FRANKLIN REGIONAL SCHOOL DISTRICT STUDENT …...Franklin Regional School District is now accepting...

FRANKLIN REGIONAL SCHOOL DISTRICT

STUDENT REGISTRATION PACKET - Kindergarten

3210 SCHOOL ROAD, MURRYSVILLE, PA 15668

http://www.franklinregional.k12.pa.us

Fax Number 724-327-6149

Email - [email protected]

Please call Ericka Cowell

724-327-5456 x7622

with any questions and to make an appointment

Appointments accepted Monday through Friday during regular school hours

http://www.franklinregional.k12.pa.us/

mailto:[email protected]


Striving for Excellence

ADMINISTRATION OFFICE 3210 School Road Murrysville, PA 15668 724-327-5456

FRANKLIN REGIONAL SENIOR HIGH 3200 School Road Murrysville, PA 15668 724-327-5456 X5005

FRANKLIN REGIONAL MIDDLE SCHOOL 4660 Old William Penn Highway Murrysville, PA 15668 724-327-5456 X2003

HERITAGE ELEMENTARY 3240 School Road Murrysville, PA 15668 724-327-5456 X7002

NEWLONSBURG ELEMENTARY 3170 School Road Murrysville, PA 15668 724-327-5456 X4002

SLOAN ELEMENTARY 4121 Sardis Road Murrysville, PA 15668 724-327-5456 X3002

ATHLETIC DEPARTMENT 3200 School Road Murrysville, PA 15668 724-327-5456 X5013

FACILITIES DEPARTMENT 3200 School Road Murrysville, PA 15668 724-327-5456 X5030

WELCOME to the 2017-2018 School Year!

Dear Parent(s)/Guardian(s), Franklin Regional School District is now accepting registration for children who will be entering Kindergarten in the 2017-2018 school year. Children must be (5) five years of age on or prior to September 1, 2017 to enter school this year. In order to register your child, the papers in the enclosed registration packet must be completed in entirety and returned in person. You will not be able to register your child without the following information:

• Child’s original birth certificate (with raised seal) or passport

• Completed immunization records printout from pediatrician

• Proof of residency – (2) Two are required Current tax receipt Utility bill Sales/lease agreement Closing settlement agreement

Valid PA Driver’s License – this is for identification purposes only. FRSD is no longer able to accept a Driver’s License as Proof of Residency. Kindergarten registrations will be accepted, by appointment, on March 13th, 14th, and 15th, 2017. Registrations for all elementary buildings will be held at the Administration Office in the Conference room on the ground floor of Heritage Elementary. Parents can sign up for an appointment time at the Parents of Preschoolers meeting on February 27, 2017 for Newlonsburg, February 28, 2017 for Heritage Elementary, or February 27, 2017 for Sloan Elementary.

Beginning March 28, 2017, those who could not attend during one of the dates noted above may make

an appointment to register their child by calling Ericka Cowell at 724-327-5456 ext. 7622. Registrations

will continue to be accepted at the Franklin Regional Administration Office during daytime hours (8:30

am to 2:30 pm); however the formal registration period will close on Friday, April 28, 2017.

At the registration appointment, your child will also be scheduled to participate in the Readiness and Vision screenings that will be held at each building. Again, screenings will be by appointment on the following dates: Newlonsburg: May 25 or May 26, 2017 Heritage: May 23, 25, 26 2017 Sloan: May 24, 25, 26, 2017

Families are strongly encouraged to register prior to the April 28, 2017 cut off for formal registration.

Please be aware that placements for the neighborhood school may not be guaranteed for any registration taken after April 28, 2017 as school assignments are based on the classroom capacity in each building.

This registration packet includes dental and physical forms which must be completed and returned to

your school nurse before the start of the 2017-2018 school year. Examinations by the school’s

physician and the school’s dentist may be scheduled with the school nurse.

The entire Franklin Regional School District staff looks forward to working with you as your child begins

this exciting and rewarding educational journey with us. If you have any questions, please call us at

724-327-5456 x 7622 or x 7625.

Sincerely,

Linda Miller

Assistant Director of Financial Services

724-327-5456 x 7625

Timeline of Kindergarten Transition Events Preparation for 2017-2018

Franklin Regional School District

PHASE 1 Parents of Preschoolers Meeting ~ Orientation for Kindergarten

(Meet Staff, Program Intro, Q/A, Appointments for Registration)

Incoming preschoolers to Newlonsburg Elementary

Monday, February 27, 2017 @ 7:00 P.M., Newlonsburg Cafeteria

Incoming preschoolers to Sloan Elementary:

Monday, February 27, 2017 @ 7:00 P.M., Sloan LGI

Incoming preschoolers to Heritage Elementary

Tuesday, February 28, 2017 @ 7:00 P.M., Heritage Gym

PHASE 2 Central Kindergarten Registration by Appointment Only

(Parents bring completed forms from Registration Packet, Immunization Records, Original

Birth Certificate, Proof of Residency and Make Appointments for Student Screenings)

Incoming preschoolers to Heritage, Newlonsburg and Sloan will be

registered across the following dates:

March 13-15, 2017 (by appointment)

Location: Administration Building (on campus)

Formal Registration will close on April 28, 2017

PHASE 3 “I Love My NEW School” Literacy Event

Featuring...the Franklin Regional Kindergarten Teachers & Pete the Cat!

Parents and their preschool children are cordially invited to

an evening of fun at their home school!

