NEW STUDENT APPLICATION

 
 
 

UTTC STUDENT (Priority)
 UTTC Staff
 Off Campus

A COMPLETED REGISTRATION PACKET WITH SIGNED FORMS MUST BE COMPLETED PRIOR TO ANY STUDENT(S) ATTENDING THE FIRST DAY OF CLASS. THE FOLLOWING FORMS MUST BE COMPLETED BEFORE LEAVING THE OFFICE.

When registering for enrollment parents/guardians must fill out 1 application per student. If you have multiple students registering we can help assist you. Here is a checklist to ensure all forms are completed.

 Student Registration Form
 Allergy Information/Emergency Contact Information
 Request for Cumulative & Confidential Education Records
 Field Trip Consent/Publication Consent
 Student Residency Questionnaire
 Library Registration Card
 Home Language Survey
 Technology Policy
 Back Pack Program

The following documents are requirements by TJES and the Bureau of Indian Education, therefore must be turned in with registration packet to be considered complete.
 Birth Certificate
 Degree of Indian Blood
 Immunization Record
 Custody Documentation (If Applicable)
 UTTC/Class Schedule

STUDENT REGISTRATION FORM

School Year/Term
STUDENT INFORMATION:

LAST NAME
 FIRST NAME
MI

 PREFERRED NAME

DATE OF BIRTH
 
GRADE STUDENT WILL BE ENTERING:

PARENT INFORMATION:

ON/OFF CAMPUS ADDRESS INFORMATION

 UTTC STUDENT
 UTTC STAFF
 OFF CAMPUS

PARENT/GUARDIAN:

CHOOSE (MOTHER/FATHER/GUARDIAN)
 
 
 
 

PLACE OF EMPLOYMENT:
PHONE:
WORK:
CAMPUS BOX #:
UTTC HOUSE #:
MAILING ADDRESS:
 
 
 
 

 
 
OTHER PARENT/GUARDIAN
CHOOSE (MOTHER/FATHER/GUARDIAN)

NAME: Last, First, Middle
 
 
 
 
PLACE OF EMPLOYMENT:
PHONE:
WORK:
CAMPUS BOX #:
UTTC HOUSE #:
MAILING ADDRESS:
 
 
 

E-MAIL:
 
*IF ADDRESS CHANGES AT ANY TIME DURING THE SCHOOL YEAR IT IS THE PARENT/GUARDIANS RESPONSIBILITY TO INFORM TJES AS SOON AS POSSIBLE.

PLEASE LIST OTHER STUDENTS ATTENDING TJES

NAME:
GRADE:
NAME:
GRADE:

PLEASE LIST OTHER HOUSEHOLD MEMBERS

NAME:
NAME:

TRIBAL ENROLLMENT:

(NEED DEGREE OF BLOOD QUANTUM)

NAME OF CHILD:
ENROLLMENT NUMBER:
NAME OF TRIBE OR BAND FOR WHICH THE ABOVE CHILD CLAIMS MEMBERSHIP:

IF THE CHILD IS A DESCENDENT OF A PARENT WHO IS ENROLLED, PROVIDE INFORMATION AND DOCUMENTS.
PARENT:
NAME OR TRIBE OR BAND FOR WHICH THE PARENT IS CLAIMING MEMBERSHIP:

TRANSPORTATION

*TJES provides transportation to students who reside near designated bus stops. It will be parent/guardian responsibility to get students to and from designated bus stops at scheduled times. No exceptions.

LOCATION:     BISMARCK OR     MANDAN

PHYSICAL ADDRESS
RIDING THE BUS IS A PRIVILEGE, ALL STUDENTS BISMARCK BUS RIDERS AND PARENTS WILL BE PROVIDED WITH THE BUS RULES. FAILURE TO FOLLOW BUS RULES CAN RESULT IN LOSING BUS PRIVILEGES.

