Miyuu ubaahanyahey walidka ardeygani/masuulka adeeg turjuban? Haa / Maya luuqada uu rabo ________________

Ardeygan hada miyuu ku noolyahey degmadan Willmar ee iskulada? Haa / Maya

Hadad tiri maya, degmaduu ku noolyahey ardaygani? _____________________________

Hadii maya, miyaa la buuxiyey arji lagu diiwaan galinayo loona direy xafiiska Kormeeraha Dugsiyada? Haa / Maya

Ardeyga magaciisa oo buuxa sida sharciga ah ee ugu muuqato warqada dhalashada

Magaca awowgiis _____________________ Magaciisa ___________________ Aabaha ____________ Horgalka_______

Halkan jag sii hadii magac dhexe laheyn ___ Naaneys ______________________________

Fasalka ______________

Dhalashada ______________ Jaadka: Lab / Dhadig

Jinsiyada/Asal ahan meeshu ka yimid- Fadlan dhameystir suaalaha 1-2

1. Warbixin dowlada dhexe darteed. Ardaygu ma Isbaanish baaa ama Laatino? Haa / Maya Qof ka yimid Mexico, Puerto Rican, Cuban, bartamaha ama koonfurta Amerika Ama qof ka tirsan dhaqanka isbaanishka asal ahan ayadoo la eegeynin jinsiyada.

2. Warbixin dowlada dhexe darted, fadlan xariiq wixii quseeya ardayga– Waxaa qasab ah in aad xariiqdo ugu yaraan hal.

____ Ameerikan hindi a oo ama Alaska ka yimid – qof asal ahaan ku leh fir waqooyiga galbeedka ah Ameriko (oo ay ku jirto bartamaha Ameriko), iyo kuwa maamula isku xirka bulshada ama kooxaha qabiilada.

____ Indha yarta – qof ku leh fir galbeedka Aasiya, koonfurta galbeed Aasiya ama hindiya Qaaradaha yar yar oo ay ku jirto: Cambodia, China, India, Jabaanka, Kuuriyaha, Maleeshiyo, bakistaan, ka

Jasiirada filipiinka, Tayland iyo fiitnaamka.

____ Madow ama Ameerikanka madow – Qof asal ahaan ka mid ah kooxaha madow ee Afrika.

____ Udhashey Hawaiian ama xeebaha pacifika ah – Qof asal ahaan kasoo jeeda dadka dago Hawaii,Guam, Samoa ama jasiirada pasifika.

____ Cadaan – Qof asal ahaan kasoo jeeda qaarada Yurub, bariga dhexe iyo waqooyiga Afrika.

Warbixin dheerad ah oo ku saabsan ardeyga

1. Ardeygu ma dhalin waalid ah baa? Haa / Maya 2. Ardeygu hada ma guri la’aanba (Maheysto wax rasmi ah uu daganyahey malin iyo habeen? Haa / Maya 3. Ardeygu ma gobolka maamulo (Xaquuqda waalikda ma maxkamad baa looga wareejiyey)? Haa / Maya

Willmar Public Schools – ISD 347 Student Registration

Does the student’s parent/guardian need interpreter services? Yes / No Preferred Language: _________________

Does the student currently live in the Willmar School District? Yes / No

If no, what district does the student live in? ____________________________________________________________

If no, has an Application for Open Enrollment been completed and sent to the Superintendent’s Office? Yes / No

STUDENT’S FULL LEGAL NAME AS IT APPEARS ON BIRTH CERTIFICATE

Last Name: ___________________________________ First Name: ___________________ Middle: ____________

Suffix: ______ Check if No Middle Name: ____ Nickname: ____________________

Grade: ______ Birth Date: ______________ Gender: Male / Female

RACIAL/ETHNIC BACKGROUND – PLEASE COMPLETE ALL QUESTIONS

1. For Federal reporting purposes – Is the student Hispanic or Latino? Yes / No A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin regardless of race.

