BROOKFIELD PUBLIC SCHOOL DISTRICT 100 Pocono Road, Brookfield, CT Student Registration Part A

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2 BROOKFIELD PUBLIC SCHOOL DISTRICT 100 Pocono Road, Brookfield, CT Student Registration Part A Student Legal Name (as it appears on birth certificate) First Middle Last Date of Birth (mm/dd/yyyy) Student Home Telephone# Is this student a multiple? Yes No Grade Level Gender Birth Gender Male Female (as it appears on birth certificate) Non-binary (Used for students who do not identify exclusively as male or female) Male Female Residence Address of Student Street Apt.# City State Zip Mailing Address (If different than above) Street Apt. # City State Zip Ethnic Group and Race Categories Birth Place(City/State) The federal government requires that both these questions be answered and provides only the following categories for ethnic group and race. If both questions are not answered, school personnel are required to make selections for both. Country of Birth 1. Is this student Hispanic or Latino? In any of the 50 US States No, not Hispanic or Latino Commonwealth of Puerto Rico Yes, Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or District of Columbia Central American, or other Spanish culture or origin, regardless of race.) Other 2. What is the student s race ( select all that apply) If OTHER: (I) American Indian or Alaska Native Original US Entry Date (A person having origins in any of the original peoples of North and South America List Country : (including Central America), and who maintains tribal affiliation or community attachment.) (A) 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.) Is this student a U.S. Citizen? (B) Black or African American Yes No (A person having origins in any of the black racial groups of Africa.) (W) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa) (P) Native Hawaiian / Other Pac Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.) Has this student ever Number of full academic years completed Does this student receive any of the following services? been retained? in the U.S. Yes No Yes No or more (check all that apply) If yes, what grade Special Education 504 Plan EL Other If other, please explain Has this student ever attended BPS? Has this student ever been Yes No suspended or expelled? Name of School Grade Year Yes No If yes, what grade If ANY are checked, a copy of the current PLAN and/or IEP are required before registration is complete. LIST SCHOOLS PREVIOUSLY ATTENDED Name of School: Address: Start Date (month/day/year): End Date (month/day/year): Public NonPublic Name of School: Address: Start Date (month/day/year): End Date (month/day/year): Public NonPublic

3 BROOKFIELD PUBLIC SCHOOL DISTRICT 100 Pocono Road, Brookfield, CT Student Registration Part B Student Legal Name SIBLING INFORMATION - Please list all of the student s siblings. Name Grade Name Grade Name Grade Name Grade PARENT/GUARDIAN INFORMATION PARENT/GUARDIAN 1 Name Relationship Phone# Address Street City State Zip Contact Allowed - Yes No Legal Guardian -Yes No Lives with- Yes No PARENT/GUARDIAN 2 Name Relationship Phone# Address Street City State Zip Contact Allowed - Yes No Legal Guardian -Yes No Lives with- Yes No Student Resides With (check all that apply) Migrant Status Homeless: Not Homeless Mother Father Both Parents This student and family has moved within the past 36 Hotel/Motel Legal Guardian Step Father months across state or district boundaries to obtain Shelter Step Mother Other temporary/seasonal employment? Yes No Double Up Unsheltered Military Status Student s parent or guardian is a member of the Armed Forces on active duty or serves on full-time National Guard duty. Yes No Should the school be aware of any Court Order for the protection of your student? Yes No If yes, please make arrangements to meet with the school administration and provide custodial documentation to your student s school. NOTE: A current legal court document must be provided to ensure compliance with custody orders. Please inform your student s school of changes in custodial arrangements. Additional Comments: Enter any other comments or facts that might help with your student s placement. The information within this student registration packet is true and correct to the best of my knowledge and belief. Registering Parent Signature Date For Office Use Only: Date of new entry Proof of Residency: Homeless : Entry Grade Level: Birth Certificate: Date records requested: Health Forms Language Survey Transportation: Contact Restriction Yes No District ID #: State ID #: Parent Correspondence Language Today s Date: BPS Staff Registrar Signature

