Fillable Printable Proof of Residency Letter
Fillable Printable Proof of Residency Letter
Proof of Residency Letter
POR-01 ANNUAL – Stu Type REG rev. 4.11
RED OAK INDEPENDENT SCHOOL DISTRICT
VERIFICATION OF STUDENT ADMISSION INFORMATION
(FOR STUDENT RESIDING WITH PARENT OR GUARDIAN)
PROOF OF RESIDENCY
I have personal knowledge of each of the facts contained herein, and know them all to be true and correct.
I am the parent, guardian, foster parent, or person having lawful control or legal power of attorney over:
________________________________________________________________________________
Last name First Name Middle Initial
____________________ _______________
Date of Birth Grade Level
who is over five years and under the age of 21 on the first day of September of the year which admission is sought. The
child (is) (is not) currently under an order for placement in an alternative education program or under an expulsion
order. If the child is under any such order, please provide an explanation or a copy of the order.
_________________________________________________________________________________
_________________________________________________________________________________
I currently reside within the boundaries of the RED OAK INDEPENDENT SCHOOL DISTRICT at:
_________________________________________________________________________________
Complete address – Street # and Street, Apt. #, City, State, Zip Code
and said student resides with me at said address. I realize that any known falsification of the information set out in this
document is a criminal offense under Section 37.10 of the Texas Penal Code, and if an ineligible student is enrolled in the
District on the basis of information knowingly falsified on this form by me, I am liable to the District for the cost of that
student’s education.
I also understand if residence is established in another district while school is in session, this enrollment form is invalid
and the student must be withdrawn. Failure to withdraw student makes me liable to the district for the number of days
ineligibly enrolled.
AT THE TIME OF REGISTRATION, THE PARENT, GUARDIAN, OR OTHER PERSON HAVING LAWFUL CONTROL
UNDER ORDER OF A COURT, MUST PRESENT PROOF OF RESIDENCY IN THE ATTENDANCE ZONE OF THE
SCHOOL IN WHICH THE STUDENT SEEKS ENROLLMENT IN THE FORM OF ONE OR MORE OF THE FOLLOWING:
1. A current water, electricity, or gas bill (no telephone bills) indicating address and the parent/guardian’s name.
2. The most recent tax receipt indicating home ownership
3. A current lease or rental agreement
4. Other timely documents that indicate location of residence, as approved by the campus principal.
Also a copy of parent, guardian, or other person having lawful control under order of a court, must present a
current Texas Driver’s License or Government issued ID. The name and address on current Driver’s License or
valid ID must match the name and address on the proof of residency presented.
In addition, a legal contract to purchase or build a home within the District shall be accepted as proof of residency for a
period not to exceed 120 days. If at the end of the 120-day period, the parent/guardian is not actually residing in the
District, the student shall be withdrawn.
A parent or guardian may be required at anytime to produce proof of residency. Proof of residency shall be required each
time a student attempts to enroll after moving away and returning or changing schools within the District. FD (LOCAL)
The District may withdraw students for non-attendance in accordance with FDD (LOCAL). Student-initiated withdrawal
shall be in accordance with FDA (LOCAL).
_______________________________________ ____________________
Signature of Parent/Guardian Date
Student Residency Questionnaire
Red Oak Independent School District
This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help
determine the services the student may be eligible to receive. A questionnaire must be completed for each child enrolling in the Red
Oak Independent School District.
Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false
documents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3) (d)
Name of Student _________________________________________________________________________ Gender: Male Female
Last First Middle
Birth Date: __________/__________/__________ School: _______________________________________ Grade: __________
Month Day Year
Check the box that best describes with whom the student resides (Please note: Legal guardianship may be granted only by a court. Students
living on their own or with friends or relatives who do not have legal guardianship are allowed to enroll in and attend school. The school
cannot require proof of guardianship for enrollment or continued attendance.)