2. For Federal reporting purposes – Please check all that apply for the student. You must check at least one. ____ American Indian or Alaska native – a person having origins in any of the original people of North and South America (including Central America), and who maintains 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, Middle East or North Africa.

ADDITIONAL INFORMATION

1. Is the student a teen parent? Yes / No 2. Is the student currently homeless (lacks a fixed, regular and adequate nighttime residence)? Yes / No 3. Is the student a Ward of the State (parental rights have been terminated by court order)? Yes / No

Student Registration

Warbixinta Waxbarashada

Fadlan xariiq: Ardey cusub ___ Ardeyga horey ayuu dugsiga Willmar udhigtay ___ Tariikhda ___

Ardeyga horey ayuu u aadey Dugsiga minasota ___ Meesha ku yaalo ___ Tariikhda ___

Iskuulada uu soodhigtay (ku qor sidey ukala danbeeyeen) Magaalada gobolka Tariikhda uu Dhigtey

Heerka

Fasalka

ADEEGYADA WAXBARASHADA GAARKA AH

Ardeygu ma heystaa qorshe waxbarasho ee shaqsi waqtigan xaAdirka ah (IEP)? Haa / Maya

Fadlan ku lifaaq warqad koobi ah oo ku saabsan IEP/IFSP/IIIP xiliga diiwaan galinta.

Ma loo qorey gadiid khaas ah oo qaado qorshaha waxbarasha ee shaqsi IEP? Haa / Maya

Ilmahaagu miyu helay waxbarasha adeeg oo gaar ah dugsigiisii ugu danbeeyey? Haa / Maya

Ilmahaagu ma heysta qorshaha hoyiga ee 504? Haa / Maya

MACLUUMAADKA DADKA GURIGA KUGULA NOOL Cinwaanka Ardeygu uu ku noolyahey __________________________________________________________________ Magaalada ____________________________ Gobolka _______ Furaha magaalada ____________ Tariikhda lagu guuray cinwaankan ________________ Cinwaanka warqadaha lagugu soo diro-(bii-obokiskaga, magalada)- Hadii uu ka duwanyahyey kan kale ______________________ Taleefoonka Guriga ___________________________________ Ardeyga wuu la noolyahey ( Fadlan mid goobaabi) Labada Waalid Hooyo Aabo Hooyo iyo ninka qabo Aabo iyo Aayo Walidka isoo koriyey Qoys marti aan lajoogo Mida-kale: Fadlan Sheeg xiriirkan

EDUCATIONAL INFORMATION

Please check: New Student ____ Student has previously attended a Willmar school ____ Dates _______________

Student has previously attended a Minnesota school: ____ Location __________________ Dates _______________

Previous Schools Attended

(list most recent school first)

City State Dates of

Attendance

Grade

Level

SPECIAL EDUCATION SERVICES

Does the student have a current Individual Education Plan (IEP)? Yes / No

*Please submit a copy of an IEP/IFSP/IIIP upon registration.

Is Special transportation documented in the IEP? Yes / No

Did your child receive Special Education services at their last school? Yes / No

Does your child have a 504 Accommodation Plan? Yes / No

HOUSEHOLD INFORMATION

Primary Resident Address of Student: _________________________________________________________________

City: ___________________________ State: ______________ Zip Code: ______________

Date moved to this Address: _______________

Mailing Address of Student (PO Box, including City) – if different from resident address:

____________________________________________________________________________

Primary Phone number: ________________________________

Student Lives With (please circle):

Both Parents Mother Father Mother & Stepfather Father & Stepmother Foster Parents Host Family

Other: Please Specify Relationship ___________________________________________________________________

Sheeg dhamaan magacyada caruurta xita kuwa farbaradka ee guriga ku gula nool:

Magacaaga, Aabaha, Magaca awowaha Tariiqda dhalashada

Lab ama dhedig

Walidka/Masuulka waxa uu uyahey ilmaha

Baritanka iskulka (Caruurta 0-6 sano jira kaliya)

