WINSTON.SALEN{/FORSYTH COUNTY SCHOOLS

WINSTON.SALEN{/FORSYTH COUNTY SCHOOLS
STUDENT INFORMATION -..-.-. INFORMACION DEL ESTUDIANTE
Last
Name/Apellido:
First
Name/Nombre: Middle Name/2do.Nombre:
Address/Direcci6n:
Student Num ber,4.,l[mero del Estudiante:
Social Security #l # de Seguro Social:
City/Ciudad:
ZiplCodigo Postal
State/Estado:
Student Accident Insurance:
Segurodeaccidente:
Date of Birth:
Fecha de nacimiento:
Birth (City, State, Country):
Age:
Grade:
Place of
Edad:
Grado:
Lugar de Nacimiento: (Ciudad, Estado, Pais):
[ ]yes [ ]No
[ ]Walker/Camina [ ]Car riderA/a en Auto
[ ] Bus rider/Va en Autobris
Bus #
am:
Bus # pm:
RACE AND GENDER. WS/FCS is required by law to file statistical reports regarding students' race and gender. The following information
optional. It will not be used to discriminate against your child with respect to any programs or activities provided by WS/FCS.
RAZA Y GENERO. El gobierno federal y estatal requiere que WS/FCS haga reportes estadisticos acerca de la raza y g6nero de los estudiantes. Esta
is
informaci6n es opcional. No ser6 usada para discriminar a los estudiantes con respecto a programas o actividades proveidas por WS/FCS.
Race: [ ]Asian/ Pacific Islander/Asi6tico/ Islef,o
[ | White/Blanco
I Male/Masculino:
I lAmerican Indian/lndio Americano
Raza: I I Black/African-American/Africano Americanol lHisoa n ic/Hisoano
I lMulti-raciallDe razas mriltioles
I Female/Femenino:
Father's Last Name /Apellido del Padre:
Home Phone lTellcasa.
Work Phone
First Name i Nombre:
Employer / Empleador:
Employer Address i Direcci6n del trabajo:
Mother's Last Name / Apellido de la madre:
Home Phone lTellcasa'.
Work Phone / Tel/trabajo
First Name / Nombre:
Employer / Empleador:
Employer Address / Direcci6n del trabajo:
Guardianns Last Name /Apellido del E,ncargado
(If not mother or father/si no es padre o madre)
Home Phone /Tel/casa:
Work Phone lT elltrabajo
First Name / Nombre:
Employer / Empleador:
Employer Address / Direcci6n del trabajo:
Cell Phone /Tel-celular
lT ell trabajo
Cell Phone /Tel-celular
Cell Phone /Tel-celular
MARITAL STATUS. If the parents are separated or divorced, the school
needs the following information to determine the legal rights of the
parents. As a general rule, both parents have an equal right to make decisions regarding their child's education, to visit with their child at school,
and to access their child's education records. These rights may be restricted to one parent by court order or agreement.
ESTADO MARITAL. Si los padres del estudiante est6n divorciados o separados, la escuela necesita la siguiente informaci6n para determinar los derechos
de los padres. Como regla general, los dos padres tienen
a tener acceso a sus exoedientes escolares.
Parent's marital status/
Estado marital de los
Padres:
I
[
el
mismo derecho en hacer decisiones sobre la educaci6n de sus hijos, a visitarlos en la escuel4 y
] Married/Casados
[
] Separated/Separados
I I Divorced/Divorciados
lSinele/Soltero(a)
lWidow/Viudo(a)
Ifseparated or divorced, who has custody? /Si separado(a) o divorciado(a) iquidn tiene la custodia?
[ ] Father/Padre
[ ]Mother/Madre
[ ] Other/Otro
[ ] Joint/Juntos
How was custody awarded? /;C6mo recibi6 la custodia? [ ]OralAVritten Agreement/Acuerdo oral/escrito [ ]Court Order/Orden de la Corte
Does the court order or separation agreement limit the non-custodial parent's rights? / 6Ha limitado la corte los derechos del padre sin custodia?
