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Welcome to Adams 12 Five Star Schools!We are glad that you are joining our growing family.Enrollment in Adams 12 Five Star Schools is a simple process: Step 1: Check your address on our handy boundary locator to determine which school your student willattend. Our locator is online at http://www.adams12.org/en/boundary locator. Step 2: Pick up an enrollment packet at one of our school locations or download the forms from ourwebsite. You will need only one Household Information Packet and individual Student InformationPackets for each student. Step 3: Complete your forms and gather the necessary documentation. Documentation includes:Parent/Guardian Photo ID; Child’s Birth Certificate; Two Proofs of Residence; Immunization Records; andprior school records. Step 4: Take your completed enrollment forms and all required documentation to your student’s school.NOTE: Kindergarteners must be 5-years old and first graders must be 6 years old on or before October 1st.For exceptions, please see Superintendent Policy 5230.See reverse side for detailed information onRequired Documentation
Required DocumentsThe following are documents required by Adams 12 Five Star Schools to enroll your child(ren):1. PARENT/GUARDIAN PHOTO I.D.A driver’s license or any other photo I.D. is acceptable. The biological, foster or adoptive parent may enroll the student. Guardians must have proper guardianship forms signed and notarized or a copy of court authorization. Custody documentation is required, if applicable.2. DOCUMENTATION OF CHILD’S DATE OF BIRTHPlease bring ONE of the following government issued proofs: Birth Certificate (full size certificate, showing parent’s names as well as child’s is preferred) Valid passport3. PROOF OF RESIDENCETo enroll, the student’s parents or legal guardian and the student must be a full-time resident in the Adams 12 FiveStar Schools attendance boundaries.Please use our Boundary Lookup tool on our web page athttp://www.adams12.org/en/boundary locator.(NOTE: Disconnect notices are not acceptable forms of proofof residence)a. If you own your home, please bring TWO of the following (only originals will be accepted): Warranty Deed, Deed of Trust, or Bill of Sale Purchase contract with possession date or closing date not more than 90 days out Current utility bill (i.e. Xcel Energy, water, cable, trash) or mortgage statement -- your name andaddress must be clearly marked (both portions of a bill are required, property/service address mustmatch mailing address) – last or current month; disconnect notices are not accepted Homeowner’s insurance or property tax bill for current year (property/service address must matchmailing address) -- Adams or Broomfield countyb. If you rent, please bring TWO of the following (only originals will be accepted): Current Signed Lease or Rental Agreement Lease agreement with possession date not more than 60 days out Current utility bill (i.e. Xcel Energy, water, cable, trash)-- your name and address must be clearlymarked (both portions of a bill are required, property/service address must match mailing address) –last or current month; disconnect notices are not accepted Renter’s insurancec. If you are living with another family – ALL of the following are required: Declaration of Residence must be completed and signed by the owner/renter of the residence withwhom you live stating the length of time you will be staying in the presence of school or districtpersonnel. Two proofs of address from the owner/renter of the residence. (See required documents above) Current proof of your residence at that address (i.e. bank statement, insurance statement, newColorado drivers license receipt, US Postal Service official address change form, bills receivedincluding cell phone, etc. with your name and address clearly listed)d. Families who have changed their address and currently have a student enrolled in Adams 12 Five Star Schoolswill need to verify their new address by providing the required documents for proof of residence listed above.Note: Please notify us if you are unable to provide documentation because of loss of housing or economic hardship.4. IMMUNIZATION RECORDS – Required by state law5. PREVIOUS SCHOOL INFORMATION Name, address, phone and fax number of previous school Withdrawal form from previous school Most recent report card Transcripts for students entering middle or high schools Attendance record and discipline report IEP and 504 information, if applicable.