Hadad haa tiri, Sheeg goobta

L / DH L / DH

L / DH L / DH

L / DH L / DH

L / DH L / DH

L / DH L / DH

L / DH L / DH

Walidka/Masuulka – Wuxuu ladaganyahey ardeyga – Isticmaal magaca sharciga oo buuxo

Magaca awoowga _________________________ Magacaada _______________________ Abaha _________ Horgalka _______

Dhalasha ___________ Jinsiyada: lab ama dhedig _______ Wuxuu uyahey ardeyga ________harci ahaan masuul makayahey Haa / Maya

Maku dhigtay magac ka duwan magaciisa Dugsiyada Dadweynaha Willmar (Ku qor halkan) _________________________________________

Telafoonka guriga _____________________ Midka gacanta _____________________ midka shaqada _______________

Emailkaada __________________________________________

Goobta aad ka shaqeyso ________________________________________

Walidka/Masuulka – Wuxuu ladaganyahey ardeyga – Isticmaal magaca sharciga oo buuxo

Magaca awoowgaa __________________________ Magacaada _______________________ Aabaha _________ Horgalka _______

Dhalasha ___________ Jinsiyada :lab ama dhedig _______ Waxey isku yihin ardeyga _________ Sharci ahaan masuul makayahey Haa/Maya

Maku dhigtay magac ka duwan magaciisa Dugsiyada Dadweynaha Willmar (Ku qor halkan)____________________________________ Telefoonka guriga _____________________ Midka gacanta _____________________ midka shaqada _______________

Emailkaada __________________________________________

Goobta aad ka shaqeyso ________________________________________

List legal names of all children, including pre-school age, residing in the home:

First, Middle, Last Name Birth

Date Gender

Relationship to

Parent/Guardian

Pre-School

Screened (0-6 year

old children only)

If yes, list location

M / F Y / N

M / F Y / N

M / F Y / N

M / F Y / N

M / F Y / N

M / F Y / N

Parent/Guardian – RESIDES AT THE SAME ADDRESS WITH STUDENT – Use full legal name

Last Name: __________________________ First Name: ________________________ Middle: ________________

Suffix: _____ Birth Date: ______________ Gender: Male / Female

Relationship to Student: _________________________ Legal Guardian: Yes / No

Attended Willmar Public Schools Under Different Name (List Name): _______________________________________

Home Phone: __________________ Cell Phone: __________________ Work Phone: ________________________

Email: _____________________________________ Employer:___________________________________________

Parent/Guardian – RESIDES AT THE SAME ADDRESS WITH STUDENT – Use full legal name

Last Name: __________________________ First Name: ________________________ Middle: ________________

Suffix: _____ Birth Date: ______________ Gender: Male / Female

Relationship to Student: _________________________ Legal Guardian: Yes / No

Attended Willmar Public Schools Under Different Name (List Name): _______________________________________

Home Phone: __________________ Cell Phone: __________________ Work Phone: ________________________

Email: _____________________________________ Employer: ___________________________________________

1

Walidka/Masuulka –Aanan ladaganayn ardeyga – Isticmaal magaca sharciga oo buuxo

Magaca awoowgaa _________________________ Magacaada _______________________ Aabaha _________ Horgalka _______

Dhalasha ___________ lab ama dhedig _______ Waxey isku yihin ardeyga ________________ Sharci ahaan masuul makayahey Haa / Maya

Maku dhigtay magac ka duwan magaciisa Dugsiyada Dadweynaha Willmar (Ku qor halkan) _________________________________________

Telefoonka guriga _____________________ Midka gacanta _____________________ midka shaqada _______________