I lYes/Si I j No .............If yes, what rights are limited or restricted? / Si es asi, ique derechos han sido limitados?
I I Educational decisions/Decisiones de educaci6n
I I Visitation/Visitas
I I Access to records/Acceso a expedientes
EMERGENCY INIORNIATION-P|ease list person(s) who you authorize to pick-up your child or to act for you,in an emergency.
INFORMACION DE EMERGENCIA- Por favor nombre las oirsonas a ouidn Ud. autoriza a recoser al estudiante Ln .^o de emersencia.
Name/Nombre:
Relation/Relaci6n
llome Phone /Tel/casa:
Cell Phone /Tel-celular
Work Phone lT elltrabajo
Name,AIombre:
Relation/Relaci6n
Name of after school care provider /
persona que cuida al estudiante despuds de
Address/Direcci6n:
la escuela:
Home Phone lTel/casa:
Work Phone lT elltrabajo
Cell Phone /Tel-celular
Work Phone lT elltrabajo
Cell Phone /Tel-celular
EDUCATIONAL INFORM.A.TION
INFORMACIOlY EDUCACIONAL
For new enrollees or students transferring schools only
56lo para nuevos estudiantes o estudiantes transferidos
Name of School Last attended / Escuela que asisti6 anteriormente:
Street Address / Direcci6n:
City / Ciudad:
Grade / Grado:
Date enrolled / Fecha que comenzo:
Zip
Countrv / Pais:
Code / C6digo Postal:
Date exited / Fecha que termin6:
Was this student prwiously enrolled in this school system? J I Yes [ ] No If yes, give name of school & year attended:
;El estudiante ha aiiitido anteriormente a las escuelas de Winston Salem?[ ] Si t I No Si es asi, dd el nombre de la escuela y el affo
oue asisti6:
Name / Nombre:
Year / Aflo
What is the primary language spoken in the home? iCuril
es el idioma
principal que se habla en la casa.
I lEnglish/lngles [ ] Spanish/Espaflol [ ]Other-describe/Otro-describir
Name(s) of brothersfuisters in schodl l Nombres de hermanas(os) que van a la escuela
School they attend/Escuela que asisten
Giade/Grado:
Please provide any emergency medical information the school needs for the health, safety and welfare of your child:
Por favor proveer cualquier informaci6n m6dica de emergencia que la escuela necesite para la salud, seguridad y bienestar de su hiio(a):
Special Education. Has this child been identified as a child with disabilities? [ | No
Educaci6n Especial. ;Ha sido el estudiante identificado con incapacidades? [ ] No [
[
(AU)
Autismo
I
I Developmental Delay (DD)
[
] Learning Disability
Retrasado
(LD)
Incapacidad de Aprendizaje
I j Traumatic Brain Injury (TBI)
Lesi6n Traum6tica del Cerebro
[ ] Multiple Disabilities (MU)
Incapacidades Mriltiples
Desarrollo
What
(ED)
Emocional
[ ] Intellectual Disability (ID)
Incapacidad Intelectual
[ ] Speech/Lang. Impairment (SI)
Incapacidad del Habla
[ ] Orthopedic Impairment (O!
Incapacidad Ortopddica
[ ] Visual Impairment (VI)
[
]Autism
]Emotional Disability
[ | Yes If yes, please check the area(s) of service.
]Si Si es asi, marque la(s) 6rea(s) de servicio.
[ ] Hearing Impairment (HI)
Incapacidad Auditiva
Incapacidad
[
] Deaf-Blindness (DB)
[
] Deafness (DeaQ
[
] Other Health Impairment (OHI)
Sordera-Ceguera
Sordera
Otra Incapacidad de Salud
Incapacidad Visual
child's level ofspecial education services? ;Cu6l
nivel de servicio de educaci6n especial del estudiante?
ISelf-containedProqram/Programalndependiente
DISCPLINE RDCORD. GS.SIlC-366 requires parents enrolling students into WS/FCS to provide the following information.
