqually Indian TribeChehalis Reservation (N03)(N16) Confederated Tribes of the Nooksack Indian Tribe ofColville Reservation (N04)Washington (N17) Cowlitz Indian Tribe (N05) Port Gamble S’KlallamTribe (N18) Duwamish Tribe (N06) Puyallup Tribe of Puyallup Hoh Indian Tribe (N07)Reservation (N19) Jamestown S’Klallam Tribe Quileute Tribe of the(N08)Quileute Reservation (N20) Kalispel Indian Community Quinault Indian Nationof the Kalispel Reservation(N21)(N09) Kikiallus Indian Nation (N10) Samish Indian Nation(N22) Lower Elwha Tribal Sauk-Suiattle Indian TribeCommunity (N11)of Washington (N23) Lummi Tribe of the Lummi Shoalwater Bay IndianReservation (N12)Tribe of the Shoalwater BayIndian Reservation (N24)Asian Asian (A00) Hmong (A09) Asian Indian (A01) Indonesian (A10) Bangladeshi (A02) Japanese (A11) Bhutanese (A03) Korean (A12) Burmese/Myanmar (A04) Lao (A13) Cambodian/Khmer (A05) Malaysian (A14) Cham (A06) Mien (A15) Chinese (A07) Mongolian (A16) Filipino (A08) Nepali (A17)Okinawan (A18)Ethnicity and Race Data Collection Form Middle Eastern Other(W34) North African Other (W35) White Other (W36) Skokomish Indian Tribe(N25) Snohomish Tribe (N26) Snoqualmie Indian Tribe(N27) Snoqualmoo Tribe (N28) Spokane Tribe of theSpokane Reservation (N2 ) Squaxin Island Tribe of theSquaxin Island Reservation(N30) Steilacoom Tribe (N31) Stillaguamish Tribe ofIndians of Washington (N32) Suquamish Indian Tribe ofthe Port MadisonReservation (N33) Swinomish Indian TribalCommunity (N34) Tulalip Tribes ofWashington (N35)Other Alaska Native Write in(N36) American Indian Other(N37) Pakistani (A19) Punjabi (A20) Singaporean (A21) Sri Lankan (A22) Taiwanese (A23) Thai (A24) Tibetan (A25) Vietnamese (A26) Asian Other (A27)DF-101A-13

Native American/Pacific Islander Native Hawaiian/Other Kosraean (P06)Pacific Islander (P00) Maori (P07)Pacific Islander Marshallese (P08) Carolinian (P01) Native Hawaiian (P08) Chamorro (P02) Ni-Vanuatu (P10) Chuukese (P03) Palauan (P11) Fijian (P04) Papuan (P12) i-Kiribati/Gilbertese (P05) Pohpeian (P13) Samoan (P14) Solomon Islander (P15) Tahitian (P16) Tokelauan (P17) Tongan (P18) Tuvaluan (P19) Yapese (P20) Pacific Islander Other (P21)Guardian Signature DateEthnicity and Race Data Collection FormDF-101A-13

Office of Superintendent of Public Instruction (OSPI)Home Language SurveyThe Home Language Survey is given to all students enrolling in Washington schools.Student Name:Parent/Guardian NameGrade:Date:Parent/Guardian SignatureRight to Translation andInterpretation ServicesIndicate your language preference sowe can provide an interpreter ortranslated documents, free ofcharge, when you need them.All parents have the right to information about their child’seducation in a language they understand.Eligibility for LanguageDevelopment SupportInformation about the student’slanguage helps us identify studentswho qualify for support to developthe language skills necessary forsuccess in school. Testing may benecessary to determine if languagesupports are needed.2. What language did your child learn first?1. In what language(s) would your family prefer to communicatewith the school?3. What language does your child use the most at home?4. What is the primary language used in the home, regardless ofthe language spoken by your child?5. Has your child received English language development supportin a previous school? YesPrior EducationYour responses about your child’sbirth country and previouseducation: Give us information about theknowledge and skills your child isbringing to school. May enable the school district toreceive additional federal fundingto provide support to your child.NoDon’t Know6. In what country was your child born?7. Has your child ever received formal education outside of theUnited States?(Kindergarten – 12th grade)YesNoIf yes: Number of months:Language of instruction:8. When did your child first attend a school in the United States?(Kindergarten – 12th grade)MonthDayYearThis form is not used to identifystudents’ immigration status.Thank you for providing the information needed on the Home Language Survey. Contact your schooldistrict if you have further questions about this form or about services available at your child’s school.Note to district: This form is available in multiple languages on .aspx. A response thatincludes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses toquestions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearlyunderstood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.

