NEW STUDENT ENROLLMENT ONLY Entry : Homeroom Teacher: MONTGOMERY COUNTY SCHOOLS STUDENT INFORMATION FORM Student s Legal Name: Last First Middle Suffix Social Security Number: / / of Birth: Birthplace: Gender: M F School: Preschool Ethnicity: (must choose one) Hispanic OR Not Hispanic/Latino Camargo Elementary Choose all that apply: Mapleton Elementary White Black or African American Asian Mount Sterling Elementary American Indian or Native Alaskan McNabb Middle School Native Hawaiian or Pacific Islander Montgomery County Intermediate School Montgomery County High School The Sterling School Montgomery County Accelerated Academy Grade: Last School attended: (preschool, public, private, or homeschool)? Special Services Needed (Check): Special Education: (Speech, Physical Therapy, Occupational Therapy, etc.) 504 Plan Gifted/Talented Other Specify: Does student ride a bus in the morning? Yes No If yes, how far? Bus No. Does student ride a bus in the afternoon? Yes No If yes, how far? Bus No. Primary language spoken in the home? Language your child speaks most at home? Language your child learned to speak first when he/she learned to talk? What language do you most frequently speak to your child? Student has an IEP or 504 Plan Yes No If yes please specify which plan Please list names and schools of any other students living within this household: STUDENT NAME SCHOOL ATTENDING GUARDIAN INFORMATION: Father/Legal Guardian #1 Mother/Legal Guardian #2 Please list only parents/guardians with whom the student lives with. Legal Name (last/first/middle): Relationship to Student: (natural, step, grand parent, etc.) Place of Employment: Work Telephone: Additional Phones: (cell, other): E-Mail Address(es): Household Information: Primary Household Telephone: ( ) Physical Address of Student: (Do not use P.O Box Numbers) Street Address City State Zip County Mailing Address of Student: (If different from above) Street Address/P.O. City State Zip County Please list any other parents/guardians with whom the student DOES NOT live. Guardian #1 Guardian #2 Legal Name (last/first/middle): Relationship to Student: Physical Address: Place of Employment: Phones: (cell, work, etc): 1
COMPLETE ONE PER STUDENT Is there a court order restricting this parent s/guardian s access to the student? Yes No If yes, a copy of the court order must be provided. List persons allowed to pick up student (photo identification required). Name Telephone Name Telephone PARENTAL PERMISSION/CONSENT/VERIFICATION Student Name: Home Room: Grade Level: If there is a custody issue regarding this student it is important that the school district know: (1) who the legal guardian(s) is; (2) if a parent is forbidden by court order to have access to the child or his/her records (copy of court order must be on file); and (3) who is authorized to pick up your child and make decisions on his/her behalf. Please explain any guardian/ custodial issues regarding this student: I have received the Publication Consent Form (use of my child s picture, videos, etc.). If you wish to permit the release of information as described on form 09.14 AP.251, please complete and return the form to your child s school. See Attachment #1. Directory information about students in the Montgomery County Schools will be used for school purposes and/or provided to members of the public or to requesting organizations as allowed by law. Directory information can include name, address, phone number, birth date, photograph, etc. Requesting organizations may include institutions of higher education, potential employers, Armed Forces recruiters, etc. For a complete list of directory information that may be provided, please refer to Student Directory Information Notification Form 9.14 AP.12 as included in this packet. To request that information not be disclosed, please complete form at the check-out table. My child and I have read and reviewed the Montgomery County Schools Rules and Regulations for Students Riding School Buses, and agree to abide by the rules and assume responsibility for my child s conduct on the school bus. I have been informed of the health and immunization requirements for enrollment in Kentucky schools. I understand that it is my responsibility to ensure that up to date information is submitted to the school nurse or principal of my child s school. Harassment/Discrimination is prohibited at all times on school property and off school grounds during school sponsored activities. Examples of conduct or action that could be considered a violation of this policy include but are not limited to: Nick names, jokes, vulgar or profane written materials or pictures; unwanted touching, sexual advances, requests for sexual favors, spreading sexual rumors, etc.; causing another student to believe he/she must submit to unwelcome conduct in order to receive