Black Hawk School District Enrollment/Emergency Information Form

Student’s Full Legal Name: Birth Date________________ Grade_____ Gender_____

______________________________________________________________________________________

First Middle Last

SSN____________________________ Home Phone____________________________ Bus Rider: Yes No

Address_________________________________________________________________________________________________________

Birthplace_________________________/_________________________/_________________________/________________________ City County State Country Primary Language_________________________Other Languages Spoken in the home_______________________________

Please Circle One: White Hispanic Black American/Alaskan Indian Asian Other_______________

Household #1 _____Both Parents _____Mother Only _____Father Only _____Joint Custody

_____Parent/Stepparent _____Foster Home _____Legal Guardian _____Relative _____Other

Father_____ Stepfather_____ Guardian_____

Name_________________________________________________________ Second Phone #:_______________________________________________________

E-mail Address_____________________________________________________________________ Please Circle: Cell Pager Other

Employer_____________________________________________________ Work Phone #:_______________________ Hours of Work:_______________

Mother_____ Stepmother_____ Guardian_____

Name_________________________________________________________ Second Phone #:_______________________________________________________

E-mail Address_____________________________________________________________________ Please Circle: Cell Pager Other

Employer_____________________________________________________ Work Phone #:_______________________ Hours of Work:_______________

Household #2 _____Both Parents _____Mother Only _____Father Only _____Joint Custody

_____Parent/Stepparent _____Foster Home _____Legal Guardian _____Relative _____Other

Father_____ Stepfather_____ Guardian_____

Name__________________________________________________________ Second Phone #:______________________________________________________

E-mail Address_____________________________________________________________________ Please Circle: Cell Pager Other

Address__________________________________________________________________________________________________________________________________

Home Phone________________________________ Receives Report Card: Yes No Receives Forms: Yes No

Employer______________________________________________________ Work Phone #:_______________________ Hours of Work:______________

Mother_____ Stepmother_____ Guardian_____

Name__________________________________________________________ Second Phone #:______________________________________________________

E-mail Address_____________________________________________________________________ Please Circle: Cell Pager Other

Address__________________________________________________________________________________________________________________________________

Home Phone________________________________ Receives Report Card: Yes No Receives Forms: Yes No

Employer______________________________________________________ Work Phone #:_______________________ Hours of Work:______________

Siblings:

Name____________________________________________________ Birthdate__________________ Grade_________________

Name____________________________________________________ Birthdate__________________ Grade_________________

Name____________________________________________________ Birthdate__________________ Grade_________________

Name____________________________________________________ Birthdate__________________ Grade_________________

Please list emergency contacts in the case you cannot be reached: please remember that these are the individuals who may pick up your child from school if your child can no longer remain in school. These are the only individuals that the school may legally release your children to other than parents.

Name_____________________________ Phone_______________ City________________ Relationship_________________

Name_____________________________ Phone_______________ City________________ Relationship_________________

Name_____________________________ Phone_______________ City________________ Relationship_________________

Name_____________________________ Phone_______________ City________________ Relationship_________________

MON TUE WED THU FRI MON TUE WED THU FRI

16 17 18 19 20 3 4 5 6 723 24 25 26 27 10 11 12 13 1430 31 17 18 19 20 21

24 25 26 27 2831

August 23rd: Teacher In-serviceMON TUE WED THU FRI August 24th: Techer In-service

1 2 3 August 25th: Teacher In-service/Open House 1-7pm MON TUE WED THU FRI

6 7 8 9 10 August 26th: Teacher Work Day 1 2 3 413 14 15 16 17 August 30-31st: Summer2School 7 8 9 10 1120 21 22 23 24 15 16 17 18 1927 28 29 30 21 22 23 24 25

September 6th: No School/Labor Day 28September 22nd: Picture Day

MON TUE WED THU FRI

1 October 7th: Picture Retake Day MON TUE WED THU FRI

4 5 6 7 8 1 2 3 411 12 13 14 15 November 4th: End of 1st Quarter 7 8 9 10 1118 19 20 21 22 November 5th: No School/Teacher Work Day 14 15 16 17 1825 26 27 28 29 November 11th: Parent-Teacher Conferences 5-8pm 21 22 23 24 25

November 12th: No School/Parent-Teacher Conferences 9-12pm 28 29 30 31November 24th-26th: No School/Thanksgiving Break

MON TUE WED THU FRI

1 2 3 4 5 December 23rd-December 31st: No School/Christmas Break MON TUE WED THU FRI

