Fillable Houston Independent School District American Indian or Alaska (Houston Independent School District)

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Houston Independent School District American Indian or Alaska (Houston Independent School District)

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20____ - 20____
Houston Independent School District
Enrollment Information
Homeroom Teacher:
Last School/Daycare AttendedHas student ever attended an HISD School?
¨ Yes
¨ No
HISD Student ID
Date of Enrollment
Date of Birth
Gender
Legal Student Last Name
First Name
Middle Name
Generation
Student SS# / State Alt. #
(Jr., III, etc.)
¨ Male
¨ Female
Student Birthplace:
Year Started School in US
Student Lives with
¨ Mother
¨ Both Parents
¨ Other
¨ Father
City, State, Country
Federal
Student Ethnicity
(Select One)
Home Phone
¨ American Indian or Alaska Native ¨ Asian ¨ Black or African American
¨ Native Hawaiian/Other Pacific Islander ¨ White
Street Number
Student
Address
CountyApartment State
Texas Education Code §25.002(f) requires the school district to record the name, address, and birth date of the person enrolling a child.
Contact #1 Name (Last, First) Relationship
Employer Occupation Home Phone Work Phone Cell Phone
Preferred
Language
¨ English ¨ Vietnamese
Translator Needed?
e-mail Address
¨ Spanish ¨ Other
¨ Yes
¨ No
Contact #2 Name (Last, First)
Relationship
Employer Occupation Home Phone Work Phone Cell Phone
Preferred
Language
¨ English
¨ Spanish
¨ Vietnamese
¨ Other
Translator Needed?
¨ Yes
¨ No
Contact #3 Name (Last, First) Relationship
Employer Occupation Home Phone
Work Phone
Cell Phone
e-mail Address
e-mail Address
Translator Needed?
Preferred
Language
¨ English
¨ Spanish
¨ Vietnamese
¨ Other
¨ Yes
¨ No
What type of medical insurance do you carry for this child? Family Physician Physician Phone
¨ CHIP ¨ Medicaid ¨ HCHD ¨ Private Insurance ¨ None
Signature below certifies that all the information above is true and accurate.
Enrollment of the child under false documents subjects the person to liability for tuition or costs under Texas Education Code §25.001(h).
Signature of Contact 1/Legal Guardian TX Driver's License Number Date of Birth (Contact 1/Legal Guardian)
Signature of Contact 2/Legal Guardian
TX Driver's License Number
Date of Birth (Contact 2/Legal Guardian)
Total Monthly Family Income: Total Number In Household:
City ZipStreet Name
Street Number Street Name Apartment
City State Zip
ZipStateCityApartmentStreet Name
Street Number
ZipStateCityApartmentStreet NameStreet Number
Student Race
¨ Not Hispanic/Latino
¨ Hispanic/Latino
(Select all that apply)
List the names of all brothers and sisters under 18 years of age. (If additional room is needed, write on reverse side.)
Last, First, and Middle Names
Birthdate
Address of This Child
Gender
Grade
Student Cell Phone Student e-mail Address
v 4.3 - JK 07-24-2014
-
-
-
-
-
STUDENT ASSISTANCE QUESTIONNAIRE (SAQ)
All information MUST be completed by parent, school personnel or community liaison.
School _________________________________________________________________________________Date_____________________
Student Name ___________________________________________________ Date of Birth_______________ HISD ID ________________
Current Address _____________________________________________________________ Grade ________
o Male o Female
Lives with: o Both Parents, o Mother, o Father, o Legal Guardian, o Caretaker/Relative without legal guardianship, o Other ______________
relation
Is the student currently in the conservatorship of the Department of Family & Protective Services (Foster Care)?
o Yes o No
If Yes – name of DFPS Case Manager: ___________________________________ Contact information: ___________________________________
Was the student previously in the conservatorship of the Department of Family & Protective Services (Foster Care)? o Yes o No
Please complete the Current Housing Situation AND Background Situation sections below to determine Mckinney-Vento eligibility:
Part A: CURRENT HOUSING SITUATION – Check the student’s current housing situation
I CURRENTLY LIVE:
o In my own home or apartment, in Section 8 housing, HUD Subsidized Housing or in military housing with parent(s), legal guardian(s), or
caregiver(s) (if you checked this box, check one or both of the boxes below, if applicable.
o My home has no electricity o My home has no running water
OR I CURRENTLY LIVE IN A TRANSITIONAL HOUSING SITUATION:
o Living in a shelter o Living in a motel or hotel
o Living with more than one family in a house or apartment (Doubled-up) due to economic hardship
Unsheltered
o Moving from place to place o Living in a structure not usually used for housing o Living in a car, park, campsite, camper, or outside
UNACCOMPANIED YOUTH - o Yes o No (An unaccompanied youth is a student who is not in the physical custody of a parent or
legal guardian. This would include students living with non-custodial relatives or friends without a parent or legal guardian.)
