Summit Elementary School Informational Newsletter for Fall 2015 Registration

You must register online between July 7th and August 13th!

Dear Summit Families,

Greetings! We are quickly approaching the end of another school year and before we know it, a new school year will be upon us. I anticipate an exciting year of learning for your student.

With this registration letter, you will find many important links as we move into a more digital process (to use the links, you can refer to the copy of this news letter that is posted on our website) . We will once again be using Online Registration for all OASD students.

The Oconomowoc Area School District will conduct Registration for the 2015-16 school year on-line from July 6th- August 10th via your Family Access account. Please note, late registration ($25) will be assessed after this date! You are required to complete the process for each student. Upon completion of online registration, you will receive an email confirming that you have completed the process. If you do not re-ceive an email please verify that the process has been completed for each student.

For families unable to access a computer or who may need help, computer stations and assistance will be available at Oconomowoc High School on August 10th from 11:00 a.m. to 7:00 p.m. There is also a com-puter station available in the Summit office during Summer School (8 to noon through July 31st).

The Oconomowoc Area School District will use Family Access to post classroom placements for next school year on August 21st at 12:00 p.m.

Summit’s Open House is Wednesday, August 26th from 3-6 p.m. The purpose of this time is to allow chil-dren to meet their teacher, and drop off school supplies. School begins on Tuesday, September 1, 2015 at 8:40 a.m.

Picture Day will be held at Summit on September 15th, during the school day. Picture retakes will happen October 15th. Please remember to order picture packages as part of the online registration process.

Finally, I hope this letter finds you and your child in the midst of some great summer reading. I am looking forward to talking to the children about some of their favorite books they read over the summer.

Please feel free to contact me at any time with questions that you may have. I look forward to working to-gether with you as a partner in your child’s education.

Sincerely, Brian Stuckey Principal

StuckeyB@oasd.org

Contact Numbers:

School Office: 262-560-8305/ 262-560-8306

Attendance: 262-560-8302

Health Room: 262-560-8303

Sodexo Lunch Program: 262-560-2148

Ocon. Transport Bus Co.: 920-355-4040

Summer School Info: 262-560-2115

Summer School Office: 262-560-8306

(from June 16 to July 25)

Summit Open House

Drop off your school supplies and meet your

new teacher!

Wednesday, August, 26, 2015

Come anytime between 3:00-6:00 pm

Teacher Assignments

You will be able to find out who your child’s new teacher will be

in Family Access starting on Friday, August 21 at noon.

Family Access Log-In

http://www.oasd.k12.wi.us/page.cfm?p=3115

School Photo

School Photos will be taken:

Tuesday, September 15, 2015

Photo Retake Day:

Thursday, October 15, 2015

Lifetouch Photography Website

http://www.lifetouch.com/

Bus Information

Oconomowoc Transport Company

920-355-4040

Bus route information will be available mid-

August. Go to the school website under Family Resources/Bus

to find out times and pick-up locations.

Bus Look-Up System

http://www.oasd.k12.wi.us/page.cfm?p=3123

SCHOOL LUNCH PROGRAM

Information about the school lunch program can be found on the OASD website (click the link below)

Sodexo Website http://www.oasd.k12.wi.us/page.cfm?p=3585.

School lunch prices for the 2015-16 school year are $2.35 for an elementary meal and $0.50 for milk.

Families wishing to apply for Free or Reduced Lunch must apply each year by filling out the Free & Re-

duced Price School Meal Application. Snack milk for all 4K & 5K students is $0.50.

Balances on school lunch accounts will be carried forward over the summer! Money can be added to

lunch accounts through the food service tab in Family Access.

A Few Notes About Online Registration, & School Pictures Oconomowoc Area School District will again be using Online Registration for the 2015-16 school year. We have updated the look

and feel for more convenient use based on feedback from last year!

Similar to last year you will be able to view and pay your student fees and lunch account balance online through Family Access.

Computer access for families that need it will be available at Summit, Silver Lake, and OHS during normal summer school hours.

All registrations must be completed by August 10th to ensure accurate records for the first day of school. Upon completion of

the online registration you will receive an email confirming that you have completed the process. A late fee will be assessed for

each student that is not registered by August 10th.