4 BROOKFIELD PUBLIC SCHOOL DISTRICT 100 Pocono Road, Brookfield, CT BUS INFORMATION For Office Use Only Bus In # Bus Out # Student # Date Student s Name Student s Address Student s Grade Home Phone# M F My student should be picked up at Address My student should be dropped off at Address Additional Information Parent s Name Parent s Signature Phone Number Date CENTER ELEMENTARY SCHOOL ONLY Center Elementary School children must be met by an adult at the bus stop or the student will be brought back to school for your immediate pickup. Children are not allowed to change buses or bus stops. Please include the names and phone numbers below of any adult, other than parents, who may be meeting the student at the bus stop.

5 BROOKFIELD PUBLIC SCHOOL DISTRICT 100 Pocono Road, Brookfield, CT STUDENT RECORDS RELEASE FORM I hereby give my permission for my child s school records to be released to the Brookfield Public School District. (Please Print) Parent/Guardian Parent/Guardian s Signature Date Parent Phone Number Name of Student / / Date of Birth Sending School: (Name of Last School Student Attended) Last Grade Level Completed (Address) City State Zip Code ( ) Phone ( ) Fax Please include all items checked below. Academic Record (Report Card/Transcript/Withdrawal Grades) 504 Individual Education Programs Health Record Speech /Hearing/Language Evaluations Educational Evaluations Other Pertinent and/or Confidential Information Psychological Evaluations Testing Scores (Standardized or Special Education) Special Education File Discipline Records ESL placement/exit info;las Scores(or WIDA);ESL Screening/Proficiency Level Please send information to selected school. Center Elementary School 8 Obtuse Hill Road Brookfield, CT (fax) Huckleberry Hill Elementary School 100 Candlewood Lake Road Brookfield, CT (fax) Whisconier Middle School 17 West Whisconier Rd Brookfield, CT (fax) Brookfield High School 45 Longmeadow Hill Road Brookfield, CT (fax) Thank you for your cooperation in this regard. It is greatly appreciated.

6 BROOKFIELD PUBLIC SCHOOLS DEVELOPMENTAL HISTORY Student s Last Name First Name Middle Name Gender Birth Date Please check all areas that apply to your child and explain below: Pregnancy complication Birth injury/complication Premature birth at weeks Complications after birth Over/under active Poor appetite/eating problem Sleeping difficulty Tires easily Toileting problem Explain: DEVELOPMENTAL MILESTONES At what age did your child: Sit up alone Use single words Toilet trained Crawl Use 2-4 word sentences Ride a bicycle Walk alone Sleep through the night Has your child been evaluated by the birth to three program? Does your child have any developmental concerns that have required an evaluation by a specialist (speech pathologist, occupational or physical therapist, psychologist, psychiatrist etc)? If so, explain: My child s development has been similar to his/her peers: yes no If no, explain: Do you think your child has a fine or gross motor problem? yes no If yes, explain: Do you think your child has a speech or language problem? yes no If yes, explain:

7 SOCIAL AND EMOTIONAL DEVELOPMENT (Please check areas that apply to your child and comment below): Cries easily Has one or more good friends Bites nails Is quiet or shy Sucks thumb Is confident Gets angry easily Joins group activities Has a hard time focusing Plays easily with peers Daydreams Prefers solitary play Has nightmares Shares easily Has temper tantrums Sticks to tasks Is impulsive Tolerates changes in routine Is moody Usually seems happy Is aggressive Is affectionate Comment: Does your child have any fears or anxieties that may interfere with learning at school? Is there anything you feel we should know about your child in order to help him/her make a satisfactory adjustment to school? FAMILY AND HOME BACKGROUND Is there any relevant information we should know regarding the home? Please include things such as recent moves, job changes, death in the family, divorce, adoption/birth etc. Student s primary language: Other languages spoken at home: Other children (names and ages): Parent/Guardian Signature Date Parent/Guardian Signature Date 9/06

10 Brookfield Public Schools Tuberculosis Risk Questionnaire Student Name Grade Please check below: One or more of the listed Tuberculosis risk factors applies to my child None of the listed Tuberculosis risk factors apply to my child Parent/Guardian Signature Date Recent or prolonged contact with someone who has infectious TB or positive TB skin test Born in a high-prevalence TB area (Africa, Asia, including the former Soviet Union and India, Central and South America, Eastern Europe, Mexico, Haiti, Philippines or the Dominican Republic) Travel outside the US to a high-prevalence TB area (Africa, Asia, including the former Soviet Union and India, Central and South America, Eastern Europe, Mexico, Haiti, Philippines or the Dominican Republic) Exposure to a person who has been in jail, has HIV, is homeless, lives in a group home or shelter, uses illegal drugs or is a migrant farm worker Has a health problem that lowers the immune system Has a household member who was born in or has traveled to a high-prevalence TB area Has symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray Has drunk raw milk or eaten unpasturized cheese since last TB skin test Any student identified as to having one or more TB risk factors will be required to have a TB skin test placed and read before school entry. A history of BCG vaccination is not a contraindication to testing nor should it be considered in interpretation of the skin test result. A positive reaction to the TB skin test requires a letter from a physician stating that a chest x-ray has been done and the child is free of active TB. 3/2008

11 BROOKFIELD PUBLIC SCHOOLS BROOKFIELD, CT STUDENT HEALTH HISTORY Student s Last name First Middle Gender Birth date Grade Please complete all the items below by marking the yes or no box. If an item is marked yes, indicate the date(s) of the occurrence. Space is provided for any additional comments you may have relative to health issues. A. CHILDHOOD ILLNESSES YES NO DATE(S) H. RESPIRATORY YES NO DATE(S) Lyme Disease Meningitis Rheumatic Fever Varicella/Chickenpox Asthma Inhaler required in school Wheezing or difficulty breathing with exercise B. SEVERE ALLERGIES (Explain below) Frequent colds/cough Bee Sting Food Drug Epi-pen required Benadryl required Pneumonia/bronchitis I. SKELETAL J. SKIN Broken bones C. CARDIOVASCULAR Eczema History of heart disease Surgical Procedures History of scoliosis Hives or rashes K. URINARY D. EARS, NOSE and THROAT History of urinary infection Hearing impairment More than 2 ear infections/year Ear tubes Frequent nosebleeds More than 2 throat infections/year and/or strep History of urinary tract condition L. SPECIAL CONSIDERATIONS Diabetes Other chronic condition Under the care of a specialist E. EYES Special Needs (OT,PT, bracing) History of eye problems Glasses/contacts for reading/distance Physical Restriction Medication on a regular basis F. GASTROINTESTINAL Medical/Religious Exemption Frequent stomachaches/constipation/diarrhea Food sensitivity or intolerance (Explain below) M. HOSPITALIZATIONS G. NEUROMUSCULAR COMMENTS History of neuromuscular condition History of seizure disorder Include reasons under comments Continue on back if necessary In case of serious injury or illness at school, your child will be sent to an emergency medical facility. The parent/guardian will be contacted immediately and is responsible for all expenses. Physician s Name: Telephone: Dentist s Name: Telephone: Parent/Guardian Signature Date 3/2013

State of Connecticut Department of Education Health Assessment Record To Parent or Guardian: In order to provide the best educational experience, school personnel must understand your child s health

State law requires complete primary immunizations and a health assessment by a legally qualified practitioner of medicine, an advanced practice registered nurse or registered nurse, licensed pursuant

12 State of Connecticut Department of Education Health Assessment Record To Parent or Guardian: In order to provide the best educational experience, school personnel must understand your child s health needs. This form requests information from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II). State law requires complete primary immunizations and a health assessment by a legally qualified practitioner of medicine, an advanced practice registered nurse or registered nurse, licensed pursuant to chapter 378, a physician assistant, licensed pursuant to chapter 370, a school medical advisor, or a legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to school entrance in Connecticut (C.G.S. Secs a and ). An immunization update and additional health assessments are required in the 6th or 7th grade and in the 9th or 10th grade. Specific grade level will be determined by the local board of education. This form may also be used for health assessments required every year for students participating on sports teams. Please print Student Name (Last, First, Middle) Birth Date Male Female Address (Street, Town and ZIP code) Parent/Guardian Name (Last, First, Middle) Home Phone Cell Phone School/Grade Primary Care Provider Health Insurance Company/Number or Medicaid/Number Race/Ethnicity American Indian/ Alaskan Native Hispanic/Latino Black, not of Hispanic origin White, not of Hispanic origin Asian/Pacific Islander Other Does your child have health insurance? Y N Does your child have dental insurance? Y N If applicable If your child does not have health insurance, call CT-HUSKY Part I To be completed by parent/guardian. Please answer these health history questions about your child before the physical examination. Any health concerns Y N Allergies to food or bee stings Y N Allergies to medication Y N Any other allergies Y N Any daily medications Y N Any problems with vision Y N Uses contacts or glasses Y N Any problems hearing Y N Any problems with speech Y N Please circle Y if yes or N if no. Explain all yes answers in the space provided below. Hospitalization or Emergency Room visit Y N Any broken bones or dislocations Y N Any muscle or joint injuries Y N Any neck or back injuries Y N Problems running Y N Mono (past 1 year) Y N Has only 1 kidney or testicle Y N Excessive weight gain/loss Y N Dental braces, caps, or bridges Y N Family History Any relative ever have a sudden unexplained death (less than 50 years old) Y N Any immediate family members have high cholesterol Y N Concussion Y N Fainting or blacking out Y N Chest pain Y N Heart problems Y N High blood pressure Y N Bleeding more than expected Y N Problems breathing or coughing Y N Any smoking Y N Asthma treatment (past 3 years) Y N Seizure treatment (past 2 years) Y N Diabetes Y N ADHD/ADD Y N Please explain all yes answers here. For illnesses/injuries/etc., include the year and/or your child s age at the time. Is there anything you want to discuss with the school nurse? Y N If yes, explain: Please list any medications your child will need to take in school: All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian. I give permission for release and exchange of information on this form between the school nurse and health care provider for confidential use in meeting my child s health and educational needs in school. Signature of Parent/Guardian Date HAR-3 REV. 4/2012 To be maintained in the student s Cumulative School Health Record

13 HAR-3 REV. 4/2012 Part II Medical Evaluation Health Care Provider must complete and sign the medical evaluation and physical examination Student Name I have reviewed the health history information provided in Part I of this form Physical Exam Birth Date Note: Mandated Screening/Test to be completed by provider under Connecticut State Law Date of Exam Height in. / % Weight lbs. / % BMI / % Pulse Blood Pressure / Neurologic HEENT Gross Dental Lymphatic Heart Lungs Abdomen Genitalia/ hernia Skin Screenings Vision Screening Type: Normal Right With glasses 20/ Left 20/ Without glasses 20/ 20/ Referral made Describe Abnormal Auditory Screening Type: Referral made Right Pass Fail Neck Shoulders Arms/Hands Hips Knees Ortho Feet/Ankles Normal Describe Abnormal Postural No spinal Spine abnormality: abnormality Mild Moderate Marked Referral made Left Pass Fail History of Lead level 5µg/dL No Yes HCT/HGB: Other: TB: High-risk group? No Yes PPD date read: Results: Treatment: IMMUNIZATIONS Up to Date or Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED Chronic Disease Assessment: Asthma No Yes: Intermittent Mild Persistent Moderate Persistent Severe Persistent Exercise induced If yes, please provide a copy of the Asthma Action Plan to School Anaphylaxis No Yes: Food Insects Latex Unknown source Allergies If yes, please provide a copy of the Emergency Allergy Plan to School History of Anaphylaxis No Yes Epi Pen required No Yes Diabetes No Yes: Type I Type II Other Chronic Disease: Seizures No Yes, type: Speech (school entry only) This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience. Explain: Daily Medications (specify): This student may: participate fully in the school program participate in the school program with the following restriction/adaptation: This student may: participate fully in athletic activities and competitive sports participate in athletic activities and competitive sports with the following restriction/adaptation: Yes No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness. Is this the student s medical home? Yes No I would like to discuss information in this report with the school nurse. Date Signature of health care provider MD / DO / APRN / PA Date Signed Printed/Stamped Provider Name and Phone Number

14 Student Name: Birth Date: HAR-3 REV. 4/2012 Immunization Record To the Health Care Provider: Please complete and initial below. Vaccine (Month/Day/Year) Note: Minimum requirements prior to school enrollment. At subsequent exams, note booster shots only. DTP/DTaP DT/Td Tdap IPV/OPV MMR Measles Mumps Rubella HIB Hep A Hep B Varicella PCV Meningococcal HPV Flu Other Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6 Required for 7th grade entry Required K-12th grade Required K-12th grade Required K-12th grade Required K-12th grade PK and K (Students under age 5) PK and K (born 1/1/2007 or later) Required PK-12th grade 2 doses required for K & 7th grade as of 8/1/2011 PK and K (born 1/1/2007 or later) Required for 7th grade entry PK students months old given annually Disease Hx of above (Specify) (Date) (Confirmed by) Exemption Religious Medical: Permanent Temporary Date Recertify Date Recertify Date Recertify Date Immunization Requirements for Newly Enrolled Students at Connecticut Schools KINDERGARTEN DTaP: At least 4 doses. The last dose must be given on or after 4th birthday. Polio: At least 3 doses. The last dose must be given on or after 4th birthday. MMR: 2 doses given at least 28 day apart 1st dose on or after the 1st birthday. Hib: 1 dose on or after 1st birthday (Children 5 years and older do not need proof of Hib vaccination). Pneumococcal: 1 dose on or after 1st birthday (born 1/1/2007 or later and less than 5 years old). Hep A: 2 doses given six months apart-1st dose on or after 1st birthday. Hep B: 3 doses-the last dose on or after 24 weeks of age. Varicella: For students enrolled before August 1, 2011, 1 dose given on or after 1st birthday; for students enrolled on or after August 1, doses given 3 months apart 1st dose on or after 1st birthday or verification of disease. GRADES 1-6 DTaP /Td/Tdap: At least 4 doses. The last dose must be given on or after 4th birthday; students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine. Polio: At least 3 doses. The last dose must be given on or after 4th birthday. MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday. Hep B: 3 doses the last dose on or after 24 weeks of age. Varicella: 1 dose on or after the 1st birthday or verification of disease. GRADE 7 Tdap/Td: 1 dose of Tdap for students 11 yrs. or older enrolled in 7th grade who completed their primary DTaP series; For those students who start the series at age 7 or older a total of 3 doses of tetanus-diphtheria containing vaccines are needed, one of which must be Tdap. Polio: At least 3 doses. The last dose must be given on or after 4th birthday. MMR: 2 doses given at least 28 days apart 1st dose on or after the 1st birthday. Meningococcal: one dose for students enrolled in 7th grade. Hep B: 3 doses-the last dose on or after 24 weeks of age. Varicella: 2 doses given 3 months apart 1st dose on or after 1st birthday or verification of disease. GRADES 8-12 Td: At least 3 doses. Students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine one of which should be Tdap. Polio: At least 3 doses. The last dose must be given on or after 4th birthday. MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday. Hep B: 3 doses-the last dose on or after 24 weeks of age. Varicella: For students <13 years of age, 1 dose given on or after the 1st birthday. For students 13 years of age or older, 2 doses given at least 4 weeks apart or verification of disease. Verification of disease: Confirmation in writing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history. Note: The Commissioner of Public Health may issue a temporary waiver to the schedule for active immunization for any vaccine if the National Centers for Disease Control and Prevention recognizes a nation-wide shortage of supply for such vaccine. Initial/Signature of health care provider Date Signed Printed/Stamped Provider Name and Phone Number MD / DO / APRN / PA

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