Part B: BACKGROUND SITUATION (If a Transitional Housing Situation is checked above - please Check ANY below that apply)
o Catastrophic illness / medical expenses / disability o Natural disaster / evacuation
o New to Town o Domestic Issue
o Loss of Employment o Migrant work in fishing or agriculture
o Economic hardship/low earnings o Awaiting placement in foster care / CPS custody
o Evicted/kicked out o Parent(s) involved in military deployment
o House fire or other destruction o Parent Incarcerated/Recently released from incarceration
Part C: NEEDED SERVICES – based on availability (Check services needed and call 713-556-7237 to speak to an Outreach Worker)
o Enrollment Assistance o Transportation o Emergency Clothing, Uniforms
o Free Lunch/Breakfast (Child Nutrition) o School Supplies o Personal Hygiene Items
o Immunizations o Medicaid/CHIP Assistance o Food Stamps (SNAP) Assistance
o Temporary Assistance for Needy Families (TANF) o Other ___________________________
To the best of my knowledge this information is true and correct.
Name (PLEASE PRINT): _____________________________________ Signature ____________________________ Phone #’s _________________________
School Personnel: This form is intended to address the McKinney-Vento Act U.S.C. 11435. If any “Transitional Housing Situation” is checked under “Current
Housing Situation” AND the family has indicated one of the “Background Situations” (1) immediately add PEIMS Coding on the At-risk Chancery panel for
At-risk reason code 12, (2) code all of the McKinney-Vento Panels on that screen (the start date should be the date the form was completed and also add the
end date, and (3)Email forms to HomelessEducation@houstonisd.org. If information is missing, please follow-up with the parent/guardian/school personnel
who completed the form to make sure each section is completed, as needed.
Multilingual Programs Department | October 2018
HOME LANGUAGE SURVEY
19 TAC Chapter 89, Subchapter BB, §89.1215
(Home Language Survey applicable ONLY if administered
for students enrolling in prekindergarten through grade 12)
TO BE COMPLETED BY PARENT OR GUARDIAN FOR STUDENTS ENROLLING IN
PREKINDERGARTEN THROUGH GRADE 8 (OR BY STUDENT IN GRADES 9-12): The state of Texas
requires that the following information be completed for each student who enrolls in a Texas public school
for the first time. It is the responsibility of the parent or guardian, not the school, to provide the language
information requested by the questions below.
Dear Parent or Guardian:
To determine if your child would benefit from Bilingual or English as a Second Language program services,
please answer the two questions below.
If either of your responses indicates the use of a language other than English, then the school district must
conduct an assessment to determine how well your child communicates in English. This assessment
information will be used to determine if Bilingual or English as a Second Language program services are
appropriate and to inform instructional and program placement recommendations. If you have questions
about the purpose and use of the Home Language Survey, or you would like assistance in completing the
form, please contact your school/district personnel.
For more information on the process that must be followed, please visit the following website:
https://projects.esc20.net/upload/page/0081/docs/JuneUpdates/EnglishLearnerIdentification-
ReclassificationFlowchart.pdf
This survey s
hall be kept in each student’s permanent record folder.
NAME OF STUDE
NT: _________________________________ STUDENT ID #:__________________
ADDRESS: _________________________________________ TELEPHONE #:__________________
CAMPUS: _________________________________________________________________________
NOTE: PLEASE INDICATE ONLY ONE LANGUAGE PER RESPONSE.
1. What language is spoken in the child’s home most of the time? _____________________________
2. What language does the child speak most of the time? ____________________________________
________________________________________ ________________________________
Signature of Parent/Guardian Date
________________________________________ ________________________________
Signature of Student if Grades 9-12 Date
NOTE: If you believe you made an error when completing this Home Language Survey, you may request a correction, in writing, only if:
1) your child has not yet been assessed for English proficiency; and
2) your written correction request is made within two calendar weeks of your child’s enrollment date.
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signature
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Health and Medical Services GJ/slr 3/2012
HOUSTON INDEPENDENT SCHOOL DISTRICT
HEALTH INVENTORY
SCHOOL DATE
TEACHER SCHOOL LAST ATTENDED
Please fill in this form and return to the teacher or nurse. The information given on this form will help the school staff
to have a better understanding of your child’s health needs:
Name Sex Birthdate Birth weight
Address Phone
Have you ever been told by a doctor that your child had:
Age
First
Identified
Under Doctor’s
Care?
Age
First
Identified
Under Doctor’s Care?
