student enrollment at mililani high school · an affirmative action and equal opportunity employer....

Mililani High School 95-1200 Meheula Parkway Mililani, HI 96789 email: [email protected] Ph: (808) 307-4200 Fax: (808) 627-7463

STUDENT ENROLLMENT AT MILILANI HIGH SCHOOL

Registration Hours: Monday-Friday (except Holidays & Closed School Days) 8:00am-11:00am

NOTICE: If living at any of the following addresses, student must register at Leilehua High School WAIKALANI DRIVE 95-227 (BLDG A) 95-269 (BLDG C) 95-249 (REC CTR POOL) 95-270 (EVERGREEN) 95-257 (BLDG B) 95-273 (BLDG D) WIKAO STREET (ALL) including Launani Valley

Students who are planning to enroll at Mililani High School must provide the following documents BEFORE the enrollment process may begin:

(Parent/Guardian MUST be present at Registration if student is under age 18)

1. PROOF OF RESIDENCY (A home visit could occur should questions arise regarding Mililani residency) If Homeowners, please provide: - any mortgage document OR Real Property Assessment document - AND most current water OR electric bill (NOT cable or telephone) If renters, please provide: - rental agreement - AND water or electric bill or bank statement with parent/guardian name and address - NO cable or telephone bill If living with another family, please provide: - notarized letter from named homeowner/renter AND - homeowner’s mortgage documents or rental agreement AND - homeowner’s water OR electric bill AND - student’s parent/guardian bank statement with name and Mililani address

2. MEDICAL RECORDS (must include) - Negative TB clearance within last school year

(if positive reading, chest x-ray must be performed) - Current physical administered within last school year OR an appointment card w/clinic name - Updated shot records (DOH website below for more information)

http://www.hawaii.gov/health/family-child-health/immunization/school-health/index.html

3. RELEASE PACKET FROM PREVIOUS SCHOOL to include: a. Withdrawal/Transfer form b. If entering grade level is 10, 11, or 12 an UNOFFICIAL transcript with grades and credits c. If entering grade level is 9 a FINAL REPORT CARD prior to start of new school year

4. BIRTH CERTIFICATE AND/OR PASSPORT

5. GUARDIANSHIP PAPERS (if applicable)

6. CURRENT IEP (if applicable for special services)

7. CLEAR PHOTO I.D. OF BOTH PARENT(S) AND STUDENT(S)

According to HRS § 710-1063, falsification on a government application is a misdemeanor and that when such a violation is found, the child will be sent back to the school where he/she should properly be attending. The DOE may pursue prosecution at its discretion.

Nov 2015

Preschool Experience Yes No If “Yes” – attended: less than 6 months between 6 and 12 months

more than 1 year

Country of Birth: _______________________________ If Country of Birth is other than US, give year of arrival: ____________________

US Citizen: Yes No If not US Citizen, indicate status: Refugee Immigrant Non-Immigrant

Not Homeless Homeless* Completed MVA Packet

_____________________________________ DOE Representative Signature

_____________________________________ Parent/Legal Guardian Signature

*“Homeless” means individuals who lack a fixed, regular and adequate nighttime residence (within the meaning of section 42 USCS §11302(a)(1)) and includes: (i) children and youth who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels,

hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement.

(ii) children and youth who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping

accommodation for human beings (within the meaning of 42 USCS §11302(a)(2)(C)); (iii) children and youth who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations or similar settings;

and (iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for the

purposes of this subtitle.

