Brentwood School District
|
|
- Edgar Goodwin
- 8 years ago
- Views:
Transcription
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.
3
4 Grade Name of School District City State
5
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
8
9
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.
Address: Street City State Zip Code Home Phone: E-mail Address:
SANDWICH CUSD #430 REGISTRATION FORM SCHOOL YEAR 2013-2014 SELECT AN ATTENDANCE CENTER LG Haskin Prairie View WW Woodbury HE Dummer Middle School High School 1. NAME: 5. SEX: Male Female Last Name First
More informationMaple Heights City Schools
Maple Heights City Schools ENROLLMENT OFFICE 5740 Lawn Avenue Maple Heights, Ohio 44137 ENROLLMENT OFFICE Phone: 216.587.6100, Ext. 3701 CHANGE OF ADDRESS REGISTRATION PACKET USE THIS PACKET FOR A CHANGE
More information2014-2015 Enrollment Packet
2014-2015 Enrollment Packet Please review the information below. Based on your student (s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in
More informationCHARLOTTE-MECKLENBURG SCHOOLS
STUDENT PLACEMENT ENROLLMENT INFORMATION The following documents are required for enrollment: q Student Enrollment Form q Original Certified copy of student s birth certificate - hospital, souvenir or
More informationTUITION RATES SCHOOL YEAR 2015-2016
TUITION RATES SCHOOL YEAR 2015-2016 REGISTRATION FEE: $65.00 per child DISCOUNTS: Family discount apply to families with two or more children in the Extended Day program. Full price is paid for the youngest
More informationOther Forms from Seattle Public School District
SEATTLE PUBLIC SCHOOLS Other Forms from Seattle Public School District Medical & Other Forms Privacy Rights Student Survey Form to Identify Disabled Students (504-2) Authorization for Medications to be
More informationDIABETES FOR STUDENT SELF-MANAGEMENT OF HEALTH CONDITION STEP 1 PARENT OR GUARDIAN REQUEST TO ALLOW STUDENT TO SELF-MANAGE HEALTH CONDITION AT SCHOOL
DIABETES DIABETES FOR STUDENT SELF-MANAGEMENT OF HEALTH CONDITION STEP 1 PARENT OR GUARDIAN REQUEST TO ALLOW STUDENT TO SELF-MANAGE HEALTH CONDITION AT SCHOOL ( the Student ) has diabetes. I/we hereby
More informationMontessori Children s House Registration Form. Child s Name: Start date: Place of Employment. Place of Employment
Montessori Children s House Registration Form Child s Name: Start date: Date of Birth: Nickname: Mother s Name: Mother s Address: Contact Numbers Place of Employment Work Address Work Phone Social Security
More informationOFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO
OFFICE OF CATHOLIC SCHOOLS ARCHDIOCESE OF CHICAGO SCHOOL MEDICATION PROCEDURES Parents/guardians have the primary respomibility for (he adminislration of medical ion to their children. The administration
More informationChoptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL
Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline County Public School system, your child has access to the School-Based
More informationFort Vermilion School Division No. 52
P.O. Bag 1 (5213 River Road) Fort Vermilion, AB T0H 1N0 Phone: 780-927-3766 Fax: 780-927-4625 STUDENT INFORMATION REGISTRATION FORM Student s Legal Name: Last First Middle Student s Preferred Name: (if
More informationHealthCareers. Discovery Camp. Post Acute Medical Specialty Hospital Corpus Christi, TX June 17 & 18, 2015. Application Packet
HealthCareers Discovery Camp Post Acute Medical Specialty Hospital Corpus Christi, TX June 17 & 18, 2015 Application Packet Personal Information Name: Address: City: State: Date of birth: ZIP code: Home
More informationCommunity House High School Programs Standing with families since 1969
Dear Parents/Guardians, Founded in 1969, Community House is devoted to standing with Princeton families by providing tools for academic success and social- emotional wellness through programs that bolster
More informationCONTRACT. Southwest Tour. Arkansas and Texas
27 th Annual Tour CONTRACT Southwest Tour Arkansas and Texas APRIL 3 rd April 10, 2016 COLLEGES and UNIVERSITIES (Tentative) Arkansas Baptist College, Huston-Tillotson University, Jarvis Christian College,
More informationDescriptor Term: STUDENT ADMISSIONS ISSUE DATE: 8-6-07 REVISED: 4-22-13 REVISED: 4-13-15
The Jackson County School District exists to provide publicly supported education to district residents. A child s residence is the residence of his or her parents or full legal guardian. The Jackson County
More informationHEALTH REQUIREMENTS & SERVICES: MEDICAL TREATMENT
DESCRIPTOR TERM: Students Millard District Policy File Code: 6200 1 st Reading: 05-08-14 HEALTH REQUIREMENTS & SERVICES: MEDICAL TREATMENT Purpose The purpose of this policy is to authorize school personnel
More informationDr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
More informationANCHOR BAY SCHOOL DISTRICT 5201 County Line Road, Suite 100 Casco, Michigan 48064 Phone: 586-725-2861, Fax: 586-727-9059
ANCHOR BAY SCHOOL DISTRICT 5201 County Line Road, Suite 100 Casco, Michigan 48064 Phone: 586-725-2861, Fax: 586-727-9059 Anchor Bay Website: http://anchorbay.misd.net Elementary Registration Checklist
More informationCENTRAL VALLEY CENTRAL SCHOOL DISTRICT REGISTRATION GUIDELINES
CENTRAL VALLEY CENTRAL SCHOOL DISTRICT REGISTRATION GUIDELINES Parents or Guardians need to supply the following paperwork in order to register a child: 1) Proof of Residency (see addendum A) 2) Proof
More informationStonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
More informationPlum Borough School District Nursing Services Department
Information Regarding the Student with an Allergy Student s Name Grade Homeroom Date Physician s Name Physician s Phone # Type of Allergy (Food, Bee, Wasp, Latex, Other: Specify): Type of Reaction: For
More informationWATONGA ELEMENTARY SCHOOL 900 North Leach Main Office: (580) 623-5248 P.O. Box 640 Facsimile: (580) 623-5238 Watonga, Oklahoma 73772
WATONGA ELEMENTARY SCHOOL 900 North Leach Main Office: (580) 623-5248 P.O. Box 640 Facsimile: (580) 623-5238 Watonga, Oklahoma 73772 Website: www.watongapublicschools.com 2014-2015 STUDENT ENROLLMENT INFORMATION
More informationJACKSON PUBLIC SCHOOL DISTRICT 2015 2016 Pupil Registration
JACKSON PUBLIC SCHOOL DISTRICT 2015 2016 Pupil Registration Welcome to our online registration site powered by InfoSnap! To begin the registration process, both new and returning students should receive
More informationTHE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP
THE CENTER FOR GLOBAL EDUCATION & CITIZENSHIP 2011 SUMMER FASHION PROGRAM STUDENT APPLICATION CHECKLIST To apply for the Summer Fashion Program, please submit the required documents to The Center for Global
More informationNew River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
More informationJohns Creek Montessori School Of Georgia
ENROLLMENT FORM Pre-Primary (Toddler) Primary Half Day Full Day All Day Start : Child s Information: Child s Name Street Address Nickname of Birth Subdivision Name Primary Language Spoken Parent/Guardian
More informationWinter Camp 2015 Church Registration Instructions and Policies
Winter Camp 2015 Church Registration Instructions and Policies Registration Instructions: 1) Choose your weekend(s). Prayerfully consider which available weekend is the best for your church. Bring your
More informationImportant Information Please keep this page for your records
Camp Horizon Important Information Please keep this page for your records 1. Complete the enclosed application and the scholarship form thoroughly. Mail them immediately to the camp address listed below.
More informationDear Parents: We appreciate the opportunity to work with your child and look forward to getting to know your family. Sincerely,
Dear Parents: Thank you for considering Mobile Therapy Centers of America, LLC (MTC) for your child s therapy needs. At MTC, we strive to provide the highest quality of therapeutic intervention. Our services
More informationLearning 2 Mastery After-School Reading and Math Program Parent Packet
Parent Packet 700 Pelham Road North, Jacksonville AL 36265 Dear Parents! Welcome to a new and exciting time with the Learning 2 Mastery program. The hours of operation during the program are 3:15 p.m.
More informationGREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER
GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires
More informationRegistration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015
Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. Date of Program Please print in ink or type, and
More informationSOUTHWEST OHIO INLINE HOCKEY PLAYER DOCUMENTATION COVERSHEET
SOUTHWEST OHIO INLINE HOCKEY PLAYER DOCUMENTATION COVERSHEET School / Team: Name: Address: City, State, Zip: Home Phone: Cell Phone: Email: (please circle your responses) Do you attend the above named
More informationRULE. The Administration of Medication in Louisiana Public Schools
RULE The Administration of Medication in Louisiana Public Schools Developed in 1994 by The Louisiana State Board of Elementary and Secondary Education and The Louisiana State Board of Nursing Amendments
More informationEnrollment Application
Enrollment Application MVA: Leading the Way Based on your student(s) grade and applicable circumstances, complete one enrollment packet per student and review the information below to determine what you
More informationSummer Institute 2015 for CCS Students Arts Impact Middle School (Located on Ft. Hayes Campus) 680 Jack Gibbs Boulevard, Columbus, Ohio 43215
Summer Institute 2015 for CCS Students Arts Impact Middle School (Located on Ft. Hayes Campus) 680 Jack Gibbs Boulevard, Columbus, Ohio 43215 Columbus City Schools will offer the Summer Institute to assist
More informationEnrollment Application 2014-2015
Enrollment Application 2014-2015 Student Name: Date: Current Grade Level: Current School: Date of College Track Presentation: Submit Application by: Checklist of items that must be returned to College
More informationCONSENT FOR MEDICAL TREATMENT
CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern
More informationRegulation 757-3 STUDENTS November 13, 2013 STUDENTS. Student Health Services and Requirements
STUDENTS November 13, 2013 STUDENTS Student Health Services and Requirements Guidelines for School Staff/Child Care Contractor (CCC) to Carry Out Health Treatment Procedure and/or Emergency Treatment Procedures
More informationChicago Public Schools Policy Manual
Chicago Public Schools Policy Manual Title: ADMINISTRATION OF MEDICATION DURING SCHOOL HOURS Section: 704.2 Board Report: 06-0927-PO1 Date Adopted: September 27, 2006 Policy: The Chief Executive Officer
More information2015 Annual Patient Paperwork Update for Existing Patients
2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě
More informationGLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR 2015-2016 SCHOOL YEAR
GLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR 2015-2016 SCHOOL YEAR Welcome Child s Enrollment Form Parent Pick-Up Authorization Emergency Information, Waiver & Medical
More informationRainbows of Learning School Age Child Care Program At Frankford Township School
Rainbows of Learning School Age Child Care Program At Frankford Township School Parent/Guardian #1 Name: Address: Employer: Parent/Guardian #2 Name: Address: Employer: Child s Name: Birth date: Gender:
More informationOKLAHOMA SCHOOL FOR THE DEAF DEAF AND HARD OF HEARING SUMMER CAMP HIGH SCHOOL JUNE 14-19, 2015 ELEMENTARY SCHOOL JUNE 21-24, 2015 REGISTRATION DAY
OKLAHOMA SCHOOL FOR THE DEAF DEAF AND HARD OF HEARING SUMMER CAMP HIGH SCHOOL JUNE 14-19, 2015 ELEMENTARY SCHOOL JUNE 21-24, 2015 REGISTRATION DAY WHEN: JUNE 14 th (High School) JUNE 21 nd (Elementary)
More informationUNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
More informationMath + Leadership Camp at CSUSM Registration Forms
Math + Leadership Camp at CSUSM Registration Forms CONTACT INFORMATION Math for America San Diego Email: sandiego@mathforamerica.org Phone: 858-822-6284 Registration Checklist Complete all sections of
More informationIf your child fails the screening, you will be informed of test results. Please direct any questions to the. school nurse at.
If your child passes the vision screening, you may not be contacted by the school nurse. A vision screening provides only a snapshot of how your child performs on the day the test was administered and
More informationColquitt County Schools Enrollment Packet. Request Forms Middle School
Enrollment Packet Request Forms Middle School Statement of Objection to Use of Social Security Number for Student Identification Request I do not wish to provide the Social Security Number of my child/children.
More informationApplication for Childcare
261 Sky River Parkway Monroe, WA 98272 Tel: (360) 794 4775 DSHS Provider #: 827175 Application for Childcare Child s Name: Grade (current/going into): School: Please indicate which program you will be
More informationKU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION
KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance
More informationOnline registration TH Bell Print documents
Online registration TH Bell Print documents RETURN THIS FORM COMPLETED T.H. BELL JUNIOR HIGH SCHOOL REGISTRATION FEE CHECKLIST Student Name: Grade: REQUIRED FEES Student Activity Card $18.00 Textbook Rental
More informationTOWN OF POUGHKEEPSIE POLICE DEPARTMENT
TOWN OF POUGHKEEPSIE POLICE DEPARTMENT INFORMATION PACKET OVERVIEW The Town of Poughkeepsie Police Department is seeking to provide an innovative program for youth residing in the Town of Poughkeepsie.
More informationSTEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire.
New Rising Star Missionary Baptist Church Rising Stars Enrichment Program Registration Packet 7400 London Avenue, Eastlake Birmingham, Alabama 35206 Phone: (205) 833-3676 Email Address: risingstarscamp@nrschurch.org
More informationADMINISTRATION OF MEDICATIONS POLICY
Policy 6.007. ADMINISTRATION OF MEDICATIONS POLICY It is the policy of Cooperative Educational Services (C.E.S.) that students who require any medications to be administered during school hours, including
More informationROCHESTER AREA SCHOOL DISTRICT
No. 210 SECTION: PUPILS ROCHESTER AREA SCHOOL DISTRICT TITLE: USE OF MEDICATIONS ADOPTED: August 11, 2008 REVISED: August 25, 2014 210. USE OF MEDICATIONS 1. Purpose The Board shall not be responsible
More informationDear Corner Stone Charter Parent:
Dear Corner Stone Charter Parent: Welcome to Boll Family YMCA s School Age Child Care (SACC) program. We are looking forward to sharing the next 11 months with your child before and after school. Attached
More informationINSURANCE VERIFICATION FORM - Atco Medical Associates
INSURANCE VERIFICATION FORM - Atco Medical Associates Patient Name Date of Birth Social Security # Single Married Separated Widowed Home Phone Cell Phone # 1 Cell Phone # 2 E-Mail Address Spouse's Name
More informationE. C. GLASS HIGH SCHOOL 2111 MEMORIAL AVENUE, LYNCHBURG, VA 24501
E. C. GLASS HIGH SCHOOL 2111 MEMORIAL AVENUE, LYNCHBURG, VA 24501 COUNSELING DEPARTMENT MAIN OFFICE Janet Reynolds Director Dr. Tracy Richardson, Principal 434-515-5372 / FAX: 434-522-3746 434-515-5370
More informationIMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
More informationDear Prospective Student:
Dr. Shalamon Duke Dean, Support Services West Los Angeles College 9000 Overland Avenue Culver City, CA 90230 (310) 287-4423 Office (310) 287-4417 Fax www.wlac.edu Dear Prospective Student: Welcome to the
More informationChoptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL
School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline, Dorchester and Talbot County Public School system, your child has access to the
More informationForrest M. Bird Charter School
Permission to Release Records To: Forrest M. Bird Charter School 614 South Madison Avenue, Sandpoint ID 83864 208-255-7771 Phone * 208-263-9441 Fax Student Information: Please Print Student s First Name
More informationThis registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015
STUDENT REGISTRATION FORM Camp Session Dates: June 22, 2015- June 26, 2015 This registration form is also accessible online at: https://www.csuohio.edu/business/gyes-2015 Last Name: First Name: M.I.: Preferred
More informationTHE SCHOOL DISTRICT OF PHILADELPHIA NORTHEAST HIGH SCHOOL COTTMAN AND ALGON AVENUES PHILADELPHIA, PENNSYLVANIA 19111-3499.
THE SCHOOL DISTRICT OF PHILADELPHIA NORTHEAST HIGH SCHOOL COTTMAN AND ALGON AVENUES PHILADELPHIA, PENNSYLVANIA 19111-3499 Re: 2014-2015 School Year To the Parent / Guardian All students entering ninth
More informationFERNDALE AREA SCHOOL DISTRICT
No. 210 SECTION: PUPILS FERNDALE AREA SCHOOL DISTRICT TITLE: MEDICATIONS ADOPTED: AUGUST 1985 REVISED: DECEMBER 6, 2000 MAY 9, 2007 JUNE 17, 2009 JUNE 18, 2014 210. MEDICATIONS REVISED: 1. Purpose The
More informationMother Stepmother Guardian. Your Child. Father Stepfather Guardian. Parent s Marital Status. Primary Dental Insurance. How Did You Hear About Us?
