Proof that Family lives in Hutchinson School District boundary lines (Present one from each column)
Present one of the following (must include address):






AND
Most recent income tax return
Current paycheck stub
Current residential property tax statement
Current home purchase agreement
Current homeowner’s insurance policy
Current lease/rental agreement
One of the following:
 Current gas bill
 Current water bill
 Current electric bill
If the student’s family is residing in the home or apartment of another individual, the following is
necessary for enrollment:
1. Notarized third-person affidavit of residency including:
-Signature of person with whom the family is living,
-Signature of parent/legal guardian of student;
-Apartment manager’s signature, if applicable.
2. Two forms of Proof of Residency for person with whom family is living (See above)
Proof of Authorized Person to Enroll
The following persons are authorized to enroll students:




Parent (natural or adoptive)
Legal guardian (must provide legal documentation)
Foster parent appointed by state agency
Sponsor for approved International Exchange Program
Student’s Proof of Age
Present one of the following:


A certified copy of a birth certificate; or
A federal, state, county, or school document with date of birth
Immunization/Health Certificates


Current Immunization record from Health Provider (form available in enrollment forms)
Notarized Conscientious Objector form (available in enrollment forms)
Primary Household Information: Please include full legal names as they appear on a Driver’s
License or other official ID.
Street Address: ________________________________________________ Apt/Unit # ____________
City: ____________________ State: ______ Zip: _____________
*Proof of Residency must be turned in with enrollment forms. See front cover for more info
Is this address within the Hutchinson School District Boundaries? Y or N
(Please fill out Enrollment Options form if household address is outside of District lines)
Primary Parent/Guardian #1:
Last Name: __________________ First Name: _______________ Middle Name: ____________
Date of Birth: ___/___/______ Relationship to student: ______________ Gender: M or F
Email Address: _______________________ Cell #: _______________ Work #: _______________
Employer: __________________
Legal Guardian? Y or N
Primary Parent/Guardian #2:
Last Name: __________________ First Name: _______________ Middle Name: ____________
Date of Birth: ___/___/______ Relationship to student: ______________ Gender: M or F
Email Address: _______________________ Cell #: _______________ Work #: ______________
Employer: ____________________
Legal Guardian? Y or N
Other Members: Please list full names of all other children and/or adults living at this address.
First, Middle,
Last Name
Date of Birth
/
/
/
/
/
/
/
/
/
/
Gender
M/F
M/F
M/F
M/F
M/F
Relationship to Preschool
student
Screened
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
If yes, list
location
Non-Household Emergency Contact- Please list someone other than Parent/Guardian
Emergency Contact Name: _________________ Address: ___________________________________
Home Phone: __________________ Work Phone: ________________ Cell Phone: _______________
Relationship to student: __________________
Secondary Household Information (if applicable)
Street Address: ________________________________________________ Apt/Unit # ____________
City: ____________________ State: ______ Zip: _____________
Is this address within the Hutchinson School District Boundaries?
Y or N
(Please fill out Enrollment Options form if household address is outside of District lines)
Primary Parent/Guardian #1:
Last Name: __________________ First Name: _______________ Middle Name: ____________
Date of Birth: ___/___/______ Relationship to student: ______________ Gender: M or F
Email Address: _______________________ Cell #: _______________ Work #: ________________
Employer: ______________________
Legal Guardian? Y or N
Student Information: Please enter the student’s full legal name as it appears on their birth certificate
Last Name: _________________ First Name: _______________ Middle Name: ________________
Date of Birth: ___/___/______ Current Age: ____
Gender: M or F
Enrolling in Grade: ____
Name student goes by: ________________ Previous School attended: _______________________
Previous school City/State: ___________/_____
Dates of att.: ___________________
Has this student attended Hutchinson Schools in the past: Y / N
Special Services
Does this student currently receive specialized services on an Individual Education Plan (IEP) Y / N
a. If yes, please identify the areas of service or primary disability area from the options below:
Autism Spectrum / Blind-Visually Impaired / Deaf and Hard of Hearing / Developmental Cognitive
Disabilities / Developmental Delay / Emotional or Behavioral Disorders / Learning Disabilities / Other
Health Disabilities / Physically Impaired / Speech or Language Impairments / Traumatic Brain Injury / or
Uncertain
b. Do you have a copy of the IEP with you today?
Y / N
Does this student currently receive accommodations through a 504 plan? Y / N
Does this student currently receive Gifted and Talented services? Y / N
Do you give permission for your child to be tested and possibly placed in Title 1 Programing? Y / N
Does your student currently receive English as a Second Language (ELL) services? Y / N
Additional Student Information
Is the student a teen parent?
Y / N
Is the student Homeless? Y / N
Is the student in Foster Care?
Y / N
A student may be homeless if:
Is the student a ward of the county or state? Y / N  Shared housing (doubled up) due to loss of
Is your child a Military Connected Youth? Y / N housing, economic hardship, or similar reason
 Living in cars, parks, public spaces,
Military Personnel’s Relationship to student:
abandoned building, not a regular sleeping
_________________________
place