If you have any questions regarding the above, please call 1-866-927-7095

Last Name: ____________________________________ Gender: M F Grade Level: __________

First Name: ____________________________________ Birth Date: ___________________________

Middle Initial: __________ Lineage: (Jr, II, III, etc): ___________________________ Verification of DOB: ______________________________

Home Phone: ____________________________ Unlisted: Yes No

Residence (Identifiable location required) Number Street Apt. #

City State Zip code

Name: Address:

Student ID No. Entry Date Entry Code Room

School Name:

STUDENT ENROLLMENT FORM SIS-10W (Revised) INSTRUCTIONS: PRINT YOUR ENTRIES LEGIBLY

CITIZENSHIP

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PRESCHOOL EXPERIENCE

Complex Area:

LAST HAWAII PUBLIC SCHOOL ATTENDED

Name: Last Grade Attended: Year:

PRIOR SCHOOL ATTENDED (If not Hawaii Public School)

For school use only

STUDENT PERSONAL DATA

Page 1/3, SIS-10W Rev 08/10 IRMB

Mailing Address (if different from home address) Number/P.O. Box # Street Apt. #

City State Zip code

Ethnicity/Race Observed: _________ Initial _________ Date

PARENT/GUARDIAN CONTACT INFORMATION

PRIMARY ETHNICITY/RACE INFORMATION

Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________

Marital Status: Married Divorced Separated Single

______________________________________ ______________________________________ ____________________________________ Last Name First Name Employer’s Name

__________________________ __________________________ __________________________ __________________________ Home Phone # Cellular Phone # Pager # Work Phone # (include ext.)

______________________________________________________________________ __________________________________________ Address (if different from student’s) Email Address

Custody of Child: Yes No Child lives with this contact: Yes No

Is this parent/guardian a member of the Armed Services, National Guard or Reserves? Yes No

Military Status (check one): Traditional Reservist / M-Day Active Duty (Title 10) Federal Technician (Title 32)

Deployed? Yes No

Branch of Service (check one):

Army Marine Air National Guard Navy Reserves

Air Force Coast Guard Army Reserves Marine Reserves

Navy Army National Guard Air Force Reserves Coast Guard Reserves

Are you (J) Hispanic (Ex. Cuban, Mexican, Puerto Rican, Spanish, Other Hispanic)? Yes No

Check all that apply:

A – American Indian or Alaska Native E – Native Hawaiian K – Samoan P – Tongan

B – Black G – Japanese L – White Q – Guamanian/Chamorro

C – Chinese H – Korean

N – Indo-Chinese (Ex. Cambodian, Laotian, Vietnamese)

O – Micronesian (Ex. Chuukese, Marshallese Pohnpeian,)

R – Other Asian

D – Filipino

I – Portuguese

S – Other Pacific Islander

I decline to provide ethnicity and race information. I understand that if I do not provide this information, a school representative will designate the ethnicity and race categories for my child.


F I R S T PARENT/GUARDIAN

RACE INFORMATION

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ETHNICITY INFORMATION

LANGUAGE INFORMATION

Language Codes: (Select a letter from the list and fill in the blanks below) Student’s First Language Most Often Language Most Often Acquired Language Spoken at Home Used by Student A – English F – Cebuano/Visayan K – Vietnamese Q – Fijian V – Pangasinan L – Other (Specify):

B – Cantonese G – Hawaiian M – Chuukese R – Hmong W – Portuguese ________

C – Mandarin H – Japanese N – Pohnpeian S – Lao X – Spanish

D – Ilocano I – Korean O – Cambodian T – Marshallese Y – Thai

E – Tagalog J – Samoan P – Chamorro U – Pampango Z - Tongan

What is the student’s primary race? (Select only ONE letter from either the ethnicity or race list and fill in the blank) ________

Please complete ETHNICITY INFORMATION, RACE INFORMATION, and PRIMARY ETHNICITY/RACE INFORMATION

PARENT/GUARDIAN CONTACT INFORMATION

Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________

Marital Status: Married Divorced Separated Single

______________________________________ ______________________________________ ____________________________________ Last Name First Name Employer’s Name


______________________________________________________________________ __________________________________________ Address (if different from student’s) Email Address

Custody of Child: Yes No Child lives with this contact: Yes No

Is this parent/guardian a member of the Armed Services, National Guard or Reserves? Yes No

Military Status (check one): Traditional Reservist / M-Day Active Duty (Title 10) Federal Technician (Title 32)

