Richmond Community Schools€¦ · Handbook Acknowledgement Form ... Rent Payment Receipts, a copy of money order made for payment of rent, or letter from employer that is written

Guaranteed Learning for All Students! Rev 5/2020

Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565 * (586) 727-2098 (FAX) * www.richmond.k12.mi.us

Registration Packet Checklist Welcome to Richmond Community Schools! The following forms must be completed to register your student. Registration only takes a few minutes if the forms are filled out in advance. Please check each line to ensure that you have completed all information. Student Name: _______________________________________________________________________________________ Student Registration Information (must be completed): ____ Student Registration Information Form (pages 1-2) Documentation Required for Registration: ☐ Birth Certificate

Original document with the official seal ☐ High School Students

Required: Report Card or Transcript

☐ Record Release Form ☐ Custody Papers (if applicable) ☐ Immunization Record ☐ Consent for Disclosure of Immunization Information

☐ Parent Identification (Driver’s License or State ID) ☐ Parent PowerSchool Portal Agreement (4th-12th Grade)

☐ Current IEP (Special Education only) ☐ Technology Agreement (K-2nd Form or 3rd-12th Form)

☐ Home Language Survey Form - required ☐ Handbook Acknowledgement Form ☐ Parental Consent for Virtual Courses (9th-12th Grade) ☐ 2 Required Proofs of Residency

One Item listed here: Lease or Mortgage Statement, Purchase Agreement, Property Tax Bill, Deed, Building Permit, Voters Registration

One Item listed here: Utility Bill, Rent Payment Receipts, a copy of money order made for payment of rent, or letter from employer that is written on company letterhead.

Is the family of the student living with another family already residing in the district (doubled up)?

☐ Fill Out the Residency Verification Form **Proof of Residency will be required from both the homeowner/leaser and family residing within the home.

Required Health Forms: ______ Hearing and Vision Testing – Kindergarten Only ______ Statement of Varicella Disease – Only if student has had Chicken Pox (Varicella) Additional Forms to Complete ONLY If Applicable: _____ School of Choice – Required only if you are a non-resident and wish for your child to attend Richmond Schools _____ Kindergarten Waiver Request – Required only if the child will not be age five on September 1 but will be five years of age no

later than December 1. _____ Free and Reduced Lunch Application

_____ Indian Education Form

_____ Pesticide Notification Advisory to Parents _____ Pay to Participate Information _____ Do Not Photo/Video Form Authorization for:

_____Prescribed Medication Form – Grades K-12th _____Non-prescribed Medication Form– Grades 5th-12th

http://www.richmond.k12.mi.us/

Richmond Community Schools35276 Division * Richmond, Michigan 48062 * (586) 727-3565 * (586) 727-2098 (FAX) * www.richmond.k12.mi.us

STUDENT REGISTRATION INFORMATION

Student Information School Entering

Grade Entering

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

Last Name First Name Middle Name Primary Phone

Birth Date Birth City & State (if born in US) Gender M F

Secondary Phone:

Street Address City State Zip Code County

Ethnicity Is the student Hispanic/Latino? No, not Hispanic or Latino

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Race The question to the left is about ethnicity, not race. No matter what you selected, please answer the following by marking one or more boxes to indicate what you consider your student’s race to be:

American Indian/Alaskan Native Asian American Black or African American Native Hawaiian/Other Pacific Islander White

Born in US? Yes NoDate First Attended School in US (month & year)

Previous School

Has your child attended school in Richmond before? (Include Pre-K) Yes No

If Yes, School Attended Year Grade

Previous School Suspended or Expelled from Former School?

Did your child receive Special Services at Former School? Yes No If yes, check all that apply below and provide copy of plan.

Special Education 504 Plan Speech/Language Title 1 Math Reading Social Work Other Services

Please describe other services:

Primary Household Information Student lives with:

Both Parents Father/Stepmother Mother/Stepfather Father Only Mother Only Guardian Relative Foster Court Placed Divorced, Joint Custody Other:

Parent/Guardian Name Relationship to Child Email Address

Home Phone Cell Phone Employer Work Phone

Parent/GuardianName Relationship to Child Email Address

Home Phone Cell Phone Employer Work Phone

Name of Parent Living Elsewhere Relationship to Child Email Address

Address Home Phone Cell Phone

Have custody papers been provided to the office? Yes No Custody Restrictions

Military Connected Student: Check if at least one parent is a member of the Armed Forces on active duty

Emergency Contacts My student may be released to the following local contacts when primary contacts above cannot be reached:

1. Name Relationship to Child Primary Phone Secondary Phone



Unlisted

UnlistedUnlistedUnlisted

Rev 2/21/20

Yes No

STUDENT ENROLLMENT FORM (page 2 of 2) Student Name:

New Enrollee Transportation (If eligible, please check transportation requested)

No transportation needed Both to school and home To school only Home from school only

Other Children Who Reside in the Home

Name Birth Date School/Grade Relationship to Student




Health Information If nothing known, please check

Asthma Allergy Diabetes Heart Condition Seizure Hearing Problem

Vision Problem

List all non-food allergies Epi-Pen

List all food allergies Epi-Pen

Other Medical Alerts/Health Conditions

Physical Limitations

Medications Taken (include inhaler) Is your child required to take medication or inhaler during the school day? Yes No

Medical Plan: Complete a medical plan if your child has allergies/asthma/diabetes/seizures or other conditions which requires treatment during the school day.

Information for Parents

Your preschool-aged and school-aged children have certain rights or protections under the McKinney-Vento Homeless Education Assistance Act. Is your current living arrangement the result of a loss of housing or economic hardship? Yes No Unsure Your truthful and accurate answers help the district identify services that your student may be eligible to receive. If YES, a Richmond Community Schools' employee will complete a homeless student referral form in order to determine your eligibility for services.

Verification of Information-the undersigned acknowledges that the information provided on this form is true and accurate

Parent/Legal Guardian Signature Date

Preferred Hospital: Physician Name:

Physician Phone:

Dentist Name:

Dentist Phone:

In compliance with Title VI of the Civil Rights Act of 1964, Title IX of the Education amendments of 1972, Section 504 of Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disability Act of 1990, and Elliott-Larsen Civil Rights Act of 1977, it is the policy of the Richmond Community School District that no person shall, on the basis of race, color, religion ,military status, national origin or ancestry, sex (including sexual orientation), disability, age (except as authorized by law,) height, weight, or marital status be excluded from participation in, be denied the benefits of, or be subjected to, discrimination during any program, activity, service or employment. Inquiries related to any nondiscrimination policies should be directed to the Superintendent, 35276 Division Road, Richmond, MI 48062, (586) 727-3565.

Concussion Awareness Educational Material Acknowledgment FormBy my name and signature below, I acknowledge in accordance with Public Act 342 and 343 of 2012 that I received and reviewed the Concussion Fact Sheet for Parents provided by Richmond Community Schools. The form shall be kept on file with the student CA-60 for the duration of attendance in Richmond Community Schools or age 18. Students and Parents should keep the educational materials for future reference.

Parent/Legal Guardian Signature Date

Rev 2/21/20

Richmond Community Schools35276 Division*Richmond, Michigan 48062*(586)727-3565*www.richmond.k12.mi.us

Macomb Intermediate School District

Home Language Survey

The Richmond Community School District is required by Federal and state law to collect information

regarding the language background of each student. This information will be used by the district to determine

the number of children who should be provided bilingual instruction according to Sections

380.1152-380.1157 of the Michigan School Code of 1995, Michigan’s Bilingual Education law.

Name of Student: ____________________________________ Grade: ________ Age: __________

Name of School Building: _________________________________________________________________

1. What language did your child first learn to speak? __________________________________________

2. Is your child’s native tongue a language other than English?

Yes ___ No ___ If yes, what is that language? _____________________________________

3. Is the “primary language” (the dominant language used by a person for communication) used in your

child’s home a language other than English?

Yes___ No ___ If yes, what is that language? _____________________________________

4. Has your student been identified or have they received Bilingual/ESL services in another district?

Yes___ No___ If yes, what district? ____________________________________________

No ____5. *Was your student born in the US? Yes ____

6. *Month and Year First School Attended? ______________

*Optional

Parent/Guardian Signature: _______________________________________________________________

Date Completed: _______________________________________________________________

Rev 2/21/20



Page 1 | 1 2020-2020 School Year

RECORD RELEASE FROM FORMER SCHOOL

Former School’s Name Student’s First and Last Name

Former School’s Address Birth Date Date of Entry Grade

Phone Number Fax Number

Request for student’s CUMULATIVE FOLDER AND SPECIAL EDUCATION RECORDS. The student listed above has enrolled in our school. Please forward the following information listed below to Brian J. Walmsley, Ed.S., Superintendent of Schools: 35276 Division Richmond, Michigan 48062:

□ CUMULATIVE RECORD (e.g. CA60) including but not limited toacademic assessment results, attendance record, transcripts, etc.

□ SECTION 504 and any evaluation reports including but not limitedto any medical, neurological, psychologic, or psychiatric records.