EXPEDIENTE DE DISCPLINA. La ley del estado, G.S. Sl I l5C-366 requiere que los padres de estudiantes registrados en WS/FS provean la
is the
I IPlan504
es el
[ ]Mainstreamed/Curriculoregular I IResource/Recurso I
siguiente informaci6n.
Was this child suspended or expelled from the school he/she last
attended?
[ ] No [ ] Yes/ Si
iEstuvo suspendido o expulsado el estudiante de la riltima escuela que asisti6?
Ifyes, what was the reason for the suspension/expulsion?
/
Si es asi, icu6l fue laraz6n de la suspensi6n o expulsi6n?
Hasthischildbeenconvictedofafelony?/ l,Hasidoel estudianteconvictodeunaofensa?
If
yes, what was the date of conviction? Si es asi, 6cu6l fue la fecha de convicci6n?
If
yes, what was the offense?
/
[]No [
]Yes/Si
Si es asi, ;cu6l fue el crimen?
CERTIFICATION: I, the undersigned parent, guardian or caretaker of the child named above, certify that all of the information provided
above is true to the best of my knowledge and belief.
VERIFICACION: Yo el padre o tutor del estudiante, verifico que toda la informaci6n provista es verdadera.
Signature of Parent, Guardian, or Caretaker: / Firma del Padre o Encargado:
Revised by Newcomer Center 4/08
Date: / Fecha:
WINSTON SALEM FORSYTH COLNTY SCHOOLS
School Escuela)
PERMISSION TO SECURE MEDICAL CARE
Permiso paru obtener Servicios Midicos
Dear Parent or Guardian: Estimados padres defamilia o guardianes'.
It is extremely important that the school have on file current information for emergency use
regarding your place of employment, work hours, names and telephone numbers of neighbors,
relatives, baby-sitters, and child care providers. Please make an effort to keep this information on
your child's record up-to-date. En caso de una emergencia, es muy importante que la escuela tenga
archivada la siguiente informaci1n: el lugar de su empleo, su horario de trabajo, los nombres y ruimeros
de vecinos o parientes. Por favor inJ6rmenos de cualquier cambio de direcciin o telifonos,
In the event that your child becomes seriously ill or injured while at schoolo the school will take
action as outlined below: Si su hijo(a) se enferma o sufre un accidente en la escuelq, la escuela tomara
acciin de acuerdo a lo siguiente:
l. Appropriate first aid witl be administered immediately when the situation calls for it. Se le
dardn los primeros auxilios si la situaciin asl lo exige.
2. In extreme emergencies, your child will be taken immediately to the hospital emergency room
by ambulance or private vehicle and you will be contacted and advised of the situation. In most
cases, however, efforts will be made to contact you first and seek your advice concerning the
action to be taken by the school. En caso de una emergencia muy grave su hijo(a) serd llevado al
servicio de emergencia del hospital en ambulancia o en carro privado. Usted sera avisado de
inmediato. En la mayorla de los casos la escuela tratara de llamar a los padres primero para pedir
consejo en cuanto a la acci1n a tomar.
3. In the event you cannot be located, or in extreme emergencies, school officials will decide
whether immediate medical treatment is needed and will act accordingly. In order to assure
that proper medical treatment can be obtained under the conditions described above, the school
system requests that you complete the form below giving the school permission to obtain
medical treatment for your child and certifying that you will accept the financial responsibility
for payment of any ambulance, hospital and/or physicians.
Si no podentos encontrar a los padres o en extrema urgencia, los oficiales de la escuela decidirdn si
se necesitct tratamiento mddico inmediato. Para que la escuela se pueda asegurar que el tratamiento
m,ldico se aplique seg[m lqs condiciones mencionadas arriba, el sistema escolar exige que complete
la informaciin de abajo. Laforma certifica que usted autoriza a la escuela a obtener tratamiento
mddico para su hijo(a).Tambien que usted acepta la responsabilidad de pagar el costo de lq
ambulancia, hospital y/o el costo de los midicos.