Asthma
Bone/Joint Problem
Allergies
Rheumatic Fever
Blood Disorder
Surgery/Fractures
Diabetes
T. B. Disease
Epilepsy/Seizures
Hearing Loss
Heart Disease
Vision Loss
Kidney Disorder
Severe Menstrual Cramps
Cancer
Eating Disorder
Please check if you have observed any of the following in your child:
Signature
Tires easily Earaches Wheezing, shortness of breath with exercise
Frequent headaches Difficulty making friends Nail Biting
Fainting Coughs frequently at night Restlessness
Has your child been seen by a doctor for any of the above? Yes No
Is your child on any kind of medication? Yes No
If so, what?
For what condition?
Further comment
Please see the School Nurse (or School Principal) if your child has other needs or is:
• A pregnant or parenting teen
and/or
• Has a severe life-threatening food allergy
What type of medical insurance do you carry for this child?
CHIPMedicaidHCHD Private InsuranceNone
■
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signature
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HISD Media Relations | July 2018
STUDENT MEDIA CONSENT AND RELEASE FORM
This release allows the Houston Independent School District (HISD) to print, photograph, and record my child
for use in efforts to promote HISD’s activities and achievements. The consent includes allowing my child to be
included and/or featured in materials to train teachers and/or increase public awareness of HISD schools
through digital and print media including: newspaper, radio, TV, websites, blogs, and social media channels
(Facebook, Twitter, YouTube, etc.), DVDs, displays, and brochures. This release includes the use of my child’s
work, name, image, and/or voice.
q I attest that I am the parent or guardian of ______________ and I GIVE HISD and its employees and
representatives permission to print, photograph, and record my child for use in electronic, digital, and
printed media.
q I attest that I am the parent or guardian of _____________ and I DO NOT GIVE HISD and its
employees and representatives permission to print, photograph, and record my child for use in audio,
video, film or any other electronic, digital, or printed media.
I agree to release the Houston Independent School District, its past, present and future trustees, officers,
employees, representatives, and agents, from any and all liability, claims, demands, and causes of action
arising out of the use of this material.
I certify that I have read this document and fully understand its terms and conditions. I also understand that I
may withdraw consent at any time by sending a written request to the principal of my child’s school.
PLEASE PRINT
Name of child __________________________________________ Grade_____________________________
Address _________________________________________________________________________________
City, State, Zip____________________________________________________________________________
Name of parent or guardian _________________________________________________________________
School _________________________________________________________________________________
Signature of parent or guardian ______________________________________________________________
Date____________________ Phone Number ___________________________________________________
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signature
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!
HISD External Funding Department | June 2019
!
SOCIOECONOMIC INFORMATION FORM
Complete and return one form to each school where you have a child enrolled. Print using a pen.
*CONFIDENTIAL* - For HISD purposes only
Houston ISD is required to collect the socioeconomic status of each student as a performance indicator for student
achievement (TEC § 39 for Texas state requirements and ESEA §§1111 and 1116 for U.S. Department of Education
requirements) and for use in disbursement of federal funds (ESEA §1113). This information is not shared with outside
agencies.
It is very important that families complete this socioeconomic form in order for schools to receive Title I and State
Compensatory Education funding. This funding will directly benefit your child's school. Title I and State Compensatory
Education funding can be used to hire personnel, provide tutoring services, order technology, and provide professional
development for teachers. We want to continue to provide these necessary learning supports, but without your assistance
we may not be able to.
STEP 1 (List all Houston ISD students in the household)!
Student ID
(office use only)
First Name
Last Name
MI
Date of Birth
School Name
Grade Level
STEP 2
Do you receive Supplemental Nutrition Assistance (SNAP)? □ YES □ NO
Do you receive Temporary Assistance to Needy Families (TANF)? □ YES □ NO
If you answered YES on either of the above, skip Step 3 and continue to Step 4.
If you answered NO on both of the above, you must complete Steps 3 and 4.
STEP 3 (Complete only if all answers in Step 2 are NO)
How many total members are in the household (include all adults and children)? __________
TOTAL YEARLY INCOME BEFORE DEDUCTIONS OF ALL HOUSEHOLD MEMBERS _________________
Include wages, salary, welfare payments, child support, alimony, pensions, Social Security, worker’s
compensation, unemployment, and all other sources of income (before any type of deductions)
STEP 4 (Check one of the following two boxes as appropriate and sign below.)
In accordance with the provisions of the Protection of Pupil Rights Amendment (PPRA) no student shall be required, as part
of any program funded in whole or in part by the U.S. Department of Education, to submit to a survey, analysis, or
evaluation that reveals information concerning income (other than that required by law to determine eligibility for
participation in a program or for receiving financial assistance under such program), without the prior written consent of the
adult student, parent, or legal guardian.