SCHOOL BUS POLICY

Riding the Bus is a Privilege Not a Right

Bus Rules-Passengers must:

Bus Route:

Late Bus Pass: 

Parent Responsibility:

Bus infractions include but not limited to:

Pushing, littering, shouting, insubordination, assault, vandalism, promiscuous behavior, harassment of a student, fighting, tripping, weapons, profane language, threatening to other student, or driver/rider, possession of tobacco/Alcohol or other drugs.
1st Offense:
   Written report to the principal and parent. Principal meets with student. Bus privileges may be suspended up to 3 days.
2nd Offense:
  Written report to the principal and parent, principal meet with student and parent. May result in a suspension of bus privileges for up to 5 days
3rd Offense:
  Written report to the principal and parent, may result in loss of bus privileges for the remainder of the school year.
 
Parents have the right to appeal the above consequence to the TJES School Board.

I HAVE RECEIVED, REVIEWED AND AGREE TO THIS BUS POLICY.
 

Date

Student Name
Bus Stop

HEALTH INFORMATION

Student Name:
Grade

ALLERGY INFORMATION

DOES YOUR CHILD HAVE AN ALLERGY:      Yes             No

IF YES WHAT IS THE ALLERGY:
MEDICATIONS TAKEN:
IF ALLERGIC REACTION OCCURS AT SCHOOL, WHAT STEPS SHOULD BE FOLLOWED:

HEALTH CONDITIONS

DOES YOUR CHILD HAVE ANY OTHER HEALTH CONDITIONS TJES NEEDS TO BE AWARE OF:      Yes             No

MEDICATIONS TO BE TAKEN AT SCHOOL:

NAMES OF MEDICATION
PRIMARY CARE PROVIDER
CLINIC NAME
ADDRESS
PHONE NUMBERS
 

EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT (MUST BE THE BISMARCK/MANDAN AREA):
NAME:
RELATIONSHIP:
(Other than Parent Or Guardian)
PHONE#:
PHYSICAL ADDRESS:
IN CASE OF AN EMERGENCY & PARENT/GUARDIAN CANNOT BE REACHED, MY PRIMARY DOCTOR OR ANY ATTENDING PHYSICIAN HAS MY PERMISSION TO ADMINISTER MEDICAL TREATMENT.

THE FOLLOWING PEOPLE HAVE MY PERMISSION TO CHECK MY CHILD OUT OR PICK THEM UP FROM SCHOOL: (ONLY THOSE ON THE LIST WILL BE ALLOWED TO PICK UP YOUR CHILD)
NAME:
RELATIONSHIP TO CHILD
PHONE NUMBER
NAME:
RELATIONSHIP TO CHILD
PHONE NUMBER
NAME:
RELATIONSHIP TO CHILD
PHONE NUMBER

ANYTHING ELSE THAT YOU WOULD LIKE US TO KNOW ABOUT YOUR CHILD:
I AM LEGALLY RESPONSIBLE FOR THE ABOVE STUDENT & HERE BY APPLY FOR HIS/HER ADMISSION TO TJES. I UNDERSTAND THAT ADDITIONAL INFORMATION MAY BE REQUESTED BEFORE ADMISSION IS GRANTED.
 

DATE:


In accordance with 5 CFR 1320.5(b) 1076-0122 Data Elements for Student Enrollment in Bureau-Funded School

TRANSCRIPT REQUEST

STUDENT INFORMATION:

 
 
 
  PREFERRED NAME
DATE OF BIRTH:


GRADE STUDENT WILL BE ENTERING:
NAME OF PREVIOUS SCHOOL
PHONE NUMBER OF PREVIOUS SCHOOL:
FAX NO. OF PREVIOUS SCHOOL:
The following information is requested:
 TRANSCRIPTS OF GRADES AND CREDITS
 ATTENDANCE INFORMATION
 IMMUNIZATION RECORD
 BEHAVIOR REPORT

SPED Information: Student Referral, Pre-Referral Information, Signed Parental Consent for Placement Form, Consent to Evaluate Form, Most Current Psychological Evaluation, Most Current Academic Testing, Assessment Plan, Evaluation Team Summary Report, Most Current Prior IEP Meeting Notice, Current IEP

Authorization:

I, the undersigned, authorize the release of the information shown above.

