Amundsen High School 5110 North Damen Avenue Chicago, Illinois Telephone (773) Fax (773)

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1 Amundsen High School 5110 North Damen Avenue Chicago, Illinois Telephone (773) Fax (773) Anna Pavichevich Principal Kristi Eilers Assistant Principal Minh Nguyen Assistant Principal Cybill Ortiz Assistant Principal July 25, 2013 Dear Viking Students and Parents, If you are receiving this letter, it means that summer vacation is almost over, and it is already time to start thinking about the school year. For all of the Viking administration and staff, this is the most exciting time of year. We hope you feel the same way! Here are just a few of the things to which we can all look forward during this upcoming school year: lots of great sports and fun activities; challenging classes and many connections with teachers and fellow students; Homecoming Pep Rally, Game, and Dance; field-trips; college fairs; International Week; Winter Carnival; musical performances by the orchestra, band, and chorus; science and history fairs; and, if you are a Senior, the prom, luncheon, and, most importantly, graduation! We are particularly excited about welcoming the Viking class of 2017! We know that your next four years with us are going to be among the most important of your lives because you will be making lifelong friendships and creating lasting memories! The Sophomores, Juniors, and Seniors will be more than happy to show you the ropes and help you adjust to your new environment quickly. To our returning Vikings, you may notice when you return that a few things look a little bit different. We have been working hard to make our building ready for your return and to make sure that you have access to the best materials and resources, which you deserve. For now, take a deep breath and relax while you can. When you return, we will be making sure you have the greatest experiences possible and will give you plenty of opportunities to live and demonstrate the Viking Way, as Accountable, Honorable, and Scholarly students. I ll see you soon! Ms. Pavichevich (Ms. P.) Principal

2 Amundsen High School 5110 North Damen Avenue Chicago, Illinois Telephone (773) Fax (773) There is a three-day Freshmen Connection Workshop for the incoming Freshmen class on August 5-7, For Freshmen students that are not able to attend the workshop, Registration and Program Pick-up is Wednesday, August 14, Program Pickup Dates: Complete the enclosed forms with your current phone and address. Please be sure to bring proof of current address with you to program Pick-up Day A parent/guardian must sign the form(s) where necessary Bring completed forms to program Pick-up Day Bring cash or money order for fees Class Date Time Location Reminder Freshmen Wednesday, 8:30 am 2:00 Auditorium Complete Sophomores August 14, 2013 attached Juniors Seniors Make-ups Thursday, August 15, 2013 Friday, August 16, :30 am 2:00 8:30 am 2:00 Tentative Fees Auditorium Auditorium Type of Fee Cost Explanation forms Complete attached forms Complete attached forms Student Activity Fee $70.00 Combination Lock Fee $11.00 Bus Pass Fee $5.00 The activity fee is used for school-wide class activities in academics and program activities. Locks are required on all hall and gym lockers and must be purchased from the school. A bus pass entitles a student to pay a reduced rate for student use of public transportation with student ID. This purchase is optional.

3 Amundsen High School 5110 North Damen Avenue Chicago, Illinois Telephone (773) Fax (773) All fees must be paid in cash or with money order at the time of registration. Personal checks will not be accepted. Additional Fee for SENIORS Type of Fee Cost Explanation Senior Fee $ Graduation activities which will be determined by the senior class. The following are replacement fees only Lost ID Card Fee $5.00 This is a fee for students who wish to replace a lost ID. Temporary ID Card Fee $1.00 This is a fee for a temporary ID card. Temporary IDs are valid for one day only Bell Schedule Period M T Th F Per Regular W Per Staff Dev W 1 7:45-8:36 1 7:45-8:32 1 7:45-8:27 Announcements 8:36-8:40 2 8:36-9:23 2 8:31-9:13 2 8:44-9:35 ADV 9:27-9:59 ADV 9:17-9:34 3 9:39-10: :03-10:50 3 9:38-10: :34-11: :54-11: :24-11: :29-12: :45-12: :10-11: :24-1: :36-1: :56-12:38 7 1:19-2:10 7 1:27-2: :43-1:24 8 2:14-3:05 8 2:18-3:05 8 1:28-2:10 Students are expected to wear their ID card and to dress appropriately in accordance with the school s dress code policy pursuant to the Student Code of Conduct.