Emailkada __________________________________________

Goobta aad ka shaqeyso ________________________________________

Ku dir warqadaha nuqulka ah ciwaankan? Haa / Maya

Nidaamka Wicitaanka ee tooska ah

Nimaamka wicitaanka ee tooska ah ee iskuulada Dadweynaha ee Willmar waxay isticmaali doonan hab wicitaan oo mashiin ku shaqeeya si ay ula socodsiiyaan

waalidiinta/mas’uuliyiinta arimaha la xidhiidha cimilada isbaddalkeeda, ka-maqnaanshaha iskuulka Dugisga Sare, iyo fariin kasta oo ay maamulku u arkaan inay muhiim utahey in

loo isticmaalo mashiin si toos ah wax uwaco. Telefoonadan hoos ku qoran ayaa si toos ah loo soo wici doona marka ay jiraan arimo laxiidhadha cimilida/hawada ama xaalad deg-

deg ah ay jirto. Fadlan noo soo kala sheeg telefonada iyo sida aad u rabtid in laguula soo xidhiidho.

Arimaha deg dega: Mid-Guud Imaanshaha

Telefonka guriga:

Tel.gacanta:

Tel.Shaqada:

E-mailka:

Markastoo aad ubaahato inad wax-kabadasho macluumaadkan fadlan booqo barta internetka ee iskuulada qaybta akontiga Portalka si aad wax uga badasho ama la xiriir

iskuulka uu ilmahaagu dhigto.

XAALADDA SOO GALOOTIGA

Qoyskagu ma guureen sidey u raadsadaan shaqo xannanada la xiriirto

sadexdii sano ee lasoo dhaafey?

Tusaale: Hilib, Digaag, kaluunka, Alwaax, beeraha, ukumaha la gurayo

Haa

Maya

Garanmaayo

Saxiixa Walidka/ Masuulka

Waxaan cadeynaya dhamaan warbixintan iney runtahey ayna saxsantahey intan ka aqoonsanahey.

Walidka/Masuulka sharciga ah Saxiixa: __________________________________________ Date: ____________

Parent/Guardian – DOES NOT RESIDE AT THE SAME ADDRESS WITH STUDENT – Use full legal name

Last Name: __________________________ First Name: ________________________ Middle: ________________

Suffix: _____ Birth Date: ______________ Gender: Male / Female

Relationship to Student: _________________________ Legal Guardian: Yes / No

Attended Willmar Public Schools Under Different Name (List Name): _______________________________________

Mailing address: _________________________________________________________________________________

Home Phone: __________________ Cell Phone: __________________ Work Phone: ________________________

Email: _____________________________________ Employer: ___________________________________________

Send duplicate mailings to this address? Yes / No

AUTOMATED CALLING SYSTEM

Automated Calling System – Willmar Public Schools utilizes an automated calling system to notify parent/guardians

for reasons such as weather related announcements, attendance absence at our Senior High, and any message

administrators feel important to communicate via the automated caller. All Emergency phone numbers/emails

listed below will automatically be called for weather related announcements or emergencies. Please list the phone

numbers/emails below for calls that are:

Type of Phone Emergency General Attendance

Home

Cell

Work

Email

If you would like your preferences changed, please log on to your portal account or contact your child’s school.

MIGRANT STATUS

Has your family moved to seek or obtain agricultural related work in the last three years? Yes / No / Don’t Know

Examples: meat, poultry, fish, timber, field work, or picking eggs.

PARENT/GUARDIAN SIGNATURE

I certify that all the information given is true and correct to the best of my knowledge.

Parent/Legal Guardian Signature: _____________________________________________ Date: __________________

Willmar Public Schools – ISD 347

611 5th

St. S.W.

Willmar MN 56201

(P) 320-231-8500

(F) 320-231-8504

Waxan Halkan u ogalahey: ____________________________________________________________________________

(Dugsiga Hore/Degmada Dugsiga)

_____________________________________________________________________________

(Wadada Mise P.O. bokiska)

____________________________________________________________________________

(Magalada, Wadada iyo goobta numberkeda)

Nambarka: ________________________________ Fakiska: _____________________________

In loodiro wax walbo oo warbixin ah oo ay kamid yihiin Talaalada, Cafimadka, Waxbarashada, waxa maskaxda la xiriiro,

imtixaanka asaasiga ee cabbiro aqoonta ardeyga heerka buundadiisa , Barnaamijka Title 1 looyaqano, Luuqada barashada ELLka,

