Enrollment Documentation Requirements KINDERGARTEN 2014 … · NCUSD203 2014-2015 Centralized...
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NCUSD203 2014-2015 Centralized Enrollment Office rev 11.19.13 Enrollment Documentation Requirements KINDERGARTEN 2014-2015 Please find below a list of required documents necessary to enroll your student in Naperville School District 203. ENROLLMENT DOCUMENTS Enrollment Form Birth Certificate – original or certified copy Pre-K Questionnaire Home Language Survey Needs Assessment of Special Education, Early Intervention or Gifted Students Parental Consent for Release of Records Denial of Permissions for Publications, Media Releases, Directory Information and Military Recruitment Emergency Card – To be completed at Centralized Enrollment Office Dual Language Program Application (completed) OR Not participating State of Illinois Department of Human Services Certificate of Child Health Examination • All Kindergarten, 6 th & 9 th grade students and all students enrolling from out of state shall have a physical examination before October 15 of the year of the required exam or within 30 days of enrollment for new students from out of state. The exam must be dated within one year prior to the date the student enters school. Illinois Department of Public Health Eye Examination Report • All Kindergarten students and all students enrolling from out of state shall have an eye examination before October 15 of the year of the required exam or within 30 days of enrollment for new students from out of state. Illinois Department of Public Health Proof of School Dental Exam • All Kindergarten, 2 nd and 6 th grade students must have an oral health examination performed by a licensed dentist. The exam is due no later than May 15 of the year of the required exam. The exam must have been performed any time within an 18-month period prior to this due date.
Transcript of Enrollment Documentation Requirements KINDERGARTEN 2014 … · NCUSD203 2014-2015 Centralized...
NCUSD203 2014-2015 Centralized Enrollment Office rev 11.19.13
Enrollment Documentation Requirements KINDERGARTEN 2014-2015
Please find below a list of required documents necessary to enroll your student in
Naperville School District 203. ENROLLMENT DOCUMENTS Enrollment Form Birth Certificate – original or certified copy Pre-K Questionnaire Home Language Survey Needs Assessment of Special Education, Early Intervention or Gifted Students Parental Consent for Release of Records Denial of Permissions for Publications, Media Releases, Directory Information and Military Recruitment
Emergency Card – To be completed at Centralized Enrollment Office Dual Language Program Application (completed) OR Not participating State of Illinois Department of Human Services Certificate of Child Health Examination
• All Kindergarten, 6th & 9th grade students and all students enrolling from out of state shall have a physical examination before October 15 of the year of the required exam or within 30 days of enrollment for new students from out of state. The exam must be dated within one year prior to the date the student enters school.
Illinois Department of Public Health Eye Examination Report • All Kindergarten students and all students enrolling from out of state shall have an eye
examination before October 15 of the year of the required exam or within 30 days of enrollment for new students from out of state.
Illinois Department of Public Health Proof of School Dental Exam • All Kindergarten, 2nd and 6th grade students must have an oral health examination
performed by a licensed dentist. The exam is due no later than May 15 of the year of the required exam. The exam must have been performed any time within an 18-month period prior to this due date.
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Spec
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cas
e of
an
emer
genc
y if
you
cann
ot b
e re
ache
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hori
ze th
is sc
hool
to se
ek th
e ne
cess
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genc
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re a
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eatm
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dir
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SIG
NA
TU
RE
OF
PAR
EN
T/G
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St
uden
t req
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for
the
loan
of t
extb
ooks
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ques
t the
loan
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ar te
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cord
ance
with
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lic A
ct 7
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1 of
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und
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rem
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s a st
uden
t is e
nrol
led
in th
is sc
hool
and
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I m
ay a
t any
tim
e w
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st.
SIG
NA
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RE
OF
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R
ev.
4.24
.14
X
X
NCUSD203 Centralized Enrollment Office Rev. 11.19.13
Pre-Kindergarten Questionnaire The purpose of this questionnaire is to help us get to know your child. The information will be shared with your child’s kindergarten teacher. Please return this at Kindergarten Preview.