May 9, 2017: Newlonsburg Elem. 6:00-7:30 P.M. @ Newlonsburg Gym

May 10, 2017: Heritage Elementary 6:00-7:30 P.M. @ Heritage

May 11, 2017: Sloan Elem. 6:00-7:30 P.M. @ Sloan LGI

Revised: 1/10/17

PHASE 5 Kindergarten Meet & Greet

(Parents bring children for School/Class Tour, meet their assigned Teacher, Bus Experience)


Wednesday, August 9, 2017 @ Newlonsburg (Time: 11:15 AM)


Wednesday, August 9, 2017 @ Sloan Elementary (Times: 11:15 or 1:00 P.M.)

Incoming preschoolers to Heritage Elementary:

Wednesday, August 9, 2017 @ Heritage Elementary (Times: 11:15 or 1:00 P.M.)

PHASE 4 Kindergarten Screen (by appointment)

(Parents bring children for Brigance and Vision Screenings)


May 25, 2017 or May 26, 2017


May 24, 25 or 26, 2017 @ Sloan Elementary

Incoming preschoolers to Heritage Elementary:

May 23, 25 or 26, 2017 @ Heritage Elementary

(Letters will be mailed to homes in late July with

Teacher Assignments for each building as well as Meet & Greet details)

PHASE 6

Staggered Start (sign up @ Meet & Greet) (Small Groups of Parents/Students attend an abbreviated day/Curriculum, School Routines)

ONE of the First Few Academic Days of 2017-2018

Exact Dates to be determined once the official school calendar is set for

2017-2018 by the Board of School Directors

~ All students at their home building with their homeroom teacher ~

Abbreviated Day: Times to be Announced

PLEASE BRING THE COMPLETED FORMS AND REQUIRED INFORMATION WITH YOU. ALL FORMS MUST BE COMPLETED IN FULL AND PRESENTED AT REGISTRATION.

DISTRICT FORMS – INCLUDED IN PACKET:

� Student Entry Information Form – Please complete and sign � Census Enumeration – Please complete in its entirety � Student Residency Questionnaire – Please complete � Alternative Transportation Request Form – If Applicable � Auto Call List From – Please complete � Special Services Form – Please complete and sign � Home Language Survey – Please complete this form in its entirety � Internet Use Agreement – You may sign for your child � Authorization for Verification of Address

FORMS PARENT (S) ARE TO PROVIDE:

� Your child’s ORIGINAL birth certificate or Passport � PROOF OF RESIDENCY in the Franklin Regional School District (see below)

We can no longer accept a driver’s license as proof of residency • Current tax receipt • Utility Bill • Sales / Lease Agreement • Closing Settlement Statement

� Well –Visit report from the pediatrician dated between August 23, 2016 and August 23, 2017 � Immunization Record / Print Out from Pediatrician � Dental Form dated between August 23, 2016 and August 23, 2017

Additional Forms: (only as needed – available at the Administration office or on line)

� Certificate of Multiple Occupancy – Only if residing with another family within the Franklin Regional School District PLEASE NOTE: WE WILL NOT BE ABLE TO FULLY REGISTER YOUR CHILD IF ANY OF THIS INFORMAITON IS MISSING. WE APPRECIATE YOUR ATTENTION TO THIS MATTER.

TO: Prospective Kindergarten Parent(s) and/or Guardians

FROM: The Franklin Regional Team

RE: Kindergarten Registration Forms

DATE: School Year 2017-2018

Residency Qualification

In order for your child to attend school in the Franklin Regional School district, you must reside in the Franklin Regional District or be in the process of building or buying a home within the boundaries of the District.

NON-RESIDENT / PRE-RESIDENT STATUS

Families not yet living the District but who are in the process of building or buying a home in the District and would like to register their children to begin school are required to pay tuition until their residency is established.

1. You must write a letter to the Superintendent attaching a copy of lease agreement or builder’s agreement to the letter.

2. Upon approval from the Superintendent, the Business Office will send you a letter stating the amount of tuition due and the date it is due.

3. A copy of the District Policy #8304 is available on the website.

MULTIPLE OCCUPANCY

If you are sharing a residence with another family within the Franklin Regional School District you must file a NOTARIZED Certificate of Multiple Occupancy. Forms are available in the Administration Building or on the Franklin Regional website.

FRANKLIN REGIONAL SCHOOL DISTRICT – STUDENT ENTRY INFORMATION Resident Y / N

Student Information (Please Print) Grade__________ Full / Half Day

Legal Last Name

Gender: M or F

Part A: circle one

Part B: circle one

First Name Middle Suffix (Jr., III)

Birth Date: ___/___/___ City and State of Birth: ___________________________ Country: _________________

Hispanic/Latino or Not Hispanic/Latino

A- Asian / B – Black, African American / I- Indian / N – American Indian or Alaskan Native / H- Hispanic

M – Multi-Racial / P – Native Hawaiian or Pacific Islander / W- White

Student's Home Address:

Street # Street Name City Zip Primary Phone #

Date First Enrolled in US Schools ____/____/____ Preschool or Previous School’s Name__________________________________________

Previous Schools’ Address:

Street # Street Name City Zip # of days attended per week

_____________________________________________________________________________________________________________________

Student lives with: (circle one) Both Parents / Father / Mother / Other ___________________________________

1) Last Name _________________________________________First Name______________________________________ Father/Mother/Guardian)

W Phone____________________ C Phone__________________ Email Address___________________________________________

2) Last Name __________________________________________First Name____________________________________ (Father/Mother/Guardian)

W Phone____________________ C Phone__________________ Email Address___________________________________________

If Student does not live with both parents, yet both parents are to review mailings, please list additional mailing information below:

Last Name _________________________________________First Name______________________________________ Father/Mother/Guardian)

Mailing Address: ___________________________________________________________________________________

