***Office Use*** Home School: ______________________________ School Year: _______________ Grade: ______

Lakeshore Public Schools Required Documents Checklist **Please return this form with ALL enrollment documents**

PARENT USE

STUDENT’S FULL NAME: OFFICE USE

Complete Missing

Parent/Guardian Photo ID (Driver’s License or Passport) Enrollment Form Request for Records Form Concussion Form Acceptable Use of Technology Agreement Transportation Form Free/Reduced Lunch Form (If enrolling after Sept 1) Elementary ONLY: ½ Day Sack Lunch Permission Form (If enrolling after Sept 1)

Additional Kindergarten & Y5 Documents: Y5 ONLY: Parent Input Form Y5 Y5-K ONLY: Prior Care Form Y5-K ONLY: Green Health Appraisal Form (Take form to Physician Appt.) Y5-K ONLY: Hearing and Vision Screening (See Health Dept. Schedule) Y5-K ONLY: Kindergarten Waiver Form (Required if child turns 5 between Sept 1st & Dec 1st)

Other Documents if applicable: School of Choice Application (Only during open SOC period)

Custody and Guardianship documentation (in the event of custody issues or educational rights. Otherwise BOTH parents are given equal rights)

CERTIFIED BIRTH CERTIFICATE:

A certified original state or court issued Birth Certificate (available from the County Clerk’s Office in the county of your child’s birth) The hospital or “footprint” copy of the birth certificate is not acceptable documentation

STUDENTS IMMUNIZATION RECORDS

1. Student must be up-to-date or have a waiver signed by the health department. Lakeshore Public Schools will accept CURRENT immunization records from your physician’s office or health dept.

2. Consent for Disclosure of Immunization Information to Local and State Health Departments

PROOF OF RESIDENCY (2 items) -Only the documents listed below will be accepted as proof of residency:

HOMEOWNER—If you own or are purchasing a home within the District, you must provide the following:

1. Current* utility bill in the name and address of person enrolling the student (gas, electric,

water or cable bill only – MAILING ADDRESS MUST MATCH SERVICE ADDRESS. *A current bill covers a service period ending within 30 days

2. AND ONE of the following: Current Property Tax Bill with name and address; or Purchase Agreement (if closing occurred within the last 6 months)

TENANT—If you are renting a home within the district, you must provide the following:

1. Current* utility bill in the name and address of person enrolling the student (gas, electric,

water or cable bill only - MAILING ADDRESS MUST MATCH SERVICE ADDRESS. *A current bill covers a service period ending within 30 days

2. Rental agreement with name and property address of person enrolling the student. LIVING WITH RESIDENT OR OTHER LIVING SITUATION:

If you are NOT the homeowner or signer of the lease, please contact the District’s Central Office at (269) 428-1400 to identify your current living situation and schedule an appointment to verify the necessary residence requirements.

dvaldezTypewritten TextNOT REQUIRED 20-21

STUDENT ENROLLMENT FORM

Lakeshore Public Schools 5771 Cleveland Avenue, Stevensville, MI 49127 Phone: (269)428-1400 Fax: (269)428-1574 Date: _________________________

School Last Attended: ________________________________________ Location: _____________________________

Current Resident District: ________________________________________ Grade Level (Last Completed):____________

Re-enrolling in Lakeshore Public Schools? Yes No Date Last Attended Lakeshore Public Schools: _________________

Discipline: Yes No Has student been expelled from another school or has an expulsion pending?

Yes No Is student currently under suspension from another school? If yes to either of the above, which district? __________________________________ Location: _______________________ Please explain:

STUDENT INFORMATION

Student’s Legal Name (as shown on Certified Birth Certificate)

Last Name: _______________________________ First Name: ________________________________ Middle: _________________________

Gender: Male Female DOB: _____/_____ /_____ Age: _______ City/State of Birth: _______________________________________

If born outside the United States, how long has the student resided in the US? ____________________________________________________

Grade student to be enrolled in: _________________

PRIMARY HOUSEHOLD INFORMATION

Home Phone Number: (_______) _______-_________ Student’s Personal Cell Phone Number: (_______) _______-_________ (Instant alerts are sent to the Primary Home Phone)

Current Physical Address: ______________________________________________________________________________________________ (STREET ADDRESS) (CITY) (STATE) (ZIP) (COUNTY)

Current Mailing Address: _____________________________________________________________________________________________ (If different) (STREET ADDRESS) (CITY) (STATE) (ZIP) (COUNTY)

RESIDENCY VERIFICATION

Own a Home Rent/Lease Family Shares with Relatives/Friends Shelter Hotel Other: ______________________________

If needed, please explain your current living situation: ________________________________________________________________

SPECIAL NEEDS INFORMATION

1. Special Services – Please indicate any services your child received at previous school (please check all that apply):

Special Education/IEP Speech & Language 504 Plan Title 1 Services Other _______________________ explain)_____________________________ 2. Does your child qualify for Migrant Services? Yes No

3. Does your child have a parent/legal guardian ACTIVE in the Military? Yes No If Yes, Name & Relation: _____________________

HOME LANGUAGE SURVEY Lakeshore Public School District is collecting information regarding the language background of each of its students. This information will be used by the District to determine the number of children who should be provided bilingual instruction according to Sections 380.1152-380.1158 of the School Code of 1995 Michigan’s Bilingual Education Law.

