FRANKLIN REGIONAL SCHOOL DISTRICT

STUDENT REGISTRATION PACKET – Grade 1-12

3210 SCHOOL ROAD, MURRYSVILLE, PA 15668

http://www.franklinregional.k12.pa.us

Fax Number 724-327-6149

Email - ecowell@franklinregional.k12.pa.us

Please call Ericka Cowell

724-327-5456 x7622

with any questions and to make an appointment

Appointments accepted Monday through Friday during regular school hours

FRANKLIN REGIONAL SCHOOL DISTRICT – STUDENT ENTRY INFORMATION Resident Y / N

Student Information (Please Print) Grade__________ IF Kindergarten – Full day or AM

Student’s Legal Last Name First Name Middle Suffix (Jr., III)

Gender: M or F Birth Date: ___/___/___ City and State of Birth: ____________________________ Country: _________________

Part A: circle one Hispanic/Latino or Not Hispanic/Latino

Part B: circle one A- Asian / B – Black, African American / I- Indian / N – American Indian or Alaskan Native / H- Hispanic

M – Multi-Racial / P – Native Hawaiian or Pacific Islander / W- White

Student’s Home Address:

Street # Street Name City Zip Primary Phone #

Date First Enrolled in US Schools ____/____/____ Preschool or Previous School’s Name__________________________________________

Previous Schools’ Address:

Street # Street Name City Zip # of days attended per week

School Phone: ____________________________ School Fax: ___________________________________

_____________________________________________________________________________________________________________________

Student lives with: (circle one) Both Parents / Father / Mother / Other ___________________________________

1) Last Name _________________________________________First Name______________________________________ Father/Mother/Guardian)

W Phone____________________ C Phone__________________ Email Address___________________________________________

2) Last Name __________________________________________First Name____________________________________ (Father/Mother/Guardian)

W Phone____________________ C Phone__________________ Email Address___________________________________________

If Student does not live with both parents, yet both parents are to review mailings, please list additional mailing information below:

Last Name _________________________________________First Name______________________________________ Father/Mother/Guardian)

Mailing Address: ___________________________________________________________________________________

Phone: ________________________________ Email: _________________________________________

Parent/ Guardian Signature__________________________________________ Date____________________

****CHILD ACCOUNTING USE ONLY****

Student ID_________________ BLDG ASSIGN_____________ CENSUS______________ CUSTODY ORDER? Y / N - IF YES, COPY PROVIDED? YES / NO

Residency Qualification

In order for your child to attend school in the Franklin Regional School district, you must reside in the Franklin Regional District or be in the process of building or buying a home within the boundaries of the District.

NON-RESIDENT / PRE-RESIDENT STATUS

Families not yet living the District but who are in the process of building or buying a home in the District and would like to register their children to begin school are required to pay tuition until their residency is established.

1. You must write a letter to the Superintendent attaching a copy of lease agreement or builder’s agreement to the letter.

2. Upon approval from the Superintendent, the Business Office will send you a letter stating the amount of tuition due and the date it is due.

3. A copy of the District Policy #8304 is available on the website.

MULTIPLE OCCUPANCY

If you are sharing a residence with another family within the Franklin Regional School District you must file a NOTARIZED Certificate of Multiple Occupancy. Forms are available in the Administration Building or on the Franklin Regional website.

CENSUS ENUMERATION – FRANKLIN REGIONAL SCHOOL DISTRICT

Borough of Delmont Borough of Export Municipality of Murrysville

ADDRESS: ____________________________________________________________________ ZIP CODE ____________

RESIDENCE CODE: 1 - OWN HOME 2 - RENT HOME Best number to reach you in the case of emergency: #___________________________

LIST ANYONE IN THE HOUSEHOLD 21 YEARS OF AGE OR OVER

LAST FIRST SEX BIRTHDATE E-MAIL ADDRESS EMPLOYER NAME PLEASE LIST ANY PARENT OR GUARDIAN CURRENTLY SERVING IN US MILITARY BELOW LAST FIRST BRANCH OF SERVICE

LIST ANYONE IN THE HOUSEHOLD CHILDREN - UNDER 21 YEARS OF AGE (Admin use only)

LAST FIRST SEX BIRTHDATE GRADE FR SCH STU ID#

FAMILY

RELATIONSHIP SCHOOL 1 - Head of House 1 - Public 2 – Son/ Daughter 2 - Non-Public 3 - Foster Child 3 - Not In School 4 - Other 4 - Other

INFORMATION PROVIDED BY: ___________________________________ DATE: ______________________________

School District Student Residency Questionnaire

Dear Parent or Guardian,

Your responses to these questions will help staff determine what residency documents are necessary to enroll your

child. Thank you for your cooperation.

