AD Henderson University School

A. D. Henderson University School
K-8 Enrollment Packet
2014-2015
All forms must be completed by the parent/guardian of
newly selected students.
Student Name:
Entering Grade:
Dear Parent/Guardian,
It is our pleasure to invite you to apply for admittance of your child for the 2014-2015 school year. Your child’s admission is
contingent upon prompt receipt and review of the following documentation as outline in our Admissions Policy. Failure to return all
necessary documentation within 5 business days of invitation acceptance will result in repeal of your invitation. Please return all
forms to the ADHUS/FAU High main office, attention C. Raducanu (Registrar), 777 Glades Road, Bldg. 26, Boca Raton, FL 33431.
Faxed or emailed forms will not be accepted.
Date
Received
(Office only)
Document/Form
Registration Checklist
Format
Needed
Birth Certificate
Social Security Card
Copy
Copy
Annual Admission Agreement
Student Information Form
FAUS Health Forms
Blackboard Connect/AlertNow Form
Immunization Record (DH-680 Form) or
Permanent Religious Exception (DH-681
Form)
Original
Original
Original
Original
Original
Form
These forms can be obtained at your child
Physician’s Office.
Students will not be allowed to start school
without a complete/appropriate Form.
Physical Exam (DH-3040 Form)
Original
Form
The form can be obtained at your child
Physician’s Office.
Students will not be allowed to start school
without DH-3040 Form
Important Notes
Parents of students entering kindergarten must bring in
the original and allow the office to make a copy for the
student’s file.
Do not leave any areas blank; use N/A where needed.
If the student has an incomplete Immunization Form,
please make an appointment w/the Physician’s Office
when the child is due for the yearly physical exam and
follow up with the updated/complete Immunization
Form after the physical.
(DH-680) Form should include the dates of
immunization.
If the student’s last Physical Exam was made prior
08/19/13, please make an appointment w/the
Physician’s Office when the child is due for the yearly
physical exam and follow up with the new form after the
physical.
Exam must be performed after August 19, 2013.
Form has two pages and must be completed on both
sides, page one completed by the parent, page two
completed by the doctor.
If applicable
Students under suspension at their current school
must finish the terms of their suspension before
enrolling. Students under expulsion are not eligible
to enroll at A. D. Henderson.
The following records should be dropped off or mailed AFTER THE END OF THE 2013-2014 SCHOOL YEAR.
Individual Educational Plan (IEP)
Discipline Status Report, as applicable
Copy
Copy
Final Report Cards
Original
FCAT Scores-2012-2013 and 2013-2014
Copy
(Reading, Math, Writing, and Science as
applicable)
End-of-Course Assessment Results as
Copy
applicable (Algebra I, Geometry, and/or
Civics)
Incomplete Forms/Documents will be returned for completion.
All documents received on: _____________________________
2013-14 and 2012-2013
For students from Private Schools, please provide
relevant standardized assessment scores for the
previous two years.
1st incomplete noticed
mailed home:
2nd incomplete
noticed mailed home:
3rd incomplete noticed
mailed home:
ANNUAL ADMISSION AGREEMENT- 2014-2015
This agreement must be completed (one per family), signed and returned to the school by July 1, 2014 for returning students, or the date
indicated in your lottery selection information. If all forms are not received by this date, we assume admission or continued enrollment
is not desired.
By applying for admission/continued enrollment of:
Student:
Grade:
Student:
Grade:
Student:
Grade:
Student:
Grade:
to A. D. Henderson University School/Florida Atlantic University High School, we the parents/guardians agree to the following conditions for
the duration of the above listed students’ enrollment.
1. Pay all costs and fees in a timely manner according to the guidelines below.
A. Annual Activity Fees as follows:
Grades K-5: Three hundred dollars ($300) per student or one hundred fifty dollars ($150) per student if approved for reduced
lunch. No charge if approved for free lunch.
Grades 6-8: Four hundred fifty dollars ($450) per student or two hundred twenty-five dollars ($225) per student if approved for
reduced lunch. No charge if approved for free lunch.
Grades 9-12: Five hundred fifty dollars ($550) per student or two hundred seventy-five dollars ($275) per student if approved for
reduced lunch. No charge if approved for free lunch.
B.
C.
2.
3.
4.
5.
6.
7.
8.
First half of payment due July 1, 2014. Fees not paid by July 31, 2014 may result in your student(s) not being allowed to attend
school.
