Student Residency Questionnaire

Transcription

1 Student Residency Questionnaire Note: The Bethlehem Central School District uses this page to help identify students in homeless situations as required by the McKinney-Vento Homeless Assistance Improvements Act, 42 U.S.C Answers to this residency information help determine the services the student may be eligible to receive. Assistance is provided by our Homeless Liaison, Mr. David F. Hurst. He can be reached at (518) or in the Educational Service Center at 700 Delaware Avenue. Name of School: Name of Student : Sex: Male Last First Middle Female Birth Date / / Grade: Student ID #: Month Day Year (optional) Address: Phone: The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don t have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services. Where is the student currently living? (Check one box.)! In a motel/hotel! In a shelter! With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as doubled-up )! In a car, park, bus, train, or campsite! Other temporary living situation (Please describe):! In permanent housing Print Name of Parent, Guardian, or Student (for unaccompanied homeless youth) Signature of Parent, Guardian, or Student (for unaccompanied homeless youth Date If the student is NOT living in permanent housing, proof of residency and other documents normally needed for enrollment are not required and the student is to be immediately enrolled. The district s LEA liaison is required to assist the student obtaining any necessary documents, including immunization or school records after the student has been enrolled.

2 MelissaHaas Central Registrar DearParents: WelcometoBethlehemCentralSchoolDistrict.Enclosedaretheregistrationformstobefilled out completely and neatly. Along with the forms enclosed, please bring the following documentation when registering your child, to Central Registration located at 700 Delaware Avenue,Delmar,NY12054: M! Proof%of%Residency%!!!! A copy of a resident lease or proof of ownership of a house or condominium, suchasadeedormortgagestatement;or AstatementbyathirdMpartylandlord,ownerortenantfromwhomtheparentor personinaparentalrelationshipleasesorwithwhomtheysharepropertywithin thedistrict,whichmaybeswornorunsworn;or Suchotherstatementbyathirdpartyrelatingtotheparentorpersoninparental relation sphysicalpresenceinthedistrict;or Other forms of documentation and/or information establishing physical presenceinthedistrictwhichmayincludebutarenotlimitedto:!! Paystub;!! Incometaxform;!! Utilityorotherbills;!! Membershipdocuments(e.g.,librarycards)baseduponresidency;!! Voterregistrationdocuments(s);!! Officialdriver slicense,learner spermitornonmdriveridentification;!! Stateorothergovernmentissuedidentification;or!! Documents issued by federal, state or local agencies (e.g., local social serviceagency,federalofficeofresettlement). Educational Services Center 700 Delaware Avenue Delmar, NY fax

3 M! Proof%of%Age%!! Acertifiedtranscriptofabirthcertificate;or Arecordofbaptismconfirmingthedateofbirthforthechildtobeenrolledin thedistrict(aforeignbirthcertificateofrecordofbaptismwillalsobeaccepted). If a certified transcript of a birth certificate or a record of baptism is not available, please submitacopyofthechild spassport.aforeignpassportwillbeaccepted. In the event you cannot provide a passport, the District will consider an executed written affidavit of the child s age or any of the following documents as long as it was issued two or moreyearsago: 1.! Officialdriver slicense; 2.! Stateorothergovernmentissuedidentification; 3.! Schoolphotoidentificationwithdateofbirth; 4.! Consulateidentificationcard; 5.! Hospitalorhealthrecords; 6.! Militarydependentidentificationcard; 7.! Documents issued by federal, state or local agencies, such as local social service agencyorfederalofficeofrefugeeresettlement; 8.! CourtordersorothercourtMissueddocuments; 9.! NativeAmericantribaldocument;or 10.! RecordsfromnonMprofitinternationalaidagenciesandvoluntaryagencies. M! Proof%of%Custody%and/or%Lawful%Residence% In order for the District to confirm your custody of and/or lawful residence with your child,pleasesubmiteither:!!! A written affidavit indicating that you are the parent(s) with whom the child lawfullyresides;or Awrittenaffidavitindicatingthatyouaretheperson(s)inaparentalrelationto the child, over whom you have total and permanent custody and control and describing how you obtained total and permanent custody and whether it is throughaguardianshiporotherwise. Ajudicialcustodyorderorguardianshippapersmay,butneednotbe,submitted. The District will also accept other proof of custody and/or lawful residence such as documentation which indicates that the child has been placed by a federal agency with a sponsor. M! Current%Immunization%Record%(official%record%signed%by%physician)