Waxbarasha gaarka ah iyo diiwaanada ku saabsan farbaradka ardeyda yar yar:

Ardeyga ____________________________________________________________________________________________

Magaca Koobad Dhaxe ugudanbeya

Fasalka _______________________________ Tariikhda Dhalashada _______________________________

Fadlan udir Warbixinta cinwaanada iskuuladan mise ufakis garee:

Kennedy Elementary Roosevelt Elementary Willmar Middle School Willmar Senior High

824 7th

St. S.W. 1800 19th

Ave. S.W. 209 Willmar Ave S.E. 2701 30th

St. N.E.

Willmar, MN 56201 Willmar, MN 56201 Willmar, MN 56201 Willmar, MN 56201

(P) 320-214-6688 (P) 320-231-8471 (P) 320-214-6000 (P) 320-231-8300

(F) 320-235-9536824 (F) 320-231-1170 (F) 320-235-1254 (F) 320-231-8400

District Office Jefferson Learning Center Alternative Learning Center (ALC)

611 5th

St. S.W. 1234 Kandiyohi Ave. S.W. 512 8th

St. S.W.

Willmar, MN 56201 Willmar, MN 56201 Willmar, MN 56201

(P) 320-231-8500 (P) 320-231-8490 (P) 320-214-6692

(F) 320-231-1061 (F) 320-231-5484 (F) 320-235-5352

Willmar Public Schools – ISD 347 Codsiga Diiwaanada Ardeyga

I hereby authorize: _______________________________________________________________________

(Former School /School District)

_______________________________________________________________________

(Street or P.O. Box)

_______________________________________________________________________

(City, State and Zip Code)

Phone: ________________________________ Fax: __________________________________

To forward all information including Immunizations/Health, Educational, Psychological, Standardized & Basic Test

Scores, Title I, ELL, Special Education and /or Early Childhood Records concerning:

Student: ___________________________________________________________________________________

First Middle Last

Grade _______________________________ Birth Date __________________________________

Parent/Guardian Signature _____________________________________________________________________

Date ________________________________

Please forward this information to the following school address or fax to:

Ke Kennedy Elementary Roosevelt Elementary Willmar Middle School Willmar Senior High

824 7th

St. S.W. 1800 19th

Ave. S.W. 209 Willmar Ave S.E. 2701 30th

St. N.E.

Willmar, MN 56201 Willmar, MN 56201 Willmar, MN 56201 Willmar, MN 56201

(P) 320-214-6688 (P) 320-231-8471 (P) 320-214-6000 (P) 320-231-8300

(F) 320-235-9536 (F) 320-231-1170 (F) 320-235-1254 (F) 320-231-8460

District Office Jefferson Learning Center Alternative Learning Center (ALC)

611 5th

St. S.W. 1234 Kandiyohi Ave. S.W. 512 8th

St. S.W.

Willmar, MN 56201 Willmar, MN 56201 Willmar, MN 56201

(P) 320-231-8500 (P) 320-231-8490 (P) 320-214-6692

(F) 320-231-1061 (F) 320-231-5484 (F) 320-235-5352

Request for Student Records

1

Midaan soo socoto waa inuu buuxiya walidka mise musuulka. Sida loocaawiyo cunugada waxbarashadiisa, macalinkiisa wuxuu

ubahanyahey inuu go’aansado cunugaada luuqada uu isticmaalo inta badan. Fadlan ka jawaab sualaha hoos adigoo

goobaabinayo midka ku haboon.

