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ATTENTION! IMPORTANT INFORMATION FOR THE2017-18 REGISTRATION PROCESS FOR NEW STUDENTS
Student Fees for 2017-18 District 13 is pleased to be in a financial position that allows us to keep student registration fees at a relatively low cost. We have consistently charged one of the lowest rates in the surrounding area.
EC/Kindergarten $50 Grades 1-5 $50 Grades 6-8 $50 Milk (optional) $24 Bus (where applicable) $380
Kindergarten Technology Fee $50 Grades 1-8 Technology Fee $75
To enhance communication and data collection, please verify and fill in any missing data fields. Please remember to return the Student Registration and Emergency Consent Form for each student regardless if you paid by check or cash.
• FULL LEGAL NAME. YOU ARE REQUIRED to provide the full legal name for your child. Enter the full first name – DO NOT enter nicknames or shortened names. Enter the full middle name – DO NOT enter a middle initial. Enter the full legal last name of the child.
• MOTHER’S MAIDEN NAME. This information is required, and will help to insure that your child isidentified correctly in the ISBE student database.
• E-MAIL ADDRESS. This will help us communicate better with you. At the present time, you receiveschool newsletters and other messages directly on your computer.
• Automated Calling System. In case of school closings, emergencies, and other important information it may be necessary to contact you. Please provide one phone number for such situations. This must be adirect line (no extension). This area is located in the lower left side of the registration form.
Please Make Checks Payable to "Bloomingdale School District 13"
BLOOMINGDALE SCHOOL DISTRICT 13
2017-18 NEW STUDENT REGISTRATION CHECKLIST
*Please return this sheet with completed documents to the school office. Student’s Legal Name ________________________________________________________________ School ____________________________________________________________________________
Proof of Residency Three documents are required as shown on the “Proof of Residency” form. A child cannot start until the residency requirement is complete.
Certified Birth Certificate. Please have the parent contact the appropriate county office vital records department to obtain the official birth record for their child. Phone numbers for surrounding counties are: DuPage County – 630-682-7400; Cook County – 866.252.8974; Kane County – 630-232-5950; Lake County – 847-377-2400. The parent can also go to a local Currency Exchange to obtain a birth certificate.
Illinois Student Transfer form. For students transferring from another Illinois public school only.
Children may not start school without this form. Parents should obtain this form from the previous school the child was enrolled in.
Eight registration forms:
Proof of Residency Sheet
Student Registration & Emergency Consent Form Ethnicity/Race Letter and Form
Records Consent Form Class Placement Background Information Sheet
Language Survey Medical information/Release form
Military Letter
Student fees. These fees are current fees that should be paid as part of registration. If fees are part at a later date, it is possible they will increase.
Student textbook fees ($50.00) – mandatory
Student technology fee (grades 1-8) ($75.00) – mandatory Student milk fees ($24.00) – optional Student bus fees ($380.00) – when applicable
Optional Forms. Affidavit Fee Waiver
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ISBE
05/
01/0
8
Category 2A: Only complete if a Category 2 document cannot be provided (If Applicable)
Category 3: Provide one of the following documents:
Category 2: Provide one of the following documents:
BLOOMINGDALE SCHOOL DISTRICT 13 2017-2018 PROOF OF RESIDENCY FORM
(Students must be District residents as of the August 23, 2017)
ALL DOCUMENTS ACCEPTED FOR PROOF OF RESIDENCY MUST HAVE THE SAME ADDRESS:
Illinois Driver’s License Illinois State ID Other Photo ID
Current mortgage statement or closing statement from bank or lender Real estate tax bill from current school year Current lease showing the name, address and phone number of landlord
Notarized Affidavit of Residency Form (See Attached)
Current electric, water, gas or cable/internet bill in your name Valid Illinois vehicle registration Current pay stub from your employer Current public aid card or document from DHS or DCFS that includes your name▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪This proof of residency form is to attest that the child is not enrolling in the District solely for school purposes and is living on a permanent basis with the person having complete custody and control. Registration of a student who is not a resident is a fraudulent act. Any student found to have been fraudulently registered will be dropped from the attendance rolls immediately. Parents or guardians making a fraudulent registration will be subject to the payment of retroactive tuition charged for non-resident students, not to exceed 110% of the per capita cost. A person who knowingly or willfully presents the District with any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in the District shall have committed a Class C misdemeanor and shall be prosecuted by the District. The District will employee an agency to conducted an investigation if fraud is suspected.
I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.