4 The student s recent report card, standardize test results, I.E.P., or any other informationfromthepreviousschoolwouldbehelpful. Enrollment%and%Registration%Process:%% Uponrequest,yourchildwillbeenrolledandpermittedtoattendschoolintheDistrict thenextschoolday,orassoonaspracticable. Withinthree(3)businessdaysofthechild sinitialenrollment,theboardofeducation ( Board ), or its designee, will review all of the registration/enrollment documentation submitted and determine whether the child is entitled to attend school in the District. If it is determined that the child does not reside in the District, the Board, within two (2) business days,willissueawrittennotificationconfirmingthebasisforthisdeterminationandthedate the child is to be excluded from the District. The written notification will also confirm the parent srighttoappealtheboard sdecisiontothenewyorkcommissionerofeducationwithin thirty(30)daysandadvisethattheinstructions,formsandproceduresforanappeal,including translatedinstructionformsandprocedurescanbefoundatthefollowing: OnlineattheOfficeofCounsel, MailaddressedtotheOfficeofCounsel,NewYorkStateEducationDepartment, StateEducationBuildinginAlbany,NewYork12234;or CallingtheAppealsCoordinatorat(518)474M8927. Thank you in advance for your cooperation with the District s registration and enrollmentprocess.ilookforwardtomeetingyouandifyouhaveanyquestions,pleasefeel freetocallmeat439m2442. Sincerely, MelissaHaas, CentralRegistrar

5 CENTRAL SCHOOL DISTRICT Welcome to Bethlehem Schools! STAY CONNECTED TO BETHLEHEM IN MANY WAYS For a large portion of the day, you leave your kids in our care. The education of the students in our community is a responsibility we dont take lightly, and something we know doesnt stop when students leave school. Working together has always been a huge part of our process, so please stay connected! District Website Have you been to Bethlehem Central s website lately? Visit to access all kinds of information about district activities, programs and announcements. BC on Social Media Follow us on Get up-to-date district news, livetweets of important district meetings, and answers to your questions. Become a fan on Facebook! View photos of what s happening in our schools and recieve updates on events and district happenings. Follow us on Instagram! View photos of what s going on in our schools. Aspen Aspen is a password protected parent portal that offers parents and students online access to a secure site with personalized information about a student s academic program and progress. Student report cards and bus schedules are posted here, as well as interim reports and academic schedules for students in grades Some teachers also use Aspen to post assignments and to communicate with individual students/families. School News Notifier (SNN) Are you signed up for our School News Notifier? SNN is an opt-in news and information service where you control the content you receive. Users can choose to receive updates about athletics, district-wide news, closings and delays, news from individual schools or any combination thereof. Notices about school closings can also be text messaged to you. SNN is the primary method for schools to communicate with parents about what is going on in their student s school. We strongly encourage that you at least sign up for your school s SNN list. Visit for more information and to sign-up. (Additionally, existing SNN registrants may wish to log-in to their accounts at the page listed above to ensure their notification settings reflect their childrens current schools.) School Calendar for Events Would you like up-to-date event information about your school s and even district events? A comprehensive online calendar is available at You can view multiple calendars on this one webpage, so if you have children in multiple schools, you can view events for both in one place. Also available on this website are directions on how you can sync the calendars for our individual schools to your mobile devices. Bethlehem believes that strong parents help develop strong students. We want to thank the parents of Bethlehem for their continued engagement in the education of the children in our community. We want to offer you a way to be even more engaged. Parent Today is an award-winning opt-in newsletter delivered to subscribers inboxes twice a month. The information it provides allows us to foster stronger connections between families and our schools and encourages parents to be even more involved in the education of their children. We hope youll sign up, its free! SIGN UP FOR PARENT TODAY! To sign up for Parent Today, families can visit bethlehemschools.org, click on the Parent Today icon and follow the on-screen instructions. Or, sign up at parenttoday.org. DISTRICT ID: 12054