1. Is your child’s native tongue* a language other than English? Yes No If yes, what is that language? __________________________ 2. Is the primary language** used in your child’s home or environment a language other than English? Yes No

If yes, what is that language? _____________________________________ 3. If born outside the United States, how long has the student attended school in the US? _________________________________________

* “Native tongue” means the first language the child learned from his/her parents. ** “Primary language” means the dominant language used by a person for communication.

ETHNICITY (Part A) and RACE (Part B) Both Parts A and B of the question must be answered. If either part is not answered, the US Department of Education requires the District to supply an answer on your behalf.

Part A: Ethnicity

Is this student Hispanic/Latino? Yes No (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race.)

Part B: Race (choose only one)

American Indian or Alaska Native (Origins from any of the original peoples of North/South America, or Central America) Asian (Origins from any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent) Black or African American (Origins from any of the black racial groups of Africa) Native Hawaiian or other Pacific Islander (Origins from any of the original peoples of any Pacific Island) White (Origins from any of the original peoples of Europe, the Middle East or North Africa) Hispanic/Latino

Office Use Only—Enrollment Type

Resident SOC

CONTACT RELATIONSHIP TYPES (SEC 1-3 below) Father/Mother

Stepfather/Stepmother

Foster Parent

Host Parent (Foreign Exchange)

Partner

Child Care Provider

Friend

Neighbor

Brother/Sister

Uncle/Aunt

Grandfather/Grandmother

Grandparents

Other

SEC 1: PRIMARY HOUSEHOLD CONTACT (Lives with at least 50% of the time) PRIMARY Household Contact: PRIMARY Household Parent/Guardian 1 PRIMARY Household Parent/Guardian 2

Name (Last, First)

Relationship to Student (see list above)

Cell Phone

Employer

Work Phone

Email Address

SEC 2: SECOND HOUSEHOLD CONTACT (Parent/Guardian living elsewhere) 1. Does the child have a second parent/second residence? Yes No If yes, please complete this section. 2. Primary household & second household have shared custody? Yes No 3. Should this household be included in all mailings? Yes No 4. Okay to release student to second household parent? Yes No

If you answered “No” to any of these questions, please attach legal documentation; specific to this child and legal documentation; specific to communication with the second household parent.

If you answered “Yes” to any of these questions, ALL fields for the second household must be complete.

SECOND Household Contact: SECOND Household Parent/Guardian 1 SECOND Household Parent/Guardian 2

Name (Last, First)

Relationship to Student (see list above)

Home Phone

Cell Phone

Employer

Work Phone

Email Address

Mailing Address

Mailing City & State

Mailing Zip Code

SEC 3: EMERGENCY CONTACT (Other than parents) Mark Box(s) Below

Name (Last, First) Relationship to Student

(see list above) Phone Number & Type

(Mobile, Work or Home) Emergency

Contact School Pickup

OTHER CHILDREN WHO RESIDE IN THE HOME (If Applicable) Name Gender DOB School Grade

M F

M F

M F

HEALTH INFORMATION Medical information is confidential and will be shared with personnel on a need to know basis. In a medical emergency, Lakeshore Public Schools is authorized to take whatever reasonable and appropriate steps are necessary to

care for my child. I accept all responsibility, financial and otherwise, for this care. Yes No

I give permission for the school office personnel to discuss the medical information of my child with any school staff member that they feel necessary for the safety of the child. Yes No

If student is currently taking prescription medications? Please list:

Nothing Known Allergies

Epileptic/Seizures Insects/Bee Sting * Has Epi Pen? Yes No Allergic Sensitive

Rheumatic Medication: Allergic Sensitive

Heart Food: Allergic Sensitive

Muscle Weakness Environmental: Allergic Sensitive

Hemophiliac Asthma * Uses Inhaler? Yes No

Severe Nose Bleeds Diabetic

Wears Glasses Contacts Hearing Problems * Wears Hearing Aids? Yes No If any health conditions are marked above, please give further detail on how we can best meet the needs of your child:

PERMISSION FOR EDUCATIONAL TRAVEL I give permission for my child to take part in all school sponsored field trips. I assume responsibility for my child on these trips, both financially and otherwise. Yes No

PERMISSION FOR PUBLICATION OF STUDENT PHOTO OR WORK Checking YES gives permission for your child’s name and/or photo/writing/artwork to be used in publications, presentations, social

media, videos, web pages, or news releases produced by Lakeshore Public Schools or agencies working with the District.

Checking NO means that your child’s name and/or photo/writing/artwork WILL NOT be used in publications, presentations, social media, videos, web pages, or news releases produced by Lakeshore Public Schools or agencies working with the District. Yes No

Annual school yearbooks and PTO publications are considered internal school publications and are not subject to these restrictions. If you do not want your child’s name/photo to be included in these publications, please notify the school principal in writing.

The undersigned hereby acknowledges that the information provided on this form is true and accurate. The undersigned understands that it is his/her responsibility to inform the appropriate school office if and when any of the information set in this form changes. Failure to inform the District will subject the student to termination of enrollment in Lakeshore Public Schools.