Parent(s)/Legal Guardian(s) Caregiver(s) who are not legal guardian(s) How long? _______ Other________________________
(Example: friends, relatives, parents of friends, etc) Describe
Name of person with whom student resides: _____________________________________________________________________________
Address _________________________________________________________________________ Phone __________________________
Check one box that best describes where the student is presently living. (Please note: Proof of residency is not required for students who
live in temporary situations due to loss of housing or economic hardship)
In my own house or apartment, in Section 8 housing, or in military housing with parent(s), legal guardian(s), or caregiver(s)
A. In the home of a friend or relative because I lost my housing(Examples: fire, flood, lost job, divorce, domestic violence, kicked out
by parents, parent in military and was deployed, parents(s) in jail, etc.) Name of Apartments___________________________________
B. In a Shelter because I do not have permanent housing (Example: living in a family shelter, domestic violence shelter, children/youth
shelter, FEMA housing) in Transitional Housing (housing that is available for a specific length of time only and is partly or completely
paid for by a church, a nonprofit organization, or another organization)
C. In a motel/hotel (because of economic hardship, eviction, cannot get deposits for permanent home, flood, fire, hurricane, etc.)
Name of motel ___________________________________________________City__________________________________________
D. Unsheltered (Examples: in a tent, car, van, abandoned building, on the streets, at a campground, in the park, or other unsheltered
location)
Please provide the following information for school-age siblings (brothers and/or sisters) of the student:
Child
School
Grade
DOB
Parent/Legal Guardian/Unaccompanied Youth __________________________________________________ Date ____________________
Signature
For school use only
Procedures: 1. If this child has immediate needs, the parent/student may call the Student Family Services office at 972-617-4658 for services
2. If any of the boxes A-D are checked, immediately scan and email the completed form to the District Homeless Liaison, Donna Knight at
donna.knight@redoakisd.org for approval and Food Service authorization
Other needs expressed by the student, parent or guardian ________________________________________________________________________________
Interviewer ______________________________________________________Referral Date __________________Entry Date _________________________
Student ID
Teacher
ROISD NEW STUDENT ENROLLMENT FORM
ENR-01 Page 1 rev. 2.24.2012
CAMPUS: ______________________ SCHOOL YEAR: __________ ___ Check if Address or Phone# changed since Last Year
Student’s Social Security or State ID#________________________________ Student’s Local ID# (Skyward) ______________________
Student’s Legal Name (**) __________________________________________________________________________________________________________________
(Last) (First) (Middle) (Name Student Goes By)
[**ROISD is required by the State of Texas to use the Student’s Legal Name as it appears on the student’s official birth certificate.]
Date of Birth________________ Age______ Grade________ Gender: ___Male___Female Place of Birth (City, State)_________________________________________
Ethnicity: Hispanic YES__NO__ Fed Race: (check all that apply)__Am Indian/Alaskan Native __Asian__Black/African Am __Hawaiian/other Pacific Islander__White
Language Spoken in Home____________________________________Permission to Distribute Student Directory Information (see attached explanation) ___YES ___NO
Student’s Address__________________________________________________________________________________________ Primary Phone___________________
(Number/Street) (Apt #) (City) (Zip)
Is there a Custody Judgment Regarding this Child that the School needs to have on file? __YES __NO Has Student been Retained __YES __NO If YES, Grade______
Has student ever been enrolled in TX Public School? __YES __NO If yes, a Red Oak School? __YES__NO If YES: ___________________________________________
(Red Oak School) (Last Grade or YR Enrolled)
List previous school attended: (not in Red Oak ISD):
________________________________________________________________________________________________________________________________________
(School & District) (Grade) (Entry/Withdrawal Dates) (City) (State)
INDICATE IF THE STUDENT WAS PREVIUOSLY ENROLLED IN THE FOLLOWING PROGRAMS/SERVICES:
______ Special Education District/Campus_____________________________________ Years_______
______ Gifted/Talented Ed District/Campus_____________________________________ Years_______
______ 504 District/Campus_____________________________________ Years_______
______ Title 1 Services District/Campus_____________________________________ Years_______
______ Dyslexia District/Campus_____________________________________ Years_______
______ Bilingual/ESL District/Campus_____________________________________ Years_______
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PARENT/GUARDIAN INFORMATION (who child lives with) __Both Parents or __Father __Step Father or __Mother __Step Mother or __Other Guardian
Parent /Guard #1____________________________________________________________________ Primary Phone#_______________Cell Phone#______________
(Last) (First)
Parent’s Address____________________________________________________________________ Email Address_________________________________________