KENT SCHOOL DISTRICTKent, WashingtonTo be completed by parent/guardianHEALTH HISTORYToday’s DateSchoolGradeTeacherName of Student Birthdate Sex: MFThis information is needed to plan an appropriate program for your student and to prepare for any emergency situation if one shouldarise. Your school nurse will contact you if there are any additional questions.DOES THE STUDENT HAVE:MEDICAL HISTORY (check all that apply)Allergies (specify)Life threatening allergy (anaphylaxis)*Bee/insect allergyAsthma *Concerns/defect present at birthFrequent ear infectionsHearing lossSpeech difficultiesSevere headachesSeizuresNeurological conditionADD/ADHD (circle one, diagnosed by whom)Heart conditionDiabetes *Blood disorderOrthopedic conditionChronic condition/disabilityVision concernsSerious injury/surgeryEmotional health concernsOther health concernsNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesMEDICATIONIs medication needed at home?No YesPlease explain any yes answers.(*If yes, complete reverse side)(*If yes, complete reverse side)(*If yes, see reverse side)Wears: Glasses Contacts OtherDate:Name of medicationIs medication needed at school?**No YesName of medication**State law requires written permission from a licensed health care provider and parent before any medication, prescriptionor over-the-counter, may be taken at school. A form is available from the school office.Is there anything you want to tell us about your student which you feel will help school staff to better understand and work withhim/her?I understand that the information given above will be shared with appropriate school staff who need to know in order toprovide for the heath and safety of my student. If parents/guardian or authorized emergency contact cannot be reached atthe time of a medical emergency, and if immediate care is urgent in the judgment of school authorities, I authorize anddirect the school authorities to send the student to the hospital or doctor most easily accessible. I understand that I willassume full responsibility for the payment of any services rendered.Signature Relationship Phone- Please turn over for more information -HS-33-07

AnaphylaxisIf your student has an anaphylactic allergy as indicated on the reverse side of this form, please answer thefollowing questions:1. What is your student allergic to?2. What are your student’s symptoms?3. Has your student been prescribed an Epi-pen?Please contact the school nurse to help implement your student’s individualized healthcare plan.DiabetesThere is a state law, which requires all students with diabetes to have an individualized health care planimplemented in the school setting. If your student is diabetic, please contact the school nurse to help write yourstudent’s plan.AsthmaIf your student has asthma as indicated on the reverse side of this form, please answer the following questions:1. How long has your child had asthma?yearsmonths2. How many days would you estimate he/she missed school last year due to asthma?3. How many times in the past year has your child been:a) Hospitalized overnight or longer for asthma? (check one) none one two-four more than fourb) Treated in an emergency room?(check one) none one two-four more than fourc) Treated in a Doctor’s office for non-routine asthma? (check one) none one two-fourmore than four4. What are your child’s early warning signs of an asthma episode? (check all that apply)coughcold symptomsdrop in peak flowwheezingdecreased exerciseother5. If your child’s asthma is monitored with a peak flow meter, write in his/her best peak flow rate.6. Does your child have and use a nebulizer machine at home?yesno7. If your child takes medication for their asthma at home please provide the name of any medications:Life Threatening ConditionsRCW 28A.210.320-Children with Life-Threatening Conditions, requires a medication or treatment order as aprerequisite for children with life-threatening conditions to attend public schools. The new law defines “lifethreatening condition” as a health condition that will put the child in danger of death during the school day, if amedication or treatment order and a nursing care plan are not in place. Potential life-threatening conditionsinclude, but are not limited to, students with seizure disorders, diabetes, life-threatening allergies, and somestudents with asthma and heart conditions. If this law applies to your student, please contact the nurse at yourchild’s school.Signed:Date:

Student Immunization ChangeAll new students enrolling for 2020-21 school year will be required to provide medically verified immunization records.If your child is currently enrolled in Kent School District and already meets immunization requirements,you do not need to do anything. If you aren’t sure, or if you have any questions, please contact your child’s school nurse.What are medically verified immunization records?This means immunization records turned in to the school for incoming students must be from a health care provider,or paperwork from a health care provider must be attached to a handwritten form showing your child’s records areaccurate.Examples include:A Certificate of Immunization Status (CIS) printed from the Immunization Information System. A physical copy of the CIS form with a healthcare provider signature. A physical copy of the CIS with accompanying medical immunization recordsfrom a healthcare provider verified and signed by school staff. A CIS printed from MyIR. To register go to: https://wa.myir.net/register More information can be obtained at the Washington State Department of Health munization/SchoolandChildCare/RuleChanges