Lifetouch School Photography will be taking school pictures again this year. Please click on the link to Lifetouch in the online reg-

istration process and place the order for your student’s school picture, payment will be made on line and it is a good idea to print

your receipt. Pictures will be taken during the school day on September 15th with a make up day on October 15th.

Summit Open House - Wednesday, August 26th 3 to 6 p.m. (Meet your teacher, find your seat, drop off supplies)

First Day of School

Tuesday, September 1st (Summit’s School day is 8:40 a.m. to 3:40 p.m.)

4K AM (8:40 a.m. to 11:20 a.m.) 4K PM (1:00 p.m. to 3:40 p.m.)

Picture Day (Lifetouch Photography will take pictures during the school day)

Tuesday, September 15th with a make up day on Thursday, October 15th

Early Release Days— Dismissal at 12:40 — (AM & PM 4 -Year-Old Kindergarten do not attend these days)

Thursday, November 5th

Thursday, June 9th (severe weather emergency days could change this)

Parent Teacher Conferences (These dates & times are specific to Summit)

Tuesday, November 3rd, 3:45 p.m. to 8:15 p.m.

Thursday, November 5th, 12:45 p.m. to 8:15 p.m.

Tuesday, February 9th, 4:00 p.m. to 7:00 p.m.

Thursday, February 11th, 4:00 p.m. to 7:00 p.m.

Celebration of Learning –Wednesday, May 11th, 5:00 p.m. to 7:00 p.m.

Breaks and Holidays

Labor Day– September 7th

Thanksgiving Holiday Break-November 25th through November 30th (Monday 11/30 is a non school day for Prof. Development)

Winter Holiday Break - December 23rd through January 1st (students return on January 4th)

Spring Break - March 25th through April 1st

Memorial Day Weekend— Friday, May 27th (may be used as a emergency weather day) , Monday, May 30th

Other Non School Days

Friday, September 25th (Teacher Professional Development Day)

Friday, November 6th (Designated Conference Comp Day)

Monday, November 30th (Teacher Professional Development Day)

Monday, February 22nd (Teacher Professional Development Day)

Concerts and Special Events - please see the Summit calendar enclosed

Last Student Day

Thursday, June 9th (half day dismissal at 12:40—subject to change if there are emergency weather days)

Updated 5/28/15

Ms. LaGrange

ART

Please bring a paint shirt without buttons

to wear in art class.

Supplies are appreciated! While you are

shopping for school supplies, please pick

up extra bottles of glue and packages of

regular pencils and send them in for the

art room.

Mr. Dirkmann

Physical Education

Please have a clean pair of

tennis shoes that you can

leave at school for gym

days.

Mrs. Jenkel

Music

All 4th graders need a re-

corder for Music Class. 4th

graders will order recorders

in the spring through their

music class.

Please Label Everything!

Summit Elementary School Supply List 2015-2016 1680 Valley Road, Oconomowoc, WI 53066-4896

262-560-8300 Fax 262-560-8318

4-YEAR OLD KINDERGARTEN SUPPLY LIST 5K SUPPLY LIST

1 Dozen plain yellow pencils - sharpened

1 Set colored pencils

1 Large school bag or backpack 2 White school glue (medium sized bottles)* + 1 bottle for the Art Room

1 Bottle of white school glue 2 Boxes crayons (24-count) *

6 Large glue sticks 2 Plain pocket folders (1 take home & 1 for class use)

1 Scissors (kids) 2 blue pens

1 Pocket folder 2 black permanent markers.

2 Boxes of washable fat tip markers (non-recycled) 2 Sets washable large-tipped markers (non-recycled) *

1 Set watercolor paints (girls) 1 Metal scissors

1 Package of glitter glue 1 Set watercolor paints

2 Containers of Play Dough 1 Paint smock (oversized t-shirt/no buttons/name on the front of it)

1 Package of napkins (girls) 1 Large box tissue to share

1 Container of baby wipes (boys) 6 Large glue sticks *

2 Dry erase markers 1 Vinyl, foldable rest mat (no large exercise mats/sleeping bags/blankets)

1 Box of crayons 24 count (boys) 1 Pair gym shoes

1 Box of tissue 1 Package 3X3 sticky notes

1 Package of theme or holiday stickers 1 Plastic bin (6 quart/clear only) 1 Box zip lock slider bags -sandwich(girls)/gallon(boys) 1 Box zip to lock slider bags (quart or sandwich size) (last names A-M)

Students will bring their own peanut/tree nut free snack to school each day.