(Number/Street) (Apt#) (City) (Zip)
Place of Employment______________________________________________________________________________________________________________________
(Name) (City) (Work Phone#)
Parent /Guard #2____________________________________________________________________ Primary Phone#_______________Cell Phone#______________
(Last) (First)
Parent’s Address____________________________________________________________________ Email Address_________________________________________
(Number/Street) (Apt#) (City) (Zip)
Place of Employment______________________________________________________________________________________________________________________
(Name) (City) (Work Phone#)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
OTHER CHILDREN IN THE HOUSEHOLD ENROLLED IN ROISD
_______________________________________________________________________________________________________________________________________
(Name) (Age) (ROISD Campus) (Relationship to Student)
_______________________________________________________________________________________________________________________________________
(Name) (Age) (ROISD Campus) (Relationship to Student)
_______________________________________________________________________________________________________________________________________
(Name) (Age) (ROISD Campus) (Relationship to Student)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
EMERGENCY CONTACTS (Other than Parent/Guardian)
_______________________________________________________________________________________________________________________________________
(Emergency Contact #1) (Phone) (Other Phone) (Relationship to Student)
_______________________________________________________________________________________________________________________________________
(Emergency Contact #2) (Phone) (Other Phone) (Relationship to Student)
_______________________________________________________________________________________________________________________________________
(Emergency Contact #3) (Phone) (Other Phone) (Relationship to Student)
_______________________________________________________________________________________________________________________________________
(Emergency Contact #4) (Phone) (Other Phone) (Relationship to Student)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
_____________________________________________________ ______________ ___________________________________ __________________________
(SIGNATURE OF PERSON ENROLLING STUDENT) DOB (Relationship to Student) Date Enrolled
FOR OFFICE USE ONLY
RECEIVED DOCUMENTATION
9TH GRADE COHORT
BIRTH CERTIFICATE
SOCIAL SECURITY CARD/STATE ID
IMMUNIZATION RECORDS
PROOF OF RESIDENCE/DRIVER’S LICENSE
PRE-KINDER DOCUMENTATION
PREVIOUS SCHOOL RECORDS
SKYWARD STUD ID#___________________
DAYCARE NAME:
BUS NUMBER:
ROISD NEW STUDENT ENROLLMENT FORM
ENR-01 Page 2 rev. 3.22.11
CAMPUS: ______________________ SCHOOL YEAR: __________
Student’s Legal Name_________________________________________________________________________
(Last) (First) (Middle)
Red Oak Independent School District requires your signature as acknowledgement of agreement to read and become
acquainted with specific printed materials located in the ROISD Student Handbook and/or Student Code of Conduct.
Your signature will signify that you have acknowledged and have agreed to read and become acquainted with the
following documents and will return this acknowledgement of your agreement within ten school days of the first
day of instruction.
_________Red Oak Independent School District Student Handbook
_________Red Oak Independent School District Code of Conduct
_________Truancy Warning Notice
_________Acceptable Use of District Technology Resources
_________Notice regarding Directory Information
DIRECTORY INFORMATION ACKNOWLEDGEMENT (see Student Handbook for full details)
According to the state and federal law, certain information about the district’s students is considered “directory information” and will be released to
anyone who follows the procedures for requesting the information unless the parent or guardian objects to the release of the directory information.
(See Student Handbook)
Red Oak ISD has designated the following information as “directory information “ for school sponsored purposes:
Student’s name, address, telephone number, date and place of birth, major field of study and email address
Photograph, participation in officially recognized and sports, and weight and height of athletic teams
Dates of attendance, grade level, enrollment status, degrees, honors and awards received in school, and most recent school attended
previously
Directory information for all other purposes includes student’s name, address, and grade level.
A parent is allowed to record their objection to the release of all directory information or just one or more specific
categories of directory information. Please read each statement below and indicate your preference by putting a
checkmark beside your choices.
IN-SCHOOL PUBLICATIONS:
______ Red Oak ISD should NOT release my child’s student directory information for ANY specified school-sponsored
purposes listed above.
Example: If this preference is checked, your student’s name will NOT appear in school publications, campus newsletters,
school/District webpage or local newspapers for winning awards, scholarships, honor roll lists, etc…
NOTE: Your student’s picture WILL NOT be included in any Yearbook or ROISD video.