Deployed? Yes No

Branch of Service (check one):

Army Marine Air National Guard Navy Reserves

Air Force Coast Guard Army Reserves Marine Reserves

Navy Army National Guard Air Force Reserves Coast Guard Reserves

Does student’s father, mother, or guardian work for the Federal Government or work on Federal Property? Yes No

(Person To Notify In Case Of Emergency Other than First or Second Parent/Guardian Contact)

Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________ ______________________________________ ______________________________________ ____________________________________ Last Name First Name Employer’s Name


(Person To Notify In Case Of Emergency Other than First or Second Parent/Guardian Contact)

Check one: Mr. Mrs. Ms. Other (specify): ______________________ Relation: ___________________________ ______________________________________ ______________________________________ ____________________________________ Last Name First Name Employer’s Name


SECOND PARENT/GUARDIAN

EMERGENCY CONTACT INFORMATION

MISCELLANEOUS INFORMATION

S E C ON D

F I R S T

Parent/Legal Guardian Signature: Date:


Doctor’s Name or Clinic Name Office Phone #

SCHOOL SUPPLEMENTARY INFORMATION

Name Age Name Age 1. 4. 2. 5. 3. 6.

Other Children In The Family:

MV 1, Rev. 4/13 RS 13-1133 (Rev. of RS 12-1187)

MV-1 State of Hawaii Department of Education

HOMELESS CONCERNS OFFICE 475 22"d Avenue Room 126

Honolulu, Hawaii 96816 Telephone: 808- 203-5521 Toll Free: 1-866-927-7095

FAX: 808-735-8229

QUESTIONNAIRE TO DETERMINE ELIGIBILITY

McKinney-Vente Homeless Assistance Improvements Act

("MVA")

Schools are required to keep a

chronological file of completed

Questionnaires for each school

year.

STUDENT'S NAME: ______________ SCHOOL: ________ _

Section 1. Action Requested: (A copy of this form must be attached to each of the following forms.) o Enrollment o Geographical Exception* o Exit, Release or Transfer o Transportation (ONLY when a box in Section 3 is checked)

Section 2. o Student I Parent I Guardian IS NOT in a homeless situation (includes living with friends or family due to personal choice)

If Section 2 is checked, STOP and complete Parent/Guardian signature below; form is complete.

Section 3. Does The Student I Parent I Guardian: (Check the box that applies- you may be eligible for services) o Live with friends or family due to economic hardship such as loss of housing or income

o Live on the beach, at a campground, in a park, or in a hotel

o Live in a tent, car, bus, or other non-permanent structure

o Live in a domestic violence shelter: (name) _________________ _

o Live in an emergency or transitional shelter: (Please circle or if your shelter is not listed, please write in the name.)

o Kaua 'i: Manaolana, Kuapo, other: ______ _

o Hawai'i: Kihei Pua, Beyond Shelter, Kaloko Transitional , other: _______ _

o Maui: Ho'olanani, Ka Hale A Ke Ola, Ka Hale A Ke Ola- Westside, other: _______ _

o O'ahu: Family Promise, Institute for Human Services (IHS), Loliana, Ohana Ola 0 Kahumana, Maili Land, Next Step, Vancouver House, Onemalu, Onelauena (Hope for a New Beginning), Pai'olu Kaiaulu (Waianae Civic Center), Weinberg Village Waimanalo, Ulu Ke Kukui , Ka Ohu Hou o Manoa, Lighthouse Shelter, Kahi Kolu Ohana Hale 0 Wai 'anae, other: ______________ _

o Have no regular place to stay at night

o The student is awaiting foster care

o The student is an unaccompanied youth

Parent/Guardian Signature Print Name/Contact Phone No. Date

When any box in Section 3. "Does The Student/Parent/Guardian:" is checked, the student may be eligible to receive MVA services. School personnel are to assist the parent, guardian or unaccompanied youth with the completion of the reverse side of this form and the McKinney-Vento Act (MVA) School Packet.

