daim ntawv tso npe rau lub tsev kawm ntawv ib cheeb tsam anchorage

Office Only School Name/Code:____________________________________________________School Entry date: _______/_______/______
Student District ID: _________________Student State ID (SSID):_________________
DAIM NTAWV TSO NPE RAU LUB TSEV KAWM NTAWV IB CHEEB TSAM ANCHORAGE (ADS) QIB K-12
Niam Txiv/Tus Saib Xyuas Menyuam teb Tshooj I-V kom tiav. Thov siv tus cwjmem xim dub lossis xim xiav sau.
I. TEJ YAM UAS QHIA TXOG TUS NEEG KAWM NTAWV
1. Tus neeg kawm ntawv lub Xeem
Tus neeg kawm ntawv lub Npe
Tus neeg kawm ntawv lub
npe Nrab
2. Tus Neeg Kawm
Ntawv hnub yug:
HLI/HNUB/XYOO:
____/____/_____
4. Poj Niam/Txiv Neej:
5. Tus neeg kawm ntawv puas yog haiv neeg Hispanic (Haiv Neeg Mev Hispasniv) lossis Latino (Haiv
Neeg Mev Lastinaum)? Yog Tsis Yog
5a. Xaiv ib lossis ob ntawm hom haiv neeg no: Neeg Dawb Neeg Esxias Neeg Dub Neeg
Keeb Kwm AK Neeg Khab Asmesliskas
Neeg Keeb Kwm Hawaii (Hasvaisis) lossis Haiv Neeg Nyob Thooj Av Hauv Dej Hia Txwv Pacific
3. Nyob Qib Li Cas:
 Txiv Neej
 Poj Niam
6. Tus neeg kawm ntawv hom lus hais tom tsev:
Ob Tug Ntawv Lawv Qab
Lub Npe (Suffix)
7. Tus neeg kawm ntawv thawj hom lus:
8*. Thawj tus xovtooj tseem ceeb: ntawm tes  hauv tsev
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)___________________________
 Tsis pom tshwm nrog lwm cov xovtooj
*Tus xovtooj no siv nug txog kev
(Unlisted) *
mus kawm ntawv thiab tej ntaub
Tso Lus Xwb
ntawv ubno.
11. Tus neeg kawm ntawv qhov chaw nyob:
9. Tus xovtooj thaum nruab hnub rau xwm ceev: (Rau cov xovtooj uas lub tshuab hu tau thaum muaj xwm
ceev – cov xovtooj uas hu tau ncaj qha rau xwb; yuav tsum muaj)
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10. Lwm tus xovtooj uas qhia tau lus rau: (Rau cov xovtooj uas lub tshuab hu tau thaum muaj xwm ceev thiab hu
qhia lus rau; tsis muaj los tau)
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Nroog, Xeev:
ZIP + 4:
12. Tus neeg kawm ntawv qhov chaw xa ntawv yog tias nws txawv qhov chaw nyob:
13. Tus neeg kawm ntawv qhov email (Xav tau yog HS tus menyuam kawm ntawv kawm raws on-line)
15. Tus Nab Npawb Tsheb Npav Sawv Ntxov:
Tus Nab Npawb Tsheb Npav Tsaus Ntuj:
Lwm lub npe uas tus neeg kawm ntawv
siv.
Nroog, Xeev:
ZIP + 4:
14. Qhov chaw yug:
Qhov chaw mus tos nce tsheb npav thaum sawv ntxov – yog txawv
ntawm tus menyuam kawm ntawv lub tsev:
Lub tsheb npav mus tos nce tsheb sawv ntxov tus nab
npawb xovtooj:
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16.  Yog muaj cai raug xaiv, kuv tus menyuam yuav
Qhov chaw nqis tsheb npav thaum yav tsaus ntuj – yog txawv ntawm tus
Lub tsheb npav xa mus nqis tsheb thaum yav tsaus ntuj
caij lub tsheb npav
menyuam kawm ntawv lub tsev:
tus nab npawb xovtooj:
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17. Ib daim ntawv txib los tom lub tsev hais plaub puas cuam tshuam rau tus menyuam kawm ntawv?
 Yog  Tsis yog (Yog yog, thov theej ib daim ntawv raug cai xa mus rau tom
lub tsev kawm ntawv chav lis haujlwm.)