Please Print FAMILY DATA: Child’s Name:__________________________________ Birthdate:_____________ Boy_____Girl____ First Last Please call my child by the following name:_______________________________________________ Home Phone:_________________ Cell Phone _________________E-Mail:______________________ Street Address:______________________________________________________________________ City:____________________________________ State:_______________________ Zip:__________ Father’s Name:_________________________________ Father’s Work Phone:___________________ Mother’s Name:_________________________________ Mother’s Work Phone:_________________ Siblings: (Names and ages)____________________________________________________________ Child lives with: Mother_______ Father________ Stepmother________ Name:_________________________________________ Stepfather_________ Name:_________________________________________ Other_____________ Name:_________________________________________ What language is spoken most frequently in the home?___________________________ What other languages are spoken in the home?__________________________________ HEALTH DATA: Was there anything unusual in your child’s early medical history? __________________________________________________________________________________ __________________________________________________________________________________ Are there any physical/health concerns including allergies, vision, hearing, etc.? __________________________________________________________________________________ __________________________________________________________________________________ Does your child require any medication? If so what kind? __________________________________________________________________________________ __________________________________________________________________________________
NCUSD203 Centralized Enrollment Office Rev. 11.19.13
Has your child ever been to preschool or day care center?____________________________________ Name of preschool your child attended:_______________________ For how long?____________ Can your child say his/her first and last name?______ Can your child print his/her first name?______ About how often do you read to your child?_______________________________________________ About how many hours a day does your child watch TV/video?___________ Does your child use a computer? If yes, how often?____________________ Does your child have special fears (dogs darkness, etc.?)_____________________________________ __________________________________________________________________________________ What concerns, if any, do you have about your child? ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_____________________________________________________________________________
Thank you for taking time to fill out this survey. We hope it will help us get to know your child a little better. Is there anything else you would like us to know about our kindergartner from your home? ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
NCUSD203 Centralized Enrollment Office Rev 6.23.14
Naperville Community Unit School District 203 Home Language Survey
Student’s Legal Name:__________________________________________________________________________________________ (First name) (Last name) Date of Birth :_____________ School Grade:________ Male Female
Address:___________________________________________________________________ Home Phone:______________________ Father’s Name:_________________________________________ Cell Phone:____________________ (First name) (Last name)
Mother’s Name:_________________________________________ Cell Phone:_____________________ (First name) (Last name)
MOST RECENT SCHOOL ATTENDED _____________________________________________________________________________ _ School City State District Grade
The state of Illinois requires each district to collect a Home Language Survey for every new student. This information is used to count the students whose families speak a language other than English at home. The Home Language Survey also helps to identify students who need to be assessed for English language proficiency. If the answer to either question #1 or #2 below is “YES,” the Illinois School Code requires the school to assess your child’s English language proficiency.
1. Is a language other than English spoken in your home? No Yes What language? (Infinite Campus Entry: Home Language/Native Language)
2. Does your child speak a language other than English? No Yes What language? (If yes, answer 2a and 2b.) (Infinite Campus Entry: Home Language/Native Language)
2a. Does your child read in this language? No Yes 2b. Does your child write in this language? No Yes
3. Was the student ever in a Bilingual, Dual Language or ESL Program? No Yes (If yes, please answer questions 3a and 3b.)
3a. Please indicate which program: Bilingual Dual Language ESL 3b. Please mark the grade(s) in which the student was in a Bilingual, Dual Language or an ESL Program:
PreK K 1 2 3 4 5 6 7 8 9 10 11 12
4. Indicate your preferred language for communication. English Spanish
___________________________________ _______________ (Signature of parent or guardian) (Date)
Send copy to Office of Language Learning: [email protected], [email protected] and [email protected] for all grade levels
[email protected] for junior high [email protected] for high school
NCUSD203 Centralized Enrollment Office rev 11.19.13
Naperville Community Unit School District 203 Needs Assessment of
Special Education, Early Intervention or Gifted Students To: Parents of New Students enrolled in Naperville Community Unit School District 203
Re: Individual Special Education Needs
Date: Student’s Name: School:
Phone number(s): Grade: ID#
Please examine the questions below and provide us with information to best address your child’s individual needs. This information will help us to make the most appropriate placement and to have the necessary supports and programs in place as needed. Please answer the following questions by circling the correct response. If you circle YES, please give specific information after the question.
