Fort Pierce Westwood Academy · 2020. 4. 3. · Fort Pierce Westwood Academy 1801 Panther Lane *...

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Fort Pierce Westwood Academy 1801 Panther Lane * Fort Pierce, FL 34947 * PHONE: (772) 468-5400 Mr. Joseph Lezeau, Principal Assistant Principals: Ms. Makeda Brome * Mr. Jason Martin * Dr. Matthew Roy * Mrs. Leslie Taylor * Mr. Fred Woltjen Welcome Panther! We are truly excited to meet, greet and welcome new members into the Panther family. Please note: Your child is not registered until you submit documents to the assigned school. The criteria for registering at Fort Pierce Westwood Academy is as follows: 1. The student will need to complete our District application and be assigned to FPWA. If you have not received notification of your assigned school, your application is incomplete. Please visit https://www.stlucie.k12.fl.us/departments/student-assignment/. 2. Please withdraw from the school that you are currently enrolled. 3. The student must have been promoted to the ninth (9 th ) grade level to matriculate in high school. Proof is required via transcript or final report card. 4. The Registration Packet must be completed by the registering parents/guardians. 5. After the registration packet is complete, you will also need to upload: a. If coming from out of State, health records are required: proof of shots and recent physical b. Birth certificate c. Social Security Card (if available) d. Passport (if applicable) e. Transcript or last report card from the last school the student attended. f. Any forms that show guardianship (if the guardian is anyone other than the parent.) g. Any court custody documentation showing legal custody (if applicable) 6. As soon as you have the required documents uploaded; email all documents and the completed registration packet to our School Registrar, Melody Golden at [email protected]. 7. Once your attachments are reviewed and accepted, you will receive an email from one of our School Counselors to complete a course selection sheet and receive your child’s schedule.

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  • Fort Pierce Westwood Academy 1801 Panther Lane * Fort Pierce, FL 34947 * PHONE: (772) 468-5400

    Mr. Joseph Lezeau, Principal

    Assistant Principals: Ms. Makeda Brome * Mr. Jason Martin * Dr. Matthew Roy * Mrs. Leslie Taylor * Mr. Fred Woltjen

    Welcome Panther! We are truly excited to meet, greet and welcome new members into the Panther family. Please note: Your child is not registered until you submit documents to the assigned school. The criteria for registering at Fort Pierce Westwood Academy is as follows:

    1. The student will need to complete our District application and be assigned to FPWA. If you have not received notification of your assigned school, your application is incomplete. Please visit https://www.stlucie.k12.fl.us/departments/student-assignment/.

    2. Please withdraw from the school that you are currently enrolled.

    3. The student must have been promoted to the ninth (9th) grade level to matriculate in high school. Proof is required via transcript or final report card.

    4. The Registration Packet must be completed by the registering parents/guardians.

    5. After the registration packet is complete, you will also need to upload:

    a. If coming from out of State, health records are required: proof of shots

    and recent physical b. Birth certificate c. Social Security Card (if available) d. Passport (if applicable) e. Transcript or last report card from the last school the student attended. f. Any forms that show guardianship (if the guardian is anyone other than

    the parent.) g. Any court custody documentation showing legal custody (if applicable)

    6. As soon as you have the required documents uploaded; email all documents

    and the completed registration packet to our School Registrar, Melody Golden at [email protected]

    7. Once your attachments are reviewed and accepted, you will receive an email

    from one of our School Counselors to complete a course selection sheet and receive your child’s schedule.

    https://www.stlucie.k12.fl.us/departments/student-assignment/mailto:[email protected]

  • White: ESOL Folder Canary: School Counselor Pink: Parent FED0023A revised March 2014

    St. Lucie Public Schools

    Home Language Survey

    In accordance with Rule 6A-1.0955, FAC: Each student, upon initial enrollment in a school district, shall be surveyed at the time of enrollment by being asked the questions identified below. Student Name______________________________________________Date_________________Grade______________

    School Name ________________________________Parent/Guardian Name____________________________________

    Date of Birth_________________________________Birthplace______________________________________________ Date Student 1st enrolled in a school in ANY of the USA 50 states in grades K-12___________________(month/day/year)

    Has the student previously attended any school in Florida? No Yes If “Yes” please complete: Last date attended __________City_______________ School Name_____________________

    You must answer ALL of the following questions by checking Yes or No and answering the questions

    A. Does the student most frequently speak a language other than English? YES What language_________________________________

    NO

    B. Did the student have a first language other than English? YES What language_________________________________

    NO

    C. Is a language other than English used in the home? YES What language_________________________________

    NO

    D. What language would you prefer for home/school communication?

    Spanish Haitian-Creole English

    Read the following statements for Notification of Testing Procedure and Initial on the line provided

    _____If you answer “yes” to any of the above questions your child will be tested for English proficiency so that the teacher(s) can better serve him/her. The St. Lucie County School District administers an oral language test in all grades to determine listening and speaking proficiency, as well as, an English reading/writing proficiency test for grades 3‐12. ____ If you answer “yes” to questions A & B, your child will receive services from the ESOL program until completion of the eligibility assessment.