6 BethlehemCentralSchool District OfficeoftheRegistrar 700DelawareAvenue Delmar,NY12054 (518)439E g. STUDENTENROLLMENTFORM EnrollDate The.information.on.this.form.is.very.important.!PLEASE!PRINT!CLEARLY.. ForOfficeUseOnly Immunizations:YorN BirthCertificate:YorN StudentID# StudentName MorF Grade. (First.name, Middle.initial,.Last.name)..(Circle.one). PreferredName DateofBirth HomePhone HomeAddress (Number) (Street) (Town) (ZipCode) MailingAddress(ifdifferentand/orP.O.box) PreviousSchoolDistrictAttended: HasyourchildeverattendedaBethlehemschool?YESorNOIfYes,When? LastGrade Name(s)ofBrothersandSistersresidingwithstudent:(Attachadditionalsheetifneeded.) Name(First,.Middle.initial,.Last) MorF Birthdate(m/d/yy) Grade School ProofsofResidence HomeSchool:EAGELGLHAMSLMSHS Other Family# Arethereanyrestrictedreleasesforthischild?[Documentationrequired.Pleaseattach.] Parent1Name: Dr./Mr./Mrs./Ms. (First.name,.Middle.initial,.Last.name). Relationshiptostudent Address(ifdifferentfromstudent) LiveswithStudent HasCustodyofStudent ShouldReceiveStudentMailings/Aspen HomePhone WorkPhone CellPhone Primary Address: Employer sname: Position: Parent2Name: Dr./Mr./Mrs./Ms. (First.name,.Middle.initial,.Last.name). Relationshiptostudent Address(ifdifferentfromstudent) LiveswithStudent HasCustodyofStudent ShouldReceiveStudentMailings/Aspen HomePhone WorkPhone CellPhone Primary Address: Employer sname: Position:. If.parent./.guardian.cannot!be!reached!please!contact:!!(see!backside).

7 EmergencyContact1Name: Dr./Mr./Mrs./Ms. (First.name,.Middle.initial,.Last.name). Relationshiptostudent Address LiveswithStudent HasCustodyofStudent ShouldReceiveStudentMailings/Aspen HomePhone WorkPhone CellPhone Primary Employer sname: Position: EmergencyContact2Name: Dr./Mr./Mrs./Ms. (First.name,.Middle.initial,.Last.name). Relationshiptostudent Address LiveswithStudent HasCustodyofStudent ShouldReceiveStudentMailings/Aspen HomePhone WorkPhone CellPhone Primary Employer sname Position: IfyourchildhasreceivedspecialeducationservicesoraccommodationthroughanIndividualizedEducationProgram(IEP)ora Section504,pleasesignaconsentforthereleaseofspecialeducationrecordssothatspecialeducationservicescanbeginas soonaspossible. ParentStatement: Consent!for!release!of!special!education!records!signed?! YES NO Icertifytheaboveinformationistrueandcorrect.Anymisinformationregardingresidencymayresultinbeingbilledtocoverthecostof instructionand/orexclusionfromattendingthebethlehemcentralschooldistrict. Parent.Signature..Date. 08/25/15

8 FORM B/Buff KINDERGARTEN QUESTIONNAIRE Bethlehem Central Schools Kindergarten Registration This questionnaire will help the kindergarten teachers get acquainted with your child and will assist the teacher in planning a program appropriate to your child and his/her classmates. All responses will be kept confidential, and the questionnaire will not become a part of your child s records. 1. Name of child 2. Male Female 3. Name child prefers/nickname 4. Birthdate 5. Home telephone number 6. Child lives with: (check one) Mother and Father Mother only Other Mother and Stepfather Father and Stepmother Father only Guardian 7. Are there any health considerations/health history we should be aware of? 8. Are there any special situations, in your family that might affect the behavior or learning needs of your child (e.g., unemployment, illness, death)? No Yes Explain 9. Has your child had these educational experiences? (check those that apply) nursery school (Name ½ day full day ) day care center (Name ½ day full day ) 10. Is your child s speech sometimes difficult to understand? No Yes 11. Please check items that your child has had experience with in the home: books paints puzzles paste pencils scissors crayons computers 12. Is a language other than English spoken in the home? No Yes If so, what language? 13. Please share with us any other information that you feel might help us to better understand your child this year. (Any special talents, needs, preschool experiences, fears and /or anxieties, and favorite activities.) 14. Please share goals you have for your child for this year (social, emotional, language, and cognitive). 12/11

