Sims Middle School 2200 Whitmire Highway Union, SC Phone: (864) Fax: (864)

Transcription

1 Sims Middle School 2200 Whitmire Highway Union, SC Phone: (864) Fax: (864) Student s Name: I have received and agree for my child to abide by the following district rules and policies: Dress Code Attendance (tardiness and absences) Medications * (storage and adminstering) *If your child has a special medical needs such as severe allergies, diabetes, use of inhalers, ect., please contact the school nurse Cell Phone Internet usage Media release form Parent Signature Date

2 Dear Parent or Guardian: Sims Middle School 2200 Whitmire Highway Union, South Carolina Phone: (864) Fax: (864) ALERT-NOW TELEPHONE CALLS Recently, new laws were passed to protect cell phone users from having unsolicited phone calls made to their number. This change was put in place by the FCC as recently as August Union County Schools uses an automated calling program to distribute information to our Parents/Guardians. In order for the School District to comply with the new rules, written permission must be obtained along with the number or numbers we are allowed to call. The new law allows us to make calls for school cancellations or for other informational/emergency related reasons. In order to be compliant with the new law, we are asking that you fill out the information below and return it to your child s homeroom teacher. If you agree to allow calls, please enter the number or numbers at which we may contact you. Thank you for assisting us in this matter. Student Name Phone Numbers You Allow Us to Call: Phone 1: Phone 2: Print Name of Parent/Guardian Signature of Parent/Guardian By signing above, I agree to allow Union County School District to contact me at the numbers listed above for information and emergency messages.

3 Sims Middle School 2200 Whitmire Highway Union, SC INTERNET AGREEMENT STUDENT ASSURANCES When conducting research on the Internet, I will: Use the Internet for legitimate educational purposes. Send only at the direction of my teacher or media specialist. Not register the name, home address, or telephone number of myself or anyone else in any location on the Internet. Not attempt to download or save files to the computer hard drive or to a disk without teacher permission. Not search for, download, or print any material that violates school handbook codes regarding possession or display of inappropriate, offensive, or vulgar material, or assist any other student in such activities. Not use or attempt to use Telnet, Internet Relay Chats or other interactive exchanges without teacher permission. Not damage or alter computers, computer systems, or computer networks. Not violate copyright laws. Not trespass in another s folders, work or files. I understand that my participation in any violation of the Internet student assurances will result in disciplinary action and possible loss of access privileges to Internet, depending on the nature of the offense. Student Signature Date I give permission for my child to conduct research on the Internet under the conditions described above. Parent Signature Date

4 Sims Middle School 2200 Whitmire Highway Union, South Carolina Phone: (864) Fax: (864) MEDIA COVERAGE PARENTAL PERMISSION FORM I,, as of (Parent s Name) (Father, Mother, Guardian), as, minor, grant permission for my child s name and/or pictures to be used in newspaper, magazine, television and/or radio coverage and stories concerning school-related activities in Union County Schools. I understand that my child s name and/or picture will be used when it will add to public understanding of school-related activities. I understand that if my child is in special education, he or she may be identified as a special education student. I further understand, however, that although the school district will only solicit student participation in publicity that it deems to be positive and non-controversial, the district will not have any control over how the media will prepare and deliver its coverage of school activities. Finally, I do hereby release the school district and its Board of Trustees, employees and agents from liability for a claim I might have regarding the use of my child s name and/or pictures in any type of news coverage or stores. (Parent/Guardian Signature) (Parent/Guardian Address) Date IF YOU DO NOT WANT YOUR CHILD S NAME AND/OR PHOTO RELEASED TO THE MEDIA, CHECK HERE. UNION COUNTY SCHOOL DISTRICT