4 Dry erase markers (last names A-M)

1 bag of cotton balls (last names A-M)

1 New white prewashed t-shirt labeled with your

child’s name on the tag (We will make this into a

field trip shirt. Please send a t-shirt one size larger than your child wears).

Please label your child’s new white t-shirt, folder, and school bag. All other items will

be shared and do not need to be labeled.

1 Box zip to lock slider bags (gallon size) (last names N-Z)

1 Package of jumbo size lunch bags (last names N-Z)

1 4-Pack of Play Dough (last names N-Z)

1 Large school bag or backpack

Please label scissors, folders and school bag. All other items will be shared and do not need to be labeled. (*) Please

replenish these items midyear.

GRADE ONE SUPPLY LIST GRADE TWO SUPPLY LIST

1 Plastic Box (6 quart w/lid) (to be used as a supply box for art class)

1 School box (6 inch x 12 inch size plastic container)

3 Dozen pencils (yellow #2 plain) sharpened

2 Dozen plain pencils to share (sharpened) 2 large pink erasers

2 Large Pink Erasers 1 Box crayons (24-count only)

1 Box crayons (24-count) * 1 Scissors (kids, pointed)

1 Scissors (kids) 1 Bottle white school glue

2 Bottles white school glue 1 Set markers (classic colors only)

1 Set markers (8-color) * 1 Set colored pencils

2 Plain plastic pocket folders – 1 green, 1 blue 1 Large box tissue to share

1 Set colored pencils (12 pack) 2 Spiral bound notebooks-wide ruled

1 Large box tissue to share 4 Composition notebooks (different colors/wide ruled)

1 Paint smock (oversized t-shirt/no buttons/name on it) 1 Paint smock (oversized t-shirt/no buttons/name on it)

1 Pair gym shoes 1 Pair gym shoes

2 Highlighters 4 Large glue sticks

8 glue sticks * 1 Take home folder (your choice)

8 Large dry erase markers * (Expo brand please) 2 Black permanent marker (Sharpie)

1 1 dry erase eraser 4 Dry Erase markers & 1 dry erase eraser

1 Take home folder (your choice) 1 Ruler

1 Black permanent marker (like Sharpie) + 1 for Art Room 2 Red pens

1 Pack of 3X3 sticky notes (plain) 5 Packages sticky notes (3X5 or 4X4)

1 Box zip to lock bags – quart(girls)/gallon(boys) 1 Box zip to lock bags – snack size (girls)/gallon (boys)

1 Book bag or backpack 1 Yellow plain pocket folder w/3 prongs 4 Plain pocket folders (blue/red/green/purple)

Please label scissors, paint shirt, folders, school bag.

Items with * will need to be replenished mid-year.

Please label all items.

Summit Elementary School Supply List 2014-2015 (Page 2)

GRADE THREE SUPPLY LIST GRADE FOUR SUPPLY LIST

1 Plain paper pocket folders w/ prongs (green)

1 Plain paper pocket folders w/ prongs (orange/yellow) 1 Plain plastic pocket folder w/prongs (red)

1 Plain paper pocket folders w/ prongs (blue) 1 Plain plastic pocket folder w/prongs (green)

1 Plain paper pocket folders w/ prongs (pink/red) 1 Plain plastic pocket folder w/prongs (yellow)

2 Pocket folder (your choice) take home folder 1 Plain plastic pocket folder w/prongs for Music (your choice)

1 Pair gym shoes 1 Plain pocket folder w/prongs for take home papers (your choice)

4 Dozen #2 pencils with erasers 1 Plain pocket folder w/prongs for computer

1 Ruler with standard/metric measure 1 Wide-lined wire-spiral bound notebook (blue)

1 Small pencil sharpener 1 Wide-lined wire-spiral bound notebooks (green) NO PERFORATED SPIRALS 1 Scissors (pointed)

2 Black permanent markers (like Sharpie) 2 Composition notebooks

1 Art smock with name on it 1 Package loose leaf paper (wide-lined/reinforced)

1 package of loose leaf paper – wide rule 3 Dozen #2 pencils with erasers

1 Plastic shoe box w/lid (12” X 6” size) 1 Ruler with standard/metric measure (easy to read, clear & non-bendable) 1 Set dry erase wide-tipped markers

