Pdf department of defense education activity omb no 0704 0495

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Title: DoDEA Form 600, DoDEA Student Registration, March 2013
Author: WHS/ESD/IMD
Creator: Adobe LiveCycle Designer ES 9.0
Producer: Adobe LiveCycle Designer ES 9.0
CreationDate: Thu Mar 28 10:20:09 2013
ModDate: Thu Mar 13 13:19:46 2014
Tagged: yes
Form: static XFA
Pages: 2
Encrypted: no
Page size: 612 x 792 pts (letter) (rotated 0 degrees)
File size: 85169 bytes
Optimized: yes
PDF version: 1.6

  • DEPARTMENT OF DEFENSE EDUCATION ACTIVITY OMB No. 0704 …
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  • DoDEA Form 5013, DoDEA Schools Verification of ...

DoDEA Form 5013, DoDEA Schools Verification of ...

DEPARTMENT OF DEFENSE EDUCATION ACTIVITY OMB No. 0704-0495
STUDENT REGISTRATION OMB approval expires
SY / Mar 31, 2016
The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria,
VA 22350-3100 (0704-0495). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it
does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE SCHOOL IN WHICH THE STUDENT IS ENROLLING.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Section 2164, and 20 U.S.C. Sections 921-932.
PRINCIPAL PURPOSE(S): To obtain information necessary to enroll students, administer school operations, and protect student health and welfare in DoD
operated dependent educational programs. Completed forms are covered by the DoDEA Dependent Children's School Program Files SORN located at
located at .
ROUTINE USE(S): To Federal, State and local government officials to protect health and safety in the event of emergencies. The DoD Blanket Routine
Uses found at also apply to this collection.
DISCLOSURE: Voluntary; however, failure to disclose the information collected on this form may delay and/or prevent the enrollment of a child and/or the
delivery of educational and emergency services.
This form is completed by the sponsor, who is a parent, spouse, or a legal guardian, to request enrollment of his/her dependent(s) at a DoDEA school. A
dependent is a minor individual who has not completed secondary schooling and who is the child, stepchild, adopted child, ward or spouse of the sponsor.
The information collected is used internally to determine the student's eligibility to enroll on a tuition-free or tuition-paying basis, and whether the student is
space-required or space-available. It is also used to ensure that DoDEA makes available the appropriate classrooms, staffing, and supportive educational
services, places students in the appropriate grade, identifies students with special needs, and to ensure compliance with laws protecting student rights.
SECTION I - SPONSOR INFORMATION
1. TITLE (Rank/Mr./Mrs.) 2.a. SPONSOR LAST NAME b. SPONSOR FIRST NAME c. SPONSOR MIDDLE NAME 3. RELATIONSHIP TO STUDENT
4. TELEPHONE NUMBERS (Include Area Code or DSN) 5. EMAIL ADDRESS
a. HOME b. DUTY/WORK c. CELL
6. ORGANIZATION 7. PAY GRADE (E-1/O-1/GS-1) 8. ROTATION/DEPARTURE
DATE (YYYYMMDD)
9. ORGANIZATION MILITARY INSTALLATION/CITY/COUNTRY
10. MAILING ADDRESS (e.g., Local/APO/FPO) (Required) 11. PHYSICAL QUARTERS (Street, City, etc.) (Enter only if different from mailing address)
SECTION II - SPONSOR'S SPOUSE INFORMATION
1. TITLE 2.a. SPOUSE LAST NAME b. SPOUSE FIRST NAME c. SPOUSE MIDDLE NAME 3. RELATIONSHIP TO STUDENT
4. TELEPHONE NUMBERS (Include Area Code or DSN) 5. EMAIL ADDRESS
a. HOME (If different) b. DUTY/WORK c. CELL
6. ORGANIZATION MILITARY INSTALLATION/CITY/COUNTRY
SECTION III - FIRST LOCAL EMERGENCY CONTACT AND RELEASE INFORMATION
The person identified will be contacted if there is an emergency and the sponsor/spouse/legal guardian cannot be contacted. I permit the dependent that I
am registering with this form to be released to the emergency contact identified in this section if I or my spouse are not available.