5 517 East Main Street Union, SC (864) CONSENT TO BILL PRIVATE INSURANCE AND MEDICAID The Union County Schools and the South Carolina Department of Education (SCDE) have my permission to provide services to my child and release and exchange medical, psychological, and other personally-identifiable confidential information, as necessary, to the South Carolina Department of Health and Human Services (SCDHHS) and any applicable third-party insurer regarding billable services provided to my child. I understand the purpose of this consent is to bill Medicaid and/or private third-party insurer for services under the Individuals with Disabilities Education Act (IDEA). By signing this form, I give the District and the SCDE my permission to bill and receive payment from Medicaid and any third-party insurer for diagnostic and psychological evaluation services, behavioral health services, nursing services, and other health-related screenings and treatment services billable to Medicaid or a third-party insurer with or without the requirement of an individualized education program (IEP). The District provided me written notification consistent with the IDEA regulation at 34 C.F.R (d)(2)(v) and (c), prior to my signing this consent to release information to bill Medicaid or any third-party insurer and prior to accessing Medicaid or my child's third-party insurance benefits. I further understand that the District must provide me annual written notification of my rights relative to Medicaid or any third-party insurer accessing my child s information and before the District and the SCDE access my benefits to pay for services under the IDEA. This consent for release of information to bill Medicaid and any third-party insurer is a one-time consent and is not required annually thereafter, unless there is a change in the type or amount of services to be provided to my child or a change in the cost of the services to be charged to Medicaid or a third-party insurer. I understand that Medicaid and third-party insurance reimbursement for billable services provided by the District and the SCDE will not affect any other Medicaid services or insurance benefits for which my child is eligible. I understand that my child will receive the services listed in the IEP regardless of whether my child is covered by public or private insurance programs and regardless of whether I provide consent to access those benefits. I understand that my refusal to consent to the SCDHHS or any third-party insurer accessing my child's personally-identifiable information does not relieve the District of its responsibility to ensure that all required services in my child's IEP are provided at no cost to me. I understand that this consent is voluntary on my part and may be revoked at any time. If I later revoke consent, the revocation is not retroactive (i.e., it does not negate an action that occurred after the consent was given and before the consent was revoked). I also understand that the District and the SCDE will operate under the guidelines of the IDEA and the Family Educational Rights and Privacy Act (FERPA) to ensure confidentiality regarding my child s treatment and provision of services. STUDENT S NAME: STUDENT S DATE OF BIRTH: SCHOOL: MEDICAID NUMBER: 3 RD PARTY INSURER: 3 RD PARTY ID NUMBER: Signature of Parent/Guardian/Adult Student Date

6 UNION COUNTY SCHOOL DISTRICT 517 East Main Street Union, South Carolina (864) NOTIFICATION OF USE OF PUBLIC BENEFITS (MEDICAID) OR PRIVATE INSURANCE TO PAY FOR SERVICES UNDER THE IDEA This notification is to inform you of the intent of the Union County Schools and the South Carolina Department of Education (SCDE) to bill Medicaid and/or third party insurance and receive payment from Medicaid and/or any third party insurer for services, as permitted under the Individuals with Disabilities Education Act (IDEA), and as set forth in your child s individualized education program (IEP). The District and the SCDE may bill Medicaid for diagnostic and psychological evaluation services, behavioral health services, nursing services, and other health-related screenings and treatment services billable to Medicaid or a third-party insurer with or without the requirement of an IEP. The District must provide this notice to you prior to requesting your consent to bill Medicaid and/or any third party insurer once a year for services that the District will provide in the future. This document also serves as notice that the District and the SCDE will release and exchange medical, psychological, and other personally-identifiable confidential information, as necessary, to the South Carolina Department of Health and Human Services and any applicable third-party insurer regarding services provided to your child. Medicaid and third-party insurance reimbursement for billable services provided by the District will not affect any other Medicaid services or insurance benefits for which your child is eligible. The District cannot bill Medicaid or your child s insurance program if it will decrease available lifetime coverage or any other insurance benefit, result in the family paying for services that would otherwise be covered, increase your insurance premiums, or risk loss of eligibility for waivered programs. You are not responsible for paying any outstanding deductibles, co-payments, or co-insurance related to the District billing Medicaid or your child s insurance program for services provided by the District. Your child will receive the services listed in the IEP regardless of whether your child is covered by public or private insurance programs and regardless of whether you provide consent to access those benefits. Your refusal to provide consent to release personally-identifiable information to Medicaid or any third-party insurer does not relieve the District of its responsibility to ensure that all required services are provided at no cost to you. Any previous, current, or future consent to bill Medicaid or third-party insurance was voluntary and you may revoke your consent at any time. If you choose to revoke consent, that revocation is not retroactive (i.e., it does not negate an action that occurred after the consent was given and before the consent was revoked). The District and the SCDE will continue to operate under the guidelines of the Family Educational Rights and Privacy Act (FERPA) to ensure confidentiality regarding your child s treatment and provision of services. PLEASE COMPLETE REVERSE SIDE OF FORM.

