MY CHILD HAS A MEDICAL CONDITION WHICH MAY REQUIRE ATTENTION AT SCHOOL (MEDIC ALERT)

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1 TILLAMOOK School District #9 Teacher: Grade: HEALTH QUESTIONAIRE STUDENT S NAME: BIRTHDATE: COUNTRY OF BIRTH: STUDENT S ADDRESS: PHONE: CELL: MY CHILD HAS A MEDICAL CONDITION WHICH MAY REQUIRE ATTENTION AT SCHOOL (MEDIC ALERT) DOES YOUR CHILD HAVE ANY OF THE FOLLOWING? CIRCLE ONE Hearing Problem NO YES Speech Problem NO YES Vision Problem NO YES Has your child been prescribed Glasses or contact lens? NO YES Allergies Environmental (dust, etc.) Insect Allergy NO YES Food Allergy Medicine Allergy Severe allergic reaction, that a doctor/nurse practitioner NO YES has prescribed an Epipen or Epipen Jr? Diabetes (if yes, please circle) Type 1 Type 2 Other NO YES Digestive Problems (Ulcer, Colitis, Vomiting, etc.) NO YES Heart Condition NO YES If yes, what is the medical diagnosis? Asthma or Other type of breathing problem NO YES Epilepsy or Seizure Disorder NO YES If yes, what kind of seizures? Cancer has your child ever been diagnosed with cancer? NO YES If yes, what type of cancer? Is your child still being treated for cancer? YES NO Headaches which are frequent or severe? NO YES If yes, what helps your child when a headache occurs? Has your child had one or more previous head injuries or concussions? NO YES If yes, when did this occur? Blood Disorder (Anemia, Hemophilia, Bleeding Disorder) NO YES Cerebral Palsy NO YES Orthopedic (Bone) Problem NO YES Bowel or Bladder Problem NO YES Kidney Problem NO YES Skin Problem (eczema, hives, etc.) NO YES If yes what type of skin problem? Special Diet NO YES If yes, type of diet: Only students with the appropriate medical documentation on file at school can have food substitutions in the school breakfast/lunch program. Learning Difficulties NO YES If yes, please describe: Attention Deficit Disorder or ADHD NO YES Does your child have any other health concerns not listed above? NO YES If yes, please describe: **A medication form must be filled out for all medication taken during school. **To protect your child, this information will be shared with school staff working with your child. If you would like to speak to the health nurse regarding any special health needs your child may have, please leave a message at the school office or call the Tillamook Health Department at Parent/Guardian Signature NO MEDICAL CONCERNS Date:

2 TILLAMOOK SCHOOL DISTRICT #9 PERMISSION TO RELEASE RECORDS TO: (Student s former school/agency) (Address of former school/agency) Office Use Only: Date Faxed: Second Request: Phone: Fax: (Student Name) (Date of Birth) (Grade) has entered Tillamook School District. I am requesting all records for the above named student(s) which include: Student Education Records which include full legal name of student, birth date and place of birth, name of parents/guardians, date of entry, name of previous school, subject taken, marks received, credits earned, attendance, date of withdrawal, social security number (if provided), tests related specifically to achievement or measurement of ability. Health Records which include immunization records, sports physical examinations, health screening records, medication administration records, and other related documents. Behavioral Records which include psychological tests, personality evaluations, records of observations and any written transcript of incident(s) relating specifically to student behavior. TAG identification and records. This should include information relating to youth s history of engaging in activity that is likely to place school staff or other student safety at risk, or that requires appropriate counseling or education. Special Education Records including, but not limited to, records of eligibility, correspondence with parent/guardian, and all previous and current IEP s. Portfolio OTHER (specify) Signature Parent or School Registrar Date PLEASE SEND ALL RECORDS TO: Tillamook High School th Street Tillamook, OR Ph# (503) X2210 Fax# (503) **Office Use Only: Withdraw Date: Enrollment Date: Subject to ORS , a district receiving this request shall transfer all education records no later than 10 days after receipt of request. Should any of the requested records be on file in other departments, please forward this request to the appropriate office. If no records are on file, please contact the school requesting the records.

3 TILLAMOOK SCHOOL DISTRICT #9 AUTORIZACIN DE ACCESO A LOS REGISTROS PARA: (Escuela/Agencia anterior del estudiante) (Domicilio de la escuela/agencia anterior) Office Use Only: Date Faxed: Second Request: Telefono: Fax: (Nombre del Estudiante) (Fecha de Nacimiento) (Grado) ha entrado al Distrito Escolar de Tillamook. Yo estoy solicitando todos los registros del estudiante(s) nombrado(s) arriba que incluyen: $ Registros de Educación del Estudiante que incluye el nombre completo y legal des estudiante, fecha de nacimiento y lugar de nacimiento, nombre de los padres/guardan, fecha de entrada, nombre de la escuela anterior, materias tomadas, calificaciones recibidas, créditos recibidos, asistencia, fecha de retiro, numero de seguro social (si se proveo), exámenes relacionados específicamente al prueba de rendimiento o evaluación de aptitudes. $ Historial Medico que incluye el registro de inmunización, examen físico relacionado a los deportes, registros de exámenes de salud, registros de medicamentos administrados, y otros documentos pertinentes. $ Registros de Conducta que incluye pruebas psicológicos, evaluaciones de personalidad, registros de observaciones y cualquier transcripción de incidente(s) relacionadas específicamente al comportamiento del estudiante puesto por escrito. Identificación y archivos de TAG. $ Registros de Educación Especial incluyendo, pero no limitado a, registros de elegibilidad, correspondencia con los padres/guardián, el IEP actual y todos los anteriores. $ Portafolio $ OTRO (especifique) Firma Padre(s) o Secretaria de Alumnos Fecha PLEASE SEND ALL RECORDS TO: Tillamook High School th Street Tillamook, OR Ph# (503) X2210 Fax# (503) **Office Use Only: Withdraw Date: Enrollment Date: Subject to ORS , a district receiving this request shall transfer all education records no later than 10 days after receipt of request. Should any of the requested records be on file in other departments, please forward this request to the appropriate office. If no records are on file, please contact the school requesting the records.