Parent/Guardian Signature Date
Parent Guardian Address Telephone
Name of Student Grade School
Name of Student Grade School
Name of Student Grade School
Name of Student Grade School
Category 1: Provide one of the following documents:
BLOOMINGDALE SCHOOL DISTRICT 13 2017-2018 AFFIDAVIT OF RESIDENCY FORM
AFFIDAVIT OF RESIDENCY FORM IF APPLICABLE (If box 2A was checked)
(Students must be District residents as of August 16, 2017)
*The Bloomingdale School District 13 resident must also submit residency documents from Category I and Category III along with this form. These documents must come from the resident, not the person who will be living with the resident. I, ________________________________________, the parent or legal guardian of (Printed Name of Parent/Legal Guardian) __________________________________________, being first duly sworn, state on oath that (Printed Name of Student or Students) the named student(s) above is/are under my custody, but we will be residing with _______________________________________ at ___________________________________
(Printed Name of Resident) (Address)
for the 2017-2018 school year. The reason that the student must reside at this address is _________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________
▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ This affidavit of residency form is to attest that the above child is not enrolling in the District solely for school purposes and is living on a permanent basis with the person having complete custody and control. Registration of a student who is not a resident is a fraudulent act. Any student found to have been fraudulently registered will be dropped from the attendance rolls immediately. Parents or guardians making a fraudulent registration will be subject to the payment of retroactive tuition charged for non-resident students, not to exceed 110% of the per capita cost. A person who knowingly or willfully presents the District with any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in the District shall have committed a Class C misdemeanor and shall be prosecuted by the District. The District will employee an agency to conduct if fraud is suspected. I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.
SUBSCRIBED AND SWORN TO _________________________ before me this _________ day Parent Signature of _____________, 20______
_________________________ Telephone ________________________ _
Notary Public Owner of Property Signature (Stamp)
_________________________ Telephone
BLOOMINGDALE SCHOOL DISTRICT 13 RECORDS CONSENT FORM
(Students must be District residents as of August 23, 2017)
I hereby give permission for Bloomingdale School District 13 to obtain the necessary files and records regarding my child from the last school attended.
These records should include all confidential records such as educational records, health records, individual educational plans, and psychological reports.
It is understood that the school district will maintain professional confidentiality of any records received.
Signature of Parent/Guardian (if child is less than age 12): Date:
Signature of Student: Date: (only if age 12 and older, OR child 12-17 and receiving substance abuse treatment without parental consent)
Mental Health Records Redisclosure: Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, communication and records may be redisclosed ONLY IF the person or persons who consented to this disclosure specifically consents to such redisclosure.
Substance Abuse Records Redisclosure: This information has been disclosed to you from records protected by Federal Confidentiality Rules (42- CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical and other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Name of Student: Birth date: Address: Last School Attended: Grade completed: Last School’s Address:
1st Request: 2nd Request: (Date) (Date)
Please fax upon receipt:
□ Illinois Transfer Form □ Latest MAP scores □ IMMUNIZATIONS/PHYSICAL FORM □ STATE OF ILLINOIS EYE EXAMINATION REPORT □ PROOF OF SCHOOL DENTAL EXAMINATION FORM
** PLEASE MAIL ALL OTHER RECORDS TO SCHOOL CHECKED BELOW **
□ Erickson Elementary School
277 Springfield Dr. Bloomingdale, IL 60108 P: 630-529-2223 F: 630-893-9849
□ DuJardin Elementary School
166 S. Euclid Ave. Bloomingdale, IL 60108 P: 630-894-9200 F: 630-894-9545
□ Westfield Middle School
149 Fairfield Way Bloomingdale, IL 60108 P: 630-529-6211 F: 630-893-9336
BLOOMINGDALE ELEMENTARY SCHOOLS
DR. JON BARTELT
Superintendenc
DR. EVONNE WAUGH
Assistanc St1perincendenc
Dear Parent or Guardian:
Re: Illinois State Board of Education New U.S. Department of Education Race and Ethnicity Data Standards
DU PAGE SCHOOL DISTRICT 13
DISTRICT OFFICE
164 Soulh Euclid Avenue
Bloomingdale. IL 60108-1634
(630) 893-9590
Fax (630) 893-1818
www.sd13.org
In fall 2007, the U.S. Department of Education issued new guidance on the collection and reporting of race and ethnicity data for public school students and staff. The guidance implements new federal race and ethnicity categories that were developed to obtain a more accurate picture of the nation's diversity. The new data collection process requires respondents to answer a two-part question, indicating ethnicity first and then one or more of five races. (In the past, individuals were allowed to choose only one race or ethnicity category.)
The Illinois State Board of Education (ISBE) will use the new categories for data to be reported for the 2017·2018 school year. This requires school districts to re-identify race andethnicity for all students and the identification is to be done by parents or guardians. If a student's parents or guardians decline to indicate race and/or ethnicity, observer identification by school district staff is required.
The new race and ethnicity data will be used in the same manner as previously collected data, e.g. in reporting and analyzing test results by race and ethnicity. The information will not beused to check immigration status, and the confidentiality of individual student information will beprotected.
On the back of this letter is the form that parents or guardians need to complete to identify race and ethnicity for their children. Please complete one form per child, and be sure to answer both parts of the two-part question. School district staff is required to provide any missing information by observer identification. Please return the completed form with your child's school registration form.
Thank you for your cooperation in providing the needed data. Please direct any questions you may have to my office at the telephone number and address listed above.
Sincerely,
Developing Actively lnvolved Learners. Well-Rounded Students. and Responsible Citizens in Partnership with the Community
Illinois State Board of Education New U.S. Department of Education Race and Ethnicity Data Standards
Student’s Name:
INSTRUCTIONS: This form is to be filled out by the student’s parents or guardians, and both questions must be answered. Part A asks about the student’s ethnicity and Part B asks about the student’s race. If you decline to respond to either question, the school district is required to provide the missing information by observer identification.
Part A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Choose only one.