Phone: ________________________________ Email: _________________________________________

Parent/ Guardian Signature__________________________________________ Date____________________

****CHILD ACCOUNTING USE ONLY****

Student ID___________________ BLDG ASSIGN_______________ CENSUS______________

IMMUNIZATION CERT? YES / NO BIRTH CERT / PASSPORT MULTI OCCUPANCY ? YES / NO

CUSTODY ORDER? YES / NO IF YES, COPY PROVIDED ? YES / NO 2 PROOFS OF RES ? YES / NO

CENSUS ENUMERATION

Borough of Delmont Borough of Export Municipality of Murrysville Franklin Regional School District

ADDRESS:____________________________________________________________________ ZIP CODE ____________

RESIDENCE CODE: 1 - OWN HOME Best number to reach you in the case of emergency:

2 - RENT HOME #___________________________

LIST ANYONE IN THE HOUSEHOLD 21 YEARS OF AGE OR OVER LAST FIRST SEX BIRTHDATE E-MAIL ADDRESS EMPLOYER NAME LIST ANYONE IN THE HOUSEHOLD CHILDREN - UNDER 21 YEARS OF AGE (Admin use only) LAST FIRST SEX BIRTHDATE GRADE FR SCH STU ID#

FAMILY

RELATIONSHIP SCHOOL 1 - Head of House 1 - Public 2 – Son/ Daughter 2 - Non-Public 3 - Foster Child 3 - Not In School 4 - Other 4 - Other

INFORMATION PROVIDED BY: ___________________________________ DATE: ______________________________


Office of Child Accounting and Student Registration

3210 School Road, Murrysville, PA 15668

APPLICATION FOR MULTIPLE OCCUPANCY REGISTRATION

This form MUST BE NOTARIZED by a notary public within the Franklin Regional School District in Delmont, Export or Murrysville, Pennsylvania.

Name(s) of Student(s) __________________________________________________

__________________________________________________

__________________________________________________

I am the parent (or legal guardian) if the child (ren) named above. We reside in the Franklin Regional School District in a (home or apartment) this is owned or leased by a resident of the Franklin Regional School District living at the same address. (An affidavit of the owner or lessor will be submitted to the Franklin Regional School District attesting to our residence in the home or apartment before this application is considered complete.)

I ASSUME RESPONSIBILITY for notifying the Franklin Regional School District should my residence, name, or relationship to the owner/lessor changes with ten school days of the change. AT THT TIME I will provide evidence of my NEW ADDRESS, NAME OR RELATIONSHIP to the owner/lessor to the REGISTRATION OFFICE so that my residency and parent/guardianship remains up to date.

I understand that if any information proves to be incorrect, now or in the future, the Franklin Regional School District has the right to reject the application and eject the student)s) from school district classes being attended. I also understand that the School District has the right to collect tuition for each student enrolled.

I understand that I am to submit my W-2 Internal Revenue Statement for proof of residency at this address each year my child (ren) are enrolled in the Franklin Regional School District. This is to be done at the Registration Office in the Administration Building of the Franklin Regional School District at 3210 School Road, Murrysville,

Sworn to and Subscribed to this ______________________________________

Signature of Parent/ Legal Guardian

____Day of_________ ______________________________________

Relationship to Child(ren)

Address of Property in Franklin Regional


Office of Child Accounting and Student Registration

3210 School Road, Murrysville, PA 15668

CERTIFICATION OF MULTIPLE OCCUPANCY

Your residence is claimed to be the residence of a family, which has neither a lease nor a deed to establish proof of residence with the Franklin Regional School District. This form is required for the parent/legal guardian to register children to attend the Franklin Regional School District. In addition to completing this form, you must co-sign the registration forms for each child (ren) the parent/legal guardian registers.

I,________________________________________________________________________

Printed name of Owner or Lessor’s Name

Certify that I am the Legal Owner or Lessor of the property or apartment located at this address:

_______________________________________________________________________ which is located in the Franklin Regional School District.

I further swear that the following parent/guardian and children are residing at this same address on a permanent basis.

____________________________________ ________________________________________

____________________________________ ________________________________________

I ASSUME RESPONSIBILITY FOR NOTIFYING THE Franklin Regional School District at the Registration Office, 3210 School Rd, Murrysville, PA 15668 if their residence, name, or relationship to me changes.

I am aware that the fact of this testimony are subject to investigation, and should it be determined that they are not true wither NOW OR IN THE FUTURE, I shall then be liable for fraudulent enrollment of students an will reimburse Franklin Regional School District for tuition.

I verify the statement made in the foregoing document are true and correct to the best of my knowledge, information or belief. I understand that false statements made herein are made subject to other penalties of 18 Pa.C.S. 8 4904, relating to unsworn falsification to authorities.

NOTARIZED:

Sworn to and Subscribed to this ______ ________________________________

Signature of Owner/Lessor (Verify) / Date

______Day of_________________, _______ ______________________________________

Relationship to Parent/Guardian

Primary Phone #_______________________

FRANKLIN REGIONAL AUTOMATED CALL LIST FORM

From time to time it is necessary for the School District to send out an automated call to parents/guardians information them of changes to our normal schedule or evening activities. Please enter the preferred phone contact information for us to use if such a situation should arise. Our automated calling system can call up to 4 phone numbers for each student. Please be aware that ALL of the phone numbers you provide will be called EVERY Time we use the automated system.