1. Student name: Birth date:

Person completing form: Relationship to child:

2. In what type of setting is the child living now? Check one box below:

Section A Section B

In an emergency or transitional shelter

Sharing the housing of other persons due to loss of housing, economic

hardship, or similar reason

In a motel, hotel, campsite, or car due to a lack of alternative, adequate accommodations

In a car, park, public space, abandoned building, substandard housing, bus or train stations, or similar settings

Other places not designed for, or ordinarily used as, regular sleeping accommodations for human beings CONTINUE TO THE QUESTIONS BELOW if you checked a box in SECTION A

None of the choices in

SECTION A apply

If you checked this section, you do not need to complete questions 3 through 6. Please sign and date the form and turn it in.

3. Contact number for person completing this form:

Address where the child is now living:

4. The child lives with (Check all that apply):

Parent or legal guardian Relative, friend or other adult Alone Other:

5. Name, Address & Phone Number of the school the child attended last: 6. Does the child have an IEP or a Chapter 15/504 agreement? No. Yes. Please explain: Signature of Parent/Legal Guardian: Date:

FRANKLIN REGIONAL AUTOMATED CALL LIST FORM

From time to time it is necessary for the School District to send out an automated call to parents/guardians information them of changes to our normal schedule or evening activities. Please enter the preferred phone contact information for us to use if such a situation should arise. Our automated calling system can call up to 4 phone numbers for each student. Please be aware that ALL of the phone numbers you provide will be called EVERY Time we use the automated system.

STUDENT’S NAME: _______________________________________________________

MOTHER’S NAME: _______________________________________________________

FATHER’S NAME: _______________________________________________________

GUARDIAN/STEP PARENT 1 : ________________________________________________

GUARDIAN/STEP PARENT 2 : ________________________________________________

BEFORE/AFTER SCHOOL CARE GIVER : _________________________________________

Child lives with (circle one) : Both Parents Father Mother Guardian/Other

AUTO CALL NUMBER 1: _______________________________________________

AUTO CALL NUMBER 2: _______________________________________________

AUTO CALL NUMBER 3: _______________________________________________

AUTO CALL NUMBER 4: _______________________________________________

Thank you for providing us with the best contact information for the care of your child. Please remember to contact us with any / all updates to your phone number(s).

Franklin Regional School District

Alternative Transportation Request

• An alternative transportation request may be approved to accommodate childcare arrangements or emergencies that may arise during the school year. • This bus transfer request only applies to a request from within the school’s attendance area and will be approved based on space availability. • Allow up to one week for processing. • You must receive notification of approval from the Transportation Office before these changes take effect. Student’s name ______________________________________________ Grade ____________________ Address ____________________________________________________ Phone ____________________ Name of Parent ______________________________________________ 2nd Phone__________________ Parent email _________________________________________________ School of Attendance _________________________________________ Reason for Request: Babysitter/daycare (must be within attending school’s attendance area)

Shared parenting

Intradistrict transfer approved; requesting the nearest bus stop within the transportation eligibility area. Name of Childcare Provider ___________________________________________________________________ Address _______________________________________________________ Phone ____________________ The parent or guardian hereby assumes responsibility for the dependability and reliability of the childcare provider. If the student is eligible for transportation, the parent/guardian grants consent to the school officials to pick up or drop off a student at the alternate location by signing below. The District/Board of Education does not assume liability for a student prior to boarding the bus or after being dismissed from the bus at the designated location. Parents are responsible for ensuring the safe passage of their children to and from the bus stop. Please indicate with an “X” which days you are requesting transportation to the alternate address.

Monday Tuesday Wednesday Thursday Friday

Pick up Drop off Signature of Parent/Guardian ______________________________________ Date ____________________ __________________________________________________________________________________________ For office use only: Approved Disapproved Sent to Myers Initials______Date_______ Pick up: Bus # _____ Day/Time ________________ Stop __________________________________ Drop off: Bus # _____ Day/Time ________________ Stop __________________________________ Pick up: Bus # _____ Day/Time ________________ Stop __________________________________ Drop off: Bus # _____ Day/Time ________________ Stop__________________________________

Franklin Regional School District 3210 School Road

Murrysville, Pennsylvania 15668

SPECIAL SERVICES - REGISTRATION FORM

� My child has an I.E.P. or a 504 Service Agreement on file at the previous school attended.