4 Tillamook School District # 9 Confidential Prior Services Student Name: Current School: Current Grade: An awareness of any special services is important in order to plan the most appropriate educational program for a child. Has your child ever received or participated in the following services? 1. Special Education a. Currently on an IEP? i. Speech ii. Academics (please specify, math/read/write/etc.) iii. Other (e.g. vision, hearing) b. Currently in testing or evaluation process? c. Previously on an IEP or evaluated? YES NO Plan 3. Talented and Gifted (TAG) 4. Extra Academic Assistance If yes, what kind: 5. Counseling If yes, what issue: 6. Medication If yes, what type: 7. Special health issues or concerns If yes, list: 8. Does your child need any special services at this time? (e.g. Title I, ELL) If yes, what special services: 9. Has your child received any special services in the past two years? (Title I, ELL) If yes, what specific services: 10. Would you like one of our administrators to contact you at this time to discuss any issues or concerns? Contact number: Parent Signature: Date:

5 TILLAMOOK SCHOOL DISTRICT NO st Street Tillamook, Oregon PARENT CUSTODY NOTIFICATION By law, if parents are legally separated or divorced, each parent has equal rights to the custody of the child/children UNLESS a parent has a court order that indicates which parent has custody of the child/children. The school MUST HAVE A COPY OF THE COURT ORDER on file, otherwise, either parent may check the child out of the school with proper identification. If a parent comes in with a court order stating current custody over the enrolling parent, they may take the child/children after documents are verified, as needed, and after every effort has been made to reach the enrolling parent by phone. I have read the above statement of the law. Student s Name Grade Signature of Parent/Guardian Date ~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~

6 TILLAMOOK SCHOOL DISTRICT NO st Street Tillamook, Oregon IMPORTANT Recent Arrivers Information Randy Schild, Superintendent 503/ FAX 503/ What Beginning in 2012, the Oregon Department of Education requires that we collect information to determine the number of Recent Arrivers in our school district. Why Title III is a Federal grant that provides funding for language instruction for Limited English Proficient and Immigrant Students. Title III will use information about Recent Arrivers to help in distributing these funds. Therefore, the Oregon Department of Education is required to provide information about Recent Arrivers to the US Department of Education every year. Who All new to TSD9 students/families must respond to this questionnaire. Any student born outside of the US or Puerto Rico, including foreign exchange students and students born abroad to military members, must be included in the Recent Arriver count, if they meet all three criteria. The Questions Student first and last name: Student school : 1. Is the student 3 to 21 years of age? Yes No Student date of birth: 2. Was the student born outside of the United States or Puerto Rico? Yes No (This includes foreign exchange students and students born abroad to military members.) 3. Has the student attended school in the United States for less than a total of three full school years? Yes No Date the student first attended school in the United States Has the student left US schools at any time since that date? Yes No If Yes, please give dates that student was not in US schools. Parent signature Date: ~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~

7 TILLAMOOK SCHOOL DISTRICT 9 Student Residency Questionnaire Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, and/or Federal McKinney-Vento Education Act. Eligibility can be determined by completing this questionnaire. 1. Are you and/or your family in any of the following situations? Check if true A. Student staying with friends or couch surfing and not living with parent/guardian B. Staying in a shelter or transitional housing C. Sharing housing with others due to loss of housing, money difficulties or similar reason D. Living in a car, park, campground, RV, public space, abandoned building, or housing not appropriate for your family E. Temporarily living in a motel or hotel 2. Have you moved across school districts in the past 3 years to seek or obtain temporary or seasonal work in any type of fishing, agriculture, forestry or dairy? Yes STOP If you did not check any boxes, stop and do not continue. Turn the form in with the rest of your registration packet. If you did check any of the boxes in section 1 or 2 above, please continue filling out the form. 3. Student Name First Middle Last M/F D.O.B. Grade School Name 4. Are there other children in the home? (Check one) Yes No How many? Print Parent/Guardian Name Signature Date Phone number where you can be reached Please submit this form with your registration packet. ************************************************************************************************************************************ For District Use Only: If parent has checked boxes in #1 or #2, make copy for school counselor. Return original form to the District Office, Office of Student Success.

8 Student Name School Year Grade Tillamook High School offers parents the option of receiving their student's report cards electronically or by mail. Please indicate your choice below: I agree to access my student's report card through ParentVUE. I prefer to receive my student's report card by US Mail. I understand that this will apply for the years that my student attends THS. If I decide to change my preference, I will notify the THS office in writing. Parent Signature Date * * * * * * * * * * * * * Nombre de Estudiante Año Escolar Grado La escuela de Tillamook High les ofrece a los padres la opción de recibir las boletas de calificaciones de sus estudiantes electrónicamente o por correo. Por favor, especifique su elección abajo: Estoy de acuerdo en acceder a la libreta de calificaciones de mi estudiante a través de ParentVue Prefiero recibir boleta de calificaciones de mi estudiante por correo postal. Entiendo que esto se aplicará para los años en los cuales que mi estudiante asiste a THS. Si decido cambiar mi preferencia, notificaré a la oficina de THS por escrito. Firma de padre Date

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