STUDENT’S NAME: _______________________________________________________

MOTHER’S NAME: _______________________________________________________

FATHER’S NAME: _______________________________________________________

GUARDIAN/STEP PARENT 1 : ________________________________________________

GUARDIAN/STEP PARENT 2 : ________________________________________________

BEFORE/AFTER SCHOOL CARE GIVER : _________________________________________

Child lives with (circle one) : Both Parents Father Mother Guardian/Other

AUTO CALL NUMBER 1: _______________________________________________

AUTO CALL NUMBER 2: _______________________________________________

AUTO CALL NUMBER 3: _______________________________________________

AUTO CALL NUMBER 4: _______________________________________________

Thank you for providing us with the best contact information for the care of your child. Please remember to contact us with any / all updates to your phone number(s).

School District Student Residency Questionnaire

Dear Parent or Guardian,

Your responses to these questions will help staff determine what residency documents are necessary to enroll your

child. Thank you for your cooperation.

1. Student name: Birth date:

Person completing form: Relationship to child:

2. In what type of setting is the child living now? Check one box below:

Section A Section B

In an emergency or transitional shelter

Sharing the housing of other persons due to loss of housing, economic

hardship, or similar reason

In a motel, hotel, campsite, or car due to a lack of alternative, adequate accommodations

In a car, park, public space, abandoned building, substandard housing, bus or train stations, or similar settings

Other places not designed for, or ordinarily used as, regular sleeping accommodations for human beings CONTINUE TO THE QUESTIONS BELOW if you checked a box in SECTION A

None of the choices in

SECTION A apply

If you checked this section, you do not need to complete questions 3 through 6. Please sign and date the form and turn it in.

3. Contact number for person completing this form:

Address where the child is now living:

4. The child lives with (Check all that apply):

Parent or legal guardian Relative, friend or other adult Alone Other:

5. Name, Address & Phone Number of the school the child attended last: 6. Does the child have an IEP or a Chapter 15/504 agreement? No. Yes. Please explain: Signature of Parent/Legal Guardian: Date:

Revised July 2013 1

HOME LANGUAGE SURVEY1 The Office of Civil Rights (OCR) requires that all Local Education Agencies (LEA’s) identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the initial step in the identification process.

School District: Date:

School:

Student’s Name: Grade:

1. What is/was the student’s first language?

2. Does the student speak a language(s) other than English? Yes No

(Do not include languages learned in school.)

If yes, specify the language(s):

3. What language(s) is/are spoken in your home?

4. Has the student attended any United States school in any Yes No

3 years during his/her lifetime?

If yes, complete the following:

Name of School State Dates Attended

Person completing this form:

(if other than parent/guardian)

Parent/Guardian signature:

1 The local education agency (LEA) has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the LEA has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the LEA may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the LEA in the future.

Franklin Regional School District 3210 School Road

Murrysville, Pennsylvania 15668

SPECIAL SERVICES - REGISTRATION FORM

� My child has an I.E.P. or a 504 Service Agreement on file at the previous school attended.

If your child currently has an IEP, please check area/areas of exceptionality.

� Autistic Support � Learning Disability � Gifted � Vision � Physical Disability � Mental Retardation � Speech/Language � Hearing � Physical Therapy � Occupational Therapy � Special Transportation Needs (related to disability) � Emotionally Disturbed � Neurological Impairment � Other Health Impairment � Other (Please specify) _

� Multidisciplinary Evaluation in Progress (MDE) � My child does not need any special education services.

Parent Signature

Date


Alternative Transportation Request

• An alternative transportation request may be approved to accommodate childcare arrangements or emergencies that may arise during the school year. • This bus transfer request only applies to a request from within the school’s attendance area and will be approved based on space availability. • Allow up to one week for processing. • You must receive notification of approval from the Transportation Office before these changes take effect. Student’s name ______________________________________________ Grade ____________________ Address ____________________________________________________ Phone ____________________ Name of Parent ______________________________________________ 2nd Phone__________________ Parent email _________________________________________________ School of Attendance _________________________________________ Reason for Request: Babysitter/daycare (must be within attending school’s attendance area)

Shared parenting

Intradistrict transfer approved; requesting the nearest bus stop within the transportation eligibility area. Name of Childcare Provider ___________________________________________________________________ Address _______________________________________________________ Phone ____________________ The parent or guardian hereby assumes responsibility for the dependability and reliability of the childcare provider. If the student is eligible for transportation, the parent/guardian grants consent to the school officials to pick up or drop off a student at the alternate location by signing below. The District/Board of Education does not assume liability for a student prior to boarding the bus or after being dismissed from the bus at the designated location. Parents are responsible for ensuring the safe passage of their children to and from the bus stop. Please indicate with an “X” which days you are requesting transportation to the alternate address.

Monday Tuesday Wednesday Thursday Friday

Pick up Drop off Signature of Parent/Guardian ______________________________________ Date ____________________ __________________________________________________________________________________________ For office use only: Approved Disapproved Sent to Myers Initials______Date_______ Pick up: Bus # _____ Day/Time ________________ Stop __________________________________ Drop off: Bus # _____ Day/Time ________________ Stop __________________________________ Pick up: Bus # _____ Day/Time ________________ Stop __________________________________ Drop off: Bus # _____ Day/Time ________________ Stop__________________________________


POLICY 7008 INTERNET and COMPUTER USAGE

The Franklin Regional School district makes every effort to provide a secure and productive computing environment. It supports confidentiality of information through the Family Educational Rights and Privacy ACT (FERPA) and Internet Content Filtering guidelines through the Child Internet Protection ACT (CIPA). In no way will the Franklin Regional School District assume responsibility for its students and staff for computer misconduct resulting from inappropriate use or redirection of bandwidth and unauthorized charges or fees. This Acceptable Use Policy will be reviewed annually with student and staff and revised as needed.