7 Sims Middle School 2200 Whitmire Highway Union, SC PARENT PERMISSION FOR STUDENT SIGN-OUT GRADE My child,, has permission to be signed out of school by the persons listed below. I understand that only persons listed below, and no one else, will be permitted to sign my child out. Name Relationship Daytime Telephone No Emergency contact numbers I understand that in the event of accident or illness involving my child; it may become necessary for school officials to contact me and could require me to pick up my child from school without delay. I understand, as a parent it is my responsibility to pick up the child, if the school requires such. Primary Daytime Emergency Contact Number Alternative Daytime Emergency Contact Number Parent Signature Date

8 Sims Middle School 2200 Whitmire Highway Union, SC Phone: (864) Fax: (864) Dear Parent or Guardian: Union County Schools began offering classes in Comprehensive Health for students in grades 6-12 beginning Monday, Dec 7, The human sexuality classes will be offered during the health portion of PE classes for grades 6-9 and during Enrichment Time for students in grades The district has selected abstinencebased health curriculum entitled Choosing the Best, a sequential program that provides a common message from middle grades to high school. This curriculum is a research-based, medical learning model that motivates students through relationship education, refusal-skill coaching, character education, and parent-teen interviews. The material to be used were unanimously approved by the Comprehensive Health Task Force of Union County and the Union County Board. Each component consists of 5 to 8 student lessons depending on the specific grade level. Comprehensive Health classes are offered in grades 9-12 as mandated by the Comprehensive Health Act of April 19, The curriculum at grades 6-8 is provided to offer skill-building in areas such as decision-making, self-esteem building, refusal skills in addressing inappropriate peer pressure, etc. The curriculum is available for parental preview in the school nurse s office.. If you would like to preview the materials, please call the school to arrange a meeting. Parental permission is required for students to attend the classes on human sexuality. If you wish for your child to participate in the class, please sign and return the form. Each child will receive a consumable student book that he/she can bring home at the end of the class. Please participate in the short homework assignments involving student and family interactions throughout our upcoming class sessions. Sincerely, Kelly Jenkins, Jennifer Jansen, and Rocky Cooper, Health Instructors COMPREHENSIVE HEALTH EDUCATION PERMISSION FORM Yes, my child has permission to participate in a Comprehensive Health Education class on human sexuality. No, my child does not have permission to participate in a Comprehensive Health Education class on human sexuality. Parent s Signature Date Student s Name Homeroom Teacher Grade

9 PHYSICIAN S FORM FOR LONG-TERM PRESCRIPTION MEDICATION AND ADMINISTRATION Union County Schools requires the following information when children need administration of prescription drugs at school. Please complete the following information and forward to the school. Name of Student Date of Birth School Grade Phone No. Fax No Name of Medication Oral Dosage Diagnosis or Indication for Medication Times medication to be administered Administration of medication to begin and end: Begin: End: Side effects (adverse reactions) which should be reported to the physician: Special instructions for administration of drug, including sterile conditions, cold storage, etc.: Date / Physician s Signature Office Phone Emergency Phone Parent/Guardian s Signature Parent/Guardian s Phone Note: A MEDICATION CHANGE FORM must be submitted if there are any changes in the medication. The medication must be delivered to the school office in the container in which it was dispensed by the prescribing physician or licensed pharmacist.

10 Routine PRN Start Date: School Health Services Permission for Non-Prescription Medication SCHOOL DISTRICT UNION COUNTY Sims Middle School 2200 Whitmire Hwy Union, SC Fax: When possible, medications should be given to students before or after school by the parent or guardian. Over the counter medications may only be given within the limits of what is printed on the label on the container or the package insert. Medications must be provided to the school by the parent or guardian in the original container. Please note that the school district may reject requests for certain medications to be given at school. Please complete a separate form for each medication to be given at school. If the medication is to be given to more than one of your children, please complete a separate form for each child. Child s Name Date of Birth Sims Middle School Name of School Teacher Grade Is your child allergic to any food, medicines, or other items? Yes If yes, list allergies. No Circle meds that may be given to your child at school OR check the All of the Above box -Tylenol -Ibuprofen(/Motrin) -Benadryl -Tums/ Rolaids Antacid -Ora-gel - Chlora-septic Throat Spray Aches/pains, fever allergies, insect stings upset stomach, nausea toothache, ulcers sore throat All of the above medicines may be given to my child Amount of medication to be given: Time of day medication to be given at school: Per package instructions Note any special storage requirements: None Refrigerate Other Does your child take any other medications at home or at school? Yes If yes, what are the medications? As needed according to package instructions Estimated number of days medication needs to be given at school (choose one): days weeks Until the end of the current school year 2016/2017 No Child s Health Care Provider s Name and Address: Office Phone Number: Office Fax Number: I give permission for the school nurse, the principal, or the principal s designee to give my child the medication noted above. I give permission for the school principal or the school nurse to contact the health care provider named above to discuss this medication and my child s health care provider. I give permission for the health care provider named above or his/her employees to share information about this medication and my child s health with the school nurse or the school principal Signature of Parent/Guardian Date Print or Type Name of Parent/Guardian Day Phone Number