Second half of payment due December 1, 2014. Fees not paid by December 31, 2014 may result in your student(s) not being
allowed to attend school.
FAU Transportation Access Fee:
Grades 9-12: $76.90 for Fall, $76.90 for Spring, and $32.04 for Summer. See attached letter for additional details.
Any and all incidental costs which may accrue, including lunch fees.
Furnish a health history, including immunization record of the student. For all children entering school, an official birth certificate and
social security card are required.
Arrange safe transportation to and from school for the student.
Permit the filming and/or taping of our child in a school activity for teacher training and research purposes.
Permit direct (live) and remote (video) observation of your child by university students and educators.
Permit the teaching and/or tutoring by our non-faculty members who have been approved by the administration and faculty of
ADHUS.
Comply with all policies and procedures implemented by the school.
Parents/guardians of all students attending A. D. Henderson University School/FAU High School must read and accept the
following2013-2014 school policy documents posted on the school website or you may obtain a paper copy from the school office:
 Student/Parent Handbook
 Attendance Policy
 Code of Student Conduct
 Dress Code and Uniform Policy
 Technology Policy & Guidelines
 Policy Against Bullying and Harassment
 Fee Policy
Furthermore, it is understood that the experimental nature of the instructional program at ADHUS or FAU High School may not be
advantageous to or in the best interest of the student. If this should be the case, parents/guardians may wish to or be asked to withdraw
the student. It is understood that standards of conduct and behavior are high and that close cooperation between home and school in
these matters is required. Serious misbehavior or repeated unacceptable conduct constitutes grounds for dismissal of a student from
school.
I (We) have read the entire admission agreement and the Admission Policy. I (we) understand all of the conditions for admission,
including the school’s right to request withdrawal of a student or to dismiss a student once admitted.
Signature of Parent/Guardian
Print Parent/Guardian Name
Date
Signature of Parent/Guardian
Print Parent/Guardian Name
Date
Complete ALL AREAS of the form.
STUDENT LEGAL NAME - LAST NAME
FIRST NAME
PRIMARY RESIDENCE (If multiple addresses, fill out two information forms)
APT. #
MIDDLE NAME
ALSO KNOWN AS
CITY
STATE
ZIP CODE
 YES
 NO
MAILING ADDRESS IF DIFFERENT (House Number, Street Name, Apartment Number, City, State, Zip Code)
STUDENT SOCIAL SECURITY NUMBER
HOME TELEPHONE NUMBER
IF APPLICABLE
______ - ________ - _________
SEX (M/F)
ENTERING
GRADE
________ - ________ - ___________
DATE OF BIRTH (MM/DD/YEAR)
PLACE OF BIRTH (City, State, Country)
RACE/ETHNIC ORIGIN
a) Is your child Hispanic or Latino?
(Please, mark only one)
b) What is your child’s race? (Check all that apply)
 I – American Indian/Alaskan Native  P – Native Hawaiian or
(Please provide the Document that
Other Pacific Islander
Confirms the Affiliation to a Tribe)
 A – Asian
 B - Black or African American
 W - White
USA ENTRY DATE
US CITIZEN
(MM/DD/YEAR)
□ NO
□ YES
□ NON-RESIDENT ALIEN
□ PERMANENT RESIDENT ALIEN
________/________/____________
_______/_______/_________
RESIDENT STATUS
 Foreign Exchange Student  Out-of-Country Resident  Out-of State Resident  In-County Resident  Out of County Resident
Preschool Enrollment Information (Check each program attended. Indicate with an asterisk [*] the program your child was in the longest.)
 Fee for Services
 Title I Pre-K
 Head Start
 Teenage Parent Program
 Pre-K Disabilities  Private Pre-K
 None
 Migrant Pre-K
 VPK Program
 Other _____________________
MOTHER/GUARDIAN – LAST NAME
FIRST NAME
FATHER /GUARDIAN – LAST NAME
FIRST NAME
OCCUPATION
PLACE OF EMPLOYMENT
OCCUPATION
PLACE OF EMPLOYMENT
HOME ADDRESS IF NOT THE SAME AS STUDENT (House # , Street Name, City, State, Zip)
HOME PHONE IF APPLICABLE
WORK PHONE
CELL PHONE
EMAIL ADDRESS
HOME ADDRESS IF NOT THE SAME AS STUDENT (House # , Street Name, City, State, Zip)
(Please print)
HOME PHONE IF APPLICABLE
WORK PHONE
CELL PHONE
EMAIL ADDRESS (Please print)
Provide the name(s) of person(s), other than the parent/guardian, allowed to pick up student and/or be contacted in an emergency.