1. The Internet will be used to support the functions of the Franklin Regional School District, its curriculum, the educational community, and projects between schools, communication and research for school district administrators, teachers and students.

2. The Internet and computer technology will not be used for illegal activity, transmitting offensive materials, hate mail, discriminatory remarks or obtaining, transmitting or otherwise communicating indecent, obscene or pornographic material. Sending harassing, abusive, intimidating, discriminatory or other offensive e-mails is strictly prohibited.

3. The Internet and computer network will not be used for sending or initiating chain-mail, playing non-instructional games, downloading and storage of unauthorized multimedia files, and peer-to-peer file sharing systems such as KaZaa, Croakster, or similar systems.

4. The use of unauthorized chat, instant messaging systems, or discussion boards is strictly prohibited. 5. The Internet and computer technology will not be used for profit purposes, lobbying or advertising on behalf of any

individual or employee of the Franklin Regional School District. 6. Use of the Franklin Regional School District’s computer technology or the Internet for fraudulent or illegal copying,

communication, taking or modification of material or any other activity in violation of the law is prohibited and will be referred to the proper authorities.

7. In no event shall the Franklin Regional School District be liable for any damage, whether direct, indirect, special or consequential, arising out of the use of the Internet, accuracy or correctness of databases or information contained therein or related directly or indirectly, to any failure or delay of access to the Internet.

8. The Franklin Regional School District may terminate the availability of the Internet and Network Accessibility at its sole discretion.

9. From time to time, the Franklin Regional School District will make determination on whether specific uses of the Internet and Network are consistent with this policy and notify users of the same.

10. The Franklin Regional School District, in its discretion, reserves the right to log Internet use in terms of time and content and to monitor file server disk space utilization by users. It also reserves the right to process grievances against individuals who use the Internet in a manner inconsistent with this policy.

11. The Franklin Regional School District reserves the right to remove a user account on the Internet and Network to prevent further unauthorized activity as specified in this document.

12. The Network shall not be used to disrupt the work of others; hardware or software shall not be destroyed, modified or abused in any way.

13. Network accounts are to be used only by the authorized owner of the account for the authorized purpose. 14. Diligent effort must be made by the user to delete mail daily from personal mail directories to avoid unnecessary use

of file server disk space. 15. Diligent effort must be made by the user to periodically delete obsolete files from the Network file server. 16. Users shall not intentionally seek information, obtain copies of or modify files, other data or passwords belonging to

others users, or misrepresent other users in the Network. 17. Uploading, downloading, installation, or use of unauthorized games, programs, files or other electronic media is

prohibited. 18. The illegal use of copyrighted software is prohibited. 19. In order to maintain a high level of security on the Local Area Network, all Network users may need to update their

passwords as needed. 20. The user shall be responsible for damages to the Franklin Regional School District’s equipment, systems and software

resulting from deliberate or willful acts. 21. The Internet, Network and e-mail are not guaranteed to be private. People who operate the systems do have access

to all e-mail and files. Messages relating to or in support of, illegal activities may be reported to the authorities.

22. Confidential information shall never be transmitted to unauthorized sources. This includes health records, academic records, financial information, and social security numbers of passwords.

23. Failure to follow the procedures listed above by students of the Franklin Regional School District may result in suspension or loss of the right to access the Internet, to use the Franklin Regional School District’s computer technology, and be subject to other disciplinary actions, including but not limited to expulsion.

24. Violations of this policy and procedures by employees of the Franklin Regional School District may result in discipline, including but no limited to, dismissal.

25. All students in 7th grade and above who wish to use the Internet, Network and computer technology tools must sign an Internet Agreement form which will be kept on file. Parents or guardians must sign for all students who are under the age of 18. Such signed agreements will be stored in the student’s permanent file.

26. All staff must sign an Internet Agreement that will be kept on file. 27. Electronic e-mail messages will be stored by the District for the duration prescribed by law.

This policy covers the use of all company owned electronic communication systems: e-mail, Internet access, district Intranet, district-wide telephone systems and all licenses software programs, whether or not they are associated with any of the above mentioned systems.

Applicable Laws and Regulations/Policy History Adopted: 2/28/05/Amended/ Effective: 2/28/05 As a student user of the FRSD network, I hereby agree to comply with the terms and conditions listed above: Student Name (printed legibly) _______________________________________________________ Student Signature__________________________________________________________________ School Building ________________________________________Date _______________________ As a parent or legal guardian of the minor student signing above, I grant permission for my son/daughter to access networked computer services such as email and the Internet. I understand that individuals and families may be held liable for violations. I understand that some materials on the Internet may be objectionable, but I accept responsibility for guidance of Internet use, setting and conveying standards for my son/daughter to follow when selecting, sharing or exploring information and media. Parent Name (printed legibly) _______________________________________________________ Parent Signature__________________________________________________________________ Address_________________________________________________________________________ Phone _____________________ Grade ______________________Date _____________________


OFFICE OF CHILD ACCOUNTING AND STUDENT REGISTRATION

3210 SCHOOL ROAD, MURRYSVILLE, PA 15668

AUTHORIZATION FOR VERIFICATION OF ADDRESS

RELEASE OF INFORMATION AGREEMENT

I, _________________________________________________________(parent/guardian printed name), do hereby give the Franklin Regional School District authorization to contact any or all of the following to obtain verification of my address which is on file, or which I have sued in completing the registration forms with them. I further authorize the agency or employer contacted to release the requested information which will verify my address upon receipt of a photocopy or electronically transmitted copy of this form.

