Thackerville Public Schools · Thackerville Public Schools P.O. Box 377 Thackerville, OK 73459...

Thackerville Public SchoolsP.O. Box 377

Thackerville, OK 73459 580.276.9655

Russell Noland Heather Holland Elementary Principal Superintendent

Welcome to Thackerville Public Schools!! We are glad that you desire to enroll your student(s) in our

school. Student Enrollment Eligibility must be established prior to the enrollment process. If you are a

new student at Thackerville Schools, then please contact the building principal to see if your student is

eligible to enroll.

Upon establishing enrollment eligibility, then the enrollment process can begin. We hope that the

enrollment process is an easy one for you and that you feel welcome here. There are a few requirements

that need to be met during this process:

** All new student enrollment forms should be obtained from the secretary’s office**

Requirements:

1. Legal Custody – The adult enrolling a student must have legal custody of the student. Legal

custody is obtained through court proceedings and signed by a judge or biologically.

2. Residence Verification – Documents which meet this requirement are utility bills such as water,

gas, or electric or documentation through the County Assessor’s Office.

3. Current Immunizations – A copy of current immunization requirements must be presented at

enrollment. All immunizations must be up to date.

4. Birth Certificate – A copy of the student’s birth certificate must remain on file for the entirety of

the student’s enrollment at Thackerville Elementary.

Other needed documents:

1. CDIB Card

2. Social Security Card

3. OCCT Test Results (If requesting transfer)

If Requesting Transfer:

1. Current Grades

2. Attendance Records

3. Behavior Records

4. OCCT Test Results

5. If student was receiving special education services

**All of the above information will be reviewed and previous school contacted by the principal before a

decision is made regarding accepting or declining a transfer**

Brenda PyleMS/HS Principal

Thackerville Elementary

Enrollment Form 2019-2020

Student's FULL LEGAL Name __________________________________________ SS# ___________________ Last First Middle

Date of Birth ________________________ Gender: Male Female Grade: ________________

Mailing Address: ____________________________________________________________________________________

Physical Address: ____________________________________________________________________________________

Home Phone (____)_____________________ Birthplace ___________________________________________________

Is student of Hispanic /Latino Descent? Yes No Indian Tribe ________________________________

Check all races that apply: African American American Indian Asian Pacific Islander White

Female Parent with Whom Student Resides: Legal Custody? Yes No

Please Indicate Relationship: Natural Mother Step Mother Grandmother Foster Parent Guardian

Name: _________________________________ Employer: ________________________________

Work: (____)______________ Cell: (____)______________ Email: ___________________________________________

Male Parent with Whom Student Resides: Legal Custody? Yes No

Please Indicate Relationship: Natural Father Step Father Grandfather Foster Parent Guardian

Name: _________________________________ Employer: ________________________________

Work: (____)______________ Cell: (____)______________ Email: ___________________________________________

Emergency Contact If Parents Cannot Be Reached

Name ___________________ Work (____)___________ Cell (____)___________ Relationship to student ____________




**Please list a cell phone number for immediate school-wide emergency notification: __________________________

If new to the District

Last School Attended: _____________________________________________________________________________ School Name City State Phone Number if known

If your child attended Pre-K, where: ________________________________________________________________

Does your child require special services as required by IEP? Yes No If yes, please check services received: Speech Physical Therapy Occupational Therapy

Resource Room Section 504 Other

If student has any other siblings in Thackerville Public Schools, please list Name and Grade.

Parent/Guardian Signature ______________________________ Date ___________________

Student Planner Implementation

Dear Parent(s)/Guardian(s):

Welcome back to Thackerville Elementary for a new academic year! We spent all summer preparing for your child’s return and are excited to invite you back too! We are looking forward to a successful and productive year.

We are continually working to develop a partnership with our parents. One goal at Thackerville Elementary is to establish positive communication between home and school. We are excited to announce that we will be implementing SchoolMate Student Planners for all students again this year. This resource is designed to teach students time management, organization, and goal setting skills. Each planner contains resources for maintaining communication among teachers, students, and parents.