www.hendersonvilledentalspa4kidz.com Your Child First MI Last Preferred Sex Age School Grade Child s Home Address City State/Prov. Zip/P.C. _ Phone Primary Dental Insurance 264 New Shackle Island Rd.,
More informationWELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes)
Robert D. Fowler Family YMCA Middle School Enrichment Program Student Registration Form 2015-16 Ivy Prep Academy Program Hours: 7am-7:45am & 4pm-7pm Transportation AM: Group leaves at 7:30am Transportation
More informationLawyers Autism Awareness Foundation Treatment Grant Notice
Lawyers Autism Awareness Foundation Treatment Grant Notice ( LAAF ) is a nonprofit 501(c)(3) corporation whose mission is to foster autism spectrum awareness in the Tampa Bay area and raise funds to give
More informationBackcountry Outdoor Adventure Camp
Backcountry Outdoor Adventure Camp Get outdoors. Connect with nature. Focused on combining a passion for biology, conservation, and ecology with outdoor recreation. Registration Packet is due by: Registration
More informationP.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
More informationJoin the Future Inspired Native American Leaders Program!
Join the Future Inspired Native American Leaders Program! What is it? An exciting program that prepares American Indian high school young men to become college and career ready and learn about their culture!
More informationYouth Camp Civic Center
Youth Camp Civic Center Household ID # Please circle the session(s) that your child(ren) will attend Session One June 8- June 12 Session Two June 15 June 19 Session Three June 22 June 26 Session Four June
More informationJacob s Ladder Pediatric Rehabilitation Center, Inc. Child Respite Program
Page 1 of 5 Intake Sheet Child s Name #1 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Child s Name #2 Age Birth Date Grade: School: Sex: M F Diagnosis/Disability: Father/Mother/Guardian:
More informationTECHNOLOGY USAGE ACKNOWLEDGEMENT
TECHNOLOGY USAGE ACKNOWLEDGEMENT (Grades 3-8) Computers, networks, and online communications and information systems such as the Internet and email are becoming more commonplace in our classrooms and media
More informationVolunteer Driver Application Form
Road to Recovery Volunteer Driver Application Form Please Print Name: Street Address: City State Zip: Other Address Information/ Email: Home Phone: Work Phone: Date of Birth: Occupation: Emergency Contact
More informationEighth Graders Israel Experience May 7-19- 2014 APPLICATION
please attach photo Part I: Applicant Information Eighth Graders Israel Experience May 7-19- 2014 APPLICATION Applicant's name (As appears on passport) Last first middle what do you want to be called?
More information5530.01 - DRUG TESTING DRUG TESTING PROGRAMS
5530.01 - DRUG TESTING Drug and alcohol abuse in any school is a threat to the safety and health of students, faculty, staff, and the community as a whole. It jeopardizes the efficiency and the quality
More informationPlease put above in a plastic Ziploc bag with your child s name on it.
Dear Parent(s), You have noted your child has medications related to an allergic reaction. The Stamford Museum & Nature Center s requirements for noted medications are as follows: Epi-pen requirements
More informationLighthouse Christian Academy
Lighthouse Christian Academy APPLICATION - FORM 1 of 9 Term 20-20 Date Office Use Only Interviewed By: Status: STUDENT INFORMATION (Please print or type) Name (Last) (First) (Middle) Address (Street) (City)
More informationThis technical advisory is intended to help clarify issues related to delegation of medications during the school day.
This technical advisory is intended to help clarify issues related to delegation of medications during the school day. Actual Text - Ed 311.02 Medication During School Day (a) For the purpose of this rule
More informationGrande Prairie Public School District #2357 Student Registration Form
Grande Prairie Public School District #2357 Student Registration Form STUDENT INFORMATION SCHOOL ID: ENROLLING IN GRADE: LEGAL LAST NAME LEGAL FIRST NAME LEGAL MIDDLE NAME(S) PREFERRED LAST NAME PREFERRED
More informationWelcome to Latta Public Schools
Welcome to Latta Public Schools 2015-2016 Pre-K-4 th Online Enrollment Packet Forms Included: Enrollment Form Student Health Inventory Form Student Enrollment Questionnaire Home Language Survey Tribal
More informationThank you for your interest in the Illinois Association for College Admission Counseling s 2015 CAMP COLLEGE program!