    ____ A letter of explanation will be sent if the testing cannot be administered within 20 school days of the date above. You will be notified regarding your son’s/daughter’s eligibility for ESOL services once testing is complete. The ESOL program provides services to Limited English Proficient students by placing students with classroom teachers who have had training in strategies to make English and subject area content understandable to them. If you have questions concerning the ESOL services of assessment of English proficiency, please call the school and ask to speak to the ESOL contact.

    Relationship to student Mother Father Guardian Self Other (specify): _________________________________

    _________________________________________ _________________________________ Signature of person completing survey Date

  • Saint Lucie Public Schools Pupil Identification Data Student ID# School Year School Name

    FT PIERCE WESTWOOD Grade Enrollment Date

    / / Student Last Name Student First Name Student Middle Name

    Male Female

    Race **Social Security # ‐ ‐

    Birth Date / /

    Birth City Birth State Birth Country Date entered US / /

    ** SS# is collected in order to identify students within the District’s computer system, Medicaid billing if eligible, and program follow‐up. What is the student’s Race (choose all that apply)? American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

    What is the student’s ethnicity? Hispanic or Latino Not Hispanic or Latino

    Street Address

    Street #, Name, Apt/Lot# City, State, Zip Home Phone ( ) ‐

    Mailing Address

    Check if same as above City, State, Zip

    Name of school student last attended: What Grade? School Phone ( ) ‐

    Address of School (if not in St. Lucie County) City, State, Zip County Country

    Parent/Guardian Contact Information – Please number your contacts in the order they should be called in case of emergency (circle 1‐5)

    1 2 3 4 5 Mr. Mrs. Ms. Dr. Last Name, First Name Relation Lives With: Yes No

    Custody/Shared Custody: Yes No If custody is “NO,” legal documentation is required

    Street Address (if different) Home Phone ( ) ‐

    Work Phone ( ) ‐

    Cell Phone ( ) ‐

    1 2 3 4 5 Mr. Mrs. Ms. Dr. Last Name, First Name Relation Lives With: Yes No

    Custody/Shared Custody: Yes No If custody is “NO,” legal documentation is required

    Street Address (if different) Home Phone ( ) ‐

    Work Phone ( ) ‐

    Cell Phone ( ) ‐

    Other Emergency Contact Information ‐ Any persons listed below will be identified as being able to pick up your child from school

    1 2 3 4 5 Mr. Mrs. Ms. Dr.

    Last Name First Name Relation

    Street Address Home Phone ( ) ‐

    Work Phone ( ) ‐

    Cell Phone ( ) ‐

    1 2 3 4 5 Mr. Mrs. Ms. Dr.

    Last Name First Name Relation

    Street Address Home Phone ( ) ‐

    Work Phone ( ) ‐

    Cell Phone ( ) ‐

    1 2 3 4 5 Mr. Mrs. Ms. Dr.

    Last Name First Name Relation

    Street Address Home Phone ( ) ‐

    Work Phone ( ) ‐

    Cell Phone ( ) ‐

    Military Activity Yes No A parent* of this child is an Active Member of our Armed Forces. (* For this question, parent is defined as natural parent or appointed legal guardian).Release of Information I agree that the following information may be released for my child (Failure to check “NO” may result in the release of information): Yes No My child’s name and contact information to Military Recruiters. (High School Student’s Only) Yes No My child’s name and contact information to Higher Education Institutions. (High School Student’s Only) Yes No My child’s name, photo, voice & video to the press for recognition or news purposes. (Applicable to All Students) Yes No My child’s name, photo, voice & video for publicly assessable school or district websites or broadcast. (Applicable to All Students) Yes No My child’s name, photo, and contact information to the yearbook photographers’. (Applicable to All Students) Yes No My child’s directory information (student’s name and grade) (Applicable to All Students) Note: A limited release of information is required for participation in student athletics as described on the Parent/Player Agreement, Permission, and Release form.

