STUDENT INTAKE RECORD Office of ESOL, Baltimore County Public Schools

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STUDENT INTAKE RECORD Office of ESOL, Baltimore County Public Schools Last Name: First Name: Middle Name: Birthdate: Gender: Grade Placement: Country of Origin: U.S. Arrival Date: Address: Father s Name: Mother s Name: Language(s) Spoken at Home: U.

1 STUDENT INTAKE RECORD Office of ESOL, Baltimore County Public Schools Last Name: First Name: Middle Name: Birthdate: Gender: Grade Placement: Country of Origin: U.S. Arrival Date: Address: Father s Name: Mother s Name: Language(s) Spoken at Home: U.S. School Enrollment: Father s Preferred Phone: Mother s Preferred Phone: Interrupted Schooling: If yes, details: Newcomer: Comments: REGISTRATION INFORMATION Date at Welcome Center: Home School: ASSESSMENT INFORMATION W-APT Assessment School Year: ESOL Center: Math Assessment (Secondary Only) Reading: Writing: Math Placement: Speaking: Listening: Oral: Literacy: Math Credits Awarded: Overall: K/1 st semester ESOL Recommended Completed at WC Intake Form School registration Form Home Language Survey Referral to health clinic Parent Notification Free and reduced meals form Offered the Privacy Opt-Out option OFFICE USE ONLY Person completing intake: Date updated as ESOL in STARS: FOREIGN TRANSCRIPT EVALUATION

2 Transcripts will be evaluated only if presented within one year of enrollment at the Welcome Center. _(parent initials) Grade 9 Subject Grade Received Credit Awarded Grade 10 Subject Grade Received Credit Awarded Grade 11 Subject Grade Received Credit Awarded Grade 12 Subject Grade Received Credit Awarded

4 Baltimore Highlands Lansdowne 3902 Annapolis Road Baltimore, Maryland Phone: Dundalk Health Center 7700 Dunmanway Baltimore, Maryland Phone: Eastern Family Resource Center 9100 Franklin Square Drive Baltimore, Maryland Phone: Essex Health Center 201 Back River Neck Road Baltimore, Maryland Phone: Hannah More Health Center Reisterstown Road Reisterstown, Maryland Phone: Liberty Family Resource Center 3525 Resource Drive Randallstown, Maryland Phone: Towson Health Center 1046 Taylor Avenue Baltimore, Maryland Note: The women, infants and children (WIC) and human immunodeficiency virus (HIV) clinics are the only services at this site. Woodlawn Health Center 1811 Woodlawn Drive Baltimore, Maryland Phone:

6 Candice Lenet Registrar Tema Encarnacion ESOL Specialist Candice Lenet Registrar

7 BALTIMORE COUNTY PUBLIC SCHOOLS SCHOOL REGISTRATION FORM PS 515, F1 STUDENT INFORMATION Date: Student s Last Name: Student s First Name: Middle Name: No Middle Name: Suffix: Preferred Name: Gender: Male Female Birth Date: (mm/dd/yy) Grade Level: U.S. Citizen: Yes No Country of Birth: Documentation of Birth: (Name of Document) Is a language other than English the student s first or home language? Yes No (If yes, indicate the language): The U.S. Department of Education requires all public schools to collect racial and ethnicity information. Please complete Part I and II. Part I Hispanic (Check yes if your child is a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. YES Part II 1. American Indian or Alaskan Native A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment. 2. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. 3. Black or African American A person having origins in any of the black racial groups of Africa. 4. Native Hawaiian/Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 5. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. SIBLING INFORMATION Siblings Brother/Sister Age School Grade Resides with registering student (yes or no) STUDENT ADDRESS Street Address:, Apartment No.: City, State, Zip Code:,, STUDENT SUPPORT SERVICES INFORMATION Check the services below that your child currently receives: ELL (English Language Learners IEP Free and Reduced-Price Meals 504 Gifted and Talented/Advanced Academics