1. Internal Revenue Service 2. Employer 3. Welfare Agency or related Health Service Agencies 4. Bureau of Motor Vehicles 5. U.S. Postal Service 6. Credit Reporting Agencies 7. Landlord of previous address_____________________________________________________________ 8. Landlord of current address ______________________________________________________________

Date___________________

Signature of registering parent/guardian ________________________________________________________

Address:

House # Street Name City State Zip Code

Area Code & Telephone Number

Franklin Regional School District • Human Resources • 3210 School Road • Murrysville, PA 15668 • (724) 327-5456

Volunteer opportunities include (but are not limited to) the following: Musicals Field Days

Marching Band Field Trips

Plays Athletic Coaches

1-on-1 Tutoring Class Celebrations

ALL ITEMS ARE MANDATORY Initial Clearances must be dated within 60 months. They must be resubmitted every 60 months from date on clearance.

Once approved you must volunteer one time per school year to stay active.

1. Volunteer Application ‐ Please see the School Secretary or access it online by clicking on For Parents > volunteer information on your student’s

school webpage.

2. Act 151 Child Abuse Clearance – Volunteer No cost – 717-783-6211 or 1-877-371-5422 ‐ Online: Online report by going to https://www.compass.state.pa.us/cwis/public/home OR ‐ Mail: Print the form by obtaining it at http://www.dhs.pa.gov/cs/groups/webcontent/documents/form/s_001762.pdf and

mail it to the address provided on the form. This will take several weeks to process and receive the clearance in the mail. ‐

3. Act 34 PA State Criminal History (PATCH) Clearance – Volunteer No cost – 1-888-783-7972 ‐ Online: Instant report online by going to https://epatch.state.pa.us/Home.jsp ‐ Mail: Print the form by obtaining it at https://epatch.state.pa.us/help/SP4-164A.doc and mail it to the address provided

on the form. This will take several weeks to process and receive the clearance in the mail. ‐

4. Act 114 FBI Fingerprint Criminal Background Clearance - $27.00 - 1-888-439-2486 ‐ Online: Click “register online” with a credit card at https://www.pa.cogentid.com/index_pde.htm then take your

registration number to any fingerprinting facility (locations can be found on the Cogent website at https://www.pa.cogentid.com/index_pdeNew.htm): OR Signed volunteer residency affidavit: If you will be unaccompanied with students or chaperone a field trip, you will be required to obtain an Act 114 FBI Fingerprint Criminal Background Clearance; the volunteer residency affidavit form is not acceptable (per Franklin Regional School Board Policy: 7407 Volunteer Policy).

5. PA Dept. of Education – Arrest/Conviction Report and Certification Form ‐ This form is available on the volunteer information webpage or can be obtained in the school office.

For questions or to turn in all necessary clearances/forms, please bring original documents to the School Secretary. More information on volunteering in Franklin Regional can be found online by clicking on For Parents > volunteer information on your school webpage.

Franklin Regional School District HEALTH NEEDS IDENTIFICATION FORM

STUDENT’S NAME

GRADE__________

DOB__________________

GENDER______________

PARENT/LEGAL GUARDIAN ____________________________________________________

HOME PHONE CELL PHONE WORK PHONE

PHYSICIAN PHYSICIAN’S PHONE No.

Is your child allergic to any medications? YES NO

If yes, please list

MEDICAL HISTORY: Please check below if your child has now or has had in the past: Now Past Now Past

Please describe other medical problems:

Does your child have any physical, hearing, speech or visual disability? Yes No

If yes, please describe:

Does your child have a medical procedure that must be performed during the school day? Yes No

If yes, please list:

Does your child use a walker or wheelchair? Yes No


Does your child have allergies to food or insects? Yes No


*Has your child experienced an anaphylactic reaction in the past (including, but not limited to, difficulty breathing or shock)? Yes No

*Has an emergency epinephrine injector been used on your child due to an anaphylactic reaction? Yes No

If yes, please describe the circumstances:

List any medication(s) your child is taking that the school nurse and/or staff should be aware of:

The school cannot administer any medication until a medication authorization form has been completed for each medication. Medication must be provided by a parent/legal guardian.

Parent/Legal Guardian Signature Date

Asthma treated with daily medication Nosebleeds Diabetes Respiratory problems Seizures/Epilepsy Cancer Heart Problems Kidney problems Headaches Blood disorders Skin diseases Other: *Allergies (see below) Other:

THIS FORM IS TO BE COMPLETED BY THE PARENT/LEGAL GUARDIAN AND RETURNED TO THE SCHOOL NURSE.

WELCOME FROM YOUR SCHOOL NURSES

You and your child are beginning an exciting thirteen – year journey and we would like to extend to you a special welcome and supply you with some information about the services we provide.

SCREENINGS:

Vision: Every year, K through 12

Hearing : K-3, 7, 11 – any time a problem is suspected; we can recheck hearing with the

Audiometer and inspect the ear for wax blockage.

Growth: Every year, K through 12

Dental: K, 3, 7 (your dentist or at school)

Physical: K, 6, 11 (your physician or at school)

Scoliosis: 6-7

MEDICATIONS:

At the beginning of each year we will furnish a list of available medications and treatments (standing orders by the school physician) for you to review. You may approve which medications and treatments that you would like your child to receive.

If you child needs long or short-term medication other than those available at school, they must be approved IN WRITING BY YOUR PHYSICIAN. We have forms which must be completed before any other medication can be given. Otherwise we are not permitted to administer them.

ILLNESS:

A sore throat; vomiting/diarrhea during the night; or a skin rash are reasons for keeping your child at home, since these are thing which may be passed on to others. If your child has had a fever (>100F.), they should be kept at home until their symptoms are done and their

IMMUNIZATIONS:

A record of the immunizations your child has received is required to enter school. Please keep us informed with SPECIFIC DATES of any boosters given after registration and we will update your child’s record. You will get the complete history when your child graduates.