□ INDIVIDUAL EDUCATION PLAN (IEP) AND MULTIDISCIPLINARYTEAM REPORT (MET) including but not limited to any medical,neurological, psychological, or psychiatric record.

□ DISCIPLINARY RECORDS, including suspensions and expulsions.

Federal Statute Entitled:

Privacy Right of Parents and Students Schools may send a student’s educational records to officials of other schools or school system in which the student seeks or intends to enroll, upon conditions that the student’s parents be notified of the transfer, receive a copy of the records, if desired, and have an opportunity to challenge the content of the records.

School Transfer “Weapon Free” School Zone Statement The student named above, has enrolled in the Richmond Community Schools. In order to comply with Public Act 32B, please verify that the above named student has not been suspended or expelled from school for a weapon, arson, or criminal sexual conduct violation subsequent to January 1, 1995. If the above named student has been suspended or expelled for one of the above named violation, please attached an explanation as to the current status of the student. In accordance with Michigan Public Act 32B the Richmond Board of Education shall permanently expel pupil who possesses a weapon in a weapon-free school zone, commits an arson violation, or a sexual assault violation. Students expelled under this policy are expelled from all Michigan School Districts unless placed in an appropriate alternative education program. Please return a signed copy of this form with the requested cumulative folder (e.g. CA60)

Verification of Information: I verify the above information to be true and accurate. I request student records and information be disclosed to Richmond Community School District.

Legal Parent/Guardian’s Signature Date

Please provide the following information □ Expelled / □ Suspended Violation/Infraction:

Authorized Signature Telephone Date PLEASE FAX TRANSCRIPT, CURRENT GRADES, AND ANY STUDENT

SUPPORT SERVICES TO FAX# (586) 727-2098




STATEMENT OF VARICELLA DISEASE


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 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 Richmond Community Schools to release my child’s immunization record 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: ___/___/____

Signature of Parent/Guardian or Eligible Student: _________________________________________ Date: ___/___/____

Printed Parent/Guardian Name: __________________________________________


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

District Contact Person: Brian J. Walmsley, Ed.S., Superintendent [email protected] * (586) 727-3565

Page 1 of 1 Rev 1-30-20



Page 1 | 1

2020-2021 School Year



Page 1 | 1

2020-2021 School Year

Richmond Community Schools

CONCUSSION INFORMATION SHEET

This sheet has information to help protect your children or teens from concussion or other serious brain injury. Use this information at your children’s or teens’ games and practices to learn how to spot a concussion and what to do if a concussion occurs.

WHAT IS A CONCUSSION?

A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth. This fast movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging the brain cells.

HOW CAN I SPOT A POSSIBLE CONCUSSION?

Children and teens who show or report one or more of the signs and symptoms listed below—or simply say they just “don’t feel right” after a bump, blow, or jolt to the head or body—may have a concussion or other serious brain injury.

SIGNS OBSERVED BY PARENTS OR COACHES

• Appears dazed or stunned.• Forgets an instruction, is confused about an

assignment or position, or is unsure of the game,score, or opponent.

• Moves clumsily.• Answers questions slowly.• Loses consciousness (even briefly).• Shows mood, behavior, or personality changes.• Can’t recall events prior to or after a hit or fall.

SYMPTOMS REPORTED BY CHILDREN AND TEENS

• Headache or “pressure” in head.• Nausea or vomiting.• Balance problems or dizziness, or double or blurry

vision.• Bothered by light or noise.• Feeling sluggish, hazy, foggy, or groggy.• Confusion, or concentration or memory problems.• Just not “feeling right,” or “feeling down.”

WHAT ARE SOME MORE SERIOUS DANGER SIGNS TO LOOK OUT FOR?

In rare cases, a dangerous collection of blood (hematoma) may form on the brain after a bump, blow, or jolt to the head or body and can squeeze the brain against the skull. Call 9-1-1 or take your child or teen to the emergency department right away if, after a bump, blow, or jolt to the head or body, he or she has one or more of these danger signs:

• One pupil larger than the other.• Drowsiness or inability to wake up.• A headache that gets worse and does not go away.• Slurred speech, weakness, numbness, or decreased

coordination.• Repeated vomiting or nausea, convulsions or seizures

(shaking or twitching).• Unusual behavior, increased confusion, restlessness, or

agitation.• Loss of consciousness (passed out/knocked out). Even a

brief loss of consciousness should be taken seriously.

WHAT SHOULD I DO IF MY CHILD OR TEEN HAS A POSSIBLE CONCUSSION?

