FORM CHECKLIST. You must complete online registration at

FORM CHECKLIST You must complete online registration at http://my.cherrycreekschools.org The following optional forms should be brought to Student Check-In on August 2 nd, or returned to the school office no later than Friday, August 17th. School Forms Technology Usage Form Yearbook Order Form Authorization to Use Privately Owned Vehicle on School District Business (Along with a copy of your Driver s License and Auto Insurance Declarations Page) Locker Agreement Middle School Students West Carpool Lot Form Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders Colorado School Asthma Care Plan Consent for Prescription/Homeopathic Medication at School PTCO Howler Order Optional Online Forms Application for Free or Reduced Price School Meals available at www.ccsdcafe.org Application for Prepayment of School Meals available at www.paypams.com Optional Student Accident Insurance available at www.studentinsurance-kk.com

Challenge School YEARBOOK 2018/19 Purchase a yearbook today and capture the memories of the 2018-2019 school year! Created by our own 5th through 8th grade students, the yearbook is a 68 page full-color hardback book filled with fun photos and creative layouts. Purchase the insert and you will also receive a four-color professionally developed review of the year s world and national news. Buy today and you are guaranteed to receive a yearbook at the end of the school year. Price today is $26 for yearbook, $3 for insert. After January 11, 2019, the price is $28 for yearbook only. (Insert not available after January 11th). Order forms with checks may be dropped off during Check-In Day or at the front office. 2018-2019 Yearbook Order Form MUST BE TURNED IN BY JANUARY 11, 2019 Checks only (no staples, cash can not be accepted) payable to: CHALLENGE SCHOOL Student Name Grade Teacher/ Connections Yearbook ($26) Insert ($3) Total TOTAL ORDER = $

Would you like to 1) Earn lots of Volunteer Hours? 2) Spend fun and rewarding time with the kids? 3) Be a super hero to the Challenge Community? THEN BECOME AN APPROVED DRIVER FOR IMMERSION AND OTHER SCHOOL FIELD TRIPS! It s easy as 1.2.3.. At August Check-In Day each driver wishing to be approved must bring the following 3 items: 1) A copy of his/her CURRENT Colorado Driver s License. 2) A copy of his/her CURRENT Automobile Declarations Page. (The page that states the amount of liability coverage you carry.) You must carry the following in order to be approved by CCSD: $300,000 per accident coverage $100,000 per person coverage $50,000 property damage 3) A copy of his/her completed CCSD EEAG-E Form (see attached). It really is that easy! In order for our Immersion Program to run smoothly and be a success, we need as many approved drivers as we can get. Please become an approved driver today!

Exhibit: EEAG-E AUTHORIZATION TO USE PRIVATELY OWNED VEHICLE ON SCHOOL DISTRICT BUSINESS Please print and complete all boxes. I. DRIVER INFORMATION Driver s Name School/Dept. Challenge School Purpose(s) Field Trip Driving Driver s Address Phone Position with school Volunteer Date(s) of Driving No. of Passengers Vehicle Description Various 2018-19 SY II. CERTIFICATION In accordance with district policy, approval is requested to use a privately owned automobile on official school district business. A. I certify that whenever I drive a privately owned vehicle on school district business, the vehicle will always be: 1. Covered by liability insurance for the minimum amount prescribed by the district: $300,000 single limit or $100,000/$300,000/$50,000 automobile liability insurance. 2. Equipped with one seat belt or child restraint system for every passenger. 3. To the best of my knowledge, in safe mechanical condition and adequate for passenger transportation and/or work to be performed. B. I further certify that while using a privately owned vehicle on official district business, all motor vehicle laws will be obeyed, including all passengers use of seat belts and the appropriate child restraint systems. Any traffic accidents, no matter how minor, will be reported immediately to Risk Management at 720-554-4643. C. I further certify that I am at least 21 years old, and that I possess a valid Colorado driver s license as follows: Driver's License Number Date of Birth Expiration Year D. I further certify that I have not been convicted of driving under the influence, driving while impaired, careless driving, or reckless driving in the past five years. I have either attached a current Colorado Motor Vehicle Report (MVR) or I authorize the school district to obtain a copy of my MVR from the State of Colorado. Individual s Signature Date Cherry Creek School District No. 5, Greenwood Village, Colorado 1 of 2

