Fort Cobb - Broxton Public Schools - Elementary Enrollment Form (Required)

Fort Cobb-Broxton Elementary School Enrollment

Welcome to our On-line Enrollment Page. This Page is for Elementary School Students ONLY, if you are looking for High School or Middle School enrollment please navigate to their respective page. One student per form, please take the time to read through the FYI section. Also once you start the enrollment form it does not save until you submit. You may want to glance through the form and gather all required information before you begin, please Do NOT enter incorrect information. Please check that you have answered all fields with an * and have chosen the correct answer on the yes and no radio buttons. When you begin to fill out the form, do not use the back and forward buttons on your browser toolbar, if you do you will lose your work. Remember the form does not save and will not let you submit until all required fields are complete.

Please do not submit a form with incorrect information.

IF THERE IS A QUESTION THAT IS NOT APPLICABLE PLEASE TYPE NA DO NOT LEAVE BLANK

Thank you.

Please Fill Out The Elementary Enrollment Form (Required) Below

Grade

Reaquired field: Pre-Kindergarten (If you didn’t pre-enroll for Pre-K in May your child may be added to the wait list.)

Reaquired field: Kindergarten

Reaquired field: 1st Grade

Reaquired field: 2nd Grade

Reaquired field: 3rd Grade

Reaquired field: 4th Grade

Reaquired field: 5th Grade

Child's Last Name:

Child's First Name:

Child's Middle Name:

STUDENT'S FULL LEGAL NAME AS ON BIRTH CERTIFICATE, ADOPTION PAPERS, ETC.:

Last Name:

First Name:

Middle Name:

Mailing Address:

Physical Address:

City:

State:

Zip:

Phone Number:

SOCIAL SECURITY NUMBER:

Does this student have a parent/guardian that is:

Reaquired field: Armed Forces

Reaquired field: Reserve

Reaquired field: National Guard

Reaquired field: None

Please choose one or more:

Reaquired field: African American

Reaquired field: American Indian

Reaquired field: Asian

Reaquired field: Pacific Islander

Reaquired field: White/Caucasian

Ethnicity: Please mark only one

Reaquired field: Hispanic/Latino

Reaquired field: Not Hispanic/Latino

Birth Month:

Birth Day:

Birth Year:

City of Birth:

State of Birth:

Parent/Guardian Information

Parent/Guardian Name:

Relationship to Student:

Reaquired field: Parent (Natural or Legally Adopted)

Reaquired field: Step-parent

Reaquired field: Legal Guardian

Reaquired field: Foster Parent

Reaquired field: Other

Mailing Address (If different from student mailing address):

City:

State:

Zip Code:

Place of Employment:

Work Phone:

Home Phone/Cell Phone:

I hereby give permission to Fort Cobb Broxton School District to email information to me at the following email address:

Cell Phone(s): (These Phones may receive text messages or notifications)

#1 Contact Choice (Will receive text):

#2 Contact Choice:

#3 Contact Choice:

I give Fort Cobb-Broxton School personnel permission to use these means listed, including text messaging, as a means to contact me or my child concerning school related topics. I understand that I may receive information regarding my child(ren) to include, but be limited to, student absences, grade notices, lunch bills, and other information specific to the school district. My signature below constitutes permission to send this information to my email address listed above. Parent/Guardian Signature:

Second Parent/Guardian

Parent/Guardian Name:

Relationship to Student:

Parent (Natural or Legally Adopted)

Step-parent

Legal Guardian

Foster Parent

Other

Mailing Address (If different from student mailing address):

City:

State:

Zip Code:

Place of Employment:

Work Phone:

Home Phone/Cell Phone:

I hereby give permission to Fort Cobb Broxton School District to email information to me at the following email address:

Cell Phone(s): (These Phones may receive text messages or notifications)

Contact Choice (Will receive text):

Please list any non-custodial parent information that should receive educational information for this child.

