WELCOME TO SEATTLE PUBLIC SCHOOLS!

Help us serve you better by using the ADMISSION CHECKLIST below as you collect the

information and documents necessary to enroll your child in Seattle Public Schools.

New students are assigned to their attendance area school based on verified

residence address. ASSIGNMENT CANNOT BE MADE WITHOUT ADDRESS

VERIFICATION.

Students who need specialized services not available at their attendance area school

will be assigned to a designated “linked” school.

To find your attendance area school, use our online Address Look Up Tool. Go to

www.seattleschools.org/enrollment or call (206) 252-0760 for assistance.

Students may also apply to attend any other school in the district. Assignment

depends on space availability and the assignment rules in effect at the time of

application. If you wish to apply for another school, you will need to submit a School

Choice Form in addition to this Admission Form.

SPS is implementing a new student assignment plan, and a Transition Plan is in place

for assignment of current students, students who have moved, and returning students

previously enrolled in the district.

Non-Resident Students: If you live outside the boundaries of the Seattle School

District, please go to , www.seattleschools.org/enrollment or call (206)252-0760 to

learn about the application process and requirements.

FORMS (Please fill out all forms completely and sign where indicated.)

ADMISSION FORM

Complete all information on the following three pages and sign the form. Attach any Court documents

relating to guardianship or a parenting plan, if applicable. Sign and date.

CERTIFICATE OF IMMUNIZATION STATUS (CIS)

Washington State requires that you use the official CIS form, which must be signed by the parent/guardian.

All immunization dates MUST appear on this form! Sign and date.

SPECIAL EDUCATION FORM

For students who have an Individual Education Plan (IEP).

SCHOOL CHOICE FORM (OPTIONAL)

DOCUMENTS (Please bring or enclose a photo copy of all documents when you enroll your student.)

PHOTO ID OF THE PARENT/GUARDIAN REGISTERING THE STUDENT

If faxing a photo ID, please be sure it will be legible by making a light copy first and then faxing the copy.

TWO ADDRESS VERIFICATION DOCUMENTS (MUST CONTAIN THE PARENT’S NAME AND BE DATED WITHIN THE PAST 8 WEEKS)

Examples include: copies of current land-line telephone, utility, or cable bills; mortgage information; renters or

homeowners insurance documents; or documents from public agencies, such as Courts or DSHS. Lease or rental

agreements must include the first page and the signature page. We do not accept personal correspondence or

copies of envelopes.

BIRTH CERTIFICATE (or similar document, such as a passport) for PreK, Kindergarten, and 1st grade only.

OFFICE: 2445 Third Avenue South (M-F 8:30 to 4:00; closed at noon the third MAILING ADDRESS:

Wednesday of each month except during peak enrollment periods) SPS Service Center

WEB: www.seattleschools.org/enrollment Seattle Public Schools

FAX: (206) 252-0761 MS 11-174

E-MAIL: servicecenter@seattleschools.org PO Box 34165

Seattle, WA 98124-1165

ADMISSION CHECKLIST

ASSIGNMENT INFORMATION

Assistance for those with a

disability or who do not speak

English is available at the SPS

Service Center.

(206)252-0760

servicecenter@seattleschools.org

PLEASE NOTE!

Incomplete applications

cannot be accepted and

will delay your

student’s enrollment.

STUDENT’S LAST NAME FIRST NAME ASSIGNED TO:

ADMISSION FORM

OFFICE

USE ONLY

Residence Verification

ACP Olympia # ID

2014-15 2015-16

Rec’d By B-Date Ver Photo ID CIS Sped Health Title VII MK/Vento ELL DE

HAS STUDENT RECEIVED SPECIAL EDUCATION SERVICES…

Yes No Has student received special education services during the past three years?

Yes No Has student received special education services during the past one year?

If YES, estimated amount of time student receives special education services: 1/2 day or less More than 1/2 day

If YES, Special Education form must be completed and signed. (0-4 hours) (more than 4 hours)

DISCIPLINE

Yes No Does the student have any pending disciplinary actions; history of violent or disruptive behavior; past, current, or pending criminal or

juvenile court proceedings; or history of gang affiliation?

Yes No Does the student currently have, or has the student had in the past, a restraining order filed against him/her?

REFUGEE STATUS

Check here if student is (or was) a refugee. (A refugee, as defined by the

Office of Refugee Resettlement; an asylee; a Cuban or Haitian entrant; an

Amerasian from Vietnam; or a victim of trafficking.)

Country

of Origin

HOME LANGUAGE (do not leave blank)

Yes No Is a language other than English spoken at home?

Yes No Is your child’s first language a language other than

English?