The planners will be implemented in grades Pre-K – 5th, but will be implemented in different ways for each grade level. We need your help to ensure success. Together, we can support our children as they learn skills for their future. Time management, organization, and goal setting skills will last a lifetime. We welcome you as a member of our team to promote student success.

Sincerely,

Heather Holland Elementary Principal

I understand that Thackerville Elementary School has adopted SchoolMate Student Planners for the 2019-2020 school year as a tool to increase communication between home and school. I agree to work together as a team by doing my part in the utilization of the student planners. I understand that my child will be supplied one student planner and that I will be responsible for the replacement fee of $5.00 should my child’s planner be lost or damaged.

Parent Signature Date

Student Name

CORPORAL PUNISHMENT

Thackerville Public Schools will be utilizing corporal punishment (paddling) as a discipline measure for

students. The State of Oklahoma authorizes public schools to use corporal punishment as a discipline

measure without parental/guardian consent. However, Thackerville Public Schools chooses to ONLY use

corporal punishment with parental/guardian consent. If you choose to allow an administrator from

Thackerville Public Schools to use corporal punishment as a discipline measure, then the following

guidelines will be used in each situation.

Guidelines for each discipline situation:

If corporal punishment is appropriate for the behavior in question, the administrator would first

check on file to see if the parent/guardian has given written permission to paddle.

The administrator would then call the parent/guardian to share the situation and see if the

parent/guardian is in agreement that corporal punishment is the best choice of discipline. If the

parent/guardian does not agree with paddling at this point, then another form of discipline will be

used.

The site administrator will then contact the school superintendent to explain the entire situation

prior to implementing the corporal punishment. The school superintendent will make a

conclusion as to the appropriateness of corporal punishment in regards to the behavior in question

and also review the procedures used to that point.

Administration of the corporal punishment will be appropriate for the size and age of the student

according to state law. The maximum number of swats per day for any student is two according

to school board policy. All instances of paddling require a certified school employee to witness

the paddling. All corporal punishment will be administered in private.

If the student refuses to be paddled, then another form of discipline will be used.

_______ Using the previous guidelines, I give Thackerville Public Schools authority to use corporal

punishment as a discipline measure for my student.

_______ Please do not use corporal punishment as a discipline measure for my child.

Parent Signature ____________________________________________ Date _____________________

Student Name ____________________________________________________________

Thackerville Schools Transportation Form

Student Name: Grade:

Parent(s) Name:

Physical Street Address:

Contact phone #:

Please select type(s) of transportation from the following. Mark all that apply to your student:

My child will be using bus transportation before and after school.

My child will not be using bus transportation unless I notify the school.

My child will walk/ride bike to and from school.

My child will be picked up and dropped off at the school in a vehicle.

Other (Please explain):

Do you live 1.5 miles or more from the school? YES NO

Students MUST have a note written by a parent before changes will be made in transportation. If an emergency arises and a note cannot be sent, please call the office as early in the day as possible.

*********************************Office use only*********************************

Bus #1 Bus #2 Bus #3

Drop-off: Students may only be dropped off after 7:35 am. The cafeteria will remain locked until that time.

Parents should drop students off at the sidewalk leading to the cafeteria. Students must be dropped off between 7:35am and 7:50 am if students plan to eat breakfast. If parents wish to waitfor their child’s class, they can wait with their child under the breezeway until the class comes through. If students are being dropped off after 8:00, they will need to enter the Elementary building through the front entrance.

Pick-up: Parents wishing to pick their child up at the end of the day will need to pull into the drive

to the West of the elementary building. Students will wait in the Multi-purpose room until their name is called to be picked up. Parents are welcome to park in the front of the building and walk to the breezeway for pickup as well. If you have any questions, please contact the elementary office at (580) 276-9655.

Thackerville Public Schools

TRANSPORTATION AGREEMENT

Please complete the following form and return to the school office.

This agreement is between Thackerville Public Schools and the parents/guardians of students being transported to and from school.