Does your child have a current IEP and receive special education services? Yes No
*If yes, please provide a copy of your child’s IEP (Individualized Education Program) Has your child ever been enrolled in a special education program? Yes No
Has your child ever had private or school-based speech or language therapy? Yes No
Has your child ever had private or school-based occupational or physical therapy? Yes No
Has your child received early intervention to address any learning difficulties? Yes No
Has your child ever been evaluated for possible learning difficulties? Yes No
Do you have concerns about your child’s learning and achievement that need Yes No
to be reviewed by the school? Has your child ever been evaluated or placed in a gifted program? Yes No
If your child is transported to school in a wheelchair, please indicate here and Yes No
request a “wheelchair information” form.
Please provide us with any additional information regarding your child’s individual or special academic or social needs. If there are any special considerations that would affect educational progress, please list them below.
NCUSD203 Centralized Enrollment Office rev 11.19.13
Dan Bridges, Superintendent
NAPERVILLE COMMUNITY UNIT SCHOOL DISTRICT 203
Administrative Center | 203 West Hillside Road | Naperville, Illinois 60540-6589
PARENTAL CONSENT FOR RELEASE OF STUDENT RECORDS
Date:
Student Name: DOB:
Has enrolled at in __________ grade. District 203 School
I hereby authorize: ___________________________________ Phone: Name of Student’s Current School ___________________________________ Fax: Street Address
___________________________________ City, State, Zip To release to NAPERVILLE COMMUNITY UNIT SCHOOL DISTRICT 203 the following information on the above named student:
• Academic Records • Health Records • Special Education Records (if applicable) • ISBE Transfer Form or Letter of Good Standing
SEND RECORDS TO: Phone: (to be completed by Name of School Enrollment Office) Fax: Street Address
City, State, Zip __________________________________ _________________ Parent/Guardian Signature Date The Federal Register Volume 41, No, 118 Section 99.31 of June 17, 1976, states that prior consent for the disclosure of school records is not required if the disclosure is to officials of another school or school system in which the student seeks or intends to enroll.
PERMISSIONS: Please select the categories that apply or indicate no restrictions. Public events, such as concerts, com-munity activities, awards, athletics, superintendent visits, etc. are excluded from this permissions denial. Unrestricted: I have read the above statements and agree to my student’s participation WITHOUT restrictions. (Proceed to Directory Section)
Full Denial: I DENY PERMISSION for use of student’s full name, InDIvIDual Image and nameD work except when the event is deemed public, as described above. (Proceed to Directory Section)
Image: I DENY PERMISSION for use of an InDIvIDual Image. I understand this denial does not apply to photos where my student appears as part of a group.
Full Name: I DENY PERMISSION for use of a full name. This does not exclude the use of first name with last initial only.
Work Product: I DENY PERMISSION for nameD work to be shared.
we are very proud of our students and their accomplishments, and we enjoy highlighting their work and activities. In publicizing and supporting learning, events, programs, services and recognitions that take place within our schools or for our students, there will be times when the district will share information through broadcast, print, web site and social media postings. The purpose of this form is to make you aware of these requests and to allow you to remove your student from involvement. Permission preferences indicated on this form will remain in a student’s record unless you submit a Changed Permissions Status Form (available at the school office). If a Permission Denial form is NOT FILED, then UNRESTRICTED permission is applied.
Naperville School DiStrict 203203 W. hillSiDe roaD, Naperville, il 60540
ceNtralizeD eNrollmeNt office 630-548-4320
Denial of Permissions Form for 2014-2015for Publications, media releases, Directory Information and military recruitment
Student name__________________________________ School_______________________________________
Student I.D. number___________________ grade_______Home Phone________________________________
Parent/guardian Signature_____________________________________________Date____________________
SCHOOL DIRECTORY: The following denial concerns Home&School directories which contain student information. I do NOT give permission to use my student’s name, parent/guardian name, address, telephone or email address in any school directory (print/electronic). Does not apply to information kept for official school district use.
HIgH SCHOOL JUNIORS aND SENIORS ONLY: federal law requires a student’s name, address and telephone number to be released to military recruiters unless the parent/guardian objects in writing.
I do NOT give permission for my student’s information to be released to military recruiters.
or choose from the following:
NCUSD 203 Centralized Enrollment Office 11-19-13
Please read and complete aLL SECTIONS of the Permission Denial Form.
NOTICE: I understand requesting my student to be excluded from any or all of the above DOES NOT EXCLUDE the publishing of my student’s name, portrait, works or other photographs in the school yearbook.