DOE Representative's Signature Print Name Date

• Geographical exceptions apply to MVA eligible students ONLY WHEN there is a request to have the student attend a school other than the student's school of origin or home school.

This questionnaire is intended to address the McKinney-Vento Act (42 U.S.C. 11434a(2)). The answers provided help determine appropriate and comparable MVA services.

All collected information will only be used for the purposes of providing educational services pursuant to the McKinney-Vento Act and is protected by federal and state laws.

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Mililani High School

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AN AFFIRMATIVE ACTION AND EQUAL OPPORTUNITY EMPLOYER

Dav id Y . Ige

G O V E R N O R

STATE OF HAWAII

DEPARTMENT OF EDUCATION Mililani High School

95-1200 Meheula Pkwy. Mililani, HI 96789

Kathryn Matayosh i S U P E R I N T E N D E N T

PARENT/GUARDIAN STATEMENT

_______________________________________________ _____________ STUDENT’S FIRST NAME MI LAST NAME DATE OF BIRTH

Please read carefully and select the statement below which best describes your relationship to the student whom you wish to register at this school. ____ The above named child lives with both parents and I am the parent (birth or adopted) of

this child. ____ I am the parent (birth or adopted) of this child and am not currently married to the other

parent, but I have Physical Custody. *NOTE: It will be assumed by Mililani High School that both parents will have joint legal custody unless legal court documents are provided. To assist us in complying, you must provide us with a copy of the most recent legal court documents.

____ I am a foster parent. ____ I am not the parent (birth or adopted) of this child. I am a relative or friend. (Please choose one of the following)

A. ____ I have been awarded Power of Attorney of this child from birth/adopted Parent(s) B. ____ I have been awarded legal guardianship of this child through court.

To assist us in complying with court orders, you must provide us with a copy of the most recent legal court documents BEFORE your student can enroll in school.

_____ None of the above statements describe my relationship to this child. Please describe

your relationship to this child. ___________________________________________________________________________ ___________________________________________________________________________ I attest that I have been truthful and accurate in providing the foregoing information and/or documents to Mililani High School, its administrators, and/or staff. __________________________________________________ ___________________ Print Name Date __________________________________________________ ___________________ Signature Relationship to Student

MILILANI HIGH SCHOOL SPECIAL EDUCATION / SECTION 504 ELIGIBILITY

_______________________________________ _________________________________ ______ STUDENT LAST NAME FIRST NAME MI _______________ ____________________________________________________________ BIRTHDATE PREVIOUS SCHOOL

Please select one of the following ____ My child NEVER was eligible for Special Education and/or Section 504 Services ____ My child IS CURRENTLY receiving: ____ Special Education Services or ___ Section 504 Services I have copies of the following: (check all that apply) ___ IEP ___ 504 Plan ___ Diagnostic Reports ____ My child WAS receiving and is NO LONGER eligible for: ___ Special Education Services ___ Section 504 Services I understand that my child’s classes may need to be adjusted should his/her office school records reflect failure to ear

credit required by the State of Hawaii. ___________________________________________ ________________________________________ Parent/Guardian Name (PLEASE PRINT) Parent/Guardian Signature

For office use only: C/O:_____________ SID:______________________________________ CC: ____ SSC ___ Counselor Date:________________

MILILANI HIGH SCHOOL FALSIFICATION DECLARATION

According to HRS §710-1063, falsification on a government application is a misdemeanor and that when such a violation is found; the child will be sent back to the school where he/she should properly be attending. The DOE may pursue prosecution at its discretion. I have read and understand the above statements and I hereby declare that he information I have provided on all documents for Mililani High School is truthful and accurate. ____________________________________ ____________________________________ Parent/Guardian Name (Please Print) Parent/Guardian Signature ____________________________________ ____________________________________ Relationship to Student Date

student enrollment at mililani high school · an affirmative action and equal opportunity employer....

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