No, not Hispanic/Latino
Yes, Hispanic/Latino
The question above is about ethnicity, not race. No matter which answer you selected, continue and respond to the question below by marking one or more boxes to indicate what you consider this student’s race to be.
Part B. What is the student’s race? Choose one or more.
American Indian or Alaska Native (A person having origins in any of the original peoples ofNorth and South America, including Central America, and who maintains tribal affiliation orcommunity attachment.)
Asian (A person having origins in any of the original peoples of the Far East, SoutheastAsia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan,Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
Black or African American (A person having origins in any of the black racial groups ofAfrica.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the originalpeoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East, orNorth Africa.)
Note: Data collected on this form must be maintained by the school district for three years. However, when there is litigation, a claim, an audit, or another action involving this record, the original responses must be retained until the completion of the action.
Illinois State Board of Education, Division of Data Analysis and Progress Reporting December 2009
CLASS PLACEMENT BACKGROUND INFORMATION SHEET
Student's Name Date of Birth________________
Date School _____________ Last Grade Completed ___________
Yes No
Was the student last enrolled in a regular education classroom? If no, please list type of classroom:
Was the student ever enrolled in a special education program? If yes,
Was it a full day class?
Was it a partial day class?
Was it for Learning Disabilities?
Was it for Speech?
Was it another type of class?
Does the student have special needs in:
Learning?
Communication?
Physical?
Health?
Social?
Has the student been in a gifted and/or talent program?
Has the student been in a Title I Program?
Has the student been in a Bilingual Education Program?
01/2017
STUDENT LANGUAGE SURVEY Indicate the best answer to each question: 1. Was English the first language the student learned? Yes No 2. If no is the answer to question # 1. What was the first language learned by
the child? ______________________________ 3. Can the student speak a language other than English? Yes No 4. Code number of language spoken in the home, if other than English. ______ 5. What language is spoken in the home? ________________________________ 6. What language do you most often use to speak to your child?
_________________________________ 7. What language does the student use most often when speaking to parents?
(Specific language spoken) ___________________________________________
8. What language does the child use most often with friends outside the home? _____________________________________
9. Please circle the number that corresponds with your appropriate race.
1. American Indian or Alaska Native 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Island 5. White
10. Can an adult family member or extended family member speak English?
______________________ If yes, who can speak English? _______________ Can they read English? ___________________
Prior Schooling: 11. When did your child first enter school in the USA? In what state?
_____________________________________
12. Was the student enrolled in a bi-lingual or ESL program? Yes No (over)
13. If #11 is yes, give the name and location of the school where the student
received the bi-lingual instruction. 14. Did the student exit the program? ____________ Exit Date: ______________ 15. What country was the student born in? 16. What is the student’s native country? 17. How many years has the student been in the United States? 18. What is the father’s native country? 19. What is the mother’s native country? Parent/Guardian Signature
3/2010
BLOOMINGDALE SCHOOL DISTRICT 13 2017-2018 REGISTRATION FEE WAIVER APPLICATION
The Board of Education of Bloomingdale School District 13 waives school fees for children whose parents are experiencing
economic hardships. If you believe your child(ren) may qualify for a fee waiver due to current financial or emergency
conditions, please complete this form and return it with the registration materials. If you have any questions, please contact
the Director of Finance, John Reiniche, at 630.671.5031. You will be notified of acceptance or denial within 14 days.
----------------------------------------------------------------------------------------------------------------------------------
Name of Student: ______________________________________________ School _________________
Name of parent or guardian: _____________________________________ Grade _________
I hereby request school fees are waived for the above listed student for the following reason:
Household Income Section:____________________________________________________________
[ ] The student’s household gross income meets the Federal income requirement for waiver approval. Documentation must be
attached that supports household size and gross income level. The following documents must be enclosed: Recent W-2
form(s); recent pay stub; Front page of most current Federal 1040 tax form.
Household
Size
Annual Household
Income (Gross)
Monthly Household
Income (Gross)
Weekly Household
Income (Gross)
[ ] I have attached a copy of my most current pay stub
[ ] I have attached a copy of my most current W-2 form (s)
[ ] I have attached a copy of my most current Federal 1040 tax form showing dependents
OR
Public Aid Section: ___________________________________________________________________
[ ] The household is receiving public aid (i.e. Aid to Families with Dependent Children (AFDC), Temporary Assistance for Needy
Families (FANF), or Department of Human Services Food Stamps). Evidence of participation in AFDC, TANF, or Food Stamp
Program must be attached. LINK card and Illinois Department of Public Aid MediPlan cards will not be accepted as
verification of pubic aid.
[ ] I have attached a copy of my card indicating participation in AFDC, TANF or Food Stamp Program.
Case ID Number: ______________________________________________________________
I have reviewed the District’s policy and I am aware supplying false information is a class 4 Felony (720 ILCS S/17-6). I attest
that the statements made here are true and correct.
_________________________________________________________________ _____________________ Parent Signature Date
*********************************************************************************************
Office Use Only:
____ Approved ____ Disapproved
Director of Finance’s Signature: __________________________________________________ Date: _________________
BLOOMINGDALE SCHOOL DISTRICT 13
MEDICAL REQUIREMENTS CHECKLIST FOR TRANSFER STUDENTS
The Illinois school code requires all children entering Illinois schools to have a physical exam and certain
immunizations prior to entering school in the fall. A dental exam and eye exam are also required. Please use
this checklist to help answer questions and complete the necessary requirements for school attendance.
