SALEM PUBLIC SCHOOLS SCHOOL HEALTH SERVICES MEDICAL INFORMATION SHEET

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3 SALEM PUBLIC SCHOOLS SCHOOL HEALTH SERVICES MEDICAL INFORMATION SHEET Student s Name: Date of birth: Parent/Guardian Name: Address: Phone: Cell: Parent/GuardianName: Address: Phone: Cell: Pediatrician: MD Phone: Dentist: DMD Phone: Prescribed Medications: Health Insurance Name: Does your child have any allergies? YES NO If yes, please specify: Foods: Insects/Bees: Medicines: Animals: Seasonal/environmental allergies: Other: Allergy medication used: Describe any reaction; include date(s) of reaction(s): What treatment was given to your child? Has your child ever been given an Epi- Pen? Does your child have an Epi- Pen? Has your child been seen by an allergist, if so when: Allergy doctor: Phone:

4 Does your child have any health conditions? YES NO asthma Nebulizer yes no Inhaler yes no YES NO headaches YES NO constipation YES NO heart condition YES NO sickle cell YES NO diabetes YES NO ADHD YES NO urinary tract infections YES NO bedwetting YES NO seizures YES NO food intolerances YES NO short attention span YES NO temper tantrums YES NO celiac disease YES NO hearing difficulty hearing aid? yes no YES NO difficulty seeing wear glasses? yes no YES NO speech problems Has your child ever been hospitalized or had surgery? yes no If yes, please explain Is there anything else you think we should know about your child?

5 Salem Public Schools City of Salem Parent Information Center 29 Highland Avenue, Salem, Massachusetts (978) Fax (978) Registration Document Checklist In order to properly register your child for school, you must provide the Parent Information Center with the following documents: Required Forms Assignment Application Form (please complete & sign) Home Language Survey Household Information Survey, and Acknowledgement Form Birth Certificate (one of the following documents) Child s birth certificate (original or certified copy) Passport I-94 Card Resident Alien Card Immunization Records (Please provide your child's most recent physical examination and immunizations. If your child has an appointment during the summer, send a copy of the updated information to PIC attention Paula Dobrow, RN. By law, children cannot be admitted to school until the documentation has been received). Medical Information Sheet & Emergency form Proof of Parent/Guardian s Identity provide one of the following: Massachusetts Driver s License, Massachusetts Photo ID Passport Proof of Address in Salem (two of the following documents) Lease or mortgage statement in parent s/guardian s name, current electric, gas, cable, water, or telephone bills in parent s/guardian s name If you do not have any utilities under your name and you reside with a family member or friend: please provide a notarized letter from the person you live with and two proofs of address under that person s name. Special Education Individualized Educational Plan (IEP), if applicable 504 Plan, if applicable Proof of address Residency fraud is a violation of Massachusetts state law and is subject to per diem fines for every day that a student attends school outside the district in which s/he legally resides. Legal guardianship Legal guardianship requires additional documentation from a court or agency. Homeless families The McKinney-Vento Act requires schools to enroll homeless children and youth immediately, in the absence of the normally required documents, please talk to a PIC staff member.

6 Escuelas Públicas de Salem Ciudad de Salem Centro de Información para Padres 29 Highland Avenue, Salem, Massachusetts (978) Fax (978) Lista de Verificación para Inscripción Para matricular a su niño/a en la escuela, debe proveer al Centro de Información para Padres los siguientes documentos: Documentos Requeridos Aplicación de Asignación (completada y firmada) Encuesta del Idioma Hablado en el Hogar Encuesta de Información Familiar y Forma de Reconocimiento Acta de Nacimiento (uno de los siguientes documentos) Certificado de nacimiento (original o copia certificada) Pasaporte Tarjeta I-94 Tarjeta de residencia Vacunas (incluya el examen físico y las vacunas más recientes de su hijo. Si su hijo tiene una cita durante el verano, envíe una copia de la información actualizada a Paula Dobrow, RN. Por ley, los niños no pueden ser admitidos a la escuela hasta que la documentación haya sido recibida). Hoja de Información Médica & Formulario de Emergencia Prueba de Identidad del Padre/Tutor (uno de los siguientes documentos) Licencia de conducir de Massachusetts Identificación con foto de Massachusetts Pasaporte Prueba de Dirección en la Ciudad de Salem (dos de los siguientes documentos) Arrendamiento o estado de hipoteca en nombre de los padres/tutor, factura de electricidad, gas, cable, agua, o teléfono a nombre de los padres/tutor Si usted no tiene ninguna prueba de dirección bajo su nombre y vive con un familiar o amigo/a: Necesitamos una carta de la persona con quien vive, certificada por un notario, acompañada de dos pruebas de dirección con el nombre de esa persona. Plan Educacional Individualizado (PEI), si aplica Plan 504, si aplica Comprobante de domicilio El fraude de residencia es una violación a las leyes estatales de Massachusetts y está sujeto a multas diarias por cada día que un estudiante asista a una escuela fuera del distrito en el cual él/ella reside legalmente. La tutela legal La custodia legal requiere documentación adicional de un tribunal o agencia. Familias sin hogar La Ley McKinney-Vento ordena que las escuelas matriculen a niños y jóvenes sin hogar de inmediato, aún si no posee los documentos normalmente requeridos, por favor hable con un miembro del personal del Centro de Información para Padres.