State of Illinois
Certificate of Child Health Examination
IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
Student’s Name Last First Middle
Birth Date Month/Day/Year
Sex Race/Ethnicity School /Grade Level/ID#
Address Street City Zip Code
Parent/Guardian Telephone # Home Work
IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication.
Vaccine / Dose 1 MO DA YR
2 MO DA YR
3 MO DA YR
4 MO DA YR
5 MO DA YR
6 MO DA YR
DTP or DTaP
Tdap; Td or Pediatric DT (Check specific type)
TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT
Polio (Check specific type)
IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV
Hib Haemophilus influenza type b
Hepatitis B (HB)
Varicella (Chickenpox)
COMMENTS:
MMR Combined Measles Mumps. Rubella
Single Antigen Vaccines
Measles Rubella Mumps
Pneumococcal Conjugate
Other/Specify Meningococcal, Hepatitis A, HPV, Influenza
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date MO DA YR (Attach copy of lab result)
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN
Date Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts
Age/ Grade
R L R L R L R L R L R L R L R L R L
Vision Hearing
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013
Birth Date Sex School Grade Level/ ID
# Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.)
Diagnosis of asthma? Child wakes during night coughing?
Yes No Yes No
Loss of function of one of paired organs? (eye/ear/kidney/testicle)
Yes No Birth defects? Yes No Hospitalizations?
When? What for? Yes No
Developmental delay? Yes No
Blood disorders? Hemophilia, Sickle Cell, Other? Explain.
Yes No Surgery? (List all.) When? What for?
Yes No
Diabetes? Yes No Serious injury or illness? Yes No
Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No
Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No
Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No
Dizziness or chest pain with exercise?
Yes No Family history of sudden death before age 50? (Cause?)
Yes No
Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Dental Braces Bridge Plate Other
Ear/Hearing problems?
Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date Bone/Joint problem/injury/scoliosis? Yes No
PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P
DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered ? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm ______________ Blood Test: Date Reported / / Result: Positive Negative Value ______________ LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Sickle Cell (when indicated) Urinalysis Developmental Screening Tool
SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Endocrine Ears Gastrointestinal
Eyes Amblyopia Yes No Genito-Urinary LMP Nose Neurological
Throat Musculoskeletal Mouth/Dental Spinal Exam
Cardiovascular/HTN Nutritional status
Respiratory Diagnosis of Asthma Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid)
Other
NEEDS/MODIFICATIONS required in the school setting
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal
EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited
Print Name (MD,DO, APN, PA) Signature Date
Address Phone
(Complete Both Sides)
State of IllinoisEye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eyeexaminations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school forother children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinoisschool system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.
Student Name ________________________________________________________________________________________________(Last) (First) (Middle Initial)
Birth Date ____________________ Gender ______ Grade _____(Month/Day/Year)
Parent or Guardian ____________________________________________________________________________________________(Last) (First)
Phone ______________________________(Area Code)
Address _____________________________________________________________________________________________________(Number) (Street) (City) (ZIP Code)
County ____________________________________________
To Be Completed By Examining Doctor
Case HistoryDate of exam ________________
Ocular history: � Normal or Positive for ___________________________________________________________________
Medical history: � Normal or Positive for ___________________________________________________________________
Drug allergies: � NKDA or Allergic to ____________________________________________________________________
Other information _____________________________________________________________________________________________
ExaminationDistance NearRight Left Both Both
Uncorrected visual acuity 20/ 20/ 20/ 20/Best corrected visual acuity 20/ 20/ 20/ 20/
Was refraction performed with dilation? �Yes � No
Normal Abnormal Not Able to Assess CommentsExternal exam (lids, lashes, cornea, etc.) � � � __________Internal exam (vitreous, lens, fundus, etc.) � � � __________Pupillary reflex (pupils) � � � __________Binocular function (stereopsis) � � � __________Accommodation and vergence � � � __________Color vision � � � __________Glaucoma evaluation � � � __________Oculomotor assessment � � � __________Other _________________________ � � � __________NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.