If your child currently has an IEP, please check area/areas of exceptionality.

� Autistic Support � Learning Disability � Gifted � Vision � Physical Disability � Mental Retardation � Speech/Language � Hearing � Physical Therapy � Occupational Therapy � Special Transportation Needs (related to disability) � Emotionally Disturbed � Neurological Impairment � Other Health Impairment � Other (Please specify) _

� Multidisciplinary Evaluation in Progress (MDE) � My child does not need any special education services.

Parent Signature

Date

Revised July 2013 1

HOME LANGUAGE SURVEY1 The Office of Civil Rights (OCR) requires that all Local Education Agencies (LEA’s) identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the initial step in the identification process.

School District: Date:

School:

Student’s Name: Grade:

1. What is/was the student’s first language?

2. Does the student speak a language(s) other than English? Yes No

(Do not include languages learned in school.)

If yes, specify the language(s):

3. What language(s) is/are spoken in your home?

4. Has the student attended any United States school in any Yes No

3 years during his/her lifetime?

If yes, complete the following:

Name of School State Dates Attended

Person completing this form:

(if other than parent/guardian)

Parent/Guardian signature:

1 The local education agency (LEA) has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the LEA has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the LEA may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the LEA in the future.

FRANKLIN REGIONAL SCHOOL DISTRICT

POLICY 7008 INTERNET and COMPUTER USAGE

The Franklin Regional School district makes every effort to provide a secure and productive computing environment. It supports confidentiality of information through the Family Educational Rights and Privacy ACT (FERPA) and Internet Content Filtering guidelines through the Child Internet Protection ACT (CIPA). In no way will the Franklin Regional School District assume responsibility for its students and staff for computer misconduct resulting from inappropriate use or redirection of bandwidth and unauthorized charges or fees. This Acceptable Use Policy will be reviewed annually with student and staff and revised as needed.

1. The Internet will be used to support the functions of the Franklin Regional School District, its curriculum, the educational community, and projects between schools, communication and research for school district administrators, teachers and students.

2. The Internet and computer technology will not be used for illegal activity, transmitting offensive materials, hate mail, discriminatory remarks or obtaining, transmitting or otherwise communicating indecent, obscene or pornographic material. Sending harassing, abusive, intimidating, discriminatory or other offensive e-mails is strictly prohibited.

3. The Internet and computer network will not be used for sending or initiating chain-mail, playing non-instructional games, downloading and storage of unauthorized multimedia files, and peer-to-peer file sharing systems such as KaZaa, Croakster, or similar systems.

4. The use of unauthorized chat, instant messaging systems, or discussion boards is strictly prohibited. 5. The Internet and computer technology will not be used for profit purposes, lobbying or advertising on behalf of any

individual or employee of the Franklin Regional School District. 6. Use of the Franklin Regional School District’s computer technology or the Internet for fraudulent or illegal copying,

communication, taking or modification of material or any other activity in violation of the law is prohibited and will be referred to the proper authorities.

7. In no event shall the Franklin Regional School District be liable for any damage, whether direct, indirect, special or consequential, arising out of the use of the Internet, accuracy or correctness of databases or information contained therein or related directly or indirectly, to any failure or delay of access to the Internet.

8. The Franklin Regional School District may terminate the availability of the Internet and Network Accessibility at its sole discretion.

9. From time to time, the Franklin Regional School District will make determination on whether specific uses of the Internet and Network are consistent with this policy and notify users of the same.

10. The Franklin Regional School District, in its discretion, reserves the right to log Internet use in terms of time and content and to monitor file server disk space utilization by users. It also reserves the right to process grievances against individuals who use the Internet in a manner inconsistent with this policy.

11. The Franklin Regional School District reserves the right to remove a user account on the Internet and Network to prevent further unauthorized activity as specified in this document.

12. The Network shall not be used to disrupt the work of others; hardware or software shall not be destroyed, modified or abused in any way.

13. Network accounts are to be used only by the authorized owner of the account for the authorized purpose. 14. Diligent effort must be made by the user to delete mail daily from personal mail directories to avoid unnecessary use

of file server disk space. 15. Diligent effort must be made by the user to periodically delete obsolete files from the Network file server. 16. Users shall not intentionally seek information, obtain copies of or modify files, other data or passwords belonging to

others users, or misrepresent other users in the Network. 17. Uploading, downloading, installation, or use of unauthorized games, programs, files or other electronic media is

prohibited. 18. The illegal use of copyrighted software is prohibited. 19. In order to maintain a high level of security on the Local Area Network, all Network users may need to update their

passwords as needed. 20. The user shall be responsible for damages to the Franklin Regional School District’s equipment, systems and software

resulting from deliberate or willful acts. 21. The Internet, Network and e-mail are not guaranteed to be private. People who operate the systems do have access

to all e-mail and files. Messages relating to or in support of, illegal activities may be reported to the authorities.