    State legislation requires at the time of initial registration in the school district to indicate if any apply to your child: Expulsions: Date_______ Arrests resulting in a charge: Date________ Juvenile Justice Actions: Date______ Referrals to mental health services: Date________ I understand that in case of emergency, my child will be taken to a hospital and given the necessary treatment. I understand that I am to pay the bill, including transport. I understand that certain educational records of my child will be shared with the District Health Care Partners as needed to provide and evaluate health services to students. I also understand that my child’s medical treatment records created by health care personnel at school may be shared with school officials who have Legitimate Educational Purpose for accessing such treatment records. I certify that I have read all of the information on this form, and it is true and correct. Yes No I give my consent to allow the school district and their health care partners the ability to determine Medicaid eligibility, using my child’s DOB and SS#,

    and if eligible, to bill Medicaid for any services for which my child is eligible.

    Name (Please Print) Signature Date / / If you wish to receive communication by email, provide email address:

    OFFICE USE ONLY

    Entry Code AM BUS PM BUS Proof of Address Immunizations or 30‐day letter Physical Home Language Survey Internet Survey Emergency Card Birth Certificate FASTER Request: / / Legal Papers

    Homeroom # and Teacher DATE entered by School Data Specialist / / Initials SPI0013 Rev. 12/2018

    (PLEASE PRINT)

  • Fort Pierce Westwood Academy 1801 Panther Lane * Fort Pierce, FL 34947 * PHONE: (772) 468-5400

    Mr. Joseph Lezeau, Principal

    Assistant Principals: Ms. Makeda Brome * Mr. Jason Martin * Dr. Matthew Roy * Mrs. Leslie Taylor * Mr. Fred Woltjen

    From the Office of: Melody Golden, Registrar

    Office: (772) 468-5418 * FAX: (772) 468-5473 * Email: [email protected]

    Dear Parent/Guardian: If you have not brought your child’s previous school(s) official academic records and health records, your signature below grants permission for us to request them on your behalf. If the records are not received after three (3) attempts, it is the responsibility of the Parent/Guardian to obtain the records from the previous school(s) and bring them to the Registrar’s Office. If we do not receive the grades in a timely period, this could affect your child’s GPA and credits received. Print Name Relationship to student Signature Date Student’s Name Student ID # Respectfully, Melody Golden, Registrar

    We are a “KIDS @ HOPE” High School

    Failure is NOT an Option…WE EXPECT SUCCESS!

    mailto:[email protected]

  • Fort Pierce Westwood Academy 1801 Panther Lane * Fort Pierce, FL 34947 * PHONE: (772) 468-5400

    Mr. Joseph Lezeau, Principal

    Assistant Principals: Ms. Makeda Brome * Mr. Jason Martin * Dr. Matthew Roy * Mrs. Leslie Taylor * Mr. Fred Woltjen

    From the Office of: Melody Golden, Registrar

    Registrar’s Office: (772) 468-5418 * FAX: (772) 468-5473 Email: [email protected]

    Request Form for Student Records This student has officially enrolled in our school.

    Student’s LAST NAME FIRST NAME Date of Birth

    Name of LAST school attended Fax #

    School Address City State

    Registrar/Records/Admission Office:

    Please send all applicable school records: *OFFICIAL Transcript *Exceptional Education Records *Discipline Records *Medical Records *Withdrawal Grades *Attendance Record *FCAT/FSA Scores (Florida Schools) *EOC Scores (End of Course Exam) *Home Language Survey *ESOL/ELL Records

    Please forward the records to Fort Pierce Westwood Academy via: U.S. Mail: Fax: Email: Ft. Pierce Westwood Academy 772-468-5473 [email protected] The WEST Prep Magnet ATTN: Melody Golden, Registrar 1801 Panther Lane Fort Pierce, FL 34947-1699 Respectfully, Melody Golden

    We are a “KIDS @ HOPE” School - Failure is NOT an Option…WE EXPECT SUCCESS!

    mailto:[email protected]

  • Fort Pierce Westwood Academy 1801 Panther Lane * Fort Pierce, FL 34947

    PHONE: (772) 468-5400

    Student Record at Previous School To enable us to place your child appropriately, please answer accurately & honestly

    Student’s LAST NAME FIRST NAME Date of Birth Grade

    Has your child ever been enrolled in St. Lucie County Schools in the past?

    YES NO If yes, year & school? Has your child ever been enrolled in a FLORIDA school, other than SLC?