If YES, then your child will be assessed for English language proficiency.

MIGRANT STATUS

Yes No

If yes, what language?

STUDENT INFORMATION

Check if unlisted

Last

Name

Middle

Name

First

Name

Suffix

Birth

Date

Home Phone

Grade

In 2014-15

Grade

In 2015-16

Male Female

ADDRESS INFORMATION Check here if the student is homeless or living in temporary/transitional housing. Unaccompanied Youth

Home

Address

Apt # City State ZIP

Mailing Address

(if different)

How Long At

Home Address?

TO BE COMPLETED IF NOT BORN IN U.S.

Country

of Birth

Date of

Entry

MEDICAL AND HEALTH INFORMATION

Yes No During school hours, does your child require a non-oral medication? (Ex. Injection, eye/ear drops, application to skin, suppository, central

line)

Yes No During school hours, does your child need help with a medical procedure? (Ex. Blood sugar, NG feeding, sterile catheterization)

Yes No Does your child have a condition which causes the daily possibility of a life-threatening emergency? This includes life-threatening

allergies, diabetes, and some seizures.

If you answered “YES” to any of the above three medical/health questions,

please request a Health Packet and contact your school nurse, if available, or Health Services at 252-0750.

Physician, Clinic or

Health Care Provider

If yes, please

state what it is.

Phone

Number

PREVIOUS SCHOOL (Include Pre-K if applicable) Has student completed high school or a parallel international program? Yes No

Yes No Was student suspended or expelled from this school?

Yes No Has student been suspended or expelled from any school?

Name of

School

Current or Most

Recent Grade

If answer “Yes” to any questions in this section, please explain.

Date of Last

Attendance

Street

Address

City

State

ZIP

Have you or your family moved within the past three

years to seek or obtain temporary or seasonal work as a

primary means of livelihood?

INFORMATION FOR PARENTS/GUARDIANS

*Does the address and parent/

guardian information on this form

also apply to this sibling?

Yes No

*Does the address and parent/

guardian information on this form

also apply to this sibling?

Yes No

*Does the address and parent/

guardian information on this form

also apply to this sibling?

Yes No

WHO HAS

LEGAL CUSTODY?

Both Parents

Father

Mother

Grandparent(s)

Guardian(s)

Ward of Court

Parenting Plan

Independent

STUDENT

LIVES WITH…

Both Parents

Father

Mother

Grandparent(s)

Guardian(s)

Agency/Social

Services

Foster Parent(s)

Alone

Student’s

Spouse/Partner

Other Relative(s)

Copy of Court Order,

Parenting Plan, or

other legal

documents may be

required.

EMERGENCY CONTACTS

SIBLINGS (Please list any siblings currently living at the same address. If more than three, please request a sibling addendum.

Current School Status SPS* Private or other district Not in school

First

Name

Last

Name

Birth

Date

Current School Status SPS* Private or other district Not in school

First

Name

Last

Name

Birth

Date

Current School Status SPS* Private or other district Not in school

First

Name

Last

Name

Birth

Date

Address same

as students?

Yes No

Living with student?

Yes No

Emergency Contact?

Yes No

Does parent/guardian

speak English?

Yes No

Relationship

To Student

Employer

First

Name

Last

Name

Work

Phone

Home Address (if different than student’s)

Home

Phone

Parent/Guardian language(s), if other than English

Spoken

Correspondence

Cell

Phone

Address same

as students?

Yes No

Living with student?

Yes No

Emergency Contact?

Yes No

Does parent/guardian

speak English?

Yes No

Relationship

To Student

Employer

First

Name

Last

Name

Work

Phone

Home Address (if different than student’s)

Home

Phone

Parent/Guardian language(s), if other than English

Spoken

Correspondence

Cell

Phone

Address same

as students?

Yes No

Living with student?

Yes No

Emergency Contact?

Yes No

Does parent/guardian

speak English?

Yes No

Relationship

To Student

Employer

First

Name

Last

Name

Work

Phone

Home address (if different than student’s)

Home

Phone

Parent/Guardian language(s), if other than English

Spoken

Correspondence

Cell

Phone

Last

Name

First

Name

Relationship

To Student

Home

Phone

Other/Cell

Phone

Last

Name

First

Name

Relationship

To Student

Home

Phone

Other/Cell

Phone

Last

Name

First

Name

Relationship

To Student

Home

Phone

Other/Cell

Phone

STUDENT ETHNICITY AND RACE

INSTRUCTIONS: This form is to be filled out by the student’s parents or guardians, and both questions must be answered. Part A asks about

the student’s ethnicity and Part B asks about the student’s race.