22. Confidential information shall never be transmitted to unauthorized sources. This includes health records, academic records, financial information, and social security numbers of passwords.

23. Failure to follow the procedures listed above by students of the Franklin Regional School District may result in suspension or loss of the right to access the Internet, to use the Franklin Regional School District’s computer technology, and be subject to other disciplinary actions, including but not limited to expulsion.

24. Violations of this policy and procedures by employees of the Franklin Regional School District may result in discipline, including but no limited to, dismissal.

25. All students in 7th grade and above who wish to use the Internet, Network and computer technology tools must sign an Internet Agreement form which will be kept on file. Parents or guardians must sign for all students who are under the age of 18. Such signed agreements will be stored in the student’s permanent file.

26. All staff must sign an Internet Agreement that will be kept on file. 27. Electronic e-mail messages will be stored by the District for the duration prescribed by law.

This policy covers the use of all company owned electronic communication systems: e-mail, Internet access, district Intranet, district-wide telephone systems and all licenses software programs, whether or not they are associated with any of the above mentioned systems.

Applicable Laws and Regulations/Policy History Adopted: 2/28/05/Amended/ Effective: 2/28/05 As a student user of the FRSD network, I hereby agree to comply with the terms and conditions listed above: Student Name (printed legibly) _______________________________________________________ Student Signature__________________________________________________________________ School Building ________________________________________Date _______________________ As a parent or legal guardian of the minor student signing above, I grant permission for my son/daughter to access networked computer services such as email and the Internet. I understand that individuals and families may be held liable for violations. I understand that some materials on the Internet may be objectionable, but I accept responsibility for guidance of Internet use, setting and conveying standards for my son/daughter to follow when selecting, sharing or exploring information and media. Parent Name (printed legibly) _______________________________________________________ Parent Signature__________________________________________________________________ Address_________________________________________________________________________ Phone _____________________ Grade ______________________Date _____________________

Parental Registration Statement – Franklin Regional School District

Student Name: __________________________________ Date of Birth: _________

Parent/Guardian Name: _______________________________________________________

Address: _______________________________________________________

Telephone Number: _______________________________________________________

Pennsylvania School Code 13-1304-A states in part “Prior to admission to any school entity, the parent, guardian

or other person having control or charge of a student shall, upon registration, provide a sworn statement or

affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or

private school of the Commonwealth or any other state for an act or offense involving weapons, alcohol or

drugs, or for the willful infliction of injury to another person or for any act of violence committed on school

property.”

Please complete the following I hereby swear or affirm that my child was __________ was not __________ previously

suspended or expelled, or is not __________ presently suspended or expelled from any public or private school of this

Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or the willful infliction of injury

to another person or for any act of violence committed on school property. I make this statement subject to the penalties of

24 P.S. 13 – 1304A(b) and 18 Pa. C.S.A. 4904, relating to unsworn falsification to authorities, and the facts contained

herein are true and correct to the best of my knowledge, information and belief.

If this student has been or is presently suspended or expelled from another school, please complete:

Name of the school from which student was suspended or expelled:

_______________________________________________________________________________

Dates of suspension or expulsion:

_______________________________________________________________________________

(Please provide additional schools and dates of expulsion or suspension on back of this sheet.)

Reason for suspension/expulsion (optional) _____________________________________________

I affirm that the above information is true and correct to the best of my knowledge, information and belief and is also

subject to penalties provided by 24 P.S. §13-1304-A(b) and 18 PA C.S. §4904, relating to unsworn falsification to

authorities. Any willful false statement made above shall be a misdemeanor of the third degree.

Date: ____________________ Parent/Guardian Signature: __________________________________________

FRANKLIN REGIONAL SCHOOL DISTRICT

OFFICE OF CHILD ACCOUNTING AND STUDENT REGISTRATION

3210 SCHOOL ROAD, MURRYSVILLE, PA 15668

AUTHORIZATION FOR VERIFICATION OF ADDRESS

RELEASE OF INFORMATION AGREEMENT

I, _________________________________________________________(parent/guardian printed name), do hereby give the Franklin Regional School District authorization to contact any or all of the following to obtain verification of my address which is on file, or which I have used in completing the registration forms with them. I further authorize the agency or employer contacted to release the requested information which will verify my address upon receipt of a photocopy or electronically transmitted copy of this form.

1. Internal Revenue Service2. Employer3. Welfare Agency or related Health Service Agencies4. Bureau of Motor Vehicles5. U.S. Postal Service6. Credit Reporting Agencies7. Landlord of previous address_____________________________________________________________8. Landlord of current address ______________________________________________________________

Date___________________

Signature of registering parent/guardian ________________________________________________________

Address:

House # Street Name City State Zip Code

Area Code & Telephone Number

Franklin Regional School District • Human Resources • 3210 School Road • Murrysville, PA 15668 • (724) 327-5456

Volunteer opportunities include (but are not limited to) the following: Musicals Field Days

Marching Band Field Trips

Plays Athletic Coaches

1-on-1 Tutoring Class Celebrations

ALL ITEMS ARE MANDATORY Initial Clearances must be dated within 60 months. They must be resubmitted every 60 months from date on clearance.

Once approved you must volunteer one time per school year to stay active.

1. Volunteer Application ‐ Please see the School Secretary or access it online by clicking on For Parents > volunteer information on your student’s

school webpage.

2. Act 151 Child Abuse Clearance – Volunteer No cost – 717-783-6211 or 1-877-371-5422 ‐ Online: Online report by going to https://www.compass.state.pa.us/cwis/public/home OR ‐ Mail: Print the form by obtaining it at http://www.dhs.pa.gov/cs/groups/webcontent/documents/form/s_001762.pdf and

mail it to the address provided on the form. This will take several weeks to process and receive the clearance in the mail. ‐

3. Act 34 PA State Criminal History (PATCH) Clearance – Volunteer No cost – 1-888-783-7972 ‐ Online: Instant report online by going to https://epatch.state.pa.us/Home.jsp ‐ Mail: Print the form by obtaining it at https://epatch.state.pa.us/help/SP4-164A.doc and mail it to the address provided

on the form. This will take several weeks to process and receive the clearance in the mail. ‐

4. Act 114 FBI Fingerprint Criminal Background Clearance - $27.00 - 1-888-439-2486 ‐ Online: Click “register online” with a credit card at https://www.pa.cogentid.com/index_pde.htm then take your

registration number to any fingerprinting facility (locations can be found on the Cogent website at https://www.pa.cogentid.com/index_pdeNew.htm): OR Signed volunteer residency affidavit: If you will be unaccompanied with students or chaperone a field trip, you will be required to obtain an Act 114 FBI Fingerprint Criminal Background Clearance; the volunteer residency affidavit form is not acceptable (per Franklin Regional School Board Policy: 7407 Volunteer Policy).

5. PA Dept. of Education – Arrest/Conviction Report and Certification Form ‐ This form is available on the volunteer information webpage or can be obtained in the school office.

For questions or to turn in all necessary clearances/forms, please bring original documents to the School Secretary. More information on volunteering in Franklin Regional can be found online by clicking on For Parents > volunteer information on your school webpage.

Franklin Regional School District HEALTH NEEDS IDENTIFICATION FORM

STUDENT’S NAME

GRADE__________

DOB__________________

GENDER______________

PARENT/LEGAL GUARDIAN ____________________________________________________

HOME PHONE CELL PHONE WORK PHONE

PHYSICIAN PHYSICIAN’S PHONE No.

Is your child allergic to any medications? YES NO

If yes, please list

MEDICAL HISTORY: Please check below if your child has now or has had in the past: Now Past Now Past

Please describe other medical problems:

Does your child have any physical, hearing, speech or visual disability? Yes No

If yes, please describe:

Does your child have a medical procedure that must be performed during the school day? Yes No

If yes, please list:

Does your child use a walker or wheelchair? Yes No

If yes, please list:

Does your child have allergies to food or insects? Yes No

If yes, please list:

*Has your child experienced an anaphylactic reaction in the past (including, but not limited to, difficulty breathing or shock)? Yes No

*Has an emergency epinephrine injector been used on your child due to an anaphylactic reaction? Yes No

If yes, please describe the circumstances:

List any medication(s) your child is taking that the school nurse and/or staff should be aware of:

The school cannot administer any medication until a medication authorization form has been completed for each medication. Medication must be provided by a parent/legal guardian.

