Leavenworth Unified School District 453

Enrollment Form

Please complete the form below. Mandatory fields marked *

Student Information
  1. New Student Returning Student
  1. Enter N/A if no Student Number
  2. Male Female
  1. Yes No
  2. Yes No
  3. Yes No
Race and Ethnicity

Note: Both Part A and Part B of the question must be answered.

  1. Yes No
    (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
  2. Part A is about ethnicity, not race. No matter what you selected above, please continue to answer the following Part B of what you consider your student's race to be.

  1. American Indian or Alaska Native
    (A person having origins in any of the original peoples of North and American Indian or Alaska Native South America (including Central America), and who maintains tribal affiliation or community attachment.)
  2. Asian
    (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
  3. Black or African American
    (A person having origins in any of the black racial groups of Africa.)
  4. Native Hawaiian or Other Pacific Islander
    (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
  5. White
    (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
Student Contacts
  1. Guardian 1
  2. Mother/guardian based on legal documentation
  3. Yes No
  4. Yes No
  5. Yes No
  6. Yes No
  7. Yes No
  8. Yes No
  1. Guardian 2
  2. Father/guardian based on legal documentation
  3. Yes No
  4. Yes No
  5. Yes No
  6. Yes No
  7. Yes No
  8. Yes No
Emergency Contacts

Contacts listed here will be contacted in case of an emergency if parent/guardian cannot be contacted. Grandmother and Grandfather should be listed together

  1. Yes No
  1. Yes No
  1. Yes No
  1. Yes No
Daycare Provider Information

Please provide the Daycare Provider information.

  1. Yes No
Siblings Attending Leavenworth Schools

From time to time, it is helpful to cross reference children from the same family attending Leavenworth schools.
Please list the children in your family other than the one enrolling on this form.

Parental Insurance Waiver *

Leavenworth Public Schools does not purchase accident insurance to cover injuries by your child at school. We encourage all families to have accident coverage on their children prior to participation in any sports or school sponsored activity. A third party organization offers insurance for those who have no insurance, a high deductible, a Co-pay, or limited benefits. Brochures with the full explanation are available at enrollment.

  1. We, the undersigned, feel we have adequate insurance protection for our son/daughter while participating in Interscholastic Sports, or other school sponsored activities.
  2. We will review/sign up for the student accident insurance based on the brochure available.
Policy on Plagiarism *

For High School Only

  1. I have read the above Does Not Apply (Not a High School Student)
  1. Plagiarism is legally and ethically wrong. At Leavenworth High School, plagiarism is inconsistent with Core Value 4 of The Pioneer Way: We maintain absolute honesty and integrity in all we do. Plagiarism is the taking and using as one's own the writings or ideas of another without citation of the source. (American Heritage Dictionary, 1996 edition). The full Policy on Plagiarism is in the student handbook
LHS Student Gmail Permission *

For High School Only

  1. I give permission for my child to be assigned a Gmail account for educational purposes
  2. I DO NOT give permission for my child to be assigned a Gmail account for any purpose.
  3. Does Not Apply (Not a High School Student)

Gmail is web-based program providing email, word processing, spreadsheet, presentation and collaboration tools. USD 453 Google Apps for Education is available at school and at home via the web. Even though e-mail from known inappropriate sites is blocked and filtered, there is always a chance students will be exposed to inappropriate content. School staff will monitor student use of Google Apps when students are at school. Parents are responsible for monitoring their childs use of Google Apps when accessing programs from home. Students are responsible for their own behavior at all times. All mail is content filtered

Acceptable Use Policy for Computers *

As the parent/guardian, I understand that the use of computers in Leavenworth schools is a privilege, not a right.

  1. I have read the Acceptable Use Policy and DO give permission for my student to participate in district educational software resources.
  2. I DO NOT give permission for my student to participate in district educational software programs.

The full Acceptable Use Policy is in the student handbook

Multi-Media Production Program *

At various times during the school year, students participate in educational activities that are videotaped photographed, or recorded. The Leavenworth School District occasionally uses these images for promotional purposes in: brochures, newsletters, website display, as well as with the news media.

  1. I DO give permission and hereby release Leavenworth Unified School District 453 from any and all claims resulting from the use and public display of student's name, voice, picture, and/or student work during the school year in publicity materials related to the educational functions of the Leavenworth School District.
  2. DO NOT use the student's name, voice, picture, and/or student work in publicity materials for the school year for Leavenworth School District educational functions.
Parents/Students/Teacher Compact *

For Elementary Schools Only

  1. I DO support the efforts outlined in the Parent/Student/Teacher Compact and will contribute accordingly.
  2. I DO NOT support the Parent/Student/Teacher Compact and will not commit to the items outlined.
  3. Does Not Apply (Not an Elementary School Student)

The Leavenworth Public Schools believe that all children can and will learn. We are committed to providing the necessary elements for each child's success. We will ensure a safe and nurturing environment that fosters the fullest potential of each child. Leavenworth elementary schools are required to do a Compact with each family. This ensures a collaborative approach to each child's educational success.

The full Parent/Student/Teacher Compact is in the student handbook

Student Handbook

The handbook contains yearly required notification on the following issues:

  • Nondiscrimination
  • Family Educational Right to Privacy Act
  • Directory Information
  • Drug Free Schools and Communities Policy
  • Inoculations- Availability of Asbestos Plan

As a condition of enrollment, my child is required to abide by all regulations contained in the handbook as well as other policies established by the Board of Education. If my child chooses not to abide by the regulations contained in this handbook, any other policy established by the Board of Education, or any reasonable request by school authorities, disciplinary action may be imposed, up to and including expulsion from school.

Student Handbooks and Board of Education policies can be found on-line at the District and individual schools websites at www.usd453.org.

Hard copies are available on request at the Board of Education Offices and the school buildings

Request for Records

For students new to the district only

Please provide the following information so we can request records from your child's previous school if transferring from outside the district:


Signature
Home Language Survey

The School District is required to collect this information for Federal and State reporting purposes

  1. (if other than USA)
  2. English Spanish Other
  3. English Spanish Other
  4. English Spanish Other
  5. English Spanish Other
  6. Yes No
  7. Yes No
  8. English Spanish Other
  9. Migrant Education Program Information: The Migrant Education Program (MEP) is authorized by Title I Part C of the Elementary and SecondaryEducation Act of 1965 (ESEA). The MEP provides formula grants to local education agencies to establish or improve education programs for children who may qualify for the Migrant Program. Please help us determine your child's eligibility for the Migrant Program by responding to the following questions:
  10. Yes No
  11. Yes No
Please enter the letters on the left to the area below.
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