I certify that all the information on this form is true. I understand the school will receive
federal funds and will be rated for accountability based on the information I provide.
I choose not to provide this information. I understand that the school’s disbursement of
federal funds and accountability rating may be affected by my choice.
__________________________ _________________________ __________
Parent/Guardian Name (Print) Parent/Guardian Signature Date
!
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signature
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FAMILY SURVEY
STUDENT NAME:
DATE OF BIRTH:
CAMPUS NAME:
GRADE LEVEL:
Dear Parent/Guardian:
The Houston Independent School District is assisting the state of Texas to identify students who may qualify for the
Migrant Education Program to receive additional services.
The information provided below will be kept confidential.
Please answer the following questions and return this form to your child’s school.
1.
Have you or anyone in your household moved within the last 3 years from one school district to another in Texas or
within the United States?
YES
□
(Continue to question 2) NO
□
(Stop here and return survey to your child’s school)
2.
Were any of these moves made to find temporary/seasonal work in agriculture or fishing? (e.g., field work, canneries,
dairy work, meat processing, etc.)
YES
□
(Please check all that apply below) NO
□
(Stop here and return survey to your child’s school)
Fruit, vegetables, sunflower,
cotton, wheat, grain, farms or
ranches, fields & vineyards
□
Dairy farm
□
Fishery
□
Cannery
□
Poultry farm
□
Plant nursery, orchard, tree
growing or harvesting
□
Slaughterhouse
□
Other similar work,
please explain:
□
If you answered “yes” to the questions above, an education representative will contact you to provide
additional information. Please complete the following information:
Parent/Guardian Name Home Address Telephone Number
— FOR SCHOOL USE ONLY—
PLEASE SUBMIT THIS INFORMATION AND FORMS AT
https://form.jotform.com/200065674657156
MIGRANT EDUCATION PROGRAM
4400 W. 18
th
Street, Route 1 | Houston, TX 77092 |713-556-7288
HISD Multilingual Programs | 713-556-6980 Fax | January 2020
Multilingual Programs Department | Compliance Division | August 2020
SCHOOL ENROLLMENT HISTORY
(Only for students enrolling in 2
nd
grade or above whose
Home Language Survey indicates a language other than English)
Student Name: _________________________ Student ID: ________________________
Grade Level: __________ School: ________________________
Date of Enrollment in U.S. schools: __________________
Has student ever attended school outside the U.S.?
□
No If “no” then stop. No need to continue filling out this form.
□
Yes If “yes” please provide student’s academic history below.
Please use the back of this form if more space is needed.
Parent Signature: __________________________________________ Date:_________________
Student History Worksheet
School
Year
Grade
Country/
U.S.
State
Total Time Enrolled
If student did not attend
school for a full
academic year, specify
months attended
For Office Use
Document TELPAS Reading
rating if available/Yrs in U.S.
Schools
Kinder
□ All Year □ No Schooling
□ Partial (
Specify)
1
st
□ All Year □ No Schooling
□ Partial (Specify)
2
nd
□ All Year □ No Schooling
□ Partial (
Specify)
3
rd
□ All Year □ No Schooling
□ Partial (Specify)
4th
□ All Year □ No Schooling
□ Partial (
Specify)
5
th
□ All Year □ No Schooling
□ Partial (Specify)
6
th
□ All Year □ No Schooling
□ Partial (
Specify)
7
th
□ All Year □ No Schooling
□ Partial (Specify)
8
th
□ All Year □ No Schooling
□ Partial (
Specify)
9
th
□ All Year □ No Schooling
□ Partial (Specify)
10
th
□ All Year □ No Schooling
□ Partial (
Specify)
11
th
□ All Year □ No Schooling
□ Partial (Specify)
12
th
□ All Year □ No Schooling
□ Partial (
Specify)
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HISD Office of Legal Services | June 2019
CODE OF STUDENT CONDUCT
CÓDIGO DE CONDUCTA ESTUDIANTIL
Students and parents are expected to become familiar with the provisions of the districtwide Code of Student
Conduct and the rules and regulations adopted and implemented by individual schools. Students are also
expected to abide by the policies set forth in the Code so that they can get the most out of their years in school.
Todos los estudiantes y sus padres deben familiarizarse con las directivas del Código de Conducta Estudiantil vigente
en el Distrito y con las reglas y normativas adoptadas e implementadas en las escuelas. Es de esperar también que los
estudiantes cumplan con las normas del Código para que puedan lograr el máximo provecho de su carrera escolar.
You may access the entire HISD Code of Student Conduct online at www.HoustonISD.org/CodeofConduct or
by requesting a copy at the front office of your student’s school.