Parent/Guardian Name:

Relationship to Student:

Parent (Natural or Legally Adopted)

Step-parent

Legal Guardian

Foster Parent

Other

Mailing Address:

City:

State:

Zip Code:

Home Phone/Cell Phone:

Place of Employment:

Work Phone:

Cell Phone(s): (These Phones may receive text messages or notifications)

Contact Choice (Will receive text):

I understand that the above listed contact may receive information regarding my child to include, but be limited to, student absences, grade notices, lunch bills, and other information specific to the school district. Parent/Guardian Signature:

Emergency Contact Information

PERSON TO CONTACT IN CASE OF EMERGENCY. In order of contact preference:

Name

Phone Number

Relationship:

Name:

Phone Number:

Relationship:

Name

Phone Number

Relationship:

PHYSICAL OR BEHAVIORAL CONDITIONS THAT THE SCHOOL SHOULD BE AWARE OF:

WILL YOUR CHILD RIDE A SCHOOL BUS?

Reaquired field: No

Reaquired field: Yes

(IF YES, GIVE DIRECTIONS TO YOUR HOUSE).

IS STUDENT A RESIDENT OF THIS SCHOOL DISTRICT?

Reaquired field: Yes

Reaquired field: No

IF NO, HAVE YOU RECEIVED A TRANSFER FROM THE DISTRICT IN WHICH YOU RESIDE?

Yes

LAST SCHOOL ATTENDED:

ADDRESS:

WAS YOUR CHILD IN ANY SPECIAL CLASSES AT HIS LAST SCHOOL?

Yes

IF SO, PLEASE NAME THEM:

School Health History

Allergies:

Illnesses (include dates):

Hospitalizations (reasons and dates):

List any medical or health problem (ex. Diabetes, asthma):

List any medicine taken on a daily basis:

Will this medication be taken while at school?

Yes

The Tylenol/Acetaminophen and Chewable antacid are on hand in the office for students with, headache, mild pain, or upset stomach. Please initial which of these you give permission for school personnel to administer to your child:

Tylenol/Acetaminophen

Chewable Antacid

Cough Drops

I do not wish for my child to receive any medication at school:

Parent/Guardian Signature:

Date

Photo/Name Release

Who is currently enrolled at Fort Cobb-Broxton Public School District, permission is granted to the Fort Cobb-Broxton Public School District and its Board members, employees, agents, servants and representatives to use this student's name, photographic likeness, alone or in a group, in any Fort Cobb-Broxton Public School District publication, document, TV production, video or to release said names or likeness to any media outlets including, but not limited to, newspapers, magazines or TV stations for publicity and/or recognition purposes. Additionally, I extend permission to use this student's name and/or photographic likeness, alone or in a group, on the official web site of the Fort Cobb-Broxton Public School District, Facebook, or a web site available through the official web site. The official web site is owned and maintained by the District as a service to the parents, students of Fort Cobb-Broxton Public School District and can be accessed and viewed at www.fcbmustangs.com. I release the Fort Cobb-Broxton Public School District, its Board members, employees, agents, servants, representatives and all organizations and individuals related the Fort Cobb-Broxton Board of Education's Internet Network form any and all liabilities or damages that result from the use of this student's name and/or photographic likeness as described above. This permission shall remain in effect unless revoked by me and communicated to the Fort Cobb-Broxton Public School District in writing.

Reaquired field: Yes I give Fort Cobb-Broxton School Permission

Reaquired field: No I Do Not give Fort Cobb-Broxton Permission

Signature of Parent/Guardian:

Protecting Your Child

Parent/Guardian: So that the school can better protect your child while he/she is at school, we ask that you make a list of those individuals who can pick up your child from school. You may add or delete any names by coming into the office and updating your list. Should anyone not on the list come to school to pick up your child we would notify you by phone and you could tell us what to do. Child's Name:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