4 Rev. 07/2012 Request for Emergency and Health Information Chicago Public Schools School Name: Date: PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a change in this information, immediately notify the school in writing. Student ID# Last Name First Name Middle Name Homeroom # Birth Date (mm/dd/yyyy) Student Home Address Student Home Phone # Confidential Information Box 1 Complete this box only if (1) it reflects your child s current living situation; OR (2) it reflects your living situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff with enrollment and may enable the student to receive additional services.) Check one box if you are living: in an abandoned apartment/building in a car/park/other public place in a hotel/motel in a residence of other individuals or family in a shelter in a temporary foster care placement Note to School: If any box is checked, see the CPS Education of Homeless Children and Youth Policy (702.5). Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed. Contact Name Relationship to Student Parent/Guardian Contact Parent/Guardian Contact Check all that apply: Lives With Gets Mailings Home Address, if different from student s Emergency Permission to Pickup Lives With Emergency Gets Mailings Permission to Pickup Home Phone Number, if different from student s * Cell Phone Number * Address *reply N/A if not available Name and Address of Employer Work Phone Number List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student: Name Home Address Telephone # Relationship Confidential Information Box 2 Is there a current Order of Protection or No Contact Order which concerns this student? Yes No Note to School: If Yes is checked, please follow the procedures of CPS Policy Enter the information into the Legal Alert field and update contact information, as needed, in SIM. Family Doctor s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency. Student Health Insurance: (select only one of the three) Illinois Medical Card/All Kids: provide student s medical ID # (9-digit number located on back of card) No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No Private/Employer Health Insurance: no additional information needed I certify that the information on this form is correct. (Parent/Guardian Signature)

5 Chicago Public Schools Media Consent Form and Release Consent/Release I hereby consent to have my student photographed, video taped, audio taped and/or interviewed by the Board or the news media when school is in session or when my child is under the supervision of the Board. I understand that during the school year, the Board might like to celebrate my child s accomplishments and work. Therefore, I further consent to allow the Board to release my student s name, academic/non-academic awards, and information concerning my child s participation in school-sponsored activities, organizations and athletics. I also consent to the Board s use of my student s name, photograph or likeness, voice or creative work(s) on the Internet or on a CD or any other electronic/digital media or print media. As the child s parent or legal guardian, I agree to release and hold harmless the Board, its members, trustees, agents, officers, contractors, volunteers and employees from and against any and all claims, demands, actions, complaints, suits or other forms of liability that shall arise out of or by reason of, or be caused by the use of my child s name, photograph or likeness, voice or creative work(s), on television, radio or motion pictures, or on the Internet, or on a CD, or any other electronic/digital media or print media. It is further understood and I do agree that no monies or other consideration in any form, including reimbursement for any expenses incurred by me or my child, will become due to me, my child, our heirs, agents, or assigns at any time because of my child s participation in any of the above activities or the above-described use of my child s name, photograph or likeness, voice or creative work(s). I understand that I may cancel this release by providing written notice to the principal. I also understand that this release is valid for one school year, including the following summer. Instructions: Check Box #1 or Box #2 1. I consent as outlined in the above consent/release section. 2. I DO NOT consent to my child being photographed, video taped, audio taped and/or interviewed by the Board or the news media when school is in session or when my child is under the supervision of the Board. Furthermore, I do not consent for the Board to release my student s name, academic/non-academic awards, and information concerning my child s participation in school-sponsored activities, organizations and athletics. I do not consent for the Board to use my student s name, photograph or likeness, voice or creative work(s) on the Internet or on a CD or any other electronic/digital media or print media. Signature of Parent/Guardian/Student if age 18 or older Printed Name of Parent/Guardian/Student if age 18 or older Student s Name Student ID # Date School I understand that I have the right to inspect and copy my student s records, challenge the contents of such records; and limit my consent to the designated records or designated portions of information within the records. Department of Policy and Procedures July 2012