El Código de Conducta Estudiantil de HISD completo se encuentra en www.HoustonISD.org/CodeofConduct y es posible
además obtener una copia impresa en la recepción de la escuela de su hijo.
Parent and Student Acknowledgement and Optional Request for Printed Copy of the Code of Student Conduct
Confirmación de recibo del Código de Conducta Estudiantil y opción de solicitar una copia impresa
____ No, I do not want a printed copy of the HISD Code of Student Conduct, as I will access it online at
www.HoustonISD.org/CodeofConduct.
____ No, no necesito una copia impresa del Código de Conducta Estudiantil de HISD ya que lo consultaré en línea en
www.HoustonISD.org/CodeofConduct.
____ Yes, I do want a printed copy of the HISD Code of Student Conduct.
____ Sí, quiero tener una copia impresa del Código de Conducta Estudiantil de HISD.
It is important that every student understands the Code of Student Conduct and is expected by his or her
parent(s) or guardian(s) to follow the rules and regulations set forth in it. By signing below, the parent and
student acknowledge that they understand how to access and obtain a printed copy of the Code. These
signatures also certify that both parent and student accept their responsibilities as described in the Code of
Student Conduct.
Es importante que todos los estudiantes entiendan el Código de Conducta Estudiantil y que sus padres o tutores les
exijan que sigan las reglas y directivas establecidas en él. Al firmar al pie, los padres y el estudiante afirman que
comprenden cómo lograr acceso al Código en línea y cómo obtener una copia impresa. Las firmas certifican también
que tanto los padres como el estudiante aceptan las responsabilidades descritas en el Código de Conducta Estudiantil.
________________________________________________________________________________________________
Student Last Name First Name Grade Student ID Number
Apellido del estudiante Nombre Grado Núm. de identificación estudiantil
________________________________________________________________________________________________
Student Signature Date
Firma del estudiante Fecha
________________________________________________________________________________________________
Parent or Guardian’s Signature Date
Firma del padre o tutor Fecha
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HISD Information Technology Department | July 2018
STUDENT LAPTOP LOAN AGREEMENT
A district laptop will be loaned to the student named below under the following conditions:
o
The student and the student’s parent/guardian must sign this laptop loan agreement. The
school will keep this agreement on file.
o
The laptop may only be used for educational purposes. Any other use may result in the loss of
laptop loan privileges.
o
The laptop may not be used for any inappropriate, unethical, or illegal purposes, to include
activities on the Internet, use of email and messaging, and access to digital media and
programs. Violations of this policy may result in the loss of laptop loan privileges and/or
disciplinary action.
o
The laptop hardware and district-installed software may not be modified in any way. No
software can be copied from the laptop, nor can any unapproved software be installed on the
laptop. Occasionally teachers may direct students to install authorized software packages from
the HISD Software Center.
o
Parents/guardians are required to pay a non-refundable fee of $25.
o
The student’s parent/guardian accepts financial responsibility for any intentional damage to the
laptop or damage due to gross negligence. The district may take legal action to recover any
unpaid costs of such damage. More information regarding the care of the laptop and
instructional materials is in the student manual.
o
The district will provide a padded laptop bag or case to each student. The bag/case will fit
inside a backpack. The laptop must always be secured and carried in its case when not in use
or being moved.
o
The laptop is the property of Houston ISD. The laptop must be returned to the student’s school
prior to the end of each school year, or if the student withdraws from school or changes
schools midyear. Laptops not returned as required may be reported to the police as stol
en.
o
The student will promptly report to school officials if the laptop is lost, stolen, or damaged.
o
The district provides information to both students and parents/guardians about proper care of
the laptop and the responsible use of technology. Students attend a digital citizenship
orientation, and parents are invited to open house events with presentations and handouts on
these topics.
o
The student and the student’s parent/guardian have read both the: a) Acceptable Use Policy
for Electronic Services for St
udents and b) Responsible Digital Citizenship Policy Agreement.
We, the undersigned student and parent/guardian, agree to assume full responsibility for the proper
care and educational use of the laptop computer equipment described in this document.
Student Name (print) _____________________________________ Phone
Address/City/State/Zip __________________________________________________________
Student Signature_______________________________________ Date _______
Parent Signature________________________________________ Date __________
Student ID _______________________________________ Grade Level
School Name_________________________________________________________________
HISD Office of Community Partnerships, Strategy & Innovation | September 2019
METRO Q
®
FARE CARD
METRO is offering Houston ISD students from kindergarten through 12th grade the opportunity to register and receive a
discounted METRO Student Q
®
fare card on campus. The discounted METRO Student Q
®
fare card allows students to
ride all METRO services for 50 percent off the regular fare when they use the Student METRO Q
®
fare card. METRO
Local bus and light-rail service costs just 60 cents each way. (NOTE: Park & Ride service cost will vary). There is no cost
to receive the Student METRO Q
®
fare card, but to participate and receive a discounted METRO Student Q
®
fare card on
campus, students must have parental/guardian consent and they must register by providing the information below.