Parent/Legal Guardian Signature_________________________________________

Relationship to Student ______________________________________________ Date ________________

OFFICE USE

CENTRAL OFFICE

Records Request Faxed Initials: _______

Transportation Form Scanned To Dept. Initials: _______

Special Services Information Scanned to Dept. Initials: _______

Free/Reduced Lunch & Sack Lunch Form Sent to Dept. Initials: _______

PowerSchool Documents Attached School of Choice Initials: _______

Legal Documents Initials: _______

Notarized Proof of Residency Initials: _______

4/2020

4/2018

REQUEST FOR RECORDS

From: Lakeshore Public Schools 5771 Cleveland Avenue Stevensville, MI 49127

Phone: 269-428-1400 Fax: 269-428-_________

Today’s Date: __________________

I hereby request that: ____________________________________________

Name of Last School Attended

Address of last school attended: __________________________________ Street Number

____________________________________________________________ City State Zip Code

Phone Number of School: ______________________________________

Fax Number of School: ________________________________________

Release to Lakeshore Public Schools, all school records of: (including

academic, medical, physical, psychiatric and/or neurological information, and special

education records [if applicable])

___________________________________________ ________________

Student’s Name Birthdate

Last grade completed: ______________ Current grade level: ____________

Former address for student was: ___________________________________ Street Number ____________________________________________________________ City State Zip Code

Parent/Guardian’s Present Address: ________________________________ Street Number ____________________________________________________________ City State Zip Code ______________________________________________________________

Parent/Legal Guardian Signature Printed Name of Parent/Legal Guardian

PLEASE FAX THE FOLLOWING ASAP (if applicable) TO: Lakeshore Public Schools Fax: (269) 428-________

All Transcripts

Semester/Exit Grades

Immunization/Health Records

Disciplinary Record, if applicable

Latest IEP, if applicable

PLEASE MAIL CUMULATIVE FILE

(CA-60) TO:

Hollywood Elementary 143 East John Beers Rd Stevensville, MI 49127 Fax #: (269) 428-1578 Roosevelt Elementary 2000 El Dorado Drive Stevensville, MI 49127 Fax: (269) 428-1576

Stewart Elementary 2750 Orchard Lane Stevensville, MI 49127 Fax: (269) 428-1580

Lakeshore Middle School 1459 West John Beers Rd Stevensville, MI 49127 Fax: (269) 428-1571

Lakeshore High School 5771 Cleveland Avenue Stevensville, MI 49127 Fax: (269) 428-1573

-AND – PLEASE MAIL SPECIAL EDUCATION

RECORDS TO: Lakeshore Public Schools Attention: Special Programs 5771 Cleveland Avenue Stevensville, MI 49127

Transportation Form Lakeshore Public Schools

5771 Cleveland Avenue, Stevensville, MI 49127 Phone: (269)428-1400 Transportation Dept.: (269)428-1412

STUDENT INFORMATION

Student’s Name: _________________________________ Home Address: _____________________________________

Home Phone: ____________________________ School: __________________________________ Grade: ___________

Please Note: Parents are to designate only one pickup point and only one drop off point. Infrequent and/or irregular pick up and drop

off requests cannot be accommodated. If the need arises for your child to change buses, such as babysitter problems, work schedule

changes, etc., you need to send a note to your child’s teacher and the school office.

TRANSPORTATION METHOD

My child is a: Car Rider Self-Drive Walker Bus Rider

AM Only

PM Only

BOTH AM and PM

FOR BUS STUDENTS

A.M.: My child will be transported from _________________________________________________________ (Address)

This address is: Child’s Home

Caregiver Name: __________________________________ Phone: ____________________

Daily Monday Tuesday Wednesday Thursday Friday

P.M.: My child will return to the address above where he/she was picked up? YES NO

If no: My child should be dropped off at ___________________________________________________________

(Address)

This address is: Child’s Home

Caregiver Name: __________________________________ Phone: ____________________

Daily Monday Tuesday We dnesday Thu rsd ay Friday

EMERGENCY CONTACTS (3 Requested) Name Relationship to Child Cell Phone Work Phone

1.

2.

3

You are responsible for notifying your child’s school of any changes in this information.

Parent/Legal Guardian Signature: _____________________________________________ Date: _____________

FOR TRANSPORTATION OFFICE USE ONLY Start Date: ________________________ Bus No: ______________________

Stop Location: ______________________________________________ PU Time: _____________ DO Time: _____________

4/2018

Educational Material for Parents and Students (Content Meets MDCH Requirements) Sources: Michigan Department of Community Health. CDC and the National Operating Committee on Standards for Athletic Equipment (NOCSAE)

UNDERSTANDING CONCUSSION Some Common Symptoms

Headache Balance Problems Sensitive to Noise Poor Concentration Not “Feeling Right” Pressure in the Head Double Vision Sluggishness Memory Problems Feeling Irritable

Nausea/Vomiting Blurry Vision Haziness Confusion Slow Reaction Time Dizziness Sensitive to Light Fogginess “Feeling Down” Sleep Problems

Grogginess

WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a fall, bump, blow, or jolt to the

head or body that causes the head and brain to move quickly back and forth. A concussion can be caused by a shaking, spinning or a sudden stopping and

starting of the head. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious. A concussion can happen

even if you haven’t been knocked out.