Exhibit: EEAG-E III. PROOF OF INSURANCE Insurance Company Policy No. Expiration Date Attached is a copy of my current insurance policy declarations page (or a Certificate of Insurance) stating my coverage limits, policy effective dates, and covered vehicle information. IV. AUTHORIZATION Use of a privately owned vehicle on school district business is authorized. Administrator s Signature Date INSTRUCTIONS 1. This form should be submitted to the Principal s secretary so it can be received by Risk Management a minimum of two weeks prior to the event to insure adequate time to process. 2. Attach a copy of your proof of insurance, and a copy of your Colorado driver s license. 3. This form must be signed by a site administrator. Approved by Superintendent Monte C. Moses, October 24, 2006. Cherry Creek School District No. 5, Greenwood Village, Colorado 2 of 2

Challenge School Locker Agreement for the 2018-2019 School Year Students are responsible for their own lockers, including their locks. All rules, conditions, and policies as stated by Cherry Creek School District, the Challenge School Student-Parent Handbook, and the Locker Letter with locker assignments and combinations handed out to each student at Check-In Day apply. A lock will be provided for each student. If at any time the student needs assistance with locks and or lockers please see the security guard. Any damage done to the lockers and/or lost locks are the student s responsibility. In addition, the Challenge school is not responsible for missing, lost, or stolen items. The cost to fix a locker is approximately $300. The cost to replace a lost or broken lock is $5.00. In order to receive your locker assignment, this form must be returned by Check-In Day on August 2, 2018. Please sign below to verify that both the student and parent(s) agree to abide by the Agreement. Student s Name Student s Signature Parent s Signature Please return this along with your other completed paperwork by August 2, 2018. Thank you!

School Year 2018-2019 WEST CARPOOL LOT REGISTRATION FORM In order to have the privilege of using the West Carpool Lot, you must be picking up or dropping off 5 or more Challenge School students, in the morning and afternoon, 5 days per week. Any violation of these rules will result in the loss of your privilege to use the West Lot. Complete this form, turn in to the front office, and passes will be issued to eligible drivers. Provide a list of all drivers in your carpool, their contact information, and all the student passengers in your carpool. You must notify the office immediately if any drivers or students are added to or deleted from your carpool throughout the year. Afternoon pick-up rules: In the event that a driver is delayed in picking up students in the West Lot beyond 3:15 pm, the students will be required to go to the front office to wait and the driver must park, go inside, and sign out the students. Students will not be allowed to wait in the lot beyond 3:15 pm. Also, attached to this form you will find copies of the West Carpool Lot Rules. Each driver should read and keep a copy for reference, then initial below to confirm they understand the procedures. The Security Guard will then issue each driver their assigned West Carpool Lot Pass. Display it in your windshield ON THE PASSENGER SIDE. If you have questions, please contact The Security Guard at 720-747- 2167. Carpool main contact person: Drivers: (Add these parents to your Emergency Contacts in PowerSchool in order to give them permission to pick up the children listed below in the case of bad weather or an emergency. Please refer to the Parent/Student Handbook for complete storm and emergency schedule information.) 1. email cell home x initials* [First name] [Last name] 2. email cell home x initials* 3. email cell home x initials* 4. email cell home x initials* 5. email cell home x initials* 6. email cell home x initials* 7. email cell home x initials* 8. email cell home x initials* * By initialing you agree that you have read and understand the West Carpool Lot Rules Names of Challenge students in carpool: 1. Grade [First name] [Last name] 2. Grade 3. Grade 4. Grade 5. Grade 6. Grade