The deadline for students to provide a signed parental/guardian permission form to obtain a Student METRO Q
®
fare card
on campus is [Date____________ ]. If a student already has a Student METRO Q
®
fare card, and applies for a second
card, one of the cards will be deactivated. Students should only have one active card.
PLEASE PRINT:
________________________________________________________________________________________________
Student Name Date of Birth
________________________________________________________________________________________________
Address (Street. Apt.#, City, State, Zip)
________________________________________________________________________________________________
Email Telephone Number
________________________________________________________________________________________________
School Student ID Number
________________________________________________________________________________________________
Homeroom Teacher Grade
PLEASE CHECK ONE:
____ YES, I am aware of the opportunity to register my child to receive a discounted Student METRO Q
®
fare card
on campus. Houston ISD has my permission and is authorized to release any of the information above to METRO to
facilitate my child’s participation in the program.
____ NO, I request that Houston ISD not release any of the information above to METRO to receive a discounted Student
METRO Q
®
fare card on campus. I am aware of the opportunity for my child to receive the Student METRO Q
®
fare card
on campus and I decline.
________________________________________________________________________________________________
Parent/Guardian’s Name Parent/Guardian’s Signature Date
NOTE: If this form is not on file at the school, your child will not receive a Student METRO Q
®
fare card on campus. If you have
questions, you may contact METRO Client Services at 713-739-4015 or Client.Services@ridemetro.org or your child’s school.
!
HISD!Federal!and!State!Compliance!|!July!2017"
!
!
MILITARY CONNECTED FAMILIES SURVEY
!
!
All information MUST be completed by parent, school personnel or community liaison.
School
Date
Student Name HISD ID#
!
Dear Parent or Guardian,
!
The State of Texas requires schools to collect data relating to the enrollment of military-
connected students. This collection is done to allow educational institutions the ability to
monitor critical elements of education success for children who are dependents of military
personnel, and show the state’s commitment to military personnel and their children.
!
!
!
For students in grades Kindergarten through 12:
!
1. The student is a dependent of an active duty member of the United States Army,
Navy, Air F
orce, M
arine Corps, or Coast Guard
!
o Yes o No
!
2. The student is a dependent of a member of the Texas National Guard
(Army, Air Guard, or State
Guard)
!
o Yes o No
!
3. The 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)
!
o Yes o No
!
For pre-kindergarten students only:
!
4. The student is a dependent of an active duty uniformed member of the Army,
Navy, Air Force, Marine Corps, or Coast Guard,
or activated/mobilized uniformed
member of the Texas National Guard (Army, Air Guard, or State Guard) who was
injured or killed while serving on active duty.
!
o Yes o No
!
HISD Office Of Student Support | July 2017
PRIVACY CODE: STUDENT RECORDS, RIGHTS, AND RESPONSIBILITIES
Student Records: State law requires the Houston Independent School District (HISD) to maintain an
education record for each student attending its schools. These records contain identifying data pertaining to
the student and may include information concerning demographics, grades, attendance, health, discipline,
guidance, assessment, and appraisals.
Access to Records: In addition to HISD employees, who have a legitimate educational interest in a student’s
records, parents, guardians, and the student are the only persons who have access to student records
maintained by the district.
Both parents—married, separated, or divorced—have access to a student’s records until the student becomes
18 years of age and is no longer a dependent student under Section 152 of the Internal Revenue Code. A
parent’s rights to access student records may be restricted by a court order. Legal guardians have the same
rights of access as parents. Parents and students may review records during regular school hours by
contacting their school principal.
After the student becomes 18 and is no longer a dependent, only the student has access to his or her records.
However, that student may consent to others having access.
Under certain restricted conditions, other individuals may review a student’s records. These conditions include:
• Other schools to which a student is transferring.
• Specified officials for audit or evaluation purposes.
• Appropriate parties in connection with financial aid to a student.
• Accrediting organizations.
• State and local juvenile justice system authorities pursuant to state law.
• Appropriate officials in cases of health and safety emergencies.
Records may also be reviewed to comply with a judicial order or lawfully issued subpoena provided the parent
and student received notice before compliance. No other persons are allowed to review a student’s records
without either permission of the parent or that of the student if over 18 years of age.