I, the undersigned, give permission to the Winston-Salem/Forsyth County School System and my
child's school to act in my behalf in my absence or in emergency situations to obtain medical
treatment for my child
I agree to accept full responsibility for the payment of all ambulance, hospital and physicians for
any services rendered.
Phone
Date
Parent's Signature
Yo, el que firma, doy permiso al sistema escolar de Winston-Salem/Forsyth County y a la escuela de mi
hijo(a), para que puedan actuar en mi lugar en mi ausencia y en caso de emergencia para obtener
tratamiento mddico para mi hijo(a)
Acepto la responsabilidad completa de pagar los servicios de ambulancia, hospital y/o mddicos,
Firma del Padre/guardidn
Fechq
_Teldfono
MedicalInsurance(SeguroM6dico)-PolicyNumber(nirmerodepo1iza)-
preferencia):
_
Hospital_
Forsyth
Baptist Hospital
Check your preference (marque su
Name of nearest Relative or friend and relationship (Nombre del Pariente mds cercano o amigo y
Phone (teldfono)
relaci6n con su htjo(a)
ffi
Lti
Wi
I
l:
_/f
nston-Salem/Forsyth Gou nty Schools
Student Health History and
Emergency Medical information
Student's Name:
School:
Parent, Guardian, Caretaker Name:
Graoe:
Home Telephone:
Work Telephone:
Date of Birth:
Please complete this brief health history form and return it to your child's teacher or
This information is needed to care for your child in case of illness or injury and
needs at school. lf your child needs medication at school, an Administration of
completed and returned to the teacher or school. The form can be obtained at
secretary if you need to talk with the school nurse.
school as soon as possible.
to meet your child's health
Medication Form must be
school. Contact the school
The information contained on this form is confidential as provided by federal law, the Family Education Rights
and Privacy Act, FERPA, 20 USC 12329 and state law. Only those school employees with a good educational
reason may access and inspect this form. The school nurse has the right of access to this form. ln a health
related emergency, emergency personnel may be granted access to the information on this for.m.
Where does the child receive health care:
Name of Doctor/Clinic:
r
Name of Dentist:
Date of last physical exam:
erepnone:
Telephone:
Date of last dental exam:
Does your child have:
AllergiesIYesnruo
Asthma
nYesnNo
Diabetes
n
Yes
flruo
SeizuresIYesnNo
Vision Problem
I
Yes
E
Hearing Problem
E
Yes
D
Heart Problem
I
Yes
I
D
lf yes, what is your child allergic to:
ls medication needed at school:
E
Yes
E
No
lf yes, when was last attack?
ls medication needed at school:
E
Yes
E
No
lf yes, does your child need a diabetes care plan?
ls medication needed at school:
D
Yes
E
No
lf yes, when was last seizure?
ls medication needed at school:
E
Yes
E
No
E
No
Does your child wear glasses or contiacts?
ruo
tto
No
Does child have a hearing toss?
rI yes, name proDrem:
n
Orthopedic Problem
Yes
No
Other health problems. lf yes, please
E
Yes
E
No
E
Yes
E Yes E No
ls medication needed at school: E Yes E No
ls exercise limited? E Yes D No
Does child wear a hearing aid?
It yes, oescnDe proorem:
describe:
Was your child hospitalized or did your child have major changes in health within the past year?
n
Yes
lf yes, please describe:
Signature of parent, guardian or caretaker:
Date:
11
fl
No
Student Nome:
Porenl/Guordion Nome:
Studenl #:
Groduotion Yeor:
networked resources, oll studenls must sign ond return this form, ond ihose under oge 'lB
must obtoin porentol permission. The octivities listed below ore not permitted:
o Sending or disploying offensive messoges or pictures
a
Using obscene longuoge
a
Giving personolinformotion, such os complete nome, phone number, oddress or
identifioble photo, without permission from teocher ond porent or guordion
a
Horossing. insulling or ottocking others
a
Domoging or modifying computers, compuler systems or computer networks
a
Violoting copyrighl lows
a
Using others' posswords. logins. ond/or usernomes
a
Trespossing in others' folders. work or files
a
lnteniionolly wosting limited resources (i.e. printing)
a
Employing the network for commerciol purposes, finonciol Eoin, froud or illegol octivities.