11 Permission for School Administration of Non-Prescription Medication Non-prescription medications are medicines that you can buy without a written prescription from a health care practitioner. Non-prescription medications are sometimes called over the counter medicines. In order for a child to be given non-prescription medicines at school, the child s parent/guardian must sign a permission form. A permission form for non-prescription medicines is provided on the other side of this page. Schools may have special rules for non-prescription medicines and may require parents or guardians to sign additional forms. A responsible adult should deliver the medicine and the permission form to the school. The medicine must be in the original container with the label on it.

12 UNION COUNTY SCHOOL Special Services P.O. Box 907 Union, South Carolina RELEASE OF INFORMATION / CONSENT FOR SERVICES STUDENT SNAME (LAST) FIRST) (MIDDLE) SOCIAL SECURITY # MEDICAID# DATE OF BIRTH PARENT OR GUARDIAN ADDRESS TELEPHONE NO. By signing this form, I give the School District of Union County permission to provide health-related services to my child. These services may include psychological, audiological, speech therapy, physical therapy, occupational therapy and/or nursing services. I understand that my child will receive these health-related services because he/she is being evaluated for eligibility for speech therapy services or special education, and/or is enrolled in special education, or as a part of a routine school health assessment. I understand that if my child is Medicaid eligible the School District of Union County may bill the South Carolina Medicaid Program for these services and the Medicaid Program will pay the School District for providing these services. By signing this form, I am giving permission for the School District of Union County to release to the South Carolina Medicaid Program any information related to these services that may be necessary for the processing of Medicaid claims. I also understand that Medicaid payment for services provided by the School District of Union County will not affect any other Medicaid services for which my child might be eligible. If you have any questions, please call the Office of Special Services at Signature of Parent or Legal Guardian Date RELEASE OF INFORMATION / CONSENT FOR TREATMENT

13 SIMS MIDDLE SCHOOL Student Health History & Consent for Treatment Student: Last First Middle Initial Date of Birth: Grade: Sex: Male Female Primary MD Phone # Dentist Phone # Other Physicians treating student Phone # Medications to be taken while at school: Medications taken at home: Health History Severe Allergy to Foods (list): Severe Allergy to Insect Stings/Bites (list): Allergy to medications: (list) Other allergies: Please list any surgeries: Has he/she ever had a severe allergic reaction (anaphylaxis) that required medical care Yes No Asthma Bowel problem Frequent nosebleed Heart problem Stomach problem Chickenpox Seizures Bone / joint problem Hearing problem Diabetes Behavior problem Vision problem Frequent earache / infection ADHD Speech problem Pneumonia Eczema / skin problem Wears eye glasses Kidney / bladder problem Frequent headache Wears hearing aid Other: Does your child have any other condition that would affect his/her classroom performance or P.E. activities? Yes No If yes, explain: Name of person to contact in case of emergency: 1. Phone numbers 2. Phone numbers 3. Phone numbers I hereby give my consent for my child to receive emergency care in school if needed. In the event of a serious accident or illness, I request the school to contact me. I authorize the school to make whatever arrangements are necessary to provide emergency treatment and transportation for my child. In case of an accident or illness where treatment is not needed, but where my child is unable to remain at school, I request the school to contact me. If I am unable to be reached, I request that a person designated by me be contacted to care for my child until I can be reached. Signature of Parent/Guardian Date This information is considered confidential. It will be shared with school staff as needed during the time your child is enrolled in Union County School District in order to ensure the health and safety of your child, unless otherwise requested by you in writing.

14 Sims Middle School Eric Childers, Principal Welcome to Sims Middle School! Please complete the following information for our files. Date: Home Phone # Cell # Name:,, Last First Middle Social Security # - - Grade Sex Birthdate Race Home Address:,,, Street City State Zip Mailing Address:,,, Street City State Zip Name of Adults you live with (First & Last Names and Relationship to you) Mother/Guardian Name Father/Guardian Name Mother/Guardian Employer and work # Father/Guardian Employer and work # Name of Last School Attended Address of School if Outside of Union County Grade on date of withdrawal. List special classes (Advance, Remedial, Special Education, Speech, etc.) to be included in student s schedule. Student s Medicaid # Doctor s Name Doctor s Phone# List any Student Health Problems List Student Allergies List Medications student takes on a daily basis