18. Puas yog tus menyuam: Kawm Lub Tsev Kawm Ntawv Hauv Lub Zos?  Yog  Tsis yog Mus kawm ib Lub Tsev Kawm Ntawv Muaj Tswv?  Yog  Tsis yog
Lub Tsev Kawm
Ntawv Muaj Tswv/Lub Tsev Kawm Ntawv Hauv Lub Zos Lub Npe: ____________________
Puas Yog Ib Tus Menyuam Kawm Ntawv Txawv Tebchaws?  Yog  Tsis yog Puas yog tus menyuam kawm ntawv ntawm tsoomfwv lub tsev kawm ntawv qub/lub tsev kawm ntawv muaj tswv
Theem Xub Pib?  Yog  Tsis Lub Tsev Kawm Ntawv Theem Xub Pib Lub Npe: __________________
II. Sau tshooj no kom tiav yog koj tus menyuam TSIS TAU mus kawm rau tom Lub Tsev Kawm Ntawv Ib Cheeb Tsam Anchorage kom mus txog thaum kawg
ntawm xyoo ua ntej yuav kawm ntawv.
19. Thov sau sau cov npe tejyam keeb kwm ubno qub thaum kawm hauv Lub Tsev Kawm Ntawv Ib Cheeb Tsam Anchorage thiab suav nrog thaum kawm hauv Lub Tsev Kawm Ntawv Xub Pib:
(Yog xav sau rau lwm nplooj ntawv ntxiv, mus ntsib tus kws saib xyuas cov ntaub ntawv tso npe.)
Lub npe tsev kawm ntawv:___________________________ Chaw nyob:________________________________Nroog:__________________Xeev:_______ Zip: _________
Tsev kawm ntawv tus nab npawb xovtooj (_________) _________________ Hnub mus kawm ntawv zaum kawg:____/____/____ Cov xyoo mus kawm:______ Qib kawm xyoo zaum
kawg:_____________
20. Yav dhau los puas yog tau mus tso npe kawm hauv ASD (suav txog Lub Tsev Kawm Ntawv Xub Pib)?  Yog*  Tsis yog *Yog yog, lub npe tsev kawm ntawv_________________________
xyoo kawm zaum kawg dhau los______
21. Tamsis no lossis yav dhau los tus menyuam xeem puas tau qhov kev kawm IEP?
 Yog  Tsis yog
22. Puas yog tamsis no tus menyuam puas muaj hom kev npaj 504?
 Yog  Tsis yog
III. COV KWVTIJ VIV-NCAUS LOSYOG NUS-MUAM COV NTAUB NTAWV (Yog xav sau rau lwm nplooj ntawv ntxiv, mus ntsib tus kws saib xyuas cov ntaub ntawv tso npe.)
24. Yuav sau tshooj no kom tiav yog muaj. Tsuas suav cov kwvtij viv ncaus losyog nus-muam xwb uas tamsis no yog tus tau tso npe kawm rau Qeb K-12 rau hauv Lub Tsev Kawm
Ntawv Ib Cheeb Tsam Anchorage.
Tus kwvtij losyog viv ncaus losyog nus-muam 1 lub npe thiab lub xeev:
Qib kawm:
Lub npe tsev kawm ntawv:
Tus kwvtij losyog viv ncaus losyog nus-muam 2 lub npe thiab lub xeev:
Qib kawm:
Lub npe tsev kawm ntawv:
Tus kwvtij losyog viv ncaus losyog nus-muam 3 lub npe thiab lub xeev:
Qib kawm:
Lub npe tsev kawm ntawv:
Address/Boundary Information
FOR OFFICE USE ONLY
1. Home address verified:  Yes*  No *If yes: Date:____/____/____ Address verification document:_____________________________________________
2. Birth verification basis:  Birth Certificate  Affidavit (3 required) ______________________, _________________________, __________________________
3. Immunizations verified  Yes*  No *If yes: Date:____/____/____
4. School of residence:____________________________________________________5. District of residence:____________________________________________
6. Boundary exception: Transfer Type:  In-District  Out-of-District
Reason:  Continuing Current Exemption  Educational Program  Grandfathered  Medical/Extenuating  NCLB School Choice
 NCLB Victim  Open Enrollment  Special Education
7. Copy of court order legal documentation was provided by parent/guardian.  Yes  No
Received Date:____/____/____
8. Federal Impact data entered in Zangle?  Yes  No
IV. TEJ YAM UAS QHIA TXOG THAWJ TUS NEEG UAS YUAV HU RAU
25.
TUS NEEG THIB 1 UAS YUAV HU RAU.