1 Whiteboard dry eraser – no spray cleaner 1 Pencil sharpener (not battery operated)

1 Set colored pencils 2 Large erasers

1 Large pink eraser 2 Highlighters (yellow)

2 Ballpoint pens (1 red, 1 blue/black) 1 Set colored pencils

2 Highlighter broad-tip 1 Box crayons (24 count)

1 Bottle white school glue (8 oz.) 2 Black permanent markers (fine tip-like Sharpie)

1 Box crayons (24-count) 1 Set markers

1 Set markers (washable) 1 Plastic art box (large)

1 Roll transparent tape 1 Scissors (large)

4 Packs of Post-it Notes 2 Glue sticks

1 Large box tissue to share 4 Pens (red)

4 Glue Sticks 4 Pens (blue)

1 Non-spiral composition notebook (9 ¾ X 7 ½) 4 Packages sticky notes (2X3)

1 Box zip to lock freezer bags - quart (last name A-L) 1 Pair gym shoes

1 Box zip to lock freezer bags- gallon (last name M-Z) 1 3-Ring binder (1 inch any color)

2 Three subject wide ruled notebook 1 Dry erase eraser

2 Wide lined wire spiral notebook 8 dry erase whiteboard markers

1 LARGE box of tissues to share

1 Box zip to lock bags (quart size) (last names A-M)

1 Box zip to lock bags (gallon size) (last names N-Z)

No 3-ring binders 1 Art smock with name on it

1 set of binder dividers (5 dividers)

Please label all supplies with child’s name.

The fee for Assignment notebooks will be

included in the cost of registration fees paid on- line. Assignment notebooks will be distributed in

class.

Please label all supplies with child’s name

The fee for Assignment notebooks will be included in the

cost of registration fees paid on-line. Assignment notebooks will be distributed in class.

Student gym shoes should be clean, with good support, with no black soles that could leave black marks on the gym floor.

Please feel free to bring school supplies to Open House prior to the first day of school.

All 2nd – 4th Graders will have a $5.00 fee assigned for an assignment notebook. All 5K – 4th Graders will have a $5.00 fee assigned for earbuds to use with school Technology All 5K Students will have a $5.00 fee assigned for take home book bags. 4th graders will have the option of adding TI 15 calculators to their account, these are optional.

SUMMIT ELEMENTARY 2015-2016 SCHOOL YEAR CALENDAR *

7/6-7/24 Online Registration Open – All

families will need to register students by

8/10!!

Last day of Summer School 2015 – 7/31

JULY 2015

S M T W T F S

1 2 3 4

5 6 7 8 9 10 11

12 13 14 15 16 17 18

19 20 21 22 23 24 25

26 27 28 29 30 31

JANUARY 2016

S M T W T F S

1 2

3 4 5 6 7 8 9

10 11 12 13 14 15 16

17 18 19 20 21 22 23

24 25 26 27 28 29 30

31

Winter Holiday Break – 12/23 – 1/3

8/10 Online registration closes!