Diagnosis� Normal � Myopia � Hyperopia �Astigmatism � Strabismus �Amblyopia
Other _______________________________________________________________________________________________________
Continued on backPage 1
State of IllinoisEye Examination Report
Recommendations1. Corrective lenses: � No �Yes, glasses or contacts should be worn for:
� Constant wear � Near vision � Far vision� May be removed for physical education
2. Preferential seating recommended: � No �Yes
Comments ________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Recommend re-examination: � 3 months � 6 months � 12 months
� Other ____________________________________
4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________
Print name____________________________________________ License Number_____________________________________Optometrist or physician (such as an ophthalmologist)
who provided the eye examination � MD � OD � DO
Address ____________________________________________
____________________________________________
Phone ____________________________________________
Signature ____________________________________________ Date ___________________
(Source: Amended at 32 Ill. Reg. _________, effective ___________)
Consent of Parent or GuardianI agree to release the above information on my childor ward to appropriate school or health authorities.
(Parent or Guardian’s Signature)
(Date)
Page 2Printed by Authority of the State of Illinois
6/09IOCI1271-09
State of Illinois Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student's Name: Last First Middle Birth Date: (Month/Day/Year)
/ /
Address: Street City ZIP Code Telephone:
Name of School: Grade Level: Gender:
❑ Male ❑ Female
Parent or Guardian: Address (of parent/guardian):
To be completed by dentist:
Oral Health Status (check all that apply)
❑ Yes ❑ No Dental Sealants Present
❑ Yes ❑ No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it was
extracted as a result of caries OR missing permanent 1st molars.
❑ Yes ❑ No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid- ered sound unless a cavitated lesion is also present.
❑ Yes ❑ No Soft Tissue Pathology
❑ Yes ❑ No Malocclusion
Treatment Needs (check all that apply)
❑ Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
❑ Restorative Care — amalgams, composites, crowns, etc.
❑ Preventive Care — sealants, fluoride treatment, prophylaxis
❑ Other — periodontal, orthodontic
Please note
Signature of Dentist Date of Exam
Address
Telephone Street City ZIP Code
Illinois Department of Public Health, Division of Oral Health 217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us
Printed by Authority of the State of Illinois IOC! 0600-10
Naperville Community Unit School District 203 www.naperville203.org
Revised 12/4/2013
Hola
Hello
You are invited to an Orientation and Question & Answer Session to learn about our
Spanish/English Dual Language Program
When: Thursday, March 6, 2014 at 6:30 p.m.
Where: Elmwood School Gym, 1024 Magnolia Lane, Naperville
Students learn in two languages!
District 203 offers Dual Language in 5 buildings. The Magnet Dual Language Program is located at River Woods.
Beebe, Elmwood, Steeple Run and Mill Street offer the program as well. The Dual Language Programs at these four buildings are for students living within those specific attendance areas.
Please join us to learn more about enrolling your child entering Kindergarten in the Dual Language Program for the 2014-2015 school year.
Please RSVP by calling (630) 420-7011.
Students who participate in dual language programs develop true bilingualism, biliteracy, and multiculturalism!
All interested families should complete a registration form which can be found.at: http://www.naperville203.org/departments/curriculum/DLKindergartenReg.asp
Naperville Community Unit School District 203 Dual Language Program Registration Form
2014-2015
Beebe Elementary School Mill St. Elementary School River Woods Elementary School (K-5 Beebe attendance area students only) (K-4 Mill St. attendance area students only) (K-5 Current magnet site for Dual Language) Steeple Run Elementary School Elmwood Elementary School (K-2 Steeple Run attendance area students only) (K-2 Elmwood attendance area students only)
Name of Student: _______________________________________ Male Female Home Address: _______________________________________ Child’s Birth Date:____________________ (month/day/year) City: _________________________ Zip Code: ___________ Home Phone: (______)___________________________ Alternative Phone: (______)________________________ E-mail Address: ____________________________________ Home School: _______________________________ (School your child would normally attend) Grade entering in fall 2014: K 1 2 3 4 5 Language Dominance: Spanish English Mother’s name: __________________________________________ (Academic Dominance: a language in which the child would be a good language model) Father’s name: ___________________________________________ -OR- Guardian’s name: _________________________________________ Balanced Bilingual Student
My child receives Special Education Services Additional.Information:_________________________________________________________________________________________________________________________________________________________________________________________ We understand the information below regarding the Dual Language Program in District 203, and we are interested in continuing with the registration process for our child: Dual language is a bilingual education model that consistently uses two languages for instruction and communication, with a balanced number of students from two language groups who are integrated for instruction at least half of the school day. Dual language promotes cross-cultural understanding and acceptance. The goal of dual language instruction is bilingualism and biliteracy for all students in appropriate grade-level content. The level of bilingualism and biliteracy developed through dual language are usually not attained through other bilingual or foreign language instruction models. This level of biliteracy is achieved because:
o Literacy and content instruction are provided in both languages.