1. LAST NAME (Not sponsor or spouse) 2. FIRST NAME 3. TITLE 4. RELATIONSHIP TO STUDENT
5. HOME TELEPHONE 6. DUTY/WORK TELEPHONE 7. CELL PHONE
SECTION IIIA - SECOND LOCAL EMERGENCY CONTACT AND RELEASE INFORMATION
The person identified will be contacted if there is an emergency and the sponsor/spouse/legal guardian or the first local emergency contact cannot be
contacted. I permit the dependent that I am registering with this form to be released to the emergency contact identified in this section if I or my spouse are
not available.
1. LAST NAME (Not sponsor or spouse) 2. FIRST NAME 3. TITLE 4. RELATIONSHIP TO STUDENT
5. HOME TELEPHONE 6. DUTY/WORK TELEPHONE 7. CELL PHONE
SECTION IIIB - PERMANENT STATESIDE EMERGENCY CONTACT INFORMATION
1. LAST NAME 2. FIRST NAME 3. TITLE 4. RELATIONSHIP TO STUDENT
5. HOME TELEPHONE 6. DUTY/WORK TELEPHONE 7. CELL PHONE
8. PERMANENT STATESIDE ADDRESS
DoDEA FORM 600, MAR 2013 REPLACES SD FORM 600, WHICH IS OBSOLETE. Adobe Designer 9.0
SECTION IV - STUDENT INFORMATION
1.a. LEGAL LAST NAME b. LEGAL FIRST NAME c. LEGAL MIDDLE NAME d. PREFERRED FIRST NAME
(Include Jr./Sr./II)
2. STUDENT GRADE 3. GENDER (X one) 4. DATE OF BIRTH 5. STUDENT ETHNICITY: HISPANIC OR LATINO (X one)
(YYYYMMDD)
"M "F "Y "N
6. STUDENT RACE (X all that apply)
a. American Indian or Alaska Native c. Black or African American e. Native Hawaiian or Other Pacific Islander
b. Asian d. White
7. STUDENT CELL PHONE 8. STUDENT EMAIL ADDRESS (May be assigned by school) 9. PASSPORT NUMBER 10. PASSPORT EXPIRATION
(Include Area Code) (H.S. only) DATE (YYYYMMDD)
11. DOES THE STUDENT SPEAK A LANGUAGE OTHER 12. IS THERE AN ADULT WHO SPEAKS A LANGUAGE 13. WHAT IS THE HOME
THAN ENGLISH IN THE HOME? OTHER THAN ENGLISH? LANGUAGE?
(X one) (If Yes, what language?) (X one) (If Yes, what language?)
"Y "N "Y "N
SECTION V - STUDENT HEALTH INFORMATION
The information for physical and medical facility is for use in an emergency. Other information is collected to ensure compliance with immunization
requirements and provide staff with the student's medical background.
1. PHYSICIAN OR MEDICAL FACILITY NAME 2. PHYSICIAN OR MEDICAL FACILITY TELEPHONE NUMBER
(Include Area Code or DSN)
3. FOR NEW STUDENT: I have provided school officials with the DoDEA Form 2942.0-M-F1, "DoDEA Student Health History."
YN
4. FOR RETURNING STUDENT: I have provided school officials with the DoDEA Form 2942.0-M-F2, "DoDEA Returning Student Health History."
YN
5. IMMUNIZATIONS (Only for new student) (X and initial)
" I have provided or " will provide a copy of the Immunization Record as soon as possible to meet the provision allowing 30-calendar day
grace period to obtain required immunizations.
6. OTHER CONCERNS
7. DOES THE STUDENT HAVE A HEALTH CONDITION REQUIRING POSSIBLE EMERGENCY CARE? (X one)
" Y " N (If Yes, specify:)
SECTION VI - VERIFICATION
1. I AM REGISTERING (how many) STUDENT(S).
2. I declare under penalty of perjury that the statements made by me on this form are true, complete and correct.
a. SIGNATURE OF SPONSOR/SPOUSE/LEGAL GUARDIAN b. DATE (YYYYMMDD)
SIGN HERE
SECTION VII - FINAL DETERMINATION
The final determination for placement of a child in a DoDEA school is the responsibility of DoDEA. You may be provided the opportunity to personally
explain, refute, or clarify any information before a final decision is made.
SECTION VIII - SCHOOL USE
1. STUDENT NUMBER 2. STUDENT GRADE 3. ENROLLMENT CODE 4. SCHOOL CODE (DODAAC)
5. SCHOOL NAME 6. FIRST DAY STUDENT STARTS SCHOOL (YYYYMMDD)
7. ORDERS ON FILE/VERIFIED (X one) 8. BIRTH DATE VERIFIED (Birth Certificate or Passport for Pre-Kindergarten, Sure Start, Kindergarten,
" Y " N First Grade) " Y " N
9. I verify that the information is correct.
a. SIGNATURE OF REGISTRAR b. DATE (YYYYMMDD)
SIGN HERE
DoDEA FORM 600 (BACK), MAR 2013

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