For transfer students from out of the State or out of the country, or from a federal Head Start program, a
health form that is comparable to the Illinois requirements may be accepted only at the time of first entry into
an Illinois school. (A statement by a physician or other health care provider indicating only that an
examination was conducted is not acceptable.)
COMPLETED PHYSICAL EXAM REQUIREMENTS
_______________ “Certificate of Child Health Examination” form (or similar form if student is out of
state) must be completed and returned to school no later than 2 weeks before the
start of school.
_______________ Complete all information on top of the Physical form (name, address, birth date, and
grade). Please put student’s name on both sides of form.
_______________ Parent/Guardian completes and signs the “Health History” portion of the form (top
of back side of form).
_______________ IMMUNIZATIONS (front side of form). Include all immunizations child has had.
The month, day, and year in which the immunizations were given must be noted.
Doctor or Health Care Professional needs to sign and date immunization
portion of the form.
_______________ DIABETES SCREENING is required. The doctor should identify if your child is at
risk.
_______________ LEAD SCREEN RISK QUESTIONNAIRE All children 6 months through 6 years
of age should be assessed for lead poisoning. A lead assessment is a required part of
the physical exam for kindergarten entry.
_______________ PHYSICAL EXAMINATION (Bottom portion of back side of form) Physical must
include: Height, Weight, Blood Pressure, BMI and a review of systems. Lab work is
not required but strongly recommended.
_______________ Physical must be dated within 1 year of entering school and must be signed by the
Physician. The Illinois School Code also allows advanced practice nurses and
physician assistants who have a collaborative agreement with a physician to conduct
and sign a health examination.
IMMUNIZATION REQUIREMENTS
Immunization requirements are grade dependent. Please check with the
individual school for additional required vaccinations.
_______________ DPT (Diphtheria, Pertussis, Tetanus) Need a total of 4 doses, given at least 4 weeks
apart, with the last dose given after 4 years of age.
_______________ OPV/IPV (Polio) 4 or more doses, the first three doses in the series are no less than 4
weeks apart, with the last or 4th
dose given on or after 4 years of age and the last dose
shall be administered at least 6 months after the previous dose.
_______________ MEASLES 2 doses of Measles Vaccine, the first dose must have been received on or
after the first birthday and the second dose no less than 4 weeks later.
_______________ RUBELLA 2 doses of Rubella Vaccine, the first dose must have been received on or
after the first birthday and the second dose no less than 4 weeks later.
_______________ MUMPS 2 doses of Mumps Vaccine, the first dose must have been received on or
after the first birthday and the second dose no less than 4 weeks later.
_______________ MMR (Measles, Mumps, Rubella) If all 3 are given together, the shot must have been
given after 12 months of age.
_______________ VARICELLA (Chickenpox vaccine) 2 doses of Varicella Vaccine, the first dose must
have been received on or after the first birthday and the second dose no less than 4
weeks later, or verification of disease by physician or health care provider with date
and signature placed in the section labeled “Alternate Proof of Immunity.”
_______________ TB A Tuberculin Test is strongly recommended as a part of the physical exam.
OTHER MANDATED EXAMINATIONS
_______________ DENTAL EXAMINATION is required for Kindergarten and 6th
grade. Included
in your packet is a dental form, which the dentist should complete, sign, and date.
_______________ EYE EXAMINATION is required for Kindergarteners and transfer students.
Included in your packet is an eye examination form which the doctor should sign and
date, after completion.
IF YOU REQUEST RELIGIOUS EXEMPTION
A parent-signed letter detailing specific religious beliefs which conflict with a specific
immunization and/or exam must also now be signed by a health care provider
(physician, advanced practice nurse, or physician assistant) and submitted to the school
at which your child is registered. Please refer to the Joint Committee on Administrative
Rules, Administrative Code, Title 77 and PA 099-0249 for further information.
MAKE APPOINTMENTS EARLY. Doctors/Dentists offices get very busy during the summer months. Don’t
wait until August. Immunizations may also be obtained through the DuPage County Health Department. Call
630-682-7400.
When the physical/immunization, eye or dental forms are completed, you may return them to the Health Office at
the school where you registered. There will be drop boxes at all the schools in which to place your completed
health forms. PLEASE DO NOT PUT THEM WITH SCHOOL REGISTRATION FORMS.
If you have any questions, please call the Health Office at the school where you registered.
Thank you for your cooperation in fulfilling these health requirements.
DISTRICT 13 NURSES
Erickson Elementary School 630.529.2233
DuJardin Elementary School 630.894.9200
Westfield Middle School 630.671.5315
MEDICAL INFORMATION/RELEASE FORM Return to Health Office
*** THIS FORM MUST BE SIGNED and DATED ***
THIS FORM IS IMPORTANT IN THE CARE OF YOUR STUDENT WHILE AT SCHOOL, and IF YOUR CHILD SHOULD NEED IMMEDIATE EMERGENCY CARE, IT WOULD BE NECESSARY FOR THE HEALTH OFFICE TO HAVE THIS INFORMATION AVAILABLE IMMEDIATELY. PLEASE REMEMBER TO PROVIDE UPDATED INFORMATION TO THE NURSE WHEN HEALTH CHANGES OCCUR AND UPDATED INFORMATION TO THE SCHOOL OFFICE WHEN CONTACT INFORMATION CHANGES.