    YES NO If yes, what school district? Is your child currently suspended or pending expulsion at previous school?

    YES NO If yes, what offense?

    Has your child been placed in an Alternative School Setting / Program within the last year? Yes or No Does your child receive any of the following services? Exceptional Student Education, (IEP) if YES, check program(s)

    Learning Disability (SLD/LD) Speech Language Hearing Impaired Autism Spectrum Disorder (ASD) Visually Impaired Emotional Behavioral Disorder (EBD) Occupational Therapy Intellectually Disabled (IND) Orthopedically Impaired Traumatic Brain Injury (TBI) Physical Therapy Other Health Impairment Gifted (EP)

    Section 504 English Speakers of Other Languages (LEP/ELL/ESOL) Other

    Was previous school: public / private / virtual / homeschool / alternative

    Parent/Guardian Signature Date

    Print Name Contact #

    Notify:

    ESE Counselor Clinic _______

  • Student Laptop Usage Agreement “Powered UP”

    School Year 2019‐20 and 2020‐2021.

    A business class Dell Latitude 3390 2n1 will be loaned to the student named below under the following conditions:

    • This student laptop loan agreement, which is signed by the parent/guardian, student and

    staff member of the school, will be kept on file at the school. • Use of this equipment for any purpose other than educational use may result in loss of

    privileges. • The district does not permit unethical use of the Internet, email, or any other media. Violation of

    this policy may result in the loss of laptop loan privileges and disciplinary action by the school. • The configuration of the hardware equipment and all accompanying software may not be

    altered, nor can software be copied to or from the computer, or installed on the computer under any circumstances.

    • Parents/guardians are required to pay a non‐refundable security deposit of $25. The payment must be made prior to the student receiving the laptop.

    • Parents/guardians accept financial responsibility for cost related to damage due to purposeful action or gross negligence. The district will proceed with legal action, should financial obligation be ignored. For more information, refer to care of instructional materials in student manual.

    • The laptop, which is the property of St. Lucie Public Schools, must be returned prior to the end of the 2019‐20 school year and the 2020‐2021 school year, or in the event of school change or early withdrawal.

    • The district has provided students with a “Digital Citizenship Orientation” and information for parents, via Open House events and handouts, including information about how to care for the device and how to make responsible use of technology.

    I have read the Student Code of Conduct for Electronic Services for Students Digital Citizenship Policy Agreement.

    We, the undersigned student and parent/guardian, agree to assume full responsibility for the proper care and educational use of the computer equipment described in this document.

    Student Name (print) Phone

    Address/City/State/Zip

    Student Signature Date

    Parent Signature Date

    Student ID Lunch # Grade

    School Name

  • SAO0036

    St. Lucie County School District School Family Access Form

    After filling out this form, you must go to your child’s school to have your account activated by showing a picture id for verification. We assure you that your child’s privacy is very important to us. Access to information is restricted by a secure parent log-on and password, and state-of-the-art technology for encryption that scrambles the information as it is transferred to your computer via the internet. If you have any questions, concerns, or suggestions to make this portal better, please contact your child’s school between the hours of 8:00am and 3:00pm.

    Home Address: City and Zip Code

    PARENT/GUARDIAN NAME: Last Appendage __Jr__II__III

    First Middle

    Residential Guardian: Y/N

    Email Address: Primary Phone Number

    CHILD NAME: Last Appendage __Jr__II__III

    First Middle

    Current Grade:

    Birth Date:month/day/year / /

    Current School Placement:

    PARENT/GUARDIAN NAME: Last Appendage __Jr__II__III

    First Middle

    Residential Guardian: Y/N

    Email Address: Primary Phone Number

    CHILD NAME: Last Appendage __Jr__II__III

    First Middle

    Current Grade:

    Birth Date:month/day/year / /

    Current School Placement:

    CHILD NAME: Last Appendage __Jr__II__III

    First Middle

    Current Grade:

    Birth Date:month/day/year / /

    Current School Placement:

    CHILD NAME: Last Appendage __Jr__II__III

    First Middle

    Current Grade:

    Birth Date:month/day/year / /

    Current School Placement:

    CHILD NAME: Last Appendage __Jr__II__III

    First Middle

    Current Grade:

    Birth Date:month/day/year / /

    Current School Placement:

    CHILD NAME: Last Appendage __Jr__II__III

    First Middle

    Current Grade:

    Birth Date:month/day/year / /

    Current School Placement:

  • For parents registering students coming from out of state

    Beginning with the 2016-17 school year we are no longer able to give 30 day exemptions to students entering from out of.state. Parents will need to present a valid immunization record on the Florida 680 Form and a physical done within the past year in order to enroll at the school.