educational services or participation in school activities; physical threats (implied, spoken, or written) or acts of aggression or assault based on any of the protected categories described in district policy 09.42811; seeking to involve students with disabilities in inappropriate, dangerous, or criminal activity; destroying or damaging an individual s property based on the protected categories as defined by district policy 09.42811. Students who engage in harassment or discrimination of employees or fellow students on the basis of the prohibited areas shall be subject to disciplinary action including but not limited to suspension or expulsion. Students who believe they have been a victim of harassment/discrimination or who have observed incidents involving the previously listed behaviors should report the incident to the building principal or another responsible adult. Further information regarding harassment/discrimination can be found in district policy 09.42811. I understand that I will be notified about school-related trips in advance. In the event of an accident or sudden illness while on the school-related trip, I authorize school personnel to contact the physician indicated in my child s medical information to render such treatment as may be deemed necessary in an emergency. In the event the physician, parent, or other persons designated by the parent cannot be contacted, school personnel are hereby authorized to take whatever action is deemed necessary for the health of my child. I have received, read and understand the attendance and discipline policies of the school district and my child s school. Upon initial enrollment I received a school district handbook, which outlines policies, procedures, rules and regulations for the school system. See school attachments. If handbooks are not available at time of enrollment they will be available by the beginning of the school year. I have received, reviewed and if applicable completed the Household Application for Free or Reduced-Priced Meals. (If not included, the Application will be available in July for the next school year.) Please contact me. It is very important for the school district to know the following additional information about my child and/or I have questions/concerns/need more information about: I hereby certify that the information provided on this form is correct and do, with this signature, give my consent/ permission/verification for the items above. Parent/Guardian Signature 2
COMPLETE ONE PER HOUSEHOLD STUDENT RESIDENCY STATEMENT This form is intended to address the requirements of the McKinney-Vento Act (Title X, Part C of the No Child Left Behind Act). The questions below are to assist in determining if the student meets the eligibility criteria for services provided under the McKinney-Vento Act. Information provided on this form is confidential. School: : Student Name: Birth : Grade: Where does the student stay at night: [ ] in a shelter (family shelter, domestic violence shelter, or transitional living program); [ ] in a motel, hotel, or weekly-rate housing; [ ] in a house with parent(s); [ ] in a house or apartment with more than one family because of economic hardship or loss; [ ] in an abandoned building, a car, at a campground, or on the street; [ ] in temporary foster care or with an adult who is not the parent or legal guardian; [ ] in substandard housing (no electricity, no water, and/or no heat); [ ] with friends or family because student is a runaway or unaccompanied youth; or [ ] other (please specify): The student lives with: [ ] 1 parent [ ] 2 parents [ ] 1 parent & another adult [ ] a relative (grandparent), friend(s) or other adult(s) [ ] alone with no adults [ ] an adult that is not the parent or the legal guardian [ ] other (please specify): Please list other children that currently live with you (PLEASE PRINT): Birth : Grade: Birth : Grade: Birth : Grade: Birth : Grade: Name of person completing this form: Address: Phone Number: I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act. McKinney-Vento Liaison Signature 3
NEW STUDENT ENROLLMENT ONLY Publication Consent Form School Attachment #1 STUDENTS 09.14 AP.251 Dear Parent/Guardian: PLEASE COMPLETE THIS FORM AND SUBMIT IT TO THE SCHOOL. At some time during the school year, school/district personnel or other District-authorized persons may videotape or photograph classroom activities or special projects in which your child participates during or after the school day for public awareness purposes. On special occasions such as a videotape or photograph of a class or school play or of an academic or athletic event, with your permission, the film or photograph may be viewed by a general audience including, but not limited to, publishing pictures in yearbooks, event programs and newsletters, or posting a likeness of your