7 Dear Parent / Guardian, Salem Public Schools School Health Services Massachusetts State Law, Chapter 76, s. 15 requires that all children receive these immunizations before the first day of Kindergarten. Your child s health records for Kindergarten entry must contain: Physical Examination (must be within 6 months of entering school) All immunizations DTP #1 #2 #3 #4 #5 Polio #1 #2 #3 #4 MMR #1 #2 Hepatitis B #1 #2 #3 Varicella #1 #2 or physician s documentation of having had chicken pox disease Lead Test Health Questionnaire Vision Screening including stereopsis screening Please contact your health care provider to schedule the required physical and/or immunization visit(s). Vaccines are available, free of charge, at the Lydia Pinkham Clinic, 250 Derby Street, Salem, MA on Tuesday and Thursday afternoons from 1 PM until 4 PM. All health forms must be reviewed by the school nurse before the start of Kindergarten. Children will not be allowed to be in school until the documentation has been received. If you have any questions, please contact your school nurse. Please submit any health information completed during the summer to the Parent Information Center at Collins Middle School, 29 Highland Ave, attention Paula Dobrow, RN. Thank you for your prompt attention. Paula J. Dobrow, RN, MSN Director of Nursing and Health Services

8 Salem Public Schools - Assignment Application Date of Application: School Year: Date of Enrollment: September 2015 Student Information Child s Full Name: Grade Entering: Kindergarten First Full Middle Last Address: Age Male Female Place of Birth: Date of Birth: City Country If born in another country, date of arrival in USA: Is your child repeating Kindergarten? No Yes Name of last school /daycare of attendance: City/State: Last day attended: Parent/Guardian Information I am the child s Parent Legal Guardian Home Phone: Mother s Name: child lives with Yes No Mobile Phone: Father s Name: child lives with Yes No Mobile Phone: Mother s Work #: Guardian s Name: Father s Work #: Relationship: Parent s address, if different from student s: Home Phone: Contact s Name: child lives with Yes No Phone #: (if parents are not available) Ethnic/Racial Group: Primary Home Language Hispanic or Latino: Yes No AND check all that apply: English Spanish Vietnamese Asian American Indian or Alaskan Native Russian Portuguese Albanian Black White Other Hawaiian/Pacific Islander In which language would you prefer your school notification sent? Is student receiving special services? Yes No If Yes IEP 504 Plan Is student receiving the following services? Title 1 LEP (English Lang. Learner) Medical Concerns/Daily Medications Yes No (If not in violation of confidentiality) Special Circumstances: Homeless Other: Siblings: Name Date of Birth School Attending Grade My Household qualifies for Free/Reduced Meals Yes No Staff Initials Opt IN to the Bentley Academy Charter school lottery Yes No Parent s School Choices Would you like information about the Parent-Child Home Program for 2 and 3 year olds? Yes No Parent s signature: Date: Office Use Only School Assignment: Prog.: Reg. ESL Dual NCP SEI SPED Sibling Preference: Yes No If YES school: SASID # : Sibling Attending SPS: Yes No If YES school: School Closest to Home: Language Eval: Yes No If YES level: Free Transportation: Yes No Proximity: Waiting List: Yes No If YES which school: Free/Reduced meals: Yes No