STUDENT NAME: DOB: GENDER: SCHOOL: GRADE:
HEALTH/MEDICAL INFORMATION:
Any known health conditions (please be specific): Current treatment: Any illnesses, injuries, or surgery within this last year: YES NO (If yes, please explain.)
Does your child need an asthma inhaler during the school day or for sports? YES NO
(If yes, please note any restrictions, include a copy of the emergency plan, and complete the medication authorization form. This form must be completed by both physician and parent. )
Does your child have any vision or hearing difficulties? If yes, please specify:
Please circle corrective devices your child may need at school: Glasses Contacts Hearing aid Orthopedic aides Other:
Is there anything about your child’s health (physical or emotional) that you would like the teacher or nurse to know? If yes, please specify:
ALLERGIES:
Insects/Bees: Localized: YES NO Severe: YES NO Epi-Pen required? YES NO Benadryl required? YES NO Foods (please list): Epi-Pen required? YES NO Benadryl required? YES NO
(If yes, please note any restrictions, include a copy of the emergency plan, and complete the medication authorization form. This form must be completed by both physician and parent. )
Medication allergies (please list): MEDICATIONS:
Medication taken at HOME on a regular basis: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason:
Medication needed at SCHOOL on a regular basis: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason:
IF NEITHER PARENT/GUARDIAN CAN BE CONTACTED, I AUTHORIZE THE SCHOOL ADMINISTRATION TO TAKE SUCH EMERGENCY ACTION AS NEEDED. DATE: SIGNATURE OF PARENT/GUARDIAN: PRINTED NAME OF PARENT/GUARDIAN: PHONE:
11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
State of Illinois Certificate of Child Health Examination
Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.
Student’s Name Last First Middle
Birth Date Month/Day/Year
Sex Race/Ethnicity School /Grade Level/ID#
Address Street City Zip Code
Parent/Guardian Telephone # Home Work
IMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication. REQUIRED Vaccine / Dose
DOSE 1
MO DA YR
DOSE 2
MO DA YR
DOSE 3
MO DA YR
DOSE 4
MO DA YR
DOSE 5
MO DA YR
DOSE 6
MO DA YR
DTP or DTaP
Tdap; Td or Pediatric DT (Check specific type)
TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT
Polio (Check specific type)
IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV
Hib Haemophilus influenza type b
Pneumococcal Conjugate
Hepatitis B
MMR Measles Mumps. Rubella
Comments: Varicella
(Chickenpox)
Meningococcal conjugate (MCV4)
RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose Hepatitis A
HPV
Influenza
Other: Specify Immunization Administered/Dates
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here. Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result. *MEASLES (Rubeola) MO DA YR **MUMPS MO DA YR HEPATITIS B MO DA YR VARICELLA MO DA YR 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title 3. Laboratory Evidence of Immunity (check one) Measles* Mumps** Rubella Varicella Attach copy of lab result. *All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence. **All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.
Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________ Physician Statements of Immunity MUST be submitted to IDPH for review.
Student’s Name
Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year
HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other)
Yes No
List: MEDICATION (Prescribed or taken on a regular basis.)
Yes No
List:
Diagnosis of asthma? Child wakes during night coughing?
Yes No Yes No
Loss of function of one of paired organs? (eye/ear/kidney/testicle)
Yes No Birth defects? Yes No Hospitalizations?
When? What for? Yes No
Developmental delay? Yes No
Blood disorders? Hemophilia, Sickle Cell, Other? Explain.
Yes No Surgery? (List all.) When? What for?
Yes No
Diabetes? Yes No Serious injury or illness? Yes No
Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No
Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No
Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No
Dizziness or chest pain with exercise?
Yes No Family history of sudden death before age 50? (Cause?)
Yes No
Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Dental Braces Bridge Plate Other
Ear/Hearing problems?
Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date Bone/Joint problem/injury/scoliosis? Yes No
PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P
DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE: Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm__________ Blood Test: Date Reported / / Result: Positive Negative Value LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Sickle Cell (when indicated) Urinalysis Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs
Skin Endocrine
Ears Screening Result: Gastrointestinal
Eyes Screening Result: Genito-Urinary LMP
Nose Neurological
Throat Musculoskeletal
Mouth/Dental Spinal Exam
Cardiovascular/HTN Nutritional status
Respiratory Diagnosis of Asthma Mental Health
Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid)
Other
NEEDS/MODIFICATIONS required in the school setting
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal
EMERGENCY ACTION needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Modified
Print Name (MD,DO, APN, PA) Signature Date
Address Phone
State of IllinoisEye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eyeexaminations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school forother children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinoisschool system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.