Lub npe tuav hu (kos ib qho):
Tus neeg uas yuav hu rau lub npe
tagnrho (lub xeem, lub npe):
Tus neeg uas yuav hu rau yog
leejtwg:
Kev txheeb ze rau tus menyuam
kawm ntawv:
Tus neeg uas yuav hu rau puas
nyob nrog tus neeg kawm ntawv:
(Tus lej tsev & Txoj kev)
(Nroog, Xeev, Zip+ 4)
Tseem Yog Tub Rog:
 Yog  Tsis yog
Lub Npe ntawm Tsoomfwv Lub
Chaw
(xws li nce raws tsev haujlwm tub
rog, BLM, ANSCA)
Tus tswvnum tus neeg tiv tauj lub
npe:
Qhov chaw tiv tauj:
(Xav tau yog nyob ntawm
Tsoomfwv Lub Chaw)
Tus xovtooj tiv tauj hauv tsev:
Tus xovtooj tiv tauj ntawm tes
Tus xovtooj tiv tauj tom chaw ua
haujlwm:
Hom lus tiv tauj nrog koj tham:
 Mr.
 Mrs.
NIAM TXIV/TUS SAIB XYUAS
 Ms.
TUS NEEG THIB 2 UAS YUAV HU RAU
LWM TUS NIAM TXIV/TUS
SAIB XYUAS
 Mr.
 Mrs.
 Ms.
Khij ib qho xwb: Niam txiv Tus saib xyuas
Khij ib qho xwb: Niam txiv Tus saib xyuas
Khij ib qho xwb:  Niam  Txiv  Niam Tshiab  Txiv Tshiab
 Niam qhuav  Txiv qhuav  Pog/niam tais  Yawg/yawm txiv
 Phauj/niam tais/niam ntxawm/niam hlob  Txiv hlob/txiv ntxawm/dab laug
 Nus muag  Tus saib xyuas uas lub tsev txiav txim plaub ntug pom zoo
 Tus Sawv Cev Tom Ib Lub Chaw Haujlwm
 Lwm yam kev txheeb______________________________
Yog Tsis Yog*
*Yog tias tsis yog, sau qhov chaw koj nyob kom
txhij rau qhov no:
__________________________________________________
___________________________________________________
 Yog  Tsis yog Tub Rog Ceev Tseg
 Tsis ua ntxiv lawm
Qib:____________________________________
Lub Chaw Haujlwm Tub Rog:__________________________
 Tseem ua Nat. Guard/A.D.O.S.  Nat. Guard Coj Li Qub
 Tsem ua Pej Xeem Tus Rog/Title X  Pej Xeem Tus Rog Coj Li Qub
 Tsis ua Tus Rog Ntxiv los Tus Rog So
Khij ib qho xwb:  Niam  Txiv  Niam Tshiab  Txiv Tshiab
 Niam qhuav  Txiv qhuav  Pog/niam tais  Yawg/yawm txiv
 Phauj/niam tais/niam ntxawm/niam hlob  Txiv hlob/txiv ntxawm/dab laug
 Nus muag  Tus saib xyuas uas lub tsev txiav txim plaub ntug pom zoo
 Tus Sawv Cev Tom Ib Lub Chaw Haujlwm
 Lwm yam kev txheeb________________________________________
Yog Tsis Yog*
*Yog tias tsis yog, sau qhov chaw koj nyob kom
txhij rau qhov no:
______________________________________________________
______________________________________________________
 Yog  Tsis yog Tub Rog Ceev Tseg
 Tsis ua ntxiv lawm
Qib:____________________________________
Lub Chaw Haujlwm Tub Rog:__________________________
 Tseem ua Nat. Guard/A.D.O.S.  Nat. Guard Coj Li Qub
 Tsem ua Pej Xeem Tus Rog/Title X  Pej Xeem Tus Rog Coj Li Qub
 Tsis ua Tus Rog Ntxiv los Tus Rog So
Nroog:
Nroog:
Xeev:
Zip:
Xeev:
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Zip:
Chaw nyob tiv tauj email
 Kev Coj Cwj Pwm  Kev Noj Qab Haus Huv  Tsev Kawm Ntawv Lus
 Kev Coj Cwj Pwm  Kev Noj Qab Haus Huv  Tsev Kawm Ntawv Lus
Tshaj Tawm
Tshaj Tawm
 Tso Cai Rau Tus Tiv Tauj Coj Menyuam Mus Tsev
 Tso Cai Rau Tus Tiv Tauj Coj Menyuam Mus Tsev
 Tso Cai Nkag Mus Siv Web (ParentConnect)
 Tso Cai Nkag Mus Siv Web (ParentConnect)
Thov muab tej yam uas qhia ntxiv txog lwm cov neeg uas yuav hu tau tso rau hauv qab. Peb yuav siv qhov no yog tias peb hu tsis tau rau Tus (cov) Thawj Tus Neeg Uas Yuav Hu Rau.