9 Bethlehem Central School District Office of the Registrar 700 Delaware Avenue Delmar, NY (518) HEALTH HISTORY FOR NEW ENTRANTS This form should be completed and signed by the parent or guardian Home School (Please circle one) EAG ELS GLE HAM SLI Name Family Physician DOB Phone Last visit to M.D.(date, reason) Date of last physical Next M.D. visit (date, reason) Dentist Phone Pregnancy History (gestational diabetes, bed rest, medication needs) Labor and Birth History (emergency delivery, premature labor, birth trauma, delayed discharge from hospital): Gestation: Full term Premature Delivery: Normal Cesarean Birth Weight: Growth and Development / Walked at age: Spoke first word at age: Spoke sentences at age: Health History Serious illness: Serious injury: Surgery: Check if your child has, or has had, any of the following and provide date when appropriate: Allergies Animals Bee sting Food Medication Seasonal Other Anemia Asthma Cerebral Palsy Chicken Pox (documentation) Colds Sore Throats Concussion, date: Convulsions With fever Without fever Cystic Fibrosis Diabetes Ear Infections History of PE Tubes Eye Conditions Hearing Problem Heart Disease Hypotonia Kidney Disease Learning Disabilities Leukemia Lyme Disease, date: Measles Mononucleosis Mumps Orthopedic Conditions Pneumonia Rheumatic Disease Rubella Disease Scarlet Fever Seizure Disorder Speech Problem Strep Throat TB, date: Chest X-ray, date: Urinary Infections Urinary Reflux Vision Problem Last Vision Exam: Vision Specialist: Glasses Worn: YES NO Whooping Cough Current Health Status (Please state if your child is, or has been, under treatment, or taking medication): Health conditions under treatment: Medical provider(s) providing treatment: Medication(s) Please list all over the counter and prescription medications, including dose and frequency: Will medications need to be given while your child is at school? Yes Not known at this time Are the any physical restrictions or limitations for physical education or other activities at school? Yes No * If restrictions or limitations, M.D. documentation is required Has your child ever received, or is currently receiving, the following services: OT PT Speech Other Parent/Guardian Signature Date 11/13

10 Bethlehem Central School District Office of the Registrar 700 Delaware Avenue Delmar, NY Tel: (518) Fax: (518) Required Immunizations for Attending School * Please obtain a complete, signed written or electronic record of administered immunizations from your child s Health Care Provider Ø 3-5 Polio (IPV/OPV) * Note: Children who receive all 4 polio doses before age 4, will require an additional 5 th dose in order to have 4 valid doses; that is, a booster dose is required after age 4. A student may no longer wait until age 7 Ø 4-5 DTap, DPT, or Tdap ( Diphtheria, Tetanus and Pertussis) * Note: 4 doses are adequate if 1 dose was given after age 4, otherwise a 5 th booster vaccine is required. A booster dose is required after age 4. A student may no longer wait until age 7 Ø 1 Tdap (Tetanus, Diphtheria and Pertussis) * Note: Required only for students enrolling grades 6-12 who have not previously received a Tdap at 7 years of age or older Ø 2 MMR (Measles, Mumps, Rubella) * Note: A student may no longer wait until age 7 Ø 3 Hepatitis B * Note: Administration of a total of 4 doses of hepatitis B vaccine may be necessary when a combination vaccine containing hepatitis B is administered after the birth dose resulting in an inadequate interval between doses. Ø 2 Varicella (chickenpox) Please be advised that students not in compliance with the immunization requirements, or those lacking proof of satisfactory progress toward completion, will be excluded from attending school until adequate proof is submitted. BCSD needs proof of compliance with Public Health Law 2164 before your child may enter school. Adequate proof is a certificate or record from the physician s office or Health Care Clinic. Transcript records from other schools are NOT acceptable proof of immunization. Demonstrated serologic evidence of measles, mumps, rubella, hepatitis B, varicella or all three serotypes of polio antibodies is acceptable proof of immunity to these diseases. Diagnosis by a physician, physician assistant or nurse practitioner that a child has had varicella disease is acceptable proof of immunity to varicella. July 1, 2015