The school bus driver has a great responsibility. Each day he/she carries a “precious cargo” your child and his/her only concern should be to ensure that all of his/her passengers are transported to and from school safely. Unfortunately, there are times when children (young and old) do things that causes the driver to be distracted from his/her job. This is dangerous and cannot be allowed. It is necessary therefore, that Student Conduct Rules and Regulations be in force and that they be followed. Each parent/guardian must ensure that their child understands the importance of good behavior while riding the bus. (see attachment)

Riding a school bus is not a right but a privilege granted to those who are eligible and are able to abide by the rules and regulations. It is not right that a student be allowed to ride a school bus when he/she continues to jeopardize the safety of others. The Board of Education realizes that a hardship may result in your having to transport your child to and from school, but it is sometimes necessary.

Therefore, the school system asks the parents/guardians to sign an agreement that their child will abide by the rules and regulations. If the rules are broken, there will be punishment administered on an increasing scale.

We the parents/guardians have read and discussed with our children the school bus policy and rules. We agree with the School District that these rules should be in force and that if any student who cannot abide by them should and shall be disciplined with accordance to the school policy. As parents/guardians, we ask the school district to contact us each time our children are involved in incidents so we may further counsel our children on proper bus conduct.

Parent’s Signature Date Phone

Physical Address

Please write the names and grade of each child in your family that will ride the school bus. This statement will be in effect for the current school year 2018-19.

Name Grade Bus #

Name Grade Bus #

Name Grade Bus #

Name Grade Bus #

Bus Procedures

Prior to loading, students should:

1. Be on time at the designated school bus stops; students need to be at theircorrect bus stop for the safety of all.

2. Stay off the road at all times while waiting for the bus.3. Wait until the bus comes to a complete stop before attempting to enter.4. Be careful in approaching bus stops.

While on the bus, students should:

1. Keep all parts of the body inside the bus.2. Keep the bus safe & sanitary at all times.3. No loud talking, laughing or unnecessary confusion as it diverts the driver.4. Be respectful of bus driver and other bus passengers.5. No vandalizing or destruction of the bus.6. Never tamper with the bus or its equipment.7. Leave no books, lunches or other articles on the bus.8. Keep books, packages, coats, and other objects out of aisles.9. Help look after the safety & comfort of small children.10. In case of road emergency, children are to remain in seats on the bus.11. No eating, drinking, or gum chewing.

After leaving the bus, students should:

1. Go at least ten (10) feet in front of the bus, stop, check traffic, and waitfor bus driver's signal, then cross the road.

2. Students living on right side of the road should immediately leave the busand stay clear of traffic.

3. Help look after the safety and comfort of small children.4. The driver will not discharge riders at places other than the regular bus

stop.

THACKERVILLE PUBLIC SCHOOLS

PARENT/GUARDIAN CONSIDERATIONS/DISCLAIMERS

PLEASE PRINT

Student Name Grade

School Travel

I DO , I DO NOT give permission for my child to travel with school officials by bus, van, or car, to

attend academic field trips, athletic events, non-academic field trips, class outings, and other activities

as scheduled by Thackerville Public Schools.

Publication of Name and/or Picture

I DO , I DO NOT give permission for my child to have their picture on Thackerville Public School's

web page, television, newspaper, social media, or other school related media outlets as well as

child/parent name.

Gifted/Talented

I DO , I DO NOT give permission for my child to be referred and/or tested to receive

Gifted/Talented services.

Vision/Hearing Screening

I DO , I DO NOT give permission for my child to have a vision and/or hearing screening.

Parent Signature Date

Disclaimer

THACKERVILLE ELEMENTARY STUDENT HANDBOOK

I understand that the Elementary School handbook is located on the Thackerville School

Website in PDF Format at www.thackervilleschools.org. I understand that this website

and subsequent handbook is available to me at any time. I understand that should I have

difficulty with access to this handbook that I can speak with school administration for

help. Not only is the handbook accessible on the school website, but a paper copy is

distributed at enrollment.

By signing this document, I understand that it is my responsibility to read the 2019-20 Elementary School handbook and that I am responsible for all guidelines and

expectations pertaining to me as a student of Thackerville Elementary

Student Signature: _______________________________ Date: __________________

Student Printed Name: ___________________________________

I am aware that my child has been notified of the process to view and responsibility to

read the 2019-20 Elementary School handbook. I am also aware that it is my child’s

responsibility to be knowledgeable of the contents of the handbook.