To use
Other expectotions ore listed in the Winston-Solem/Forsyth County School Sysiem Boord Policy
(AR 6161.1) for Acceptoble Use of lnternet ond Websites.
It is understood thot occess to the lnternet through the Winston-Solem/Forsyth County School
network is o privilege thot is to be used for educotionol purposes. We hove reod ond
understond the Winston-Solem/Forsyth County SchoolStudent Network ond lnternet
Acceptoble Use Guidelines ond ogree to obide by these guidelines. We hove discussed
oppropriote.ond inoppropriote use of the computer network.
It is understood thot ony violotion of these guidelines is unethicolond moy constitute o criminol
offense. Any violotion of these guidelines will couse occess privileges to be revoked ond school
disciplinory ond/or oppropriote legol oction will be token.
Since ollfiles ore on o public network ond on equipment provided by the schoolsystem, it
understood thot these files ore subject to exominotion ond review of ony time.
Although the Winston-Solem/Forsyth County School System provides lnternet occess thot is
constontly filtered ond supervised, il is understood thot there ore text ond grophic files
ovoiloble on the lnternet which ore inoppropriote for minors. lt is olso understood thot the
sludent is ultimotely responsible for his/her octions ond the school system will not be held
responsible for moteriols which the siudent might occess.
Sludenl Signolure
Dole
Porent Signoture
Dole
is
,i:.'arr.
,iri!:ir'+::, t:ji..:1.,.:rr..1i.a+,
l:.
WINSTON.SALEh{/FORSYTH COIJNTY SCHOOLS
Trans,portation Routing Request Fomr @orma para pedir transporte)
All informqtionmtxt
be provided Do not leove ary) information
Student'sNC Wise #
Nimero de Estudiante
Student's [,astName:
Apellido del Estudiante
Steet Address:
Direcci6n
Crty:
Ciudad
Grade:
Grado
blank. Qleru todo)
Date:
Feclm
FirstName:
Nombre
Apt #
lip
Codq
Cddigo Postal
Parent LastName: (Apellido de los padres)
First Name : (Primer Nombre)
Daytime PhoneNumber: (Numero de teldfono durante el dia)
E-mail: (Coneo electrdnico)
Requested Stop
location:
Localizacidn de Pmada Solicitada
A.M:
P.M.:
in mind ftat buses can only tavel on sute or city maintained rcads and will be routed on main orprimary
rcads and not onto side sEeets or into housing developments rmless certain criteria stated in Policy 3541 arc met
Policy 3541 details the criteria for assigring bus stops in fte'1nalk zone". A complete copy of this policy can be
located on the WSiFC Schools website: htto:/lwsfcs.kl2.nc.us/
Please kcep
Por favor tenga en msnte que los autobuses puden viajar solamente e,n caminos mantenidos por el esdado o la ciudad y
serdn encaminados en los caminos principales y no sobre las calles laterales o dentro de complcjos multifrmiliares a
mcnos que se reilnan ciertos criterios declarados en la Politica 3541. La Politica 3541 detalla los criterios para asignar
paradas de autobrls en la *zona de caminar'. Una oopia completa de esta politica puede ser localiada en la pagina de
web de las escuelas de WS/FC: http://wsfcs.k12.nc.us/
Note: lf a family cannoi complete this form, additional
assistance may be needed
from an interpreter or
school personnel.