child on the school or District Web site. Under 09.14 A.P.12, the District has designated student photographs as directory information. Consistent with that annual notice, a photograph of an individual student may be released to others and/or reproduced in school yearbooks as long as the parent or adult student has not submitted written notice (by returning form 09.14 AP.12) indicating that they do not wish photographs of the student to be released. This form covers permission for the District to record and use the recorded image, voice, or work of the student (photographed, filmed, taped, or digitally recorded) for public awareness purposes, including publication on the school and/or District s web site. Please review this form carefully, sign and date the form, and submit the form to the school. Once signed and dated, this form shall remain in effect for your child s enrollment in the District schools. However, at any time during the school year, you may amend this form only for future uses/preferences by notifying the Principal in writing of your request. As the parent(s)/guardians(s) of, I/we give the Student s Name (PLEASE PRINT) Montgomery County School District permission to release my/our child s name, photograph, and/or audio/video reproduction for publication to the general public concerning school functions and activities, including academic and athletic activities. Parent/Guardian s Signature ------------------------------------------------------------------------------------------------------------------------------ As the parent(s)/guardian(s), I/we do not give permission to release information to the public. Form 09.14 AP.12 will need to be completed at the check-out table. Parent/Guardian s Signature Name of Parent(s)/Guardian(s) (PLEASE PRINT) 4
COMPLETE ONE PER STUDENT TRANSPORTATION VERIFICATION FORM MONTGOMERY COUNTY SCHOOL 2014-2015 SCHOOL YEAR The Montgomery County Board of Education is updating student transportation records. Please have a parent or guardian complete this form for each student and return it to the student s teacher. If not completed by student or parents, then a school official (teacher, clerk or other) may interview the student and complete the form. Information must be verified and entered into the Student Information System for each student. STUDENT NAME: FIRST MIDDLE LAST PHYSICAL ADDRESS: MAILING ADDRESS (if different than above) HOME TELEPHONE: CELL NUMBER: SCHOOL: ************************************************************************************ BUS RIDER INFORMATION In general as a matter of routine: RIDER INFORMATION YES NO I RIDE THE BUS I RIDE THE BUS TWICE DAILY OVER ONE MILE I RIDE THE BUS ONCE DAILY OVER ONE MILE I RIDE THE BUS TWICE DAILY UNDER ONE MILE I RIDE THE BUS ONCE DAILY UNDER ONE MILE BUS NUMBER THAT PICKS YOU UP AT HOME BUS NUMBER THAT DROPS YOU OFF AT HOME For school use only: T-code assigned in IC: Verified: Subsequent change notes (used to document any changes to the information above during the school year) 1) 2) 3) 5
STUDENTS Emergency Information Form 09.224 AP.21 Students Birth date: Grade Legal Street Address Legal Guardian(s): Mother s Name Father s Name Home # ( ) Cell # ( ) Home # ( ) Cell # ( ) Please mark the following conditions that have been diagnosed by a healthcare provider: ADD/ ADHD Past Present DIABETES Past Present ANAPHYLACTIC/ SEVERE ALLERGIC EPISODE Past Present METABOLIC DISORDER Past Present ASTHMA Past Present MIGRAINES Past Present CARDIAC/ HEART DISORDER Past Present SEIZURES Past Present CYSTIC FIBROSIS Past Present OTHER PLEASE SPECIFY PLEASE LIST ALL MEDICATION* YOUR CHILD TAKES AT SCHOOL OR HOME (appropriate consent forms must be completed): If you mark a condition as PRESENT, an individualized health plan (IHP) must be completed by you and your child s healthcare provider and returned to the nurse. Please contact the school nurse for the appropriate forms(s). This information helps the nurse manage and monitor your child s condition. *A student may not carry a medication (insulin, asthma inhalers, Epi-pens etc) with them UNLESS written permission from their health care provider is provided. Prescription meds must have written authorization of prescribing healthcare provider and OTC medications must have written approval of parent/guardian. *All medications must be in the original container. Medications not authorized for student to carry and administer must be given to the staff member designated to provide health services or the supervising teacher/sponsor/coach for proper storage. (Includes field trips) EMERGENCY CONTACTS: Please name two (2) persons (other than legal guardians) that may take responsibility for your child or make decisions for health care: 1) Phone # 2) Phone # Child s Doctor Phone # Child s Insurance Coverage (for Emergency Care) DAYTIME & IN-STATE