GRIFFITH PUBLIC SCHOOLS

Transcription

1 RETURNING STUDENT REGISTRATION Elementary School Application Packet School Year REQUIRED DOCUMENTS AT REGISTRATION: (Parent or legal guardian must be present) 1. PROOF OF RESIDENCY: HOMEOWNERS: 1. Mortgage statement 2. Two utility bills in homeowner s name (NIPSCO, phone, water bill, etc.) 3. Valid Indiana driver s license or State I.D. (Griffith resident address) 4. Valid Indiana vehicle registration (Griffith resident address) RENTERS: 2, 3, 4 above, plus lease agreement listing custodial parent and student name 2. IMMUNIZATIONS required medical documentation for Kindergarten, First Grade, and Sixth Grade students REQUIRED FORMS (attached): 1. RESIDENCY VERIFICATION required, review, complete information, sign 2. EARLY DISMISSAL PLAN - required, review, complete information, and sign 3. ONECALL NOW INFORMATION required, complete 4. ADULT PARTICIPATION optional, must be completed before any school volunteer activity 5. FREE AND REDUCED MEALS and TEXTBOOK ASSISTANCE optional, application provided 6. HEALTH SERVICES INFORMATION SHEET required, review, complete information, and sign

2 RESIDENCY VERIFICATION Student Name Address I,, the parent and legal guardian of named student do hereby attest that we are residents within the boundaries of the Griffith Public Schools and currently reside at the address given on this form. I fully understand that should the information contained herein not be true and correct, or should the conditions change, and should it be determined that my child is /children are not living as a legal Griffith resident, the school corporation will initiate student exclusion proceedings against my child/children and charge for any legal, collection, or other costs the school may have incurred. I hereby furnish proof of residency within the boundaries of the Griffith Public Schools: a. Current lease (if renter), Mortgage statement (if owner.) b. Affidavit supporting residency (notarized) if living with another party c. Indiana Driver s License (or state I.D. with Griffith address) d. Valid Indiana vehicle registration (with Griffith address) e. 2 copies of homeowner s business mail (ex. Nipsco, Phone, or Water bill) Parent Signature Date Notice: READ CAREFULLY: Knowingly falsifying this document is a violation of the I.C which is a class D Felony. Further the affidavit will be billed (and prosecuted in court, if necessary) to collect all back tuition which may be due. Inaccurate and/or false information will result in immediate withdrawal of your child(ren) from the Griffith Public School Corporation.

3 EARLY DISMISSAL PLAN Student Name EARLY DISMISSAL PLAN Parents and school personnel share a common concern Where do children go if school is dismissed early? There are a few situations, which may arise that could lead to an early dismissal. Some of these include weather, plumbing/heating problems, and electrical outages. School personnel will inform parents as soon as possible through the OneCall system. In addition, emergency closure information will be posted on the Griffith Public Schools website. However, we will NOT be able to allow students to call out from the school office and we will not be able to handle messages or calls from parents because our telephone lines would be needed for emergency calls. For this reason, we are asking each of you to complete and return the form below for your children. Teach your child the plan and quiz him/her from time-to-time to be certain he/she knows what to do. We want to stress that it is your responsibility to develop a plan for your family. This plan should include the procedures for your child to follow. Please completely fill out the form below and turn it in at the office. Your child s teacher will keep it on file to be certain your child knows what to do in case of an early dismissal. YOU MUST BE CERTAIN TO CONTACT YOUR CHILD'S TEACHER IF THIS PLAN CHANGES FOR ANY REASON. Please check the appropriate line(s). 1. My child should go home in the following manner on early dismissal days: a. Ride the bus home (only if your child rides the bus on a daily basis) b. Walk home c. My special instructions for my child on early dismissal are: Parent Signature Day time phone number Date

4 ONECALL NOW SYSTEM Student Name: Grade Level: The OneCall Now System, is an automated calling system used by Griffith Public Schools for the purpose of contacting the parents or guardians of students with building announcements, or any school emergency. Please list two phone numbers that you would like the OneCall Now System to call to receive information. Phone Number 1: Area Code Number Phone Number 2: Area Code Number Date:

5 SCHOOL ACTIVITY ADULT PARTICIPATION FORM Student Name Individuals named below would like to participate in school activities during the school year, and understand that a criminal history background check is REQUIRED, per Board policy (examples: PTC, Grandparents Day, Field Day, field trips, Daddy-Daughter Dance, Market Day, choir events, Reality Store, dances, etc.). Please list below all family members who will be participating in any school function throughout the school year. I/We agree to abide by all relevant School Board policies and administrative guidelines while on duty volunteering for the District or attending a District function, and understand that, although covered under the District's liability insurance policy, I/we are not covered by its health insurance policy or eligible for workers' compensation. Should I/we become ill or suffer an accident while doing volunteer work for the Corporation or attending an activity as a guest, it is agreed that the District shall not be responsible for any hospital or medical charges that may accrue. I/We understand further that, as a volunteer or District guest, I/we are in no manner considered an employee or entitled to any benefits provided to employees. I/we further release the Board from any and all liability for any damages, whatever their nature, which may result as a consequence of my/our volunteer services or status as a guest. For the protection of the children in the schools, the District inquires of its volunteers and guests whether or not they have ever been convicted of a crime related to children. We would appreciate your cooperation by indicating that no one listed below has ever been convicted of any of the following offenses: aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, aggravated menacing, abuse or neglect of a child, kidnapping, abduction, child stealing, criminal child enticement, rape, sexual battery, corruption of a minor, gross sexual imposition, importuning, voyeurism, public indecency, felonious sexual penetration, compelling prostitution, promoting prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually-oriented matter involving a minor, illegal use of a minor in nudity-oriented material or performance, endangering children, contributing to the delinquency of children, carrying concealed weapons, improperly discharging a firearm at or into a school or house, corrupting another with drugs, placing harmful objects in or adulterating food or confection. Your signature below confirms no one listed has ever been so convicted. Signature/Date Indiana State Police Criminal History Information/Limited Criminal History, First Name Last Name Activities (list all anticipated activities for each person) Date of Birth mo/date/yr Gender Race* Administrator(Principal or Athletic Director) *Race: I = American/Pacific Islander A=Asian W=White B=Black M=Multi Racial U=Unknown

6 FREE AND REDUCED MEALS AND TEXTBOOK ASSISTANCE APPLICATION - Only one application is required per family, regardless of which school your child attends - Application for the free and reduced meal / textbook assistance program is optional - All applications remain confidential - Because of the school district s computerized cafeteria cash register system, students on assistance are not identified as free or reduced in the school lunch line - Families who have received pre-certification letters in the mail over the summer do not need to complete these forms

7 Dear Parent/Guardian: Children need healthy meals to learn. Griffith Public Schools offer healthy meals every school day. The Elementary breakfast regular price is $1.25; lunch is $1.90. The Middle and High school breakfast regular price is $1.50; lunch is $2.15. Your children may qualify for free meals or for reduced price meals. Reduced price is $0.30 for breakfast and $0.40 for lunch. 1. Who can get free or reduced price meals? All children in households receiving Food Stamps or TANF can get free meals regardless of your income. Also, if your household income is within the limits on the Federal Income Chart, your children can get free or reduced price meals. 2. Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price meals. Use one application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to your child s school. 3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. 4. My child s application was approved last year. Do I need to fill out another one? Yes. Your child s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year. 5. Should I fill out an application if I received a letter this school year saying my children are approved for free meals? Please read the letter you got carefully and follow the instructions. Call the school if you have questions. 6. I get WIC. Can my children get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application. 7. Can migrant, homeless, or runaway children get free meals? Yes, children who meet the definition of homeless, runaway, or migrant qualify for free meals. If you haven t been told your children will get free meals, please call or , Mr. Aron Borowiak, Homeless Liaison; phone , aborowiak@griffith.k12.in.us, to see if they qualify. 8. May I apply if someone in my household is not a U. S. citizen? Yes. You or your children do not have to be a U.S. citizen to qualify for free or reduced price meals. 9. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with you. If you live with other people who are economically independent (for example, people who do not support, who do not share income with you or your children, and who pay a pro-rate share of expenses), do not include. 10. Will the information I give be checked? Yes, we may ask you to provide written proof. 11. What if my income is not always the same? List the amount that you normally receive. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income. 12. We are in the military; do we include our housing allowance as income? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. 13. My spouse is deployed to a combat zone. Is her/his combat pay counted as income? No, if the combat pay is received in addition to her basic pay because of her deployment and it wasn t received before she was deployed, combat pay is not counted as income. Contact your school for more information. 14. If I don t qualify now, may I apply again later? Yes. You may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit. 15. My family needs more help. Are there other programs available? To find out how to apply for food stamps or other assistance benefits, contact your local assistance office. 16. What if I disagree with the school s decision about my application? You should talk to the school officials. You also may ask for a hearing by calling or writing to: We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: Kathy Carter Beiriger Elementary School 601 N. Lillian, Griffith IN ext. 26 If you have other questions or need help, call: Kathy ext 26 Si necesita ayuda, por favor llame at teléfono: ext 26 Si vous voudriez d aide, contactez nous au numero: ext 26 Sincerely, Kathleen L. Carter 2013 Parent Letter/Instructions Page 1 of 4