8 9 10 11 12 115 16 17 18 19 January 3rd: Classes Resume 4 5 6 7 822 23 24 25 26 January 21st: End of 2nd Quarter 11 12 13 14 1529 30 January 24th: No School/Teacher Work Day 18 19 20 21 22

25 26 27 28 29February 25th: No School-Students/Staff

MON TUE WED THU FRI

1 2 3 March 25th: End of 3rd Quarter MON TUE WED THU FRI

6 7 8 9 10 March 28th: No School/Teacher Work Day 2 3 4 5 613 14 15 167 17 9 10 11 12 1320 21 22 23 24 April 15th-19th: No School/Easter Break 16 17 18 19 2027 28 29 30 31 23 24 25 26 27

May 27th: High School Graduation @ 7pm 30 31End of Quarter May 30th: No School/Memorial DayTeacher Work DayParent/Teacher Confe June 2nd: 8th Grade Promotion @ 7 pm MON TUE WED THU FRI

No School June 3rd: Last Day of School/End of 4th Quarter 1 2 3Graduation/Promotion

October

SeptemberFebruary

March

SCHOOL DISTRICT OF BLACK HAWKAugust January

December

April

May

June

November

School District of Black Hawk 202 East Center Street South Wayne, WI 53587 P: 608.439.5371 F: 608.439.1022

Proudly serving the communities of Gratiot, Martintown, South Wayne, Wiota and Woodford

Administration: William Chambers – Superintendent and Director of Special Education │Cory Milz - 4K-12th Principal │Roger Trame, Athletic Director

School Board Kerry Holland, President │ Dee Paulson, Vice President │ Jason Figi, Clerk │ Alicia Sigafus, Treasurer │Jason Herbst │Jon Satterlee│ Jessica Seffrood

Informed consent: COVID-19 Vaccination

I authorize the Black Hawk School District to access the Wisconsin Immunization Registry to verify if ______________________ is fully vaccinated against COVID-19. (student’s name) I further authorize the Black Hawk School District to contact the parent/guardian (or myself if an adult student) to provide evidence of vaccination for COVID-19, if the registry does not provide evidence of such vaccination.

The consent to check the registry and/or contact the parent/guardian/adult student for evidence of vaccination will be valid for the full 2021-2022 school year unless the district is otherwise notified.

The Black Hawk School District will hold the position that a student has not been vaccinated if permission to view the information on the registry is not granted or evidence is not provided by the parent/guardian/adult student that the above named person has been vaccinated.

If no evidence of vaccination is provided to the district the student will need to adhere to district adopted COVID-19 mitigation protocols which may include the student’s exclusion from school if an unvaccinated student is deemed to be a close contact to an individual who tests positive for COVID-19 and/or demonstrates symptom(s) of COVID-19 (e.g. application of quarantine recommendations as prescribed by the Centers for Disease Control).

____________________________________ ______________ (parent/guardian, adult student’s signature) Date

To families with students attending Black Hawk School:

Parent in Military is a new data element and is needed for federal reportingof assessment data.

Please include the name of parent/guardian and service start date whichthis applies to.

Please notify the school of one of the following:

● Is either parent or guardian on active duty in the military?● Yes or No

● Is either parent or guardian a traditional member of the Guard orReserve?

● Yes or No

● Is either parent or guardian a member of the Active Guard/Reserve(ARG) under Title 10or full time national Guard under Title 32?

● Yes or No

BLACK HAWK SCHOOL DISTRICT 202 E Center Street

South Wayne, WI 53587 (608)439-5371

STUDENT RECORDS RELEASE FORM

Student Name: _________________________________ Birth Date: ________________ Grade: ____ Parents’ Names: _______________________________________________________________________ Address: _____________________________________________________________________________ Street City State Zip Code

Transferring from School A:

__________________________________________________________ Name of School/District

__________________________________________________________ Street

__________________________________________________________ City State Zip Cod

Transferring to School B:

BLACK HAWK SCHOOL DISTRICT 202 E. Center St.

South Wayne, WI 53587

Was the student enrolled in a special education program? Yes ______ No ______ I, the undersigned parent/guardian, give permission to the officials of School A to release and send progress reports, transcripts, test results, health records, psychological, and other pertinent reports regarding my child to School B. I understand that this consent may be revoked by me at any time, except to the extent that action has already been taken in reliance thereon. This consent expires one (1) year from this date unless expressly revoked earlier. I hereby release you, as custodian of such records from any and all liability for damages of whatever kind which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request for release of information or any attempt to comply with it.

_______________________________________________________________ ____________________ Parent/Guardian Signature Date _______________________________________________________________ ____________________ Student (if 18 or older) Date