WMS ON SITE REGISTRATION FOR 2015-2016

WMS ON SITE REGISTRATION FOR 2015-2016
Tuesday, May 5th and Wednesday, May 6th 4:00 – 7:00 PM
We are holding Registration for both schools on May 5thand 6th from 4-7p.m. at Willowbrook Middle School.
SIXTH GRADE HEALTH REQUIREMENTS
Physical Examination on an Illinois form
Current immunizations, including Hepatitis B
Diabetic Screening
BMI
Dental Examination
TRANSFER STUDENTS HEALTH REQUIREMENTS
From Illinois schools
An eye examination on an Illinois form
A dental exam on an Illinois form
A new physical examination is NOT required, unless entering sixth grade.
From other states
A physical examination is required of all students, recorded on an Illinois form. Immunizations must be
current, and follow the requirements of the entering grade level.
Dental examinations must be recorded on an Illinois form.
Eye Examination by Optometrist or Ophthalmologist
PARENTS WILL NEED TO BRING:
PROOF OF RESIDENCY:
Current Tax Bill, Closing Statement, or Signed Lease Agreement
Plus 2 of the following Current documents:
Illinois Driver’s License
Automobile Registration
Voter’s Registration Card
Public Aid/Medical Aid Card
Gas or Electric Bill
Homeowner’s Insurance
If you don’t completely prove residency your child will not be enrolled in school and will not be able to attend.
EMERGENCY CONTACT INFORMATION
COPY OF MEDICAL FORMS: Medical and Dental Exams for 6TH Grade
NEW STUDENTS:
Certified Copy of Child’s Birth Certificate
CHECKS FOR REGISTRATION FEES (SEPARATE CHECKS REQUIRED FOR EACH SCHOOL)
6th – 8th Gr. Registration Fee: $70.00
5th Gr. Registration Fee:
$60.00
5th Gr. Enhancement Fee:
$10.00
th
P.E. Lock: (5 Gr.& New)
$7.00
Year Book:
$23.00
Lunch:
$2.50
Milk:
$.35
All checks must have a telephone number and be made payable to: “PHCCSD #133”
SEPARATE CHECKS FOR THE FOLLOWING IF NEEDED:
P.E. Uniform
Choir Shirt (6-8)
Band Shirt
$20.00
$11.00
$9.00
(Custom Inks)
(American Bell)
(American Bell)
CREDIT AND DEBIT CARDS WILL BE ACCEPTED
Student Information
Today’s Date: ________________________
Student’s Name: _______________________________________________________________ M or F (Circle)
DOB__________ Age______Grade______
Student’s Name: _______________________________________________________________ M or F (Circle)
DOB__________ Age______Grade______
Student’s Name: _______________________________________________________________ M or F (Circle)
DOB__________ Age______Grade______
Last
First
Last
First
Last
First
Middle
Middle
Middle
Address: ________________________________________________________________________
Street/City/State/Zip Code
Does your child speak another Language? YES NO If yes: Which language? _______________Which Language is spoken at home? __________________
Is either parent actively serving in the military? YES NO
Child lives with: (Circle all that apply) Both Parents/Father/Mother/Stepfather/Stepmother/Guardian
Father’s / Stepfather’s (Circle)
Mother’s / Stepmother’s (Circle)
Full Name: ________________________________________________
Full Name: _______________________________________________
Place of Employment: _______________________________________
Place of Employment: ______________________________________
Work phone: __________________ Cell phone: __________________
Work phone: __________________ Cell phone: __________________
Home phone: __________________ Email: ______________________
Home phone: __________________Email: ______________________
If parents are divorced, separated or unmarried, are there any court restrictions placed on parental rights of non-custodial parent?
Yes/No (Circle)
If “yes”, a copy of the court order must be on file in the school office.
Please list two relative’s or neighbor’s to call in case of an emergency:
Name__________________________ Relationship _______________
Name_____________________________ Relationship________________
Phone number: __________________________________
Phone number: __________________________________
Last Name: ______________________
Health Information
First Name_______________________
Grade: __________________________
Has your child’s vision been tested outside of school? Yes/No (Circle) Does your child wear eyeglasses? Yes/No (Circle)
Has your child had eye surgery? ____________________________________________________ Date: ____________________________
Has your child’s hearing been tested outside of school? Yes/No (Circle) If “yes”, what were the results? Normal Yes/No (Circle)
Circle all that apply: Wears a hearing aide/Has had ear surgery/Has tubes Dates: ______________________________________________
Please list any medications your child is currently taking at home or school:
Medication: _________________________
Dose: _________________________
Medication: _________________________
Dose: _________________________
Time(s) given: _________________________
Time(s) given: _________________________
Does your child have an allergy to any foods, medications, insects, latex, or other substances? Yes/No (Circle)
If “yes”, is allergy severe/moderate/mild (Circle) Describe in DETAIL what the allergy is: ____________________________________________
What medications or treatments are used to treat the allergy? ________________________________________________________________
Please circle all that apply to your student:
Eating Disorder
Dyslexia/Learning Disorder
Asthma
Epilepsy/Seizure Disorder
Cystic Fibrosis
Heart Condition
ADHD
Diabetes
Other: _________________________________
Muscular/Orthopedic Disorder
Psychiatric/Psychological Disorder
Serious Accident/Head Injury
Kidney Disorder
Down Syndrome
Chicken Pox-Date__________
Migraine Headaches
Surgery
If you circled any of the above, please describe: _______________________________________________________________________________
Please note any concerns or diagnosed health concerns of which the school nurse needs to be aware: ___________________________________
Physician and phone number: ____________________________Hospital preference in case of emergency: ______________________________
Signature of Parent/Guardian: _____________________________________________________ Date: __________________________________
RELEASE OF INFORMATION REQUEST FORM
I hereby give permission to release the following information pertaining to my child(ren) to the
Prairie Hill Community Consolidated School District #133:
1.
2.
3.
4.
5.
6.
Cumulative Records – including current grades, attendance, and testing.
Health Records – including dental, immunizations, and physicals
All Prior records from school systems other than your district.
Expulsion Records and reasons if applicable.
Any additional information regarding this student’s strengths, weaknesses, family
background, social adjustments, etc. that would help in understanding and best providing
for this student.
Other:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
AUTHORIZATION AND RELEASE OF INFORMATION
I hereby authorize ________________________________________________(Previous School)
_______________________________________________(Street Address)
_______________________________________________(City, State, Zip)
________________________(Phone #)_______________________(Fax #)
to release information and school records of ____________________________DOB_________
____________________________DOB_________
____________________________DOB_________
(Students’ Names)
to Prairie Hill Community Consolidated District #133.
Signed:_____________________________________ Date___________________
( Parent or Guardian)
SPECIAL EDUCATION RECORDS
I hereby give my permission for the release of information regarding Special Education Records
– INCLUDING IEPs, psychological reports and other testing.
AUTHORIZATION AND RELEASE OF SPECIAL EDUCATION INFORMATION
I hereby authorize ____________________________________(Previous School)
_____________________________________(Street Address)
_____________________________________(City, State, Zip)
__________________(Phone #)___________________(Fax #)
to release information and school records of ___________________________DOB_________
___________________________DOB_________
___________________________DOB_________
(Students’ Names)
to Prairie Hill Community Consolidated District #133.
Signed:_____________________________________ Date___________________
( Parent or Guardian)
PROOF OF RESIDENCY – SCHOOL YEAR 2015-2016
PRAIRIE HILL COMMUNITY CONSOLIDATED DISTRICT #133
Prairie Hill CCSD #133 requires that all students attending Prairie Hill or Willowbrook be bona fide residents of
the District. To be a bona fide resident, a student must be living with a parent or court-appointed guardian
who is a resident of the District. Parents or guardians are required to provide proof of residency. Only one
form required per family. THE DISTRICT ACTIVELY INVESTIGATES RESIDENCY.
Parents/Guardians______________________________, _________________________________
Address: ______________________________________ Please check: ____Parent ____Guardian ___Foster Parent
City, State, Zip_________________________________
Telephone: ______________________
Name of Student: ____________________________
Grade: _____ School: ____PHS ____Willowbrook
Name of Student: ____________________________
Grade: _____ School: ____PHS ____Willowbrook
Name of Student: ____________________________
Grade: _____ School: ____PHS ____Willowbrook
In all situations where residence is claimed, the following conditions must be demonstrated to the District’s satisfaction:
1. The child’s residence has not been established solely for the purpose of attending District #133.
2. The child regularly takes his or her meals at the residence.
3. The child sleeps regularly at that residence.
4. The child spends his or her weekends regularly at that residence.
5. The child spends his or her summers regularly at that residence.
6. The child is not financially supported by natural parents who live elsewhere.
IT IS A CRIMINAL OFFENSE TO ENROLL OR ATTEMPT TO ENROLL A NON-RESIDENT STUDENT1
THIS PROOF OF RESIDENCY FORM IS TO ATTEST TO THE FACT THAT THE ABOVE-MENTIONED CHILD IS LIVING, ON A
PERMANENT BASIS, WITH THE PERSON HAVING COMPLETE LEGAL CUSTODY AND CONTROL, AT THIS ADDRESS. ANY
STUDENT FOUND TO HAVE BEEN FRAUDULENTLY REGISTERED MAY BE DROPPED FROM THE ATTENDANCE ROLLS
IMMEDIATELY. ANYONE WHO ENROLLS A NON-RESIDENT STUDENT MAY BE SUBJECTED TO CRIMINAL PROSECUTION AND
2
THE PAYMENT OF RETROACTIVE TUITION, NOT TO EXCEED 110% OF THE PER CAPITA TUITION COST. EACH PERSON
SIGNING THIS DOCUMENT HEREBY AGREES TO PAY ANY AND ALL LEGAL AND COLLECTION EXPENSES THE DISTRICT MAY
INCUR TO COLLECT TUITION FOR THE NON-RESIDENT STUDENT.
THE PER-CAPITA TUITION CHARGE FOR 2014-2015 WAS $8,740.
___________________________________ ______________________________________ ___________________
Signature of Parents/Guardians/Foster Parents
Date
SIGNATURE(S) MUST BE WITNESSED BY THE SCHOOL PRINCIPAL OR A DESIGNEE.
School District Use Only ______________________________
Witnessed by
1
2
______________________ COMPLETE ___YES ____NO
Date
105 ILCS 5/10-20.12b Proofs presented: Tax Bill ____ Lease____Gas____Water___Sewer____ILL D.L.____Voter___
105 ILCS 5/10-20.12a
Home Ins.____Public Aid____Auto Reg___Electric____Closing Stmt____
720 N. Blackhawk Blvd.
Rockton, IL 61072
815-624-0294
Student Transportation Request Form
Date Requested
School District
Effective Date
PHS District #133
School Name
Child's Name
Child's Name
Child's Name
Grade
Grade
Grade
Address
Phone #
Willowbrook Middle School
Parent / Guardian
Name
Address
Phone
(Please check one)
Address
Change
New Student
Sitter Change
**BUS TRANSPORTATION WILL BE LIMITED TO ONE PICK-UP ADDRESS AND ONE
DROP OFF ADDRESS**
AM Information
Select One:
Bus:
Bus Pick-Up Location
different than home)
Walk/Bike:
Parent:
(if
Name
Address
Phone
(select the ONE form of transportation your child will use the majority of the time)
PM Information
Select One:
Bus:
Bus Drop-off Location
(if different than home)
Walk/Bike:
Name
Parent:
Address
Phone
(select the ONE form of transportation your child will use the majority of the time)
Emergency Contact:
Name
Address
Phone
WILLOWBROOK MIDDLE SCHOOL
PRAIRIE HILL SCHOOL DISTRICT # 133
STUDENT REQUEST FOR THE LOAN OF TEXTBOOKS
I hereby request the loan of secular textbooks for my child/children in accordance with Public
Act 79-961 of 1975. I understand that this request will remain in effect for the duration of
my child’s/children’s attendance in the Prairie Hill School District #133, and that I may at any
time withdraw this request. I am aware that I am responsible for any book which is lost or
damaged. The replacement or payment will be due no later than the last day of the current
school year.
Student Name
Grade in 2015 - 2016
Parent / Guardian Signature
Date
WMS GYM UNIFORM ORDER FORM
Gym Uniforms are MANDATORY for all students in grades 5-8
There is a box of sample sizes available in the school office to help with purchasing the correct size.
A Complete
A Complete
Shirt and
Shirt and
Short Set is
Short Set is
MANDATORY ITEMS
$20.00
YOUTH
MEDIUM
(10-12)
$8.55
YOUTH
MEDIUM
$11.45
SHIRT
SHORTS
YOUTH
LARGE
(14-16)
$8.55
YOUTH
LARGE
$11.45
$20.00
ADULT
SMALL
$8.55
ADULT
MEDIUM
$8.55
ADULT
LARGE
$8.55
ADULT
X-LARGE
$8.55
ADULT
XX-LARGE
$10.55
ADULT
SMALL
$11.45
ADULT
MEDIUM
$11.45
ADULT
LARGE
$11.45
ADULT
X-LARGE
$11.45
ADULT
XX-LARGE
$13.45
Circle shirt and short size you wish to order. Use one order form PER CHILD!
*OPTIONAL ITEMS*
HOODIE
SWEATSHIRT
SWEATPANTS
YOUTH
MEDIUM
(10-12)
$20.00
YOUTH
MEDIUM
$15.00
YOUTH
LARGE
(14-16)
$20.00
YOUTH
LARGE
$15.00
ADULT
SMALL
$20.00
ADULT
MEDIUM
$20.00
ADULT
LARGE
$20.00
ADULT
X-LARGE
$20.00
ADULT
XX-LARGE
$22.00
ADULT
SMALL
$15.00
ADULT
MEDIUM
$15.00
ADULT
LARGE
$15.00
ADULT
X-LARGE
$15.00
ADULT
XX-LARGE
$17.00
Circle sizes you wish to order. Use one order form PER CHILD!
Student Name_____________________________________________________________________
Phone Number__________________Amount Enclosed_________________Check #___________
CHECKS SHOULD BE MADE PAYABLE TO CUSTOM INKS!
PRAIRIE HILL SCHOOL DISCTRICT #133
Refusal for The
Photography of Students
2015 - 2016
Exhibit - Using a Photograph or Video Recording of a Student
Distribute to parent(s)/guardian(s) at the time they register a child for school and/or annually at the
beginning of the school year. Return to the Building Principal to be kept in the student’s temporary record.
Student
Grade
Student
Grade
Student
Grade
Student
Grade
Pictures of Unnamed Students
Students may occasionally appear in photographs and video recordings taken by school staff members,
other students, or other individuals authorized by the Building Principal. The school may use these
pictures, without identifying the student, in various publications, including the school yearbook, school
newspaper, and school website. No consent or notice is needed or will be given before the school uses
pictures of unnamed students taken while they are at school or a school-related activity.
Pictures of Named Students
Sometimes the school may want to identify a student in a school picture. For example, school officials
want to acknowledge those students who participate in a school activity or deserve special recognition.
In order for the school to publish a picture with a student identified by name, one of the student’s parents
or guardians must sign the consent below. Please complete and sign this form to allow the school to
publish and otherwise use photographs and video recordings, with your child identified, while he or she is
enrolled in this school.
I DO NOT grant consent to the School District to identify a picture of my child, by full name and/or the
school he or she attends, in any school sponsored material, publication, video recording, or website. This
consent is valid for the entire time my child is enrolled in the District. I may revoke this consent at any time
by notifying the Building Principal.
Parent/Guardian (PLEASE PRINT)
Parent/Guardian signature
Date
Pictures of Students Taken By Non-School Agencies
While the school limits access to school buildings by outside photographers, it has no control over news
media or other entities that may publish a picture of a named or unnamed student. School staff members
will not, however, identify a student for an outside photographer.
Illinois State Board of Education
U.S. Department of Education Race and Ethnicity Data Standards
DATA COLLECTION FORM
Student’s Name:________________________
Instructions: This form is to be filled out by the student’s parents or guardians, and both questions must be
answered. Part A asks about the student’s ethnicity and Part B asks about the student’s race. If you decline to
respond to either question, the school district is required to provide the missing information by observer
identification.
Part A. Is this student Hispanic / Latino? (A person of Cuban, Mexican, Puerto Rican, South of Central
American, or other Spanish culture or origin, regardless of race.) Choose only one.
No, not Hispanic / Latino
Yes, Hispanic / Latino
The question above is about ethnicity, not race. No matter which answer you selected, continue
and respond to the question below by marking one or more boxes to indicate what you consider
this student’s race to be.
Part B. What is the student’s race? Choose one or more.
American Indian or Alaska Native ( A person having origins in any of the original peoples of
North and South America, including Central America, and who maintains tribal affiliation or
community attachment.)
Asian ( A person having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
Black or African American (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.)
Note: Data collected on this form must be maintained by the school district for three years. However, when there is litigation, a claim,
an audit, or another action involving this record, the original responses must be retained until the completion of the action.
DATA REQUEST
2015-2016
ONE FORM PER FAMILY
Please list any child living in your household that is under the age of 5 as of
September 1st of this year. This information will help plan for the needs of the
school district in the future.
1.) _________________________________ DOB ____________Gender_____
First
Middle
Last
2.) _________________________________ DOB ____________Gender_____
First
Middle
Last
3.) _________________________________ DOB ____________Gender_____
First
Middle
Last
4.) _________________________________ DOB ____________Gender_____
First
Middle
Last
Parent Name:________________________________ Phone_________________
Home Language Survey
Please complete and return this survey with your Registration Materials.
Student’s Name: _____________________________________________________________
Today’s Date: _______________________
Grade: ___________________________
Birth Date: __________________________
Phone: ___________________________
Sex: Male_____ Female_____ Birthplace (City, State, Country) _______________________
My child’s primary language is English: YES____ No______
If YES, Stop Here & Sign Below!
If NO, please continue.
1. What was the first language your child learned? _________________________________
2. What language do you (parent/guardian) use most frequently to speak to your child?
__________________________________________________________________
3. Which language does your child use the most when he/she:
Talks to you______________
b. Talks with friends__________________
Please share any information about your customs, country, etc., that will help us educate your child:
__________________________________________________________________________________________
__________________________________________
If you have any questions, please contact the school within two weeks.
____________________________________
Signature of Parent or Guardian
DISTRICT #133 SCHOOL CALENDAR
2015-2016
August 19
First Day of Attendance
September 7
Labor Day-No School
October 9
October 12
October 16
SIP Day-No School
Columbus Day-No School
End of First Quarter
November 12
November 13
November 19
November 20
November 25-27
Parent/Teacher Conferences
No School
Parent/Teacher Conferences
No School
Thanksgiving Break-No School
December 21-Jan 1 Winter Break-No School
January 4, 2016
January 8
January 15
January 18
School Resumes
End of Second Quarter
Teacher Institute-No School
Martin Luther King’s Birthday-No School
February 18
February 19
February 25
February 26
February 29
Parent/Teacher Conferences
No School
Parent/Teacher Conferences
No School
Casimir Pulaski Day-No School
March 18
March 25
March 28-April 1
End of Third Quarter
No School
Spring Break-No School
April 22
SIP Day-No School
May 26
Last Day of Attendance