You can’t see a concussion. Signs and symptoms of concussions can show up right after the injury or may not appear or be noticed until days or weeks after

the injury. If the student reports any symptoms of a concussion, or if you notice symptoms yourself, seek medical attention right away. A student who may

have had a concussion should not return to play on the day of the injury and until a health care professional says they are okay to return to play.

IF YOU SUSPECT A CONCUSSION:

1. SEEK MEDICAL ATTENTION RIGHT AWAY – A health care professional will be able to decide how serious the concussion is and when it is safe for the

student to return to regular activities, including sports. Don’t hide it, report it. Ignoring symptoms and trying to “tough it out” often makes it worse.

2. KEEP YOUR STUDENT OUT OF PLAY – Concussions take time to heal. Don’t let the student return to play the day of injury and until a heath care

professional says it’s okay. A student who returns to play too soon, while the brain is still healing, risks a greater chance of having a second concussion.

Young children and teens are more likely to get a concussion and take longer to recover than adults. Repeat or second concussions increase the time it

takes to recover and can be very serious. They can cause permanent brain damage, affecting the student for a lifetime. They can be fatal. It is better to

miss one game than the whole season.

3. TELL THE SCHOOL ABOUT ANY PREVIOUS CONCUSSION – Schools should know if a student had a previous concussion. A student’s school may not know

about a concussion received in another sport or activity unless you notify them.

SIGNS OBSERVED BY PARENTS:

Appears dazed or stunned Can’t recall events prior to or after a hit or fall Answers questions slowly

Is confused about assignment or position Is unsure of game, score, or opponent Loses consciousness (even briefly)

Forgets an instruction Moves clumsily changes Shows mood, behavior, or personality

CONCUSSION DANGER SIGNS: In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. A student should receive

immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other Repeated vomiting or nausea Becomes increasingly confused, restless or agitated

Is drowsy or cannot be awakened Slurred speech Has unusual behavior

A headache that gets worse Convulsions or seizures Loses consciousness (even a brief loss of consciousness should be taken seriously) Weakness, numbness, or decreased coordination Cannot recognize people/places

HOW TO RESPOND TO A REPORT OF A CONCUSSION: If a student reports one or more symptoms of a concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of athletic play the day

of the injury. The student should only return to play with permission from a health care professional experienced in evaluating for concussion. During

recovery, rest is key. Exercising or activities that involve a lot of concentration (such as studying, working on the computer, or playing video games) may

cause concussion symptoms to reappear or get worse. Students who return to school after a concussion may need to spend fewer hours at school, take rest

breaks, be given extra help and time, and spend less time reading, writing or on a computer. After a concussion, returning to sports and school is a gradual

process that should be monitored by a health care professional.

Remember: Concussion affects people differently. While most students with a concussion recover quickly and fully, some will have symptoms that last for

days, or even weeks. A more serious concussion can last for months or longer. To learn more, go to www.cdc.gov/concussion.

Parents and Students Must Sign and Return the Educational Material Acknowledgement Form

http://www.cdc.gov/concussionhttp://www.cdc.gov/concussion

CONCUSSION AWARENESS

EDUCATIONAL MATERIAL ACKNOWLEDGEMENT FORM

Lakeshore Public Schools is requesting that parents of all students read and review the Concussion Fact Sheet

whether or not they are a member of a sports team, because injuries may occur in situations other than the

athletic field (such as recess and activity classes).

By my name and signature below, I acknowledge in accordance with Public Acts 342 and 343 of 2012 that I have

received and reviewed the Concussion Fact Sheet for Parents and/or the Concussion Fact

Sheet for Students provided by Lakeshore Public Schools.

_______________________________________ ______________________________________ Student Name Printed Parent/Legal Guardian Name Printed

_______________________________________ ______________________________________ Student Signature Parent/Legal Guardian Signature

_______________________________________ ______________________________________ Date Date

Participants and parents--Please review and keep the educational materials available for future reference.

1

Student Technology Acceptable Use and Safety

Technology has fundamentally altered the ways in which information is accessed, communicated, and transferred in society. As a result, educators are continually adapting their means and methods of instruction, and the way they approach student learning, to incorporate the vast, diverse, and unique resources available through the internet. The Board of Education provides Technology Resources (as defined in Bylaw 0100) to support the educational and professional needs of its students and staff. With respect to students, District Technology Resources afford them the opportunity to acquire the skills and knowledge to learn effectively and live productively in a digital world. The Board provides students with access to the internet for limited educational purposes only and utilizes online educational services/apps to enhance the instruction delivered to its students. The Districts computer network and Internet system does not serve as a public access service or a public forum, and the Board imposes reasonable restrictions on its use consistent with its limited educational purpose.

The Board regulates the use of District Technology Resources by principles consistent with applicable local, State, and Federal laws, the Districts educational mission, and articulated expectations of student conduct as delineated in the Student Code of Conduct. This policy and its related administrative guidelines and the Student Code of Conduct govern students’ use of District Technology Resources and students’ personal communication devices when they are connected to the District computer network, Internet connection, and/or online educational services/apps, or when used while the student is on Board-owned property or at a Board-sponsored activity (see Policy 5136).