_______ Red Oak ISD has my permission to use directory information for school related communications and publicity ONLY
but ROISD may not release my child’s directory information to any other requestor, political candidate or business.
Example: Permissible uses: school yearbook, newsletters, district website, videos, PTO, Booster Clubs, press
releases, etc.
_______ Red Oak ISD does not have my permission to release my child’s name, address, and telephone number to
a military recruiter or institutions of higher education upon their request without my prior written consent.
_________________________________________ ________________________________
Parent/Guardian Signature Date of Acknowledgement
ENR-02 rev. 3.2011
Red Oak Independent School District
P.O. Box 9000, Red Oak, Texas 75154
Home Language/Migrant Survey
Pre-Kindergarten – grade 12
Please provide the following information to help us place the student in the appropriate instructional
program.
Mark your responses with ( ).
1. What language is spoken in your home most of the time?*
English __________Spanish __________ Other ___________________ (Specify Language)
2. What language does your child speak most of the time?*
English __________ Spanish __________ Other ___________________ (Specify language)
3. Has your family moved any time during the last three years from one school district to another in
Texas, from another state, or outside the USA? Yes______ No ______
4. Were any of these moves made to find temporary or seasonal work in agriculture, agriculture
related (packing, processing, harvesting, cultivating or crops), food processing, dairy work,
forestry, fishing, ect.? Yes______ No ______
If you answered “Yes” to question #4 above, please complete the information below.
Name of Parent/Guardian: ______________________________________________________
Address: _____________________________________________________________________
Telephone:___________________________________________________________________
I certify that the above information is true and correct to the best of my knowledge.
Grades pre-k – 8:_______________________________
Parent or Guardian’s Signature
Grades 9-12:_______________________________
Parent, Guardian, or Student’s signature
Student’s Name:________________________________________ ID#__________________________
School: ________________________________ Grade: __________ Date: _______________________
PRIOR EDUCATIONAL EXPERIENCES (GRADES 2-12)
1. Has the student lived outside of the U.S. for two or more consecutive years? ______Yes _______No
If yes, Where and When? _____________________________________________________________
2. What is the date the student first enrolled in the U.S.? ______________________________________
3. What school/district did the student attend prior to this one? __________________________________
4. Did the student attend school regularly while residing outside of the U.S.? ______Yes _______ No
Indicate the grade levels completed: ___pre-k ___k ___1 ___2 ___4 ___5 ___6 ___7 ___8
___9 ___10 ___ 11 ___12
FOR OFFICE USE ONLY
Note to Registrar:
*An answer of a language other than English to
either or both questions will require notification of
the Bilingual and ESL teachers.
*If parents answer #4, please forward a copy to
District Migrant Coordinator, Sylvia Chastain.
ENR-03(b) Rev. 6.4.2013
Texas Education Agency
Texas Public School Student/Staff Ethnicity and Race Data Questionnaire
The United States Department of Education (USDE) requires all state and local education
institutions to collect data on ethnicity and race for students and staff. This information is used
for state and federal accountability reporting as well as for reporting to the Office of Civil Rights
(OCR) and the Equal Employment Opportunity Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to
provide this information. If you decline to provide this information, please be aware that the USDE
requires school districts to use observer identification as a last resort for collecting the data for
federal reporting.
Please answer both parts of the following questions on the student’s or staff member’s ethnicity
and race. United States Federal Register (71 FR 44866)
Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one)
Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race.
Not Hispanic/Latino
Part 2. Race: What is the person’s race? (Choose one or more)
American Indian or Alaska Native - A person having origins in any of the original peoples of
North and South America (including Central America), and who maintains a tribal affiliation or
community attachment.
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.
Black or African American - A person having origins in any of the black racial groups of
Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
________________________________
Student/Staff Name (please print)
________________________________
(Parent/Guardian)/(Staff) Signature
________________________________
Student/Staff Identification Number
________________________________
Date
This space reserved for Local school observer – upon completion and entering data in student software
system, file this form in student’s permanent folder.