WINSTON-SALEM/FORSYTH COUNTY SCHOOLS
Revised and updated 9-19-Og
This survey must be administered'to every student prior to his/her enrollment in school. lf the answer to anv one of the ouestions reveals that
the student or familv speaks a lanquaqe other than Enqlish. the student must take an Enqlish Lanquaqe assessment (W-APT) at the
Newcomer Center 047.6804). The purpose of this English language assessment is to identify students who niay need additional academic
support as they acquire English language skills ([au. v. Nichols, U.S. Supreme Court, 197$. lf a student is identified as needing additional
English language support, parents orluardians will have the option to accept or waive ESL services.
escuela. Si la respuesta a cualquiera de estas
prequntas revela que el estudiante o la familia hablan un idioma diferente del inql6s. el estudiante deberi tomar una evaluaci6n del idioma
inql6s M APT) en el Centro de Matricula para Reci6n Lleqados. El proposito de esta evaluacion del idioma del ingles es para idenlificar a los
estudiantes que necesilen apoyo acad6mico adicionalmienkas adquieren destrezas en elidioma de inglds (Corte Suprema: Lav. Vs. Nichols 1974). Si
Este cueslionario se debe administrar a todos los estudiantes antes de ser registrados en la
el estudiante es identificado como un estudiante que necesita ayuda adicional en el idioma de ingl6s, los padres o encargados tendr6n la opcion de
aceptar o rechazar los sevicios de lngl6s como Segundo ldioma. y si es necesario, como manda la LEY FEDEML, reciba una ensenanza adecuada y
asistencia en ingl6s. Si la familia no pueden llenar esta forma, puede que necesiten asistencia adicional de un int6rprele o empleado de la
escuela.
Birthdate/Fecha de Nacimiento
Student's Name/Nombre del Estudiante
Last
(Apellido) First (Nombre) Middle (Segundo Nombre)
School/Escuela
Country of Birth/Pais de Nacimiento
Month/Day/Year Mes/DiaiAno
Grade/Grado
Phone #ffeldfono
Parent's Name/Nombre de los Padres
Address/Direcci6n
Date of Entry into US Public Schools/Fecha de entrada a las Escuelas P0blicas de EE.UU
(Do nol count Pre-K as a year in US public schools/ No cuente el Pre-kinder como un ano en las escuelas ptblicas de EE.UU.)
1.
An s wer e ach q ue s ti on c arcfully / Co
What is the first language the student learned to speak?
;Cu6l es el primer idioma que el estudiante aprendi6 a hablar?
n te ste
cai d a do s am
e
n te
:
I{hat language is most often spoken in the home?
;Qu6 idioma se habla con m5s frecuencia en la casa?
What language does the student use most often?
;Qu6 idioma el estudiante usa con m6s frecuencia?
4.
Does the student speak any other language at home qnilegulal_bagis?
;El estudiante habla otro idioma en la casa regularmente?
No
Yes/Si
lf so, what are they? /iSi es asi, cu6l es?
Do not include foreign languages'sfudied in school or solely learned through media (TV,tape,CDs, toys)/No incluya idiomas
esludiados en la escuela o aquellos aprendidos por medio de la television, casetes, CDS oTuguetes.
Signature/Firma del Padre de Familia o Encargado
Home Language Survey Date/Fecha en que se adminisho esta evaluacion
This form is to be filled out one time and placed in the student's cumulative folder.
Esta forma se debe llenar una vez y ser colocada en el expediente cumulativo.
Ronald Wilson Reagan High School
3750 Transou Rd
Pfafftown, NC 27040
336-703-6778 (Phone)
336-922-0538 (Fax)
i.t
Previous School's Name:
Telephone Number:
Has
Fax Number:
the student ever been enrolled in the $/INSTON-SALEM FORSYTH COUNTY SCHOOL
System?
lf yes, list the last school attended:
{;
:tj
:
':.i :
&
J
Student's Name
Date of Birth
Parent Signature
Date
-.r'*'#.")}u.
Request for Parent lfssistant Login
{s5r
Parent Name:
Parent Contact Numbers:
ext.
Home
Cell
Student Name(s)
Birth date:
School:
Birth date:
School:
Birth date:
School:
If separated/divorced, do you have primary physical custody? Yes
*
Work
No
Pl"ur" check. I choose to receive Parent Assistant Information:
(
) in
person
(
) via US
Mail (
) via Email - Email address:
(Please print clearly)
Your signature authorizes the school to communicate your Parent Assistant account information based on the above selection.
Signature:
ID verified by:
Date: