2021-2022 Enrollment Packet Grades 1-12Instructions for Completing Enrollment Forms**Please Note – Google Chrome will not work to complete the forms**Use Internet Explorer, Microsoft Edge or Firefox browser to complete the forms1. Download and SAVE AS the documents to your devicea. Name your document: First Name.Last Name.Enrollmentb. Example- Jane.smith.enrollment2. Open the saved document3. Complete all the enrollment forms4. Sign forms using adobe digital signature. You will be prompted to savethe document after each signature.5. Review forms to make sure you did not miss anything6. Once you have completed the packet, click the submit button belowthis will create an email with the form attached to our enrollmentspecialist for processing.7. Include the following in the emaila. Subject line: New Enrollment 2021-22 School Yearb. Body of the email: Include student name, grade & addressSubmit PacketEnrollment Forms Checklist:Student Information and Enrollment FormParent QuestionnaireEthnicity and Race Data Collection FormHome Language SurveyHealth HistoryImmunization RecordsMilitary Affiliation FormEmergency Early Dismissal PlanStudent Housing QuestionnaireIndian Student Eligibility Form (optional)

Student Information and Enrollment FormKent School District No. 415Kent, Washington 98030DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLYDate Registration Received:Date Entered into Student Information System:Student Start/Entry Date:Student ID:School Resident Area:Homeroom/Advisor:STUDENT NAME Legal Last NameLegal First NameBIRTHDATE (Month/Day/Year)BIRTHPLACECityStateBus Route Assigned:Legal Middle NameGENDERMaleFemaleCountryPRIMARY HOUSEHOLD (parent/guardian where student resides)Last Name (LEGAL)First NameM.I. Proof of birth Proof of residence Parent/Guardian ID CIS Legal or custody paperworkPrevious Name ( if applicable)GRADE LEVELSTUDENT LIVES WITH Both parents Mother only Grandparents Father only OtherRelation to Student: Mom Step-Mother Guardian Father Step-Father Other Father/Stepmother Mother/Stepfather Guardian Foster ParentPRIMARY HOUSEHOLD (parent/guardian where student resides)Last Name (LEGAL)First NameM.I.RESIDENTADDRESSStreetApt #MAILINGADDRESSStreetApt #PO Box Self AgencyRelation to Student: Mom Step-Mother Guardian Father Step-Father OtherCityStateZIPCityStateZIP(If different)RESIDENT (HOME) Phone: (Include area code)Please check if unlisted Please check if cell number Guardian #1 Work Phone (include area code)Active Military Yes NoGuardian #2 Work Phone (include area code)Guardian #1 Cell Phone (include area code)Guardian #2 Cell Phone (include area code)GUARDIAN #1 EMAIL ADDRESS:GUARDIAN #2 EMAIL ADDRESS:Active Military Yes NoFILL OUT THIS SECTION ONLY IF STUDENT HAS A PARENT/LEGAL GUARDIAN NOT LIVING AT THE ADDRESS ABOVESECONDARY HOUSEHOLD (non-custodial parent not residing withstudent)Last NameFirst NameM.I.PHONE #1 (include area code) Home Work CellPHONE #2 (include area code) Work CellSECONDARY HOUSEHOLD (non-custodial parent not residing withstudent)Last NameFirst NameM.I.PHONE #1 (include area code) Home Work CellPHONE #2 (include area code) Work CellSECOND HOUSEHOLD ADDRESS(Street/PO Box, City, State, ZIP)Active MilitaryRelationship to student: Father Mother Stepmother Stepfather OtherRelationship to student: Father Mother Stepmother Stepfather OtherSECOND HOUSEHOLD EMAIL Yes NoIS THERE A PARENTING PLAN IN EFFECT? Yes NoIf yes, please provide a copy to the office.IS THERE A COURT ORDER IN EFFECT THAT LIMITS EDUCATIONAL DECISION MAKING OR CONTACT WITH THE STUDENT ORSCHOOL (RESTRAINING ORDER, PROTECTION ORDER, NO CONTACT ORDER, ANTI-HARRASSMENT ORDER, ETC.)? Yes NoIf yes, please provide a copy to the office.Court order limits Mother Father OtherPlease fill out back of formRevised 01/2015DF-101-14