8 INSTRUCTIONS for APPLYING Households getting TANF or Food Stamps: 1. In Part 1, list each enrolled child, include the TANF or Food Stamp case number for any child, and the name of the school. EBT and Hoosier Healthwise numbers DO NOT qualify you for benefits. 2. In Part 2, enter the name and case number of any other household member who has a valid TANF or Food Stamp case number. 3. In Part 3, check the appropriate box, if any. 4. In Part 5, an adult must sign the application. The last four digits of the Social Security number are not required. 5. Part 6 and Part 7 are optional for meal benefits. Migrant, Homeless, or Runaway: 1. In Part 1, list each enrolled child which are homeless, migrant, or runaway and the name of the school. 2. In Part 3, check the appropriate box and contact the school s homeless liaison or migrant coordinator. 3. In Part 5, an adult must sign the application. The last four digits of the Social Security number are not required. 4. Part 6 and Part 7 are optional for meal benefits. Foster Child: If all children in the household are foster children: 1. In Part 1, list each enrolled foster child and the school name for each child. Check the box indication the child is a foster child. 2. In Part 5, an adult must sign the application. The last four digits of the Social Security number are not required. 3. Part 6 and Part 7 are optional for meal benefits. If some of the children in the household are foster children: 1. In Part 1, list each enrolled child, include the TANF or Food Stamp case number for any child with a case number, and the name of the school. Check the box if the child is a foster child. 2. In Part 2, enter the name and case number of any other household member who has a valid TANF or Food Stamp case number. 3. In Part 3, check the appropriate box and contact the school s homeless liaison or migrant coordinator for any listed child which are homeless, migrant, or runaway. 4. If no one in the household has a valid TANF or Food Stamp case number, in Part 4 list everyone related or unrelated living in your household. Include yourself, spouse, all children, grandparents, other relatives, and unrelated people. Use another sheet of paper if you need to. a. For each household member, list each type of income received for the month. You must tell us how often the money is received weekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker s Compensation, unemployment or strike benefits, regular contributions, from people who do not live in your household, and any other income. Do not include income from SNAP, FDIR, WIC, Federal education benefits, and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings From Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. If you have no income, put a checkmark ( ) in the box. 5. In Part 5, an adult household member must sign the form, and if income information was provided, the adult household member must provide the last four digits of their Social Security Number (or mark the box if s/he doesn t have one). 6. Part 6 and Part 7 are optional for meal benefits. All Other Household Types: Including WIC households 1. In Part 1, list each enrolled child. 2. In Part 2, check the appropriate box, if any. Skip Part In Part 4, list everyone related or unrelated living in your household. Include yourself, spouse, all children, grandparents, other relatives, and unrelated people. Use another sheet of paper if you need to. a. For each household member, list each type of income received for the month. You must tell us how often the money is received weekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You 2013 Parent Letter/Instructions Page 2 of 4

