THE SCHOOL DISTRICT OF PHILADELPHIA NORTHEAST HIGH SCHOOL COTTMAN AND ALGON AVENUES PHILADELPHIA, PENNSYLVANIA

Transcription

1 THE SCHOOL DISTRICT OF PHILADELPHIA NORTHEAST HIGH SCHOOL COTTMAN AND ALGON AVENUES PHILADELPHIA, PENNSYLVANIA Re: School Year To the Parent / Guardian All students entering ninth grade, as well as students newly admitted to Philadelphia public schools, are required by Pennsylvania State Law to have a physical examination, dental exam and complete immunizatons to enter in September. Complete immunizations include: 4 Tetnus, at least one after 4th birthday Tdap- 1 dose recommended 2 MMR (after 1st birthday) 3 Polio 3 Hepatitis B 2 Varicella or documentated date of Chicken Pox illness 1 Meningitis Recommended HPV recommended The following forms which must be completed are: 1. Information for Medical Emergencies form (to be completed by the parent / guardian). 2. Private Physician s Medical Report form (to be completed by the family physician). These forms must be returned to Northeast High School Health Room (145) by September. The prompt return of these documents will help us to best meet the health needs of your child.. Thank you for your attention. Sincerely, Maureen Travagline RN Anne Johnson RN Chris Babcock RN cc: L. Carroll, Principal Enclosures ALL FORMS ARE TO BE RETURNED BEFORE SEPTEMBER TO: M. Travagline, RN SCHOOL NURSE ROOM 145 NORTHEAST HIGH SCHOOL COTTMAN AND ALGON AVES.

2 PHILADELPHIA, PA 19111

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4 Name of School THE SCHOOL DISTRICT OF PHILADELPHIA REPORT OF PRIVATE DENTAL EXAMINATION Student ID Date Issued Name of Student Date of Birth Room/Section/Book Grade TO THE DENTIST Pennsylvania law requires that students attending school in the Commonwealth receive periodic dental examinations at stated intervals (upon original entry, while in third grade, and while in seventh grade). These examinations are required for school attendance. Payment for these examinations is the responsibility of the parent/guardian. If the student/family does not have health insurance the school nurse will help the family apply for health insurance. Please attach a copy of the student s dental examination or record the data below. Thank you for your cooperation. UNDER TREATMENT / WORK BEGUN Date Work Begun Scheduled Follow-up Appointment Date of Dental Examination COMPLETION OF WORK / NO TREATMENT NECESSARY No Treatment Required Now All Necessary Dental Work Completed Expected Completion Date Comments / Follow-up Treatment / Special Instructions to School Name of Dentist Telephone Signature of Dentist Date Signed Address Fax Number IMPORTANT: Return this form to: Certified School Nurse/Practitioner School School Address Phone Number MEH-155 (Rev. 3/01) COMM. CODE

5 NORTHEAST HIGH SCHOOL COTTMAN AND ALGON AVENUES PHILADELPHIA, PA LAST NAME OF STUDENT FIRST MIDDLE DATE OF BIRTH GRADE/SECTION LAST SCHOOL ATTENDED NAME (PARENT OR GUARDIAN) HOME ADDRESS HOME PHONE MOTHER S NAME WORK PHONE CELL FATHER S NAME WORK PHONE CELL EMERGENCY CONTACT NAME RELATIONSHIP PHONE EMERGENCY CONTACT NAME RELATIONSHIP PHONE PHYSICIAN NAME ADDRESS PHONE HEALTH INSURANCE PLAN NAME NUMBER IF NO INS.CHECK HERE SPECIAL HEALTH NEEDS It would be helpful to have the following information so that the school can immediately meet any special health needs of your child. Has your child ever had any serious illness or operations. Yes No What? When? Is your child going to a hospital, clinic or doctor now? Yes No What for? Where? Apart from vitamins, is your child taking any medicines? Yes No What? What for? Is your child allergic to anything, such as foods, plants, insects, or medicines? What? Yes No Does your child have any special health needs or problems the school should know? Yes No If your child needs to take medication during the school day please see Mrs. Travagline in Room 145. Medication must be in a labeled container from a pharmacy with child s name,name of medication,dosage,instructions for administration,and your doctor s name. A MED-1 must be on file. If you have any questions regarding your child s health needs please contact me. MRS. TRAVAGLINE SCHOOL NURSE OR EXT 1400

6 NORTHEAST HIGH SCHOOL 1601 COTTMAN AVENUE PHILADELPHIA, PENNSYLVANIA Fax (215) DATE: GRADE: STUDENT I.D. # LAST NAME FIRST NAME MIDDLE HOME ADDRESS ZIP CODE HOME PHONE NUMBER CELL PHONE NUMBER GENDER RACE DATE OF BIRTH NAME OF FATHER NAME OF FATHER S EMPLOYER NAME OF MOTHER NAME OF MOTHER S EMPLOYER TELEPHONE # FATHERS EMPLOYER TELEPHONE # MOTHER S EMPLOYER GUARDIAN S NAME: Last school attended before admitted to Northeast H.S: School Address LAST PHILADELPHIA PUBLIC SCHOOL ATTENDED NAME OF SCHOOL DISMISS DATE GRADE *************************************************************************************F OR OFFICIAL USE : Pocket Requested Roll Sheet Blue Card Pocket Received/or created Admit Book Computer Immunizations on Computer