PLEASE LIST SIBLINGS ATTENDING THE KENT SCHOOL DISTRICTLast NameFirst NameSchoolDOES STUDENT ATTEND CHILD CARE? Before school After schoolCHILD CARE PROVIDERNameGradeAddressPhone Number Before and after schoolPlease provide additional childcare arrangements to the school in writing. YesHAS YOUR CHILD EVER ATTENDED A PRESCHOOL(S)? NoPreschool NamePreschool AddressHAS YOUR CHILD EVER BEEN RETAINED?HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN:Special Education Program (IEP)LAP Yes Yes No No Highly Capable Yes No504 plan Yes No YesTitle Yes NoEnglish as a Second Language (ELL/ESL) Yes No NoIf yes, at what grade level(s)OtherLAST SCHOOL ATTENDEDSCHOOL DISTRICTSCHOOL INFORMATION (Phone, FAX, City and State)HAS YOUR CHILD EVER ATTENDED A SCHOOL IN WASHINGTON STATE? YesHAS YOUR CHILD EVER ATTENDED THE KENT SCHOOL DISTRICT? Yes No NoIF YES, NAME OF SCHOOL(S) ATTENDEDIF YES, NAME OF SCHOOL(S) ATTENDEDHAS YOUR CHILD EVER BEEN SUSPENDED/EXPELLED FOR A WEAPONS VIOLATION? Yes NoDATE LAST ATTENDED (Month/Year)DATE LAST ATTENDED (Month/Year)Date(s)When an emergency situation occurs involving your child, we want to be able to quickly reach responsible adults. In the event we cannotreach a parent/guardian, please list persons you trust who are available during the day to provide care for your child.EMERGENCY CONTACT INFORMATIONFIRST CONTACT (other than parent/guardian)Last NameFirst NameM.I.SECOND CONTACT (other than parent/guardian)Last NameFirst NameM.I.THIRD CONTACT (other than parent/guardian)Last NameFirst NameM.I.Relationship To Child:PHONE #1 (include area code) Home Work CellPHONE #2 (include area code) Home Work CellRelationship To Child:PHONE #1 (include area code) Home Work CellPHONE #2 (include area code) Home Work CellRelationship To Child:PHONE #1 (include area code) Home Work CellPHONE #2 (include area code) Home Work CellSTUDENT RELEASE AUTHORIZATION: In the event the school is unable to contact the parents or legal guardian, Iauthorize my child to be released to the person(s) listed above.Legal Parent/Guardian Signature DateEMERGENCY MEDICAL AUTHORIZATION: If the parents or legal guardian on this registration record cannot be reached atthe time of an emergency, and if immediate observation or treatment is urgent in the judgment of the school authorities, I authorizeand direct the school authorities to send the student (properly accompanied) to the hospital or doctor most easily accessible. Iunderstand I will assume full responsibility for the payment of any services rendered.Legal Parent/Guardian Signature Date

Kent School DistrictParent QuestionnaireStudent Name: (first, middle, last):Likes to be called:Birth date:Parent/Guardian(s) name:Address where student is living:Family BackgroundPlease list the names of the adults the student resides with and the relationship to him/her:Other children in the :Name:Age:School:Grade:What language is spoken most often in your home?Has there been an event (divorce, death, illness, etc.) in the family that might affect your child?Do you celebrate birthdays and/or holidays in your home?YesNo If no, please explain:School BackgroundHow many schools has your child attended in the last year?Name, district and state of the last school attended:Does your child have any unpaid fines or fees at prior schools?YesHas your child been in any special programs (special education, ELL etc.)?No If yes, please explain:YesNo If yes, please list:How does your child like school, previous teachers, other students?How is your child doing in school (grades, teacher feedback, etc.)?Are there any past, current or pending disciplinary actions involving your child?YesNo If yes, please explain:Does your child have any history of violent behavior, sex or criminal offense, or controlled substance or alcohol violation?YesNo If yes, please explain:Briefly describe your child’s strengths and weaknesses:Additional information:Parent/guardian signature:Date:

Ethnicity and Race Data Collection FormEach year, school districts in Washington are required to report student data by ethnicity and race categories tothe State's Office of Superintendent of Public Instruction (OSPI). OSPI is required to report the total number ofstudents in various categories in each school to the federal government, but it does not report individualstudent data. Recently, the federal government and OSPI changed the reporting categories for student ethnicand race data. As a result of the new reporting categories, we are required to ask you to identify your child aseither Hispanic/Latino or not Hispanic/Latino (Question 1) and by one or more racial groups (Question 2).Student’s Legal NameQuestion 1 Is your child of Hispanic or Latino origin? (Check all that apply) Hispanic (H00) Not Hispanic/Latino (H01) Argentine (H02) Bolivian (H03) Brazilian (H04) Chicano(Mexican/American) (H05) Chilean (H06) Colombian (H07) Costa Rican (H08) Cuban (H09) Dominican (H10) Ecuadorian (H11) Guatemalan (H12) Guyanese (H13) Honduran (H14) Jamaican (H15) Mexican (H16) Mestizo (H17) Native (H18) Nicaraguan (H19) Panamanian (H20) Paraguayan (H21) Peruvian (H22) Puerto Rician (H23) Salvadorian (H24) Spaniard (H25) Surinamese (H26) Uruguayan (H27) Venezuelan (H280 Other Hispanic/Latino(H29)Question 2 What race(s) do you consider your child? (Check all that apply)Black/African American Black/African American(B00) African American (B01) African Canadian (B02)Caribbean Anguillan (B03) Antiguan (B04) Bahamian (B05) Barbadian (B06) Barthélemois/es (SaintBarthélemy) (B07) British Virgin Islander (B08) Caymanian (Cayman Island)(B09) Cuba Dominican (B10) Dominican (DominicanRepublic) (B11) Dutch Antillean(Netherlands Antilles) (B12) Grenadian (B13) Guadeloupian (B14) Haitian (B15) Jamaican (B16) Martiniquais/e (B17) Montserratian (B18) Puerto Rican (B19 Caribbean Other (B20)Ethnicity and Race Data Collection FormCentral African Angolan (B21) Cameroonian (B22) Central African (CentralAfrican Republic) (B23) Chadian (B24) Congolese (Republic of theCongo) (B25) Congolese (DemocraticRepublic of the Congo) (B26) Equatorial Guinean (B27) Gabonese (B28) São Toméan (B29) Principe (B30)DF-101A-13

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: 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 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 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