9 should be able to find it on your pay stub or your boss can tell you. Do not include income from SNAP, FDIR, WIC, Federal education benefits, and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings From Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. If you have no income, put a checkmark ( ) in the box. INCOME TO REPORT: Earnings from Work Before Deductions Wages/salaries/tips Strike benefits Unemployment compensation Workman s compensation Net income from self-owned business or farm Welfare/Child Support/Alimony Public assistance payments Welfare payments Alimony payments Child support payments Pensions/Retirement/Social Security Pensions Retirement income Social Security Veteran payments Supplemental Social Security Income All Other Income Earnings from second job Disability benefits Interest/Dividends Cash withdrawn from savings Income from Estates/Trusts/Investments Regular contributions from persons not living in the household Royalties/Annuities/Rental Income Any other monies that may be available to pay for the child s meals 4. Part 5. An adult must sign the application and list the last four digits his/her Social Security number, or put a checkmark ( ) in the box if you have no social security number. 5. Part 6 and Part 7 are optional for meals benefits FEDERAL INCOME CHART FOR SCHOOL YEAR Household Size Yearly Monthly Twice Per Month Every Two Weeks Weekly Your children may qualify for free or reduced price meals if your household income falls within the limits on this chart. 1 20,665 1, ,991 2,333 1,167 1, ,317 2,944 1,472 1, ,643 3,554 1,777 1, ,969 4,165 2,083 1, ,295 4,775 2,388 2,204 1, ,621 5,386 2,693 2,486 1, ,947 5,996 2,998 2,768 1,384 For each additional person: +7, OTHER BENEFITS: Put a checkmark where you want the information released. By signing this section you will allow the school to release information that shows you have applied for free or reduced price benefits under the NSLP. The information will only be used for the programs you have marked on the application. Textbook Assistance You must answer this question and sign, in order to receive textbook assistance. You are not required to answer this question to receive meal benefits. PLEASE NOTE: For Textbook Assistance, these are specific things that you must complete in addition to the required items for meal benefits. 1) Living with parent/caretaker relative, (The definition of a caretaker relative is a relative, either by blood or by law, who lives with the child and exercises parental responsibility [care and control] in the absence of the child s parent. Examples include, but are not limited to: Grandparents, Aunts, Uncles, Cousins, Step-Parents, and Adult Siblings.) 2) grade, and 3) check if you are applying for textbook assistance and sign under Other Benefits. Your application must contain 2 signatures for meals and textbooks Parent Letter/Instructions Page 3 of 4

10 Hoosier Healthwise Your child(ren) may qualify for free or low-cost health insurance under Medicaid or Hoosier Healthwise. If you DO WANT this information released for the purpose of Hoosier Healthwise, please sign. For more information about Hoosier Healthwise health insurance, call Parent Letter/Instructions Page 4 of 4