Family and HouseholdInformationComplete 1 set of forms per family
NEW HOUSEHOLD ENROLLMENT FORMFor Office Use Only:Date Received:Received By:School:Residency: Lease Agreement Mortgage Statement Utility Bill(s) Declaration of Residence Hardship (Title X) Address Confidentiality ProgramGuardianship: Court OrderedSchool Assignment: Elementary Power of Attorney Middle Foster Placement HighForms Sent: Migrant Education Student Records Access Home Language 506 FormPRIMARY HOUSEHOLD(where student(s) resides majority of the time)Residence Street AddressCityStateZipCountyHome PhoneMailing Address (if different than above)CityWe prefer our correspondence in:EnglishSpanishOtherStateParent/Guardian Last NameZipCountyParent/Guardian First NameWork PhoneCell PhoneMaleEmail AddressParent/Guardian Last NameDOBParent/Guardian First NameWork PhoneCell PhoneFemaleMaleEmail AddressFemaleDOBSCHOOL AGED CHILDREN* RESIDING WITH PARENT/GUARDIAN IN THE ABOVE HOUSEHOLD*Include student(s) enrollingSTUDENT LEGAL LAST NAMESTUDENT LEGAL FIRSTNAMEGRADEPARENT/GUARDIAN NAME(specify relationship to child below)Mother Step-MotherFosterGuardianPARENT/GUARDIAN NAME(specify relationship to child below)FatherStep-FatherFosterGuardian Mother Step-Mother Foster Guardian Father Step-Father Foster Guardian Mother Step-Mother Foster Guardian Father Step-Father Foster Guardian Mother Step-Mother Foster Guardian Father Step-Father Foster GuardianCURRENT RESIDENCE STATUS(where student(s) reside majority of the time)Residency is important as it can directly relate to rights under the McKinney-Vento Homeless Assistance Act. Transitional Housing Program Are you living with friends/family due to loss of housing or financial hardship? Are you a student not living with a parent or legal guardian? Other, please describe House/Apt/Condo/Townhouse/Duplex Motel/Hotel Campground/RV/Car Emergency ShelterRevised 4.13
SECONDARY HOUSEHOLD(Parent/Guardian that resides at another address)Residence Street AddressCityStateZipCountyMailing Address (if different than above)We prefer our correspondence in: English Spanish OtherCityStateParent/Guardian Last NameWork PhoneZipCountyParent/Guardian First NameCell Phone MaleEmail AddressParent/Guardian Last NameWork PhoneHome PhoneDOBParent/Guardian First NameCell Phone Female MaleEmail Address FemaleDOBSCHOOL AGED CHILDREN* RESIDING WITH PARENT/GUARDIAN AT ANOTHER ADDRESS*Include student(s) enrollingSTUDENT LEGAL LAST NAMESTUDENT LEGAL FIRSTNAMEGRADEPARENT/GUARDIAN NAME(specify relationship to child below)PARENT/GUARDIAN NAME(specify relationship to child below) Mother Step-Mother Foster Guardian Father Step-Father Foster Guardian Mother Step-Mother Foster Guardian Father Step-Father Foster Guardian Mother Step-Mother Foster Guardian Father Step-Father Foster Guardian Mother Step-Mother Foster Guardian Father Step-Father Foster GuardianNON-HOUSEHOLD EMERGENCY CONTACT INFORMATIONThe following persons are authorized to give consent for urgent health, dental, surgical procedures or hospital care for my child(ren)in the event District staff cannot reach an authorized parent/legal guardian.PRIORITYCONTACT NAME(First – Last)GENDERRELATIONSHIP TOSTUDENTHOME PHONECELL PHONE1231.2.3.Please note that federal law requires that educational records concerning a child be shared with a parent regardless of his/her custodystatus or decision making authority absent a court order limiting such disclosures. Please submit such court order if applicable.By default, parents who reside at both the primary household and secondary household will be allowed to pick up the child from school.Be aware that without prior notice or verification, students will not be released early during the day to anyone other than a parent/legalguardian.Parent/Guardian SignaturePRINT Parent/Guardian NameDate
Migrant Education SurveyPlease answer the following questions and return this form to school as soon as possible.All information you give us is confidential.Please fill out one survey per family. Thank you.1. Have you lived in this school district for less than 3 years? YesNo2. When you relocated to this school district was your primary intent to look for work in any of the following areas?YesNoIf yes, please mark the appropriate employment areas with an X.Vegetables/ fruits/ seedsFarm/Ranch (Including Dairy and Sod)Meat Packing Plant/Slaughter HousePoultryGreenhouse / NurseryOrchardsChristmas Tree Processing / Forestry3. Parents/guardians Name:Date:Address:Apt #City:Zip Code:Best time to call:Phone number4. Please list all children in your home from birth to 21 years:First and last NameDate of BirthSchools please submit to:District Grants OfficeEducational Support Center (ESC)Revised 4/20/12School