Users are required to refrain from actions that are illegal (such as attacks, slander, vandalism, harassment, theft, plagiarism, access, and the like) or unkind (such as attacks, invasion of privacy, injurious comment, and the like). Because its Technology Resources are not unlimited, the Board has also instituted restrictions aimed at preserving these resources, such as placing limits on use of bandwidth, storage space, and printers.

Users have no right or expectation to privacy when using District Technology Resources (including, but not limited to, privacy in the content of their personal files, e-mails, and records of their online activity when using the District’s computer network and/or Internet connection).

First, the Board may not be able to technologically limit access, through its Technology Resources, to only those services and resources that have been authorized for the purpose of instruction, study and research related to the curriculum. Unlike in the past when educators and community members had the opportunity to review and screen materials to assess their appropriateness for supporting and enriching the curriculum according to adopted guidelines and reasonable selection criteria (taking into account the varied instructional needs, learning styles, abilities, and developmental levels of the students who would be exposed to them), access to the internet, because it serves as a gateway to any publicly available file server in the world, opens classrooms and students to electronic information resources that may not have been screened by educators for use by students of various ages.

Pursuant to Federal law, the Board has implemented technology protection measures that protect against (e.g., filter or block) access to visual displays/depictions/materials that are obscene, constitute child pornography, and/or are harmful to minors, as defined by the Children’s Internet Protection Act. At the discretion of the Board or the Superintendent, the technology protection measures may be configured to protect against access to other material considered inappropriate for students to access. The Board also utilizes software and/or hardware to monitor online activity of students to restrict access to child pornography and other material that is obscene, objectionable, inappropriate and/or harmful minors. The technology protection measures may not be disabled at any time that students may be using District Technology Resources, if such disabling will cease to protect against access to materials that are prohibited under the Children’s Internet Protection Act. Any student who attempts to disable the technology protection measures will be subject to discipline.

The Superintendent or Director of Technology may temporarily or permanently unlock access to websites or online educational services/aps containing appropriate material, if access to such sites has been inappropriately blocked by the technology

2

protection measures. The determination of whether material is appropriate or inappropriate shall be based on the content of the material and the intended use of the material, not on the protection actions of the technology protection measures.

Parents are advised that a determined user may be able to gain access to services and/or resources on the Internet that the Board has not authorized for educational purposes. In fact, it is impossible to guarantee students will not gain access through the Internet to information and communications that they and/or their parents may find inappropriate, offensive, objectionable or controversial. Parents of minors are responsible for setting and conveying the standards that their children should follow when using the Internet.

Pursuant to Federal law, students shall receive education about the following: A. safety and security while using email, chat rooms, social media, and other forms of direct electronic communications B. the dangers inherent with the online disclosure of personally identifiable information C. the consequences of unauthorized access (e.g., “hacking”, “harvesting”, “digital piracy”, “data mining”, etc.),

cyberbullying and other unlawful or inappropriate activities by students online, and D. unauthorized disclosure, use, and dissemination of personally-identifiable information regarding minors

Staff members shall provide instruction for their students regarding the appropriate use of technology and online safety and security as specified above. Furthermore, staff members will monitor the online activities of students while at school.

Monitoring may include, but is not necessarily limited to, visual observations of online activities during class sessions; or use of specific monitoring tools to review browser history and network, server, and computer logs.

Building principals are responsible for providing training so that Internet users under their supervision are knowledgeable about this policy and its accompanying guidelines. The Board expects that staff members will provide guidance and instruction to students in the appropriate use of District Technology Resource. Such training shall include, but not be limited to, education concerning appropriate online behavior, including interacting with other individuals on social media, including in chat rooms, and cyberbullying awareness and response. All users of District Technology Resources (and their parents if they are minors) are required to sign a written agreement to abide by the terms and conditions of this policy and its accompanying guidelines.

Students will be assigned a school email account that they are required to utilize for all school-related electronic communications, including those to staff members, peers, and individuals and/or organizations outside the District with whom they are communicating for school-related projects and assignments. Further, as directed and authorized by their teachers, they shall use their school-assigned email account when signing up /registering for access to various online educational services, including mobile applications/apps that will be utilized by the student for educational purposes.

Students are responsible for good behavior when using District Technology Resources—i.e., behavior comparable to that expected of students when they are in classrooms, school hallways, and other school premises and school sponsored events. Communications on the Internet are often public in nature. General school rules for behavior and communications apply. The Board does not approve any use of its Technology Resources that is not authorized by or conducted strictly in compliance with this policy and its accompanying guidelines.

Students may only use District Technology Resources to access or use social media if it is done for educational purposes in accordance with their teachers approved plan for such use.

User who disregard this policy and its accompanying guidelines may have their use privileges suspended or revoked, and disciplinary action taken against them. Users are personally responsible and liable, both civilly and criminally, for uses of District Technology Resources that are not authorized by this policy and its accompanying guidelines.

The Board designates the Superintendent and Director of Technology as the administrators responsible for initiating, implementing, and enforcing this policy and its accompanying guidelines as they apply to students’ use of District Technology Resources.