Is your student of Hispanic or Latino origin? If yes, check all that apply. A

Seattle Public Schools provides Equal Educational Opportunity without regard to race, creed, color, religion, age, ancestry, national origin, economic

status, gender, sexual orientation, gender identity, pregnancy, marital status, families with children, honorably discharged veteran or military status,

physical appearance, or mental, physical or sensory disability.

The District complies with all applicable state and federal laws and regulations to include, but not limited to, Title IX, Title VI of the Civil Rights Act, Section

504 of the Rehabilitation Act, RCW 49.60 “The Law Against Discrimination,” and covers, but is not limited to, all District programs, courses, activities,

including extra-curricular activities, services, access to facilities, etc.

The Title IX Officer and 504 Coordinator with the overall responsibility for monitoring, auditing, and ensuring compliance with this policy is: Manager,

Office of Equity and Compliance Officer, P.O. Box 34165, Mail Stop 33-157, Seattle, WA 98124-1165. Phone: (206) 252-0024. Individuals who believe they

have been discriminated against in any of the District’s educational or employment activities can file an internal discrimination complaint with the

District’s Office of Equity and Compliance.

Not Hispanic/Latino

Central American

Cuban

Dominican

Latin American

Mexican/ Mexican American/ Chicano

Puerto Rican

South American

Spaniard

Other Hispanic/Latino

What race(s) do you consider your child?

Check all that apply. Please circle your primary choice. A

Office Use: Obsv Init

African American/ Black

White

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Indonesian

Japanese

Korean

Laotian

Malaysian

Pakistani

Singaporean

Taiwanese

Thai

Vietnamese

Other Asian

Makah

Muckleshoot

Nisqually

Nooksack

Port Gamble Klallam

Puyallup

Quileute

Quinault

Samish

Sauk-Suiattle

Shoalwater

Skokomish

Snoqualmie

Spokane

Squaxin Island

Stillaguamish

Suquamish

Swinomish

Tulalip

Yakama

Other Washington Indian

Other American Indian

Office Use: Obsv Init

Native Hawaiian

Fijian

Guamanian Or Chamorro

Mariana Islander

Melanesian

Micronesian

Samoan

Tongan

Other Pacific Islander

Alaska Native

Chehalis

Colville

Cowlitz

Hoh

Jamestown

Kalispel

Lower Elwha

Lummi

PARENT/GUARDIAN STATEMENT:

I certify that all of the information I have provided is true and accurate. I understand that falsification of any information or submission of

misleading information will be cause for revoking the student’s school assignment, that failure to provide supporting documentation may delay

the processing of this application or result in the revocation of my child’s assignment, and that my child may be excluded from school if

immunizations are not current. I understand that Seattle Public Schools may take steps to verify my address, including review of public

documents and contacting other government agencies, without further notification. I authorize the request of this student’s records from the

previous school, if applicable.

Signature of Parent/Guardian _________________________________________________

Please Print Name __________________________________________________________ Date ____________________________

Print Application

Save Application

Every student achieving, everyone accountable McKinney-Vento- Families in Transition

Student Housing Questionnaire 2014-15

*Information on this form is CONFIDENTIAL

NAME OF STUDENT: ____________________ ____________________ _________________________

FIRST MIDDLE LAST

NAME OF SCHOOL: ______________________ BIRTH DATE: _____________ GRADE:_____ SEX:F/M

Please list all of YOUR preschool and school-aged children currently living with you (PLEASE PRINT).

Name: _____________________________ Birth Date: ____________ School: ______________________

The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act

42 U.S.C. 11435.

1. Is this a temporary living arrangement due to a loss of housing or economic hardship? □YES □NO

2. Is this student awaiting foster care? □YES □NO

3. As a student, are you living with someone other than your parent or guardian? □YES □NO

*If you answered YES to any of the above questions, please complete the remainder of this form.

Where is the student currently living? (Check box)

□In a motel □In a shelter

□With more than one family in a house or apartment □Moving from place to place

□Group Home □Park or campsite

□Transitional Housing

ADDRESS OF CURRENT RESIDENCE: ____________________________________________________

NAME OF MOTEL/SHELTER OF CURRENT RESIDENCE: ______________________________________

PHONE NUMBER OR CONTACT NUMBER:__________________ NAME OF CONTACT: ______________

PRINT NAME OF PARENT(S)/LEGAL GUARDIAN

_________________________________________________________

SIGNATURE of Parent /Legal Guardian: ______________________________________________

Date:___________________

*For School Staff Only: Forward completed questionnaire to the McKinney-Vento Liaison. Dinah Ladd or Jolene Taylor McKinney Vento

Coordinator at Mail Stop 33-182 or Fax 206-252-0791

(Updated 06/13)