Parent Signature: _________________________________ Date: ___________________

THACKERVILLE PUBLIC SCHOOLS

Internet Use Agreement

2019-2020

Student Name Grade

I understand and will abide by the Thackerville Public Schools Internet Use Agreement. I further

understand that any violation of the regulations is unethical and may constitute a criminal offense.

Should I commit any violation, my access privileges may be revoked, school disciplinary and/or

appropriate legal action may be taken.

Student Signature Date

PARENT OR GUARDIAN

(If you are under the age of 18, a parent or guardian must also sign the agreement.)

As the parent or guardian of the student signing above, I have read Thackerville Public Schools’ Internet

Use Agreement. I understand that this access is designed for educational purposes, and that the

Thackerville School District has taken available precautions to restrict access to all controversial

material. However, I also recognize it is impossible for Thackerville to restrict access to all controversial

materials and I will not hold them responsible for materials acquired on the network. Further, I accept

full responsibility for supervision if and when my child's use of the Internet is not in a school setting. I

hereby give my permission to grant access for my child and certify that the information contained on

this form is correct.

Parent/Guardian Signature Date

Internet


New Technology Information

Thanks to the Oklahoma Educational Technology Trust grant, Thackerville Elementary is able to provide each student in grades K-1 with an Apple iPad and each student in grades 2-5 with a Chromebook to advance the opportunity to learn in 21st century context. We are very excited to have the opportunity to offer this technology and opportunity to our students and their families!

Teachers will receive over 40 hours of training on how to use our new devices to provide authentic instruction to our students. Devices will be assigned to students and kept in a locked charging cart in the classrooms while not being used. Students will be responsible for ensuring responsible use of their assigned device while being used. Teachers will oversee the daily use and management of the devices. Devices will strictly be used for educational purposes and students will be required to follow classroom procedures while using the devices. Students will be held accountable for purposeful misuse of devices and could ultimately lose the privilege to use the devices.

This is a very exciting time for Thackerville Elementary! We have a lot of new things in place for this school year and look forward to beginning school. If you have any questions about new things or want to know what your child’s class is up to, we encourage you to contact their teacher by e-mail or phone. Don’t forget to ask your child about the new technology on occasion! We are excited you are here!!!

Thank you,

Heather Holland Elementary Principal

MEDICAL INFORMATION

Student’s Name: Grade:

Family Physician: Phone#

Allergies:

Medications

Student is

Taking:

AUTHORIZATION TO ADMINISTER PRESCRIPTION MEDICATION TO

STUDENT

I give permission for Thackerville Public School personnel to give prescription medication

listed below to my child. I will provide medications for my child as needed.

Name of medication:

Dosage:

Time medication is to be given:

Prescription medication must be in the original prescription container with the physician’s

instructions listed on the label. All medications must be turned into the office, unless other

arrangements are made through administration.

SIGNATURE OF PARENT/GUARDIAN DATE

**PLEASE NOTE: School personnel is only able to dispense over the counter (OTC)

medications if a bottle is provided with your child’s name on it. We will maintain a list of

medication, dosage and time of administration for your child.

OSIIS - Authorization to Use or Share Protected Health Information to School orDay Care

Oklahoma State Department of HealthOklahoma Immunization Service Retain document for a minimum of 6 years

OSIIS – AuthorizationFeb. 2019

Student Name:_________________________________ Demographic/Client ID #:_____________________________________

(For School/Day Care receiving PHI to fill out) Date of Birth:___________________________________

I hereby authorize the Oklahoma Immunization Service to release my Immunization records and information located within

the Oklahoma State Immunization Information System (“OSIIS”) to: __________________________________________________.

(Name of Person/Organization receiving PHI)

The information may be disclosed for the following purpose(s):

to ensure the student meets Oklahoma eligibility requirements for schools/day cares as outlined in Title 70 O.S. §

1210.191 and Oklahoma Administrative Code ("OAC") 310:535-1-2 and OAC 310: 535-1-3

Other:

I understand that by voluntarily signing this authorization:

I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.