Parent/Legal Guardian Signature Date

Asthma treated with daily medication Nosebleeds Diabetes Respiratory problems Seizures/Epilepsy Cancer Heart Problems Kidney problems Headaches Blood disorders Skin diseases Other: *Allergies (see below) Other:

THIS FORM IS TO BE COMPLETED BY THE PARENT/LEGAL GUARDIAN AND RETURNED TO THE SCHOOL NURSE.

Dear Parent/Guardian:

The Pennsylvania Department of Health requires children to be immunized prior to school entry. Therefore, no child will be enrolled without verification of immunization or a proper exemption. The attached certificate of immunization must be completed and returned for your child to be registered.

Minimum Required Immunizations

Diphtheria/Tetanus – minimum of 4 doses with one given on or after the 4th birthday Polio – minimum of 3 doses Hepatitis B – 3 doses, properly spaced Measles, Mumps, Rubella – separately or combined as MMR after the 1st birthday. A second measles does and

mumps (preferably MMR) one month or more after the first Varicella (chickenpox) – 2 doses or history of disease

Included in this registration packet are dental and physical forms which must be completed and returned to your school nurse by the start of the 2017-2018 school year. Examinations by the school’s physician and the school’s dentist may be scheduled with the school nurse.

We look forward to working with you and your child. Please, if you have any questions at any time throughout your child’s education process, feel free to contact your child’s school nurse.

Sincerely,

Beth Frydrych, BSN, RN, NCSN Health Services Coordinator Middle School

Phone 724-324-5456 x 2013 or Fax 724-733-0949

Sandra Pianetti, BSN, RN, CSN Senior High

Phone 724-327-5456 x 5011 or Fax 724-327-6147

Cynthia Leyh, BSN, RN, CSN Elementary Schools

Heritage 724-327-5456 x 7118 or Fax 724-327-8298

Sloan 724-327-5456 x 3026 or Fax 724-733-5487

Newlonsburg 724-327-5456 x 4003 or Fax 724-327-4903

WELCOME FROM YOUR SCHOOL NURSES

You and your child are beginning an exciting thirteen – year journey and we would like to extend to you a special welcome and supply you with some information about the services we provide.

SCREENINGS:

Vision: Every year, K through 12

Hearing : K-3, 7, 11 – any time a problem is suspected; we can recheck hearing with the

Audiometer and inspect the ear for wax blockage.

Growth: Every year, K through 12

Dental: K, 3, 7 (your dentist or at school)

Physical: K, 6, 11 (your physician or at school)

Scoliosis: 6-7

MEDICATIONS:

At the beginning of each year we will furnish a list of available medications and treatments (standing orders by the school physician) for you to review. You may approve which medications and treatments that you would like your child to receive.

If you child needs long or short-term medication other than those available at school, they must be approved IN WRITING BY YOUR PHYSICIAN. We have forms which must be completed before any other medication can be given. Otherwise we are not permitted to administer them.

ILLNESS:

A sore throat; vomiting/diarrhea during the night; or a skin rash are reasons for keeping your child at home, since these are thing which may be passed on to others. If your child has had a fever (>100F.), they should be kept at home until their symptoms are done and their

IMMUNIZATIONS:

A record of the immunizations your child has received is required to enter school. Please keep us informed with SPECIFIC DATES of any boosters given after registration and we will update your child’s record. You will get the complete history when your child graduates.

Health Services Staff:

Certified School Nurses: Health Room Assistants:

Beth Frydrych, BSN, RN, NCSN Marie Festick, BSN, RN

Sandy Pianetti, BSN, RN, CSN Brittany Marcano, LPN

Cynthia Leyh, BSN, RN, CSN Myon Valentino, BSN, RN

Shari Willis, BSN, RN

Date __________________

PARENT CHECKLIST

Student’s Name __________________________________ Grade______________

� Registration Form � Original Birth Certificate (raised seal) / Passport � Census Form (must include everyone living in the home) � Proof of Residency – (2 Required)

Driver’s licenses not acceptable form of proof

� Utility Bill � Tax Receipt � Rental / Lease Agreement � Closing Settlement � Sales Agreement that indicates completion date of home

� Student Residency Questionnaire � Auto Call Form � Custody Order – ( If applicable, a copy must be made) � Alternative Transportation Request (If applicable) � Special Needs Form

� IEP / GIEP � ER / Psychological Evaluation

� Home Language Survey � Internet Use Agreement � Authorization for Verification of Address � Parental Registration Statement � Student Health Needs Identification Form � Immunization Card – Current Record / Print out from Pediatrician � Physical Exam Form � Dental Card

___________________________________________________________________________