Signature of Parent Or Relationship Intake Date Enroll Date Authorized School Personnel

Parental permission is no longer required when records are requested by authorized school personnel (Family and Education Act)

 
DATE:
 
 

STUDENT RESIDENCY QUESTIONNAIRE

 
 
   MALE        FEMALE

Information to the following questions will determine the services the student may be eligible to receive according to the McKinney-Vento Act 42 U.S.C. 11435.
Student currently lives with:

 Both parents        Mother only        Father only

 Other (List with who and relationship)
Phone:
Print name of parent(s) legal guardians(s):
Phone:
 

Date:
 
1. Is this student’s home address a temporary living arrangement? (Will it be less than 6 months)     Yes     No
2. Is this a temporary living arrangement due to a loss of housing or economic hardship?     Yes       No
3. Is this student in a temporary foster care placement or awaiting foster care?     Yes      No
4. As a student, are you living with someone other than your parent or legal guardian?     Yes       No

Where is this student currently living? (Check box)
 In a motel                                    Transitional Housing
 In a shelter                                  With more than one family in a house or apartment
 House                                         Apartment    
 In a location not designed for sleeping accommodations such as a car, park or campsite
 Other
ADDRESS OF CURRENT RESIDENCE:
NAME OF MOTEL/SHELTER OF CURRENT RESIDENCE:
I hereby verify that all information on this form is true and correct to the best of my knowledge.

 

Date:
 

FIELD TRIP CONSENT

DATE

I (Parent/Guardian)
give permission for my child
in grade,
to participate in all school activities which involve trips from the school grounds, provided such trips are under supervision of a teacher, instructor, or principal, except those instances where I have notified the school in writing.
 
Date:
 

CENTRAL DAKOTA LIBRARY NETWORK
LIBRARY CARD REGISTRATION

Student Name: 
DATE OF BIRTH


Parent/Guardian:
Grade
Current Phone Number:

PARENT/GUARDIAN E-mail address
Students are responsible for the care and return of books that they check out. I understand that any fines for the lost or damaged books need to be paid to the library. Failure to pay will result in a hold placed on the parent’s transcript, or the amount will be deducted from the parent’s check.
 
 

Date:

HOME LANGUAGE SURVEY/LIMITED ENGLISH PROFICIENCY IDENTIFICATION

Only one form per household is necessary if you have more than one student enrolled in school**

Name of Student(s):
1.
Grade
2.
Grade
3.
Grade
4.
Grade
Dear Parent/Guardian Please provide the information on this form. This information is needed to provide a program that will acknowledge the presence and use of Tribal and other languages in an effort to increase English speaking, writing, and listening abilities of the students.

Is a language other than English spoken in the home by parents or guardians?       Yes        No
If Yes, what language?
Did your child learn another language before learning English?       Yes        No
If Yes, what language?
Does your child now speak a language other than English?       Yes        No
If Yes, what language is spoken most often while your child is away from home?
If your child does not speak a language other than English, has the child been closely associated with family members (Grandparents, Uncles, Aunts, etc.) or playing with children who speak another language?       Yes        No
If Yes, what language?
Please identify the type of situations, activities, and events in which the Tribal Language is spoken within your community and or home.
 
Date:

TECHNOLOGY/ACCEPTABLE USE POLICY

Efforts are taken to protect students from inappropriate materials, however it is impossible to completely protect students from material that is not consistent with TJES goals. Students will use the Internet for educational purposes, such as doing research, learning activities, developing projects, and disseminating information.

The following rules and consequences are implemented to maximize the educational opportunities available to your child while minimizing the risk of inappropriate use. The use of technology and the Internet is a privilege, not a right. This privilege may be withdrawn if it not used responsibly. Please refer to the Social Media Policy in the Family Handbook that is provided to you and discuss the following rules with your child. These rules will also be discussed in your child’s classroom.