Student InformationComplete 1 set of forms foreach student enrolling
NEW STUDENT ENROLLMENT FORMOffice Use Only:Enrollment Start Date:Student Number:Grade:Teacher:STUDENT INFORMATIONStudent Legal Last Name: MaleStudent Legal First Name:Date of Birth: FemaleRace (select one or more):Student Legal Middle Name:Ethnic Background Hispanic/Latino?(Select One) Yes NoBlack/African AmericanAmerican Indian / Alaskan Native**please complete the attached 506 form Caucasian / White Asian Pacific Island / Native HawaiianPARENT/GUARDIAN IN PRIMARY HOUSEHOLD(parent(s) who reside with the student)Parent/Guardian Name:Relationship to Student: Mother Father Step-Mother Step-Father Court-Appointed Guardian Foster Parent Power of AttorneyCourt-Appointed Guardian Foster ParentPower of Attorney Parent/Guardian Name:Relationship to Student: Mother FatherPARENT/GUARDIAN IN SECONDARY HOUSEHOLD(parent(s) who reside at another address)Parent/Guardian Name:Relationship to Student:Step-Mother Step-Father MotherFather Step-MotherStep-Father Court-Appointed GuardianPower of AttorneyStep-Mother Step-Father Court-Appointed GuardianPower of AttorneyParent/Guardian Name:Relationship to Student: MotherFatherBy default, parents who reside at both the primary household and secondary household will be allowed to pick up the child from school.I understand that in accordance with Federal Educational Rights and Privacy Act (FERPA), parents are entitled to access their child’s education recordsunless the District is provided a court order specifically prohibiting them from doing so.I hereby attest that all information I have submitted is accurate and complete to the best of my knowledge. I understand that falsifying anyinformation may be grounds for expulsion.Parent/Guardian SignaturePRINT Parent/Guardian NameDate:Revised 4.13
New Student Enrollment FormContinuous Enrollment InformationContinuous enrollment refers to the student being enrolled in a Colorado Public or United States Public school without a break in enrollmentfor more than 10 days.Student has been continuously enrolled in a Colorado Public School since:(month) (year)Student has been continuously enrolled in a United States Public School since:(month) (year)School HistoryThis student has previously attended an Adams 12 Five Star School?If yes, school attended: Date Withdrawn:Please list the last 3 schools attended, starting with most recent (if applicable):School NamePhoneAddressDate ol NameAddressDate rSchool NameAddressDate rAd12StudEnr-A 6.12
New Student Enrollment FormStudent Legal Last NameLegal First NameLegal Middle NameStudent Services ReceivedIn order to provide your student with the appropriate academic setting, it is necessary to identify any special services they may have received attheir prior school. This student has received services for:Special EducationGrade School YearEnglish as a Second LanguageGrade School YearGifted/TalentedGrade School Year504 PlanGrade School YearLiteracy PlanGrade School YearEarly Childhood EducationGrade School YearInternational BaccalaureateGrade School YearLegacy 2000Grade School YearHomeschoolingGrade School YearSummer SchoolGrade School YearRetainedGrade School YearInterventionGrade School YearTitle IGrade School YearTitle XGrade School YearMigrantGrade School YearI verify that the information provided is true to the best of my knowledge.Print Parent/Guardian Name (please print)Parent/Guardian Signature (person completing form)DateAd12StudEnr-A 6.12
Safe Schools Enrollment FormStudent Name (please print)GradeDate of BirthEnrollment EligibilityPlease complete the Safe Schools Enrollment Form for each student you are seeking to enroll. This information assists staff inverifying each student’s eligibility to enroll. Staff will contact each student’s prior school(s) to verify accuracy of theinformation you provide. Providing incomplete or inaccurate information may delay enrollment or may result in enrollmentbeing revoked (terminated) at a later time.Authority to Deny AdmissionColorado law (C.R.S. 22-33-106.3) authorizes school districts to deny admission to students seeking enrollment under specificconditions.Declaration of EligibilityPlease answer the following questions by circling either “Yes” or “No” to each question. Based on your answers additionalinformation may be requested.YesNo1. Has your student graduated from school, completed 12th grade, or received any other certificateof completion such as a general equivalency diploma (G.E.D.) of a secondary education program?If “yes”, please consult with enrollment staff.YesNo2. Is your student between the ages of 5 and 20 (not applicable for preschool programs)?YesNo3. Has your student been expelled, considered for expulsion or otherwise asked