WAES 2015-2016 Forms - Amory School District

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WEST AMORY ELEMENTARY SCHOOL
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2015-2016 Enrollment Process
7/6/2015
Dear Parent/Guardian,
First, let me begin by saying I am thrilled to be serving you, your child and the Amory School
District as principal of West Amory Elementary School again for the 2015-2016 school year. I
am grateful to be surrounded by a community, parents and a fabulous group of teachers who
know the importance of a quality education. I am confident we will have another fantastic
school year!
Secondly, I want to list the dates and requirements for our summer enrollment process. We
will host three enrollment dates for students here at West Amory. The enrollment dates are the
following:
Kindergarten Students- July 29th- 8:00 am- 4:00 pm
1st Grade Students- July 30th- 8:00 am- 4:00 pm
2nd Grade Students- July 31st- 8:00 am- 4:00 pm
(If you have students in
more than one grade, you can enroll them on the same day.)
On the enrollment date listed for your child, you will come to the school at any time during
the hours listed above to do the following:
Turn in the paperwork included with this letter completed for your child
Pay School Fees- $25.00
3) Present two current (dated in July) proofs of residency. Must be 2 of the following:
a. Deed
b. Lease (Renter)
c. Utility Bills (Two utility bill mav be used as a proof of residency and must be dated in
Water Electric Cable/Dish TV Gas Phone (Residency Line Only) Property Tax or
2. Homestead Exemption and Tax Record (Current)
Driver's License
Voter ID. (Must be issued within the current calendar year)
Automobile Registration (TAG)
Determination letter from:
Social Security Medicaid DHS
•
July)
Garbage
Health Dept.
(You will receive the name of your child's teacher and the teacher's welcome letter on this date.)
Thank you for your partnership with us!
Letricia French, Ed. S
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Teacillitd Resources.
For School
Office Use Only MSIS ID tt Birth Certificate # Place of Birth Social Security Card # Bus #
Teacher Township Range: Special Services? Yes or No
Pre-School Yes or No
Car Rider
West Amory Elementary
Today's Date: Student's Name (Last)
Pupil Personal Data/Emergency Information Card
Age Grade Place of Birth
Birth Date
Street Address City Race Sex (Middle)
(First)
Phone # Last School Attended Zip Fill in the information below on the person the student lives with:
Name Home # Relationship Email Address
Work #
Cell #
Workplace # Name Relationship Email Address
Home # Workplace # Work #
Cell #
Additional Contact Persons: These persons may be contacted in case of an emergency & check my child out
of school. Photo identification MUST be provided before the child is released.
Relationship
1) Name
Home
#
Cell#
Relationship
3) Name
Home
Work#
#
Cell#
Work#
2) Name
Home
Relationship
#
Cell#
4) Name
Home
Work#
Relationship
#
Cell#
Work#
If parents are separated or divorced, who has legal custody? These persons listed are NOT to have ANY contact with my child: plaisbox
SIDE
Please initial each line that you are in agreement with:
I give permission for the administration to use corporal punishment as a form of punishment if needed for my
child.
I give permission for my child's picture to be taken and appear editorially and/or promotionally.
I have received a copy of my child's handbook that includes the district policies, procedures and discipline plan.
I give West Elementary Clinic permission for my minor child to receive health related services as stated in the
student handbook.
I and my child understand and will abide by the conditions, rules, regulations, and procedures of the district's
internet and computer use policy in the student handbook. I further understand my child may have their privileges
revoked permanently if he/she commits any violation.
During the school year, students may take several educational field trips. Parents will always be notified in
advance of the dates of trip. We must have permission to take your child of the school's campus.
Student Medical Information:
Allergies: Regular Medications Taken: Health Problems/Illnesses/Additional Info:
List Names of Siblings in the Amory School District:
Name: Grade: School: Name: Grade: School: Name: Grade: School: Name:
Grade:
School:
Parent Signature: Date: RESIDENCY REGISTRATION AND DOCUMENTATION CHECKLIST
TO BE COMPLETED BY PARENT, GUARDIAN, OR OTHER ADULT
AMORY SCHOOL DISTRICT
Name of Student:
(A separate form is required for each pupil)
Name of Parent, Guardian, or Other Adult: Address:
(A P.O. Box Number is not acceptable for an address; if route, give physical location directions on back)
I hereby certify that the information given above on this form is a true and correct statement of my legal residence. Should legal residence change while the above
listed student is enrolled in the above-cited school district, I will promptly notify the appropriate officials of this district. Further, I understand that a pupil is not
legally enrolled until this form is completed and signed by the parent, guardian, or other adult with whom the student may be living. I understand that residency must
be established to the satisfaction of the Amory School District and that the Amory School District may require additional documentation and proof of residency in
addition to the minimum documentation set out below. I further understand that additional documentation and proof may be required at any time before or after a
pupil is admitted, and that a pupil admitted under false information is not legally enrolled.
I understand that the Amory School District at all times, including before or after admission, may investigate the residency of a pupil, parent, guardian, or custodian,
and the truth and authenticity of any documentation and proof provided. I further understand that in the event it is discovered that a pupil, parent, guardian, or
custodian is not a resident of the district, or if false or inaccurate documentation has been provided by a parent, guardian, or other custodian, the pupil will be subject
to removal from the Amory School District.
Signature of Parent, or Guardian
Telephone Number
Dote
RESIDENCY REGISTRATION AND DOCUMENTATION CHECKLIST
TO BE COMPLETED BY THE SCHOOL DISTRICT
MINIMUM OF TWO REQUIRED OF ALL STUDENTS (PROOFS OF RESIDENCY MUST BE IN THE SAME NAME)
A.
Documents provided to me by Parent/Guardian/Other Adult/ or Student:
a. Deed
b. Lease (Renter)
c. Utility Bills (Two utility bills may be used as proofs of residency and must be dated within the past 2 months)
Cable/Dish TV
Electric
Water
Gas
Property Tax
Phone (Residency Line Only)
Garbage
Homestead Exemption and Tax Record (Current)
Driver's License
Voter I.D. (must be dated within the current year)
S.
Automobile Registration (TAG)
6.
Determination letter from:
Social Security
Medicaid
DHS
Health Dept.
Affidavit of Residency *Must have two proofs of residency by the owner of the property and one by the resident (enrolling parent or guardian)
Home Visit by a school official
Student is living with legal guardian and a certified copy of the Court Decree, was received declaring the district resident to be the legal
guardian of the student and further declaring that the guardianship was formed for a purpose other than establishing residency for school district
attendance purposes. (Still subject to two proofs of residency)
Student is living with an adult other than parent and the adult has provided sufficient documentation and sworn affidavit stating his/her
relationship to the student, that the student will be living in his/her home full time, and fully explaining the reason (other than school attendance zone or
district preference) for this arrangement; the School Board or its designee has made the necessary factual determination under II.1(c)(2) of the State
Residency Verification Procedures.*This affidavit should come from Central Office.
(Still subject to two proofs of residency)
(School District)
(Date)
School Visit:
Time
Date Student Name
Migrant Eligibility
Home Language Survey
If you have moved and/or changed jobs in the last 3 years, did you
LOOK FOR or GET any of the following jobs listed below?
Check ALL that apply.
FARMING (crops, catfish, chickens, Christmas trees, sod, etc.)
Please check the appropriate answer:
1. What is the first language the student learned to speak?
English
Other
2. What language does the student most often speak
English
Other
TREES (cutting, planting, and/or cultivating)
What language is most often spoken in the student's home?
English
Other
In what language do parents prefer that communication comes home?
English
Other
COMMERCIAL FISHING
PROCESSING CROPS (ginning, meat processing, meat
packing, or canning in a plant)
Immigrant Children and Youth Eligibility
5. Has the student been in the care of a person that speaks another
language?
English
Other
Do you have children ages 3 through 21 who were not born in any
State; and have not been attending one or more schools in any one
or more States for more than 3 full academic years?
No
Yes
q
Homeless Eligibility
Please check the appropriate answer:
1. Does the student lack a fixed, regular and adequate residence, for example: children living on the streets, cars, motel, shelter?
Yes
No q
2. Does the student have a primary nighttime residence in a supervised or privately operated shelter, for example: children who have been
No
Yes
abused and/or neglected, children of domestic violence, welfare hotels, transitional housing? q
q
3. Is the student temporarily staying with relatives or friends because of loss of job, other income loss, housing loss ("double up" families
or affidavit)?
No
Yes
n
q
Excluded from the definition of homeless: "any individual imprisoned or otherwise detained pursuant to an Act of Congress or a state law."
Parent Signature Date
AMORY ELEMENTARY SCHOOLS - STUDENT-PARENT COMPACT
As a student I,
will
Asa teacher I,
will
Work cooperatively with my classroom
Make class work and homework assignment clear and appropriate
Show respect for myself, my school, and other people
Create an atmosphere in which students can ask for help if needed
Take pride in my school
Communicate with parents/guardians regarding academic progress
and helpful suggestions
Come to school prepared with my homework and supplies
Make sure the home is aware of the student's problems early
Attend school daily except when ill or otherwise excused
Be on time for school
Expect students to excel and assist them in doing so. thus helping
them reach their full potential
Complete all in-school class work and all homework on time
Encourage students and parents to take part in school activities
Complete all make-up assignments and test on time
Show respect for each child and his/her family
Respect the rights and property of classmates, teachers, and other
Provide high quality curriculum and instruction to assist students in
learning the state standards
As a parent I, will
Enforce school and classroom rules fairly and consistently
See that my child attend school regularly and on time
Provide a home environment that encourages my child to learn
See that all homework assignment are complete
Communicate regularly with my child's teachers
Support the school in developing positive behaviors and disciplinary
measures
I, the Principal, support this form of parental involvement. Therefore, I shall
strive to do the following:
Provide an environment that allows for positive communication
between the teacher, parent, and student
Volunteer my time at the school
Make sure the school office has my current address and phone
numbers
Provide opportunities for parents to be involved in the school and in
their child's education
Encourage teachers to provide homework assignments that reinforce
Review sign and return Progress Reports and Report Cards
classroom instruction
School Health History Form
Child's Name
Date of Birth
Parent/Guardian
I.
General
Has your child had a check-up with a doctor in the last calendar year?
Phone #
Name of child's doctor Date of last visit
Reason for visit
Has your child been to a dentist in the last calendar year? Name of child's dentist Date of last visit
Reason for visit
Is your child allergic to medication?
Yes
Is your child allergic to insect bites, dust, mold, etc...
If yes to either, please list:
H. Family and Social History
Are both parents in good health?
Yes
Yes No
No
Yes
Phone # No
Yes
No
No
Does any member of your child's family (father, mother, grandparents, brothers, sisters, aunts,
uncles) have any of these conditions? (Circle all that apply)
heart disease
alcohol/drug abuse
high blood pressure
diabetes
cancer
asthma
anemia
stroke
kidney disease
allergies
seizures
deafness
nerve/mental problem
tuberculosis
sickle cell disease/trait
handicap/disability
Who does this child live with?
Does anyone help you take care of your child? If yes, who: Does anyone in the house smoke?
Yes
Yes
No
No
III. Medical History
In the past year, has your child:
Had a constant cold, hay fever, wheezing, asthma?
Had more than three (3) ear infections?
Had trouble hearing/worn a hearing aid?
Had trouble seeing/worn glasses?
Had a rash or hives?
Had any trouble with his/her teeth?
If yes, please explain: Had leg pain, aches, or limping? Had a stomach ache, vomiting, diarrhea, or constipation? Had trouble urinating? Wetting the bed? Had a convulsion?
Had to stay in the hospital?
If yes, please tell us when and why: Had a serious illness or accident?
If yes, please describe: Had surgery or an operation of any kind?
If yes, please describe: Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
No
Ever had a blood transfusion?
Yes
No
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Yes
Ever had childhood illness? (chicken pox, measles) No
Does your child have any of the following problems? (circle all that apply)
sickle cell disease/trait bone/joint
heart
diabetes
skin disorder
cerebral palsy
muscle
asthma
Developmental History
Does this child learn as quickly as other children? Is this child harder to raise than other children? Did this child sit up, crawl, walk and talk on time?
If no, please explain: Yes
Yes
Yes
No
No
No
Do you worry or have concerns about any of the following? (circle all that apply)
sleeping
nail biting
listening ability
shyness
eats dirt or paint
appetite
speech
learning ability
potty training
Prenatal/Birth History
Yes
No
Was this child a full-term baby?
If no, how many weeks did you carry this child? No
Yes
Were there any complications with the pregnancy of this child?
No
Yes
Were there any newborn complications with this child? If yes, please describe: How much did this child weigh at birth? How many days did you stay in the hospital with this delivery? How many days did the child stay in the hospital? Did this child have any trouble the first few weeks at home? (fever, vomiting, diarrhea. jaundice)
How many times have you been pregnant?
How many child have you had? VI. Psychosocial History
What kind of grades does this child get? Does this child get along well with peers?
Does this child get along well with siblings?
Does this child get upset easily?
Nutrition
Does your child eat: (circle one)
Is your child receiving WIC?
Yes
Yes
Yes
3 meals/day
2 meals/day
No
No
No
1 meal/day
Yes
No
Other
How many hours sleep does your child get on an average night? Yes
Does your child brush teeth twice a day? Yes
Does your child floss daily?
Yes
If your child is female, has she started her cycle?
If yes, at what age did menaces start? normal
Is the flow: (circle one)
heavy
No
No
No
Date
Signature of Parent/Guardian
East and West Amory Elementary School Authorization for Services
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, parent or guardian of I, Date of birth, ,
give West Amory School Clinic permission for my minor child to
receive the following health related services:
EPSDT screening which includes a through head-to-toe physical examination
Vision and hearing screening
Urine testing (to screen for diabetes)
A Finger stick (to check for anemia and lead poisoning)
Developmental and nutritional assessment
Immunization evaluation
Dental screening
I understand that my child's medical records are strictly confidential.
This authorization is limited to the services described above. I understand that if a health problem is
identified during the health check-up, the School Nurse will notify me and a referral will be made to the
appropriate doctor. This authorization is valid for one year, from the school term 2015 thru 2016.
I retain the right to withdraw permission for services at any time during the school year.
I hereby authorize payment of insurance benefits to the above named clinic under the term of the
child's policy. I hereby authorize the clinic to release any information acquired in the course of the
examination so that insurance benefits may be promptly and correctly filed.
MS Medicaid
MS Medicaid Number Insurance Company
Insurance Policy Number Parent / Guardian Signature
Date
'ermission for Release of Confidential Information
hereby consent to and authorize East Amory School Clinic to release my child's medical records to/or information
haring between the above provider and the name(s) listed below:
Doctor
Facility
Address
Phone
Fax
Doctor
Facility
Address
Phone
Fax
Doctor
Facility
Address
Phone
Fax
For the purpose of planning, coordinating or delivering my child's care of for other purposes as herein identified:
I have been given an opportunity to discuss this release of information. I understand that I have the right
to withdraw this permission at any time (except to the extent that action has already been taken). If not
already withdrawn, this consent expires one year from today's date.
Student's Name
Date of Birth
•
Parent/Guardian Signature
Date
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West Amory Elementary
Kindergarten
1 thin Red/Blue rest mat - LABELED (with child's name)
2 boxes of yellow No. 2 pencils
2 boxes of 24 count Crayola crayons - LABELED
1 pack of Expo dry erase markers
1 pair of Fiskar scissors - LABELED
4 first grade writing tablets
2 composition notebooks - LABELED
2 solid colored folders (NO brads)
4 Elmer glue sticks
1 bottle of Elmer glue
2 boxes of Kleenex
1 roll of paper towels
1 box of Ziploc sandwich size bags
1 box of Ziploc gallon size bags
1 box of cap erasers (for pencils)
1 three hole zipper pencil bag
Change of clothes (LABELED in a Ziploc bag)
1 backpack large enough to fit a binder (no rolling backpacks please) - LABELED
1 package of white copy paper ---- Boys
1 package of white card stock ---- Girls
1 package of sheet protectors
2 containers of Lysol wipes
1 package of baby wipes
1 bottle of Germ-X
1 box of Band-aids
** Teacher Wish List: these are not required materials, but would be greatly appreciated!
Thermometer covers
Walmart gift card (these are used to develop class pictures, buy items for projects, etc.)
Papermate Flair ink pens
Paper clips
Duct tape or packaging tape (this is used to hang anchor charts and student work) •
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ra:
2 boxes of crayons
2 packs of YELLOW No. 2 pencils
1 pair of Fiskars scissors
4 large glue sticks
1 pack of 3-5 large erasers
2 spiral notebooks
1 pack of index cards
1 st grade Writing tablet
2 packs of wide-ruled paper
3 pocket folders
1 small pack of dry erase markers
1 box of Baby wipes
1 roll of paper towels
1 box of Kleenex
1 pack of construction paper
1 pack of copy paper
2 bottles of Germ-x
Boys- 1 box of gallon Ziploc bags
Girls-1 box of quart Ziploc bags
We're Going Back To 5chool
West Amory Elementary
2nd Grade Supply list
2 packs of wide ruled loose leaf paper
4 five subject notebooks
4 packs of no. 2 pencils — no Dixon
3 packs of cap erasers
1 pack of expo markers (wide-not skinny)
2 highlighters
1 small post it sticky note pad
1 supply box or bag
2 packs of crayons
1 pack of markers
1 pair of scissors
2 glue sticks
2 rolls of Kleenex
1 container of Clorox wipes
2 bottles Germ X
1 box of Ziplock bags — boys(gallon) & girls(quart)
4 folders — yellow, red, green, blue
1 clipboard
1 pack of index cards
1 pack of copy paper