NAME (last, first, middle initial)
RELATIONSHIP TO STUDENT
BEST PHONE
NUMBER TYPE
 Cell  Home  Work
 Cell  Home  Work
 Cell  Home  Work
Provide a PASSWORD the person allowed to pick up the student will use. (Limit 10 Characters)
TRANSPORTATION: The student listed on this form has permission
 Car
 Walk
 Public Bus
 Train
 Other
to use the following method(s) of transportation:
__________
This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435.
Children or youth who lack a fixed, regular, and adequate nighttime residence, including: sharing the housing of others due to loss off housing,
economic hardship, or similar reason (“doubling up”); living in motels, hotels, trailer parks, camping grounds due to the lack of adequate alternative
accommodations; living in emergency or transitional shelters; abandoned in hospitals
Is your current address temporary living?  YES
 NO Is this temporary living arrangement due to economic hardship?
 YES
 NO
FEDERAL IMPACT SURVEY





Yes
Yes
Yes
Yes
Yes





No
No
No
No
No
A.
B.
C.
D.
E.
The student resides on federal property.
The student resides in low rent housing.
The parent is employed on federal property located in Palm Beach County.
The parent is employed on low rent housing located in Palm Beach County.
The parent is in the uniformed services of the United States.
If "E" is YES, is the parent on active duty? (Check service below)
 Air Force  Army  Coast Guard  National Guard  Navy
 Marines
TRANSFER INFORMATION
Name of the last school attended ___________________________________________________________________________________________
A. City __________________________________________ State _______________ Public School_____________ or Private School____________
B. County______________________________________________ Country___________________________________________________________
C. Last grade level completed (or will be completed at the end of the school year) ______ Last attendance date (at the above mentioned school) ______/_______/_______
Please use this format MM/DD/YEAR
D. Does your child have  Individual Education Plan (IEP) 504 Plan  English language Learners Plan (ELL)  Education Plan (EP)
Progress Monitoring Plan (PMP) Other Plan?  None (If any plan checked, copy of plan is required)
HEALTH SCREENING INFORMATION
Students will receive non-invasive health screenings pursuant to Florida Statue § 381.0056(7)(d). Non-invasive screenings may include vision,
hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or guardians, however, have the right to request an
exemption in writing. (This exemption will cover all types of screenings.)
If you DO NOT want your child to receive the screenings, write the words "Do not screen" here: _________________________
Does your child currently have health insurance?  Yes
 No
If YES, check insurance plan:
 Medicaid
 Healthy Kids/Kid Care
 Private
HOME LANGUAGE SURVEY for NEW STUDENTS to ADHUS and FAU HIGH SCHOOL
All new students to ADHUS and FAU High School are required to answer the following home language survey questions.
 Yes  No
A. Is a language other than English used in the home?
If YES, what language? _______________________
 Yes  No
B. Does the student have a first language other than English?
If YES, what language? _______________________
 Yes  No
C. Does the student most frequently speak a language other than English? If YES, what language? _______________________
Important: Answering “Yes” to any of the above questions, will require an ELL screening or documentation of a previous ELL plan. If you have
questions about this section, please email Lyndsay Tolerton at [email protected].
Date Student Entered United States School (First Time Elementary, Middle, or High School)
/
/
Please use this format MM/DD/YEAR
Student lives with: (check one)
 Both Parents  Mother
 Father
Custody Status of Student (check one):
 Foster
 Mother
Please circle days of the week for shared custody:
 Group Home
 Student is a ward of the state  Other
 Father
 Shared Custody
 Other
DAYS WITH MOTHER -
MON TUES
WED
THURS
FRI
SAT
SUN
DAYS WITH FATHER -
MON TUES
WED
THURS
FRI
SAT
SUN
Is There A Court Order Barring Either Parent From Removing Or Contacting The Student During The School Day?
 Yes
 No
If Yes, Provide The School With A Copy Of The Court Order.
Phone:
Person Responsible for payment: Name
Address
Verification of Student Registration Information
I verify that the information given on this student registration is true and accurate to the best of my knowledge and agree to update the school’s
main office in the event that any of this information changes.
Signature of Parent/Guardian
Date
Signature of Parent/Guardian
Date
Registration is not valid without a signature and date.
All parents/guardians MUST complete an information
form annually.
Blackboard Connect/AlertNow
Dear Parents/Guardians,
Keeping you informed, especially in emergency situations, is a top priority at A.D. Henderson University School/FAU High
School. As many of you know, the school uses a call out system that allows us to send telephone and/or e-mail messages
to you with important information about school events or emergencies. We use this system to notify you of school
delays or cancellations due to inclement weather, as well as remind you about various events, including report card
distribution, open house, field trips, and more. In the event of an emergency at school, you can have peace of mind
knowing that you will be informed immediately by phone.




What you need to know about receiving calls sent through Blackboard Connect/AlertNow:
Caller ID will display the school’s main number when a general announcement is delivered.
Caller ID will display 411 if the message is a dire emergency.
The system will leave a message on any answering machine or voicemail.
If the message stops playing, press any key 1-9 and the message will replay from the beginning.
The successful delivery of information is dependent upon accurate contact information for each student, so please
make certain that we have your most current phone numbers and e-mail addresses. Please fill out your current
information below and return to school as soon as possible. All numbers and email addresses listed on your student
information form will receive standard and emergency messages. Additional phone numbers and email addresses listed
below will also be contacted. All numbers will be dialed simultaneously. Thank you for your cooperation.
If any of your contact information changes during the year, please contact Kimberly Oliver at [email protected] or 561297-3077 to let us know immediately.
Sincerely,
Dr. Tammy Ferguson
Principal/Director
Student Name
Student Name
Student Name
Student Name
FAU High Student’s cell number
FAU High Student’s email address
E-mail address(es): list as many as you
would like to receive messages
Grade
Grade
Grade
Grade
(
)
Smart Phone? Y or N
Text Messages? Y or N
Health Information and Emergency Notification/Permission for Treatment
School Year: 2014-2015
Date Submitted:
Date Revised:
Instructions: A separate form is completed for each child in the family who attends ADHUS/FAUHS. A current health
information and emergency notification form must be on file in the Health Center when school begins or upon
enrollment. Information is updated annually. Additional information changes may be added at any time. It is critical to
maintain current contact information at all times. Any information shared is confidential and will be kept in your child’s
private health care file in the Health Center. It does not become part of the permanent school record.
Student’s Name:
M or F
(Last name, First Name)
Grade:
DOB:
(14-15)
A. Contact Information:
1. Please indicate which parent should be contacted first in case of illness or emergency AND which phone number
should be used first (cell, home, work).
First Contact:
Relationship to student:
Telephone: Home (
)
Cell (
)
Work (
)
Address:
Child lives with:  Both Parents
Best Contact # 
Best Contact # 
Best Contact # 
 Mother
Second Contact:
Relationship to student:
Telephone: Home (
)
Cell (
)
Work (
)
Address:
 Father
Best Contact # 
Best Contact # 
Best Contact # 
 Other:
2.
Additional people who are authorized to pick up my child from school if I can’t be reached. (Valid picture ID will be
required.)
Name
Relationship
Telephone
Location/Address (approx. 15 from ADHUS)
(
)
(
)
(
)
-
B. Permission to Treat or Administer Emergency Medical Care/Authorization to Release Medical Information:
1.
2.
I/We, the undersigned Parents/Guardians, in the event of an emergency or injury occurring during school hours, give permission for the
evaluation and treatment, in our absence, of the above named student as deemed necessary by a currently licensed health care provider,
hospital, emergency medical services or school staff. Every effort will be made to contact the parent/guardian. Care of the injured
student will be provided as needed. Care will not be withheld until parent arrives or are notified. I/We understand that the
parent/guardian is completely responsible for the financial costs incurred with treatment.
I/We, the undersigned, authorize the release of medical information, gathered in the course of a school emergency, to the listed medical
care providers and emergency response personnel. I/We authorize the listed medical providers to share any “personal health care
information” that will support the health of the student while in school with the designated Health Care staff.
Signature of Parent/Guardian
Date
3. Health Care Provider Information:
Pediatrician/Primary Health Care Provider:
Dentist:
Insurance Coverage:  Yes
 No Company/Carrier Name:
Signature of Parent/Guardian
Telephone:
Telephone:
Date
C.
Medical History:
1. My child will take daily or emergency medication during the school day.  Yes  No
Name of drug, dose, frequency, time to be given, date drug therapy started or to be started for each med to be given.