Challenge School WEST CARPOOL LOT RULES School Year 2017-2018 Copy for family (1) The West Lot located off Mississippi is designated as a Carpool Lot. In order to have the privilege of using the West Carpool Lot, you must be picking up or dropping off 5 or more Challenge School students, in the morning and afternoon, 5 days per week. Any violation of these rules will result in the loss of your privilege to use the West Lot. Rules for use of the West Carpool Lot: Follow the directions of Staff Members Drivers with 5 or more Challenge School students, in the morning and afternoon, 5 days per week may use the West Carpool lot. After submitting your West Carpool Lot Registration for your carpool, each driver will be issued a pass. Display the pass in the car windshield ON THE PASSENGER SIDE at all times. Loading or unloading of students-- Must be done ONLY while parked along the red curb OR while parked in a parking space. Do not stop in the middle of the traffic lane to pick up or unload students. Pull close to the red curb. Do not block the through traffic. In the morning, if the bus has not arrived yet, do not block the bus driver s ability to turn the corner to park the bus along the north curb. Stay at least 3 car lengths back from the corner along the east curb. Fill in the space toward the car in front of you. Getting into the trunk is OK along the curb, as long as you keep moving within a reasonable amount of time. If the car in front of you moves away, pull up to allow other cars to use the curb. Do not EVER leave your car while parked along the red curb. You must remain in the driver s seat. This is a FIRE LANE. It should be treated no differently than a fire lane at a shopping mall. We are allowed to use these fire lanes ONLY for loading and unloading at the beginning and the end of the school day. If you park in one of the spaces, please walk your children across traffic to the sidewalk or to the car. Thank you for your cooperation. Challenge School WEST CARPOOL LOT RULES School Year 2017-2018 Copy for family (2) The West Lot located off Mississippi is designated as a Carpool Lot. In order to have the privilege of using the West Carpool Lot, you must be picking up or dropping off 5 or more Challenge School students, in the morning and afternoon, 5 days per week. Any violation of these rules will result in the loss of your privilege to use the West Lot. Rules for use of the West Carpool Lot: Follow the directions of Staff Members Drivers with 5 or more Challenge School students, in the morning and afternoon, 5 days per week may use the West Carpool lot. After submitting your West Carpool Lot Registration for your carpool, each driver will be issued a pass. Display the pass in the car windshield ON THE PASSENGER SIDE at all times. Loading or unloading of students-- Must be done ONLY while parked along the red curb OR while parked in a parking space. Do not stop in the middle of the traffic lane to pick up or unload students. Pull close to the red curb. Do not block the through traffic. In the morning, if the bus has not arrived yet, do not block the bus driver s ability to turn the corner to park the bus along the north curb. Stay at least 3 car lengths back from the corner along the east curb. Fill in the space toward the car in front of you. Getting into the trunk is OK along the curb, as long as you keep moving within a reasonable amount of time. If the car in front of you moves away, pull up to allow other cars to use the curb. Do not EVER leave your car while parked along the red curb. You must remain in the driver s seat. This is a FIRE LANE. It should be treated no differently than a fire lane at a shopping mall. We are allowed to use these fire lanes ONLY for loading and unloading at the beginning and the end of the school day. If you park in one of the spaces, please walk your children across traffic to the sidewalk or to the car. Thank you for your cooperation.

Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders Student s Name: D.O.B. Grade: School: Teacher: ALLERGY TO: HISTORY: Asthma: YES (higher risk for severe reaction) NO Place child s photo here STEP 1: TREATMENT To be completed by healthcare provider SEVERE SYMPTOMS: Any of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Significant swelling of the tongue and/or lips SKIN: Many hives over body, widespread redness GUT: Repetitive vomiting, severe diarrhea OTHER: Feeling something bad is about to happen, confusion MILD SYMPTOMS ONLY: NOSE: Itchy, runny nose, sneezing SKIN: A few hives, mild itch GUT: Mild nausea/discomfort 1. INJECT EPINEPHRINE IMMEDIATELY 2. Call 911 and activate school emergency response team 3. Call parent/guardian and school nurse 4. Monitor student; keep them lying down 5. Administer Inhaler (quick relief) if ordered 6. Be prepared to administer 2 nd dose of epinephrine if needed *Antihistamine & quick relief inhalers are not to be depended upon to treat a severe food related reaction. USE EPINEPHRINE 1. Alert parent and school nurse 2. Antihistamines may be given if ordered by a healthcare provider, 3. Continue to observe student 4. If symptoms progress USE EPINEPHRINE 5. Follow directions in above box DOSAGE: Epinephrine: inject intramuscularly using auto injector (check one): 0.3 mg 0.15 mg If symptoms do not improve minutes or more, or symptoms return, 2 nd dose of epinephrine should be given Antihistamine: (brand and dose) Asthma Rescue Inhaler: (brand and dose) Student has been instructed and is capable of carrying and self-administering own medication. Yes No Provider (print) Phone Number: Provider s Signature: Date: If this condition warrants meal accommodations from food service, please complete the medical statement for dietary disability STEP 2: EMERGENCY CALLS 1. If epinephrine given, call 911. State that an allergic reaction has been treated and additional epinephrine, oxygen, or other medications may be needed. 2. Parent: Phone Number: 3. Emergency contacts: Name/Relationship Phone Number(s) a. 1) 2) b. 1) 2) EVEN IF PARENT/GUARDIAN CANNOT BE REACHED; DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Severe Allergy Care Plan for my child. Parent/Guardian s Signature: School Nurse: Date: Date:

Student Name: DOB: 1. 2. 3. Room Room Room Self-carry contract on file: Yes No Expiration date of epinephrine auto injector: NOTE: Consider lying on the back with legs elevated. Alternative positioning may be needed for vomiting (side lying, head to side) or difficulty breathing (sitting) Additional Information C.R.S. 22-2-135(3)(b) 1/2017

COLORADO SCHOOL ASTHMA CARE PLAN PARENT/GUARDIAN complete and sign the top portion of form. Student Name: Birth date: Parent/Guardian: Work Phone: Cell Phone: Home Phone: Other Contact: Phone: Grade: Teacher: Triggers: Weather (cold air, wind) Illness Exercise Smoke Dust Pollen Other: Life threatening allergy : Specify If there is no quick relief inhaler at school and the student is experiencing asthma symptoms: Call parents/guardians to pick up student and/or bring inhaler/ medications to school Inform them that if they cannot get to school, 911 may be called I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our physician. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Asthma Care Plan for my child. 504 PLAN OR IEP PARENT SIGNATURE DATE SCHOOL NURSE SIGNATURE DATE HEALTH CARE PROVIDER to complete all items, SIGN and DATE completed form. GREEN ZONE: Student participation in activity and need for pretreatment. No current symptoms. Pretreatment for strenuous activity: Not Required Pretreatment for strenuous activity: Routinely OR Upon request Explain: (weather, viral, seasonal, other) Give 2 puffs of quick relief med (Check One): Albuterol Other: 10 15 minutes before activity. Repeat in 4 hours if needed for additional or ongoing physical activity. If student currently experiencing symptoms, follow yellow zone. YELLOW ZONE: SICK UNCONTROLLED ASTHMA Photo of child IF YOU SEE THIS: DO THIS: Trouble breathing Wheezing 1. Stop physical activity 2. GIVE QUICK RELIEF MED: (Check One) Albuterol Other: Frequent cough 2 puffs Other: Complains of chest tightness Not able to do activities but still talking in complete sentences Peak flow between and Other: 3. Call parents/guardians and school nurse. 4. Stay with student and maintain sitting position. 5. Student may go back to normal activities once feeling better. If symptoms do not improve in 10 15 minutes or worsen after giving quick relief medicine, follow RED ZONE plan. RED ZONE: EMERGENCY SITUATION SEVERE ASTHMA SYMPTOMS IF YOU SEE THIS: DO THIS IMMEDIATELY: Coughs constantly 1. GIVE QUICK RELIEF MED: (Check One): Albuterol Other: Struggles to breathe 2 puffs Other: Trouble talking (only speaks 3 5 words) Skin of chest and/or neck pull in with breathing Lips or fingernails are gray or blue Refer to anaphylaxis plan if student has life threatening allergy. 2. Call 911 and inform EMS the reason for the call. 3. Call parents/guardians and school nurse. 4. Encourage student to take slow deep breaths. Level of consciousness 5. If symptoms continue, repeat quick relief med: Albuterol Other: Peak flow < 2 puffs Other: 6. Stay with student and remain calm. 7. If in 20 minutes from first dose, EMS has not arrived and symptoms remain, repeat quick relief medicine (up to 4 more puffs). 8. School personnel should not drive student to hospital. INSTRUCTIONS for QUICK RELIEF INHALER USE: CHECK APPROPRIATE BOX(ES) Student understands the proper use of his/her asthma medications, and in my opinion, can carry and use his/her inhaler at school independently with approval from school nurse. Student is to notify his/her designated school health officials after using inhaler. Student needs supervision or assistance to use his/her inhaler and inhaler will be kept (specify location). HEALTH CARE PROVIDER SIGNATURE PRINT PROVIDER S NAME PHONE/FAX DATE Copies of plan provided to: Teacher(s) Phys Ed/Coach Principal Main Office Bus Driver Other Colorado Department of Education Revised April 2015