FORT COBB-BROXTON SCHOOL PARENT/GUARDIAN COMPACT

This compact is a jointly developed plan that spells out what teachers and parents need to do to help children meet state educational standards. We, the Fort Cobb-Broxton School Staff, parents and community, share the responsibility, in a safe and secure environment, for student acquisition of academic, creative, emotional, physical and social skills necessary for entering society as contributing members. PARENT/GUARDIAN AGREEMENT: As Parent(s)/Guardians(s) I/We Will: Strive each day to make my child's education my number one priority. See that my child is punctual and attends school regularly. Strive to send a well-nourished, well-rested, properly dressed, well-loved child to school each day. Establish a time and quiet place for homework and check it regularly. Encourage my child's efforts to do his/her best. Provide necessary school supplies each day. Encourage daily reading at home. Monitor my child's free time, TV and movie viewing. Establish a time for sharing daily school experiences. Read and review all information my child brings home from school. Stay aware of what my child is learning. Have ongoing communication with my child's school and teacher. Encourage my child to follow all the school rules and follow up with any signs of misconduct. Support the school's discipline plan. Parent/Guardian Signature:

STUDENT AGREEMENT: As a Student I Will: Attend school regularly, be on time and prepared to learn. Complete and return homework assignments. Adhere to the school's code of conduct. Always try to work to the best of my ability. Show respect for myself, my school, and others. Believe that I can learn and I will learn. Participate in classroom activities. Do my part to keep our school clean and safe. Set aside a regular time and place each night to complete homework. Student Signature

STAFF AGREEMENT: As Professional Educators I/We Will: Provide teaching and leadership. Make efficient use of academic learning time. Utilize up-to-date methods and practices. Seek professional improvement. Provide a high quality curriculum. Provide report cards four times a year regarding student's progress. Provide an environment conductive to learning. Maintain open lines of communication with students and parents. Seek ways to involve parents in classroom activities. Respect the students, their parents, and the diverse cultures of the school. Provide a safe, positive, healthy, well managed environment where all children are treated fairly. Demonstrate care and concern for each student. Suggest ways parents can support learning at home.

Staff Signature: James Biddy

INTERNET SAFETY POLICY AND USE AGREEMENT

The following is a contract between the student , parent or guardian, and the school system. Please read carefully before signing.With access to such vast storehouses of information and instant communications with millions of people from all over the world, material will be available that may not be considered to be of educational value by the District or which is inappropriate for distribution to children. The District has taken available precautions, including, but not limited to enforcing the use of filters that block access to obscenity, child pornography, and other materials harmful to minors. However, on a global network, it is impossible to control all material and an industrious user may obtain access to inappropriate information or material. The District firmly believes that the value of the information and interaction available on the Internet far outweighs the possibility that students and employees may procure material which is not consistent with our educational goals.It is all staff member's responsibility to educate students about appropriate online behavior, including interactions with other individuals on social networking sites/chat rooms, and cyber bullying awareness response. This may be done in a variety of ways, such as once a year short training sessions, one-on-one education with individual students, and/or via educational handouts.It is also the responsibility of all staff members to monitor students’ online activity for appropriate behavior. I have read the forms and conditions and understand that violation of these can result in the denial of Internet privileges. I also agree not to hold the school, state and local boards of education, or the Internet provider responsible for the consequences resulting from the violation of these terms and conditions by the student. Parent/Guardian Signature:

Date:

As a student I agree to the following terms and conditions:*I will not use the Internet for transmission of any materials in violation any federal or state regulations. Transmission of copyrighted material threatening or obscene materials, materials protected by trade secrets, product advertisement or political lobbying is also prohibited.*I will refrain from using profanity and vulgarities on the Internet. I will not use the Internet for illegal activities.*I will not give my home address, location of my school, phone number, or any personal information about myself or any other student or school personnel to anyone via the Internet. *I understand that use of e-mail or any other communications over the Internet are not private; any messages related to or in support of illegal activities may be reported to the authorities.*I understand that I am prohibited from conducting any actions that may endanger my safety, or the safety of other students/staff members while using any component of the school's internet access and/or network (e-mail, chat rooms, etc.).*I will not use the Internet in a way that would disrupt the use of the network by others.*I will respect the trademark and copyrights of materials on the Internet and assume anything accessed via the network is private property.*the school system and service provider are not responsible for any damages or losses resulting from using Internet services or information obtained from the Internet.*If you discover any way to access unauthorized information or defeat any security measures, you must inform the lab teacher immediately. You must not share any unauthorized information with any other user.*Vandalism of any kind is prohibited.*These terms and conditions shall be governed and interpreted in accordance with the laws of the state and the United States of America.*I understand access to the Internet through Fort Cobb-Broxton School is a privilege. School authorities can deny any student access to the Internet at any time, and their decisions are final. My instructor/school sponsor has explained the terms and conditions for using the Internet to me and I agree to abide by them. Student Signature:

Date:

Epinephrine Injection Policy

All school personnel employed by or acting on behalf of the Fort Cobb-Broxton school system may administer epinephrine via an undesignated epinephrine auto-injector to an individual if the staff member in good faith believes an individual is experiencing a potentially life-threatening allergic reaction (anaphylaxis). A school employee will call 911 as soon as possible if it is believed that a student is having an anaphylactic reaction. Parent/Guardian Signature:

Date:

I have read and/or have access to the Parent FYI section of enrollment including the District FERPA Policy, District FERPA Directory Policy, Parents Right to Know, FCB Elementary Student Handbook, Meningococcal Disease and Vaccine Information, Medication Policy, and Truancy Policy. By typing your name in the signature boxes of this form, you agree that this is valid as your signature.

TOBACCO/VAPING POLICY

The use of a tobacco product or vapor product shall be prohibited 24/7 in or on an educational facility that offers an early childhood education program or in which children in grades kindergarten through twelve are educated. The use of a tobacco product or vapor product shall also be prohibited 24/7 in school vehicles, and at any school-sponsored or school-sanctioned event or activity. 1. "Educational facility” is defined as any property, building, permanent structure, facility, auditorium, stadium, arena or recreational facility owned, leased, or under the control of the school district. 2. “School Vehicle” is defined as any transportation equipment or auxiliary transportation equipment as defined in 70 O.S. § 9-104. 3. “Chewing tobacco” is defined as any Cavendish, twist, plug, scrap, and any other kinds and forms of tobacco suitable for chewing. 4. “Smoking tobacco” is defined as any granulated, plug cut, crimp cut, ready rubbed, and any other kinds and forms of tobacco suitable for smoking in a pipe or cigarette. 5. “Tobacco product” is defined as any bidis, cigars, cheroots, stogies, smoking tobacco and chewing tobacco, however prepared. Tobacco products shall include any other articles or products made of tobacco or any substitute thereof. 6. “Vapor product” is defined as noncombustible products, that may or may not contain nicotine, that employ a mechanical heating element, battery, electronic circuit or other mechanism, regardless of shape or size, that can be used to produce a vapor in a solution or other form. Vapor product shall also include any vapor cartridge or other container with or without nicotine or other form that is intended to be used with an electronic cigarette, electronic cigar, electronic cigarillo, electronic pipe or similar product or device and any vapor cartridge or other container of a solution, that may or may not contain nicotine, that is intended to be used with or in an electronic cigarette, electronic cigar, electronic cigarillo or electronic device. Vapor products do not include any products regulated by the United States Food and Drug Administration under Chapter V of the Food, Drug, and Cosmetics Act. Signs will be posted in prominent places on school property to notify the public that smoking or other use of tobacco products is prohibited Students are also prohibited from possessing tobacco on, in, or upon any school property. If students are found to be in possession of cigarettes or other tobacco products, the tobacco product will be confiscated. Students who choose to violate this policy may be placed in up to 3 days of ISD or other corrective actions plans deemed appropriate by administration. Corrective actions may include mandatory participation in tobacco cessation programs. Signature of Parent/Guardian:

Date:

ENROLLMENT DECLARATION:

I hereby certify that I am the custodial parent and legal guardian or have obtained legal guardianship through the courts for the student listed above. I certify that I have verified my address to be a legal residence within the Fort Cobb-Broxton Public Schools, Independent School District I-167 or received a transfer. I also certify that all of the above information is true and correct. By typing your name in the signature boxes of this form, you agree that this is valid as your signature. Parent/Guardian Signature:

Date:

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