11 BETHLEHEM CENTRAL SCHOOL DISTRICT HEALTH APPRAISAL FORM NYSED requires an annual physical exam UPON ENTRANCE for new entrants, students in Grades K, 2, 4, 7 and 10, sports, and working permits Name: GRADE: New K / SPORT: / WORKING: Date of Birth: School: Gender: q M q F Grade: IMMUNIZATIONS / HEALTH HISTORY Immunization record attached Sickle Cell Screen: Positive Negative Not done Date: No immunizations given today PPD: Positive Negative Not done Date: Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done Date: Dental Referral Yes No Not done Date: Significant Medical/Surgical History: See attached History of Concussion / Head Injury: Allergies: LIFE THREATENING Food: Insect: Other: Seasonal Medication: PHYSICAL EXAM Height: Weight: Pulse: Blood Pressure: Date of Exam: Referral Body Mass Index:. Vision - without glasses/contact lenses R L Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L q less than 5 th q 5 th through 49 th q 50 th through 84 th Vision - Near Point R L q 85 th through 94 th q 95 th through 98 th q 99 th and higher Hearing q Pass 20 db sc both ears or: R L EXAM ENTIRELY NORMAL Tanner: I. II. III. IV. V. Scoliosis: Negative Positive: Specify any abnormality (use reverse of form if needed): MEDICATIONS Medications (list all): None Additional medications listed on reverse of form Name: Dosage/Time: Name: Dosage/Time: I assess this student to be self-directed Yes No Student may self carry and self administer medication Yes No Note: If medication required at school, separate M.D. order required; School Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school. PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION Free from contagions physically qualified for all physical education, sports, playground, work school activities OR only as checked: Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball. Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump. Specify medical accommodations needed for school: None Known or suspected disability: Please monitor Restrictions: Please monitor Protective equipment required: Athletic Cup Sport goggles/impact resistant eyewear Other: OPTIONAL INFORMATION, if known Specify current diseases: Asthma Diabetes: Type 1 Type 2 Hyperlipidemia Hypertension Other: Provider s Signature: Phone: (Stamp below) Provider s Name/Address: Parent Signature: Fax: Date: School Physician Approval (required for BCSD athletes only): Date: This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school medical director. May 2012

12 Bethlehem Central School District Health Services Dear Parent or Guardian: As a part of your child s requirements for school, a physical examination has been required for students in Kindergarten and in Grades 2, 4, 7 and 10. A law was recently enacted that expands health screenings to include the dental health of students in New York State. After September 1, 2008, when we require that your child have a physical examination, we will be requesting a dental certificate as well. There is a sample certificate available for you to take to your child s dentist and once it is completed, it should be returned to the School Nurse, as it will be filed in your child s Cumulative Health Record. Thank you for your cooperation in this new health endeavor. Our students benefit when we work together to promote the health and achievement of all students. Please call the school s Health Office if you have any questions or concerns. Bethlehem Central High School Bethlehem Central Middle School Eagle Elementary School Elsmere Elementary School Glenmont Elementary School Hamagrael Elementary School Slingerlands Elementary School (OVER)

13 Dental Health Certificate Parent/Guardian: NYSED Law 903 (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 2, 4, 7, 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the schools medical director or school nurse as soon as possible. Section 1. To be completed by Parent or Guardian (Please Print) Child s Name: Last First Middle Birth Date: / / School: Name Month Day Year Sex: apple Male apple Female Will this be your child s first visit to a dentist? apple Yes apple No Grade Have you noticed any problem in the mouth that interferes with your child s ability to chew, speak or focus on school activities? apple Yes apple No I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below. Parent s Signature Date Section 2. To be completed by the Dentist I. The Dental Health condition of on (date of exam) The date of the exam needs to be within 12 months of the start of the school year in which it is requested. Check one: Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools. No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools. NOTE: Not in fit condition of dental health means that a condition exists that interferes with a students ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school. Dentist s name and address (please print or stamp) Dentist s Signature Optional Sections - If you agree to release this information to your child s school, please initial here. II. Oral Health Status (check all that apply). apple Yes apple No Caries Experience/Restoration History Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity]. apple Yes apple No Untreated Caries Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to darkbrown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present]. apple Yes apple No Dental Sealants Present Other problems (Specify): III. Treatment Needs (check all that apply) apple No obvious problem. Routine dental care is recommended. Visit your dentist regularly. apple May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation. apple Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