CONSENT FOR PRESCRIPTION/ HOMEOPATHIC MEDICATION AT SCHOOL To be completed by Licensed Health Care Provider with prescriptive authority: Student s Name: Date of Birth: Medication: Dosage: Route: Time(s): Special Instructions: Purpose of medication: Side effects/ adverse reactions to be reported: Starting Date: Ending Date: SIGNATURE OF HEALTH CARE PROVIDER WITH PRESCRIPTIVE AUTHORITY) LICENSE NUMBER PHONE FAX ATTENTION PRESCRIBERS: IF THIS Rx IS FOR A RESCUE INHALER OR EPI-PEN please complete the Colorado School Asthma Plan and/or Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders. School District Policy JLCA requires, as a condition to its agreement to release any medication to students, that the medicine be prescribed by a physician or dentist and furnished by the parent(s) of the student with the original pharmacy container label stating the student s name, name of the medication, the dosage, the number of dosages per day or time(s) when the medication is to be released to the student, and the date when the medication is to be stopped. New forms must be completed annually or with any changes in medication administration and the parent must pick up expired/unused medication prior to the last day of school or it will be disposed of per Board of Health Guidelines. It is understood that the medication is given at the request of, and as an accommodation to, the undersigned parent(s) or guardian(s). For safety reasons, parents are requested to bring the medication directly to the school nurse. By signing this document, I give permission for the nurse or nurse designee to administer the medication as prescribed and give my permission for this Health Care Provider to share information about this medication s administration with the Registered Nurse. The undersigned parent(s) or guardian(s) hereby agree(s) to exempt and release the Cherry Creek School District and its directors, officers, employees, volunteers and agents, from any and all liability, claims, demands or actions whatsoever arising out of any damage, loss or injury that my child or I/we might sustain or which they now have or may hereafter have arising out of the release of the medication to the student. PARENT/GUARDIAN SIGNATURE PHONE DATE This consent must be resubmitted at the beginning of every school year. RV 6/2016

Order your 2018-2019 Howler! The Howler is Challenge School s Directory. It costs just $5.00 each. The directory is created annually. It uses the information you have provided in your Parent Forms Tile on the mycherrycreekschools.org website. The directory includes parents names, phone numbers, home address and email addresses. It also includes class lists, staff phone numbers and emails, PTCO Board members and committee chairs, delayed start information and a calendar of events. Please complete the form below. Attach a check made out to Challenge School PTCO. Return it on Check In Day on August 2 nd, 2018 or place it in the PTCO Locked Box if ordering after that date. The last day to place your order is September 4 th, 2018. Your Howler(s) will be delivered to your youngest child s Connections teacher. Student Name Grade Connections Teacher If your surname is different than your child/ren please provide your name here: Number of Howlers: Check # Amount Paid $

Join the 2018-19 Challenge School Chess Club! Deadline for filling out online registration and paying fee: September 28 Who: Any student in grades K-8 (no experience necessary) What: Classes from beginner to tournament-level with Chess Instructors Where: Upstairs in Team D and E classrooms When: Fridays that we have school from 3:00-4:30 PM during the months of November-March (November 2, November 16, November 30, December 7*, December 14*, December 21*, January 11, January 18, January 25, February 1, February 8, February 22, March 1, March 8, March 15, March 29) *One of the December dates will be cancelled; that date is TBA How: 1. Fill out the online registration form at https://goo.gl/forms/wv1wlfvfnht34thw2 Note: Instead of trying to type in the registration form link, you can go to the Challenge School Website- >Clubs and Activities->School Sponsored Clubs->Chess Club Flyer to access this form electronically and click on the registration link. 2. Pay the $110 registration fee at check-in on August 2 or at the main office no later than September 28. Note: September 28 is a hard deadline because we have to have an exact count of how many members we have in order to hire the right number of instructors. Don t miss out! Parent Requirements: 1. Students must be picked up by 4:30 pm or be registered to attend Wolf Watch after chess club. Late pickups are subject to warnings, and your child may be removed from the program without a refund after repeated late pick-ups. 2. Chess Club requires a parent to volunteer twice during the academic year from 3 to 4:30 pm in order for a student to participate in chess club. Challenge School requires an adult (other than the instructor) be present during chess club class. Parents DO NOT need to know how to play chess. Parents are class facilitators for the student s learning and safety. These volunteer hours count towards the required volunteer hours. Parents must sign up on Sign Up Genius (instructions will be sent to parents). If a parent is unable to attend those days, the parent is responsible to arrange for a substitute parent.