VBHS Required Student Forms

VBHS Required Student Forms You are encouraged to fill out these forms ​before you pick up ​ your schedule for the next school year. You may bring the completed forms with you to pick up your schedule, or the parent and student may fill out the packet at schedule pick­up. Please use this checklist to ensure you do not miss any of the forms. ❏ Emergency Call ❏ Bus Medical ❏ Media Release ❏ Student Policy Handbook Acknowledgement, Computer/Technology Acceptable Use Form ❏ http://www.vbsd.us/schools/van­buren­high­school/documents You may download/view/print the High School handbook from this link ❏ District Chemical Screening Policy ❏ Home Language Survey ❏ Parent Involvement Form ❏ *Free and Reduced Lunch Form­ only available at schedule pick­up EMERGENCY CALL FORM School Year 2016 ­ 2017 Dear Parents, We want to assist you in your child’s health care in every way possible. We must know if your child has special health needs, such as medications and/or health conditions. Please return this form to your child’s school as soon as possible. ONLY a Legal Guardian can fill out and sign this Emergency Call Form!! Student’s Name: _________________________________________________________________________ Grade: ___________ Birth Date: __________________________________________ 3rd Period Teacher:________________________________________ Address: ______________________________________________ City, State, and Zip Code: ________________________________ ​PARENT/LEGAL GUARDIAN 1
​PARENT/LEGAL GUARDIAN 2 (In Household) (In Household) Name _____________________________________________________
Name __________________________________________________________________ Home/Cell Phone ___________________________________________
Home/Cell Phone ________________________________________________________ Business Name and Position ___________________________________ Business Name and Position ________________________________________________ Business Phone and Ext. ______________________________________ Business Phone and Ext. __________________________________________________ Email Address: _____________________________________________ Email Address: __________________________________________________________ Who else has permission to pick up your child that we may call in case of an emergency? (NAMES & NUMBERS MUST BE DIFFERENT FROM THOSE LISTED ABOVE): 1. Name & Relationship: _________________________________________________ Phone #: __________________________ 2. Name & Relationship: _________________________________________________ Phone #: __________________________ 3. Name & Relationship: _________________________________________________ Phone #: __________________________ PLEASE LET US KNOW OF ANY CHANGES ************************************************************************************************************ Please list below any health conditions such as heart problems, asthma, diabetes, epilepsy, severe allergies, eye or ear problems, or any chronic or other conditions that we should know about: (NOTE: ​If you list asthma you must provide the school with an inhaler​ or indicate that your child must carry their inhaler with them. Also, ​if you note severe allergic reaction, ​you must provide your child’s school with epi pen​):​ ___________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Please list any medications that the student is currently taking and specify if he/she will be taking it at school:​______________________ _______________________________________________________________________________________________________________________________________ Please note that every attempt will be made to reach a parent before transporting a child to an emergency facility: RELEASE OF INFORMATION: I hereby authorize emergency medical services for this student. I hereby authorize the Van Buren School District Health Services to share or discuss my child’s health issues with any ​pertinent​ person. Parent/Legal Guardian Signature​ _​ ___________________________________________________ ​Date​ _______________________________________ REMEMBER: IT IS THE RESPONSIBILITY OF THE PARENTS TO NOTIFY YOUR CHILD’S SCHOOL OF PHONE AND ADDRESS CHANGES! **If your child has a medical condition that you would like to discuss with the nurse personally, please call your child’s school to make an appointment** BUS MEDICAL FORM FOR BUS RIDERS ONLY! Dear Parent, If your child has a medical problem the bus driver should be aware of, please fill out the form below and return it to your child’s school. Medical services will process the forms and get them to the designated bus drivers. NOTE: This form is forwarded to your child’s bus driver ​only​ if you mark that emergency medical treatment would be required with written description of the action the bus driver should take. Thanks for your cooperation, ​Your School Nurse Student: _______________________________________ Bus #: _____ Address: ____________________________ School: _______________ Grade: _____ 3rd Period Teacher: _________________________ Parent (1): _____________________ Parent (2): ___________________ Health Problem(s): ____________________________________________________________ _____________________________________________________________________________
_____________________________________________________________________________ Would student’s health problem(s) ever require emergency treatment? _____Yes _____No If yes, Explain the appropriate action that you would like for the bus driver to take​: _____________________________________________________________________________
_____________________________________________________________________________ Parent’s Signature: _____________________________________________ ***By signing this form you are giving your permission for your child’s health information to be shared with your child’s bus driver, if an occasion arises that requires a parent to be contacted, the bus driver will notify your child’s school and the school will notify you. VAN BUREN SCHOOL DISTRICT 2221 POINTER TRAIL EAST VAN BUREN, ARKANSAS 72956 VBSD STUDENT MEDIA RELEASE FORM The Van Buren School District request signature permission to use your child’s name, recognizable picture, or video image in any district approved media releases. Throughout the year, children’s pictures may be used in local TV spots, local paper(s), or district newsletter as the district makes an effort to make the public aware of positive things happening within our schools. Please complete the information below and indicate with your signature your permission or denial of permission to use your child’s name, recognizable picture or image in any VBSD media release. Student’s Name: ______________________________ Student’s Grade: _________________ Date: _______________________________ Please sign the appropriate line: I hereby give permission to use my child’s name, recognizable picture, and/or image in any VBSD news release. Parent Signature: ______________________________________ I hereby request that my child’s name, picture, and/or image​ NOT​ ​be used in any VBSD news release Parent Signature: ______________________________________ Please return completed form to the principal’s office of your child’s school for placement in their permanent file. Student Policy Handbook Acknowledgement
Acuse de Recibo del Manual de Política para Estudiantes
This is to certify that I have reviewd the policies contained in the VBSD and VBHS Handbooks that are placed on the Van Buren High School website ​http://www.vbsd.us/ Esto certifica que he revisado la política y reglas explicadas en los Manuales para Estudiantes de VBSD y VBHS que están ubicados en el sitio web http://www.vbsd.us/ Student Name (Please Print)/Nombre del estudiante​:​ ____________________________________________________________ Student Signature/Firma del estudiante​:​ ______________________________________________________________________ ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
Technology Acceptable Use Policy/
Política del uso aceptable de tecnología Students/Estudiantes: I have reviewed the policies contained in the VBSD Acceptable Use Policy. Before technology access may be granted, signature of user must be submitted on this form to the school office. As a user of the VBSD Network, I agree to comply with the Acceptable Use Policy. He revisado completamente la política del uso aceptable de tecnología del distrito escolar de Van Buren. Antes del acceso puede ser dado a la tecnología, la firma del usuario debe ser entregado en este formulario a la oficina escolar. Como usuario de La Red VBSD, acuerdo cumplir con la política de uso aceptable de tecnología. Student Name/Nombre de estudiante:​__________________________________________________________________________ User ID/Identificacón del Usuario:​_____________________________________________________________________________ Student Signature/Firma de estudiante:​ _________________________________________________________________________ Parent/Guardian/Padres/Guardianes As parent/legal guardian of the student signing above, I grant permission for my child to access networked computer services. I have reviewed and agree to the Acceptable Use Policies, and I understand that I may be held responsible for violations by my child. I understand that some material on the Internet may be objectionable; therefore, I agree to accept responsibility for guiding my child and conveying to him/her appropriate standards for selecting, sharing, and or exploring information and media. Como padre/guardián legal del/la estudiante firmando arriba, le doy permiso para entrar en los servicios de las computadoras enredadas. He revisado y yo acuerdo con la política de uso aceptable, y entiendo que puedo ser responsable por las violaciones de mi hijo. Entiendo que a veces hay material en el Internet que puede ser objetable; por eso acuerdo aceptar la responsabilidad por guiar a mi hijo y expresando a él o ella los estandartes apropiados por elegir, compartir, y/o explorar información y medias de comunicación. Parent/Guardian Name (Nombre de Padre/Guardián):​ ________________________________________________________________ Date/Fecha:​______________​Parent/Guardian Signature (Firma de Padre/Guardian):​__________________________________________ Street Address/Dirección de casa:_______________________________________________________________________________________________ City/State/Zip (Ciudad/Estado/Código Postal):_____________________________________________Phone/Número telefónico:___________________ VAN BUREN SCHOOL DISTRICT DRUG TESTING CONSENT FORM
SCHOOL YEAR 2016-2017
Dear Parents and Students,
Below, please find the consent form for Drug Testing required for all students that participate in Sports,
Clubs, Organizations, all extracurricular activities, and/or drive a vehicle to school. Every student, 9th through 12th
grades, is required to turn in this completed form. Please be aware: parents are NOT notified prior to random
drug screening. You may access the complete Van Buren School District Mandatory Drug Testing Policy at
www.vbsd.us/districtinfo.html and click on the Student Drug Testing Link.
DRUG TESTING POLICY, GENERAL AUTHORIZATION FORM A
I understand that my performance as a participant and the reputation of my school are dependent, in part, on my
conduct as an individual. I have read and understand the contents of the Van Buren School District Drug Testing Policy.
I hereby agree to accept and abide by the policies, standards, rules and regulations set forth by the Van Buren School
District Board and the sponsors for the activity in which I participate.
I also authorize Van Buren School District to conduct a breath scan or a urinalysis to test for drugs and/or alcohol
use. I also authorize Van Buren School District to conduct random tests during the current school year. I authorize the
release of information concerning the results of such test(s) to the Van Buren School District and to the parents and/or
guardians of the student.
This shall be deemed a consent pursuant to the Family Education Right to Privacy Act for the release of above
information to the parties named above.
_________________________________
Student Name (Printed)
_________________________________
Student Signature
_________________________________
Parent/Guardian Signature
__________
Grade
__________
Gender
__________
Date
________________________
School
_________________________
Home Phone #
_________________________
Cell #
CHECK ALL AREAS OF PARTICIPATION
Students who drive to school are subject to Random Drug Testing per Van Buren School District Policy.
I drive a vehicle to school and have registered my car in the school office.
VBHS decal registration number: __________________.
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Art Club
Band
Baseball
Basketball
BETA Club
Book Club
Bowling
Cheerleading
Chess Club
Choir
CIA (Cultures in Action)
Class Officer
Cross Country
Dance Team
Drama Club
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East Lab
FBLA
FCA
FCCLA
Football
FTA
Geocaching
Golf
Journalism
Mu Alpha Theta
National History Club
National Honor Society
Optimist Club
Partners Club
Quiz Bowl
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ROTC (Drill Team)
SHH
SSA
Soccer
Softball
Student Senate
Social Justice Club
T412
TARS
Tennis
Track
Ultimate Frisbee
Volleyball
Wrestling
NONE
Van Buren School District—Home Language Survey
Insert School Name Here
Date:
Student’s Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Gender:
M
Student’s Name:
Last
Date of Birth:
First
Middle
Place of Birth:
Address:
Street
City
Zip Code
Telephone:
Father’s Name:
Place of Employment:
Mother’s Name:
Place of Employment:
1.) What was the first language spoken by the child?
2.) What language is spoken in the home most of the time?
3.) What language does the student speak most of the time?
4.) What language do parents speak to the student most of the time?
5.) A. Was this child born in the United States?
Yes
No
If your answer is “no,” continue with the following questions.
B. When did your child arrive in the United States?
C. When did your child arrive in Arkansas?
D. When did your child arrive in Van Buren?
E. How many years of schooling has your child completed in the first language?
F. How many years of schooling has your child completed in English?
Parent signature
Original: Place in student permanent record folder.
If English is a second language, send a copy to Director of Special Programs.
Revised 8/05
F
VanBurenHighSchool
2001EastPointerTrail
VanBuren,AR72956
Phone(479)474-6821
Fax(479)471-3171
2016-2017 Parent Involvement Plan Summary
AtVanBurenHighSchool(VBHS),weencourageparentalinvolvementandwouldliketoencourageparentstousethe
followingcontactinformationatyourdiscretion:
• Mr.EddieTipton,Principal–etipton@vbsd.us
• Mr.MyronHeckman,Asst.Principal–Myron.Heckman@vbsd.us
• Mr.TimMcCutchen,Asst.Principal–tmccutchen@vbsd.us
• Mr.JenksSmith,Asst.Principal–jsmith@vbsd.us
• Mrs.CourtneyCochran,ParentInvolvementFacilitator–Courtney.Cochran@vbsd.us
AtVBHS,wefeelthatthepartnershipscreatedbetweenteachers,parentsandstudentsarevitaltoouroverallsuccess.Thesepartnershipsare
createdthroughpositivecommunicationbetweentheschoolandthehomeaswellasprovidingparentsopportunitiestobeinvolvedindifferent
activities,toassistinpolicy-anddecision-making,andtovoicetheirconcerns.Wewillprovidematerialsthatcansuccessfullybeusedathome
toreinforcetheacademicsuccessofchildren.Thedistrictwillreserveaminimumof1%oftheTitleI,PartAallocationforparentalinvolvement
($20,000.00).Itisourgoaltoprovideanatmospherewhereparentsareabletoexpresstheirviewsandtoassistinproblemsolving.Wewant
parentstounderstandthatweviewthemasjointpolicyanddecisionmakersandplantoemphasizetheirrolesasadvocates.VBHSoffersawide
varietyofcommunicationsforparentssothattheymayaccessmoreinformationabouttheParentInvolvementCommittee,aswellasschool
news,aschoolactivitiescalendar,andparentingtipsrelatingtoschoolachievementsuchashomeworktips,organizationalskills,andstudy
skills.Theseareafewofthefamily-friendlywaysthatparentscangainaccesstothisinformation:
• PointerUpdateweeklynewsletter
• TheVanBurenHighSchoolwebsiteathttp://teacher.vbsd.us/vbhs
• TheVanBurenHighSchoolFacebookPage
• @VanBurenHSand@PointerUpdateonTwitter
Alsoincludedinthesecommunicationsareopportunitiesforparentinvolvementforthe2014-2015schoolyearsuchas:
•
SeniorandJuniorschedulepick-upandschool
tours
•
End-of-CourseLiteracyNight
•
Sophomoreschedulepick-upandschooltours
•
CAPSConferences
•
PTAmeetings
•
CollegeGoalSunday@UAFS
•
OpenHouse
•
VBHSCareerExpo
•
Parent-TeacherConferences/Reporttothe
Public
•
VBHSTalentShow
•
ArkansasScholarsBanquet
•
FallFestivalhostedbyCulturesinAction
•
End-of-CourseBiology/GeometryNight
•
CollegeFinancialAidNight
•
Top40Banquet
•
EASTNightOut
•
ScholarshipBanquet
•
EmptyBowlsEvent
•
VBHSBaccalaureate
•
Graduation/ProjectGraduation
Pleasesignbelowtoconfirmthatyoureceivedandunderstandthe2015-2016ParentInvolvementPlan
Summaryanddetachthebottomportiontoreturntotheschool.Pleaseretainthetopportionforyour
records.
____________________________________
(Parent’ssignature) __________________
(date) ____________________________________
(Student’ssignature)
__________________
(date)