to access a file containing all required forms in a single pdf.

Transcription

COPPER RIVER SCHOOL DISTRICT
STUDENT ENROLLMENT FORM
Alaska Student ID#:
School Year:
Grade:
Check site enrollment:
Glennallen Elementary School
Kenny
Glennallen High School
Lake School
Slana School
General Information
To be completed by parent/legal guardian (or student if age 18 or older). Form must be physically received by site school before admittance of student.
Student’s Full Name (Last, First, MI)
Birthdate (Mo/Day/Year)
Sex
M
Daytime Phone
F
(
)
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Resident School District:
Copper River School District
Race/Ethnicity/NCLB Category:
Alaskan Native
American Indian
Disabled
Yes No
Low Income
(TANF)
Asian
Black, not Hispanic Origin
LEP
(Limited English Proficiency)
Hispanic
White
Native Hawaiian/Pacific Islander
Multi-Ethnic
Has the student been expelled at any time during the previous school year or are any disciplinary proceedings pending?
Does the student receive special education?
If yes, does the student have an individualized education program (IEP)?
Parent/Guardian Signature and Permission for Release of Records
(If parents are divorced and have joint custody, both parents must sign the application form unless one parent has been
granted responsibility by the court for making education decisions.)
All information is complete and correct. I grant permission for the school district to request from the school my child last attended information
about whether my child has been referred for special education and information about my child’s special education program, including a copy of
the individualized education program (IEP). I understand that the school district may request from the previous school district any information
about my child relating to expulsion or expulsion proceedings.
Signature(s) of Parent/Guardian or Student (if 18 or older)
Parent/Guardian Name(s)
Date Signed
Signature(s) of Parent/Guardian
Parent/Guardian Name(s)
Date Signed
STUDENT ENROLLMENT FORM
Parent / Guardian Information
Father’s Name :
Phone Number:
Father’s Employer:
Cell Phone:
Father’s Email:
Mother’s Name:
Phone Number:
Mother’s Employer:
Cell Phone:
Mother’s Email:
Emergency Information
Name of Emergency Contact:
(Person to contact in case of emergency other than parent)
Phone Number:
Name of Physician:
Cell Phone:
Phone Number:
Name of Babysitter:
Cell Phone:
Phone Number:
Cell Phone:
Name of Student
Request for Student Records
Birthdate Mo/Day/Yr
To: Administrator, ______________________________________ School District
School Name:___________________________________
Address:_____________________________________________________ Phone:__________________________________________________
In accordance with Copper River School District policies, I hereby request the following information related to the
above-named student:
1.
2.
3.
4.
5.
6.
Information about whether the student has been referred for special education, but has not yet been evaluated.
Information about the student’s special education program, including a copy of the student’s individualized
education program (IEP).
Information about any pending disciplinary proceeding that could lead to expulsion, including a written
explanation of the reason(s) for the pending disciplinary proceeding and the possible outcomes of the
disciplinary proceeding.
A copy of any expulsion order involving the pupil for the previous school year, including a written explanation
of the reason(s) for the expulsion and the length of term of the expulsion.
Complete Transcript with Grades to Date.
Test Scores.
Health Card
7.
Copper River School District
Name and Title of School Official
Telephone Area/No.
Signature of School Official
Date Signed
(
)
Questions may be directed to: School Secretary, Copper River School District, P.O. Box 108, Glennallen, AK. 99588, (907) 822-3234
Parental Concerns
Directions: Do you believe your child has a special need? Please check all your concerns from
the following list.
Student’s name: _____________________________________ Grade: ____________________
1. Behavior. My child:
has tantrums
is not able to accept limits
resists rules or refuses to
comply with requests
is destructive with toys
clings to an adult
appears sluggish or lacks
energy
is fearful or worries a lot
rarely smiles, giggles, or laughs
2. Socialization. My child:
does not play with other
children
does not separate from me
easily
will not work in a group
is left out of activities with
other children
3. Speech/Language. My child:
has unclear or garbled speech
has difficulty expressing wants
uses incomplete sentences
needs instructions repeated
often
repeats what she or he says
doesn’t remember simple
information from day to day
gives inappropriate answers to
questions
4. Self Help. My child:
has toileting difficulties
has difficulty feeding or
dressing himself or herself
has difficulty following routines
5. Attention. My child:
is easily distracted
has a short attention span
darts from one task to another
persists when asked to stop
6. Developmental Abilities. My child:
does not appear to be learning
at an average rate
has had delays in
developmental milestones
does not seem to understand
well
acts much younger than his/her
age
seeks much younger friends
7. Motor. My child:
is clumsy
has difficulty using pencils,
crayons, or scissors
has difficulty buttoning or zipping
has hand/eye coordination
problems
has poor control of body
movements
8. Hearing. My child:
has trouble hearing
asks people to repeat or talk
louder
favors one ear over the other
is startled at sudden noises
has earaches
speaks loudly
watches a person’s face when
that person is talking
9. Vision Problems. My child:
has eyes that turn in
has eyes that turn out
squints
tilts his/her head
wants to sit too close to the TV
holds books very close to
his/her face
blinks a lot
rubs his/her eyes
10. Medical/Health Related. My child:
has been in the hospital ____
times.
has had serious illnesses
has had accidents
If you have a concern that is not listed, please write it here.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
This form was completed by: ______________________________________________________
Relationship to child: __________________________________________ Date: ____________
Name of Student: ___________________________________ Date of Birth: ________________ Tuberculosis (TB) Risk Assessment for Alaska Students Has the student been in contact with anyone who has active TB disease in the past year? Yes No Notes Is the student foreign‐born?* (Any country other than U.S., Canada, Australia, New Zealand, or Western/Northern Europe) Yes No Has the student traveled to a high‐TB‐prevalence country for more than a month cumulatively during the past year? (Any country other than U.S., Canada, Australia, New Zealand, or Western/Northern Europe) Yes No In Alaska, TB is most common in the Yukon‐Kuskokwim or Norton Sound regions. Does the student live in one of these regions, or has the student travelled to one of these regions for more than a month cumulatively during the past year? Yes No TB Risk Assessment Test: Alaska law requires a TB Risk Assessment be on file for all students new to the Copper River School District. I understand that my child will be given a TB skin test within 90 days of enrollment as required by State Law 7AAC27.213 if risk assessment indicates it is needed, during the period they are enrolled in the Copper River School District. An exemption for testing is permitted if documentation of one of the following is provided to your School Nurse: 1. TB skin test results within the previous 6 months 2. history of positive skin test or history of TB disease 3. Negative laboratory‐approved method within the previous 6 months (this is a parent expense and optional) My signature below attests to the accuracy of the above responses and gives the School Nurse permission to administer a TB skin test if warranted. Parent/Guardian Signature Date School Nurse Signature: _________________________________ Date: ___________________ Tuberculin Skin Test Needed? __________________ .1 ml PPD Mfg: ________________________ Lot # _________________ Exp: ______________ Admin Date: _________________ Time: _______________ by: ________________________________________________________ Forearm Site: R L (circle one) Result Date: _________________ Time: _______________ by: __________________________ RESULT: __________ mm induration Non‐Reactive/Reactive (circle one) Chest x‐ray referral: ___________________ rev. 4_10_15 Clearance given: ________________________________________________________________ AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
As legal custodian of _____________________________________________, a minor, I hereby
authorize the principal or his/her designee (agent), into whose care the aforementioned minor
pupil has been entrusted, to consent to any x-ray, examination, anesthetic, medical or surgical
diagnosis, treatment, and/or hospital care to be rendered to said minor upon the advice of any
licensed physician and/or dentist.
Every effort will be made at the time of the incident by the Copper River School District
representatives who are present to contact the legal guardians before medical treatment is
administered.
I understand that this authorization is given in advance of any required diagnosis, treatment, or
hospital care and provides authority and power to the aforementioned agent(s) to give specific
consent to any and all such diagnosis, treatment, or hospital care which licenses physicians or
dentist may deem necessary.
This authorization shall remain effective for the full school year unless revoked in writing and
delivered to said agent(s). I understand the Copper River School District, its employees and
Board assumes no liability of any nature in relation to the transportation or treatment of said
minor, and is not responsible for the medical bills in the event of an injury to my child.
Family Doctor:
Address:
Phone:
Health Plan/Insurance Company Name:
My child is allergic to the following medications:
Other medications being used:
My child has the following health problems:
Signature of Parent/Guardian:
Date:
OMB Number: 1810-0021
Expiration Date: 05/03/2016
U.S. DEPARTMENT OF EDUCATION
OFFICE OF INDIAN EDUCATION
WASHINGTON, DC 20202
TITLE VII STUDENT ELIGIBILITY CERTIFICATION
Elementary and Secondary Education Act, Title VII, Part A, Subpart 1
Parents: Please return this completed form to your child's school. In order to apply for a formula grant under
the Indian Education Program, your child's school must determine the number of Indian children enrolled. Any
child who meets the following definition may be counted for this purpose. You are not required to complete or
submit this form to the school. However, if you choose not to submit a form, the school cannot count your child
for funding under the program. This form will become part of your child's school record and will not need to
be completed every year. This form will be maintained at the school and information on the form will not be
released without your written approval.
Definition: Indian means any individual who is (1) a member (as defined by the Indian tribe or band) of an
Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized by the
State in which the tribe or band reside; or (2) a descendent in the first or second degree (parent or
grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any
purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group that
received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.
NAME OF CHILD ____________________________________
(As shown on school enrollment records)
Date of Birth ___________________
School Name ___________________________________________
Grade _____________
NAME OF TRIBE, BAND OR GROUP________________________________________________________
Tribe, Band or Group is: (check one)
Federally Recognized,
State
_____ Including Alaska Native _____ Recognized _____ Terminated
Organized Indian Group
Meeting #5 of the
_____ Definition Above
Name of individual with tribal membership: _____________________________________________
Individual named is (check one): _____ Child
_____ Child's Parent
_____ Child's
Grandparent
Proof of membership, as defined by tribe, band, or group is:
A. Membership or enrollment number (if readily available) _________________________ OR
Other (explain) _____________________________________________
Name and address of organization maintaining membership data for the tribe, band or group:
__________________________________________________________
I verify that the information provided above is accurate:
PARENT'S SIGNATURE _______________________________________ DATE ____________________
Mailing Address _______________________________________________ Telephone _________________
Notice: Public Reporting Burden Notice on Reverse Side
PAPERWORK BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number. The
valid OMB control number for this information collection is 1810-0021. The time required to
complete this portion of the information collection per type of respondent is estimated to
average: 15 minutes per Indian student certification (ED 506) form; including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: U.S. Department
of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding
the status of your individual submission of this form, write directly to: Office of Indian
Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room 3E200,
Washington, D.C. 20202-6335.
This form is required by state and federal law.
PARENT LANGUAGE QUESTIONNAIRE
(Home Language Survey)
Identification of students who may have limited proficiency in the English language enables the school to provide appropriate learning
programs for the student. Please complete this form and return it to the school office as soon as possible. If you have questions or
need help with the form, please contact the school principal.
Student Name: ___________________________________________________ Alaska Student ID #: ______________
(Last Name, First Name)
Place of Birth: ____________________________________________________ Date of Birth: ______/______/______
School: ______________________________________________________
PART I: STUDENT LANGUAGE BACKGROUND
1. What is the first language learned by the student?
Month
Grade: _____ Gender:
English
Day
Female
Year
Male
Other _____________________
Specify
2. What language(s) does the student currently use in the home?
English
Other _____________________
3. Is this student participating in a student exchange program?
Yes
No
Specify
______/_______
4. When did the student first attend a school in the United States (if known)?
Month
PART II: FAMILY LANGUAGE BACKGROUND (Please complete all columns)
Mother/Guardian
Father/Guardian
Year
Other Significant Adult*
Relationship:
1. Home community and State
2. First language learned
3. Language(s) spoken to the
student
4. Language(s) spoken in the
adult’s home
* Other significant adult could be a grandparent, aunt, uncle, daycare provider, etc. who has contributed to the student’s language
development.
PART III: PARENT VERIFICATION OF LANGUAGE USE (Please check appropriate box)
A. When the student
speaks with family,
he/she speaks:
B. When the student
speaks with friends,
he/she speaks:
Only the other
language,
no English
Mostly the other
language,
some English
The other
language &
English equally
Mostly English,
some of the
other language
Parent/Guardian Signature:
Phone Number:
Printed Name:
Date:
Form #05-08-035a
Alaska Department of Education & Early Development
Only English
March, 2008
Name of Student (first/middle/last)
Date of Birth (mo/day/yr)
__________________________________________________________________________________________________________________
Last attended: School Name ____________________________________ District _________________________________Grade_________
City:_________________________________________________________ State _______________________________________________
To: Administrator of the __________________________________ School District:
In accordance with Copper River School District policies, I hereby request the following information related to the above-named student:
Information about the student’s special education program, including a copy of the student’s individualized education program
(IEP).
Information about any pending disciplinary proceeding that could lead to expulsion, including a written explanation of the reason(s)
for pending disciplinary proceeding.
A copy of any expulsion order involving the public for the previous school year, including a written explanation of the reason(s) for
the expulsion and the length of term of the expulsion.
Complete transcript with grades to date
Test scores
Health card
Copper River School District – School Site
GLENNALLEN SCHOOL
Telephone Area/No.
907-822-5286
Date Signed
Comments:________________________________________________________
_______________________________________________________________
_______________________________________________________________
Please send information to:
Glennallen School
P.O. Box 108
Glennallen, Alaska 99588
Phone: 907-822-5286
Fax: 907-822-8501
__________________________________________________________________________________________________________________
City:_________________________________________________________ State _______________________________________________
(IEP).
Test scores
Health card
KENNY LAKE SCHOOL
Telephone Area/No.
907-822-3870
Date Signed
Comments:________________________________________________________
_______________________________________________________________
_______________________________________________________________
Kenny Lake School
HC 60 Box 224
Copper Center, Alaska 99573
Phone: 907-822-3870
Fax: 907-822-3794
__________________________________________________________________________________________________________________
City:_________________________________________________________ State _______________________________________________
(IEP).
Test scores
Health card
SLANA SCHOOL
Telephone Area/No.
907-822-5868
Date Signed
Comments:________________________________________________________
_______________________________________________________________
_______________________________________________________________
Slana School
HC 63 Box 1002
Slana, Alaska 99586
Phone: 907-822-5868
Fax: 907-822-3850
Fluoride Rinse Program
Dear Parent/Guardian,
Cross Road Medical Center and the school nursing program will be offering weekly fluoride
treatments in the schools. Fluoride rinses are an effective way to reduce dental caries and tooth
decay. This service will be provided to your child at no cost.
Once a week your child will receive two teaspoons of 0.2% sodium fluoride rinse. He/she will
rinse vigorously around and between their teeth for one minute with the fluoride and then spit it
out.
If you would like your child to participate in the fluoride rinse program, please read and sign the
consent form below. The treatments will begin September 2014 and continue for the remainder
of the 2014-2015 school year.
If you have any questions, please contact your child’s school.
Thank you,
Sarah Cook, RN
School Nurse
I, __________________________________________________, give permission
for my child(ren), __________________________________________________, to
participate in the school fluoride program for the remainder of the 2014-2015 school
year. To the best of my knowledge, my child does not have any condition which
interferes with his/her ability to swallow.** I understand what the fluoride rinse program
entails and know where to call for further information.
__________________________________
___________________________
Signature
Date
** Even though your child will not be swallowing the fluoride, it is imperative that they have the ability
to swallow normally to avoid any complications due to choking.
FOR YOUR
PROTECTION
Your Health
Care
Information Is
Private
State of Alaska Department of Health and Social Services
NOTICE OF USE OF PRIVATE HEALTH CARE INFORMATION
Effective Date April 14, 2003
Updated September 1, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
We understand that information we collect about you and your health is personal.
Keeping your health care information private is one of our most important responsibilities.
We are required by law to maintain the privacy of protected health information and to
provide notice of our legal duties and privacy practices with regard to your protected health
information. We are committed to protecting your health care information and following all
laws about its use, and we are required to abide by the terms of this notice. You have the
right to discuss with the privacy officer your concerns about how your health care
information is shared. The law says:
1. We must keep your health care information from others who do not need it.
2. You may ask us not to share certain health care information. Sometimes, we may not be
able to agree to your request.
Who Sees And
Shares My
Health Care
Information?
How Is
Payment Made
May I See My
Health Care
Information?
Your health caregivers, such as nurses, doctors, therapists and social workers may see, use
and share your health care information to determine your plan of care. This use may cover
health care services you had before now or may have later.
We review your health care information and bills (claims) to make sure that you get quality
care and that all laws about providing and paying for your health care are being followed. We
may also use your information to remind you about appointments or to tell you about
treatment alternatives.
We may share your health care information with health plans, insurance companies,
tribal or government programs to help you get your benefits and so that we can be paid or
pay for your health care services.
In most cases, you may see your health care information. There may be legal reasons or
safety concerns that may limit the amount of information that you may see. You may ask in
writing to receive a copy of your health care information.
We may charge a small amount for copying costs.
If you think some of your health care information is wrong, you may ask in writing that we
correct or add to it. You may ask that the corrected or new information be sent to others who
have received your health care information from us. You may ask us for a list of where we
sent your health care information unless it was disclosed for treatment, payment or
operations purposes.
06-5871 (9\1\2013)
Page 1 of 3
What If My
Health Care
Information
Needs To Go
Somewhere
Else?
Could My
Health Care
Information
Be Released
Without My
Authorization?
You may ask to have your health care information sent to others. You will be asked to sign a
separate form, called an authorization form, permitting your health care information to go to
them.
The authorization form tells us what, where and to whom the information must be sent. You
can stop or limit the amount of information sent at any time by letting us know in writing.
Note: If you are younger than 18 years old and, by law, you are able to give consent for your
own health care, then your health care information is kept private from others unless you
sign an authorization form.
We follow laws that tell us when we have to share health care information, even if you do not
sign an authorization form. We always report:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
contagious diseases, birth defects and cancer;
firearm injuries and other trauma events;
reactions to problems with medicines or defective medical equipment;
to the police when required by law;
when the court orders us to;
to the government to review how our programs are working;
to a provider or insurance company who needs to know if you are enrolled in one of our
programs;
to Workers Compensation for work-related injuries;
birth, death and immunization information;
to the federal government when they are investigating something important to protect
our country, the President and other government workers;
abuse, neglect and domestic violence, if related to child protection or vulnerable adults.
We may also share health care information for permitted research purposes, for matters
concerning organ donations and for serious threats to public health or safety.
Other uses and disclosures of your health care information will be made only with your
written authorization, which you may revoke at any time.
To revoke an authorization please use form 06-5872 (Revocation of Authorization For
Release of Information). This form may be obtained by contacting the Department Privacy
Officer. Contact information for the Privacy Officer is located at the bottom of this notice.
Most uses and disclosures of psychotherapy notes require an authorization.
Additional
Rights
You have the following rights with respect to your protected health information:
May I Have a
Copy of This
Notice
This notice is yours. You may ask for a copy at any time. We reserve the right to change the
terms of this notice and to make the new notice provisions effective for all protected health
information that we maintain. If there are important changes to this notice, you will get a
new one within 60 days if you are enrolled in a health plan, such as Medicaid. An electronic
version of this notice is available at:
http://dhss.alaska.gov/Documents/Pdfs/DHSS_Notice_of_Privacy_Practices.pdf
1. to receive confidential communications;
2. to receive notification of a breach of your protected health information; and
3. to request that we restrict a disclosure to a health plan when you pay in full for a
covered service.