Health Services Staff:

Certified School Nurses: Health Room Assistants:

Beth Frydrych, BSN, RN, NCSN Marie Festick, BSN, RN

Sandy Pianetti, BSN, RN, CSN Brittany Marcano, LPN

Cynthia Leyh, BSN, RN, CSN Myon Valentino, BSN, RN

Shari Willis, BSN, RN

Dear Parent/Guardian:

The Pennsylvania Department of Health requires children to be immunized prior to school entry. Therefore, no child will be enrolled without verification of immunization or a proper exemption. The attached certificate of immunization must be completed and returned for your child to be registered.

Minimum Required Immunizations

Diphtheria/Tetanus – minimum of 4 doses with one given on or after the 4th birthday Polio – minimum of 3 doses Hepatitis B – 3 doses, properly spaced Measles, Mumps, Rubella – separately or combined as MMR after the 1st birthday. A second measles does and

mumps (preferably MMR) one month or more after the first Varicella (chickenpox) – 2 doses or history of disease

Included in this registration packet are dental and physical forms which must be completed and returned to your school nurse by the start of the 2017-2018 school year. Examinations by the school’s physician and the school’s dentist may be scheduled with the school nurse.

We look forward to working with you and your child. Please, if you have any questions at any time throughout your child’s education process, feel free to contact your child’s school nurse.

Sincerely,

Beth Frydrych, BSN, RN, NCSN Health Services Coordinator Middle School

Phone 724-324-5456 x 2013 or Fax 724-733-0949

Sandra Pianetti, BSN, RN, CSN Senior High

Phone 724-327-5456 x 5011 or Fax 724-327-6147

Cynthia Leyh, BSN, RN, CSN Elementary Schools

Heritage 724-327-5456 x 7118 or Fax 724-327-8298

Sloan 724-327-5456 x 3026 or Fax 724-733-5487

Newlonsburg 724-327-5456 x 4003 or Fax 724-327-4903

Adapted in part from the Pre-participation Physical Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

H511.336 (Rev. 9/2012) Page 1 of 4: STUDENT HISTORY

Private or School

PHYSICAL EXAMINATION OF SCHOOL AGE STUDENT

Student’s name __________________________________________________________________________ Today’s date___________________________

Date of birth ________________________ Age at time of exam___________ Gender: Male Female

Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.

GENERAL HEALTH: Has the student… YES NO

1. Any ongoing medical conditions? If so, please identify:

Asthma Anemia Diabetes Infection

Other_________________________________________________

2. Ever stayed more than one night in the hospital?

3. Ever had surgery?

4. Ever had a seizure?

5. Had a history of being born without or is missing a kidney, an eye, a testicle (males), spleen, or any other organ?

6. Ever become ill while exercising in the heat?

7. Had frequent muscle cramps when exercising?

HEAD/NECK/SPINE: Has the student… YES NO

8. Had headaches with exercise?

9. Ever had a head injury or concussion?

10. Ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

11. Ever had numbness, tingling, or weakness in his/her arms or legs

after being hit or falling?

12. Ever been unable to move arms or legs after being hit or falling?

13. Noticed or been told he/she has a curved spine or scoliosis?

14. Had any problem with his/her eyes (vision) or had a history of an eye injury?

15. Been prescribed glasses or contact lenses?

HEART/LUNGS: Has the student... YES NO

16. Ever used an inhaler or taken asthma medicine?

17. Ever had the doctor say he/she has a heart problem? If so, check all that apply: Heart murmur or heart infection

High blood pressure Kawasaki disease High cholesterol Other:_____________________

18. Been told by the doctor to have a heart test? (For example, ECG/EKG, echocardiogram)?

19. Had a cough, wheeze, difficulty breathing, shortness of breath or felt lightheaded DURING or AFTER exercise?

20. Had discomfort, pain, tightness or chest pressure during exercise?

21. Felt his/her heart race or skip beats during exercise?

BONE/JOINT: Has the student... YES NO

22. Had a broken or fractured bone, stress fracture, or dislocated joint?

23. Had an injury to a muscle, ligament, or tendon?

24. Had an injury that required a brace, cast, crutches, or orthotics?

25. Needed an x-ray, MRI, CT scan, injection, or physical therapy following an injury?

26. Had joints that become painful, swollen, feel warm, or look red?

SKIN: Has the student… YES NO

27. Had any rashes, pressure sores, or other skin problems?

28. Ever had herpes or a MRSA skin infection?

GENITOURINARY: Has the student… YES NO

29. Had groin pain or a painful bulge or hernia in the groin area?

30. Had a history of urinary tract infections or bedwetting?

31. FEMALES ONLY: Had a menstrual period? Yes No

If yes: At what age was her first menstrual period? ______

How many periods has she had in the last 12 months? ______

Date of last period: ___________

DENTAL: YES NO

32. Has the student had any pain or problems with his/her gums or teeth?

33. Name of student’s dentist: ________________________________

Last dental visit: less than 1 year 1-2 years greater than 2 years

SOCIAL/LEARNING: Has the student… YES NO

34. Been told he/she has a learning disability, intellectual or developmental disability, cognitive delay, ADD/ADHD, etc.?

35. Been bullied or experienced bullying behavior?

36. Experienced major grief, trauma, or other significant life event?

37. Exhibited significant changes in behavior, social relationships,

grades, eating or sleeping habits; withdrawn from family or friends?