15 Sims Middle School Transportation Form Office Use Only Bus Route: AM Transportation Information AM Transportation: (Check One) PM Transportation: (Check One) Car Car Bus # Bus # Walk Walk Please list any important information regarding transportation. (e.g., during a particular sport season when they may not require PM drop-off, bus/car rider only on specific days, etc.) Student Information Student Name Grade Address (AM Pick-Up) Nearest intersecting roads for AM Pick-Up Address (PM Drop-Off) Nearest intersecting roads for PM Pick-Up Turn Over to Complete Form

16 Contact Information Parent/Guardian Name(s) Primary Contact # Secondary Contact # Emergency Contact #1 Relationship Contact # Emergency Contact #2 Relationship Contact # Daily changes in transportation should be sent in writing with parent/guardian signature, drop-off address, and contact phone number to the SMS main office by 9:00 AM. Students will not be allowed to ride alternate bus routes without prior approval from administrator and verification with parent. Questions regarding bus routes (pick-up/drop-off times, bus route # s, etc.) should be directed to Genelle Brandon at Parent/Guardian Signature Date

17 DRESS CODE POLICY The orderly conduct of the education process requires that the clothing and grooming of students not be distracting, disruptive, or provocative. Experience in this district has shown that the following appearances have resulted in distraction of other pupils, disruption of the classroom atmosphere and decorum, boisterous conduct, and the undermining of authority, not only by the effect upon students so presenting themselves, but also by causing harassment and reactions from other students. Therefore, the following shall not be allowed: Unusual hair styles & non-natural colors Extensive and unusual use of cosmetics, piercings, jewelry or tattoos Any style of clothing tending towards immodesty by exposure or excessive emphasis of bodily features Low neck and/or open back dresses, blouses, or shirts no cleavage No exposed midriff; blouses or shirts must be tucked or overlap the waistline Tank tops, halter tops, racer back tops, or sheer see-through blouses Hats or head covering inside the building Pajamas/leggings/biker short & pants Items that promote or advertise sex, drugs, alcohol, or tobacco products Items that promote or advertise the use of violence or weapons Disruptive bandannas, buttons, insignias, symbols, or pictures (This includes gang related items as well) Articles of clothing deemed distracting or inappropriate by the principal or his/her designee. The principal s or his/her designee s decision is final. Students in grades 6 12 must adhere to the following: Sims Middle School 2200 Whitmire Highway Union, South Carolina Phone: (864) Fax: (864) Shorts, skirts and dresses must be at mid-thigh or below; (slacks and/or pants are preferred / encouraged.) Shorts, skirts, or dresses above the knee with leggings will be allowed. Leggings will only be acceptable if accompanied by a shirt or skirt that reaches mid-thigh Shoes appropriate for the school activity / class must be worn Sleeveless shirts must be at least 3 fingers wide across the shoulder. No sagging pants; No portion of any under garment may be visible. Symbols determined by law enforcement to be associated with gangs, drugs, alcohol, etc. are prohibited Students whose clothing or grooming is in violation of this policy will be sent home, ISS, or their parents will be asked to bring a change of clothes to the student. Time missed from classes due to dress code violations will be considered unlawful absences. Repeated violations will be handled in accordance with level II of the discipline code. I have received and agree for my child to abide by the district s dress code policy. Student s Name Parent s Signature Date

18 Sims Middle School 2200 Whitmire Highway Union, South Carolina Phone: (864) Fax: (864) Electronic Device Policy At the middle school level, students may have personal communications devices (cellphones) in school as follows: The devices remain silent and are not visible or in use during instructional time. Teachers may allow, however, the instructional use of personal communication devices at their discretion. Personal communication devices are NOT permitted to be on or visible in locker rooms or restrooms. Limited use of personal communication devices will be allowed before/after school and during the students lunch (recess) time as long as the use does not disrupt the school environment. Students must understand that possession of these devices could pose a risk of loss or theft. We strongly recommend that students label their devices and take steps to keep them safe. The school will NOT be liable for lost or damaged devices. Consequences of Violation If a student is found in violation of this policy, the following offenses will be in place: 1 st Offense: Confiscation of device for 3 days. 2 nd Offense: Confiscation of device for 5 days and a $25.00 fine before the phone is returned. 3 rd Offense: Confiscation of the device for 10 days and a $25.00 fine before the phone is returned. 4 th Offense: Confiscation of the device for the remainder of the school year and a $25.00 fine before the phone is returned. I have received and agree for my child to abide by the district s electronic device policy. Student s Name Parent/Guardian Name Date

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