8/21 Teacher Assignments can be

viewed on Family Access by 12:00 pm

8/26 Open House 3:00 pm to 6:00 pm

AUGUST 2015

S M T W T F S

1

2 3 4 5 6 7 8

9 10 11 12 13 14 15

16 17 18 19 20 21 22

23 24 25 26 27 28 29

30 31

FEBRUARY 2016

S M T W T F S

1 2 3 4 5 6

7 8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23 24 25 26 27

28 29

2/4 5K Valentine’s Day Concert 2:00 pm

Summit Parent/Teacher Conferences –

2/9 4:00 to 7:00 pm

2/11 4:00 pm to 7:00 pm

Teacher Professional Development Day

– 2/22 no school for students

First Student Day – 9/1

Labor Day Holiday – 9/7

9/15 Student Picture Day

1st Grade Parent Info. Night 9/17 6:30 pm

Teacher Professional Development Day

9/25 no school for students

SEPTEMBER 2015

S M T W T F S

1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28 29 30

MARCH 2016

S M T W T F S

1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28 29 30 31

Spring Break – 3/25 – 4/3

3/18 3rd Gr Drama Club Performance 7

3/22 Family STEAM Night 5:30 to 7:30 pm

10/10 Family Cardboard Challenge

9 am to 1 pm

10/15 Picture Retake day

10/23 4th Gr. Drama Club Performance 7

11/27 & 11/28 4K/5K Hearing & Vision

Screening

(speech for new 4K/5K)

OCTOBER 2015

S M T W T F S

1 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 27 28 29 30 31

APRIL 2016

S M T W T F S

1 2

3 4 5 6 7 8 9

10 11 12 13 14 15 16

17 18 19 20 21 22 23

24 25 26 27 28 29 30

4/19 4th Grade Wisconsin Program 2:00

Spring Break – 3/25 – 4/3

Summit Parent/Teacher Conferences –

11/3 - 3:45 to 8:15 pm

11/5 – 12:45 to 8:15 pm

11/5 (1/2 student day for grades K-8)

Non-School Day – 11/6

(designated conference comp day)

Thanksgiving Holiday Break - 11/25-29

Teacher Professional Development Day

– 11/30 no school for students

NOVEMBER 2015

S M T W T F S

1 2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30

MAY 2016

S M T W T F S

1 2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31

5/5 4K/new 5K- Kindergarten Round Up

5/11 Celebration of Learning 5-7 pm

5/11-13 Spring Book Fair

5/17 3rd Gr Celebrating The Regions

Concert 2:00 pm

5/25 Imagine A Day All School Field Trip

Memorial Day Holiday – 5/27-30

* 5/27 – to be used for school closing

make-up if needed

12/3 2nd Gr. Holiday Concert 2:00 pm

12/17 1st Gr. Holiday Concert 2:00 pm

Winter Holiday Break – 12/23 – 1/3

DECEMBER 2015

S M T W T F S

1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28 29 30 31

JUNE 2016

S M T W T F S

1 2 3 4

5 6 7 8 9 10 11

12 13 14 15 16 17 18

19 20 21 22 23 24 25

26 27 28 29 30

6/8 Summit Field Day

Last Student Day – 6/9 (½ day)

Emergency Days Last Student Day

0 6/9

1 6/9

2 6/9 (use 5/27)

3 6/10

First day of Summer School 2016 – 6/20

*THESE DATES ARE SUBJECT TO CHANGE – PLEASE REFER TO DATES IN TEACHER & SCHOOL NEWSLETTERS AS THE SCHOOL YEAR PROGRESSES.

Oconomowoc Area School District

Registration Form

(Legal Name Must Be Used for Student and Parents)

Section I Student Information

Student's Legal Name: DOB:

Gender:

Address: County:

City, State & Zip:

*Home Phone (Required):

Child resides with: (mark one) Both Parents Mother Father Guardian Foster Joint Custody

Part 2 Race Background: (Check all that apply)

Primary Language Spoken:

Grade:

Birth Country: Entry date into US: Reentry date into US:

Start of school in US:

Birth City: Birth State: Birth County:

Apt #:

Black

Yes

AsianAmerican Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander White

Part 1 Ethnic Background: Hispanic/Latino

Mailing Address: Mail Zip: Mail P.O. Box:

No

Please answer Part 1 and Part 2.

Secondary Language Spoken:

WI First Time Enrollment Date (if after kindergarten):

Guardian Legal Name:

Cell Phone:

**E-mail Address (Required):

Relationship to Student:

Work Phone:

Language Spoken:

Section II Guardian Information FAMILY 1 INFORMATION

Guardian Legal Name Spouse:

Cell Phone:

E-mail Address:

Relationship to Student:

Work Phone:

Language Spoken:

FAMILY 2 INFORMATION

Guardian Legal Name: *Home Phone

(Required):

Cell Phone:

Language Spoken:

Relationship to Student:

City, State & Zip:

Address:

**E-mail Address (Required):

Work Phone:

A copy of all forms and reports will be supplied to Family 2 unless appropriate information is on file.