I have the right to withdraw permission for the release of my information and revoke this authorization at any time in writing.

I have the right to receive a copy of this authorization.

I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorizationwill not affect my eligibility for benefits, treatment, enrollment, or payment of claims.

I understand I may change this authorization at any time in writing. However, I understand I cannot restrict information that mayhave already been shared based on this authorization.

Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and may no longer beprotected by HIPAA Privacy Regulations.

Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my signature or upon

the occurrence of the following event [ e.g., child no longer enrolled in school/day care center] ___________________________________.

______________________________________________________________________________________________________________.

________________________________________________ _____________________________________________Signature of Student or Legal Representative Date

________________________________________________Description of Legal Representative’s Authority

Thackerville Public Schools

Thackerville Public Schools Residency of Child -Affidavit

The residency of any child for school purposes shall be “the school district in which the

parents or person having legal custody holds legal residence.” Oklahoma School Statutes

§14.A.1. Legal residence is defined as “the place where one’s habitation is fixed without

present purpose of removing there from”. Jones v. Burkett 346 P. 2d 338 (Okla. 1959)

Please complete the following information regarding residence:

Name of Student: ______________________________________________________

Name of Parent(s): _____________________________________________________

Residence of parent(s) where child permanently resides: _______________________

____________________________________________________________________

Child’s permanent residence: ____________________________________________

Verification of residence used (Utility Bill, Rental Agreement, etc): ___________________

How long I have lived at current residence: _________________________________

The person having legal custody of the student: ______________________________

According to Oklahoma School Statutes §14.A.1, any person who willfully makes a

statement in the affidavit which the person knows to be false shall, upon conviction, be

guilty of a misdemeanor punishable by imprisonment in the county jail for not more than

one (1) year or a fine of not more than Five Hundred Dollars ($500.00) or both such fine

and imprisonment.

Parent/Guardian Signature ________________________________ Date ____________

Student Signature _______________________________________ Date ____________

Thackerville Title I Student/Parent/Teacher Compact 2019-2020

STUDENT AGREEMENT Student Signature _______________________________ Grade ________

PARENT/GUARDIAN AGREEMENT Parent Signature ___________________________________

TEACHER AGREEMENT Teacher Signature ___________________________________________

It is important that I work to the best of my ability. Therefore, I will strive to do the following: • Attend school regularly, on time• Come to school each day with materials/supplies for learning• Complete and return homework assignments on time• Behave and follow the rules for good conduct• Respect others and their property• Keep my hands, feet, objects and comments to myself• Read for at least 30 minutes, five days a week• Respect my school, classmates, staff and family

I will support Thackerville’s programs and activities that give my child the optimum opportunity for learning by:

• Supporting the discipline policy and reinforcing the highest expectations of the schoolstaff

• Providing and maintaining accurate information on my child’s records for contact• Seeing that my child gets adequate rest and is in school on time with a positive outlook• Reading to and listening to my child read daily• Monitor my child’s progress in school• Make sure that my child attends school every day, on time, and with homework

completed• Attending parent/teacher conferences to discuss my child’s progress• Respect the school, staff, students and families

I will provide your child with every opportunity to learn and grow by:

• Having a high expectation of myself and my students• Reporting regularly to parents with returned work, written notices, and conferences• Monitoring student work on a daily basis to ensure success and progress• Endeavor to motivate my students to learn• Encourage students and parents by providing information about student progress• Teach and involve students in classes that are interesting and challenging• Enforce rules equitably and involve students in creating a warm and caring learning

environment• Provide assistance to families on what they can do to support their child’s progress in school• Respect the school, staff, students and families

HOME LANGUAGE SURVEY FOR PRE-K-12 SCHOOL DISTRICTS

Name of Student: ____________________________________________________________________ Grade:____________ Last Name First Name Middle Name

Date of Birth: __________________ School: _____________ Student ID # ___________________ Gender: Male_______ Female________ MM/DD/YYYY

Is the student of Hispanic or Latino culture or origin? Yes________ No_________

Select one or more of the following races: ______ African American/Black ______ American Indian/Alaskan Native ______ Asian ______ Native Hawaiian/Pacific Islander ______ Caucasian/White