Ethnicity – choose only one:
_____ Hispanic / Latino
_____ Not Hispanic/Latino
Race – choose one or more:
_____ American Indian or Alaska Native
_____ Asian
_____ Black or African American
_____ Native Hawaiian or Other Pacific Islander
_____ White
Observer signature:
Campus and Date:
Texas Education Agency
General Information Survey
(School Enrollment Form for Foster Care Student)
Student Name________________________________________________________________________________
DOB________________ Age:________ Grade:____________ Campus:_________
Previous School Enrolled at_______________________________________________________
1. Has your child ever attended an ROISD school? Yes____ No_____
If YES, name of ROISD school________________________________________
2. Has your child received the following services:
Bilingual program Yes_____ No____
ESL program Yes_____ No____
Special Education Yes_____ No____
A. Resources B. Speech Therapy C. Other________
504 Services Yes ____ No____
Dyslexia Yes____ No____
Intervention Assistance Team Yes_____ No_____
Gifted and Talented Classes Yes_____ No_____
Social Services Yes_____ No_____
i. 2085 Form Yes_____ No___
If yes, please specify the type: ___________________________________________
Health Care Services Yes_____ No_____
Counseling Yes_____ No_____
Retained Yes_____ No_____
If Yes, what grade? _____________
Other Services (please specify)___________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Parent/Guardian Signature_______________________________________________Date____________________
Please send form to Donna Knight, Coordinator of Student and Family Services. If you
have any questions please call her @ 972 617-4658.
Revised 3/2014
MILITARY CONNECTED STUDENT FORM
In 2009 the Texas Legislature adopted the Interstate Compact on Educational
Opportunities for Military Students. The purpose of the compact is to remove barriers to
educational success imposed on children of military families because of frequent moves
and deployment of parents. Beginning with the 2013-2014 school year, the Texas
Legislature is requiring all districts to report the enrollment of military connected
students (House Bill 525).
Student Name: __________________ _________________ Student ID: _________
Last First
Student Campus:_____________________________ Grade:______________
Parent Name (printed): _______________________ _________________________
Last First
Parent Signature:_______________________________________________________
Please indicate which of the following is applicable to your student:
_____ My student is not a dependent of a member of the United Sates military service in the
Army, Navy, Air Force, Marine Corps, or Coast Guard on active duty, the Texas National Guard,
or a reserve force of the United States Military.
_____ My student is a dependent of a member of the Army, Navy, Air Force, Marine Corps, or
Coast Guard on Active Duty.
_____ My student is a dependent of a member of the Texas National Guard (Army, Air
Guard, or State Guard)
_____ My student is a dependent of a member of a reserve force in the United States
military (Army, Navy, Air Force, Marine Corps, or Coast Guard)
______My Pre-kindergarten student is a dependent of: 1) an active duty uniformed
member of the Army, Navy, Air Force, Marine Corps, or Coast Guard, 2)
activated/mobilized uniformed member of the Texas National Guard (Army, Air Guard,
or State Guard), or 3) activated/mobilized members of the Reserve components of the
Army, Navy, Marine Corps, Air Force, or Coast Guard; who are currently on active duty
or who were injured or killed while serving on active duty.
(The term “dependent”, with respect to a member of a uniformed service, means the spouse of the member, an unmarried child of
the member, an unmarried person who is placed in the legal custody of the member and is dependent on the member for over ½ of
the person’s support, resides with the member unless separated by the necessity of military service or to receive care as a result of
disability or incapacitation)
Page | 1 REV. 7.8.2014
Red Oak Independent School District
Family Educational Rights and Privacy Act (FERPA) Signature Page
STUDENT DIRECTORY INFORMATION-LEGISLATIVE UPDATE [Sec. 26.013]
Red Oak ISD provides to the parent of each district student at the beginning of each
school year:
(1) a written explanation of the provisions of the Family Educational Rights and
Privacy Act of 1874 (20 U.S.C. Sec. 1232g), regarding the release of directory
information about the student and (2) written notice of the right of the parent to
object to the release of directory information about the student under the Family
Educational Rights and Privacy Act of 1974 (20 U.S.C. Sec. 1232g).
NOTICE
According to the state and federal law, certain information about the
district’s students is considered “directory information” and will be
released to anyone who follows the procedures for requesting the
information unless the parent or guardian objects to the release of the
directory information. If you do not want Red Oak ISD to disclose
directory information from the child’s education records without your
prior written consent, you must notify the district in writing within 10
days. ROISD encourages parents to use this form for the written consent
notification.