Has the student moved across district or state lines
 Hotels or motels
within the last 35 months?
Y / N
 Emergency/transitional shelters; awaiting
Has your family moved to seek or obtain agricultural foster care
related (Ex. Meat, poultry, fish) work? Y / N
Transportation Information
Does this student require bussing to school? Y / N
If yes, provide address to be picked up at _________________________________________________
Does this student require bussing from school? Y / N
If yes, provide address to be dropped off at ________________________________________________
I certify the information given above is true and complete to the best of my knowledge.
Parent/Legal Guardian Signature: ______________________________ Date: _________________
Hutchinson Public Schools
Independent School District 423
30 N. Glen St.
Hutchinson, MN 55350
Telephone: 320.587.2860, Fax: 320.587.4590, www.isd423.org
Daron VanderHeiden, Superintendent
REQUEST FOR STUDENT RECORDS
I hereby authorize: _________________________________________________________________
(Former School District)
________________________________________________________________
(Street or P.O. Box)
_________________________________________________________________
(City, State and Zip Code)
Phone: ________________________ Fax: _____________________________
to forward any and all information including Immunizations/Health, Educational, Psychological, Standardized & Basic
Standard Test Scores, Title I, ELL, Special Education and/or Early Childhood Records for:
Student ____________________________________ Grade _____ Birthdate ________________
Student ____________________________________ Grade _____ Birthdate _______________
Student ____________________________________ Grade _____ Birthdate _______________
Please forward this information to the following school address or fax to:
West Elementary School, Attn: Kim Grundahl,
[email protected]
875 School Rd. SW
Hutchinson, MN 55350
(320) 587-4470/Fax: (320) 587-0735
Park Elementary School, Attn: Johanna Hanneman
[email protected]
100 Glen St.
Hutchinson, MN 55350
(320) 587-2837/Fax: (320) 587-4821
Hutchinson Middle School, Attn: Bonnie Karl
[email protected]
1365 South Grade Rd. SW
Hutchinson, MN 55350
(320) 587-2854/Fax: (320) 587-2857
Hutchinson High School, Attn: Barb Wedge
[email protected]
1200 Roberts Rd.
Hutchinson, MN 55350
(320) 587-2151/Fax: (320) 234-2715
*Special Education Information needs to be sent to:
Karen Lerfald
[email protected]
Phone: 320-234-2623 Fax: 320-234-2685
It is understood that this information will be used in a confidential and professional manner in the best interest of the child(ren).
Thank you for your cooperation and prompt response.
______________________________________________ ________________________________________________
(Signature of Parent or Guardian)
(Date)
07/05/2016
Race/Ethnicity Form
Student Last Name: __________________ Student First Name: __________________________
Date of Birth: ___ /___ /________
Country of Birth: ________________________________
Parent Signature: ______________________________________ Date: ___ / ___ / ___________
A. For State Reporting purposes, please
check the ONE response that best
describes your child’s race.
American Indian or Alaska Native (persons
having origins in any of the original peoples of
North America and maintain cultural
identification through tribal affiliation or
community recognition.)
Asian or Pacific Islander (persons having
origins in any of the original peoples of the Far
East, Southeast Asian, the Pacific Islands or the
Indian subcontinent. This area includes China,
India, Japan, Korea, Philippine Islands, and
Samoa.)
Hispanic (persons of Mexican, Puerto
Rican, Cuban, Central or South American or
other Spanish culture or origin-regardless of
race.)
Black, not of Hispanic origin (persons
having origins in any of the Black racial groups of
Africa.)
White, not of Hispanic origin (persons
having origins in any of the original peoples of
Europe, North Africa or the Middle East.)
B. For federal reporting purposes, check ONE
answer that describes your child’s
Hispanic Ethnicity
Yes (Mexican, Puerto Rican, South or Central
Americans and other Spanish culture or origin,
regardless of race.)
No (Not Hispanic or Latino)
C. For federal reporting purposes, check ALL
that apply to your student:
American Indian or Alaska Native (persons
having origins in any of the original peoples of
North America or South America, including Central
America and maintains a tribal affiliation or
community attachment.)
Asian (persons having origins in any of the
original peoples of the Far East, Southeast Asia, or
the Indian sub-continent. Including, for example,
Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, Philippine Islands, Thailand, Vietnam.)
Black, not of Hispanic origin (persons 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 people
of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (a person having origins in any of the
original peoples of Europe, North Africa, or Middle
East.)
Home Language Questionnaire
ED-01336-08E
The following is to be completed by School District Personnel:
Student's Full Name
Date Of Birth
School name
STUDENT IDENTIFICATION INFORMATION
Age
Grade Level
DISTRICT INFORMATION/VERIFICATION INFORMATION
District number
I hereby verify that the above information is true and accurate to the best of my knowledge and belief.
_______________________________________________
Name (Printed)
_____________________________________
Signature – Responsible Authority
____________________ __________
Title
Date
The following is to be completed by Parent/Guardian:
STUDENT LANGUAGE INFORMATION
Dear Parents and Guardians:
In order to help your child learn, your child’s teachers need to determine which language your child uses most.
Please respond to the questions below by checking the appropriate box.
1.
2.
Which language did your child learn first?