1. What is the dominant language most often spoken by the student?

2. What is the language routinely spoken in the home, regardless of the language spoken by the student?

3. What language was first learned by the student?

4. Does the parent/guardian need interpretation services? Yes _____ No _____ If so, what language? _______________________________

5. Does the parent/guardian need translated materials? Yes _____ No _____ If so, what language? _______________________________

6. What was the date the student first enrolled in a school in the United States? ________________________ MM/YYYY

______________________________________________________________________________________________________________________

☐ Other language than English indicated TWO OR MORE times on questions 1 – 3 above. The student is classified as “more often” and automatically qualifies as bilingual on

the accreditation report.

☐ Other language than English indicated ONLY ONCE on questions 1 – 3 above. The student is classified as “less often” and only qualifies as bilingual on the accreditation

report if he or she meets one of the following (any selection below REQUIRES appropriate documentation):

☐ 1. Designated English Learner on one of the Oklahoma English language proficiency assessments: ACCESS for ELLs 2.0, Alternate ACCESS for ELLs,

WIDA Screener, WIDA MODEL, K-WAPT, W-APT or Oklahoma Pre-K Language Screening Tool (PKST).

☐ 2. Scored Basic or Below Basic in ELA on the Oklahoma State Testing Program (OSTP).

☐ 3. Scored at or below the 35th percentile (or equivalent) composite reading score from spring of the previous school year on a state approved norm-referenced test (NRT).

DOCUMENTATION OF A TEST RESULT FOR STUDENTS MARKED LESS OFTEN

Date (MM/DD/YYYY) Parent / Guardian Signature

Date(s) of Kindergarten ACCESS, ACCESS for ELLs 2.0, or Alternate ACCESS Test

Score(s) on Kindergarten ACCESS, ACCESS for ELLs 2.0,or

Alternate ACCESS

Date of WIDA Screener or K-WAPT/WAPT or

WIDA MODEL

Score(s) on WIDA Screener or K-WAPT/WAPT or

WIDA MODEL

Composite / Overall Score Composite / Overall Score

1. 1.

1.

1.

2019 - 2020

SCHOOL USE ONLY Please have test score documentation available for the Regional Accreditation Officer to review.

STUDENT INFORMATION

Date(s) of ELA OSTP Score(s) on ELA OSTP

Below Basic Basic Proficient Advanced



Date of the Oklahoma Pre-K Language Screening Tool

Score on Pre-K Language

Screening Tool

%

Date(s) Norm Reference Test (NRT) Name of the NRT Composite / Percentile Score(s)

Question 1: Reference WAVE code 1036 Question 2: Reference WAVE code 1037 Question 3: Reference WAVE code 1038

Thackerville Elem

Thackerville Public Schools Student Enrollment Questionnaire

Your children may be eligible for additional educational services through the Title X, Part C McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire. Where are you and your family currently living? Please check one of the boxes below.

Section A Rent/own my own home or apartment

STOP: If you checked the box that you rent/own your own home or apartment skip to the bottom of the page, sign the form, and then submit to school personnel. If you do not rent/own your home or apartment, please continue to the next section. Section B

Temporarily with another family member or friend until we can locate affordable housing In an emergency or transitional shelter In a vehicle, park, campground, or on the streets In a house, building, or trailer WITHOUT running water or electricity In a hotel or motel With an adult that is not a parent or legal guardian Alone or in different locations, without an adult serving as a caregiver Wherever I can find a place to stay at night Other Please Explain:

If you check a box in section B, in the space below please list all children currently living with you who attend Thackerville Public Schools.

First and Last Name of Student Date of Birth Grade

Would you like to be contacted by an employee of the school to discuss additional educational services that may be available to your child? YES NO

The undersigned certifies that the information provided is correct and accurate.

Relationship to the Student Signature

School Year 2019-20 Economically Disadvantaged Application

This application should be completed even if your student attends a Community Eligibility or Provision School.