    Parents do not need an appointment to have the immunization dates transferred from a vaccin;;ition record onto a 680 form. They can drop off a copy of the vaccination record at the Health Department located at 5150 N.W. Milner Drive (off of Midway Road, just west of the post office). It may require up to 72 hours to transfer the records and there is a small fee involved. If the student needs to get immunizations or a Religious Exemption form for immunizations, they must make an appointment.

    For appointments at the St. Lucie County Health Department: 772-462-3800

    As always, immunizations and physicals can also be obtained at pediatrician's · offices, other clinics such as Florida Community Health Center and various walk-in

    clinics.

  • List of Local Providers for Immunizations and/ or School Physicals

    The prices below are subject to change or vary. Parents and guardians should ask for current cost of services and office hours . This list is not a complete list of sites. Pediatrician offices and other clinics offer these services as well.

    Florida Walk-In Clinic 468-6969 805 Virginia Ave. Walk-ins $65 office visit Plaza, Suite 16, F.P. 7°' Grade Tdap available- $40 Physicals-

    $55 Sunshine Pediatrics 446-7800 1973 SW Savage Appointments preferred, $85 Physicals

    Blvd. Suite 205, PSL (required for visit) and $10 ner shot. Physicians Immediate 398-1588 1900 SE PSL Blvd.,· Walk-ins-Tdap for 7°' graders $60. Care PSL Office visit $98

    343-1774 4007 SW PSL Blvd., School Physical- $55 PSL Sports Physical- S,00

    460-9227 5550 S. US 1, Ft. Pierce

    872-8155 1730 SW SLW Blvd., PSL 1801 NE Jensen

    334-1700 Beach Orange A venue Health 409-4774 5420 Orange Ave. Walk-ins M-F 9:00-4:00 Care Fort Pierce Physicals only- $45 with EKG CareSpot Walk-In 878-7311 784 SE Prima Vista Walk-ins- $45 Physical. Shot prices Clinic Blvd, PSL varv. Advanced Care 461-1008 2339 s. us 1 Walk-ins-School Physicals and Sports EmergiCenter Sabal Palm Plaza, Physicals only- $40

    Fort Pierce No immunizations. SLC Health 462-3800 5150 Milner Drive, I) Immunizations are provided at no cost Department PSL (off Midway to any child 18 or under, regardless of

    Call for Rd) insurance status. appointment.

    2) School physicals are no cost for students with Medicaid, Healthy Kids or Blue Cross . Students with insurance that is a PPO should go to their preferred provider. Students with no insurance (self-pay) the cost would be $70.

    3) For current shot records to be transferred onto a Florida 680 Form as required by the state- cost is $5. May take uµ to 48 hours for the 680 to be available.

    Florida Community 461-1402 1505 Delaware Ave. Call for appointment Cost varies. Health Center (FCHC) Fort Pierce Sliding fee scale. Minimum $20 for visit.

    335-8455 170 I Hillmoor Drive, Suite 19, PSL

    Ocean Chiropractic 460-9000 805 Virginia Ave., $20 Walk in physicals. Cash, credit or Suite 10, Ft Pierce debit

    Sunrise Chiropractic 466-1301 2221 S. 25th Walk-in or Appt. $IO Physical Fort Pierce

    Express Urgent Care 772-905- 672 SW Prima Vista Walk-ins- School Physicals $40. 2560 Suite 102, PSL Discounts for physicals available on line.

    Shot nrices varv.

    Updated 11/2016

    health requirements.pdf2020 registration review web.pdfschool-family-access-form.pdf2020 prior school web.pdfStudent Loan Agreement 19-21 updated.pdf2020 records request web.pdf2020 parent agrmt web.pdf2020 Pupil ID web.pdfHL Survey.pdf