Student Name ________________________________________________________________________________________________(Last) (First) (Middle Initial)
Birth Date ____________________ Gender ______ Grade _____(Month/Day/Year)
Parent or Guardian ____________________________________________________________________________________________(Last) (First)
Phone ______________________________(Area Code)
Address _____________________________________________________________________________________________________(Number) (Street) (City) (ZIP Code)
County ____________________________________________
To Be Completed By Examining Doctor
Case HistoryDate of exam ________________
Ocular history: � Normal or Positive for ___________________________________________________________________
Medical history: � Normal or Positive for ___________________________________________________________________
Drug allergies: � NKDA or Allergic to ____________________________________________________________________
Other information _____________________________________________________________________________________________
ExaminationDistance NearRight Left Both Both
Uncorrected visual acuity 20/ 20/ 20/ 20/Best corrected visual acuity 20/ 20/ 20/ 20/
Was refraction performed with dilation? �Yes � No
Normal Abnormal Not Able to Assess CommentsExternal exam (lids, lashes, cornea, etc.) � � � __________Internal exam (vitreous, lens, fundus, etc.) � � � __________Pupillary reflex (pupils) � � � __________Binocular function (stereopsis) � � � __________Accommodation and vergence � � � __________Color vision � � � __________Glaucoma evaluation � � � __________Oculomotor assessment � � � __________Other _________________________ � � � __________NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.
Diagnosis� Normal � Myopia � Hyperopia �Astigmatism � Strabismus �Amblyopia
Other _______________________________________________________________________________________________________
Continued on backPage 1
State of IllinoisEye Examination Report
Recommendations1. Corrective lenses: � No �Yes, glasses or contacts should be worn for:
� Constant wear � Near vision � Far vision� May be removed for physical education
2. Preferential seating recommended: � No �Yes
Comments ________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Recommend re-examination: � 3 months � 6 months � 12 months
� Other ____________________________________
4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________
Print name____________________________________________ License Number_____________________________________Optometrist or physician (such as an ophthalmologist)
who provided the eye examination � MD � OD � DO
Address ____________________________________________
____________________________________________
Phone ____________________________________________
Signature ____________________________________________ Date ___________________
(Source: Amended at 32 Ill. Reg. _________, effective ___________)
Consent of Parent or GuardianI agree to release the above information on my childor ward to appropriate school or health authorities.
(Parent or Guardian’s Signature)
(Date)
Page 2Printed by Authority of the State of Illinois
6/09IOCI1271-09
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
State of IllinoisIllinois Department of Public Health
To be completed by dentist:
Oral Health Status (check all that apply)
� Yes � No Dental Sealants Present
� Yes � No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it wasextracted as a result of caries OR missing permanent 1st molars.
� Yes � No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of thewalls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retainedroot, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-ered sound unless a cavitated lesion is also present.
� Yes � No Soft Tissue Pathology
� Yes � No Malocclusion
Treatment Needs (check all that apply)
� Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
� Restorative Care — amalgams, composites, crowns, etc.
� Preventive Care — sealants, fluoride treatment, prophylaxis
� Other — periodontal, orthodontic
Please note____________________________________________________________________________________
Signature of Dentist _________________________________________ Date of Exam ____________________
Address ___________________________________________________ Telephone _______________________Street City ZIP Code
Illinois Department of Public Health, Division of Oral Health217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us
Printed by Authority of the State of Illinois
Student’s Name: Last First Middle Birth Date:/ /
Address: Street City ZIP Code Telephone:
Name of School: Grade Level: Gender:� Male � Female
Parent or Guardian: Address (of parent/guardian):
(Month/Day/Year)
IOCI 0600-10
Attention 'ParentS Of 5th Graders
The Illinois State Board of Education in conjunction with the Illinois Department of Public Health
require that all students must show proof of receiving a Tdap and an MCV vaccination in addition to
receiving a physical exam and a dental exam for entrance into sixth grade. Tdap is defined as
Tetanus/Diptheria/ A cellular Pertussis vaccine and is to be given regardless of the interval since the
last DTap, Dt or Td dose. This change was made to comply with the recommendations of the Advisory
Committee on Immunization Practices and became effective 9/27/2011. MCV is defined as
meningococcal conjugate vaccine, and sixth grade students will be required to show proof of receiving
one dose on or after 11 years of age. Lastly, the second dose of Varicella is also mandated, or a
written statement of a physician-documented history of varicella may be provided. Please make sure
that your student receives these immunizations this summer so that they will be ready to start at
Westfield in the fall of 2017.
In addition, Illinois School Code requires that all 6th graders present proof of having been examined
by a dentist. This exam should be documented on the state approved form available for download on
the District 13 website. Dentists' offices are often busy during the summer months so please make
your appointments early. The completed form may be sent to the school health office or dropped off
in the medical forms drop box. If you have any questions, please contact the building nurse at your
child's school.
Attention 'ParentS Of 1sc Graders
Illinois School Code requires that all 2nd graders present proof of having been examined by a
dentist. This exam should be documented on the state approved form available for download on the
District 13 website. Dentists' offices are often busy during the summer months so please make your
appointments early. The completed form may be sent to the school health office or dropped off in
the medical forms drop box.
In addition, for the start of the 2017-2018 school year, the second dose of Varicella is also
mandated, or a written statement of a physician-documented history of Varicella may be provided.
If you have questions, please contact the building nurse at your child's school.