38. Been worried, sad, upset, or angry much of the time?

39. Shown a general loss of energy, motivation, interest or enthusiasm?

40. Had concerns about weight; been trying to gain or lose weight or received a recommendation to gain or lose weight?

41. Used (or currently uses) tobacco, alcohol, or drugs?

FAMILY HEALTH: YES NO

42. Is there a family history of the following? If so, check all that apply:

Anemia/blood disorders Inherited disease/syndrome

Asthma/lung problems Kidney problems

Behavioral health issue Seizure disorder

Diabetes Sickle cell trait or disease

Other________________________________________________

43. Is there a family history of any of the following heart-related problems? If so, check all that apply:

Brugada syndrome QT syndrome

Cardiomyopathy Marfan syndrome

High blood pressure Ventricular tachycardia

High cholesterol Other________________

44. Has any family member had unexplained fainting, unexplained seizures, or experienced a near drowning?

45. Has any family member / relative died of heart problems before age 50 or had an unexpected / unexplained sudden death before age 50 (includes drowning, unexplained car accidents, sudden infant death syndrome)?

QUESTIONS OR CONCERNS YES NO

46. Are there any questions or concerns that the student, parent or guardian would like to discuss with the health care provider? (If yes, write them on page 4 of this form.)

I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.

Signature of parent / guardian / emancipated student_____________________________________________________ Date_______________

Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking:

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

Does the student have any allergies? No Yes (If yes, list specific allergy and reaction.)

Medicines Pollens Food Stinging Insects

Bureau of Community Health Systems Division of School Health

PARENT / GUARDIAN / STUDENT:

Complete page one of this form before

student’s exam. Take completed form to

appointment.

of 4: PHYSICAL EXAM STUDENT NAME:

STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes No

Physical exam for grade:

K/1 6 11 Other

CHECK ONE

*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS

NO

RM

AL

*AB

NO

RM

AL

DE

FE

R

Height: ( ) inches

Weight: ( ) pounds

BMI: ( )

BMI-for-Age Percentile: ( ) %

Pulse: ( )

Blood Pressure: ( / )

Hair/Scalp

Skin

Eyes/Vision Corrected

Ears/Hearing

Nose and Throat

Teeth and Gingiva

Lymph Glands

Heart

Lungs

Abdomen

Genitourinary

Neuromuscular System

Extremities

Spine (Scoliosis)

Other

TUBERCULIN TEST DATE APPLIED DATE READ RESULT/FOLLOW-UP

MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION

(Additional space on page 4)

Parent/guardian present during exam: Yes No

Physical exam performed at: Personal Health Care Provider’s Office School Date of exam______________20______

Print name of examiner _______________________________________________________________________________________________________

Print examiner’s office address___________________________________________________________________ Phone_______________________

Signature of examiner______________________________________________________________________ MD DO PAC CRNP

of 4: IMMUNIZATION HISTORY STUDENT NAME:

HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.

IMMUNIZATION EXEMPTION(S):

Medical Date Issued:___________ Reason: __________________________________________________ Date Rescinded:___________



NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.

VACCINE DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization

Diphtheria/Tetanus/Pertussis (child) Type: DTaP, DTP or DT

1 2 3 4 5

Diphtheria/Tetanus/Pertussis (adolescent/adult) Type: Tdap or Td

1 2 3 4 5

Polio Type: OPV or IPV

1 2 3 4 5

Hepatitis B (HepB)

1 2 3 4 5

Measles/Mumps/Rubella (MMR)

1 2 3 4 5

Mumps disease diagnosed by physician Date:__________

Varicella: Vaccine Disease

1 2 3 4 5

Serology: (Identify Antigen/Date/POS or NEG) i.e. Hep B, Measles, Rubella, Varicella

1 2 3 4 5

Meningococcal Conjugate Vaccine (MCV4)

1

2 3 4 5

Human Papilloma Virus (HPV) Type: HPV2 or HPV4

1 2 3 4 5

Influenza Type: TIV (injected) LAIV (nasal)

1 2 3 4 5

6 7 8 9 10

11 12 13 14 15

Haemophilus Influenzae Type b (Hib)

1 2 3 4 5

Pneumococcal Conjugate Vaccine (PCV) Type: 7 or 13

1 2 3 4 5

Hepatitis A (HepA)

1 2 3 4 5

Rotavirus

1 2 3 4 5

Other Vaccines: (Type and Date)

of 4: ADDITIONAL COMMENTS (PARENT / GUARDIAN / STUDENT / HEALTH CARE PROVIDER) STUDENT NAME:

Date __________________

KINDERGARTEN PARENT CHECKLIST

Student’s Name __________________________________ Grade______________

� Registration Form � Original Birth Certificate (raised seal) / Passport � Census Form (must include everyone living in the home) � Proof of Residency – (2 Required)

Driver’s licenses not acceptable form of proof

� Utility Bill � Tax Receipt � Rental / Lease Agreement � Closing Settlement � Sales Agreement that indicates completion date of home

� Student Residency Questionnaire � Auto Call Form � Custody Order – ( If applicable, a copy must be made) � Alternative Transportation Request (If applicable) � Special Needs Form

� IEP / GIEP � ER / Psychological Evaluation

� Home Language Survey � Internet Use Agreement � Authorization for Verification of Address � Student Health Needs Identification Form � Immunization Card – Current Record / Print out from Pediatrician � Physical Exam Form � Dental Card

___________________________________________________________________________

(Administrative Use)

Building Assignment (circle) Newlonsburg Sloan Heritage

Intake (initials) _________________________

FRANKLIN REGIONAL SCHOOL DISTRICT STUDENT …...Franklin Regional School District is now accepting...

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