Brentwood School District

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1 Brentwood School District Dear Families, It is a pleasure to welcome you to kindergarten and to the Brentwood School District! Our commitment is to grow capable learners and inspire lifetime leaders. We believe that every child is unique and work daily to help children discover their strengths. Our students are given leadership roles throughout their tenure at Mark Twain and McGrath. Our teachers and staff are truly dedicated as we serve you and your child. Parents have many opportunities to volunteer their time and enjoy doing so. The Parent Teacher Organization (PTO) seeks avenues to raise funds, which are used to enhance learning, sponsor student activities, and support our amazing teachers. Our structures and routines continually evolve with the input of our learning community. We truly believe that successful schools are built upon strong, trusting relationships. Therefore, we strive to use the expertise of our teachers, parents, and community members to meet the needs of all of our students. We welcome you to our schools. In the best interest of your child, Trina Petty-Rice Principal Mark Twain Elementary Dr. Cindy Neu Principal McGrath Elementary

2 July, 2013 This document will give you specific information on what documentation is required to enroll a student in the Brentwood School District. A parent or court-appointed legal guardian of the student must provide a valid Driver s License or state-issued I.D. and documentation from each of the lists below. All documents provided must be current and display the name of the parent or guardian, in addition to the address located within the school district. All private information may be blacked out. If the parent/legal guardian does not rent or own the district property, or does not have the required documentation, the parent/legal guardian should call Dr. Joan Oakley at to schedule an appointment to determine their eligibility to enroll the student in the Brentwood School District. The parent/legal guardian must have a valid driver s license or state-issued photo identification and one current document from List A and two current documents from List B to enroll the student. DOCUMENTATION REQUIRED: LIST A Mortgage statement Property deed Real estate tax bill Homeowner s policy Signed residential lease agreement (must be updated annually) LIST B Unpaid utility bill Credit card or bank statement Voter registration card Personal property tax invoice/receipt Paycheck stub Insurance statement IRS tax statement Social services, Social Security or other legal documents issued by local, state or federal courts Please contact your building principal or principal s secretary if you have any questions or concerns. We appreciate your interest in our district.

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4 Grade Name of School District City State

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6 STUDENT INFORMATION RELEASE FORM Student Name Date of Birth Address City Zip Parent/Guardian School Grade I hereby give my permission for Brentwood School District to obtain/provide information on the above named student from/to: Agency/Practitioner Address City Zip Phone Number The information is being obtained for educational purposes and records should be forwarded to: Date: January 2014 Parent/Guardian Signature Date Date: January 2014

7 AUTHORIZATION FOR RESIDENCY CHECK I,, authorize The Brentwood School District, its employees and agents, to inquire, and obtain documents, regarding matters of my residency and the domicile of my child (ren), from my employer(s), utility company(s), landlord, and/or appropriate government agencies as deemed necessary. I hereby certify that all documents, papers and records submitted by me as proof of residency are true and correct. Date Signature Previous Address City, State and Zip Code Authorization for Legal Action Missouri Statutes and the Safe Schools Act mandate that any person who knowingly submits false information to satisfy any requirement of the Affidavit for Residency is guilty of a Class A misdemeanor. In addition to any other penalties authorized by law, the Brentwood School District Board of Education may file a civil action to recover from the property owner and the parent/legal guardian of the student the cost of school attendance for any student who has enrolled at a school in the Brentwood School District and whose parent/legal guardian filed false information to satisfy the residency requirements of the School District of the City of Brentwood. Signature of Parent/Legal Guardian Signature of Property Owner *Note: Failure to sign this document does not prohibit the district from conducting a residency investigation. Date: January 2014

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10 Dear Parent/Guardian: We want to make you aware of additional support your child is eligible to receive as a participant in the Free and Reduced Price School Meals Program. School districts may share information with other programs for which your children may qualify. We must have your permission to share your information with the following programs. Sending in this form will not change whether your children get free or reduced price meals. No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with any of these programs. Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with the High School College and Career Office for ACT/SAT fees and college application waiver consideration. (HIGH SCHOOL ONLY) Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with my child s counselor and principal for waivers for field trip fees and other school activities, when possible. (GRADES K-12) Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with the school counselor/principal for support around the holidays. (GRADES K-12) If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the programs you checked. Child s Name: School: Child s Name: School: Child s Name: School: Child s Name: School: Signature of Parent/Guardian: Date: Printed Name: Address: For more information, you may call Dr. Joan Oakley at Return this form to your child s school principal.

11 ANNUAL PERMISSION FOR EMERGENCY CARE Please complete the requested information below as accurately as possible. In the event of a emergency (illness or accident), the information will be used by the Brentwood School District and its staff to protect the health of your child. Please contact the school as soon as any of the information changes. Student Name Date of Birth Student Address/City/State/Zip Mother s Name Home Phone Work Phone Cell Phone Father s Name Home Phone Work Phone Cell Phone If a parent cannot be reached, please contact a close relative or friend. Name Relationship Home Phone Work Phone Cell Phone Name Relationship Home Phone Work Phone Cell Phone Doctor s Name/Office Phone/Exchange Dentist s Name/Office Phone/Exchange