Neola 2017

3

Lakeshore Public Schools

5771 Cleveland Avenue, Stevensville, MI 49127

Phone: (269)428-1400 Fax: (269)428-1574

STUDENT TECHNOLOGY ACCEPTABLE USE AND SAFETY AGREEMENT

To access and use District Technology Resources (see definition in Bylaw 0100), including a school-assigned e-mail account and/or the Internet at school, students under the age of eighteen (18) must obtain parent permission and sign and return this form. Students eighteen (18) and over may sign their own forms.

Use of District Technology Resources is a privilege, not a right. The Board of Education’s Technology Resources, including its computer network, Internet connection and online educational services/apps, are provided for educational purposes only. Unauthorized and inappropriate use will result in loss of this privilege and/or other disciplinary action. Teachers and building principals are responsible for determining what unauthorized or inappropriate use is. The principal may deny, revoke or suspend access to and use of the Technology Resources to individuals who violate the Board's Student Technology Acceptable Use and Safety Policy and related Guidelines, and take such other disciplinary action as is appropriate pursuant to the Student Code of Conduct. (See Policy 7540.03) The Board has implemented technology protection measures that protect against (e.g., block/filter) Internet access to visual displays/depictions/materials that are obscene, constitute child pornography, or are harmful to minors. The Board also monitors online activity of students in an effort to restrict access to child pornography and other material that is obscene, objectionable, inappropriate and/or harmful to minors. Nevertheless, parents/guardians are advised that determined users may be able to gain access to information, communication, and/or services on the Internet that the Board has not authorized for educational purposes and/or that they and/or their parents/guardians may find inappropriate, offensive, objectionable or controversial. Students using District Technology Resources are personally responsible and liable, both civilly and criminally, for unauthorized or inappropriate use of the Resources.

The Board has the right, at any time, to access, monitor, review and inspect any directories, files and/or messages residing

on or sent using District Technology Resources. Messages relating to or in support of illegal activities will be reported to

the appropriate authorities. Individual users have no expectation of privacy related to their use of District Technology

Resources.

Please complete the following information:

Student User's Full Name (please print): _________________________________________________

School: ___________________________________________ Grade: __________________________

Parent/Legal Guardian's Name: _____________________________________________________________

CONTINUED ON NEXT PAGE

4

Parent/Guardian

As the parent/guardian of this student, I have read the Student Technology Acceptable Use and Safety Policy and

Guidelines (attached), and have discussed them with my child. I understand that student access to the Internet is designed

for educational purposes and that the Board has taken available precautions to restrict and/or control student access to

material on the Internet that is obscene, objectionable, inappropriate and/or harmful to minors. However, I recognize

that it is impossible for the Board to restrict access to all objectionable and/or controversial materials that may be found

on the Internet. I will not hold the Board (or any of its employees, administrators or officers) responsible for materials my

child may acquire or come in contact with while on the Internet. Additionally, I accept responsibility for communicating

to my child guidance concerning his/her acceptable use of the Internet - i.e., setting and conveying standards for my

daughter/son to follow when selecting, sharing and exploring information and resources on the Internet. I further

understand that individuals and families may be liable for violations.

To the extent that proprietary rights in the design of a web page, site, service or app hosted on Board-owned or

District-affiliated servers would vest in my child upon creation, I agree to assign those rights to the Board.

Please check each that applies:

I give permission for the Board to issue an e-mail account to my child. I give permission for my child's image (photograph) to be published online, provided only his/her first name is used.

I give permission for the Board to transmit "live" images of my child (as part of a group) over the Internet via a web

cam.

I authorize and license the Board to post my child's class work on the Internet without infringing upon any copyright

my child may own with respect to such class work. I understand only my child's first name will accompany such

class work.

Parent/Legal Guardian’s Signature: _______________________________________ Date: ______________

Student

I have read and agree to abide by the Student Technology Acceptable Use and Safety Policy and Guidelines. I understand that any violation of the terms and conditions set forth in the Policy and Guidelines is inappropriate and may constitute a criminal offense and/or may result in disciplinary action. As a user of District Technology Resources, I agree to communicate over the Internet and through the Technology Resources in an appropriate manner, honoring all relevant laws, restrictions and guidelines.

Student's Signature: ____________________________________________ Date: ________________

© NEOLA 2017

Y5/Kindergarten Prior Care Form Lakeshore Public Schools 5771 Cleveland Avenue, Stevensville, MI 49127

Phone: (269)428-1400 Fax: (269)428-1574

The Michigan Department of Education (MDE) requires Lakeshore Public Schools to collect information about the early

care experiences of all newly enrolling Y5/kindergarten students. Please complete the following information and return

with your enrollment packet.

Last Name: __________________________ First Name: __________________________ Middle: ___________________

Student’s Legal Name (as shown on Certified Birth Certificate)

Gender: Male Female DOB: _____/_____ /_____ Age: _______

Elementary School Enrolling in: ________________________________________________________________________

What was your child’s primary form of care since last September? (Check up to 3 relevant choices). If the child was

primarily at home during the last year, please check No Prior Care.