FIELD TRIPS OFF SCHOOL GROUNDS: Reminder for Parents: STUDENT TRIP PERMISSION FORM 09.36 AP.211 IS REQUIRED FOR OVERNIGHT OR OUT OF STATE TRAVEL Athletic Team and/or Club/Group related trips for the current school year. (Daytime, In-State trips only) All Educational related trips for the school year (Teachers/Sponsors are responsible to provide specific information to parent/guardian for each trip) I hereby give permission for my child to participate in the above-mentioned school-related student trip(s). All health information provided by me to the school for this school year is correct and accurate to the best of my knowledge. I understand that I am responsible to provide all medications and treatment supplies related to my child s health conditions indicated above. I authorize trained school personnel to assist my child with his/her medication as my child s healthcare provider or I have directed if needed. In addition, in the event of accident or sudden illness while at school or on a school-related student trip, I authorize school personnel to have EMS transport my child to the nearest hospital and authorize treatment as deemed necessary in an emergency for the health of said child. Parent/Legal Guardian Signature Page 1 of 1
MONTGOMERY COUNTY SCHOOL HEALTH UNIT CONSENT FOR SERVICES 2014-15 Student Name: Grade: School: The School Health Unit will provide care for all students. This includes, but is not limited to, illness/injury assessments, medication for minor illnesses (headache, earache, sore throat etc.) emergency first aid and/or monitoring/education for chronic disease such as asthma or diabetes. The school health unit cannot provide services to your child without this signed consent (except for emergency first aid). Consent can be withdrawn at any time by the parent or guardian. Please review this form carefully and complete all information that is requested and return to your child s homeroom teacher or directly to the school nurse. I understand that the school nurse ensures health screenings are completed including height, weight, vision & hearing as required, and that I will be notified of any abnormal findings. I understand that all medications sent from home must be accompanied by proper parent/guardian consent and taken to the school nurse immediately upon arrival to school for proper storage and administration. I understand that non-prescription medications can only be given for three days without a physician s order. I understand that the Montgomery County Board of Education Medication Policy and Procedures (09.2241) are readily available for me to read. I understand that in order to ensure my child s safety, school health services may share educationally relevant health information with other school and field trip personnel having direct involvement with my child. Medication delegation by the school nurse is based on health information on file in the health unit at the time of departure. I authorize designated school personnel to make the determination in the event of an emergency to have EMS take my child for emergency treatment. I further understand that all charges incurred will be my responsibility the student s healthcare coverage must be billed first; the school s accident insurance is a secondary insurance. Please review the following list of medications and place a by the ones you will allow your child to have: Acetaminophen (generic name for Tylenol ) Orajel (generic oral pain relief) Aloe Vera Gel Peppermint Candy Antacids (Chewable generic) Vaseline/Petroleum Jelly (generic) Anti-diarrheal (generic for Imodium) Robitussin Cough and/or Chest Congestion Anti-Itch/Sting Kill (generic) (Generic Dextromethorphan HBr and/or Guaifenesin) Benadryl (generic liquid /capsules/caplets/cream) Saltine Crackers Cough Drops (generic) Sore Throat Spray (generic) Ibuprofen (generic for Motrin ) Sterile Eye Drops/Artificial Tears (generic) Lemon/Lime Caffeine free Soda Triple Antibiotic Ointment (generic) I understand that the above over the counter (OTC) products will be available to be administered by the School Nurse, in accordance with Montgomery County School Health Protocol, after she/he has evaluated my child s complaint. I give my consent for the child listed above to receive the above checked medications. I understand that medication may be delegated by the nurse for field trips when indicated by school health consent, IHP, parental note or emergency situation. Known Allergies: Other Medical Conditions: Current Medications: By signing this consent I release Montgomery County Schools from any liability related to the administration of medications or treatment as long as Reasonable and Customary care is provided. This consent is given voluntarily and with full knowledge of its significance. Parent/Legal Guardian Signature Relationship to child