11 Weekly Every 2 Weeks Twice A Month Monthly Yearly Weekly Every 2 Weeks Twice A Month Monthly Yearly Weekly Every 2 Weeks Twice A Month Monthly Yearly Weekly Every 2 Weeks Twice A Month Monthly Yearly Prescribed by State Board of Accounts School Form No. 521 / Revised 2011 GRIFFITH PUBLIC SCHOOLS 4700 SCHOOL CORPORATION CORP. NUMBER APPLICATION FOR FREE OR REDUCED PRICE MEALS AND OTHER BENEFITS Part 1. NAME OF CHILD (First Name, MI, Last Name) LIVING WITH PARENT or CARETAKER RELATIVE Effective July 1, One Application per Household BIRTH DATE SCHOOL GRADE CHECK IF A FOSTER CHILD TANF or Food Stamps Case # (If you receive both benefits, list the TANF Case #) YES - NO / / / / / / / / / YES - NO / / / / / / / / / YES - NO / / / / / / / / / YES - NO / / / / / / / / / YES - NO / / / / / / / / / YES - NO / / / / / / / / / If ALL children listed above are foster children, skip to Part 5 and sign. If ANY of the children have a food stamp/tanf case number, skip to Part 5 and sign. Part 2. If any member of your household (adult or non-student) has a valid Food Stamp or TANF case number, please provide the name and case number for the person who receives the benefit and then skip to Part 5. Name: Case Number: / / / / / / / / / Part 3. If any child you are applying for is migrant, homeless, or a runaway, check the appropriate box and call Mr. Aron Borowiak at Migrant Homeless Runaway Part 4. LIST ALL HOUSEHOLD MEMBERS ALL OTHER HOUSEHOLD TYPES GROSS (before deductions) HOUSEHOLD INCOME FROM ALL SOURCES Examples: $100 / monthly or $100 / every 2 weeks or $100 / twice a month or $100 / weekly NAME Earnings from Work Before Deductions Welfare Payment Child Support, Alimony Pension, Retirement, Social Security All Other Income Example: Jane Smith $ 200 $ 150 $ 100 $ $ $ $ $ 2. $ $ $ $ 3. $ $ $ $ 4. $ $ $ $ 5. $ $ $ $ 6. $ $ $ $ 7. $ $ $ $ Check if NO income Part 5. SIGNATURE: An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or mark the No Social Security Number box. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. X *** - ** - No Social Signature Of Adult Household Member Social Security Number Security Number Home Telephone # / Work Telephone # Printed Name of Adult Household Member Date Signed Home Address/Apt # Zip Code Part 6. OTHER BENEFITS This section does not need to be completed to receive free or reduced price meal benefits. I certify that I am the parent/guardian of the child(ren) for whom application is being made. Do you want to receive textbook assistance? My signature below authorizes the release of information on this application for textbook assistance. I give up my right of confidentiality for this purpose only. This application YES If, YES, SIGN TO THE RIGHT information will be shared with the Indiana Family and Social Services Administration NO pursuant to I.C and I.C , solely for purposes of complying with 45 C.F.R. PARTS 260 AND 265. X SIGNATURE OF PARENT/GUARDIAN DATE SEE PAGE 2 IF YOU WANT THIS INFORMATION RELEASED FOR THE PURPOSE OF HOOSIER HEALTHWISE. SCHOOL USE ONLY: Approved Denied Not Applicable Page 1 of 2 Program Year 2013

12 This application information may be shared with the Family and Social Services Administration for the purpose of identifying children who may qualify for free or low-cost health insurance under Medicaid or Hoosier Healthwise. If you want the application information shared for this purpose, please sign below. I certify I am the parent/guardian of the child(ren) for whom application is being made. I authorize the release of information for this purpose. X For information about Hoosier Healthwise Signature of Parent/Guardian Date health insurance, call Part 7. RACE AND ETHNICITY: Optional - You are not required to answer this question. No child will be discriminated against because of race, color, sex, national origin, age, or disability. Mark one or more racial identities: Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander White Mark one ethnic identity: Hispanic or Latino Not Hispanic or Latino Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. FOR SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE INCOME CONVERSION to YEARLY: WEEKLY INCOME X 52 EVERY 2 WEEKS X 26 TWICE A MONTH X 24 MONTHLY INCOME X 12 ELIGIBILITY DETERMINATION Income Eligibility: Total Household Size: Total Income:$ per: Weekly Every 2 Weeks Monthly Twice a Month Yearly OR Categorical Eligibility: Food Stamps TANF Migrant Homeless Runaway Foster Eligibility Determination: Approved Free Approved Reduced price Denied Reason for Denial: Income Too High Incomplete Application Other(Reason) Temporary: Free Reduced Time Period: (expires after days) Signature of Determining Official: Date: Date Withdrawn: VERIFICATION Confirmation Review Official: Date Verification Notice Sent: Date Response Due from Households: Date Second Notice Sent (or N/A): Approval Based On: Food Stamps / TANF Case Number Household Size and Income Other Verification Results: No Change Free to Reduced Free to Paid Reduced to Free Reduced to Paid Reason for Change: Income: Household Size: Change in Food Stamps /TANF Did not respond Other: Date Notice of Change Sent: Date Change Made: Date Hearing Requested: Hearing Decision: Verifying Official's Signature: Date: Page 2 of 2 Program Year 2013