Which language is most often spoken in your home?
3. Which language does your child usually speak?
☐ English ☐ Other (specify): _________________
☐ English ☐ Other (specify): _________________
☐ English ☐ Other (specify): _________________
PARENT/GUARDIAN INFORMATION
I hereby verify that the above information is true and correct to the best of my knowledge and belief.
_______________________________________________
Name (Printed)
_________________________________________________________
Signature – Parent/Guardian
__________
Date
Hutchinson Public and Parochial Schools
Student Health Information Form
Minnesota Law requires students be up to date with immunizations in order to enroll in school.
School Year ______________
Student Name ____________________________ Birthdate
__ Grade
Does your child have any medical problems or illnesses?
Yes
____
No
If yes, please specify ___________________________________________________
Does your child have any mental health or behavioral needs?
Yes
No
If yes, please specify ___________________________________________________
Does your child take any medications?
Yes
No
If yes, please specify ___________________________________________________
Does your child have any allergies?
Yes
No
If yes, please specify ___________________________________________________
Does your child have asthma?
Yes
No
Does your child have a prescribed Epi-pen?
Yes
No
Has your child ever had a seizure?
Yes
No
Does your child have any hearing or vision concerns?
Yes
No
If yes, please specify ___________________________________________________
If you have answered yes to any of the above questions, please contact the Health Office at your
child’s school to obtain a plan of care and/or authorization for medications at school.
Is your child covered by a health insurance plan or medical assistance?
Yes
No
Please list any additional information that may be helpful to meet the health needs of your child
_________________________________________________________________________________
_________________________________________________________________________________
Health information is confidential, protected information. Pertinent health information regarding your
child’s health may be shared with appropriate school staff at the discretion of the school nurse. If your
child has received immunizations since last school year, please let the health office know. If you have any
questions, please contact the Licensed School Nurse at 320-234-2731. If your phone numbers have
changed, please contact Central Office at 320-587-2860 to have the information updated. Thank
you.
Parent/Guardian Signature ____________________________________ Date _______________
LSN file/forms/student health information form – revised 3/6/2015
Student Immunization Form
Student Name __________________________________________________
Birthdate ______________________Student Number ___________________
Minnesota law requires children enrolled in school to be immunized against certain
diseases or file a legal medical or conscientious exemption.
FOR SCHOOL USE ONLY
( ) Complete; booster required in ____________
( ) In process; 8 mos. expires ______________
( ) Medical exemption for __________________
( ) Conscientious objection for ______________
( ) Parental/guardian consent ______________
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.
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.
1st Dose
2nd Dose
3rd Dose
4th Dose
5th Dose
Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/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.)
Type of Vaccine
DO NOT USE () or ()
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 above
5th dose not required if 4th dose was given
on or after the 4th birthday
Tetanus, Diphtheria and Pertussis (Tdap)
• for children in 7th - 12th grade
Polio (IPV, OPV)
• final dose on or after age 4 years
4th dose not required if 3rd dose was given
on or after the 4th birthday
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
Recommended
Human Papillomavirus (HPV)
Hepatitis A (hep A)
Influenza (annually for children 6 months and older)
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.
Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize
(12/13)
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)
1. Certify Immunization Status. Complete A or B to indicate child’s immunization status.
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 diphtheria, 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
2. Exemptions to School Immunization Law. Complete A and/or B to indicate type of exemption.
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):
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 vaccinated 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 conscientiously held beliefs for my child to receive the following
vaccine(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.)
Signature of parent or legal guardian
________________ Date
Subscribed and sworn to before me this:
_______ day of ______________________ 20______
Signature of notary
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 Developed by the Minnesota Department of Health - Immunization Program Date
www.health.state.mn.us/immunize
(12/13)
Are Your Kids Ready?
Minnesota’s Immunization Law
Immunization
Requirements
Use this chart as a guide to determine which vaccines are required to enroll in child care, early childhood programs, and school (public or private).
Find the child’s age/grade level and look to see if your child had the number of shots shown by the
checkmarks under each vaccine. Children birth to age 2 may not have received all doses. Look at the
table on the back, it shows the age when doses are due.
Birth through 4 years
1
Age: 5 through 6 years
Early childhood programs
& Child care
Age: 12 years and older
Age: 7 through 11 years
For Kindergarten
For 1st through 6
grade
For 7th through 12th
grade
Hepatitis A (Hep A)

