Teays Valley Local School District Kindergarten Registration Packet

Teays Valley Local School District
Kindergarten
Registration Packet
2016-2017 School Year
CHECKLIST FOR ENROLLMENT OF NEW STUDENTS
Student previously enrolled in Teays Valley Local School District
Birth Certificate *
Custody Papers *
Proof of Residence *
-Utility Bill (1 separate bill showing name and address)
-Proof of ownership or rental agreement or purchase agreement
-If you are living with a friend or a family member (in their home) you will need to complete a
“Friends &Family Packet” and give to the building secretary where your child will attend. See
“Friends & Family Packet on the website for what is required
I.E.P. (current) *
Immunization Records *
Foster Placement Papers
-journal entry number provided by court *
-request for records signed by case worker
-name, number and agency of case worker
Academic Assessment Report *
(documentation of home schooling progress)
Any other relevant information (i.e. probation information, counseling outside of school, medical
information, etc.)
Completed 19 page packet *
Photo ID *
* Student will not be accepted for enrollment without these documents.
Page 1
Teays Valley Local School District
Teays Valley Local School District
385 Viking Way, Ashville, Ohio 43103-9417
District IRN - 049098
Phone: (740)983-5051
Fax: (740)983-4158
Website: www.tvsd.us
Robin Halley, Superintendent
Kyle Wolfe, Assistant Superintendent
Stacy Overly, Treasurer
Check One:
Authorization for Release of Records
Ashville Elementary School
90 Walnut Street
Ashville, Ohio 43103
Phone # 740-983-5000
Fax # 740-983-5073
Previous School:
Street Address
Scioto Elementary School
20 West Scioto Street
Commercial Point, Ohio 43116
Phone # 740-983-5000
Fax # 740-983-5088
City, State & Zip
South Bloomfield Elementary School
194 Dowler Drive
South Bloomfield, Ohio 43103
Phone # 740-983-5000
Fax # 740-983-5004
Grade
Walnut Elementary School
7150 Ashville-Fairfield Road
Ashville, Ohio 43103
Phone # 740-983-5000
Fax # 740-983-5049
Name of Student
Date of Birth
Phone #
Student Start Date:
You are authorized to release the records listed below for the
above named student to the school marked on the left:
School Offical Signature & Title:
Specific Data to be Released:
Teays Valley East Middle School
655 Viking Way
Ashville, Ohio 43103
Phone # 740-983-5000
Fax # 740-983-5037
Teays Valley West Middle School
200 Grove Run Road
Commercial Point, Ohio 43116
Phone # 740-983-5000
Fax # 740-983-5040
Teays Valley High School
3887 State Route 752
Ashville, Ohio 43103
Phone # 740-983-5000
Fax # 740-983-5077
Birth Certificate
Medical Records & Immunization Records
Attendance Records
ETR
Psychological Report(s) & all pertinent Special Education IEP's
State Testing Results (OAA, OGT, etc.)
Grade Card / Transcripts
Withdrawal Grades
Custody Papers
Other:
Third Grade Reading Guarantee (Grades K-3 only):
Please check only one of the following if enrolling after September 30:
On Track
Not on Track
This information is to be verified by the child's previous school,
not the parent enrolling the child.
Page 2
Teays Valley Local School District
EMERGENCY MEDICAL AUTHORIZATION FORM
School Term 2016-2017
NOTIFY THE SCHOOL OF ANY CHANGE IN PHONE OR EMERGENCY NUMBERS
School
Grade
Student Name
Date of Birth
Address
Primary Phone #
Secondary Phone #
The following is required by section 3313.712 of the Ohio Revised Code.
Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill
or injured while under school authority, when parents or guardians cannot be reached.
Residential Parent or Guardian:
Name
Name
Daytime Phone
Daytime Phone
Name of Relative or Childcare Provider
Relationship
Address
Phone
Name
Relationship
Address
Phone
Page 3
Teays Valley Local School District
PART I OR II MUST BE COMPLETED
PART I - (To Grant Consent)
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor
Phone
Dentist
Phone
Medical Specialist
Phone
Local Hospital
Emergency Room Phone
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration
of any treatment deemed necessary by the above-named physician or dentist; and (2) the transfer of the child to any hospital
reasonably accessible.
This authorization DOES NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists,
concurring in the necessity of such surgery, are obtained prior to the performance of such surgery.
Facts concerning the child’s medical history including allergies, medications being taken, and any physical
impairments to which a physician should be alerted:
Date
Signature of Parent/Guardian
Address
PART II – (REFUSAL TO GRANT CONSENT)
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency
treatment, I wish the school authorities to take the following action:
Date
Signature of Parent/Guardian
Address
Page 4
Teays Valley Local School District
Teays Valley Schools
Medical Authorization Addendum
Student ID#
School Year
Grade
Student Name
Sex:
Date of Birth
Race/Ethnic Group:
M
Citizen of USA?
F
Parents are:
Parent/Guardian
Married
Divorced
Hispanic/Latino
Caucasian/White
City
Stepparent
Birthplace (city)
Native Language
Native Hawaiian/Pacific Islander
Address : P.O. Box / Street # / Lot # /Apartment #
Student resides with:
No
American Indian/Alaskan Native
African American/Black
Asian
Yes
Zip
Grandparents
County
Other (specify)
Other (specify)
Separated
Parent/Guardian #1 (chcek one)
Check 2 #s for automated phone message system
Name
Home
Relationship to Child:
Mother
Father
Stepparent
E-mail address
FAX
Employer
Work
Grandparent
Other (specify)
Cell
Parent/Guardian #2 (check one)
Name
Home
Relationship to Child:
Mother
Father
Stepparent
E-mail address
Grandparent
Cell
FAX
Employer
Other (specify)
Work
Non-Residential Parent
*Has permission to pick up your child from school?
Name
Address
Yes
No
Phone
Relative or Friend
Name
Relationship
*Has permission to pick up your child from school?
Name
Yes
Home / Cell
No
Relationship
*Has permission to pick up your child from school?
Yes
Home / Cell
No
Address
Babysitter
*Has permission to pick up your child from school?
Yes
Home / Cell
No
Name & Grade of Sisters / Brothers attending Teays Valley Schools:
Last School Attended:
Early Dismissal – In the event of an early dismissal (calamity, etc.), please have an emergency plan worked out with your children as to where they will
go. With the nature of dismissal and the number of students, school personnel will be unable to call you. You should discuss the plan with your children
YES
NO
in advance. Do you have an emergency plan worked out with your children?
Signature of Parent/Guardian
Date
Page 5
Teays Valley Local School District
Please complete confidential information to be shared with teaching staff and EMS if necessary.
Please explain any conditions that apply to your child. Include type of each disorder, special care or restrictions, and medications
or treatments the student uses to manage the condition:
Does your child have a Vision or Hearing Impairment?
Yes
No
Wear glasses, contact lenses, or hearing aid(s) / auditory device?
Does your child have Asthma diagnosed by a physician?
Yes
No
If yes, please list any treatments or medication given:
Has your child had any Allergic Reactions to medications, foods, insects or other?
No
Yes
If yes, please list the allergens and care required:
*Note: Food allergies require a note from your doctor
Does your child have a Seizure Disorder as diagnosed by a physician?
Yes
Type?
No
If yes, please explain:
Does your child have a Cardiac (Heart) Defect?
Yes
No
Type? If yes,
please list any restrictions, surgeries, medications, amount, time of administration, etc.:
Has your child been identified as having a Bleeding Disorder/ Tendency?
No
Yes
If yes, please describe:
Does your child have Diabetes?
Yes
Type 1
No
Type 2
If yes, please list insulin type, amount, and time given:
Has your child been diagnosed as having ADD or ADHD by your physician?
Yes
No
If yes, please list medication, amount, and time of administration:
Any other pertinent medical information, conditions, or medications (amount and time) your child is currently taking:
PLEASE CHECK MEDICATION PERMITTED AND SIGN BELOW)
In the event my child needs NON-PRESCRIPTION medication for minor ailments, I give permission for the School Nurse or her designee to
dispense the following OTC medication under the guidelines of the school physician standing orders: *This does not apply to preschool
students.
First Aid antiseptic/ointment
Ibuprofen (Advil/Motrin)
Benadryl
Imodium A-D
Tums
Acetaminophen (Tylenol)
Robitussin
Parent signature required:
I GRANT permission for above checked medications
Date
I DO NOT give permission for any of the above medications
Date
Page 6
Teays Valley Local School District
SCHOOL HEALTH HISTORY
To be completed by parent or guardian
Enrolled:
School
Child’s Full Name
Female
Male
Birthday:
Month/Day/Year
FAMILY HISTORY
Parent/Guardians:
Please list this child’s brothers and sisters: (name/birthday/grade)
1.
3.
2.
4.
PERINATAL HISTORY
Was this child born:
Full Term
Early (weeks)
Infant’s birth weight
Late (weeks)
How old was the mother when this child was born?
Did the mother have any unusual physical or emotional illness during this pregnancy?
Yes
No
Yes
No
Explain:
Did the infant have any sickness or problems in delivery or while in the nursery?
Explain:
How does this child’s development compare to other children?
Same
Faster
Slower
ALLERGIES
Please list and describe allergies and/or reactions to:
Medicines/Drugs
Foods *
Environmental (plants, animals, etc.)
EPI Pen ?
Yes
NO
* food allergies listed must have written documentation from the physician.
ILLNESSES AND INJURIES
Please list any severe injuries or illnesses:
Age of Child
MEDICATIONS / TREATMENTS
What medications are given daily?
What medications are given frequently, but not daily?
Page 7
Teays Valley Local School District
Hospitalized?
HEALTH CONDITIONS
Describe any special medical routines or treatments this child requires:
Please check any that this child has:
EYE / VISION
MUSCULOSKELETAL
Lazy Eye
Abnormal spinal curvature
Wear glasses
Arthritis
Wear Contacts
Birth or congenital malformation
Other
Hernia
Other
EAR / HEARING
NEUROLOGICAL
Frequent infections
Hearing Problems
Hearing Aid
Cerebral Palsy
Right
Left
Migraines
Other
Headaches
Seizure Disorder, Type
Other
BEHAVIORAL / EMOTIONAL / SOCIAL
ADD
SKIN
Eczema
ADH
Psoriasis
Autism
Bladder Control Problem
Day
Night
Other
Depression
INFECTIOUS DISEASE
Eating Disorder, Type
Emotional Problems
Chicken Pox, age
Stool soiling
Hepatitis, Type
Substance Abuse (alcohol, drugs)
Encephalitis
Other
MRSA, age
Meningitis
Other
CARDIOVASCULAR / BLOOD
RESPIRATORY
Anemia
Bleeding Disorder, Type
Asthma, last episode
Heart Murmur, Type
Cystic Fibrosis
Heart Defect, Type
Other
Pneumnia, age
NUTRITION / DIGESTIVE / ELIMINATION /MEDICATIONS
Hepatitis, Type
Rheumatic Fever
Bladder
Sickle Cell Disease
Bowel Problems, Type
Other
Failure to Thrive
Kidney Problems, Type
ENDOCRINE
Diabetes
Type I
Thyroid Condition, Type
Obesity
Stomach Problems, Type
Type II
Other
Other
Are there any other health, development, or behavior problems not listed above?
Other comments or concerns about this child’s health, development, behavior, family, or home life that you would like the school nurse to be
aware of? If yes, explain briefly:
Completed by:
Relationship to child:
Page 8
Teays Valley Local School District
Date
IMMUNIZATION REPORT
OHIO DEPARTMENT OF HEALTH
Student’s Name
Sex:
M
F
Date of Birth
Students are required to be immunized in accordance with Ohio law (Ohio Revised Code 3313.67/3313.671). A copy of
the child’s immunization record may be attached or dates entered below.
Please note the month, day and year for each immunization should be on record.
Vaccine
Record complete dates (month, day, year) of vaccine doses given.
Diptheria, Tetanus, Pertussis..........
(DTP) Dtap, Tdap.................................
DT,Td.................................................
Polio.....................................................
Hepatitis B (HBV)................................
Measles, Mumps, Rubella (MMR).....
Varicella (Chickenpox).....................
Hepatitis A...........................................
Meningococcal (MCV4, MPSV4)......
Pneumococcal (PCV) .........................
Measles (rubella) only......................
Rubella only .....................................
Mumps only......................................
Haemophilus Influenza Type B (hib)
Influenza..............................................
Other.................................................
This information was provided by:
Health Care Provider
Other
Signature
Print Name
Date
Page 9
Teays Valley Local School District
Parent/Guardian
HOME LANGUAGE SURVEY
Date
School
Grade
Child’s Name (first, middle initial, last)
Address
Home Phone
1.
Cell Phone
Work Phone
Was your child born in the United States?
Yes
No
If yes, which state?
If no, in what other country?
2.
Has your child attended any school in the United State for any three years during their lifetime?
Yes
No
If yes, please provide school name(s), state, & dates attended:
School
State
Dates Attended
School
State
Dates Attended
3.
What is the language most frequently spoken at home?
4.
If available, in what language would you prefer to receive communication from the school?
5.
Please check if your child is:
Native American Indian
Alaska Native
Native Pacific Islander
Native U.S. Virgin Islander
6.
Is your child’s first-learned or home language anything other than English?
Yes
No
If you responded “Yes” to question number 6 above, please answer the following questions:
7.
What country did your child most recently reside?
8.
Which language did your child learn when he/she first began to talk?
9.
What language does your child most frequently speak at home?
10. What language do you most frequently speak to your child?
Mother
Father
11. Please describe the language understood by your child:
Understands only the home language and no English.
Understands mostly the home language and some English.
Understands the home language and English equally.
Understands mostly English and some of the home language.
Understands only English.
Date
Parent or Guardian’s Signature
-----------------------------------------------------------------------------------------------------------------Student ID#
OFFICE USE ONLY
Date Distributed
Page 10
Teays Valley Local School District
Date Received
RESIDENCY QUESTIONNAIRE
This questionnaire is intended to address the McKinney-Vento Act. Your answers will help the administrator determine residency documents
necessary for enrollment of this student.
1.
Presently, where is the student living? (Check One)
Section A
Section B
Choices in Section A do not apply
In a Shelter
With more than one family in a house/apartment
In a motel, car or campsite
With friends or family members (other than parent/guardian)
2.
The student lives with: (Check One)
1 parent
2 parents
1 parent & another adult
a relative, friend or other adult
alone with no adults
an adult that is not the parent or legal guardian
School
Male
Name of Student
Birthdate:
Month
Day
Female
Year
Social Security Number
*****For Kindergarten Registration Only
My child has received pre-school services.
Where?
My child has not received pre-school services.
Name of Parent(s) / Legal Guardian(s)
Address
Phone
Signature of parent or guardian
If the parent or student has checked Section B above, completion of form is not required. For any choices in Section
A, this form must be comleted and set (copies) to Kyle Wolfe, Assistant Superintendent.
Page 11
Teays Valley Local School District
RESIDENCE VERIFICATION FORM
I,
, hereby certify that I have established residency on a seven-days-a-week
basis in the Teays Valley Local School District and am not maintaining a separate residence elsewhere. I am aware
that Teays Valley Schools may use any legal means necessary to verify I am living at the address listed below.
I further certify that this residence is located at:
Address
City
Zip
Principal Owner/Resident (if different from parent)
Parent Relationship to Principal Owner/Resident
Required verification of above residence:
DO NOT TURN IN YOUR PACKET WITHOUT THE FOLLOWING:
Resident will provide:
Proof of Residence - provide one of the following:
mortgage coupon
copy of recent tax bill
Insurance Policy
closing document
Rental Agreement
Purchase Contract
AND
One Utility Bill – provide one of the following:
gas
electricity
home phone
etc.
Family living with owner will provide: Two of the following in your name and new address:
verification of address change from the US Post Office or your employer
current utility bills
other bills
paychecks
driver’s license.
bank statement
I realize that should any of the above statements be false, I am liable under the criminal code for any penalties that the law provides. Should
any of this information be false or if I move out of the district, I agree to pay the tuition cost set for the 2016-2017 school year. The current
tuition cost for the 2015-2016 school year is $25.86 per day/per student. I agree to pay this new rate for the student(s) listed below to cover
the period during which they illegally attended Teays Valley Local Schools. I understand that immediate withdrawal will also occur. Tuition
rates change annually in August and are set by the Ohio Department of Education.
Permission to enroll on the basis of the information provided shall not necessarily extend beyond the current school year. Documents may be
required to be updated by the parent(s) and verified by the school district on an annual basis for continued school attendance. The Board of
Education reserves the right to require additional documentation to establish residence to the satisfaction of the superintendent or
designee as needed.
Signature of Person Enrolling Child
Cell Phone
Relationship to Child
Home Phone
Student Name
Grade
School of Attendance
Student Name
Grade
School of Attendance
Student Name
Grade
School of Attendance
School Official Signature
Date
Page 12
Teays Valley Local School District
CUSTODY INFORMATION
School your child is attending
Date
Student Name
Please check one of the following:
Custody is not an issue because the parents are still married.
Mother was not married at the time of the child’s birth, so custody is not applicable.
Parents are separated, but there has been no documented legal action.
Parents are separated. Legal action (divorce, dissolution, etc.) had been started, but no final decree has been
rendered. I will bring a copy of the papers once they are complete.
Parents are divorced. A document verifying custody will be provided at the time of enrollment.
Other (Please explain or provide documentation)
Please tell us what the custody agreement is for your child. For example, if you have residential custody and your spouse has
visitation rights, is he/she permitted to pick up your child? Please be specific. Thank you.
The child named above is in my legal custody, and, if necessary, I can and will produce legal documents to verify this
custody. I understand that if I cannot produce such verification of custody or other records as required of all new enrollees,
the student cannot be admitted to school.
Date
Parent Signature
Please print name
Page 13
Teays Valley Local School District
FOSTER PLACED STUDENTS
In order to keep our filed updated, please fill out the following information. This needs to be completed upon
registration.
THIS IS VITAL INFORMATION. A STUDENT CANNOT BE ENROLLED WITHOUT THIS INFORMATION.
Name of Student
Name of Social Worker
Name of Agency
Phone Number
Name of Biological Parent(s)
Address of Biological Parent(s) when placed in foster care
School District Responsible for Tuition/Excess Cost
Address
Page 14
Teays Valley Local School District
Authorization to Disclose
Immunizaton Information
Date of Birth:
Name of Child:
I,
, as the parent or guardian of the above named child, hereby authorize
(Provider Name):
to disclose the specific and individually identifiable immunization records of the above named child to:
(Name of School):
for the specific purpose of presenting written evidence, satisfactory to the person in charge of admission, that the
above named child has been immunized by a method of immunization approved by the Department of Health as
required by section 3313.671 of the Ohio Revised Code.
This authorization will expire upon the presentation of written evidence sufficient to comply with section 3313.671
of the Ohio Revised Code or for the period of time needed to fulfill its purpose. I also understand that I may
revoke this authorization, in writing, at any time and that I may be asked to sign the Revocation Section at the
bottom of this form. I further understand that any action taken by the above named Provider(s) or School in
accordance to this authorization prior to it being revoked is legal and binding.
I understand that my information may not be protected from re-disclosure by the requester of the information
unless otherwise provided for by state or federal law. Please note: medical records provided to schools that receive
federal funding are protected by the Family Education Rights and Privacy Act (FERPA).
I also understand that I may refuse to sign this authroization and that my refusal to sign will not affect my ability to
obtain treatment payment for services, or my eligibility for benefits; however, if a service is requested by a nontreatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physicial
exam), service may be denied if authorization is not given.
I also understand that my refusal to sign this authorization may prevent the school from verifying that the above
named child has been immunized. I further understand that if the school cannot verify and I cannot provide
satisfactory written evidence that above named child has been immunized, the child may be excluded from school
pursuant to section 3313.671 of the Revised Code.
I further understand that I may request a copy of this signed authorization.
Signature of Personal Representative
Date
Relationship/Authority
NOTE: This authorization was revoked on:
Date
Signature of Staff
Page 15
Teays Valley Local School District
SPEECH, HEARING, AND LANGUAGE SUMMARY
Child's Name:
Please Check Those Statements Which Apply to Your Child:
I, as a parent feel there is a noticable speech/language problem that may require therapy.
He/she has a history of hearing problems (tubes, frequent headaches).
He/she has difficulty in attending to a task or following verbal directions.
He/she has difficulty using words in sentences:
Example: Me go store or him go home
He/she has difficulty pronouncing certain sounds:
Example: at for hat or tookie for cookie
He/she has received speech therapy at:
Head Start
Summer Clinic
Some other agency
Any other information the speech therapist may need to know:
Page 16
Teays Valley Local School District
DENTIST'S REPORT - OHIO SCHOOL HEALTH
Student's Name:
School:
The following services have been performed:
Examination
Oral Prophylaxis
Diagnosis
Prescription of Fluoride Supplements
Radiographs
Topical Application of Fluoride
The following oral hygiene instruction was provided:
Flossing
Tooth-brushing
Diet counseling reflecting relation of diet to dental health
Home/school use of fluoride mouth rinse
The following statements are applicable:
All necessary services have been performed
No Restorative Services are required at this time
Further treatment is indicated
Further Appointments have been arranged
Comments:
PLEASE PRINT OR STAMP
Dentist's Name:
Address:
Fax Number:
Phone:
Date Signed:
Dentist's Signature:
Please return completed form to: Teays Valley Schools % School Nurse
385 Viking Way, Ashville, Ohio 43103 or Fax to (740)983-4158
Page 17
Teays Valley Local School District
OHIO SCHOOL HEALTH RECORD
PHYSICIAN'S REPORT
Date
Age
Female
Male
Child's Name
OBJECTIVE DATA
Height
%
VISION
Weight
%
SCREENING TESTS
Date Performed
Distance Acuity
R
L
Not Done
Muscle Balance
Pass
Fail
Not Done
Farsightedness
Pass
Fail
Not Done
Color
Pass
Fail
Child wears glasses?
Yes
No
Tested with glasses
Yes
No
Referral made?
Yes
No
B.P.
HEARING (Audiometric thresholds:)
R - Ear
Pass
Fail
Not Done
L - Ear
Pass
Fail
Not Done
wears hearing aid?
Yes
No
Tested with hearing aid?
Yes
No
Referral made?
Yes
No
Other tests (specify) Child
SPEECH / LANGUAGE
Speech assessment:
Not Done
Done
Child has no discernible speech problem
No
Yes
Child has possible problem with:
Disorders: (check)
No
Yes
Speech Evaluation recommended:
Voice
Rhythm
Articulation
LABORATORY TESTS
Hematocrit/Hemoglobin
Urine Protein
Urine Glucose
Other:
Urine Blood
PHYSICAL EXAMINATION
Date examined
Abnormalities as follows
Essentially normal
Is this child able to participate fully in the following?
A. Classroom and academic activities?
Yes
No
B. Physical education classes?
Yes
No
C. Competitive Athletic?
Yes
No
D. Contact and collision sports?
Yes
No
If limitations are advised, please specify those limitations:
Page 18
Teays Valley Local School District
Language
If this child has any physical, developmental or behavioral problems, how can the school assist with special programs
placement or attention?
PHYSICIAN'S ASSESSMENT
Problem List
Recommendation for school management
1.
2.
3.
4.
Vaccine
Record complete dated (month, day, year) of vaccine doses given.
Diptheria, Tetanus, Pertussis (DPT)
Dtap, Tdap..........................................
DT, Td..................................................
Polio....................................................
Measles, Mumps, Rubella (MMR).....
Haemophilus Influenza Type B (hib)
Hepatitis B (HBV)...............................
Hepatitis A..........................................
Varicella (Chickenpox)......................
Meningococcal (MCV4, MPSV4).......
Pneumococcal (PCV).........................
Other...................................................
PLEASE PRINT OR STAMP
Physician's Name
Physician's Signature
Address
Phone
Data Signed
Page 19
Teays Valley Local School District