3/2016
BLOOMINGDALE SCHOOL DISTRICT 13
Authorization and Permission for Administration of Medication
THIS FORM IS REQUIRED IF YOUR CHILD IS TO RECEIVE NON-PRESCRIPTION AND/OR PRESCRIPTION MEDICATION AT SCHOOL AND/OR CARRY AN INHALER OR EPI-PEN.
STUDENT’S NAME: DIAGNOSIS: DOB: GRADE:
School medications and health care services are administered following these guidelines:
Physician/Prescriber signed dated authorization to administer the medication. Parent signed dated authorization to administer the medication. The medication is in the original labeled container as dispensed or the manufacturer’s labeled container. The medication label contains the student name, name of the medication, directions for use and date. Annual renewal of authorization and immediate notification, in writing, of changes.
Physician, please list medication that must be administered during school hours.
FOR SELF-ADMINISTRATION OF EPI-PEN and/or INHALER ONLY,
I certify that has been instructed in the use and self-administration of (Name of Student) (Name of Medication)
He/she understands the need for the mediation, and the necessity to report to school personnel any unusual side effects. He/she is capable of using this medication independently.
I may be reached at the following phone # in the event of a reaction to the medication or an emergency:
Signature of Physician Phone number Date
Print Name of Physician Address of Physician Date
REVISED: 10/20/15
MEDICATION DOSAGE TIME TO BE ADMINISTERED
REASON PRESCRIBED
SIDE EFFECTS SPECIAL INSTRUCTIONS
RE-EVALUATE DATE
BLOOMINGDALE SCHOOL DISTRICT 13
Student’s Name Student’s Date of Birth
FOR ALL PARENTS/GUARDIANS:
Parental authorization to administer medication at school:
By signing below, I agree that I am primarily responsible for administering medication to my child.
However, in the event that I am unable to do so or in the event of a medical emergency, I hereby
authorize Bloomingdale School District 13 and its employees and agents, in my behalf, to administer or to
attempt to administer to my child (or to allow my child to self-administer, pursuant to state law, while
under the supervision of the employees and agents of the School District), lawfully prescribed
medications in the manner described above. This includes administration of undesignated epinephrine
auto-injectors to my child when there is a good faith that my child is having an anaphylactic reaction
whether such reactions are known to me or not (105 IL CS 5/22-30, amended by P.A. 98-795). I
acknowledge that it may be necessary for the administration of medications to my child to be performed
by an individual other than a school nurse and specifically consent to such practices, and I agree to
indemnify and hold harmless the School District and its employees and agents against any claims, except
a claim based on willful and wanton conduct, arising out of the administration or the child’s self-
administration of medication.
Parent/Guardian Printed Name:
Parent/Guardian Signature:
Date:
FOR PARENTS/GUARDIANS of students who need to carry
and use their asthma medication or an epinephrine auto-injector:
I authorize the School District and its employees and agents, to allow my child or ward to self-carry and
self-administer his/her asthma medication and/or auto epinephrine auto-injector: (1) while in school, (2)
while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or
after normal school activities, such as while in before-school or after-school care on school-operated
property. Illinois law requires the School District to inform parents/guardians that it, and its employees
and agents, incur no liability, except for the willful and wanton conduct, as a result of any injury arising
from a student’s self-carry and self-administration of asthma medication or epinephrine auto-injector (105
ILCS 5/22-30).
Please initial to indicate a) receipt of this information, and b) authorization for your child to carry
and use his/her asthma medication or epinephrine auto-injector.
Parent/Guardian Initial:
ERICKSON ELEMENTARY PARENT TEACHER ORGANIZATION
277 Springfield Drive, Bloomingdale, Illinois 60108 Erickson Parents: The 2017-2018 Erickson Elementary School Parent Teacher Organization (PTO) Membership Dues are listed below. The Membership Dues for PTO participation are $15.00 for one child and $25.00 for two or more children. This fee includes: all classroom parties, and PTO membership with inclusion and access to our school directory. The PTO sponsors such events as: Fall Carnival, Fundraisers, School Assemblies, AR Night Out, Thanksgiving Feast, Teacher Wish Lists and many more. The directory information policy is contained in the district calendar. We will publish the information provided to the district (student name, address, phone number) unless you notify the school principal in writing. If you do not wish to be included in the PTO directory, please notify the principal in writing at [email protected]. The 2017-2018 PTO school directory will be an emailed pdf. A printed copy of the pdf is available for $5 per copy. Complete the bottom portion of this form. Include a check payable to Erickson PTO. Please place the form and payment in an envelope marked Erickson PTO. Do not combine these dues with other fees you may be sending in. Thank you in advance for your prompt attention and support. Sincerely, Julie Coronato PTO President Erickson Elementary