Guardian Legal Name Spouse:

Cell Phone: Relationship to Student:

E-mail Address:

Work Phone:

Language Spoken:

Legal Name Birthdate

Section III Family Sibling Information

Legal Name Birthdate

(List siblings living in your home under the age of 22 who have not graduated)

Gender Gender

* This phone number is used for notifications.

** This e-mail is used for notifications.Page 1

Over

Oconomowoc Area School District

Registration Form

(Legal Name Must Be Used for Student and Parents)

Student's Legal Name: DOB:

Emergency Name: Work Phone: Relationship to Student:

Section IV Emergency Information (Do not use a parent name as an emergency contact, the

parents/guardians are already the first contact).

Cell Phone:Home Phone:

School Address and/or Phone and Fax:

School Last Attended:

Has your child been expelled from another school ? Yes No If Yes, where from?

Section V Previous School Information (If not OASD public school)

The Oconomowoc Area School District provides assurance that no student is discriminated against

because of the student’s sex, race, color, religion, national origin, ancestry, creed, pregnancy, marital or

parental status, sexual orientation, or physical, mental, emotional, or learning disability.

Birth Certificate Verification: (New to the district)

Birth Certificate Verified

Office Workers Initials:

Date:

For Office

Use Only: Legal Name Verified

Proof of Residency Verified

Page 2Last Updated:12/5/14

SIGNATURE PAGE Information Technology and Network Use Agreement The Oconomowoc Area School District provides employees and students access to its Information Technology and Network (ITN) resources for educational and other school-related purposes. ITN resources include, but are not limited to, computers, software, mobile devices (e.g., laptops, iPods/MP3, cell phones, etc), e-mail, and Internet access. These resources are available in each school and, in some cases, via remote access. Use is a privilege and users agree to comply with all provisions of the Information Technology and Network Use Policy. As a user of District ITN resources, I recognize and understand that these resources are the exclusive property of Oconomowoc Area School District. I agree not to use ITN resources in a way that is disruptive, offensive, or harmful to others or to the District. Further, I agree not to use a password that has not been disclosed to the District. I agree not to use pass codes, access a file or retrieve any stored communication, other than where authorized, unless there has been prior clearance by a teacher or District administrator. I agree not to copy, send or receive copyrighted or confidential materials without permission. I am aware that the District reserves, and will exercise the right, to review, audit, intercept, access and, if necessary, disclose all matters on the District’s ITN resources when legitimate purposes require it. I am aware that the District may exercise these rights with or without notice. I am aware that use of a password or code does not guarantee confidentiality or privacy or restrict the District’s right to access electronic communications. ▼STUDENT / STAFF: I understand and will abide by the Information Technology and Network Use Policy. Should I commit any violation, my access privileges may be revoked and school disciplinary and/or appropriate legal action may be taken. Name (please print): Grade:______________ Signature: Date: ▼PARENT OR GUARDIAN: As the parent or guardian of this student, I have read the Information Technology and Network Use Policy. I understand that access to these resources is for educational and school-related purposes. I recognize that it is impossible for the Oconomowoc Area School District to restrict access to all controversial materials, and I will not hold them responsible for materials acquired on the network. I hereby give permission to issue accounts for my child and certify that the information contained in this form is correct. Parent or Guardian’s Name (please print): Signature: Date: Final Approval: July 10, 2001 Regular Board of Education Meeting Reviewed: March 20, 2007 Regular Board of Education Meeting Revised: December 18, 2012 Regular Board of Education Meeting

OCONOMOWOC AREA SCHOOL DISTRICT

Student Immunization/ Health Record

State law requires all public and private school students to present written evidence of immunization against

certain diseases within 30 school days of admission. These requirements can be waived only if a properly

signed health, religious, or personal conviction waiver is filed with the school.