8 BALTIMORE COUNTY PUBLIC SCHOOLS SCHOOL REGISTRATION FORM PS 515, F1 APPLICATION INFORMATION Name of Person Completing Form: Relationship: Phone: Do you have legal custody of this child? Yes No Are your custody documents on file? Yes No Year: Child Lives With Both Parents Mother Father Guardians Foster Parent(s) Other_ Name: Are you residing in temporary housing or do you lack housing? Yes No If yes, school will immediately contact pupil personnel worker to provide assistance. (Parent/Guardian is to complete HSE-1 Form) PARENT/GUARDIAN INFORMATION Primary Guardian Name: Guardian Relationship: If no, list Address or P.O. Box: City, State, Zip Code: Does the student reside with this contact? Yes No Phone Numbers Home, Work, Cell Employer: Full-Time Active Military? Yes No Secondary Guardian Name: Guardian Relationship: Does the student reside with this contact? Yes No If no, list Address or P.O. Box: City, State, Zip Code: Phone Numbers Home, Work, Cell Employer: Full-Time Active Military? Yes No Receive Texts? (Y/N) Receive Texts? (Y/N) AUTOMATED PHONE CALLS In addition to emergency notifications, the contact listed above may receive calls, s, texts, and pre-recorded messages regarding non-emergent information. Nonemergent information is that which does not pertain to a school closing, medical or safety emergency. Non-emergent information includes, but it is not limited to: school calendar updates, student testing reminders, Superintendent s messages, school activities, and notifications pertaining to your student s daily activities, school responsibilities or events. If you would like non-emergent notifications to be sent to a different number, please specify below: Non-Emergent Number: Ext: Work Home Cell Receive Texts? Yes No If you would like to opt out of non-emergent notifications, sign here: Note: Your signature confirms that you will not receive calls regarding non-emergent information. EMERGENCY CONTACT LIST (Please list by order of contact) In the event of an emergency ONLY when parents/guardians cannot be reached, please list three people we may contact to pick up your student. NOTE: This does not represent a list for general dismissals. All dismissals must be approved by a parent/guardian, preferably in writing. In case of an accident or serious illness, the school will contact the parent/guardian. If the school is unable to reach the parent/guardian, the school will contact the parties listed below or the child s physician/dentist on the health form. The school will also make whatever arrangements seem necessary, including calling an ambulance and transporting your student to the hospital. Name Relationship Telephone Elementary Only: In a school closing emergency who is responsible for the student? If not parent/guardian, list name and address: In a school closing emergency, how will the elementary student be transported? Walk Ride Bus Pick-Up Upon notification by school staff, I agree to send my child home by taxicab if necessary. I also agree to be responsible for calling the cab and for payment of the cab. Yes No Secondary Only: DO NOT permit my child to participate in the Maryland Youth Tobacco & Risk Behavior Survey (MYTRBS). TALENTED

9 BALTIMORE COUNTY PUBLIC SCHOOLS SCHOOL REGISTRATION FORM PS 515, F1 Please read carefully before signing this form: I understand that if it is determined that I have provided false information regarding my place of residence, my child will be withdrawn from school and tuition will be assessed on a pro-rated basis for the period of time that he/she was fraudulently enrolled. (Tuition rates are currently over $6,000 per year and are increased on an annual basis.) To the best of my knowledge, all information entered on this enrollment form is accurate. Signature of adult responsible for the student s enrollment Date (FOR OFFICE USE ONLY) Date: Student s Name: Student ID# Teacher: (optional) Grade: Enrollment Date: Bus Stop: Bus No. Entry Code: Shared Domicile Nonresident Informal Kinship Homeless Special Transfer Tuition Agency-Placed IEP 504 Please indicate special transfer reason(s): Terminal Grade Change of residence from attendance area Medical Program Study Change of residence to attendance area Student Adjustment Employee s Child Child Care Sibling Family Conditions PHOTO IDENTIFICATION To validate the identity of the parent/guardian responsible for the student s enrollment, photo identification must be provided at the time of enrollment and a copy made. If the photo ID contains an address, it must match the Baltimore County address appearing on other residency documents. A driver s license may not be used to verify address if used for photo ID. Driver s License Current Passport Government issued license or certificate Other Photo ID HOME/DOMICILE RESIDENCY VERIFICATION (MUST BE PRESENTED AT REGISTRATION) Residency verification must be presented at the time of registration. To establish proof of the student s domicile/address, a parent/guardian must provide one (1) of the following documents to verify the student s address and three supporting documents. Copies must be maintained in the student s record. Lease (lease end date) Property Settlement Sheet Property Title Real Estate Tax Bill Mortgage Coupon Book PPW Documentation Residency Verification Letter Property Deed NAME/ADDRESS DOCUMENTS (THREE (3) REQUIRED, DATED WITHIN THE PREVIOUS 60 DAYS) Types of Acceptable Documents: Utility Bill (BGE/phone/water) Credit Card Bill Bank Statement First-Class Mail from business or government agency Paycheck or Stub Court Documents Driver s License (if same address as student) Mailing from BCPS Voter registration card Notarized letter from landlord Government issued license or certificate Receipt of immunization Vehicle Registration Card Tax Return from previous year Cable Bill Other documentation accepted by residency investigator Notarized statement from employer Health Center mailing or appointment PROOF OF IMMUNIZATION Proof of age-appropriate immunizations is required at the time of registration. Students missing an immunization record or required shot(s) may be admitted for up to 20 days if they have an appointment to obtain missing records or shot(s). Immunization provided No immunizations/temporary Admissions Checklist for enrollment process: Task Name (of BCPS personnel employee) Title Date Enrollment Entry in BCPS One SIS Records Request