Challenge to Content of a Record: If a parent or a student over 18 feels that the student record contains
information which is misleading, incorrect, or a violation of the privacy or other rights of the student, that person
may challenge the contents of the record in an informal hearing. To initiate this procedure, contact your school
principal.
Copies: A student 18 years of age or over or a parent or guardian of a student under 18 years of age
requesting copies of his or her child’s official district records for a purpose other than the transaction of the
official business of the district shall pay 10 cents a page for each copy. A limit of three high-school transcripts
will be provided free to post-secondary schools. Each additional copy will cost $1. The Inactive Student
Records Department microfilms high-school transcripts for permanent retention.
Special Education Records: The district maintains Special Education records for seven years after the last
date of service and then destroys the records in accordance with state law. A “Notice of Destruction of Special
Education Records” is published annually through the district’s website (www.houstonisd.org) advising the
parent or adult student how they may request a copy of the records before they are destroyed. It is important
that the parent or adult student keep a copy of all Special Education records for use in later years.
Complaints: Parents or a student over the age of 18 have the right to file a complaint with the U.S.
Department of Education concerning alleged failures of the district to comply with the provisions of the Family
Education Rights and Privacy Act of 1974.
!
HISD Office Of Student Support | July 2017
PRIVACY CODE: STUDENT RECORDS, RIGHTS, AND RESPONSIBILITIES
Directory Information: Certain information about district students is considered directory information and will
be released to anyone who follows the procedures for requesting the information for school-sponsored
purposes.
Directory information may include the following:
• Student name
• Address
• Telephone listing
• Date and place of birth
• Photograph
• Major field of study
• Participation in officially recognized activities and sports
• Weight and height of members of athletic team
• Dates of attendance
• Awards received
• Most recent previous school attended by a student
If you DO NOT want to release directory information regarding your child, please check the appropriate
box on the Privacy Code Form below and return it to your child’s school.
Military Recruitment/Higher Education: Public Law 107-110 requires school districts receiving assistance
under the No Child Left Behind Act of 2002 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.
If you DO NOT want your child’s directory information released to military recruiters or institutions of
higher education without your specific, prior, written consent, check the appropriate box on the
Privacy Code Form below and return it to your child’s school.
PRIVACY CODE FORM
Please check all boxes below that apply.
______I have received the Notice of Student Rights and Responsibilities with Respect to Student Records
Maintained by the Houston Independent School District.
______I request that Houston ISD NOT release any directory information regarding my child, except as
required by law.
______I request that Houston ISD NOT release my child’s name, address, and telephone number to a military
recruiter or an institution of higher education, without my specific written approval.
Student’s Name_____________________________________________Student’s Date of Birth____________
Students’ School_________________________________________________ Student’s Grade____________
Name of Parent/Guardian__________________________________________ Date: ____________________
Parent/Guardian Signature__________________________________________________________________
Name: _________________________________________________________________________ D.O.B.: ____________________
Allergy to: __________________________________________________________________________________________________
Weight: ________________ lbs.
Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No
PLACE
PICTURE
HERE
1. Antihistamines may be given, if ordered by a
healthcare provider.
2. Stay with the person; alert emergency contacts.
3. Watch closely for changes. If symptoms worsen,
give epinephrine.
PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017
1. INJECT EPINEPHRINE IMMEDIATELY.
2. Call 911. Tell emergency dispatcher the person is having
anaphylaxis and may need epinephrine when emergency
responders arrive.
• Consider giving additional medications following epinephrine:
» Antihistamine
» Inhaler (bronchodilator) if wheezing
• Lay the person flat, raise legs and keep warm. If breathing is
difficult or they are vomiting, let them sit up or lie on their side.
• If symptoms do not improve, or symptoms return, more doses of
epinephrine can be given about 5 minutes or more after the last dose.
• Alert emergency contacts.
• Transport patient to ER, even if symptoms resolve. Patient should
remain in ER for at least 4 hours because symptoms may return.
HEART
Pale or bluish
skin, faintness,
weak pulse,
dizziness
MOUTH
Significant
swelling of the
tongue or lips
OR A
COMBINATION
of symptoms
from different
body areas.
LUNG
Shortness of
breath, wheezing,
repetitive cough
SKIN
Many hives over
body, widespread
redness
GUT
Repetitive
vomiting, severe
diarrhea
NOSE
Itchy or
runny nose,
sneezing
MOUTH
Itchy mouth
SKIN
A few hives,
mild itch
GUT
Mild
nausea or
discomfort
THROAT
Tight or hoarse
throat, trouble
breathing or
swallowing
OTHER
Feeling
something bad is
about to happen,
anxiety, confusion
Epinephrine Brand or Generic: ________________________________
Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM
Antihistamine Brand or Generic: _______________________________
Antihistamine Dose: __________________________________________
Other (e.g., inhaler-bronchodilator if wheezing): __________________
____________________________________________________________
MEDICATIONS/DOSES
SEVERE SYMPTOMS
MILD SYMPTOMS
FOR MILD SYMPTOMS FROM MORE THAN ONE
SYSTEM AREA, GIVE EPINEPHRINE.