Student’s Name:

Birthdate:

Minimum Required Immunizations

Grade Vaccine

Pre-Kindergarten (2 years through 4 years)

(includes 4 year old kindergarten)

Grades Kindergarten - 5th

4 DPT and/or DT

4 DPT and/or DT *

3 Polio

4 Polio **

1 MMR

***

2 MMR

***

3 HEP B

3 HEP B

1 Varicella or chickenpox

disease history

2 Varicella or chickenpox

disease history

NOTE: * One dose must be after their 4th birthday (either the 3rd, 4th, or 5th dose) to be compliant.

** If your child received a 3rd dose of Polio after their 4th birthday, no further doses are required.

*** 1 dose must be after 1st birthday

Immunization History

Please complete this form entering the dates (month, day and year) in the appropriate boxes for each immunization received

to date.

Dose 1 Dose 2 Dose 3 Dose 4 Dose 5

DTaP/DTP/DT/Td

Diptheria-Tetanus-Pertussis

Polio

Hepatitis B

MMR

Measles, Mumps, Rubella

Varicella

(Chicken Pox)

Has your child had chickenpox disease? Check the appropriate box and provide the year

Yes (vaccine is not required)

No or Unsure (vaccine is required)

* Hib vaccine is only required

for children in licensed day

care centers. Do not report the

dates your child received Hib

vaccine on this form.

WAIVERS

For medical reasons, this child should not receive the following vaccines:

Physician’s Signature (required only for a medical waiver)

For personal conviction reasons, this child should not be immunized

For religious reasons, this child should not be immunized.

Date:

This form is complete and accurate to the best of my knowledge.

X Date

Adolescent booster

(Check appropriate box)

Tdap Td

Grades 6-12 4 DPT and/or DT

and 1 Tdap

4 Polio ** 2 MMR

***

3 HEP B 2 Varicella or chickenpox

disease history

Grade:

List Vaccine(s) Waived

Signature of Parent/Legal Guardian/Legal Custodian or Adult Student

Waiver

***More on reverse***

School in 2015-2016:

School Year: 2015-2016

(Office Use) 13-14 HR:

Student’s Name: School in 2015-2016:

Area Immunization Clinics and General Screening ClinicsBring your child’s records or previous immunizations with you to the clinic

Waukesha County Public Health Clinic, call 262-896-8430

Jefferson County Health Department, call 920-674-7275

Last Updated:12/5/2014***More on reverse***

The Wisconsin Immunization Registry (WIR) is a secure computerized data system that tracks the immunizations given to

people in Wisconsin. Parents and legal guardians have access to look up their child's immunization record in the WIR. To

access the WIR go to: http://dhfswir.org/

STUDENT IMMUNIZATION LAW AGE/GRADE REQUIREMENTS 2014 SCHOOL YEAR and Beyond

The following are theminimum required immunizations for each age/grade level. It is not a recommended immunization

schedule for infants and preschoolers. For that schedule, contact your doctor or local health department.

1.DTP/DTaP/DTvaccine for children entering Kindergarten:Your child must have received one dose after the 4thbirthday

(either the 3rd, 4th, or 5thdose)to be compliant. (Note: a dose 4 days or less before the 4th birthday is also acceptable).

2.DTP/DTaP/DT/Tdvaccine for all students Pre Kthrough 12:Four doses are required. However, if your child received the

3rddose after the 4thbirthday, further doses are not required. (Note: a dose 4 days or less before the 4th birthday is also

acceptable).

3.Tdapmeans adolescenttetanus, diphtheria and acellularpertussis vaccine. If your child received a dose of

atetanus-containing vaccine, such as Td, within 5 yearsof entering the grade in which Tdap is required, your child is

compliant and a dose of Tdap vaccine is not required.

4.Poliovaccine for students entering grades Kindergarten through 12:Four doses are required. However, if your child

received the 3rddose after the 4thbirthday, further doses are not required. (Note: a dose 4 days or lessbefore the

4thbirthday is also acceptable).

5.The first dose of MMRvaccine must have been received on or after the first birthday (Note: a dose4 days or less before

the 1stbirthday is also acceptable).6.Var means Varicella(chickenpox) vaccine. A history of chickenpox disease is also

acceptable.