Tus tiv tauj xav tau nkag mus rau
ntawm tus menyuam kawm ntawv
cov ntawv teev num:
V. TEJ YAM UAS QHIA TXOG TUS NEEG THIB OB UAS YUAV HU TAU RAU
26.
TUS NEEG THIB 3 UAS YUAV HU TAU RAU
Tus neeg uas yuav hu rau lub npe
tagnrho:
Yog Tsis Yog*
*Yog tias tsis yog,
Tus neeg uas yuav hu tau rau
chaw koj nyob kom txhij rau qhov no:
qhov chaw nyob
(Tus lej tsev & Txoj kev)
____________________________________
(Nroog, Xeev, Zip + 4)
____________________________________
Khij ib qho xwb: Niam txiv Tus saib xyuas
Tus neeg uas yuav hu rau yog
Lwm Yam
leejtwg:
Khij ib qho xwb: Niam Txiv  Niam Tshiab
Kev txheeb ze rau tus menyuam
Txiv Tshiab
kawm ntawv:
 Niam qhuav  Txiv qhuav  Pog/niam tais
 Yawg/yawm txiv Phauj/niam tais/niam
ntxawm/niam hlob Txiv hlob/txiv ntxawm/dab
laug Nus muag
Lwm yam kev
txheeb_______________________
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Tus xovtooj tiv tauj hauv tsev:
Tus xovtooj tiv tauj ntawm tes
Tus xovtooj tiv tauj tom chaw ua
haujlwm:
Tus tiv tauj xav tau nkag mus rau
ntawm tus menyuam kawm ntawv
cov ntawv teev num:
TUS NEEG THIB 4 UAS YUAV HU TAU RAU
TUS NEEG THIB 5 UAS YUAV HU TAU RAU
Yog Tsis Yog*
*Yog tias tsis yog,
chaw koj nyob kom txhij rau qhov no:
____________________________________
____________________________________
Khij ib qho xwb: Niam txiv Tus saib xyuas
Lwm Yam
Khij ib qho xwb: Niam Txiv  Niam Tshiab
Txiv Tshiab
 Niam qhuav  Txiv qhuav  Pog/niam tais
 Yawg/yawm txiv  Phauj/niam tais/niam
ntxawm/niam hlob  Txiv hlob/txiv ntxawm/dab
laug  Nus muag
 Lwm yam kev
txheeb_______________________
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Yog Tsis Yog*
*Yog tias tsis yog, chaw
koj nyob kom txhij rau qhov no:
______________________________________
______________________________________
Khij ib qho xwb: Niam txiv Tus saib xyuas
Lwm Yam
Khij ib qho xwb: Niam Txiv  Niam Tshiab
Txiv Tshiab
 Niam qhuav  Txiv qhuav  Pog/niam tais
 Yawg/yawm txiv  Phauj/niam tais/niam
ntxawm/niam hlob  Txiv hlob/txiv ntxawm/dab laug
 Nus muag
 Lwm yam kev
txheeb_______________________
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Khij txhua qhov uas tsim nyog:
 Tso Cai Rau Tus Tiv Tauj Coj Menyuam Mus
Tsev XWB
 Kev Coj Cwj Pwm  Kev Noj Qab Haus Huv
 Tsev Kawm Ntawv Lus Tshaj Tawm
 Tso Cai Nkag Mus Siv Web (ParentConnect)
Khij txhua qhov uas tsim nyog:
 Tso Cai Rau Tus Tiv Tauj Coj Menyuam Mus
Tsev XWB
 Kev Coj Cwj Pwm  Kev Noj Qab Haus Huv
 Tsev Kawm Ntawv Lus Tshaj Tawm
 Tso Cai Nkag Mus Siv Web (ParentConnect)
Khij txhua qhov uas tsim nyog:
 Tso Cai Rau Tus Tiv Tauj Coj Menyuam Mus
Tsev XWB
 Kev Coj Cwj Pwm  Kev Noj Qab Haus Huv
 Tsev Kawm Ntawv Lus Tshaj Tawm
 Tso Cai Nkag Mus Siv Web (ParentConnect)
Cov ntaub ntawv tau muab sau los no yog muaj tseeb raws li kuv txoj kev paub
X Niam-Txiv/Tus Neeg Saib Xyuas Menyuam Kos Npe (yuav tsum muaj)____________________________________________
ATT-#002
Hmong
Hnub:____
Enrollment V5 7.112015