FOR MILD SYMPTOMS FROM A SINGLE SYSTEM
AREA, FOLLOW THE DIRECTIONS BELOW:
FOR ANY OF THE FOLLOWING:
NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.
Extremely reactive to the following allergens: _________________________________________________________
THEREFORE:
[ ] If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.
[ ] If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.
HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK
®
),
USP AUTO-INJECTOR, IMPAX LABORATORIES
1. Remove epinephrine auto-injector from its protective carrying case.
2. Pull off both blue end caps: you will now see a red tip.
3. Grasp the auto-injector in your fist with the red tip pointing downward.
4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh.
5. Press down hard and hold firmly against the thigh for approximately 10 seconds.
6. Remove and massage the area for 10 seconds.
7. Call 911 and get emergency medical help right away.
HOW TO USE EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN
®
), USP AUTO-INJECTOR, MYLAN
1. Remove the epinephrine auto-injector from the clear carrier tube.
2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward.
3. With your other hand, remove the blue safety release by pulling straight up.
4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.
5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
6. Remove and massage the injection area for 10 seconds.
7. Call 911 and get emergency medical help right away.
HOW TO USE EPIPEN
®
AND EPIPEN JR
®
(EPINEPHRINE) AUTO-INJECTOR, MYLAN
1. Remove the EpiPen
®
or EpiPen Jr
®
Auto-Injector from the clear carrier tube.
2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward.
3. With your other hand, remove the blue safety release by pulling straight up.
4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.
5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
6. Remove and massage the injection area for 10 seconds.
7. Call 911 and get emergency medical help right away.
OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017
EMERGENCY CONTACTS — CALL 911
RESCUE SQUAD: ______________________________________________________________________
DOCTOR: _________________________________________________ PHONE: ____________________
PARENT/GUARDIAN: ______________________________________ PHONE: ____________________
OTHER EMERGENCY CONTACTS
NAME/RELATIONSHIP: __________________________________________________________________
PHONE: _______________________________________________________________________________
NAME/RELATIONSHIP: __________________________________________________________________
PHONE: _______________________________________________________________________________
Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.
ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:
1. Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer
thigh. In case of accidental injection, go immediately to the nearest emergency room.
2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.
3. Epinephrine can be injected through clothing if needed.
4. Call 911 immediately after injection.
HOW TO USE AUVI-Q
®
(EPINEPHRINE INJECTION, USP), KALEO
1. Remove Auvi-Q from the outer case.
2. Pull off red safety guard.
3. Place black end of Auvi-Q against the middle of the outer thigh.
4. Press firmly, and hold in place for 5 seconds.
5. Call 911 and get emergency medical help right away.
3
3
4
5
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HISD Travel Reporting Form
1. Last Name 2. First Name 3. Employee/Student ID
4. Name of School/Department:
5. District Aliation: Student Sta Parent/Guardian
6. E-mail Address: 7. Phone Number:
8. Are you planning to travel or did you travel during Spring Break? Yes No
If yes where:
9. Is your travel for personal reasons or part of a district business/district-sponsored trip? Personal District Business/District-Sponsored Trip N/A
10. If you have traveled outside the United States, please specify where:
Mainland China Iran Europe South Korea Japan Cruise Other, please specify:
11. Please describe your travel plans. Include U.S. departure and U.S. arrival dates, as well as all cities and countries you visited during your trip.
12. Are you aware that you must self-quarantine for 14 days prior to returning to HISD if you have traveled to China, Europe, Italy, South Korea, Japan or any
other country determined to be a Level 2 or Level 3 by the CDC? Yes No
13. You must notify HISD after the 14 day self-quarantine before you return to campus by sending an email to TravelHealthServices@HoustonISD.org, and
you must receive written approval to return to campus. Initial here to confirm your understanding:
Parent/Guardian Only:
14. Last Name: 15. First Name: 16. Relationship:
17. Phone Number: 18. E-mail Address:
HISD Employees Only: Identify your HISD supervisor
19. Department:
20. Last Name: 21. First Name: 22. Title:
23. Phone Number: 24. E-mail Address:
Signature: Date:
All forms due no later than Friday, March 27, 2020.
Completed forms should be emailed to TravelHealthServices@HoustonISD.org or turned in to the student’s school or employee’s supervisor.
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Completed 31 January 2021

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