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  • Please read and respond to the questions below:

     

  • I confirm that I have the authority to request that Goshen Community Schools update the information for the child on this from.

     

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  • Goshen. Community Schools Home Language Survey (HLS)

  • The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district. The HLS is administered one time, upon initial enrollment in Indiana, and remain in the student's file. Indiana school districts are required to determine the language(s) spoken in each student's home to identify their specific language needs, per the Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures. Please note that the answers to the survey below are student specific. If a language other than English is recorded for ANY of the survey questions below the student will be given a test to determine whether the student will qualify for additional English Language Support. Please answer the following questions regarding the language spoken by the student: Circle One

     

  • By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If eligible for the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.

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  • FAMILY AND EMERGENCY CONTACT INFORMATION

  • Primary Parent/Guardian- this parent/guardian's information will be used as the student's primary address and phone number.

  • Please Mark all that apply for this parent:

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  • Spouse OR Parent 2 (Parent 2 is the biological parent sharing custody of the student)

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  • Emergency Contacts- please add at least two emergency contacts.

    *By adding an individual below, you are giving permission to your student's school to call and pick up the student if primary contacts are not available Relationship to student Preferred language

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  • Indiana Department of Education

    The Migrant Education Program (MEP) provides supplemental education and support services to eligible children through national funding. The purpose of the program is to ensure that all migrant students reach the academic standards and graduate with a high school diploma (or complete GED/HSE

    Thank you for answering the following questions. If your child is eligible for the Migrant Education Program, they may receive additional educational support. This information is strictly confidential.

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  • Student Custodial Question

    Goshen Community Schools policies are designed to keep custodial conflicts out of the school setting. Our policies seek to ensure the safety of all our students.  Goshen Community Schools needs a copy of all court documents related to custody, paternal rights, paternity, etc.

  • Because of Indiana Law, IC 31-14-7-1 related tolegal custody, we need you to answer the following questions:

  • If not, please bring this paperwork to the school as soon as possible.

  • Children and Hoosiers Immunization Registry Program (CHIRP)

  • I parent/guardian of , DOB   ,  give Goshen Community Schools permission to release the following information to the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP): All immunization records and personal identifying information from the CHIRP data base. For example, but not limited to: name, address, phone number, birth date, school name.


    I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me or my child of my child’s immunization status or that an immunization is due according to recommended immunization schedules.

    I understand that my child’s information may be available to the immunization data
    registry of another state, a healthcare provider or a provider’s designee, a local health
    department, an elementary or secondary school, a childcare center, the office of
    Medicaid policy and planning or a contractor of the office of Medicaid policy and
    planning, a licensed child placing agency, and a college or university. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3.

    I hereby consent to the release of such information.

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  • Goshen Community Schools

    Student Health History
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  • If yes, Asthma Action Plan is requested. If moderate or severe, a doctor's signature is required on this plan

  • If yes, self med. form/ emergency care plan from Dr. is required

  • If yes, Diabetic Care Plan from Dr. is required

  • If yes, seizure care plan from Dr. is required

  • Elkhart County Special Education Cooperative (ECSEC)

    For any student who has receives special education services, speech therapy, participated in first steps or any other educational, emotional or physical needs.
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