Greetings! Thank you for your interest in the Illinois Association for College Admission Counseling s 2015 CAMP COLLEGE program! These waiver forms must be completed and submitted in order for your application
More informationStudent & Health Information for Bates College Off-Campus Short Term Courses
Student & Health Information for Bates College Off-Campus Short Term Courses 1. Name Program/Course Bates ID # Email Cell phone: Home Address: Date of Birth Nationality If course is going abroad, attach
More informationROLE OF THE PARENT/LEGAL GUARDIAN IN THE ADMINISTRATION OF MEDICATION AT SCHOOL
ROLE OF THE PARENT/LEGAL GUARDIAN IN THE ADMINISTRATION OF MEDICATION AT SCHOOL The parent/legal guardian who wishes medication to be administered at school to his/her child has the following responsibilities:
More informationVirginia South Psychiatric & Family Services
All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow
More informationmedication Consequences For Minor Students
CONSENT TO FORM OF CONSENT MINOR S CONSENT TO TREATMENT The school in which a minor student is enrolled may consent to medical, dental, psychological, and surgical treatment of that student, provided all
More informationSignature: Date: Witness:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
More informationDEFINITIONS: For purposes of this policy, the definitions included in this section apply:
STUDENTS Administrative Procedures 516A Administering Prescribed Medication in School Students may require prescribed medication at school in order to benefit from their educational experience. The following
More informationPlease email: tchin@sbnature2.org for more details.
Medication Protocol: All medications (both over-the-counter and prescribed) must be cleared by the camper s guardian (additionally all prescribed meds must be cleared by a Physician) by filling out the
More informationCity College of San Francisco Gateway to College Application for Admission
Please read the application carefully before completing. Print clearly in blue or black ink. Be sure to complete the entire application and required essays. Please bring your completed application with
More informationBig House 2015. Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th
Cost for the Trip $125 if turned in by March 29th $150 if turned in by April 26th $175 if still space in the camp after April 26th Big House 2015 June 11-14 Bellville, TX Big House is a summer mission
More informationTITLE 23: EDUCATION AND CULTURAL RESOURCES SUBTITLE A: EDUCATION CHAPTER I: STATE BOARD OF EDUCATION SUBCHAPTER k: SCHOOL RECORDS
ISBE 23 ILLINOIS ADMINISTRATIVE CODE 375 TITLE 23: EDUCATION AND CULTURAL RESOURCES : EDUCATION CHAPTER I: STATE BOARD OF EDUCATION : SCHOOL RECORDS PART 375 STUDENT RECORDS Section 375.10 Definitions
More informationCOATESVILE AREA SCHOOL DISTRICT ATTENDANCE POLICY 2014/2015 SCHOOL YEAR
COATESVILE AREA SCHOOL DISTRICT ATTENDANCE POLICY 2014/2015 SCHOOL YEAR I. Compulsory Attendance (Section 1326of the PA School Code) Section 1326 of the PA School Code, defines compulsory school age as
More informationTHE NEWARK PUBLIC SCHOOLS Newark, New Jersey POLICY
THE NEWARK PUBLIC SCHOOLS Newark, New Jersey POLICY FILE CODE: 5113 (Page 1 of 6) ABSENCES AND EXCUSES In order for the Newark Public Schools to fulfill its responsibility for providing a thorough and
More information1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
More informationKidsWell School-Based
KidsWell School-Based Health Center ENROLLMENT FORM PLEASE SIGN AND RETURN COMPLETED FORM TO THE SCHOOL NURSE KidsWell School-Based Health Center Exclusively offered inside the following CCSD schools:
More informationVermont Board of Nursing INSTRUCTION TO APPLICANTS
Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org INSTRUCTION TO APPLICANTS The following applies to applications
More informationPatient Demographic Form
Patient Demographic Form New Patient Returning Patient Primary Care Physician (PCP) Name: Patient Name: Last Name First Name MI Address: P.O. Box City: State: Zip: Cellular Number: Home Number: Work Number:
More informationRARITAN BAY AREA YMCA
Dear Applicant, Enclosed please find the Youth Leaders & Junior Counselor In Training Application and the Camp Registration Packet. Please complete the application and return all documents with your $100.00
More information