Magaca ardyga oo buuxa:__________________________________________________________________________________

Tariikhda dhalashada: ___________________________________________ Dada: _______________ Fasalka: ____________

Telafoonka guriga: _____________________________________ Midka gacanta:

_________________________________

Ardeyga Warbixinta Luuqada

1. Luuqadee ayuu cunugaada oogu horbartey Ingiriiska ___ Wax kale: ___

2. Luuqadee inta badan looga hadlaa guriga Ingiriiska ___ Wax kale: ___

3. Luuqada inta badan uu ku hadlo cunugaada Ingiriiska ___ Wax kale: ___

4. Luuqadeed isticmaashaa inta badan markad la hadleysid cunugaada Ingiriiska ___ Wax kale: ___

Walidiinta/Masuuliyinta Warxbin

Halkan waxaan ka cadeynayaa warbixinta kor ku qoran iney saxyihiin inta aan ka aqoonsanahey mise ka rumeysanahay. Waan

ogahey in khidadan la badali Karin mudada uu cunugeygu ka diiwaan gashisanyahey Dugsiyada Dadweynaha Willmar.

Magaca (Halkan ku qor): ___________________________________________________________________________________

Saxiixa – Walidka mise Masuulka: _____________________________________________ Tariikhda: ________________

Willmar Public Schools – ISD 347 Suaalooyin ku saabsan luuqada guriga

1

The following is to be completed by a parent or guardian. In order to help your child learn, your child’s teachers need

to determine which language your child uses most. Please repond to the questions below by checking the

appropriate box.

Student’s Full Name: _____________________________________________________

Date of Birth: _______________________ Age: ___________ Grade: ____________

Phone: ____________________________ Cell Phone: _________________________

STUDENT LANGUAGE INFORMATION

1. Which language did your child learn first? English ____ Other: _________________

2. Which language is most often spoken in your home? English ____ Other: _________________

3. Which language does your child usually speak? English ____ Other: _________________

4. Which language do you usually use when speaking to your child? English ____ Other: _________________

PARENT/GUARDIAN SIGNATURE

I hereby verify that the above information is true and correct to the best of my knowledge and belief. I understand

the above designation cannot be changed for the duration of my child’s enrollment in Willmar Public Schools.

Name (printed): _________________________________________________________

Parent/Legal Guardian Signature: ___________________________________________

Date: _______________________

Home Language Questionnaire

Taariikhda maanta: ________________________ Magaca cunugga: ________________________________________________ Jinsi: Lab. ama Dhaddig.

Taarikhda dhalashada cunugga: _______________________________________________ Waan u oggolahey ilmaheyga iskuulkiisa inuu la wadaago cadeymaha talaalka ardeygeyga Waaxda Minnesota Nidaamka Macluumaadka Talaalka ee looyaqaano (MIIC). Haa / Maya Waalid ama ilaaliye: _______________________________________________ Taleefonka maalinta: __________________

Taariikhda Caafimaadka

1. Goorma ugu dambeeyse cunuggaga baaris caafimaad? ____________________________________________

Magaca dhakhtarka ama Isbataalka: ___________________________________________________________

2. Cunugagada Isbataal malla seexiyay ilaa iyo sannadkii la soo dhaafay? Maya Haa

Haddii jawaabtu tahay haa, fadlan sharrax sababta : ___________________________________

3. Cunuggaga daawo si joogto ah ma u qaataa? Maya Haa

Haddii jawaabtu tahay haa, dawo nooce ah? _____________________________________________________________

4. Cunuggaga ma’leyahay cunno qaadasho nidaamsan oo khaas ah? Maya Haa

Haddii jawaabtu tahay haa, fadlan sharax:________________________________________________

Cunuggaga ma’leyahay xanuunnadatan? Qabow _____ Booc xanuun _____ Jeermiska dhegaha kaga dhaca _____

Cudurka neefta ______ Cambaar _____ Dhibaato hadal _____

Xasaasiyad/Allarji: Haddii jawaabtu tahay haa, fadlan muuji riishada iyo sharax calaamadaha.