14 EAR HEALTH HISTORY FORM F/Pink Bethlehem Central Schools Kindergarten Registration Childs Name Date of Birth Date Parent/Guardian Childs Age Please help us better understand your child by answering the following questions: 1. Does your child have normal hearing (when ears are clean and healthy)? 2. Did your child ever have ear infections? If so, how many total? Between birth to 1 year old 3 to 4 years old 1 to 2 years old 4 to 5 years old 2 to 3 years old 5+ years old How long did the ear infections last? How often did they re-occur? 3. Has your child had myringotomies and PE tubes inserted? If so, how many times and at what ages? 4. Has your child ever been seen by an ear, nose, and throat doctor? 5. Has your child ever been seen by an audiologist for hearing testing? 6. Has your child received speech/language therapy? If so, at what ages and for how long? Therapy was for: articulation language or other (please explain) 7. Has your child received amplification during periods of not hearing? 8. Is there anything else in your child s ear health history that may be helpful in understanding your child s educational needs? 9. What concerns do you have about your child and school? from Davis, Dorinne. Otitis Media: Coping with the Effects in the Classroom. Hear You Are, Inc.: Stanhope, NJ, /05

15 Bethlehem Central School District Office of the Registrar 700 Delaware Avenue Delmar, NY (518) PARENT/GUARDIAN HOME LANGUAGE IDENTIFICATION SURVEY Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads, and writes English. We will use these responses to help determine if your child qualifies for our English as a Second Language program. Thank you for your assistance. Student s Name School 1. What is your relationship to the child? ( ) Mother ( ) Father ( ) Guardian 2. What language did the child learn when he/she first began to talk? 3. What language does the family speak in the home most of the time? 4. What language does the mother speak to the child most of the time? 5. What language does the father speak to the child most of the time? 6. What language does the child speak to his/her mother most of the time? 7. What language does the child speak to his/her father most of the time? 8. What language does the child speak to other adults at home most of the time? 9. What language does the child speak to his/her brothers and sisters most of the time? 10. Would you like an interpreter to assist in future communication with the school? Circle one: YES NO Signature of person completing survey Date New York State Education Department Office of Bilingual Education Albany, NY /12

16 Date Mailed or Faxed: Bethlehem Central School District Office of the Registrar Educational Service Center 700 Delaware Avenue Delmar, New York (518) (518) FAX Authorization for the Release or Transfer of Information Student Name: Name and address of school last attended: School: Address: Phone and /or Fax: The above student has enrolled in our school district. Please forward all school records including health, psychological, discipline including records of suspension, academic and other data. Thank you for your assistance. MAIL TO: Bethlehem Central School District Office of Central Registration 700 Delaware Avenue Delmar, New York (518) (518) fax Signature of Parent or Guardian Date