Rules of Responsible Technology Behavior

  1. Respect the rights of others.
  2. Do not interfere with anyone’s use of technology.
  3. Do not access anyone’s computer/profile without his or her permission.
  4. Use appropriate language.
  5. Use technology for educational purposes only.
  6. Be a responsible Internet citizen. You are not allowed to send or collect obscene, abusive, or threatening material or activities supporting racism or sexism.
  7. Help others be responsible citizens. If you see anything or anyone that does not follow these rules, immediately tell the teacher or other adult who is supervising you.
  8. Always use the Internet under the supervision of a teacher or other school staff person.
  9. NEVER give the address, phone number, or last name of yourself or other students or staff.
  10. Keep your password secure. Do not share your password with others. Do not allow others to use your account. Do not use other people’s password or account.
  11. Refer to the TJES/UTTC Social Media Policy, local, state and federal laws.
  12. Use of school technology for commercial, profit-making activities is prohibited.
  13. Use TJES e-mails and Google Drive responsibly.
  14. NEVER download unauthorized material or any material without permission from your teacher.

Responsibility of Parent or Guardians:

Initial each box.
 
I understand the use of technology is for educational purposes.
 
I understand it is impossible for TJES to completely restrict access to controversial or inappropriate materials.

I will not hold TJES responsible for material acquired on the Internet. I will report any misuse to the teacher or principal.

I give my permission for my child to have supervised access to the Internet.

I understand that if my child does not follow the rules, school &/or legal action may be taken.

Inappropriate use is defined as using the Internet in any way that is contrary to school policy, local, state and federal law.

If your child violates any rules, he/she may by subject to any one or all of the following consequences:

Suspension from class Suspension from school Loss of computer privileges

Recommendation for expulsion

ONLINE/PUBLICATION CONSENT

TJES operates a website and publishes newsletters. Student art work/writing/photo/video may be considered for publication. This may include publication on the Internet as part of our school’s web page or other media during this school year. No student’s full name, home address, telephone number, or e-mail will be published on the TJES Web pages. Group student photos can be published showing students working on projects and other activities. First names can be published with those photos. Additionally, the Bureau of Indian Education may request pictures, articles and/or artwork of TJES students to use.

Student
Date


 I do give permission
 I do not give permission
 
Date:

TECHNOLOGY AGREEMENT STUDENT AND PARENT/GUARDIAN

I understand the rules of using technology at school. I agree to the TJES rules and consequences of technology use. If I feel uncomfortable with any information I see, I will immediately tell the teacher or the adult who is in charge.

Student Name (Please Print)
 
 
Date:

FAMILY HANDBOOK/POLICY SIGNATURE PAGE

My child and I have received the Family Handbook and Policies. We understand the rules, policies, consequences, and expectations. By signing this document we are committed to helping our child be successful in school and understand each policy listed below:
 Parent Policy                Bullying Policy                 Acceptable Use Policy
 Attendance Policy        Stay in School Project Safe Touch Policy Wellness Policy
 Fire drill, Lockdown, Shelter in Place Policy McKinney-Vento
 CLASS PARTIES (treats must be delivered to the TJES office and staff will distribute to the appropriate classroom. Birthday party invitations cannot be distributed during school hours by students or parents. (8 AM To 3:15 PM)

Parent/GUARDIAN Full Name:

Student Name


Date
 

BACKPACK PROGRAM

Theodore Jamerson Elementary School participates in the community backpack program. Community Action and United Way provide food bags to participating schools. Bags are distributed bi-weekly to students/families in need. Community Action bags contain bread and other easy-to-eat essentials.

United Way bags contain after school snacks. If your family is in need please check which bags your child/family would like. You can call TJES at any time to remove your child from the list.

*Please sign only one child to be responsible for your families’ bag.

 I would like my child to receive a United Way food bag.
(please print first and last name)

 I would like my child to receive a Community Action food bag.
(please print first and last name)

 We, do not wish to receive a food bag at this time.
(please print first and last name)