Cuno ______________________________________________________________

Qaniinyo Shinni ___________________________________________________________

Wax kale ______________________________________________________________ Xaalad Wadnaha la xidhiidha ______ Kaadi sonkorow ______ Nidaam darro qallal ______

Khusaynta caafimaad kale (fadlan sharax): ________________________________________________

Willmar Public Schools – ISD 347 Su’aalaha Caafimaadka Ardayga

Today’s Date: ________________________

Child’s Name: ____________________________________________ Gender: Male / Female

Date of Birth: ________________________

I agree to allow my child’s school to share my student’s immunization documentation with Minnesota’s immunization information system (MIIC). Yes / No

Parent/Guardian: _________________________________________ Daytime Phone: _________________________

MEDICAL HISTORY

1. When was your child’s last medical exam? _______________ Physician or Clinic name: _____________________________________________________________________

2. Has your child been hospitalized within the last year? Yes / No If yes, state reason why? __________________________________________________________________________________________

3. Does your child take medication on a regular basis? Yes / No If yes, what medication? __________________________________________________________________________________________

4. Does your child have special dietary needs? Yes / No If yes, please explain. __________________________________________________________________________________________

Has your child had any of the following health concerns?

Frequent colds ____ Sore Throats ____ Ear Infections ____ Asthma ____ Eczema ____ Speech Difficulty ____ Heart Condition ____ Diabetes ____ Seizure Disorder ____

Allergies: If yes, please identify trigger and describe symptoms. Foods ___________________________________________________________________________________________ Bee Sting ________________________________________________________________________________________ Other ___________________________________________________________________________________________ Other health concerns: (please describe) ________________________________________________________________________________________________

Student Health Questionnaire

1

Arag

Wali cunuggaga ma’helay baaris indho ama daaweyn? Maya Haa; gorma? _____________

Natiijo: Arag caadi ah Ookiyaale ama aalad kale oo wax lagu arko “Il caajis” wax kale _________________

ARDAYDA DUGSIYADA HOOSE OO KALIYA

ARDAYDA DUGSIYADA HOOSE OO KALIYA: (Calaamadee dabeecadaha cunuggaga ee aad dareenka ka qabto:

__ Riyo xun __ Xanaaqa, isku cadhooda si fudud __ Burburrita waxyaabaha sikas ah

__ Wal walsan __ Suulnuugid __ Qabadashada neefta

__ Sal-fudud __ Aan Karin in uu cid wax la wadaago __ Si saa’id dareen badan

__ Masayroow ah __ Madax-adag ama aan-awoodin iskaashi __ Rabatan feejignaan aad iyo aad uu badan

__ Dhaga-adag __ Mad-luun, af-buurid, dabciraran __ Camal xun

__ Ciddiyaha qaniina __ Dhibaato kala saaridda waalidka __ Uu feejignaan ur ama dareenka taabasho ee

shayleeyahay

Wax kale: ___________________________________________________________________________

Ma awoodda cunuggaga in uu isticmaalo muusqul si madaxbanaan ama Xorriyad? Maya Haa

Cunuggaga wali muusqusha dhib kala ma’kulmay? Maya Haa

VISION

Has your child ever had a vision examination or treatment? No / Yes; when? _______________________________

Results: Normal Vision ____ Glasses/Contacts ____ “Lazy Eye” ____

Other: __________________________________________________________________________________________

ELEMENTARY STUDENTS ONLY

Check any concerns you have about the following behavior(s) in your child:

Bad Dreams ____ Irritable, easily upset ____ Destroys things purposely ____ Nervousness ____

Thumb Sucking ____ Holds Breath ____ Restlessness ____ Unable to Share____ Overly sensitive____

Jealousy ____ Stubborn, uncooperative ____ Wants too much attention ____ Disobedient ____

Glum, sulky, moody ____ Bad temper____ Nail Biting ____ Difficult separating from parents ____

Very sensitive to smells or textures____

Other: ________________________________________________________________________________

Can your child independently use the bathroom? Yes / No

Does your child still have toileting accidents? Yes / No

Minnesota law requires children enrolled in school to be immunized against certain diseases or file a legal medical or conscientious exemption.