Instructions for completing the Certificate of Immunization Status (CIS): Print the from the Immunization Information System (IIS) or fill it in by hand.To print with the immunization information filled in:Ask if your health care provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide registry). If they do, ask them to print the CIS from the IIS and yourchild’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 theDepartment 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 and birthdate, and sign your name where indicated on page one.2. 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 Guidesbelow to record each vaccine correctly. For example, record Pediatix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.3. 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 health care 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. If your child can show positive immunity by blood test (titer), have your health care provider check the boxes for the appropriate disease in the Documentation of Disease Immunity section, and sign anddate the form. You must provide lab reports with this CIS.5. Provide proof of medically verified records, following the guidelines below.Acceptable Medical RecordsAll vaccination records must be medically verified. Examples include: A Certificate of Immunization Status (CIS) form printed with the vaccination dates from the Washington State Immunization Information System (IIS), MyIR, or another state’s IIS. A completed hardcopy CIS with a health care provider validation signature. A completed hardcopy CIS with attached vaccination records printed from a health care provider’s electronic health record with a health care provider signature or stamp. The school administrator,nurse, or designee must verify the dates on the CIS have been accurately transcribed and provide a signature on the form.Conditional StatusChildren can enter and stay in school or child care in conditional status if they are catching up on required vaccines for school or child care entry. (Vaccine series doses are spread out among minimumintervals, so some children may have to wait a period of time before finishing their vaccinations. This means they may enter school while waiting for their next required vaccine dose). To enter school orchild care in conditional status, a child must have all the vaccine doses they are eligible to receive before starting school or child care.Students in conditional status may remain in school while waiting for the minimum valid date of the next vaccine dose plus another 30 days time to turn in documentation of vaccination. If a student iscatching up on multiple vaccines, conditional status continues in a similar manner until all of the required vaccines are complete.If the 30-day conditional period expires and documentation has not been given to the school or child care, then the student must be excluded from further attendance, per RCW 28A.210.120. Validdocumentation includes evidence of immunity to the disease in question, medical records showing vaccination, or a completed certificate of exemption (COE) form.Reference guide for vaccine trade names in alphabetical orderFor updated list, visit https://www.cdc.gov/vaccines/ter ms/usvaccines.htmlTrade NameVaccineTrade NameVaccineTrade NameVaccineTrade NameVaccineTrade NameVaccineActHIBHibFluarixFluHavrixHep AMenveoMeningococcalRotarixRotavirus (RV1)AdacelTdapFlucelvaxFluHiberixHibPediarixDTaP Hep B IPV RotaTeqRotavirus enivacTdBexseroMenBFluMistFluIpolIPVPentacelDTaP Hib PneumovaxPPSVTwinrixHep A Hep BCervarix2vHPVFluzoneFluKinrixDTaP IPVPrevnarPCVVaqtaHep ADaptacelDTaPGardasil4vHPVMenactraMCV or MCV4ProQuadMMR VaricellaVarivaxVaricellaEngerix-BHep BGardasil 99vHPVMenomuneMPSV4Recombivax HBHep BIf you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711).DOH 348-013 November 2019

Certificate of Immunization Status (CIS)Reviewed by:Date:Signed COE on File? Yes NoPlease print. See back for instructions on how to fill out this form or get it printed from the Washington State Immunization Information System.Child’s Last Name:First Name:Middle Initial:Birthdate (MM/DD/YYYY):I give permission to my child’s school/child care to add immunization information into theImmunization Information System to help the school maintain my child’s record.Conditional Status Only: I acknowledge that my child is entering school/child care inconditional status. For my child to remain in school, I must provide required documentationof immunization by established deadlines. See back for guidance on conditional status.XXParent/Guardian SignatureDateParent/Guardian Signature Required if Starting in Conditional StatusDateDateDateDateDateDateMM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY MM/DD/YY Required for School Required Child Care/PreschoolRequired Vaccines for School or Child Care Entry DTaP (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) (grade 7 ) DTor Td (Tetanus, Diphtheria) Hepatitis BHib (Haemophilus influenzae type b) IPV (Polio)(any combination of IPV/OPV)DateDocumentation of Disease Immunity(Health care provider use only)If the child named in this CIS has a history ofvaricella (chickenpox) disease or can showimmunity by blood test (titer), it must be verified by a health care provider.I certify that the child named on this CIS has: A verified history of varicella (chickenpox)disease. Laboratory evidence of immunity (titer) todisease(s) marked below. OPV (Polio) Diphtheria Hepatitis A Hepatitis B MMR (Measles

this will create an email with the form attached to our enrollment specialist for processing. 7. Include the following in the email-a.Subje ct line: New Enrollment 2021-22 School Year b. Body of the email: Include student name, grade & address Enrollment Forms Checklist: Student Information and Enrollment Form . Parent Questionnaire