School: Grade: Student Number:

Student Name:

Please select the income range that represents the total gross income:

Less than $22,459 Between $46,435 and $54,427 Between $78,403 and $86,395

Between $22,459 and $30,451 Between $54,427 and $62,419 Between $86,395 and $94,387



Please select the total number of people in your household:

One (1) Five (5) Nine (9)

Two (2) Six (6) Ten (10)

Three (3) Seven (7) Eleven (11)

Four (4) Eight (8) Twelve (12)

Signature: I certify that all information provided on this form is true to the best of my knowledge and that all household income is reported. I understand that this information will impact federal and state funding to the school.

Sign Here: Date:

Print Name:

For Office use only:

Qualified Not Qualified


Thackerville Public Schools PO BOX 377

THACKERVILLE, OK 73459

Dear Parent:

Thackerville Public Schools participates in the federal program called Impact Aid, sponsored by the U.S. Department of Education. The school receives funding on children whose parents are federally connected, either through employment or residing in federally subsidized housing. This would include:

1. Child has a parent(s) on active duty in the uniformed services of the United States (A copy of the military orders must beattached to this form).

2. Child has a parent(s) who is both an accredited official of a foreign government and a foreign military officer.3. Child resides in eligible low-rent housing (Indian housing).4. Child resides on federal property.5. Child resides with a parent who is employed on federal property. This would include any parent/guardian who is employed

at any Oklahoma lake marina or any Indian gaming center or business owned by any tribal government.

If your child qualifies for Impact Aid funding, please fill out the form below and return it to your child’s school. Impact Aid helps all students in the District! Your cooperation in helping our District receive its full entitlement will be greatly appreciated.

PARENT-PUPIL SURVEY FORM AS OF AUGUST 22, 2019

_______________________________________________________________________________________________________________________________________

Thackerville Public Schools Teacher _______________________ School ______________________ _______________________________________________________________________________________________________________________________________

I. STUDENT INFORMATION Name of Student ___________________________________________________ Last First MI

Birthday________________ Grade ____________ Telephone No.___________________ Month/Date/Year

Address ___________________________________________________________ ___________________________________________________________

_______________________________________________________________________________________________________________________________________

2. HOME INFORMATION If yes, check one: __ Chickasaw Housing Authority Is the student’s address on __ Restricted Land __ Trust Land Federal Property? Yes __ No __ __ Other: ______________________ _______________________________________________________________________________________________________________________________________

3. MILITARY PERSONNEL Uniformed Services includes: Air Force, Army, Navy, Marines, and Coast Guard. It also Was either parent on Active includes members of the reserve if on ACTIVE DUTY. This applies to members stationed Duty in the uniformed services anywhere in the world. anywhere in the world on If yes, provide _______________________________________ Rank_______________ August 22, 2019? Yes __ No __ Printed name of Parent/Step-Parent/Guardian

CHECK ONE: __ AIR FORCE __ ARMY __ NAVY __ MARINE CORPS __ COAST GUARD _______________________________________________________________________________________________________________________________________

4. CIVILIAN EMPLOYED Parent Name: ___________________________________________________ FEDERAL PROPERTY Employer Address: _______________________________________________

Was either parent employed Names of Most common Area Federal Properties (check one): on federal property on __ Winstar World Casino & Hotel – 777 Casino Ave, Thackerville, OK 73459

August 22, 2019? Yes __ No __ __ Winstar Golf Club – 22182 Merle Wolfe Rd, Thackerville, OK 73459

__ Chickasaw Travel Utility Authority – 22983 Brown Springs Rd., Thackerville, OK 73459 __ Border Casino – 22953 Brown Springs Rd., Thackerville, OK 73459 __ Chickasaw Nation Division of Commerce (Casino, Travel Mart, etc.) __ Any Tribal Health Clinic Name: ___________________________________________ __ Social Security Administration __ Other:__________________________________

_______________________________________________________________________________________________________________________________________

IMPORTANT – PLEASE SIGN & I certify that the above information is true and correct as of August 22, 2019.

DATE AS OF SURVEY DATE ____________________________________________________________ _____8/22/2019___________ Signature of Parent/Step-Parent/Guardian Date


Thackerville Public Schools · Thackerville Public Schools P.O. Box 377 Thackerville, OK 73459...

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