o Only one language is used during each period of instruction.
o Equal status is given to both languages.
o District curriculum objectives are used within Dual Language classrooms. *A lottery system will be used for student selection should more students indicate interest in the program than the number of available slots. IF YOU ARE APPLYING FOR THE MAGNET DUAL LANGUAGE CLASS, PLEASE TURN IN YOUR REGISTRATION PAPERWORK TO CENTRALIZED ENROLLMENT. YOUR REGISTRATION PAPERWORK WILL THEN BE TRANSFERRED TO THE DUAL LANGUAGE MAGNET SCHOOL SHOULD YOU BE ENROLLED IN THIS PROGRAM. Signature of Parent/Guardian: ________________________________ Date: ________________ Please return this form to the District 203 Administrative Center, Attention: Julie Knight, 203 W. Hillside Road, by March 14th, 2014. The Dual Language Lottery will be conducted the week of March 17th and parent notification via U.S. mail will occur no later than the week of March 31st.
Naperville CUSD 203 Apply for Free and Reduced
Meal Benefits Online!
Dear Parent/Guardian,
Naperville CUSD 203 is pleased to announce the availability of applying for Free and Reduced Price Meals online! The process is SAFE, SECURE, PRIVATE, and AVAILABLE anytime, anywhere!
Safe & Secure
We use the highest level of data encryption available, meaning that your information is always safe and guarded.
Private & Available
Apply online in the privacy of your own home. The online service is available 24/7 anytime, anywhere there is an Internet connection!
Fast
Your data is transmitted to the Naperville CUSD 203 Business Office the same day you apply, allowing for quicker processing so you can receive benefits faster.
Go Green
No more paper applications to complete and return to the school office! Applying online is so convenient and good for the environment as well!
• Visit www.heartlandapps.com • Select your State (IL) and then your School District (Naperville CUSD 203) • Follow the easy to use, step-by-step screens to enter student and household
information • Click "Apply" to submit your application for meal benefits!
The First Day of School is August 20 Online Application Entry will be available beginning July 23
Please note that all applications are subject to verification
Dear Parent/Guardian:
Children need healthy meals to learn. Naperville CUSD 203 offers healthy meals every school day. Breakfast costs $ N/A • lunch costs $ varies . Your children may qualify for free meals or for a reduced price meals. Reduced price is $ N/A for breakfast and $ .40 for lunch. To apply for free or reduced-price meals, use the Household Eligibility Application, which is enclosed. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: your school or to NCUSD203 / 203 W Hillside Rd / Naperville, IL 60540
Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart.
Income Eligibility Guidelines Effective from July 1, 2014, to June 30, 2015
Reduced-Price Meals 185% Federal Poverty Guideline
Household Size Annual Monthly Twice Per
Month Every Two
Weeks Weekly
1 21,590 1,800 900 831 416
2 29,101 2,426 1,213 1,120 560
3 36,612 3,051 1,526 1,409 705
4 44,123 3,677 1,839 1,698 849
5 51,634 4,303 2,152 1,986 993
6 59,145 4,929 2,465 2,275 1,138
7 66,656 5,555 2,778 2,564 1,282
8 74,167 6,181 3,091 2,853 1,427
For each additional family member, add
7,511 626 313 289 145
1. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Complete the application to apply for free or reduced price meals. Use one Household Eligibility Application for all students in your household per district. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to the school.
2. WHO CAN GET FREE MEALS? All children in households receiving benefits from Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) and/or are foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals regardless of your income. Also, your children can get free meals if your household's gross income is within the free limits on the Federal Income Eligibility Guidelines. Children who meet the definition of homeless, runaway, or migrant also qualify for free meals. If you haven't been told your children will get free meals, please contact your school to see if your child(ren) qualifies.
3. WHO CAN GET REDUCED PRICE MEALS? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Eligibility Income Chart, shown above.