Student Immunization Form FOR SCHOOL USE ONLY( ) Complete; booster required in ___________( ) In process; 8 mos. expires _____________( ) Medical exemption for _________________( ) Conscientious objection for _____________( ) Parental/guardian consent _____________

Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13) #140-0155

Student Name _________________________________________________

Birthdate _____________________Student Number __________________

Additional exemptions: • Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the minimum

requirements of the law.• Students in grades 7-12: A Tdap at age 11 years or later is required for students in grades 7-12. If a child received Tdap at age

7-10 years another dose is not needed at age 11-12 years. However, if it was only a Td, a Tdap dose at age 11-12 years is required. • Students 11-15 years of age: A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the

alternative 2-dose schedule.• Students 18 years of age or older: Do not need polio vaccine.

Type of Vaccine DO NOT USE () or () 1st DoseMo/Day/Yr

2nd DoseMo/Day/Yr

3rd DoseMo/Day/Yr

4th DoseMo/Day/Yr

5th DoseMo/Day/Yr

Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT)• for children age 6 years and younger• final dose on or after age 4 years

Tetanus and Diphtheria (Td) • for children age 7 years and older• 3 doses of Td required for children not up to date with DTaP,

DTP, or DT series aboveTetanus, Diphtheria and Pertussis (Tdap)

• for children in 7th - 12th grade

Polio (IPV, OPV)• final dose on or after age 4 years

Measles, Mumps, and Rubella (MMR)• minimum age: on or after 1st birthday

Hepatitis B (hep B)

Varicella (chickenpox)• minimum age: on or after 1st birthday• vaccine or disease history required

Meningococcal (MCV, MPSV) • for children in 7th - 12th grade• booster given at age 16 years

RecommendedHuman Papillomavirus (HPV)

Hepatitis A (hep A)

Influenza (annually for children 6 months and older)

5th dose not required if 4rd dose was given on or after the 4th birthday

4th dose not required if 3rd dose was given on or after the 4th birthday

School Personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it. Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space.

Parent/Guardian:You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption. Additionally, if a parent or guardian would like to give permission to the school to share their child’s immunization record with Minnesota’s immunization information system, they may sign section 3 (optional).For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.

Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13) #140-0155

Student Name _______________________________________________Instructions, please complete:Box 1 to certify the child’s immunization status Box 2 to file an exemption (medical or concientious) Box 3 to provide consent to share immunization information (optional)

3. Parental/Guardian Consent to Share Immunization Information (optional): Your child’s school is asking your permission to share your child’s immunization documentation with MIIC, Minnesota’s

immunization information system, to help better protect students from disease and allow easier access for you to retrieve your child’s immunization record. You are not required to sign this consent; it is voluntary. In addition, all the information you provide is legally classified as private data and can only be released to those legally authorized to receive it under Minnesota law.

I agree to allow school personnel to share my student’s immunization documentation with Minnesota’s immunization information system:

Signature of parent or legal guardian Date

A. Received all required immunizations: I certify that this student has received all immunizations

required by law.

Signature of Parent / Guardian OR Physician / Public Clinic

_______________ Date

B. Will complete required immunizations within the next 8 months:

I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B, varicella, measles, mumps, and rubella and will complete his/her diphthe-ria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months.

The dates on which the remaining doses are to be given are:

Signature of Physician / Public Clinic

_______________ Date

1. Certify Immunization Status. Complete A or B to indicate child’s immunization status.

A. Medical exemption: No student is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a student to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement:I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s):

Signature of physician/nurse practitioner/physician assistant _______________ Date

*History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in ___________ (year)

Signature of physician/nurse practitioner/physician assistant (If disease occured before September 2010, a parent can sign.)

B. Conscientious exemption: No student is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the student or others they come in contact with. In a disease outbreak schools may exclude children who are not vac-cinated in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized:I certify by notarization that it is contrary to my conscien-tiously held beliefs for my child to receive the following vaccine(s):

Signature of parent or legal guardian _______________ Date

Subscribed and sworn to before me this: _______ day of ______________________ 20______

Signature of notary

2. Exemptions to School Immunization Law. Complete A and/or B to indicate type of exemption.