As a parent, if you think your child or teen may have a concussion, you should:

1. Remove your child or teen from play.2. Keep your child or teen out of play the day of the

injury. Your child or teen should be seen by a healthcare provider and only return to play with permissionfrom a health care provider who is experienced inevaluating for concussion.

3. Ask your child’s or teen’s health care provider forwritten instructions on helping your child or teenreturn to school. You can give the instructions to yourchild’s or teen’s school nurse and teacher(s) andreturn-to-play instructions to the coach and/or athletictrainer.

Do not try to judge the severity of the injury yourself. Only a health care provider should assess a child or teen for a possible concussion. Concussion signs and symptoms often show up soon after the injury. But you may not know how serious the concussion is at first, and some symptoms may not show up for hours or days.

The brain needs time to heal after a concussion. A child’s or teen’s return to school and sports should be a gradual process that is carefully managed and monitored by a health care provider.

HOW CAN I HELP KEEP MY CHILDREN OR TEENS SAFE?

Sports are a great way for children and teens to stay healthy and can help them do well in school. To help lower your children’s or teens’ chances of getting a concussion or other serious brain injury, you should:

• Help create a culture of safety for the team.›› Work with their coach to teach ways to lower

the chances of getting a concussion. ›› Talk with your children or teens about

concussion and ask if they have concerns about reporting a concussion. Talk with them about their concerns; emphasize the importance of reporting concussions and taking time to recover from one.

›› Ensure that they follow their coach’s rules for safety and the rules of the sport.

›› Tell your children or teens that you expect them to practice good sportsmanship at all times.

• When appropriate for the sport or activity, teach yourchildren or teens that they must wear a helmet tolower the chances of the most serious types of brainor head injury. However, there is no “concussion-proof” helmet. So, even with a helmet, it is importantfor children and teens to avoid hits to the head.

TO LEARN MORE GO TO >> cdc.gov/HEADSUP

JOIN THE CONVERSATION AT www.facebook.com/CDCHEADSUP

Content Source: CDC’s HEADS UP campaign. Customizable HEADS UP fact sheets were made possible through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).




SCHOOLS OF CHOICE APPLICATION Non-Resident District Students Only

Applying for: □ Elementary (Gr. K-4)□ Middle School (Gr. 5-8)□ High School (Gr. 9-12)

Student’s Name: Birthdate:

Address: City/State/Zip:

Telephone: Last school attended:

School district in which you currently reside: Current grade:

School scheduled to attend in resident district: Grade entering in fall:

Parent/Guardian: Telephone:

Address: City/State/Zip:

Is there a sibling already attending the district as a Schools of Choice student? □ Yes □ No

Does the student qualify for or receive special education services? □ Yes □ No

If YES, has a copy of the IEP been attached? □ Yes □ No

If a copy of the IEP has not been provided, please sign below to consent to have the student’s IEP released from current school district.

Parent/Guardian Signature:

Have there been any disciplinary issues at the current district? □ Yes □ No

If YES, please explain:

Please sign below to consent to release discipline and transcript information from current school.

Parent/Guardian Signature

Where did you learn about Richmond Community Schools and its programs?

By signing below, I acknowledge and accept the policies and regulations regarding Richmond Community School District’s Schools of Choice Program.

Parent/Guardian Signature Date

Student/Guardian Signature Date

Accepted to District: □ Yes □ No□ Conditionally, explanation: Superintendent’s Signature




SCHOOLS OF CHOICE INFORMATION In an effort to continue providing a quality education for all students, the Richmond Community School District has offered the option of Schools of Choice. This program allows parents and students the opportunity to attend a public school of their choice, regardless of where they reside.

1. An application form must be completed for each student wishing to participate in the RichmondCommunity School District’s School of Choice program. In some cases, availability in certain grades maybe limited, and there is no guarantee that there will a spot available.

2. Students must be in good standing in their resident district to apply for Schools of Choice. For example, astudent who has been suspended during the past two years or is not attending another school due toexpulsion or dropout, may be denied admission under the Schools of Choice Program.

3. Students who are approved to the Schools of Choice program are allowed to remain in the district untilgraduation. The student does not need to reapply for admission to the district each year, once approved.If overcrowding or redistricting should occur, the Schools of Choice participant will be guaranteed a spotwithin the district.

4. If there are more requests for admission than space available, a lottery will be held by the district todetermine which applicants will be accepted. The district will make a waiting list in each case.

5. Most high school and middle school class schedules are developed prior to completion of the Schools ofChoice application process. Students requesting a transfer should be aware that not all class requests maybe granted. Prior to submitting an application, it is suggested that the student and his/her parents meetwith a counselor to determine class availability. Also, each district has developed a curriculum that isbased on the State of Michigan curriculum and benchmarks. Each district has its own locally approvedgrading system and graduation requirements. Parents and students may want to review all rules,regulations, grading systems and graduation requirements. (Transfers are subject to the requirement ofSection 105c of the Michigan School Aid Act, (MCL 388.1750c) which requires a written agreement withthe contiguous district for the provision of any special education services and programs).

6. Transportation under the Schools of Choice program is the sole responsibility of the parent. Parents willbe responsible for transporting students to and from school. Parents may have the option to drive theirchild to a pre-approved bus stop in the district, if space is available on that bus. If approved, once thechild has been transported to the bus stop, it is the responsibility of the parents to provide transportationhome for the child. If transportation can be coordinated between the district and the family, parents willassume the responsibility for the safety of the child at the bus stop. Students participating in the Schoolsof Choice program, who are eligible to ride a school bus, are required to follow the rules, regulations, andbus discipline policy of the district.

7. Eligibility to participate in interscholastic athletic contests is subject to the policies and eligibility rules ofthe enrolling school district and the Michigan High School Athletic Association regulations.

8. Applicants will be notified either by phone or in writing if they have been accepted into the Schools ofChoice program. Siblings of students already attending the district, who live in the same household, willreceive preference over other applicants.

Parent/Guardian Signature Date



Revised 1-2020


When a Parent/Guardian cannot verify that they own or rent a residence in the District this form must be completed in the presence of a Richmond Community Schools staff member and Notarized.

RESIDENCY VERIFICATION AFFIDAVIT

Student’s Name: __________________________ School and Grade Enrolling: _____________________________

Although I do not own or rent a residence in the District, this is to certify that I am the custodial parent of my child named above and our current “legal residence” means that residence where the parent/guardian in question eat their meals and sleep on a regular basis, receive their mail, and if applicable where the parent(s) are registered to vote is listed below:

Address City Zip

Where we are living as guest of:

First and Last Name Telephone

Who ( □ OWNS □ RENTS ) this residence.

Should I change this, my permanent residence, I understand that my child may no longer be eligible to attend school in the District. I will notify the school immediately if my residence changes.

Parent/Guardian’s Signature Printed Name Date

School District Witness Printed Name Date

NOTICE: READ CAREFULLY: Falsification of the document is a violation of State law: M.C.L.A. 750.423 which is a felony. Further the affiant will be billed (and prosecuted in court, if necessary) to collect all back tuition which may be due.

Inaccurate and/or false information will result in immediate withdrawal of your child(ren) from Richmond Community School District.

SWORN TO BEFORE ME and subscribed in my presence this ________ day of _____________, _________.

____________________________________________ ________________________________________

Notary Public Date

Signature of Residence Owner/Renter Date

Residency Proof Provided: Parent ______ District Resident _______


District Contact Person: Brian J. Walmsley, Ed.S., Superintendent [email protected] * (586) 727-3565

Page 1 of 1

Student-Parent Handbook Acknowledgement *Including Student-Athlete Code of Conduct Handbook*

It is understood that our signatures below acknowledge we have been informed that the Student-Parent Handbook and Student-Athlete Code of Conduct Handbook is available on the Richmond Community Schools District website. We also acknowledge that our signatures indicate our willingness to abide by the Student-Parent Handbook and the Student-Athlete Code of Conduct Handbook.

__________________________________ ____________________________________ Student’s Name Printed Parent or Guardian Name Printed

__________________________________ ____________________________________ Student’s Name Signature Parent or Guardian Name Signature __________________________________ ____________________________________ Date Date

**Any changes that are made to above named handbooks will be available online. Hard Copy versions are available in the school offices upon request.

Guaranteed Learning for All Students!



Parental Consent for Virtual Classes Richmond Community School District offers a variety of virtual learning options to students. Virtual learning describes the environment in which online courses, computer-based courses and self-scheduled virtual courses take place. Beginning in the 2017-2018 school year, the Michigan Department of Education is requiring parent or legal guardian consent for enrollment in virtual courses. Consent is not required if the pupil is at least age 18. By signing below, you are giving consent for your student to be enrolled in one or more virtual classes while enrolled in the district. Student Name: _____________________________________ Grade: _______________ Parent/Guardian Name (please print): ____________________________________________ Parent/Guardian Signature: ____________________________________________________ Date: ___________________ Prior to officially enrolling in a 21f online course the student and parent must sign and submit the Online Class Contract Form found in the course catalog.


Documents

Richmond Community Schools€¦ · Handbook Acknowledgement Form ... Rent Payment Receipts, a copy of money order made for payment of rent, or letter from employer that is written