4. A MEMBER OF MY HOUSEHOLD RECEIVED SNAP OR TANF BENEFITS. THE SCHOOL SENT A LETTER STATING THAT MY CHILD IS AUTOMATICALLYAPPROVED FOR FREE MEALS BASED ON DIRECT CERTIFICATION. DO I NEED TO DO ANYTHING MORE TO ENSURE THAT MY CHILD RECEIVES FREE MEALS? No. You do not need to do anything more to receive free meals for your child. If you have students not listed on the letter, contact the school immediately. If you do not wish to receive the free meals, you should follow the steps outlined in the letter from the school to notify school personnel immediately.
5. MY CHILD'S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child's application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year.
6. I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out the enclosed application.
7. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof.
8. IF I DON'T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit
9. WHAT IF I DISAGREE WITH THE SCHOOL'S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to the person listed above.
10. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You or your child(ren) do not have to be U.S. citizens to qualify for free or reduced price meals.
11. WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them.
12. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
13. WE ARE IN THE MILITARY. DO WE INCLUDE OUR HOUSING ALLOWANCE AS INCOME? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income.
14. MY SPOUSE IS DEPLOYED TO A COMBAT ZONE. IS HER COMBAT PAY COUNTED AS INCOME? No, if the combat pay is received in addition to her basic pay because of her deployment and it wasn't received before she was deployed, combat pay is not counted as income. Contact your school for more information.
15. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for SNAP, TANF or other assistance benefits, contact your local Department of Human Services office or call (800) 843-6154 (voice) or (800) 447-6404 (TTY).
Sincerely,
ISBE 68-06 NSLP SBP (6/14) Page 1 of 3
INSTRUCTIONS FOR APPLYING - COMPLETE ONE APPLICATION PER HOUSEHOLD PER SCHOOL DISTRICT
IF YOUR HOUSEHOLD RECEIVES SNAP OR TANF BENEFITS, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
Part 1: List all household members, school and grade for each student, and a SNAP or TANF case number for any household member including adults receiving such
benefits. (Attach another sheet of paper if necessary.) .
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. (The last four digits of a Social Security Number are not necessary.)
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
IF NO ONE IN YOUR HOUSEHOLD GETS SNAP OR TANF BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY OR HEAD
START/EVEN START, FOLLOW THESE INSTRUCTION AND RETURN THE COMPLETE FORM TO YOUR SCHOOL:
Part 1: List all household members and the name of school for each child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Complete only if a child in your household isn't eligible under Part 2. See instructions for All Other Households.
Part 4: Sign the form. Only if part 3 is completed, please include the last four digits of a Social Security Number. (or mark the box if s/he doesn't have one).
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
If children in the household are foster children that are the legal responsibility of a foster care agency or court:
Part 1: List all foster children and the school name for each child. Check the "Foster Child" box for each foster child.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
If some of the children in the household are foster children are foster children that are the legal responsibility of a foster care agency or court:
Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the "No Income" box. Check
the "Foster Child" box for each foster child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Follow these instructions to report total household income from this month or last month.
• Box 1-Name: List all household members with income.
• Box 2 -Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), and disability benefits. Under All Other Income, list Worker's Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
Part 4: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn't have one).
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
ALL OTHER HOUSEHOLDS INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the "No Income" box.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Follow these instructions to report total household income from this month or last month.
• Box 1-Name: List all household members with income.
• Box 2 -Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), and disability benefits. Under All Other Income, list Worker's Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
Part 4: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn't have one).
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in any program or activity conducted or funded by the USDA. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to the USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC 20250-9410, by fax (202) 690-7442 or email at program. [email protected]. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
ISBE 68-03 NSSTAP Application Instructions (6/14)
Page 2 of 3
Work Telephone Number (Include Area Code) Home Telephone Number (Include Area Code)
6. Children's Racial and Ethnic Identities (Optional)
Mark one ethnic identity: ❑ Hispanic/Latino ❑ Not HispanidLatino
Home Address (Number, Street, City, State, Zip Code)
❑ Native Hawaiian or Other Pacific Islander Mark one or more racial identities:
❑ Asian ❑ Black or African American ❑ White ❑ American Indian or Alaska Native
7. Sharing Application Information With All Kids—All Kids program is a complete healthcare program for every child in Illinois.