    Home Address: City and Zip Code: First: Middle: Email Address: Primary Phone Number: First_2: Middle_2: Email Address_2: Primary Phone Number_2: First_3: Middle_3: Current Grade: Current School Placement: First_4: Middle_4: Current Grade_2: Current School Placement_2: First_5: Middle_5: Current Grade_3: Current School Placement_3: First_6: Middle_6: Current Grade_4: Current School Placement_4: First_7: Middle_7: Current Grade_5: Current School Placement_5: Last: FIRST NAME: Exceptional Student Education IEP if YES check programs: Learning Disability SLDLD: Speech: Language: Hearing Impaired: Autism Spectrum Disorder ASD: Visually Impaired: Emotional Behavioral Disorder EBD: Occupational Therapy: Intellectually Disabled IND: Orthopedically Impaired: Traumatic Brain Injury TBI: Physical Therapy: Other Health Impairment: Gifted EP: Section 504: English Speakers of Other Languages LEPELLESOL: Other: Was previous school public private virtual homeschool alternative: YES: NO: If yes what school district: Student Name print: Phone: AddressCityStateZip: Date: Lunch: Grade: This student has officially enrolled in our school: Students LAST NAME: Name of LAST school attended: Print Name: Relationship to student: Students Name: Student ID: School Year: Enrollment Date: undefined_2: Student Last Name: Student First Name: Student Middle Name: undefined_3: OffRace: Social Security: undefined_4: undefined_5: undefined_6: Birth City: Birth State: Birth Country: Date entered US: undefined_7: undefined_8: American Indian or Alaska Native: OffAsian: OffBlack or African American: OffNative Hawaiian or Other Pacific Islander: OffWhite: OffHispanic or Latino: OffNot Hispanic or Latino: OffStreet Name AptLot: City State Zip: undefined_9: undefined_10: undefined_11: Check if same as above: undefined_12: OffHome Phone City State Zip: Name of school student last attended: What Grade: Address of School if not in St Lucie County: City State Zip_2: County: Country: Last Name First Name: Relation: CustodyShared Custody: OffIf custody is NO legal documentation is required: OffStreet Address if different: Home Phone: Work Phone: Cell Phone: Last Name First Name_2: Relation_2: CustodyShared Custody_2: OffIf custody is NO legal documentation is required_2: OffStreet Address if different_2: Home Phone_2: Work Phone_2: Cell Phone_2: Last Name: First Name: Relation_3: Street Address: Home Phone_3: Work Phone_3: Cell Phone_3: Last Name_2: First Name_2: Relation_4: Street Address_2: Home Phone_4: Work Phone_4: Cell Phone_4: Last Name_3: First Name_3: Relation_5: Street Address_3: Home Phone_5: Work Phone_5: Cell Phone_5: Yes_5: OffNo A parent of this child is an Active Member of our Armed Forces For this question parent is defined as natural parent or appointed legal guardian: OffNo My childs name and contact information to Military Recruiters High School Students Only: OffNo My childs name and contact information to Higher Education Institutions High School Students Only: OffNo My childs name photo voice video to the press for recognition or news purposes Applicable to All Students: OffNo My childs name photo voice video for publicly assessable school or district websites or broadcast Applicable to All Students: OffNo My childs name photo and contact information to the yearbook photographers Applicable to All Students: OffNo My childs directory information students name and grade Applicable to All Students: OffNote A limited release of information is required for participation in student athletics as described on the ParentPlayer Agreement Permission and Release form: OffState legislation requires at the time of initial registration in the school district to indicate if any apply to your child: undefined_13: undefined_14: Expulsions Date: OffArrests resulting in a charge Date: OffJuvenile Justice Actions Date: OffReferrals to mental health services Date: Offundefined_15: Yes_12: OffNo I give my consent to allow the school district and their health care partners the ability to determine Medicaid eligibility using my childs DOB and SS: OffName Please Print: undefined_16: Entry Code: AM BUS: PM BUS: Proof of Address: OffImmunizations or 30day letter: OffPhysical: Offundefined_17: undefined_18: Home Language Survey: OffInternet Survey: OffEmergency Card: OffBirth Certificate: OffFASTER Request: OffLegal Papers: OffHomeroom and Teacher: DATE entered by School Data Specialist: undefined_19: undefined_20: Initials: Student Name: School Name: ParentGuardian Name: Date of Birth: Birthplace: Text1: Check Box16: OffCheck Box17: OffIf Yes please complete Last date attended: City: School Name_2: Check Box2: OffWhat language: Check Box3: OffCheck Box4: OffB Did the student have a first language other than English: Check Box5: OffCheck Box6: OffC Is a language other than English used in the home: Check Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffIf you answer yes to any of the above questions your child will be tested for English proficiency so that the teachers can: If you answer yes to questions A B your child will receive services from the ESOL program until completion of the eligibility: A letter of explanation will be sent if the testing cannot be administered within 20 school days of the date above You will be: Check Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: Offundefined: Text18: Date_2: