Student Residency Questionnaire Fulton City School District 167 S. Fourth Street Fulton, NY 13069 Name of School: ______________________________________________ Grade: ________________ Name of Student: __________________________________________________________ Sex: Birth Date: Last / / Month/ Day / First Middle Age:_________ Male Female Year This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student may be eligible to receive. 1. Is your current address a temporary living arrangement? ______ Yes ______ No 2. Is this temporary living arrangement due to loss of housing or economic hardship? ______ Yes ______ No If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here. ________________________________________________________________________________________ Where is the student presently living? (Check one box) In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a place not designed for ordinary sleeping accommodations such as a car, park, or campsite Name of Parent(s)/Legal Guardian(s) ___________________________________________________________ Address ___________________________________ City ___________ Zip ___________ Phone ___________ Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3)(d). Signature of Parent/Legal Guardian ____________________________________________ Date ____________ Address ___________________________________ City ___________ Zip ___________ Phone ___________ Please scan and e-mail a copy to Geri Geitner, Director of Student Support Services, at the Central Office ([email protected])/phone: 315-593-5547. I certify that the above-named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act. __________________ __________________________________________ Date Geri Geitner (McKinney-Vento Liaison) Signature Cuestionario de Residencia del Estudiante Fulton City School District 167 South Fourth Street Fulton, NY 13069 Nombre de la Escuela: Grade: Nombre del Estudiante: Apellido Feche de Nacimiento: Mes Nombre / / / Día / Año Segundo Nombre Sexo: Masculino Femenino Edad: El propósito de este cuestionario es presentar los objetivos del Acta McKinney-Vento (42 U.S.C.11435.) Las respuestas a estas preguntas ayudará determinar los servicios que el estudiante debe recibir. 1. ¿Es su domicilio actual un arreglo de vivienda temporal (de poca duración)? Si 2. ¿Es este arreglo de vivienda temporal debido a la pérdida de su casa, vivienda o habitación, o debido a algún problema económico (ejemplo: desempleo)? Si No No Si usted contestó SI a estas preguntas, por favor complete el resto de este formulario. Si usted contestó NO a estas preguntas, no siga. ¿Dónde se encuentra viviendo el estudiante actualmente? (Marque una opción.) En un motel En un albergue o lugar de refugio Con más de una familia en una casa o apartamento Moviéndose de lugar en lugar En un lugar generalmente no designado para dormir (ejemplo: carro, parque, o campamento) Nombre del Padre /Madre /Guardián(s) Dirección City Zona Postal Teléfono Presentar información falsa o la falsificación de documentos para uso escolar son ofensas bajo la Sección 37.10 del Código Penal, y la inscripción del estudiante usando documentos falsos traerá como consecuencia que los responsables estarán sujetos a pagar los gastos de instrucción u otros cargos. TEC Sec. 25.002 (3)(d). Firma del Padre / Madre/ Guardián Dirección Fecha City Zona Postal Teléfono Por favor envíe una copia de este documento a Geri Geitner, Director of Student Support Services at the Central Office (El Director de Apoyo de Estudiante Servicios en la Oficina Central). ([email protected])/Phone: 315-593-5547. Yo certifico que el estudiante nombrado en este formulario califica para los programas de nutrición escolares bajo las provisiones del Acta McKinney-Ventos. Fecha Geri Geitner (McKinney-Vento Liaison) – Firma del oficial autorizado Fulton City School District Forms Needed for Registration Documentation Detail Student Residency Questionnaire Student Registration Ethincity Questionnaire (optional) Home Language Questionnaire Migrant Education Services (optional) Parent/Guardian Statement Kindergarten Students Only Physical Consent Health Appraisal Student Health History Health Record Update Dental Health Certificate (optional) Directory Information Disclosure (optional) Original Birth Certificate Up-to-date Immunization Records Proof of Residency (see below for acceptable forms) Parent/Guardian Driver’s License/ Photo ID Latest Report Card/Class Schedule Reduced/Free Lunch Documents on Website Word Format Word Format PDF Format PDF Format PDF Format PDF Format PDF Format Pertain to Completed by All Students All Students All Students All Students All Students All Students K students only All new students All new students & Students K,2,4,7&10 All Students All Students Students K,2,4,7&10 All Students All Students All Students All Students Parent/Guardian Parent/Guardian Parent/Guardian Parent/Guardian Parent/Guardian Parent/Guardian Parent/Guardian Parent/Guardian Physician Physician Parent/Guardian Parent & Dentist Parent/Guardian Check Physician All Students All Students All Students IF APPLICABLE IEP/504 Plan Special Education Students Custody Agreement and/or Court Papers Divorced/Separated Parent Complete Papers in Special Education Office Court/Parent/ Guardian Acceptable Primary Forms of Proof of Residency: Residential tax bill for residential property within the District, in the name of parent or guardian. Signed purchase agreement for residential real property within the District. Residential mortgage instrument, or deed, duly recorded in Oswego County Clerk’s Office in the name of parent or guardian, which describes real property with a residential address within the District. Lease agreement in the name of parent or guardian for real property within the District with name, address and telephone number of landlord. Rental receipt in the name of parent or guardian for real property within the District with name, address and telephone number of landlord. Notarized letter from owner of the house stating the parent or guardian and student(s) are residing with them, including the address of the property. DSS Form 2999 School District Notification of Foster Child Placed in a Foster Family, Agency Boarding or Group Home. Utility bill for service at the residential address within the District being billed in the name of parent or guardian. Bank statement in the name of parent or guardian addressed to the residential address within the District. Social Services correspondence or statement in the name of parent or guardian, addressed to a residential address within the District. US Postal Service verification of change of address to a residential address within the District, in the name of parent or guardian. Federal or NYS income tax documentation with preprinted name and address in the name of parent or guardian addressed to residential address within the District, such a W2 form, preprinted label from government, or income tax return check with preprinted address. A policy or binder of homeowner’s or residential renter’s insurance for residential real property within the District addressed and/or issued in the name of parent or guardian. Other proof acceptable to a District administrator that would demonstrate that the child actually resides (defined as the primary place where the child predominately sleeps, has a physical presence as an inhabitant, changes clothes, and has a base of operations for their care, custody and living arrangements in the school district). Fulton City School District Student Registration Student # School Grade Date Registered Starting Date Home Language Questionnaire Birth Certificate Proof of Residency Physical Exam Dental Exam Reduced/Free Lunch Form Immunization Records IEP/504 Plan Residency Form Records Release/Discipline Rcv’d / Counselor Custody Papers Date Called previous school / Entered into ST / Notes: DO NOT WRITE ABOVE THIS LINE – OFFICE USE ONLY Student’s Last Name Date of Birth First Middle Sex M F Student Grade Place of Birth Street Address City Home Phone Father’s Name Date of Birth Employer Work Phone Home Address (if different) Home Phone (if different) Cell Phone Email Mother’s Name Date of Birth Employer Work Phone Home Address (if different) Home Phone (if different) Cell Phone Email Student’s Parents are Married Separated Divorced Student is currently living with Father Grandfather Grandmother Foster Parent Are there custody papers or order of protection? Yes No Never Married Mother Step-Father Legal Guardian Other If yes, copy required Step-Mother Specify Note: Under Fulton City School District Policy unless court papers are on file with the district, both parents have equal access to their child(ren) and school records. Does your child have frequent absences? If yes, please explain Yes No Is your child receiving Academic Intervention Services? Yes No If yes, please check services ELA Math Science Social Studies Other Specify Does your child currently have a Section 504 Accommodation Plan? Yes No Does your child have an Individual Education Plan (IEP)? Yes No If yes, please check services Consultant Teacher Resource Room Speech Therapy Occupational Therapy Physical Therapy Special Class BOCES Medical Other Specify If parent is not available, in case of illness or emergency, call Name Phone Address Relationship to child Please list brothers and sisters Name School Grade Date of Birth Sex M/F If this student is transferring from another school, please complete the following information School Name School Address Phone Number Fax Number Has student attended Fulton City School District in the past? If yes, when Is student an United State citizen? Yes If no, please give date of immigration to the US Yes No No I certify that the above information is accurate to the best of my knowledge and that I have legal custody of the above-named child. Signature of parent/guardian Date Ethnicity Questionnaire By completing this part of the packet, you will help us to receive any additional State Aid that will be made available to our district based on these factors. Please answer both questions 1 and 2. Please read them before you respond. 1. Is the student Hispanic, Latino or of Spanish origin? Hispanic, Latino or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central of South America, or other Spanish culture or origin, regardless of race. Please check the box that best describes your child. Yes, Hispanic No, not Hispanic 2. Select one or more races from the following five racial groups. Check all the groups that apply to your child. You must check at least one box. American Indian or Alaska Native (A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent.) Native Hawaiian or Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.) Black (A person having origins in any of the black racial groups of Africa.) White (A person having origins in any of the original peoples of Europe, North Africa or the Middle East.) The University of the State of New York • The State Education Department • Office of Bilingual Education Albany, New York 12234 Home Language Questionnaire (HLQ) TO BE COMPLETED BY SCHOOL PERSONNEL DISTRICT Please print or type clearly Dear Parent or Guardian: SCHOOL In order to provide your child with the STUDENT NAME best possible education, we need to DATE OF BIRTH GRADE Month: determine how well he or she under- Day: Year: STUDENT IDENTIFICATION NUMBER stands, speaks, reads and writes COUNTRY OF BIRTH / ANCESTRY English. Your assistance in answering NUMBER OF YEARS ENROLLED IN SCHOOL OUTSIDE THE U.S. these questions is greatly appreciated. NAME/POSITION OF SCHOOL PERSONNEL COMPLETING THIS SECTION Thank You ❏ Possible LEP DETERMINATION: ❏ English Proficient (✔ boxes that apply) 1. 2. 3. What language(s) is spoken in the student’s home or residence? ❏ English What language(s) are spoken most of the time to the student, in the home or residence? ❏ English What language(s) does the student understand? ❏ English ❏ Other specify ❏ Other specify ❏ Other specify 4. ❏ English What language(s) does the student speak? ❏ Other specify 5. ❏ English What language(s) does the student read? ❏ Other ❏ Does Not Read specify 6. ❏ English What language(s) does the student write? ❏ Other ❏ Does Not Write specify 7. In your opinion, how well does the student understand, speak, read and write English? Very well Only a little Not at all Understands English ❏ ❏ ❏ Speaks English ❏ ❏ ❏ Reads English ❏ ❏ ❏ Writes English ❏ ❏ ❏ Month: Signature of Parent/Guardian/Other Date Day: Year: HLQ (2/00) 99-337 PM The University of the State of New York • The State Education Department • Office of Bilingual Education Albany, New York 12234 CUESTIONARIO SOBRE EL IDIOMA QUE SE HABLA EN EL HOGAR (“Home Language Questionnaire, HLQ”) – Spanish PARA SER COMPLETADO POR EL PERSONAL ESCOLAR (TO BE COMPLETED BY SCHOOL PERSONNEL) Estimado Padre/Madre o Guardián: Para poder ofrecer a su hijo(a) la mejor DISTRITO (District) IMPRIMA O ESCRIBA CLARAMENTE (Please print or type Clearly) ESCUELA (School) GRADO (Grade) NOMBRE DEL ESTUDIANTE (Student Name) educación posible, necesitamos FECHA DE NACIMIENTO (Date Of Birth) Mes: (Month) determinar cuán efectivamente él o ella entiende, habla, lee y escribe el idioma Día: (Day) Año: (Year) NUMERO DE IDENTIFICACION DEL ESTUDIANTE (Student Identification Number) inglés. Su ayuda será apreciada si PAIS NATAL O ASCENDENCIA (Country of Birth/Ancestry) contesta estas preguntas. NUMERO DE AÑOS MATRICULADO EN ESCUELA(S) FUERA DE LOS E.U. (Number of years enrolled in school outside the U.S.) Gracias. NOMBRE/POSICIÓN DEL PERSONAL ESCOLAR LLENANDO ESTA SECCION (Name/Position School Personnel Completing This Section) DETERMINACIÓN: (Determination) ❏ Posiblemente LEP (Possibly LEP) ❏ Dominante en Inglés (English Proficient) (✔ Marque las casillas que aplican) 1. ¿Qué idioma(s) se habla en el hogar ❏ Inglés ❏ Español ❏ Otro 2. o residencia del estudiante? ¿En qué idioma(s) se le habla al estudiante ❏ Inglés ❏ Español ❏ Otro 3. la mayor parte del tiempo en el hogar o residencia? ¿Qué idioma(s) entiende el estudiante? (Especifique cuál) (Especifique cuál) ❏ Inglés ❏ Español ❏ Otro (Especifique cuál) 4. ¿Qué idioma(s) habla el estudiante? ❏ Inglés ❏ Español ❏ Otro (Especifique cuál) 5. ¿En qué idioma(s) lee el estudiante? ❏ Inglés ❏ Español ❏ Otro ❏ No lee (Qué idioma) 6. ¿En qué idioma(s) escribe el estudiante? ❏ Inglés ❏ Español ❏ Otro ❏ No escribe (Qué idioma) 7. ¿En su opinión, qué tan bien el estudiante entiende, habla, lee y escribe inglés? Muy bien Un poco Entiende Inglés Habla Inglés Lee Inglés Escribe Inglés ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ Mes: (Month) Firma del Padre/Madre/Guardián/Otro (Signature of Parent/Guardian/Other) Fecha (Date) Nada ❏ ❏ ❏ ❏ Día: (Day) Año: (Year) HLQ (2/00) 99-337 PM Oswego County BOCES Migrant Education Outreach Program Paul Gugel, Migrant Education Coordinator 179 County Route 64 Mexico, NY 13114 315-963-4265 or 1-800-474-1632 Eligibility screen for Migrant Education services *** Migrant Education Program services are free of charge and may include tutoring, assistance with health needs, educational field trips, summer programs, parent involvement activities, adult education, emergency assistance and referrals to other services as needed. *** Has your family moved to a different school district in the last 3 years? YES _______ NO _______ In the last 3 years has a parent or guardian (or an older child) worked in agricultural activities such as: dairy, planting, picking/harvesting fruits or vegetables, food processing or packaging, logging or tree farming? YES _________ NO ________ If you can answer YES to BOTH of the above questions, your family MAY qualify for Migrant Education services. To be contacted by a Migrant Education recruiter, please complete the information below. Child’s name _______________________________ D.O.B. ____________Grade__________ Child’s name _______________________________ D.O.B. ____________Grade__________ Child’s name _______________________________ D.O.B. ____________Grade__________ Child’s name _______________________________ D.O.B. ____________Grade__________ Parents/ Guardians Mother’s name __________________________ Father’s Name ___________________________ Home Address __________________________ Home Phone #____________________ (Street Address) _____________________________ (city, town or village) (Zip) Work or Message # _______________ School District__________________________ School Building______________________________ School Contact Person_______________________________ Contact Number __________________ Other Useful information (directions, farm names, best time to contact, etc.) ________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ To submit this referral please fax to the Oswego BOCES at (315) 963-4242 or mail to the address above. For more information please call the Migrant Program at 963-4265 or 1-800-474-1632. Thank you for your assistance. Oswego County BOCES Migrant Education Outreach Program Paul Gugel, Migrant Education Coordinator 179 County Route 64 Mexico, NY 13114 315-963-4265 or 1-800-474-1632 Cuestionario de Eligibilidad para Servicios de Educación Migrante *** Servicios del Programa de Educación Migrante son gratuitos y pueden incluir tutoría, ayuda con necesidades de salud, viajes educacionales, programas del verano, actividades de involuncrar a los padres, educación para adultos, ayuda de emergencia y referidos a otros servicios como necesario. *** ¿Ha mudado su familia a un districto escolar diferente en los ultimos 3 años? Sí ____ NO _______ ¿En los ultimos 3 años ha trabajado un padre o guardian en actividades agriculturales como: lecheria, plantando, cosechando frutas o legumbres, el procesamiento o empacar de comida, corta de arboles o cultivo de arboles? Sí_____ _ NO_______ Si Usted contestó que Sí a AMBOS pregunatas de arriba, su familia PUEDA calificar para servicios de Educación Migrante. Para estar contactado por una reclutadora del Programa de Educación Migrante, favor de llenar la infomación de abajo. Nombre del niño(a) __________________________ Fecha de Nacimiento___________Grado______ Nombre del niño(a) _________________________ Fecha de Nacimiento __________Grado______ Nombre del niño(a) _________________________ Fecha de Nacimiento __________Grado_______ Nombre del niño(a) _________________________ Fecha de Nacimiento __________Grado_______ Padres/ Guardianes Nombre de la Mamá _____________________ Nombre del Papá _________________________ Dirección de la Casa _____________________ Numero de teléfono en casa____________________ (Dirección de la Calle) _____________________________ # de teléfono del trabajo o de Mensaje______________ (Ciudad o Pueblo) (Codigo Postal) Distrito escolar _________________________ edificio escolar ______________________________ Persona para contactar____________________ numero para contactar _________________________ Otra información Util (direcciones, nombres de granjas, mejor hora de llamar, etc.) ________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Para someter este referido, favor de mandarlo por fax al BOCES de Oswego a (315) 963-4242 o mandar por correo al dirección de arriba. Para más información, favor de llamar al Programa Migrante a 963-4265 o a 1-800-474-1632. Gracias. BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 Important Student Information Notice The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that The Fulton City School District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s education records. However, the Fulton City School District may disclose appropriately designated “directory information” without written consent, unless you have advised the District to the contrary in accordance with District procedures. The primary purpose of directory information is to allow the Fulton City School District to include this type of information from your child’s education records in certain school publications. Directory information, which is information that is generally not considered harmful or an invasion of privacy if released, can also be disclosed to outside organizations without a parent’s prior written consent. Outside organizations include, but are not limited to, colleges and universities, military recruiters, the media and prospective employers. The Fulton City School District has designated the following information as “Student Directory Information” for students in grades pre-kindergarten (Pre-K) through twelfth (12th) grade: the student’s name, name of the student’s parent or guardian, school currently attending, grade in school, participation in officially recognized activities and sports, awards received, a student’s works (written or otherwise), photographs including the student and video and/or audio clips of students. “Student Directory Information” for students in grades nine (9) through twelve (12) includes the following additional information: the student’s address, electronic mail address (email), telephone listing, date and place of birth, major field of study, weight and height of members of athletic teams, dates of attendance and the most receive previous educational institution attended by the student. Examples of publications that may contain directory information include, but are not limited to, the following: A playbill, showing your student’s role in a drama production Newspaper articles The annual yearbook Fulton City School District website Honor roll or other recognition lists Graduation programs Sports activity sheets, such as for football, showing weight and height of team members BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 DIRECTORY INFORMATION DISCLOSURE If you do NOT want the Fulton City School District to disclose directory information from your child’s education records without your prior written consent, you must notify the District in writing within twenty (20) days. You may use the form below to provide such notification. Please do NOT release directory information pertaining to the following student: ___________________________________ ___________________________________ Student Name (Please Print) Parent Signature ___________________________________ ___________________________________ Name of Teacher Date Fulton City School District Health Record Update Student Name __________________________________________________________________________________ Grade _________________ Date of Birth ____________________ Health Care Provider _________________________ Dentist ____________________________________________ 1. List any operations, serious injuries or illnesses (requiring medical care) during the last year: ______________________________________________________________________________________________ 2. Please describe any current health problems/concerns or serious allergies including recommended treatment: ______________________________________________________________________________________________ 3. List any daily or “as needed” medications prescribed by the student’s health care provider: ______________________________________________________________________________________________ **Note: NYS law requires all medications that need to be administered in school have written instructions from the health care provider, written parent permission and the medication to be brought to school in its original pharmacy container, even if child is self-administering. 4. Please provide signed proof from your health care provider for immunizations (ex- DTAP or Tdap, IPV, MMR etc) 5. Is your child seen by a doctor regularly? Yes/No Weekly/Monthly Other __________________________________ Why? _________________________________________________________________________________________ 6. Please list any special concerns for classroom, physical education or dietary restrictions. All restrictions need written orders from health care provider. ______________________________________________________________________________________________ 7. Were your child’s eyes examined by a doctor or optometrist during the past year? Yes/No Name of Eye Doctor _____________________ Corrective lens prescribed? Yes/No Reading only? Yes/No Wear full time? Yes/No Take off for Physical Education? Yes/No 8. Did your child have a dental exam and/or orthodontics this past year? Yes/No Dentist ______________________ If you have any additional information that you feel the school nurse should know about, or need to further describe any conditions listed above, please use the back of this page. I give permission for confidential and discreet use of health information to meet my child’s health needs while he/she is in school. __________________________________________________________ ______________________ Signature Parent/Guardian Date __________________________________________________________ Student Name / Date of Birth Medical Emergency Contact (please print) ___________________________________________________________ Phone Number _______________________________________________________ Fulton City School District 167 South Fourth St. Fulton, NY 13069 PARENT/GUARDIAN STATEMENT Student’s Name ____________________________________ DOB______________________ I understand that proof of New York State required immunizations for polio, mumps, diphtheria, hepatitis and rubella from a physician or clinic is required for admission to school. Failure to file either proof of immunizations or exemptions will result in the exclusion of the pupil until such time as an appropriate immunization statement is submitted. Permission is hereby granted to Fulton City School District to obtain all health records from my physician and scholastic records from previously attended school(s) as well as transfer records to a new school in the event of a move to another district or state. I certify that the information provided is accurate to the best of my knowledge and that I have legal custody of the above named child. Parent/Guardian Signature ______________________________________ Date ___________________ Doctor’s Name ______________________________________ Phone Number _____________________ Fulton City School District SCHOOL PHYSICAL CONSENT FORM Student Name ________________________________ Date of Birth ____________________ School ______________________________________ Grade _________________________ Please check the appropriate box. Sign and return to the school nurse. I give permission for the designated school physician or nurse practitioner to complete a physical examination as per school policy and as required by NYS Education Laws. I do NOT give permission for the designated school physician or nurse practitioner to complete a physical examination as per school policy and as required by NYS Education Laws. I will have a physical completed by our family physician. This consent is valid from this date unless revoked by the parent or guardian. If custody or guardianship changes in the future, it is the responsibility of the parent or guardian to notify the school district of such a change. ________________________________________ Signature Parent/Guardian ______________________ Date STUDENT'S HEALTH HISTORY IN ORDER FOR YOUR CHILD TO ENTER SCHOOL, THIS FORM MUST BE COMPLETED, SIGNED & ON FILE PRIOR TO ADMISSION AT THE SCHOOL YOUR CHILD WILL ATTEND. Student Name Parent Name Date DATE OF MEDICAL/HEALTH EXAMINATION (Must be within last 12 months) IMMUNIZATION HISTORY/MINIMUM RECOMMENDATIONS Enter the MONTH, DAY & YEAR the child received each does of the following vaccines TYPE OF VACCINE 1st DOSE 2nd DOSE 3rd DOSE 4th DOSE 5th DOSE DPT or DTAP Diphtheria Tetanus Pertussis Tdap POLIO IPV (specify injection or oral) OPV HIB Haemophilus influenzae type b Pneumococcal Conjugate (PCV) HEPATITIS B MMR Measles Mumps Rubella VARICELLA-ZOSTER (Chicken Pox) LEAD SCREENING PPD (recommended/not required) X X X X X X X X X X STUDENT'S HEALTHCARE PROVIDERS: Physician Phone Dentist Phone I CERTIFY THAT THE RECOMMENDED NUMBER OF IMMUNIZATIONS HAVE BEEN RECEIVED FOR SCHOOL ADMISSION SCHOOL NURSE OR PHYSICIAN SIGNATURE DATE 4/16/2014 Please contact the Transportation Office @ 593-5514 to set up transportation for your child. A 24-hour advance notice is required for all busing requests. Request hours: 7:30 am – 4:00 pm Thank you, FCSD Transportation Office BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 Dear Parent/Guardian: Fulton City School District would like to welcome you and your child/children. To insure that we have all the medical information necessary to provide your child with health care while at school, we request that you complete this packet of information. Attached you will find. School Physical Consent Form Fulton City School District will provide any physical required by NYS Education Law IF consent is given by parent/guardian. Please check the appropriate box on the form and return to school nurse. (Whether or not you give consent, each student must have this form on file in the Health Office.) Health Appraisal Form Physicals are required for new enterers and for students in Pre-K or K, 2, 4, 7 and 10. If you choose to have your own Health Care Provider complete the physical, please bring this form to the appointment and return it to the school nurse. Health Record Update This form is completed upon entry and updated via student confidential Health form every fall to provide the nurse with current health information regarding your child and allows us the opportunity to plan appropriate healthcare during the school day. School Policy on Medication, Health Procedures & NYS Immunization Requirements This is for your information only. Please read this information carefully and call with any questions. Dental Health Certificate The form is optional but it is appreciated if completed. If your child has any significant medical conditions/needs or will be taking medication during the school day, please contact the school nurse (listed below) prior to the child’s first day of school. There is an answering machine or voice mail at each of the buildings, so please leave a message and someone will return your call. G. Ray Bodley High School Fulton Junior High School Fairgrieve Elementary Granby Elementary Lanigan Elementary Volney Elementary 593-5400 x5414 593-5445 593-5558 593-5483 593-5473 593-5573 BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 HEALTH PROCEDURES The health and safety of children in our schools are very important to all of us. Please keep this handout about our health procedures for future reference. If you have any questions during the year, please feel free to call your school nurse or your child’s teacher. Medication in School In step with NYS regulations, in order for the nurse to give any type of medication, the nurse’s office will need a written note from the doctor; medicine must be in a prescription/pharmacy bottle; and your written permission to administer the medication. Medications prescribed to be taken three (3) times a day usually do not need to be taken during school time. (Before school, after school and at bedtime often give the best balance to three (3) times a day medication. Please check with your doctor on this point.) Bee Sting Allergies (severe) The Fulton City School District has recommended the use of EPI-PEN JR auto injection kit. This kit is a premeasured injection kit designed for convenience, which leaves less chance for error in an emergency situation. This injection kit, like any other medication, cannot be administered to your child in school unless we have a written note from your doctor and your written permission. Hepatic Prevention Children are encouraged by the teachers to wash hands regularly with soap and water. Our custodians have been instructed to disinfect bathrooms, sinks, fountains, door knobs and other high contact areas. You can help by reminding your child about hand washings, care at water fountains and not sharing food and drinks with others. With this in mind, party foods and snacks in school need be to store bought, wrapped food items. Colds and Illness Colds, flu, “pink-eye”, chicken pox and at times, head lice, affect school children. These and other communicable diseases can try the most patient parent. Please keep your child home when they have severe colds, copious nasal discharge, red eyes with yellow drainage, diarrhea, vomiting and/or a fever. (If your child has a fever, please keep him/her home until his/her temperature is normal for at least 24 hours.) Children with diagnosed strep throat must be on their medication a minimum of 24 hours before returning to school. Rest, lots of fluids and mom and dad is what your child needs to get better, stay well and not infect his/her classmates. Head lice can affect any child and is not a sign of being “dirty”. Follow the recommendations of your doctor and school nurse for treatment. Most cases respond quickly to treatment. BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 SCHOOL POLICY ON MEDICATION For the nurse to administer any medication to a student during school hours, the following rules must be applied: The nurse cannot give medications safely or legally unless these steps are followed 1. Written permission from parent/guardian 2. Written note/instructions from child’s doctor stating: Name of medication Amount of dose Time does should be given Length of administration Diagnosis and/or reason for medication Doctor/Provider signature 3. Medication must be in pharmacy-labeled, childproof container. Non-prescription medicine must be in an un-opened store package that will be kept here at school (ex – Tylenol). 4. Parent/guardian brings medication to the nurse’s office This refers to all medications, including over-the-counter (OTC) medications such as aspirin, Tylenol, ibuprofen, cough syrups, cough drops, etc. Medicine should never be sent to school in plastic bags or containers; only in the original packaging. Your cooperation is appreciated. BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 MEDICATION PERMISSION Student Name _______________________________ School Year ________________________ Medication __________________ _____________________ ______________________ __________________ _____________________ ______________________ I give the School Nurse permission to administer medication to my child for this school year. Parent Name (please print) ___________________________________________________ Parent Name (please sign) ____________________________________________________ Date ___________________________ Doctor’s Orders Received __________ Medication Received Date Medication Name Amount Initial BOARD OF EDUCATION FULTON CITY SCHOOL DISTRICT FULTON EDUCATION CENTER 167 SOUTH FOURTH ST FULTON, NEW YORK 13069 SCHOOL HEALTH SERVICES After September 1, 2008, Chapter 281 of the Education Law 903 in New York State requires that the school district request a dental certificate for each of its students who meet the following criteria: New to the school district In grades Pre-K, K, 2, 4, 7 and 10 There is a dental certificate attached for you to take to your child’s dentist and once it is completed, it should be returned to your child’s School Nurse. Failure to provide this document will not exclude your child from school. Thank you for your cooperation in this new health endeavor. Our students benefit when we work together to promote the health and achievement of all students. Please call the Health Office at your child’s school if you have any questions or concerns. Thank you. SAMPLE Dental Health Certificate- Optional Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible. Section 1. To be completed by Parent or Guardian (Please Print) Last Child’s Name: Birth Date: / Month School: Sex: Male / Day First Year Middle Will this be your child’s first visit to a dentist? Yes No Female Name Grade Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below. Parent’s Signature______________________________________________________________ Date Section 2. To be completed by the Dentist I. The Dental Health condition of _______________________________ on _________________ (date of exam) The date of the exam needs to be within 12 months of the start of the school year in which it is requested. Check one: Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools. No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools. NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school. Dentist’s name and address (please print or stamp) Dentist’s Signature Optional Sections - If you agree to release this information to your child’s school, please initial here. II. Oral Health Status (check all that apply). Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity]. Yes No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark- Yes brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present]. No Dental Sealants Present Other problems (Specify):_______________________________________________________________________________ III. Treatment Needs (check all that apply) No obvious problem. Routine dental care is recommended. Visit your dentist regularly. May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation. Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.
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