Hepatitis B (Hep B)

Hepatitis B

Hepatitis B

Hepatitis B

DTaP/DT
DTaP/DT
4
tetanus and
Tdap

Polio

MMR

Hib

Pneumococcal

Varicella

Polio

MMR

5
Polio

MMR

Polio

MMR

Meningococcal
 & booster

th
diphtheria containing doses
 6
7
8
2
3
Varicella

Immunizations recommended but not required:
3
Varicella

3
Varicella

Influenza
Annually for all children age 6 months and older
Rotavirus
For infants
Human papillomavirus
At age 11 -12 years
1 First graders who are 6 years old and younger must follow the polio and DTaP/DT schedules for kindergarten.
2 Not required after 24 months.
3 If the child has already had chickenpox disease, varicella shots are not required. If the disease occurred after 2010, the child’s doctor must sign a form.
4 Fifth shot of DTaP not needed if fourth was after age 4. Final dose of DTaP on or after age 4.
5 Fourth shot of polio not needed if third was after age 4. Final dose of polio on or after age 4.
6 An alternate 2-shot schedule of hepatitis B may also be used for kids from age 11 through 15 years.
7 Proof of at least three doses of diphtheria and tetanus vaccination needed. If a child received Tdap at age 7 through 10
years another dose of Tdap is not needed. Td does not meet the Tdap requirement.
8 One dose is required beginning at 7th grade. The booster dose is usually given at 16 years but the timing depends on
when the first dose was given.
Exemptions
To enroll in child care, early childhood programs, and school in Minnesota, children must show
they’ve had these immunizations or file a legal exemption.
Parents may file a medical exemption signed by a health care provider or a conscientious objection
signed by a parent/guardian and notarized.
Looking for
Records?
For copies of your child’s vaccination records, talk to your doctor or call the Minnesota
Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.
Minnesota Department of Health, Immunization Program
ID# 52799 (10/2014)
2
d about c
erne
o
c
n
IPV
PCV
Hib
DTaP
RV
15
months
Hep A: CC & ECP
Immunization Program
P.O. Box 64975
St. Paul, MN 55164-0975
651-201-5503 or 1-800-657-3970
www.health.state.mn.us/immunize
MMR= measles, mumps, rubella
PCV= pneumococcal
ID# 52799 (10/2014)
RV=rotavirus
MCV=meningococcal
IPV=polio
Hep B=hepatitis B
Hep A= hepatitis A
Hib = Haemophilus influenzae type b
DTaP/Td/Tdap=diphtheria, pertussis, tetanus
Key to vaccine abbreviations
Minnesota law requires written proof of certain vaccinations for children in child care, early
*The number of doses depends on the product your doctor uses.
childhood programs, and school. However, if a child has a medical reason or if his/her parents are
For copies of your child's immunization records, talk to your doctor or call the Minnesota
conscientiously opposed to any or all of the vaccinations, a legal exemption is available.
Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.
Children with certain medical conditions may need additional vaccines (e.g.,
pneumococcal or meningococcal). Talk to your doctor or clinic.
It’s not too late! If your child has fallen behind on their vaccinations, talk to your doctor or clinic to Pregnant? Protect yourself and your baby from whooping cough, get a Tdap vaccination between
catch them up.
27 and 36 weeks gestation. Talk to your doctor.
Influenza (each fall)
Hep A (2 doses at least 6 months apart)
Varicella
Varicella (12-15 months)
Varicella: CC, ECP, K-12
MMR: CC, ECP, K-12
MMR
PCV: CC & ECP
Hib: CC & ECP
MCV: 7-12
DTaP/Tdap: CC, ECP,
K- 12
Hep B: CC, ECP, K-12
Required
for:
MMR (12-15 months)
MCV
16
years
IPV: CC, ECP, K-12
MCV
Tdap
HPV
3 doses at 0,
1-2 and 6 month
interval
years
11-12
IPV
DTaP
4-6
years
CC = Child care
ECP = Early Childhood Programs
K-12 = Kindergarten through 12th grade
7-12 = 7th through 12th grade
IPV (6-18 months)
PCV (12-15 months)
PCV
PCV
IPV
Hib (12-15 months)
Hib
Hib*
18
months
DTaP (15-18 months)
DTaP
DTaP
Hep B* (6-18 months)
12
months
RV*
6
months
When to Get Vaccines
Birth to 16 Years
RV
(1-2 months after first hep B dose)
4
months
Hep B*
months
Free or low cost vaccinations
are available. Talk to your
doctor or clinic.
Co
Hep B
Birth
st?