No! I DO NOT want information from my Household Eligibility Application shared with All Kids. Sign here:
— THE FOLLOWING SECTIONS ARE FOR SCHOOL USE ONLY—
LEAs must annualize income only when multiple incomes, at varying frequencies, are reported. Annual Income Conversion Weekly X 52 Every 2 Weeks X 26 Twice a Month X 24 Once a Month X 12
❑ Free based on: ❑ homeless ❑ migrant ❑ runaway ❑ Head Start
❑ SNAP or TANF ❑ foster child ❑ household's income
I:1 Reduced based on: ❑ household's income
ODenied—Reason: ❑ income too high ❑ incomplete application ❑ Non-qualifying SNAP/TANF
Date Withdrawn: Date: Signature of Determining Official
Every 2 Twice a
NUMBER IN
Per: ❑ Week ❑ Weeks ❑ Month ❑ Month ❑ Year HOUSEHOLD: CHANGE IN STATUS: Date
TOTAL INCOME
APPLICATION FOR FREE MILK/MEAL AND REDUCED-PRICE MEALS—Complete One Application Per Household Per School District. Instructions on back. , SCHOOL USE ONLY
1. All Household Members • Check if Error Prone Application
NAMES OF ALL HOUSEHOLD MEMBERS (for Student only) (for Student only) First, Middle Initial, Last School Name Grade
SNAP OR TANF CASE N M B R SkIPto par 4 if you saSNFor TANF case At least one SNAP/TANF must
be provided below.
if NO
Income
Check if Foster Child*
- - - . 111 - - - . El - - - . . - - - . . - - - . II
- - . .
2. Homeless, Migrant, Runaway, or Head Start (Categorically eligible) A foster child is the legal responsibility of a welfare agency or court.
❑ Homeless ❑ Migrant 0 Runaway n Head Start Signature of Your School Homeless Liaison, Migrant Coordinator, or Head Start Director
Date
3. Total Household Gross Income (before deductions) You must tell us how much and how often. A.
NAMES (LIST ALL HOUSEHOLD MEMBERS
WITH INCOME)
GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month, $100 /twice a month; $100/every other week; $100/week)
Earnings From Work (Before Deductions)
Welfare, Child Support, Alimony
Pensions, Retirement, Social Security
Worker's Comp., Unemploy-ment, SSI, etc. (An other income)
B. Amount How often? C. Amount How often? D. Amount How often? E, Amount How often?
I. $ $ $ $
ii. $ $ $
iii. $ $ $
iv. $ $ $
V. $ $ $ $
4. Signature and Social Security Number (Adult must sign)
An adult household member must sign the application. If Part 3 is completed or if no income is checked xxx-xx- Ei do not have a social —in Part1 , the adult signing the form must also list the last four digits his or her social security number — — — — — — — —
Social Security Number security number.
I certify (promise) all information on this application is true and all income is reported. I understand the school will get Federal funds based on the information I give. I understand school of-ficials may verify (check) the information. I understand if I purposely give false information, my children may lose meal benefits and I may be prosecuted.
Date
Printed Name of Adult Household Member
Signature of Adult Household Member
5. Contact Information (Optional)
THE FOLLOWING SECTIONS ARE NOT REQUIRED FOR SCHOOLS/DISTRICTS THAT ONLY PARTICIPATE IN ILLINOIS FREE AND/OR SPECIAL MILK PROGRAMS
Signature of Confirming Official
Date: CONFIRMATION (Prior to verification and only for those applications selected for verification.)
VERIFICATION
DIRECT VERIFICATION COMPLETED ❑ INITIAL DETERMINATION
❑ Free based on SNAP/ TANF case number
❑ Free based on income ❑ Reduced based on
income
VERIFICATION RESULTS:
0 No Change ❑ Free to Reduced ❑ Freeto Paid ❑ Reduced to Free 0 Reduced to Paid
REASON FOR CHANGE:
0 Income: $ DATE NOTICE OF STATUS CHANGE SENT: DATE VERIFICATION NOTICE SENT:
❑ Household Size:
CEFFECTIVE
H DATE OF STATUS
ANGE :
DATE RESPONSE DUE FROM HOUSEHOLD:
❑ Change in SNAP/TANF ❑ Did not respond ❑ Other: (recommend 10 calendar days)
DATE, METHOD, RESULTS OF FOLLOW-UP:
Results
❑ Telephone Date:
❑ Personal Contact Verifying Official's Si•nature
(recommend 3 business days)
68-03 School Year 2014-2015 NSSTAP (6 14)
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