17 ACCEPTABLE USE POLICY REGULATIONS FOR STUDENTS ( R) As students prepare to enter a rapidly changing world where technology forms the infrastructure of communications, commerce and learning, the Board of Education believes that guiding students to be responsible, critical consumers and producers of information is essential to their success. The following regulations outline acceptable uses of the technology resources available through the district. All uses of the district s network shall be subject to the Acceptable Use Policy. Definitions: I. The term District Network means the district s information and telecommunications systems (including, but not limited to, all computer hardware and peripherals, software applications, networks, Internet access, Intranet access, accounts, online databases, web pages, network storage, news groups, bulletin boards, telephones, voic , district-issued or owned cellular phones, PDA/ Smart phone devices/tablets/netbooks and any other information system, communication system or communication service known or hereafter developed). II. The term Educational Purposes includes the use of the District Network for academic or classroom activities, educational research and other learning opportunities consistent with the educational mission of the District. Disclaimer of Liability: The district makes no warranties of any kind, neither expressed nor implied, in connection with a user s provision of access to and use of the District Network and the Internet. The use of the District Network and Internet is at the user s own risk. The district is not liable for any claims, losses, damages, suits, expenses or costs of any kind incurred, directly or indirectly, by any user or his or her parent(s) or guardian(s) arising out of the use of the District Network or the Internet. Acceptable Use of Technological Resources: Acceptable use is defined as applying technology as an educational tool. Internet access and access to the District Network is provided by the district to foster learning experiences that are part of approved curriculum and/or approved extracurricular activities. Uses of the Internet, the District Network or other district technology resources for any other purposes are prohibited, unless approved in writing by the administration. Access is a privilege, not a right. Access entails responsibility. Social Media Websites: Upon prior approval, social media may be used for educational purposes. Social media is defined as Internetbased media, including, but not limited to, wikis, podcasts, RSS feeds, blogs, podcasts, and sites using digital images and video, Twitter, Facebook, YouTube and other social media websites. A student s use of social media must be preapproved by the Director of Information Systems and Technology, or his/her designees, in consultation with the building principal and follow the guidelines set forth in this policy and any social media policy, administrative regulation or guidelines established by the district. Any student found to be using social media inappropriately may face disciplinary action as outlined in this policy and the Code of Conduct (#5300). No Expectation of Privacy: All messages, communication and information created, sent or retrieved on the District Network are the property of the District. Electronic mail messages, voic messages, use of the District Network and other use of district technology resources, including Internet access, should not be considered private or confidential. The Superintendent, or his/her designee(s), may monitor, inspect, copy, review, access or store, at any time and without prior notice, any and all files, information and communications transmitted or received in connection with the individual s usage of the District Network. The district will cooperate with local, state or federal authorities in any investigations resulting from alleged inappropriate or illegal activity on or related to the District Network. Page 2 of 9

18 Personal Devices: Staff and students may use personal devices to access the District Network. These devices include, but are not limited to, laptop computers, smart phones, tablet computers, ipads, netbooks, and mp3 players. All activities conducted on the District Network using a personal device, including messages, s, communications, information and Internet access, are subject to monitoring, inspection, copying, review, access and storing by the district. There is no expectation of privacy, regardless of whether a personal or district-issued device is used to access the District Network. The district will not be liable for any damages, expenses or costs associated with the student s use of the personal device to access the District Network or in the event a student s personal device is lost, damaged or stolen. Internet Filtering: In order to comply with the requirements as outlined by the Children s Internet Protection Act, the district uses an Internet filtering software, among other measures, to protect against access to materials that are obscene, child pornography or harmful to minors. Internet filtering software or other technology-based protection measures may be disabled by the Director of Information Systems and Technology, and his/her designee (s) (in consultation with the building principal), as necessary, for the purposes of bona fide research or other educational purposes. No Internet filter blocks all inappropriate material. All users and their parents/guardians are advised that access to the District Network may include the potential for access to materials inappropriate for school-aged students. The use of the District Network and Internet is at the user s own risk and every user is responsible for his or her use of the District Network, including the Internet. The district is not responsible for the accuracy of the information from the Internet accessed through the District Network. Parents and guardians of students bear responsibility for setting and conveying the appropriate standards that their children should follow when using media and information sources in and out of school. Personal Safety Confidentiality of Student Information: In using the District Network and Internet, users are cautioned not to reveal personal information about themselves or others such as home addresses, telephone numbers, social security numbers and credit card numbers. Students should not use their last name or disclose other information that may allow someone to locate the student, without first obtaining the permission of a supervising teacher. Students should not arrange face-to-face meetings with a person contacted on the District Network or Internet, without parent or guardian permission. Personally identifiable information concerning students may not be disclosed or used in any way on the Internet without the permission of a parent or guardian or, if the student is 18 years or older, the student themself. Prohibited Conduct: The District reserves the right to limit and/or terminate Internet access, District Network access or other technology use privileges in the event it determines that a user has violated any district policy or regulation or any state or federal law. The following have been deemed inappropriate uses of technology by the district: I. Cyberbullying: Refer to Policy #5810 and Policy #5300 (Code of Conduct). If it is determined that students used or accessed the District Network, including Internet access, to engage in cyberbullying, the user will be subject to discipline consistent with the Code of Conduct (#5300). It should also be noted that cyberbullying is a misdemeanor punishable by a $1,000 fine and/or up to one year in jail. II. Accessing, uploading, downloading or distributing pornographic, obscene or sexually explicit material. III. Using the District Network for illegal activity, including copyright infringement, or for uses that violate the district s Code of Conduct or other policies. IV. Vandalizing the account or data of another user. V. Gaining unauthorized access to another account, confidential records or District Network operations, including using another person s account name with or without permission. Page 3 of 9