to withdraw fromany school and/or district due to discipline, attendance or safety issues during the past 12 months?If yes, school/district/state:Reason for expulsion:Date(s) of expulsion:If “no”, please consult with enrollment staff.If “yes”, please consult with enrollment staff.YesNo4. Is your student a resident of Adams 12 School District or has your student otherwise beenformally granted a choice or transfer placement in writing?If “no”, please consult with enrollment staff.YesNo5. Have you provided the documentation that has been requested regarding your student’simmunizations?If “no”, please consult with enrollment staff.YesNo6. Has your student been suspended or expelled from school, or cited criminally, for behavior inschool or in the community during the past 12 months that may be considered to be detrimentalto the welfare or safety of other pupils or school personnel?If “yes”, please consult with school administration before completing enrollment.I verify that the information provided is accurate and true to the best of my knowledge. I further understand that providingfalse or incomplete information may delay enrollment or may result in my student’s enrollment being revoked (terminated) at alater time.Parent or GuardianSignature(please print)Date
Student Records Access – NoticeUnder federal law, parents are entitled to access their children’s education recordsunless the District is provided a court order specifically prohibiting them or otherindividuals from doing so. If you have such an order, please provide a copy to yourchild(ren)’s school(s). In the absence of such an order, both custodial and noncustodial parents have the right to access their child(ren)’s education records, the rightto seek to have the records amended and the right to consent to disclosure ofpersonally identifiable information from the records to third parties.Parents may also consent in writing to allow other individuals to access their child(ren)’seducation records. If you would like to grant other people access to your child(ren)’seducation records, please request a Student Records Access form from yourchild(ren)’s school(s), fill it out, and return it to your child(ren)’s school(s).01/2012
Student Pick-Up AuthorizationNotice: Without prior authorization from a parent/legal guardian, students will not bereleased early during the day to anyone other than a parent or legal guardian. Bydefault, a parent who resides with the student and a parent who resides at anotheraddress will be allowed to pick up the student.Parents may consent in writing to allow other individuals, including but not limited tostep-parents, older siblings and grandparents, to pick up their child(ren) prior to the endof the school day without first obtaining permission from a parent/legal guardian. If youwould like to authorize other people to pick up your child(ren), please request a StudentPick-Up Authorization form from each child’s school, fill it out, and return it to the school.According to Superintendent Policy 5700, school personnel may excuse a pupil beforethe end of the school day upon request of the parent or legal guardian for reasonswhich include, but are not limited to, the following: doctor appointments, home crises,and prior approved lunch passes.04/2013
STUDENT HEALTH INVENTORY(This form is to be used for all new enrolling students and all Special Education Eligibility Staffings)This form is confidential and will only be shared with Adams 12 Five Star School’s staff on a need to know basis for the safety and/or educational progress ofyour student. Please complete front and back.** It is the responsibility of the Parent/Guardian to contact the Transportation Department at (720) 972-4299) to inform them of any health conditions if yourstudent rides the bus.STUDENT NAME:School:Birthday / / Age M F Lives with:Grade:Parent(s)/Guardian(s) Names:Previous District / School Attended:Medical Insurance: Check the appropriate box to indicate the current health insurance status of the student: CHP # Private Insurance Uninsured student Medicaid #Please initial to the left to give permission to Adams 12 Five Star School staff members to contact you regarding information aboutMedicaid/CHP health insurance program benefits and/or the application process to determine if this student may be eligible forMedicaid/CHP health insurance.Medical Diagnosis/Conditions:Diagnosed by Physician: (Name/Date)Person completing form:NameSignatureRelationship to child:E-mail address:DateHome phone:Work phone:MEDICAL HISTORYADDADHDAutismYes NoYes NoYes NoAllergies/ReactionsYesNoIf yes, to what?Type of Reaction:
Welcome to Adams 12 Five Star Schools! We are glad that you are joining our growing family. Enrollment in