7 NORTHEAST HIGH SCHOOL 1601 COTTMAN AVENUE PHILADELPHIA, PENNSYLVANIA Fax (215) AFFIDAVIT As required by Pennsylvania Act 26 I Name of Parent/Guardian The parent/guardian of do herby swear/affirm Name of Student That the above student (check one): has has never Previously been suspended from a school (public or private) for: (a) Possession or use of a weapon, drug, or alcohol or (b) Any other act of violence on school property, including willful injury to any person I make this statement on subject to the criminal penalties in 24 PS & 1304 A (B) relating to falsification of this document. Signed Parent/Guardian Witness At the time the net student enrolls or re-enrolls in the School District of Philadelphia from a private school or a school outside the District the parent/guardian must sign a sworn statement indicating whether the student was ever suspend or expelled from any prior public or private school for an offense involving weapons, drugs, alcohol, willful injury to another person or any act of violence on school property.

8 NORTHEAST HIGH SCHOOL 1601 COTTMAN AVENUE PHILADELPHIA, PENNSYLVANIA Fax (215) REQUEST FOR STUDENT RECORDS ****************************************************************************** PARENT/GUARDIAN PLEASE FILL OUT THE INFORMATION BELOW. RECORDS REQUESTED FROM School Name of previous school Complete street address of previous school Complete address of previous school with zip code Phone# Fax# The following student enrolled at Northeast High School today. Please send all school records, including disciplinary records, medical records, standardized testing, scholastic grades, attendance records transcripts, Special Education information and any other appropriate data. Thank you. Pupil name Date of Birth Please send records to: ATTN: Roster Room Northeast High School 1601 Cottman Ave. Philadelphia, PA Consent Release: Parent/Guardian Signature

9 THE SCHOOL DISTRICT OF PHILADELPHIA NORTHEAST HIGH SCHOOL 1601 COTTMAN AVENUE PHILADELPHIA, PENNSYLVANIA Fax (215) Dear Parent or Guardian: 1. Except as hereinafter provided, every child of compulsory school age (between the ages of 8-17) having a legal residence in this Commonwealth, as provided in this article, and every migratory child of compulsory school age, is required to attend a day school in which the subjects and activities prescribed by the standards of the State Board of Education 2. Every parent, guardian, or other person having control or charge of any child or children of compulsory school age is required to send such child or children to a day school in which the subjects and activities prescribed by the standards of the State Board of Education. 3. Such child or children shall attend such school continuously through the entire term, during which the public schools in their respective districts shall be in session, or in cases of children of migrant laborers during the time the schools are in session in the districts in which such children are temporarily domiciled. 4. The financial responsibility for the education of such children of migrant laborers shall remain with the school district in which such children of migrant laborers are temporarily domiciled; except in the case of special schools or classes conducted by an intermediate unit and approved by the Department of Education or conducted by the Department of Education. 5. Parent, guardian or other person having control or charge of any such child or children of compulsory school age shall be deemed to have met the requirements of this section with a minimum of one hundred eighty (180) days of instruction or nine hundred (900) hours of instruction per year at the elementary level, or nine hundred ninety (990) hours per year of instruction at the secondary level and: If your child is found to be habitually truant, as his or her parent/guardian, you may be charged with violating the Pennsylvania School Code (24 P.S ), and may be subject to any of the following: A. A fine, up to $ B. Court costs. C. Attendance at mandatory parenting classes. D. Sentences of up to five (5) days in jail. E. Sentences of up to six (6) months community service. F. Removal of the child from his/her home after the court has declared the child dependent. If a child is 13 years old or older and has failed to comply with compulsory attendance or has been habitually truant without justification a summary citation may be filed against that child. Sec (b)(1). Upon conviction of that child the Magisterial District Judge again has a variety of options to consider including: A. Impose a fine not to exceed $ payable to the benefit of the school district (Sec (b)(1)) B. Assign the child to an adjudication alternative program pursuant to 42 Pa.C.S.A. s (Sec (b)(1) C. Suspend the sentence in whole or in part provided that the child is not longer habitually truant from school without justification (Sec (b)(3)). D. Notify the Pennsylvania Department of Transportation of the conviction (Sec (c)).5 I ACKNOWLEDGE THAT I HAVE READ THE ABOVE INFORMATION AND MAY BE SUBJECT TO ANY OR ALL OF THE ABOVE PENALTIES REGARDING TRUANCY I THE STATE OF PENNSYLVANIA: STUDENT NAME PARENT SIGNATURE DATE