Great Start Readiness Program (GSRP) (State funded program age 4 by Sept 1st)

Head Start (Federally funded program ages 3 & 4)

Early Childhood Special Education Classroom (School based preschool for special needs students with an IEP)

Young Fives/Developmental Kindergarten (Plan is for child to attend regular Kindergarten next year)

Child Care-Home Based (Operated out of a private home)

Private Child Care Center (Commercial business that may be independent or part of a chain)

Registered Family/Relative Child Care (Family or relative care provider receiving state assistance to provide care)

Tuition-Based Preschool (Full or half day of instruction and learning)

No Prior Care Program (Stay at home for care)

Kindergarten (Child has been retained for a second year of kindergarten)

Consent for Disclosure of Personally Identifiable Information and Immunization Information to Local and State Health Departments

Immunizations are an important part of keeping our children healthy. Schools and State and Local health departments must monitor immunization levels to ensure that all communities are protected from potentially life-threatening diseases and, if necessary, respond promptly to an emerging public health threat. It is important that disease threats be minimized through the monitoring of students being immunized.

Sharing immunization and personally identifiable information including the student’s name, Date of Birth, gender, and address with local and state health departments will help to keep your child safe from vaccine preventable diseases. The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g, requires written parental consent before personally identifiable information and immunization information from your child’s education records is disclosed to the health department. If your child is 18 or over, he or she is an “eligible student” and must provide consent for disclosures of information from his or her education records.

You may withdraw your consent to share this information in writing at any time.

______________________________________________________________________________

I authorize Lakeshore Public Schools to release my child’s immunization record and personally

identifiable information to the Michigan Department of Health and Human Services and Local

Health Department. I understand this information will be used to improve the quality and

timeliness of immunization services and to help schools comply with Michigan Law. This includes

any immunization information and limited personally identifiable information from the school.

Student’s Name: ______________________________________________ Date of Birth: ___/___/____

Parent/Legal Guardian Signature: __________________________________________

OR

Eligible Student (18 or over): _____________________________________ Date of Birth: ___/___/____

Printed Parent/Legal Guardian Name: __________________________________________

All Kindergarteners and

4-6 year old transfer students

All 7th Graders and 7-18 year

old transfer students

Diphtheria, Tetanus, Pertussis

(DTP, DTaP, Tdap)

4 doses DTP or DTaP

1 dose must be at or after 4 years

of age

4 doses diphtheria and tetanus or3 doses if 1st dose given at or

after 1 year of age

1 dose Tdap at 11 years of age or older upon entry into 7th grade or

higher

Polio 4 doses

3 doses if dose 3 was given at or after 4 years of age

Measles, Mumps,

Rubella (MMR)* 2 doses at or after 12 months of age

Hepatitis B* 3 doses

Meningococcal Conjugate

(MenACWY) None

1 dose at 11 years of age or older upon entry into 7th grade

or higher

Varicella

(Chickenpox)*

2 doses at or after 12 months of age or

Current lab immunity or

History of varicella disease

Vaccines Required for School Entry in MichiganSchools

Whenever children are brought into group settings, there is a chance for diseases to spread. Students

must follow state vaccine laws in order to attend school. These laws are the minimum standard to help

prevent disease outbreaks in school settings. The best way to protect students in your care from other

serious diseases is to promote the recommended vaccination schedule at www.cdc.gov/vaccines.

Encourage parents to follow CDC’s recommended schedule; by doing so, school requirements will be met.

During disease outbreaks, incompletely vaccinated students may be excluded from school. Parents and guardians choosing to decline vaccines

must obtain a certified non-medical waiver from a local health department. Read more about waivers at www.Michigan.gov/Immunize.*If the student has not received these vaccines, documented immunity is required. All doses of vaccines must be valid (correct spacing and ages) for school entry purposes.

Updated December 11, 2019

Prior Care Form Revised 2-19-20Digital Enrollment Form 20-21 (1)Digital Enrollment 20-21 (3)Digital Required Documents ChecklistDigital Enrollment Application 4-1-20Transportation Form 4-1-20Concussion Information Sheet & Sign Form 4-1-20Neola Tech Agreemement & Acceptabl Use 4-1-20Consent for Disclosure of Immunization Information 4-1-20Required Immunizations