19 VI. Sharing personal user ID or password. VII. Using any method or means to bypass the Internet filtering system. VIII. Disrupting or damaging equipment, software or the operations of the District Network, including creating or installing a computer virus or other damaging program. IX. Using district technology for personal or financial gain. X. Installing or using personal software on an individual computer or the District Network. XI. Downloading software without permission. XII. broadcasting or spamming. XIII. Misrepresenting yourself by using a false/fictitious identity in any electronic communication. XIV. Posting any material or information that may result in a disruption of normal school operations, including transmitting offensive or harassing messages. Education: In accordance with applicable law, including the Protecting Children in the 21 st Century Act, the District will educate students about appropriate online behavior, including interacting with other individuals on social networking websites and in chat rooms and cyberbullying awareness and response. Violations: Any violations of this Policy will be referred to the District administration and violations may subject students to disciplinary action, as set forth in the Code of Conduct (#5300). If applicable, violations of this policy may be referred to law enforcement. Students may also face a loss of Internet access, District Network access or other technology use privileges. In addition, the district may pursue legal action against a student (and his or her parents or guardians), who willfully, maliciously or unlawfully damages, destroys or misuses the District Network or other property of the district. Opt-Out Policy: The District provides opt-out forms on the District website with respect to use of the District Network. These forms will serve as written notification of a parent or guardian s wish to withhold Internet access or other technology privileges for their student(s) and can be completed at any time during the school year. Privileges to access the District Network and Internet may only be restored through written notification from a parent or guardian. Page 4 of 9

20 ACCEPTABLE USE POLICY E1 Student s Name AGREEMENT BY PARENT OR GUARDIAN To be read and signed by parents or guardians of students who are under 18: As the parent or legal guardian of the above student, I have read, understand and agree that my child shall comply with the terms of the District s Acceptable Use Policy. I understand that access to the District Network and Internet is being provided to students for educational purposes only. I hereby give permission for my child to access and use the District s Network and the Internet. I understand that all messages, communication and information created, sent or retrieved on the District Network are the property of the District and should not be considered private or confidential. I understand that the District may monitor, inspect, copy, review, access or store, at any time and without prior notice, any and all files, information and communications transmitted or received in connections with my child s access and usage of the District Network, and I hereby consent to such actions by the District. I understand and agree that the District makes no warranties of any kind, neither expressed nor implied, in connection with my child s access and use of the District Network and the Internet. I also understand and agree that use of the District Network and Internet is at the user s own risk and that the District is not liable for any claims, losses, damages, suits, expenses or costs of any kind incurred, directly or indirectly, arising out of my child s access and use of the District Network or the Internet. I further understand and agree that the District is not liable for any damages, expenses or costs associated with the use of my child s personal device to access the District Network or in the event my child s personal device is lost, damaged or stolen. I hereby agree to indemnify and hold harmless the District against all claims, losses, damages, suits, expenses or costs of any kind that may result from my child s access to and use of the District s Network and Internet or violation of the District s Acceptable Use Policy. Parent or Guardian Signature Date Parent or Guardian Name (PRINT CLEARLY) Page 8 of 9

21 E2 STUDENT S AGREEMENT To be signed by every student: I understand and agree to follow the District s Acceptable Use Policy. I also understand that if I violate this policy, my access to the District s Network and the Internet may be revoked and disciplinary action may be taken against me. Consolidate with the parents form above Student Signature Date Student Name (PRINT CLEARLY) Page 9 of 9