Red Oak ISD has designated the following information as “directory
information for school sponsored purposes”:
Student’s name, address, telephone number, and date and place of
birth, major field of study and email
Photograph, participation in officially recognized and sports, and
weight and height of athletic teams
Dates of attendance, grade level, enrollment status, degrees,
honors and awards received in school, and most recent school
attended previously
Page | 2 REV. 7.8.2014
Directory information for all other purposes includes student’s name,
address, and grade level.
Parent Signature_______________________________________________________
Parent Name Printed____________________________________________________
Student Name _______________________________________________GR.________
Campus____________________________________
A parent is allowed to record their objection to the release of all directory information or one or
more specific categories of directory information.
Red Oak ISD should NOT release my child’s student directory information for ANY
reason.
Example: If you check the box, your student’s name will NOT appear in school
publications or local newspapers if he or she won an award. NOTE: If you check this box,
your student will not be included in the yearbook.
Red Oak ISD has my permission to use directory information for school-related
communications and publicity ONLY but ROISD may NOT release my child’s directory
information to any other requestor, political candidate or business. (Permissible uses:
yearbook, newsletters, district website, videos, PTO, Booster Clubs, press releases, etc.)
High School Student Only
Federal Law requires districts receiving assistance under the Elementary and Secondary
Education Act of 1965 (20 U.S.C. Section 6301 et seq.) to provide a military recruiter or an
institution of higher education, on request, with the name, address, and telephone number of
a secondary student unless the parent has advised the district that the parent does not want
the student’s information disclosed without the parent’s prior written consent.
I object to the release of my child’s name, address, and telephone number to a military
recruiter or to an institution of higher education.
2015-2016
Red Oak Independent School District
Health Services
Student ID Number: Grade: Teacher:
Car Rider: Bus Rider: Walk Home: Day Care:
Car Driver (high school students): Language Spoken at Home:
Student: Birth Date:
Last First Middle
Address:
Mother/Guardian: Primary Phone: Cell Phone:
Work Phone: Email:
Father/Guardian: Primary Phone: Cell Phone:
Work Phone: Email:
Other Children at Red Oak I.S.D. (name & school):
Emergency Contact (other than parents):
Relation to Student: Phone:
**********It is important that we are able to contact someone if your child is sick or injured.***********
****Hospital Preference: 2
nd
Choice:
(If your child needs immediate medical care)
I hereby authorize the Superintendent of Red Oak ISD or a designated representative to secure any and all emergency medical care and treatment
for the above named student for acute illness suffered or injury sustained while at school or participating in school-related activities. I prefer that
emergency treatment be secured at the above named facilities. The district may use another licensed hospital or medical facility if necessary.
I understand that cost of services provide by ambulance, private physician, hospital or dentist remains the responsibility of the parent of guardian and
will not be assumed by the district or any of its officers or employees.
Parent Signature______________________________________________________________________________________________
Does Student have: (Please Circle/Answer)
Allergies Yes No
Severe Yes No
If Yes: Pollen? Drugs? Foods? Insects?
Other: (Explain)
Has emergency care been needed in the past for an allergic reaction? Yes No
If YES: Hospitalization Medication Only Swelling at site
Student will have________will not have________an Epipen or medication for the allergic reaction at school.
Sign here_____________________________________________________
Asthma Yes No Triggered by: Treat with:
Student will have_____ will not have________asthma medication at school.
Sign here_____________________________________________
Diabetes Yes No Controlled by: Insulin: Diet
Seizures Yes No Any restrictions?
Heart Condition Yes No Any restrictions?
Bone/Joint Disorder Yes No Any restrictions?
Frequent Headaches Yes No
Vision/Hearing Problem Yes No Glasses Contacts Hearing Aids
Emotional Disorder Yes No
List any other serious illness or conditions not mentioned above:
Daily Medications Yes No At home: At school:
Name of medication:
Reason for medication:
I AGREE THAT THE TEACHERS & PERTINENT PERSONNEL BE ALLOWED TO KNOW OF THE ABOVE INFORMATION AND I HAVE READ
THE ROISD MEDICATION GUIDELINES.
Parent/Guardian Signature: Date:
