Batesville Community School Corporation Student Registration Blank

Transcription

1 Batesville Community School Corporation Student Registration Blank School Year: Readiness Kindergarten (RK) Student s Name Preferred Name Last First Middle Gender: M F Date of Birth: / / Student s Home Phone: mm dd yyyy Physical Address Mailing Address: (if different than physical address) Township of Residence: Adams Butler Laughery Ray Salt Creek County of Residence: Bus Route Number: Student resides with: (check one) Father/Mother Father Mother Guardian Mother/Stepfather Father/Stepmother Foster Parents Grandparents Other Father Employer Home Address Address Mother Employer Home Address Address Stepfather Employer Address Stepmother Employer Address Guardian Employer Address Address Relationship (Continued on reverse side)

2 IF APPLICABLE- Please complete this section: Is this student subject to any court ordered custody or decree? Yes No If yes, please attach a copy of this decree or order and send to the Principal s Office. Name of person who has custody of this child Date of Custody Emergency Contact Information List 3 local persons to contact in case of an emergency if you cannot be reached. 1) Name Relationship 2) Name Relationship 3) Name Relationship Did your child attend Pre-School Yes No Pre-School attended If so, how many years Legal Residency (Please check one) My child resides within the boundaries of Batesville Community School Corporation My child lives outside the boundaries of Batesville Community School Corporation Parent/Guardian Signature Date

3 760 State Road 46 West, Batesville, IN batesvilleinschools.com/bps T: F: Request for Early Entry in Readiness Kindergarten (RK) Applications for early entrance to the RK program for the school year will be accepted through the start of the school year. Students must be at least 4 years old on or before August 1, 2017 to be eligible to apply for early entrance. They are encouraged to be toilet trained in order to attend the RK program. Parents must attend RK registration or meet with BPS staff to receive information about the program while their child takes a screening test. All applications will be reviewed by the Batesville Primary School Principal and then submitted to the Superintendent or his designee for final approval. Children who are approved for early entry will be placed in the Readiness Kindergarten classroom, which is the first year of a two-year kindergarten program. This program is capped at a maximum number. Once each class is filled, the remaining students will be placed on a waiting list. If a space becomes available, the first student on the waiting list will be given the opportunity to be in the RK program. Student Name: Date of Birth: Parent/Guardian Printed Name: Parent/Guardian Signature: Date: Contact Phone Number: Contact OFFICE USE ONLY Request for Early Entry in Readiness Kindergarten: APPROVED WAIT LIST BPS Principal: Date: BCSC Superintendent or Designee: Date:

4 760 State Road 46 West, Batesville, IN batesvilleinschools.com/bps T: F: Readiness Kindergarten (RK) FAQs Eligible students must turn 4 years old on or before August 1, Registration appointments can be made on our website. RK is the first year of a two-year kindergarten program. Kindergarten readiness is the primary goal of the RK program, which focuses on language and literacy activities as well as early math skills. There is a strong emphasis on social, emotional, and motor skill development. RK teachers are fully credentialed and will utilize a readiness curriculum aligned with Indiana State Standards. Bus transportation is available to students in the BCSC boundaries. There is no tuition fee for this program. We strongly encourage students are toilet trained to attend the RK program. Students must have current immunizations to attend the RK program. Students are eligible to receive all services provided through BCSC in which he/she qualifies for, including but not limited to: free/reduced breakfast and lunch, Response to Intervention (RTI), and special education.

5 760 State Road 46 West, Batesville, IN batesvilleinschools.com/bps T: F: IMMUNIZATION REQUIREMENTS TO ENTER SCHOOL It is very important that you have your student s health history completed before the first day of school. This is a very important piece of information for the schools. MINIMUM IMMUNIZATION REQUIREMENT FOR SCHOOL ENTRY Based on the current recommendations of the AAP and the ACIP, the minimum immunization requirements for school attendance have been revised as follows and will be effective as of the school year. When a child enrolls in a school corporation, for the first time or any subsequent time and at any level, his parents must show either that he has been immunized or that a current religious or medical objection is on file. The immunization series must be completed before your child enters school. Please call your family doctor to schedule immunizations. Immunizations are also available at the: Ripley County Health Department in Versailles Parents should call to schedule an appointment. MMH Wellness Clinic 1051 State Road 229 North (behind Main Source Bank) Appointments can be scheduled by calling Tuesdays, 12:30-7:00 Thursdays, 10:00-12:00 and 1:00-5:00 Needed immunizations are listed on the back.

6 Pre-Kindergarten 3-5 year olds 4 doses of diphtheria-tetanus-a cellular pertussis (DTaP), diphtheria-tetanus-pertussis (DTP), or pediatric diphtheria-tetanus vaccine (DT) or any combination of the three are required. 3 doses of either oral polio (OPV) or inactivated polio (IPV) vaccine in any combination 3 doses of Hepatitis B vaccine (3rd dose must be on or after 24 weeks of age). 1 dose of measles (rubella) vaccine, on or after the first birthday. 1 dose of mumps vaccine, on or after the first birthday. 1 dose of rubella (German measles) vaccine, on or after the first birthday. 1 dose of varicella (chickenpox) vaccine on or after the first birthday or physician written documentation of history of chicken pox disease, including month and year of disease.

7 Batesville Community School Corporation 626 N. Huntersville Road *** P.O. Box 121 *** Batesville, Indiana Gayla Vonderheide, RN, BSN, Director of Health Services Phone Fax I, give the Batesville Community School Corporation, Permission to release the following information concerning my child to The Indiana State Department of Health s Children and Hoosiers Immunization Registry Program (CHIRP): The information released would be name, immunization data and other information such as date of birth or other identifying information as applicable. I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me of my child s immunization status or that an immunization is due according to recommended immunization schedules. I understand that my child s information will be available to the immunization data registry of another state, a healthcare provider, a local health department, an elementary or secondary school that is attended by the individual, a child care center, and the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning. I also understand that other entities may be added to this list through amendment to I.C Any questions please contact your School Nurse, Gayla Vonderheide RN, BSN, Director or Health Services I hereby consent to the release of such information. Signature Date Printed Name of Parent or Guardian Address Child s Name School ( ) Telephone Number Grade Level A tradition of excellence ensuring success for tomorrow

8 Batesville Community School Corporation Student Medical Student Name: Last, First Gender Grade/Teacher Medical Information: Family Physician Phone Yes No Yes No Yes No Yes No Yes No While at school, this student may be given Tylenol or Ibuprofen as needed, following instructions on the container. While at school, this student may be given anti-acid preparation as needed following instructions on the container. If an extreme emergency arises, my child may be taken to an emergency care facility either by an emergency rescue unit or by a school official. I (We) give permission to share medical information with appropriate BCSC staff for the safety of our child. Does your student have health insurance coverage. Medical Please inform us of your child s current health conditions, such as allergies, asthma, seizures, vision problems (glasses or contacts), broken bones, physical, handicaps, any recent surgeries, injuries or other illness. This information will only be shared with the staff members who will be working with your child. Medications: Please list your child s medications and reasons for taking them. If a student needs to take medications during the school hours, a permission form to administer medication will need to be filled out by the doctor and parent. This form maybe obtained in the school office. Medication Dose Frequency Reason If there are any changes regarding medical information or immunizations throughout the year, please contact the school nurse. Signature of Parent/Guardian Date Revised 2/11/2014

9 Batesville Community School Corporation Home Language Survey (HLS) The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each student s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 457 U.S. 202 (1982). The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district / charter school. The HLS is administered one time, upon initial enrollment, and remains in the student's cumulative file. Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the survey questions below, the LAS Links placement test will be administered to determine whether or not the student will qualify for additional English language development support. Please answer the following questions regarding the language spoken by the student: 1. What is the native language of the student? 2. What language(s) is spoken most often by the student? 3. What language(s) is spoken by the student in the home? Student Name: Parent/Guardian Name: Parent/Guardian Signature: Date: By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency. For School Use Only: School personnel who administered and explained the HLS and the placement of a student into an English language development program if a language other than English was indicated: Name: Date:

10 Batesville Community School Corporation Race and Ethnicity Report Student Name: Date: Race and Ethnicity: (Note: Both Part 1 and Part 2 of the question must be answered.) Part 1: Ethnicity Is this individual Hispanic/Latino? (Choose only one)! No, not Hispanic/Latino! Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.) The following is a list of Hispanic ancestry groups to which Hispanic individuals may refer themselves. Spaniard, Andalusian, Asturian, Castillian, Catalonian, Balearic Islander, Gallego, Valencian, Canary Islander, Mexican, Mexican American, Mexicano, Chicano, La Raza, Mexican American Indian, Mexican State, Costa Rican, Guatemalan, Honduran, Nicaraguan, Panamanian, Salvadoran, Central American, Canal Zone, Argentinean, Bolivian, Chilean, Colombian, Ecuadorian, Paraguayan, Peruvian, Uruguayan, Venezuelan, Criollo, South American, Latin American, Latino, Puerto Rican, Dominican, Hispanic, Spanish, Californio, Tejano, Nuevo, Mexicano, Spanish American Part 2: Race What is the individual s race? (Choose one or more)! American Indian or Alaska Native: A person having origins in any of the original peoples of North America and maintaining cultural identification through tribal affiliation or community recognition.! 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.! Black or African American: A person having origins in any of the black racial groups of Africa.! Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.! White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Parent Name (Printed): Parent Signature: (Over for Race descriptions)

11 Selecting a Race The following chart may help in connecting geographic/national origin with a race: If an individual considers him-or herself to be: European American Middle Eastern American..or comes from one of the following countries or regions: Northern Europe such as Britain (Scotland, Ireland, Wales), Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, Sweden Western Europe such as Belgium, France, Holland, Luxembourg Central Europe such as Austria, Czech Republic, Germany, Hungary, Poland, Slovakia, Switzerland Eastern Europe such as Belarus, Bulgaria, Romania, Russia, Ukraine Southern Europe such as Bosnia, Catalonia, Croatia, Cyprus, Greece, Italy, Macedonia, Malta, Montenegro, Portugal, Serbia, Slovenia, Spain Other such as Caucasus, Armenia, Georgia, Azerbaijan Afghanistan, Egypt, Israel, Iraq, Jordan, Lebanon, Palestine, Saudi Arabia, Syria, Turkey, Yemen and assuming single-race, the individual may be identified as: White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East North African American Algeria, Egypt, Morocco White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East Black, African American, Afro-American Asian American Pacific Islander Australian or New Zealander not an indigenous person Aborigine, Indigenous Australian, Torres Straits Islander Form created Feb Bahamas, Barbados, Botswana, Ethiopia, Haiti, Jamaica, Liberia, Madagascar, Mozambique, Namibia, Nigeria, Nigriti, South Africa, Sudan, Tobago, Trinidad, West Indies, Zaire Asian Indian, Bangladesh, Bhutan, Burma, Cambodia, China, Taiwan, Philippines, Indonesia, Japan, Korea, Laos, Malaysia Mongolia, Nepal, Okinawa, Pakistan, Singapore, Sri Lankan, Thailand, Vietnam, or ancestry groups such as Hmongs, Mongolians, Iwo Jiman, Maldivian Caroline Islands, Fiji, Guam, Hawaiian Islands, Marshall Islands, Papua New Guinea, Polynesia, Samoa, Solomon Islands, Tahiti, Tarawa Islands, Tonga Australia, New Zealand Australia, New Zealand, Torres Straits Islands Black: A person having origins in any of the black racial groups in Africa Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent.examples of areas included are Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East Pacific Islander