12 HEALTH INFORMATION 1. Does your child have any medical or physical problem the school should be aware of? Asthma Motion Sickness Hearing Loss Diabetes Allergies Faints Easily Nose Bleeds Convulsions Constipation Sleepwalking Wears Contacts Other 2. Please explain the conditions checked above 3. Recent surgery or illness lasting more than a week 4. Month/Year of last diphtheria/tetanus shot / Month/Year of last physical / EMERGENCY AUTHORIZATION To ensure the care of my child, I agree that pertinent health information may be shared with appropriate school staff, and may be forwarded to emergency medical personnel in emergency situations. I agree to notify the school nurse of any changes in medication, dosage, or change in any health status of my child. I agree if any of the above information changes, I will notify the school immediately. I understand that in case of an emergency the school will first attempt to contact me. If I cannot be reached, I authorize the transport of my child to a hospital and authorize any physician or medical personnel to carry out any diagnostic procedures or emergency care deemed necessary. I will accept full financial responsibility for charges connected with the use of an ambulance and charges connected with any medical care necessary. I acknowledge that all foregoing above information is true and correct. Parent/Guardian Signature Date PLEASE NOTE: Physician and hospital visits are the financial responsibility of the parent/guardian. Insurance Company Name Phone Policy # Insured s Name Employer Name Phone Number Date: January 2014

13 Enrollment for School Year: ANNUAL STUDENT HEALTH SURVEY Student s Legal Name (Last/First/Middle/Nickname) Gender: Male Female Date of Birth: / / Grade Please check any of the following conditions that affect your child: ADD/ADHD Medication Allergies Specify Medication Anxiety Medication Asthma Medication Autism/Asperger s Spectrum Medication Cancer Depression Medication Diabetes Medication Heart/Lung Problems Hearing Concerns/Ear Infections Kidney/Bladder Problems Major Illness/Injury Specify Migraines Medication Orthopedic Issues Seizures Medication Stomach/Bowel Problems Surgery Vision (Glasses/Contacts/Others) Other than listed above, is your child currently taking any medication on a regular basis (prescription or over the counter)? If yes, what kind of medication and what is the reason for taking it? Dosage Is your child currently under any kind of on-going medical treatment or care? Will your child need Medical/Nursing care at school? If yes, please describe in detail. YES NO *Please note that serious, life threatening health concerns will need a health care plan. Please contact your school nurse as soon as possible to schedule an appointment to complete this information. Physician Specialist Dentist Phone Number Phone Number Phone Number Additional comments:

14 REQUEST FOR MEDICATION TO BE GIVEN AT SCHOOL I request that (child s name) be allowed to take the following medication at school: I am sending it in its original labeled container. Prescription Non-prescription Reason for Medication: Name of Medication: Dosage to be given: Frequency/Time: Can the bottle stay at school?: Yes No Student CANNOT transport medication Comments: Physician s Name (print): Physician s Phone Number: By signing this request, I understand that: Medication must be in original container Prescription medication must be labeled by pharmacist and include name, dosage, amount of medication and doctor s name. I am responsible for monitoring medication supply and obtaining refills. Parent/guardian must hand deliver the medication to the school clinic. I will notify the school personnel in writing of any change in dosage and/or time medication is to be given. No medication maybe kept in a student s locker, backpack or purse, except in certain circumstances, and then only if ordered by the child s physician, in writing. Parent/Guardian Signature: Date: * NOTE: Brentwood School District s Medication policy requires that parents provide written authorization for prescription and over the counter medications. In lieu of the physician s written request, the District will accept a prescription label properly affixed to the medication. The request shall state: name of student, name of drug, dosage, frequency of administration, route of administration, and the name of prescriber. Your pharmacy can provide an extra-labeled bottle for school. You may read the full policy, JHCD, at

15 Student Name School Student ID Grade TECHNOLOGY USAGE AGREEMENT (Parent/Guardian Technology Agreement) I have read and acknowledge the Brentwood School District s Technology Usage policy (EHB.) I understand that violation of these provisions may result in disciplinary action taken against my student including, but not limited to, suspension or revocation of my student s access to district technology and suspension or expulsion from school. I understand that my student s use of the district's technology resources is not private and that the school district may monitor my student s electronic communications and all other use of district technology resources. I consent to the district s interception of, or access to, all of my student s electronic communications using district technology resources. This includes downloaded materials, all data stored on the district s technology resources including deleted files, pursuant to state and federal law, and district technology resources accessed remotely. I agree to be responsible for any costs arising from unauthorized use of the district s technology resources by my student. I agree to be responsible for any damages incurred by my student. Online communication is critical to students learning of 21 st century skills. I understand classrooms will use Web 2.0 tools such as blogs, wikis and podcasts as part of the instructional process. I agree to my student being photographed, interviewed and/or videotaped by representatives of Brentwood School District and/or media outlets. Any information or images obtained from these activities may be reproduced by the school district and/or media outlets for use in advertising, publicity or educational activities. This includes: Brentwood School District publications - printed or electronic, school yearbooks, videos, and school websites. Terms of the Agreement I have read and acknowledge the Brentwood School District s Technology Usage policies (EHB, EHB-AP1, EHB-AP2). Verification: I verify that the information provided on this form is accurate and current, and that I am the legal parent/guardian of the student. X_ SIGNATURE of Parent/Guardian PRINT Name of Parent/Guardian Date X_ SIGNATURE of Student (if student is 18 years old) Date Terms of the Agreement Parents/guardians who do not grant their student the right to utilize the school district s technology resources or be included in media activities in the Brentwood School District must sign and return the FERPA Annual Parent/Guardian refusal form. Forms are available in every school office and on the district website at I understand that this form will be effective for the duration of my student s attendance in the current grade cluster, (K-5, 6-8, 9-12) unless revoked or changed by the district or me.

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