10 Immunization/Health Registration to Nurse Other

11 B ALTIMORE C OUNTY P UBLIC S CHOOLS C ONSENT F OR R ELEASE OF S TUDENT R ECORDS INSTRUCTIONS: This form authorizes the Baltimore County Public Schools to disclose personally identifiable information from the student record. Complete the form, sign where indicated and return the completed form to the principal where the student is enrolled. STUDENT INFORMATION Student s Last Name First Middle Initial Mailing Address City/State/Zip School STUDENT RECORD(S) AUTHORIZED TO BE RELEASED (MARK ALL THAT APPLY) Cumulative Health Discipline Psychological Special Education Other, please specify: PERSON TO WHOM RECORDS ARE TO BE RELEASED Name Business/Company Name Mailing Address City State AUTHORIZATION AND CERTIFICATION I certify that I am the parent and legal guardian of the student, or eligible student if age 18 or over. I hereby authorize Baltimore County Public Schools to release the student record(s) identified above. I understand that the recipient of the student record(s) will use the record(s) for legitimate interests only and that the information contained therein shall not be further transferred or communicated to any other party or agency without my expressed written consent except under authority of the Educational Rights and Privacy Act, 20 U.S.C. 1232g. Parent/Guardian Name (or eligible student) (Please Print) Parent/Guardian Signature (or eligible student) Date

12 Baltimore County Public Schools Towson, Maryland Baltimore County Department of Health Baltimore, Maryland Last Name: First Name: Grade: Gender: Last school your child attended? DOB: Has your child traveled or resided outside of the U.S. in the past year? Yes No If yes, list countries: Where do you usually take your child for routine medical care? Name: Phone Number: _ Does your child take any medication? Yes No If yes, list medications: Does your child require any special health treatments or procedures (e.g. tube feeding or catheterization)? Yes No If yes, describe: Where do you usually take your child for routine dental care? Name: Phone Number: _ To the best of your knowledge, has your child had any of the following? Yes No If yes, describe: Prematurity Birth defect Immunity problems Bleeding problems Lead poisoning Sickle Cell Disease Diabetes Anaphylaxis Seasonal allergies Food Allergies Behavior/emotional problems like ADHD, depression Concussion or traumatic brain injury Migraines Learning problems/disabilities Seizures Speech problems Ear or hearing problems Eye or vision problems Dental problems Asthma or breathing problems Heart problems Stomach problems Bowel problems Bladder problems Musculoskeletal problem (including cerebral palsy) Limited physical activity Other: New Student Health History Hospitalization: (please list all) Date(s) Reason(s) Surgery: (please list all) Dates(s) Reason(s) Parent Signature: Telephone: Date: Parent Address:,,, BEBCO Wellness Center

13 Health/Family History Questionnaire Student Name: Date of Birth: Sex: Form Completed By: Relationship: Today s Date: PREGNANCY AND BIRTH HISTORY Illnesses/medications during pregnancy? No Yes Alcohol/Drug Use? No Yes Problems at birth? No Yes Describe: Did child stay in intensive care nursery after birth? No Yes Why? Type of delivery? Vaginal C-section In C-section, why FAMILY HISTORY Has anyone in the family (parents, grand-parents, aunts/uncles, sisters/brothers) had: Allergies (List) Asthma TB/Lung Disease HIV/AIDS Suicide Attempts Heart Disease High Blood Pressure/Stroke High Cholesterol Blood Disorders/Sickle Cell Diabetes Seizures Mental Illness/depression Cancer Birth Defects Hearing Loss Speech Problems Kidney Disease Alcohol/Drug Abuse Hepatitis/Liver Disease Thyroid Disease Learning Problems/Attention Deficit Disorder Family Violence Any other family history concerns:_ Reviewed by: Yes No Who? PSCYHOSOCIAL HISTORY Who lives in household? Mother Father Siblings Grandparent/s Other children Other adults How many? Rent? Own? Shelter? Who cares for child during the day? Are parents working? Mother No Yes Father No Yes Foster Care? Dates: Other languages? YOUR CHILD S MEDICAL HISTORY Has your child ever had: Yes No Com ments Allergies (Medication) List Asthma Chicken Pox (Mo/Year) Frequent Ear Infection Vision/Hearing Problems Skin Problems/Eczema TB/Lung Disease Seizures/Epilepsy CP/meningitis High Blood Pressure Heart Defects/Disease Liver Disease/Hepatitis Diabetes Kidney Disease/Bladder Infections Speech or Learning Disabilities Physical limitations Bleeding Disorders/Hemophilia Sexually Transmitted Infections Emotional/Behavioral Problems Depression/Suicidal Thoughts Hospitalizations/Surgeries Physical/Emotional/Sexual Abuse Bone or Joint Injuries Obesity/Eating Disorders Other:_ Current Medication(s) (List) Date of Review

14 CO BALTIMORE COUNTY PUBLIC SCHOOLS Office of Health Services Consent for Administration of Approved Discretionary Medications and Health Contact Information Last Name: First Name: Date of Birth: School: Allergies (include all allergies): Grade /Teacher: List all medications your child receives on a regular basis: Medical/Health Problems: My Child is followed by a healthcare provider for: (Check all that apply) Asthma ADHD Diabetes Migraines Seizures Other (describe) Is there a health problem that would prevent full participation in the school program or physical education program? No Yes Describe: I would like the following medication(s) made available to my child: (please check) For Headache/Fever/Burns/Earache/Muscle Aches/Pain/Menstrual Cramps For Upset Stomach Acetaminophen (like Tylenol) Ibuprofen (like Advil) (age 12 and older/age 9 for menstrual cramps) Chewable Antacid Tablets (like Tums) Mild Allergic Reactions For Coughs/Sore Throats For Diaper Rash Diphenhydramine (like Benadryl) Cough Drops Zinc Oxide Contact Information Parent/Guardian 1 Name: I do not want any medication given to my child in school. Parent/Guardian 2 Name: Parent/Guardian 1 Home Phone: Parent/Guardian 1 Cell: Parent/Guardian 1 Work: Parent/Guardian 1 Parent/Guardian Home Address:,,, Parent/Guardian 2 Home Phone: Parent/Guardian 2 Cell: Parent/Guardian 2 Work: Parent/Guardian 2 Persons to whom student may be released other than parent: Name: Name: Phone Number(s): Phone Number(s): Do you need assistance in obtaining health insurance for your child? No Yes I understand that the above medications I have checked will be administered by the Registered Nurse/School Nurse in accordance with established protocols developed by the Chief Physician of School Health Services for the Baltimore County Department of Health and the Coordinator of Health Services for Baltimore County Public Schools. I understand that generic equivalent of medications may be used. My signature authorizes the release of my child to the persons listed on this page. Signature of Parent/Guardian/Eligible Student Date BEBCO

15 Annual Consent for Administration of Discretionary Medications and Health Contact Information Dear Parent or Guardian: On the reverse side of this letter is a form that provides the school nurse with updated health information on your child, a list of persons to be contacted in the case of an illness or injury and a section to indicate your consent for the administration of certain nonprescription medications which are available, at no charge, for all students. This form must be filled out each school year. The nonprescription medication program (called Discretionary Medications) is designed to alleviate minor discomforts and to prevent unnecessary early dismissals from school. These medications are approved by the Chief of School Health Services, Baltimore County Department of Health, and the Coordinator, Office of Health Services, Baltimore County Public Schools. Your consent must be obtained before any medication is given to your child. Only the School Nurse may administer these medications in accordance with established protocols. The consent form lists the medications which may be available. Please complete the consent form, and return it to the school nurse. Approved discretionary medications are intended for occasional use only. If your child requires any prescription or nonprescription medication on a regular basis, you must obtain a written order from your health care provider and supply the medications. If you have any questions or would like further information, please contact your school nurse. Sincerely, Deborah Somerville, RN, MPH Coordinator Office of Health Services Baltimore County Public Schools Linda Grossman, MD, FAAP Chief Bureau of Child, Adolescent, Reproductive and School Health Baltimore County Department of Health BEBCO

CORAZON PANES SANCHEZ., M.D., L.L.C.

CORAZON PANES SANCHEZ., M.D., L.L.C. PERRYVILLE, MD 21903 Rising sun, MD 21911 BALTIMORE, MD 21221 PATIENT REGISTRATION NAME: DOB: SEX: ( ) MALE ( ) FEMALE SOCIAL SECURITY #: - - ADDRESS: CITY/STATE: ZIP:_ TELEPHONE #: MOTHER S NAME: FATHER