06-5871 (9\1\2013)
Page 2 of 3
Questions or
Complaints
If you have questions or feel your privacy rights have been violated you can contact the
Department Privacy Official by calling 907-465-2150, or by writing to State of Alaska, DHSS
Privacy Official, PO Box 110650, Juneau, AK 99811-0650, or by emailing
PrivacyOfficial@health.state.ak.us. You will not be retaliated against for filing a complaint
with DHSS or the Secretary of Health and Human Services.
You can also complain to the federal government Secretary of Health and Human Services
(HHS) or to the HHS Office of Civil Rights. Your health care services will not be affected by any
complaint made to the Department Privacy Official, Secretary of Health and Human Services
or Office of Civil Rights.
06-5871 (9\1\2013)
Page 3 of 3
Department of Health and Social Services
ACKNOWLEDGEMENT OF RECEIPT OF
DHSS NOTICE OF PRIVACY PRACTICES
___________________________________________
Printed Name of Client/Patient
___________________________________________
Client/Patient Date of Birth or Other Identification
Please indicate that you have received a copy of the DHSS Notice of Privacy
Practices by checking below and signing your name*.
!
I have received a copy of the DHSS Notice of Privacy Practices.
___________________________________________
Signature of Client/Patient or Personal Representative*
(Or Witness if signature is by mark)
__________________________________________
Date Acknowledgement Signed
_____________________________________________
Printed Name of Personal Representative or Witness
__________________________________________
Description of Personal Representative’s Authority
* Personal Representative signature required if client/patient is a minor or adult who is unable to sign this form.
DHSS STAFF ONLY: This portion to be completed by DHSS staff ONLY if unable to
obtain client/patient acknowledgement signature above OR if acknowledgement was
translated for a client. Indicate that the acknowledgement was translated or the reason
acknowledgement was not obtained by checking the appropriate box, entering other
information (if necessary) and print staff name and translator name (if necessary).
! Acknowledgement was translated for Client/Patient by:
________________________________________________(Printed Name of Translator).
An attempt was made to obtain acknowledgement for receipt of DHSS Notice of Privacy
Practices. Acknowledgement was not obtained because:
! Client/Patient declined to sign acknowledgement
! Other: (explain) _______________________________________________
_______________________________________
________________________________
Printed Name of DHSS Staff
06-5876 (09/03)
HIPAA Compliant
State of Alaska Department of Health & Social Services
Date
Page 1 of 1
Enrollment Checklist & Signature Verification Form
Parent or Guardian Name: ________________________________ Date: _______________
School:
GES
GJSHS
KLS
Slana
Students being enrolled name(s): ____________________________ Grade: _____________
____________________________ Grade: _____________
____________________________ Grade: _____________
We are excited that you are enrolling your student(s) in our school district. Please verify that you have
completed and submitted electronic copies of each of the following forms.
Student Enrollment Form
Parental Concerns Form
Parent Language Questionnaire
Student Records Request Form (Transfer Students Only)
Authorization for Emergency Medical Treatment
Free and Reduced Price School Meal Application
Tuberculosis Screening Consent
Fluoride Rinse Program
Title VII Student Eligibility Certification
DHSS Notice of Use of Private Health Care Information (Read Only: Does not require signature)
DHSS Acknowledgement of Privacy Notice
Parent Permission and Acknowledgement Form
Please **PRINT** this page, sign below, and return to your child’s school. Your signature below
verifies that you have read and fully understand the information in all enrollment documents.
______________________________________________
Parent/Guardian Signature
________________________
Date
**If you do not have access to a printer, please contact your child’s school for a paper copy.
PRINT

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Transcription

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