WILLISTON PUBLIC SCHOOL DISTRICT #1
STUDENT RESIDENCY VERIFICATION
Student's Name:_________________________________________________________________
Parent/Guardian's Name:__________________________________________________________
Address:______________________________________________________________________
Phone Number:___________________________________________________________________
Student’s Physical Street Address: ____________________________________________________
(not applicable to homeless students as defined below):
Name of adult caretaker with whom student is currently residing:____________________________
______________________________________________________________________________
Relationship to student:_____________________________________________________________
Adult caretaker’s phone number:_____________________________________________________
To be completed by the parent/guardian or adult caretaker if parent/guardian cannot be reached:
1. Reason the student listed above has moved into the Williston Public Schools:
________________________________________________________________________
_______________________________________________________________________
2. Is this the student’s only home? If no, explain:___________________________________
________________________________________________________________________
_______________________________________________________________________
□
I certify that my child meets the following definition of homeless and is
living in the Williston Public School District.
Sharing the housing of other district resident due to loss of housing, economic hardship, or a
similar reason
Living in motels, hotels, trailer parks, or camping grounds within the District due to the lack
of alternative adequate accommodations
Living in emergency or transitional shelter in the District
Awaiting foster care placement
Residing in a nighttime residence that is a public or private place in the District not designed
for or ordinarily used as a regular sleeping accommodation for human beings
Living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or
train stations, or similar settings in the District
OR
□
I certify that my child is a resident of the Williston Public School District as
evidenced by one or more of the following documents (PO Box numbers are not acceptable
verification of residency). NOTE: Attach documentation to this form.
A valid North Dakota issued Driver's License with current residential address.
A valid North Dakota issued State Identification Card (non-Driver's License) with current
residential address.
A valid federally issued identification card with current residential address.
Passport with current residential address.
A valid Tribal Government issued Identification Card with residential address.
A valid United States Military Identification Card with current residential address.
Utility bill or rent receipt that includes the name and residential address of student's
parent/guardian.
A lease or property purchase agreement that includes the name and residential address of
student's parent/guardian.
Change of Address Verification Letter from US Postal Service.
A letter from the student’s custodial parent explaining why the student has moved into the
school district and with whom the student shall reside. The District may request that the
adult caretaker named in this letter verify residency using one of the methods listed above.
Should the District determine that a student is not a resident of the Williston Public School District or does
not meet the above definition of homeless, the Williston Public School District shall notify the school
district of residence and the student's parent/guardian and may withdraw the student from Williston Public
Schools (unless an exception under the McKinney Vento Homeless Education Act applies) or may
explore other enrollment arrangements with the school district of residence.
Upon receiving notice of withdrawal from Williston Public Schools, students must immediately enroll in
their district of residence. Under North Dakota law, the district of residence is obligated to comply with
compulsory attendance reporting requirements, which mandate that administrators report compulsory
attendance violations to local law enforcement agency.
I certify that the information that I provided on this form and in conjunction with this form is accurate. I
understand that providing false information on this form or in conjunction with this form may result in the
Williston Public School District withdrawing my child's enrollment in the Williston Public Schools.
_________________________________________
Parent/Guardian’s Signature
__________________
Date
Williston Public Schools Elementary Admission Form
Do Not Fill Out or Mark
Office Use ONLY
Student ID# ___________________
Entry Date____________________
Teacher______________________
Student Records:
Date Requested _______________
Today’s Date:
Grade Entering:
Student Information
Student Full Name: (Last, First, Middle)
Physical Address:
(Apt. #)
Mailing Address:
Name, address and city of school student most recently attended (other than Williston)
Did your child attend preschool?
Name and City of Preschool:
Date of Birth:
Yes
No
Birthplace:
Immunization Records Present:
Yes
No
My child receives the following:
Check all that apply.
Title
EMH
Speech
TMH
LD
ED
Birth Certificate Present:
Yes
No
Is your child on an IEP?
Yes
Has student previously attended
Williston School? Yes
No
Where:
Female
Male
Ethnicity:
White
Native American
Hispanic
Black
Asian
Other
No
Parent Information
Mother’s Name: (Last, First)
Father’s Name: (Last, First)
Physical Address:
(Apt. #)
Check One:
Legal Parent
Guardian
Check One:
Legal Parent
Guardian
Mailing Address:
Foster Parent
Step Parent
Other
Foster Parent
Step Parent
Other
Home Phone Number:
Mom’s Cell Phone:
Dad’s Cell Phone:
Mom’s Work Place:
May we call you at work?
YES
NO
May we call you at work?
YES
NO
Mom’s Work Phone Number:
Dad’s Work Place:
Marital Status:
Check one:
Single
Married
Divorced
May we contact you by email? Please list email addresses here:
Dad’s Work Phone Number:
Separated
Other
Siblings (include all children in home)
Child’s Name:
Age:
School:
Child’s Name:
Age:
School:
Child’s Name:
Age:
School:
Child’s Name
Age:
School:
Copies of report cards, school reports, etc. can be mailed to:
Non – Custodial Parent:
Address:
City, State, Zip Code:
Person to Notify, other than Parents, in case of Emergency:
(Please inform this Person that they may be called by the School)
Relationship to Child:
Work Place:
Work Phone Number:
Home Phone Number:
Cell Phone Number:
Health Information
Health Concerns
Check all that apply:
Life Threatening Allergies to________________________________________________________
Allergies (What kind?)_____________________________________________________________
Epi-Pen (Does your child have one in school?) Yes
No
Asthma
Inhaler (Does your child have one in school?) Yes No
Heart
Seizures
Diabetes (Does your child take insulin?) Yes No
(If yes, please explain)_______________________________________________________________________
Other ____________________________________________________________________________
Doctor:
Doctor’s Phone Number:
Please complete the following:
1. Submit immunization records (may already be included in previous school records).
2. Provide a copy of student’s birth certificate.
I certify that this information is true and correct.
___________________________________________________________________________
Signature of Parent/Guardian)
NEW STUDENT INFORMATION
STUDENT_____________________________________________________
GRADE_____________________
DATE____________________
How many different elementary schools has your child attended?__________
Please check all that apply:
My child:
_____
has glasses or had glasses
_____
has had many ear infections
_____
has had hearing problems
_____
has received special education services
_____
has received speech or language help
_____
has been in a Resource Room
_____
has worked with a school counselor, school psychologist or
school social worker
_____
has received extra help in reading or math
_____
has been retained (held back a grade)
_____
has been tested for possible special education
Is there anything we should know that will help us select a teacher for your
child or plan for your child?
____________________________________
Your name and relationship to child
*************************************************************************
Assigned to:_____________________________________________________
Dear Parent,
Williston Public Schools will be using ALERT SOLUTIONS, an automated computer system, to
notify you in case of an emergency, such as school closings due to weather.
Please complete the following information so our records are accurate.
Please print Child/Children’s Name:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Father’s Name:_______________________________________
Cell Number
May we text?
Yes
No
Home Number
E-Mail Address
Mother’s Name:_______________________________________
Cell Number
May we text?
Yes
No
Home Number
E-Mail Address
 Which phone number would you like to be your primary number?
Primary 1 : _______________________________________
Primary 2: _______________________________________
Thank you for your assistance!
If you have any questions, please contact your principal.
NOTICE OF DIRECTORY INFORMATION
The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that Williston School District, with
certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from
your child's education records. However, Williston School District may disclose appropriately designated "directory
information" without written consent, unless you have advised the District to the contrary in accordance with district
procedures.
The primary purpose of directory information is to allow the Williston School District to include this type of
information from your child's education records in certain school publications. Examples include:
1.
A playbill, showing your student's role in a drama production;
2.
The annual yearbook;
3.
Honor roll or other recognition lists;
4.
Graduation programs; and
5.
Sports activity sheets, such as for wrestling, showing weight and height of team members.
Directory information, which is information that is generally not considered harmful or an invasion of privacy if
released, can also be disclosed to outside organizations without a parent's prior written consent. Outside
organizations include, but are not limited to, companies that manufacture class rings or publish yearbooks. In
addition, two federal laws require school districts receiving assistance under the Elementary and Secondary
Education Act of 1965 (ESEA) to provide military recruiters, upon request, with three directory information
categories--names, addresses and telephone listings--unless parents have advised the school district that they do
not want their student's information disclosed without their prior written consent.
If you do not want Williston School District to disclose directory information from your child's education records
without your prior written consent, you must notify the District in writing within ten calendar days of enrollment.
Williston School District has designated the following information as directory information:
1.
Date and place of birth
2.
Dates of attendance
3.
Degrees, honors, and awards received
4.
Electronic personal identifier
5.
Grade level
6.
Institutional electronic mail address
7.
Participation in officially recognized activities and sports
8.
Photograph
9.
Student's name
10.
Telephone listing
11.
The most recent educational agency or institution attended
12.
Weight and height of members of athletic teams

Please do not release the following part or parts of directory information: (check all that apply)
 Name
 Telephone
 Photograph
 Other (specify): _______________________________________

Please do not release directory information to:
 Military Recruiters
 Colleges & Universities
 Other (specify): _______________________________________
Student’s Name: ______________________________________________
School: ______________________________________________________
Grade: ______________________________________________________
Parent/Guardian Signature: ________________________________________
Date: _________________________________________________________
NOTE: If the student is a high school senior or is otherwise scheduled to graduate, this opt-out request will continue
to remain effective after the student has graduated from high school.
Williston Public School District is required to have a Home Language survey in every student file. Please take a few minutes to complete and
return to the school office. Thank you!
Williston Public School District #1 (revised 10/28/10)
Home Language Survey
Student Name: _________________________________ Student School: _____________________ Student’s Grade:___________________
The US Office of Civil Rights requires that schools identify possible English Language Learner students during enrollment. This Home Language
Survey will be used as a tool to determine if your child is eligible for language support services (ELL). If a language other than English is used by
your or your child and your child meets the Limited English Proficient definition, the school may give your child an English Language Proficiency
Assessment. The school will share the results of the assessment with you.
What language(s) are spoken at home?
________________________________________________
What language(s) do you use the most to speak to your child?
________________________________________________
What language(s) does your child use the most at home?
________________________________________________
What language(s) did your child learn when he/she first began to talk?
________________________________________________
List other language(s) that your child has used with a grandparent or caretaker: ________________________________________________
If available, in what language would you prefer to receive information from the school? ________________________________________________
Yes
Has your child ever been in an English as a Second Language (ESL or ELL) Program?
No
Put an X in the boxes on the top line to show the grades your child has gone to school in the United States. Put an X in the boxes on the bottom line to show the
grades that your child went to school in another country.
School
Grade level attended school inside of the US
Grade level attended school outside of the US
PreK
PreK
K
K
1
1
2
2
3
3
4
4
Grade
5
6
5
6
7
7
8
8
9
9
10
10
11
11
12
12
If your child has gone to school outside of the United States:
In which country or countries did your child go to school?______________________________________________
Which language or languages did your child learn in school?________________________________________
(over)
This form also asks for information used by other programs to help your student in school. You are not required to answer these questions, but
if you circle yes or no for questions 1-4, your student may qualify for additional services.
Refugee Student:
NDDPI applies for a Refugee School Impact Grant to provide services for newly arrived refugee students. A refugee student left their home
country due to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or
political opinion and has fled to another country to be resettled. Newly arrived is defined as within the last three years.
1. Would your child be considered a newly arrived refugee student?
Yes
No
Immigrant Student:
Immigrant students are mentioned specifically in the LEP definition and may qualify for LEP services. Additionally, students who have
attended schools in the US for three years or less may qualify for additional services.
2. Would your child be considered an immigrant student?
Yes
No
If yes, please fill in the Country ________________________ and US entry date (mm/dd/yy) _____/_____/_____
(For refugee students, this is the country that you originally fled, not the country that you lived in most recently.)
Native American or Alaska Native student:
Native American and Alaska Native students are mentioned specifically in the LEP definition and may qualify for LEP services.
3. Would your child be considered Native American or Alaska Native student by any definition above?
Yes
No
Migrant Student:
Migrant students are mentioned specifically in the LEP definition and may qualify for LEP services. A migrant student has a parent who is a
migratory agricultural worker and in last 3 years, has moved from one school district to another, in order to work (temporary or seasonal) in
agricultural activities.
4. Would your child be considered a migrant student?
Yes
No
If yes, what is the date that you moved to this area? (mm/dd/yy)
_____/_____/_____
If your family moved to this area for agriculture (temporarily or seasonally) in what area(s) do you work: (please check all that apply)
Sugar Beet Industry
Potato Industry
Bee Keeper/Honey Processing
Turkey Farm/Processing
Egg Production
Meat Processing Plant
Chicken Farms/Processing
Plant/Cultivate Trees
General Dairy Farm Work
Transportation of Agricultural
Products
Trimming Trees
Raw Cheese Production
Custom Combining
Landscaping, laying Sod or
Planting Grass
Williston Public School District #1
McKinney-Vento Student Residency Questionnaire
IMPORTANT: Return completed form to Students in Transition Liaison
PLEASE PRINT NEATLY and complete ALL sections on this form – information is confidential.
These required questions are intended to address the law known as the McKinney-Vento Act (Title X, Part C of the No Child
Left Behind Act). Your responses will help determine if your child is eligible for specific educational services under this
federal law.
Circle ONE - who is filling out this form - Parent
Legal Guardian
Foster Parent
Unaccompanied Youth
PRINT Name(s):___________________________________________________________________________________
Primary Phone: _________________________________ Secondary Phone: ___________________________________
Current Physical Address: ____________________________________________________________________________
Mailing Address (if different from above) ________________________________________________________________
Email Address _____________________________________________________________________________________
Student’s Name
PLEASE PRINT
Gender
1
M
F
2
M
F
3
M
F
4
M
F
5
M
F
Date of
Birth
Names of Younger Children NOT enrolling at WSPD #1
1
2
3
Grade
Last School Attended/Last Date Attended
DATE OF BIRTH
AGE
Please check ONE box below that best describes your current living situation:
Own or rent apartment or home
Doubled Up with more than one family in a house, apartment or trailer
In a hotel/motel Name of hotel/motel_____________________________________________________
In a car, camper/5th wheel or public place such as: parking lot, well site, construction site, truck yard,
private yard, park, abandoned/building Name of Campground/RV Park_________________________
Moving from place to place
In an emergency shelter or transitional housing (including awaiting foster care)
With an adult that is not my parent or legal guardian, or alone without an adult
Signature ___________________________________
_____________________________ Date_________________
Presenting a false record or falsifying records is an offense under Section 37.10, penal code, and enrollm ent of the child
under false docum ents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3) (d).