13 HEALTH SERVICES INFORMATION Student Name To Parent or Guardian: In order to provide the best educational experience, the school must understand your child s health needs. Please complete this form and sign in the appropriate areas so that we can provide the best possible care for your student. * Please check any conditions that apply to your student: Yes Year Yes Year Asthma Frequent Headaches Allergies Migraines Food Gastro-Intestinal Problems Medication Kidney/Bladder Problems Insects Heart Problems/Irregularities Other Ulcer ADHD/ADD Seizures Anxiety Sickle Cell Blood Disease Other Depression Vision Problems Diabetes Glasses Fainting High Blood Pressure Contacts Skin Problems Hearing Problems History of Cancer Tubes Orthopedic Problems Hearing Aids If any of the above condition are checked Yes please explain: Please list any physical restrictions the student may have: Y or N Y or N Y or N Y or N Has your child had any hospitalizations, operations, or major illnesses? Has your child had any significant injury or accident? Has your child had any dental work we should be aware of (braces or tooth replacement)? Does your child take any medication daily? (If so please list below the name of the medications & dosages) If Yes is circled in any of the above please explain:

14 It is State Law, IC that a school corporation shall require the parents of a child who has enrolled in a school corporation to furnish, no later than the first day of school, a documented statement of the child s immunization record. The parent/guardian must assume responsibility for obtaining these records. IF at the end of 20 days the record or a schedule for the immunizations established by a physician or the Board of Health is not received, the child will be excluded from school until said records are presented to the school. Please Note: Transfer from another school corporation is not an adequate reason for lack of proper immunization records. It is the parent s/guardian s responsibility to obtain such records before enrolling the student for school. IMMUNIZATION HISTORY/CONSENT TO RELEASE INFORMATION I give Griffith Public School Corporation permission to release the following information concerning the student being registered to the Indiana State Department of Health s Children and Hoosiers Immunization Registry Program (CHIRP). This includes information such as name, immunization data and other information such as date of birth or other identifying information as applicable. I understand that the information may be used to verify that my child has received proper immunizations and to inform me or my child of my child s immunization status or that an immunization is due according to recommended immunizations schedules. I understand that my child s information will be available to the immunization data registry of another state, a healthcare provider, a local health department, an elementary or secondary school that is attended by the individual, a child care center, the office of Medicaid policy and planning, or a contractor of the Medicaid policy and planning. I also understand that other entities may be added to this list through amendment to IC I hereby consent to release of such information. History of Varicella (Chicken Pox) Disease: Please state date (month/day/year) when child had Chicken Pox / / Parent/Guardian Signature Required by IC All information that you provide is CONFIDENTIAL and is for the exclusive use of Griffith Public Schools. It will not be released to non-school personnel without the parent s written consent. Parent/Guardian Signature Printed Name of Parent/Guardian Date Daytime Phone Number

15 SCHOOL YEAR SCHOOL IMMUNIZATION REQUIREMENTS 3 to 5 years old 3 Hep B (Hepatitis B) 4 DTaP (Diphtheria, Tetanus & Pertussis) 3 Polio (Inactivated Polio) 1 MMR (Measles, Mumps, Rubella) 1 Varicella (Chicken Pox) Grades K-2 3 Hep B 5 DTaP 4 Polio 2 MMR 2 Varicella Grades Hep B 5 DTaP 4 Polio 2 MMR 1 Varicella Grades Hep B 5 DTaP 4 Polio 2 MMR 2 Varicella 1 Tdap (Tetanus, Diphtheria, Pertussis booster) 1 MCV4 (Meningococcal) Hep B: Two-dose alternative adolescent schedule (Recombivax HB given at age years x 2 doses) is acceptable if properly documented. DTaP: Four doses of DTaP/DTP/DT are acceptable if 4 th dose was administered on or after child s fourth birthday. Polio: Three doses of polio vaccine are acceptable if 3 rd dose was administered on or after child s fourth birthday and the doses are all IPV or all OPV. The 4 th dose of polio vaccine must be administered on or after child s fourth birthday. MMR: If given as single antigen, 2 Measles, 2 Mumps and 1 Rubella required Varicella: Physician documentation of disease history, including month and year, is proof of immunity for children entering preschool, kindergarten, 1 st and 2 nd grade. A signed statement from the parent/guardian indicating history of disease, including month and year is required for children in grades Two doses of varicella vaccine separated by at least 3 months are recommended for all elementary-aged students. Tdap: A Tdap booster can be given as early as 1 year after a Td vaccination.