Request for Records 4-1-20

Students Full Name: Check Box1A: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box10: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffEnrollment Date: School Last Attended: School Location: Current Resident District: Grade Level: Date Last Attended: District Name: District Location: Student Last Name: Student First Name: Student Middle Name: MM: DD: Year: Age: CityState of Birth: If born outside the United States how long has the student resided in the US: Grade student to be enrolled in: Primary Home Phone: Home Phone 1: Home Phone 2: Students Personal Cell Phone Number: Student Cell 1: Student Cell 2: Current Physical Address: Current Mailing Address: Other House: Current Living Situation: Other Special Services: Military: Home Language: If yes what is that language: Born outside US: Check Box25: OffCheck Box26A: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffExplanation: Primcary 2 Cell Phone: Primary Household Name: Primary 2 Relationship: Primary 2 Name: Primary Household Employer: Primary Cell Phone: Primary Relationship: Primary Household Work PHone: Primary Household Email: Primary 2 Employer: Primary 2 Work Phone: Primary 2 Email: 2nd Household 2 Employer: 2nd Household 2 Cell Phone: 2nd Household 2 Home Phone: 2nd Household 1 Name: 2nd Household 2 Relationship: 2nd Household 2 Name: 2nd Household 1 Work Phone: 2nd Household 1 Employer: 2nd Household 1 Cell Phone: 2nd Household 1 Home Phone: 2nd Household 1 Relationship: 2nd Household 1 Email: 2nd Household 1 Address: 2nd Household 1 City/State: 2nd Household 1 Zip Code: 2nd Household 2 Work Phone: 2nd Household 2 Email: 2nd Household 2 Street: 2nd Household 2 City/State: 2nd Household 2 Zip Code: Emergency Contact 2 Name: Emergency Contact 1 Name: Emergency Contact 2 Relationship: Emergency Contact 1 Relathionship: Emergency Contact 2 Phone: Emergency Contact 1 Phone: Emergency Contacat 3 Name: Emergency Contact 3 Relationship: Child 1 Name: Emergency Contact 3 Phone: Child 3 School: Child 1 DOB: Child 2 School: Child 1 School: Child 3 Grade: Child 2 Grade: Child 1 Grade: Child 2 Name: Child 2 DOB: Child 3 Name: Child 3 DOB: Check Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck Box71: OffCheck Box72A: OffCheck Box A: OffCheck BoxB: OffCheck Box C: OffCheck BoxD: OffCheck Box E: OffCheck BoxF: OffList of Medication: Allergies: Medication: Food: Environmental: Asthma: Diabetic: Hearing Problems: Health Conditions: Completion Relationship: Completion Date: Check Box72: OffCheck Box73: OffCheck Box74: OffCheck Box75: OffCheck Box76: OffCheck Box78: OffCheck Box80: OffCheck Box82: OffCheck Box84: OffCheck Box86: OffCheck Box88: OffCheck Box90: OffCheck Box77: OffCheck Box79: OffCheck Box81: OffCheck Box83A: OffCheck Box85: OffCheck Box87: OffCheck Box89: OffCheck Box91: OffCheck Box92A: OffCheck Box92: OffCheck Box93: OffCheck Box95: OffCheck Box97: OffCheck Box99: OffCheck Box94: OffCheck Box96: OffCheck Box98: OffCheck Box100: OffCheck Box101: OffCheck Box102: OffCheck Box103: OffCheck Box104: OffCheck Box105: OffCheck Box106: OffCheck Box107: OffCheck Box90a: OffEnrollment Form Parent Signature: Request for Record Completion Date: Request for Records Prior School: Request for Records Prior School Street: Request for Records Prior School City: Request for Records Prior School Phone Number: Request for Records Prior School FAX Number: Request for Records Prior School School Name: Request for Records Prior DOB: Request for Records Prior Last Grade: Request for Records Current Last Grade: Request for Records Former Address: Request for Records Prior School Former City: Request for Records Present Address: Request for Records Prior School Present City: Request for Records Parent Signature: Request for Records Parent Printed Name: Hollywood Elementary: OffRoosevelt Elementary: OffStewart Elementary: OffLakeshore Middle School: OffLakeshore High School: OffTransportation Student Name: Transportation Home Address: Transporation Home Phone: Transportation School: Transportation Grade Level: Transportation AM: Transport AM Name: Transport AM Phone: Child Drop Off Address: Transport PM Name: Transport PM Phone: Transportation Emergency Contact 2 Cell Phone: Transportation Emergency Contact 2 Relationship: Transportation Emergency Contact 1 Relationship: Transportation Emergency Contact 1 Cellp: Transportation Emergency Contact 3 Work Phone: Transportation Emergency Contact 2 Work Phone: Transportation Emergency Contact 1 Work Phone: Transportation Emergency Contact 3 Relationship: Transportation Emergency Contact 3 Cell phone: Transportation Sign Date: Check Box107A: OffCheck Box108: OffCheck Box109: OffCheck Box110: OffCheck Box111: OffCheck Box112: OffCheck Box113: OffCheck Box114: OffCheck Box115: OffCheck Box116: OffCheck Box117: OffCheck Box118: OffCheck Box119: OffCheck Box120A: OffCheck Box120: OffCheck Box121: OffCheck Box122: OffCheck Box123: OffCheck Box125: OffCheck Box126: OffCheck Box127: OffCheck Box128: OffCheck Box128A: OffCheck Box129: OffTransportation Emergency Contact 1 Name: Transportation Emergency Contact 2 Name: Transportation Emergency Contact 3 Name: Check Box123a: OffTransportation Form Parent Signature: Concussion Name Printed: Concussion ParentLegal Guardian Name Printed: Concussion Student Date: Concussion Parent Date: Concussion Student Signature: Transportation Parent Signature: Tech Student Name: Tech School: Tech Grade: Tech Parent Signature 1: Parent Tech Date: Student Tech Date: Check Box140: OffCheck Box141: OffCheck Box142: OffCheck Box1: OffTech pg 2 Parent Signature: Tech Student Signature: Imm DOB YY: Imm DOB: Imm DOB dd: Immunization Parent Signature: Immunization Student: Prior Care Last Name: Prior Care First Name: Prior Care MiddleName: Check Box143: OffPrior Care Male: OffPrior Care School Enrolling In: Prior Care School DOB mm: Prior Care School DOB YY: Prior Care School DOB dd: Prior Care School DOB age: Prior Care Female: OffGSPR: 0: Off

Kindergarten: OffNo Prior Care: OffTuition Based: OffFamily Child Care: OffPrivate Child Care: OffHome Based: OffY5s: OffSPED Classroom: OffHead Start: Off