2.
A current “Authorization to Administer Medication in School” form is completed by parent and healthcare provider and is in
the Health Center.  Yes  No
(This form is available in the Health Center and Main Office. It must be completed before any medication, including over the counter medications such as
Motrin, Tylenol, or cough drops may be given by the school nurse during school hours. A handwritten note from a parent is not sufficient to provide
medication authorization.)
3.
Does your child routinely take daily medication at home?  Yes
reason for administration, and any known side effects.
4.
Does your child(ren) have any disease or chronic illness we should know about? Please list below.
5.
Does your child currently have Asthma?  Yes
meds taken:
6.
Does your child currently have Allergies?  Yes
 No If your child has a strong allergic reaction to any substance,
you are encourage to bring in a completed “Authorization to Administer Medication in School” form for oral Benadryl
and/or an injectable Epi-pen, Epi-pen Jr. These will be kept locked in the Health Center.
a. Food/Medication Allergies:
Treatment:
Reaction/Reaction Time:
b. Contact Allergies (bug bites, airborne vapors, dust, pollen, lotions, latex, etc.):
Treatment:
Reaction/Reaction Time:
c. All students receive milk as part of the school dietary program. If your child may not drink milk, state law requires a
note from your child’s health care provider.
My child may drink milk provided by the school.  Yes  No
7.
Has your child been diagnosed or treated for a vision, speech, or hearing impairment?  Yes
Does your child wear glasses/contacts or hearing aids:  Yes  No Explain:
8.
Has your child been diagnosed or treated for behavioral, developmental, or learning disabilities?  Yes
If yes, please explain:
9.
Does your child require assistance as defined by the Americans with Disabilities Act?  Yes
If yes, please explain:
 No
 No
If yes, list the name, dose, time given,
If yes, list frequency of asthma attacks, date of last attack and
 No
 No
 No
D. Medication Policy:
All routine, regularly scheduled or as needed medications and treatments administered in the school setting must be authorized in advance by
a licensed health care provider. This includes nebulizer or inhaler treatments for asthma, medications, ointments, or dressing changes to the
skin and all over the counter medication (OTC’s) such as Tylenol, Motrin, Cough Medicine, and Cough Drops. A note from the parent/guardian
does not authorize the school nurse or nurse designee to provide these treatments. Before the nurse can administer any medications or
treatments the “Authorization to Administer Medication in School” form must be completed by the parent/guardian and the student’s health
care provider. This form must be given to the nurse and filed in the Health Center. The parent/guardian must provide to the Health Center
the prescribed medication stored in the original container with an appropriate pharmacy label on each bottle. All labels must include the
student’s name, dose, route and time of administration of the medication.
No student is permitted to carry any medication in his/her pocket or backpack unless special permission is granted. All medication will be kept
secure in a locked cabinet in the Health Center and dispensed by the School Nurse or designee.
I/We have read and will abide by the ADHUS/FAUHS medication policy.
Parent/Guardian Signature
Date
Authorization to Administer Medication in School
Student Name:
DOB:
Grade:
Last Name, First Name
Part I
Dear Parent or Healthcare Provider,
When considered medically necessary, students may receive medications and treatments as ordered by a licensed
healthcare provider, during the school day. Please complete the following information. Be advised that:
Orders are valid for one school year.
 NO MEDICATION OR TREATMENT may be given by the school nurse or designee until this form is completed and
properly labeled medication is received. THIS INCLUDES OVER THE COUNTER MEDICATIONS SUCH AS TYLENOL,
MOTRIN, AND COUGH DROPS.
 A physician signature and a parent signature must be on this form.
 All mediations must be stored in their original containers with an appropriate pharmacy label on each bottle. All
labels will include the student’s name, does, frequency, route, time of administration of the medication.
Part II
Dear Healthcare Provider,
The parent initiates this request and has the responsibility for supplying medication and/or treatment supplies. Should
the student display any adverse reactions, the parent will be contacted immediately, emergency care will be provided as
needed and the medication/treatment discontinued. The parent will be responsible for contacting you for follow-up
care as you deem necessary. Please sign below, acknowledging that you understand the procedure for management of
side effects to prescribed medications or treatments. Thank you for your assistance.
Part III
Medication Treatment #1:
Name of Drug/Treatment
Dosage
Route
Frequency
Medication form  pill/capsule
 inhaler
 ear drops
Known adverse reactions/side effects
Prescribed treatment for side effects, if other than as outlined above
Medication Treatment #2:
Name of Drug/Treatment
Dosage
Route
Frequency
Medication form  pill/capsule
 inhaler
 ear drops
Known adverse reactions/side effects
Prescribed treatment for side effects, if other than as outlined above
Medication Treatment #3:
Name of Drug/Treatment
Dosage
Route
Frequency
Medication form  pill/capsule
 inhaler
 ear drops
Known adverse reactions/side effects
Prescribed treatment for side effects, if other than as outlined above
 eye drops
(include times and duration)
 liquid
 injectable
 eye drops
(include times and duration)
 liquid
 injectable
 eye drops
(include times and duration)
 liquid
 injectable
Part IV
Parent Permission:
I hereby give permission for my child to receive the above medications/treatments during school hours. I
understand that medications may be administered by the school registered nurse or designee. This designee may be a
non-medical person. If a treatment requires a medical or nursing assessment prior to administration, and a licensed
medical person is not available, the medication and/or treatment will not be given. This medication and/or treatment is
considered a medical necessity and ordered by a licensed healthcare provider. I hereby release the FAUS District, its
agents and employees from any and all liability that may result from my child receiving this medication and/or
treatment.
Parent/Guardian Signature
Date
Healthcare Provider Signature
Date
Parent/Guardian Name (Print)
Phone #
Healthcare Provider Name (Print)
Phone #
Do Not Write Below This Line-School Use Only
Comments:
Medication/Treatment Received
Date:
Amount:
Approved by:
Logged in Medical Administration Book:  Yes  No
Secured in locked cabinet:  Yes
 No
Date:
Amount:
Approved by:
Logged in Medical Administration Book:  Yes  No
Secured in locked cabinet:  Yes
 No
Date:
Amount:
Approved by:
Logged in Medical Administration Book:  Yes  No
Secured in locked cabinet:  Yes
 No
Date:
Amount:
Approved by:
Logged in Medical Administration Book:  Yes  No
Secured in locked cabinet:  Yes
 No
Date:
Amount:
Approved by:
Logged in Medical Administration Book:  Yes  No
Secured in locked cabinet:  Yes
 No
Date:
Amount:
Approved by:
Logged in Medical Administration Book:  Yes  No
(School Nurse Signature)
(School Nurse Signature)
(School Nurse Signature)
(School Nurse Signature)
(School Nurse Signature)
(School Nurse Signature)
Secured in locked cabinet:  Yes
 No
Clinic Policy and Procedures 2014-2015
The ADHUS/FAU HS Policy and Procedures the nurse must follow in the clinic are listed below.
We strive to keep all our students healthy and safe. Please keep your child/children home if they are sick. In the event
of the following, students are ALWAYS sent home or should NOT come to school:
Diarrhea: This is very contagious!
Vomiting: To Be Determined by Nurse (gagging on something or sick).
Fever: 100 degrees or more (Please DO NOT give your child medication before school that will wear off by
the afternoon. Student must have a normal temperature for a period of 24 hours before returning to school.
Lice/Nits: We have a NO LICE/NITS POLICY! If your child is suspected of having lice/nits, you must take them to your
physician and have them checked. Your child MAY NOT return to school without a note from your physician stating that
they do not have either lice/nits. Lice are very contagious just like an illness; we need to keep our students healthy.
Please DO NOT send you child to school if you suspect they have lice or nits.
Pink Eye: If the teacher and the nurse suspect pink eye, you must have a note from your child’s pediatrician
Stating they are not contagious before they return to school (as long as it’s not chronic allergies TBD by the Nurse).
Sore/Red Throat: To be determined by the Nurse, unless the child has known chronic allergies and no fever they may
not remain in school.
Constant cough/Wheezing: Including chest pain. This can be something serious (TBD by nurse).
Head/Face Injury: If serious, after 911 is called the parent will be called.
Nosebleed (or any other bleeding): Bleeding that does not stop within a reasonable amount of time (15-20 minutes).
Skin Eruptions: Contagious or questionable (TBD by nurse).
Constant Sneezing (with anything but clear secretion): If the child has only clear secretions and no fever they may
remain in school, as long as they use a tissue and wash their hands frequently.
When a child becomes sick at school, the nurse will call any and all phone numbers listed on the Emergency Notification
form you have completed. Please make sure this form is current. You will have 1 hour to one hour to pick up your
child (unless other arrangements have been made with the nurse or the front office personnel due to an unforeseen
circumstance). If you do not return the nurse’s call or pick your child up within the stated time, the nurse has the
right to call the proper authorities which may include 911.
We greatly appreciate your full cooperation. If you have any questions, please call Nurse Deborah at (561) 297-2076.
Student Name
Thank you.
Deborah Baltzer RN
Rev. 2/13
Parent Signature
Photo/Video Release Name of Student (please print): School Year: Grade: Address: City: State: Zip: Name of Parent/Guardian(s): Phone Number: Email: As a parent/guardian of an A. D. Henderson University School and FAU High School, I understand
that my student may be photographed, videotaped, or interviewed by the news media or the school. I
understand that pictures and interviews may be used on the school’s website, in internal and external
publications and electronic/social media as indicated below.
If no choice is marked, or this form is not received, it will default to choice #1.
 I hereby grant permission for A. D. Henderson University School and FAU High School to use
my child's name, likeness, and biographical material solely for the purposes of school-related
promotional material and publications and waive any rights of compensation or ownership
thereto. Possible uses may include, but are not limited to, photograph and video images in
annual yearbooks, graduation programs, playbills, school productions, web sites, social media
outlets, school approved news media interviews, releases, articles, photographs and similar
school sponsored publications.
 I hereby withdraw permission for A. D. Henderson University School and FAU High School to
use my child's name, likeness, and biographical material solely for the purposes of schoolrelated promotional material and publications and waive any rights of compensation or
ownership thereto. Possible uses may include, but are not limited to, photograph and video
images in annual yearbooks, graduation programs, playbills, school productions, web sites,
social media outlets, school approved news media interviews, releases, articles, photographs
and similar school sponsored publications.
Signature of Parent/Guardian
Date Henderson After School Program Enrollment Form
School Year: _____________
(Please complete one form PER CHILD)
Please email your enrollment form(s) to [email protected] or drop off the completed form(s) to
the front office. If you are emailing this form, you will need to sign a hard copy in the After
School office upon your child’s first day in aftercare. Email or contact us at (561) 297–3952 if
you have any aftercare questions. We are looking forward to having your child(ren) attend our
program!
SECTION 1: Child & Parent Information
Student Name (Last, First): __________________________________________________
Date of Birth: _________________________ Entering Grade Level :________________
Attendance Package:
____ 5 Days until 6:00 P.M.
____ 5 Days until 4:30 P.M.
____ 3 Days until 6:00 P.M.
____ 3 Days until 4:30 P.M.
____ 2 Days until 6:00 P.M.
____ 2 Days until 4:30 P.M.
Please check the days
your child will attend:
__Monday
__Thursday
__Tuesday
__ Friday
__Wednesday
__ Half Days
Address: ________________________________________________________________
City: _______________________________ State: _______ Zip Code :_____________
Home Phone: ____________________________________________________________
Cell Phone(s): ____________________________________________________________
BEST contact number for after school hours: ___________________________________
E-mail: __________________________________________________________________
Mother’s Name: __________________________________________________________
Work Phone: _____________________________________________________________
Father’s Name: ___________________________________________________________
Work Phone: _____________________________________________________________
Person responsible for paying fees: ___________________________________________
SECTION 2: Authorization of Student Release
In addition to parent(s) / guardian(s) listed above, A.D. Henderson University School
officials are authorized to release my child(ren) to the following:
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
*Anyone other than parents or guardians MUST show proper identification when
picking up your child(ren). Custodial arrangements that prohibit students from being
released to any particular party must be on file with the After School office.
I understand that my child(ren) will NOT be released to
anyone not on this list without prior written authorization
from myself to A.D. Henderson University School.
SECTION 3: Health and Emergency Information
Allergies (food, medications, etc.):____________________________________________
Special health needs/ medications:___________________________________________
In case of emergency
I give permission to have my child treated at the Boca
Raton Regional Hospital Emergency Room in case of a
serious illness or injury. (Every effort will be made to
contact the parent immediately.)
Insurance Company: _______________________________________________________
Policy Number: ___________________________________________________________
I hereby attest that the above information is true and
accurate to the best of my knowledge, and that I am the
legal guardian of the student listed.
SECTION 4: Parent Signature
I acknowledge and agree to all the above stated policies as
well as the policies stated in the Henderson After School
Program Handbook.
Parent Signature: ________________________________________ Date: ____________