9 Salem Public Schools City of Salem Parent Information Center 29 Highland Avenue, Salem, Massachusetts (978) Fax (978) HOUSEHOLD INFORMATION SURVEY Please complete, sign and return this application to the address above. IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES MA SNAP or MA TAFDC benefits, PROVIDE THE AGENCY IDENTIFICATION NUMBER* LOCATED ON THE DEPARTMENT OF TRANSITIONAL ASSISTANCE (DTA) BENEFIT LETTER. Then proceed to Section 4. If no one receives these benefits, start with Section 1. Name: 10-Digit Case Number: INSTRUCTIONS: Complete this survey and return to your child s school or mail to the address listed above. These selections must be completed by the Head of Household or Designee 1. SIZE OF FAMILY - Indicate the total number of individuals living in your household, including all adults and children: 2. STUDENT INFORMATION - Complete for each student Pre-K through 12 th grade Last Name First Name Birth Date MM-DD-YY School Identify H if Homeless M if Migrant R if Runaway F if Foster If you need additional lines, attach a second sheet to this survey or attach a copy of this survey clearly marked as Page 2 3. TOTAL MONTHLY HOUSEHOLD INCOME Report Income for all members of household excluding foster children. If you have reported a case number above, you do not need to complete this section; proceed to section 4. Type of Income Income Circle if No Income 1. Gross Monthly Earnings: Wages, Salary, Commissions $ None 2. Monthly Welfare Payments, Child Support, Alimony $ None 3. Monthly Payments from Pensions, Retirement, Social Security $ None 4. Monthly Dividends or Interest on Savings $ None 5. Monthly Worker s Compensation, Unemployment, Strike Benefit $ None 6. Other Monthly Income (SSI, VA, Disability, Farm, other) $ None Total Monthly Household Income (Add lines 1-6) $ 4. SIGNATURE I certify (promise) that all information on this application is true and that all income is reported. I understand the school will be eligible for certain federal and/or state funds based on the information I give. Sign Here: X Print Name: Date Address City Zip Code Home Phone Work Phone Address: For Office Use Only: Circle One QUALIFIES QUALIFY DOES NOT By providing your address, you may be contact via by the district PROCESSED BY:

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11 Home Language Survey Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance. Student Information F First Name Middle Name Last Name Gender / / / / Country of Birth Date of Birth (mm/dd/yyyy) Date first enrolled in ANY U.S. school (mm/dd/yyyy) School Information / /20 Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade Questions for Parents/Guardians What is the native language(s) of each parent/guardian? (circle one) (mother / father / guardian) Which language(s) are spoken with your child? (include relatives -grandparents, uncles, aunts,etc. - and caregivers) M seldom / sometimes / often / always (mother / father / guardian) What language did your child first understand and speak? seldom / sometimes / often / always Which language do you use most with your child? Which other languages does your child know? (circle all that apply) speak / read / write speak / read / write Will you require written information from school in your native language? Y N Parent/Guardian Signature: X Which languages does your child use? (circle one) seldom / sometimes / often / always seldom / sometimes / often / always Will you require an interpreter/translator at Parent-Teacher meetings? Y N / /20 Today s Date: (mm/dd/yyyy)

12 Salem Public Schools City of Salem " 29"Highland"Avenue,"Salem,"Massachusetts"01970" """"""""""""""""""""(978)"740?1225""""""""Fax"(978)740?1176" Acknowledgement Eligibility for Free/Reduced Price Meals: How Information Will Be Used Parent Name: Student Name: I acknowledge and agree to release to the Salem Public Schools Parent Information Center and further acknowledge and agree that the Salem Public Schools free and reduced price meals officials may give to the Salem Public Schools Parent Information Center information concerning my child s eligibility or non-eligibility for price meal benefits. I acknowledge and agree that the Salem Public Schools Parent Information Center may use this information to help determine the placement of my child. I understand that both the Salem Public Schools and I free and reduced price meals officials will be releasing eligibility information to the Salem Public Schools Parent Information Center from the Price Meal Benefit Form for my child. I give up my rights to confidentiality for this purpose only. I understand that I am not required to release this information and that my declining to sign this form will not affect my child s eligibility and participation for price meal benefits or non-eligibility for price meal benefits. I understand that if I elect not to release this information, the Salem Public Schools Parent Information Center will consider my child non-eligible for free and reduced price meals only for purpose of determining school placement for my child.! I am choosing to release my eligibility for free or reduced price meal benefits and am attaching a copy of our meals application.! I am electing not to release this information and/or my family is not eligible for this benefit. I have read this release and understand its terms and sign it voluntarily. Parent/Guardian Signature Date Please Note: This voluntary disclosure is used in the registration process only. When your child begins school, you must submit your formal application for the federal free and reduced price lunch program and be determined to be eligible to receive free or reduced price meals.

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