6 ```` Escuelas Públicas de Chicago Consentimiento de prensa y dispensa de responsabilidad Consentimiento/Dispensa Por la presente autorizo a que mi estudiante sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta de Educación de Chicago o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Entiendo que en el curso del año escolar la Junta quiera celebrar los logros y el trabajo de mi niño. Por lo tanto, también autorizo a la Junta la divulgación del nombre de mi niño, de sus premios académicos y no académicos y de información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. También autorizo a la Junta el uso de fotografías o retratos de mi niño, o de su voz o trabajo creativo, en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. Como padre o tutor legal del niño, libero de toda responsabilidad a la Junta, a sus miembros, síndicos, agentes, oficiales, contratistas, voluntarios y empleados ante cualquiera y todos los reclamos, demandas, acciones, quejas, juicios u otras formas de responsabilidad que puedan surgir por cualquier razón, o puedan ser causadas por el uso del trabajo creativo, fotografía, retrato o voz en televisión, radio o películas, o en medios impresos, Internet o cualquier otro medio electrónico/digital. Es entendido además, y estoy de acuerdo, en que no se me debe a mí, a mi niño, a nuestros herederos, agentes o designados ningún dinero o consideración de ninguna especie, incluyendo el reembolso de cualquier gasto realizado por mí o por mi niño durante la participación en cualquiera de las actividades mencionadas, o por el uso de su trabajo creativo, fotografías, retrato o voz. Entiendo que puedo cancelar este consentimiento mediante una comunicación por escrito al director escolar. También entiendo que esta dispensa es válida por un año escolar, incluyendo el verano siguiente. Instrucciones: marque la caja #1 o caja #2 1. Autorizo lo señalado arriba en la sección consentimiento/dispensa. 2. NO autorizo que mi niño sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Tampoco autorizo que la Junta divulgue el nombre de mi niño, sus premios académicos y no académicos e información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. No autorizo a la Junta el uso del nombre de mi estudiante, fotografías o retratos, de su voz o trabajo creativo en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. Firma padre o tutor, o del estudiante si tiene 18 años o más Nombre en imprenta del padre o tutor, o del estudiante si tiene 18 años o más Nombre del estudiante Fecha Número de ID del estudiante Escuela Entiendo que tengo el derecho de inspeccionar y copiar los registros de mi estudiante, de disputar el contenido de dichos registros; y limito mi consentimiento a los registros designados o porciones designadas de información contenida en los registros. Departamento de Política y Procedimientos Julio 2012

7 State of Illinois Certificate of Child Health Examination FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 Student s Name Last First Middle Birth Date Month/Day/Year Sex Race/Ethnicity School /Grade Level/ID# Address Street City Zip Code Parent/Guardian Telephone # Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. Vaccine / Dose DTP or DTaP Tdap; Td or Pediatric DT (Check specific type) Polio (Check specific type) Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV Hib Haemophilus influenza type b Hepatitis B (HB) Varicella (Chickenpox) COMMENTS: MMR Combined Measles Mumps. Rubella Single Antigen Vaccines Measles Rubella Mumps Pneumococcal Conjugate Other/Specify Meningococcal, Hepatitis A, HPV, Influenza Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MUMPS VARICELLA Physician s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date (Attach copy of lab result) VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Date Age/ Grade Vision Hearing R L R L R L R L R L R L R L R L R L Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts IL (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

8 Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year HEALTH HISTORY ALLERGIES (Food, drug, insect, other) Diagnosis of asthma? Child wakes during night coughing? TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER Yes Yes No No MEDICATION (List all prescribed or taken on a regular basis.) Loss of function of one of paired organs? (eye/ear/kidney/testicle) Birth defects? Yes No Hospitalizations? Developmental delay? Yes No When? What for? Blood disorders? Hemophilia, Yes No Surgery? (List all.) Yes No Sickle Cell, Other? Explain. When? What for? Diabetes? Yes No Serious injury or illness? Yes No Head injury/concussion/passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No Heart problem/shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/high blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with Yes No Family history of sudden death Yes No exercise? before age 50? (Cause?) Eye/Vision problems? Glasses Contacts Last exam by eye doctor Dental Braces Bridge Plate Other Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Bone/Joint problem/injury/scoliosis? Yes No Signature Date PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm Blood Test: Date Reported / / Result: Positive Negative Value LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Urinalysis Sickle Cell (when indicated) Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Ears Endocrine Gastrointestinal Eyes Amblyopia Yes No Genito-Urinary LMP Nose Throat Mouth/Dental Cardiovascular/HTN Neurological Musculoskeletal Spinal Exam Nutritional status Respiratory Diagnosis of Asthma Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid) NEEDS/MODIFICATIONS required in the school setting Other DIETARY Needs/Restrictions SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child s health condition (e.g.,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child s participation in (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited Print Name (MD,DO, APN, PA) Signature Date Address Phone (Complete Both Sides) Yes Yes No No

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