ERICKSON PTO MEMBERSHIP DUES 2017-2018 _____ $15 for one child _____ $25 for two or more children _____ optional $5 for each printed copy of the school directory CHILD’S NAME _____________________________________ GRADE ______ CHILD’S NAME _____________________________________ GRADE ______ CHILD’S NAME _____________________________________ GRADE ______ FAMILY NAME ___________________________________________________ TOTAL $ _____
ERICKSON ELEMENTARY 2017-2018 SUPPLY LIST K 1 2 3 4 5
Art - Smock/Shirt (Large oversized long sleeve t-shirt or old button down) 1 1 1 1 1 1
Colored Pencils - 8 Colors (hand-held sharpener required- not for 1st grade)
- 24 Colors (hand-held sharpener required)
0 0
1 0
0 1
1 0
0 1
0 1
Colored Markers 1 box (washable) – “Classic Colors” broad point 2 1 1 1 1 1
Colored Markers 1 box (washable) – “Classic Colors” fine point 0 0 0 1 1 1
Crayons, box of 24 4 2 1 1 0 0
Elmer’s Glue - 4 oz. (white only) 1 1 0 1 2 1
Glue Sticks 12 11 12 6 4 3
Gym Shoes - LABELED and LEFT AT SCHOOL Must have Velcro 1 1 1 1 1 1
Hi-Lighters (package of 4 colors) 1 1 1 1 1 2
Kleenex – LARGE BOX 1 2 1 3 1 2
Index Cards – 3 x 5 lined white 0 0 0 0 0 1
Loose-leaf paper - wide lined not college ruled 0 0 0 0 2 0
Pen, ballpoint - Red Blue
White-out Correction Tape (not liquid, tape only)
0 0 0
0 0 0
0 0 0
0 0 0
4 0 0
4 2 1
Dry Erase Markers - Chisel Tip –low odor- package of 4(any color but yellow)
Fine Tip –low odor package of 4 (any color but yellow)
1 0
1 0
1 0
2 0
0 1
1 1
Pink Pearl Eraser (art class) 0 0 1 0 0 0
Extra Fine Black Sharpie (art class) 0 0 0 1 0 0
Fine Black Sharpie (art class) 0 0 0 0 0 1
Pencils, #2 Lead – Package of 6 (SHARPENED) 5 3 4 4 3 4
Pocket Folders Grade K 1 of each color, red, blue, (solid only) Grade 1 1 of each color, red, blue, yellow, green, orange (solid only) 3 prong folder -1 blue,1 yellow, 1 - round ring binder (1inch) Grade 2 2 of each color, red, blue, purple (solid only) 1 of each color, yellow, green (solid only) Grade 3 1 of each color, red, yellow, green, purple (solid only) 1 multicolored, 2 blue folders Grade 4 1-13 pocket expanding folder Grade 5 2 of each color, red, blue, yellow, green, purple (solid only) 3 - multicolored (NO TRAPPERS)
DO NOT LABEL WITH NAME/SUBJECT - TEACHER WILL HANDLE
Post-It Note Package (2x3) Yellow 0 0 1 0 2 2
Ruler, 12” - Metric & Standard - Wooden 0 0 0 0 1 1
Ear buds or headset (K/1st headset only) 1 1 1 1 1 1
Plastic Supply Pouch – 9 ½” x 11 ½” LARGE – no art boxes 0 1 1 1 1 1
Pencil Case 0 0 1 0 0 1
Scissors (metal blade – K/1st grade) 1 1 1 1 1 1
Spiral Notebooks (wide ruled) Composition Books
1 2 2 0 2
3 3
Ziploc Bags (gallon size) 1 box 1 1 0 0 1 1
Ziploc Bags (sandwich size) 1 box 0 0 1 0 0 1
1) Be sure all items are clearly labeled except pocket folders with the name of the student. 2) Only label gym shoes and art smocks for kindergarten and first grade. 3) Be prepared to replenish pencils, crayons, paper, glue, and eraser as the year progresses. 4) Some teachers have specific requests during the year.
5) BOOK BAGS OR BACKPACKS NEED TO FIT EASILY IN THE LOCKERS.
6) KINDERGARTEN TEACHERS REQUIRE A LARGE, OPEN-TOPPED, CANVAS BAG, RATHER THAN
BACKPACK. PTO SELLS ERICKSON KINDERGARTEN BAGS (PINK AND BLUE). PLEASE NOT NOT LABEL
ANY KINDERGARTEN SUPPLIES.
Kids’ Place
Ph. (630) 529.3650 172 S. Circle Ave., Bloomingdale, IL 60108 www.bloomingdaleparks.org
Kindergarten Kids’ Place
Why we're different from other fundraising groups: • All contributions made to the foundation are tax deductible • 100% of the contributions go directly back to the teachers and students of our district • Teachers are able to determine how the donations are utilized
Projects we've funded in the past: • eReaders for 7th grade students • special music and reading programs • a climbing wall with accessories • projectors and speakers • technology and multimedia projects • Nook books
How you can help:
• Make a financial donation using the form below and return it in your registration packet • Volunteer your time to help organize fundraisers and solicit donations • Provide services to the foundation, such as printing, signage, etc.
Please make checks payable to the: Bloomingdale SD 13 Education Foundation
PO Box 6382 Bloomingdale, IL 60108 Enclosed is my donation of: $30 $50 $75 $100 Other Please contact me about volunteering or donating services Name: Email:
Address:
Phone:
THE STUDENTS AND TEACHERS THANK YOU FOR YOUR SUPPORT!
Our Mission Due to budget cuts and economic times, there has been a decrease in the amount of traditional funding for public education. The Bloomingdale School District 13 Education Foundation was founded in 1998 as a non-profit dedicated specifically to supporting the children and staff of our district. Our mission is to raise supplemental funds to support creative and innovative projects that benefit all of the children in District 13.
