Jonathan Y. Scammon Elementary English Enrollment Packet ...
Transcript of Jonathan Y. Scammon Elementary English Enrollment Packet ...
Rev. 07/2014
Chicago Public Schools School Enrollment Form
School Name__________________________________________________________________________
Student Information
Student’s siblings’ names if currently enrolled in CPS: ___________________________ ___________________________ ___________________________
___________________ Student ID#
School Use Only: Prevent duplicate student records. Search in SIM for an existing Student ID before creating a new one.
___________________________ ______________________ __________________ ___________________ Last Name First Name Middle Name Generation (Jr., etc) ______________ _______________________________ _________________________________________ Gender Birth date (mm/dd/yyyy) Registration Grade Level (when first entering CPS)
Personal, Immigrant, and Refugee Information
To Parent/Guardian:
CPS is required to keep a count of immigrant students for Federal and State Guidelines in order to determine if additional resources and services for students are needed.
Note that this is not an inquiry on citizenship status, and all information will be kept confidential.
Y / N _______________________________________________________ Birth Certificate on File Birth Verification Type __________________________ ________________________________ ____________________________ * Birth Country Birth State Birth City
* Complete if student was not born in the United States (US) or one of its Territories:
Date of first enrollment in any US School: ____________________________
Full Years completed school in US: _________________________________ Student has refugee status: Y / N Country of refugee:_____________________________________
School Use Only: Note that “Date of first enrollment in any US School” becomes a required field in SIM if “Birth Country” is not the US or one of its Territories.
Student Address/Phone
Physical (Home) Address
Mailing Address (if different than Home)
__________________________________ ______ _________________ _________________ ___________ Street Number and Name Apt. City State Zip Code __________________________________ ______ _________________ _________________ ___________ Street Number and Name Apt. City State Zip Code Home Phone Number______________________________
Demographic, Home Language,
Parent/Guardian Contacts, Emergency/Health Information
Federal Ethnic and Race Categories: (Enter information into SIM from the Race and Ethnicity Survey form)
Home Language Survey: (Enter information into SIM from the Home Language Survey form)
Parent/Guardian Contacts: (Enter information into SIM from the Request for Emergency and Health Information form)
Emergency/Health Information: (Enter information into SIM from the Request for Emergency and Health Information form)
Enrollment Enrollment Status Codes:
01 – No Former School 02 – Chicago Public School (to incl. Charter/Contract) 03 – Chicago Private School 04 – IL Public Schl, not Chicago 05 – IL Private Schl, not Chicago 06 – US Public Schl, not Illinois 07 – US Private Schl, not Illinois 08 – Not in USA
_______________________________________________________________ __________________________________ *School Transferring From ((if not a Chicago Public, Charter or Contract School) City and State
*Is the student in good standing? Y / N (Instructions to school: for out-of-state public school or any private school students, a certification of “good standing” should be received from the Parent/Guardian. Refer to CPS Policy 10-0623-PO1 for more information.)
Last Chicago Public, Charter, or Contract School Attended _____________________________________________ Is the student receiving any type of Special Education services? Y / N (Instructions to school: if yes, please notify the Case Manager.) Student Enrolled by ____________________________________________________________________________ (Print Name and Relationship) _________________________________________________________ ________________________________ Signature of Parent/Guardian Date of Enrollment
School Use Only: Enrollment Status Code (insert a # from the left) ______ Grade Level_______ Homeroom/Division #____________
ChicagoPublic
Schools
HOME
LANGUAGE
SURVEY
HLS 1 of 2SpanishPolish
ChineseArabicBosnianCroatianSerbian
Urdu
HLS 2 of 2Romanian
YorubaAssyrianGujaratiTagalogKorean
Office ofLanguage
andCultural
Education
RevisedMay 2016
____________________________________________________ ____________________________________________________ Signature of School Official Date Signature of Parent/Guardian Date
Notes:• If the parent/guardian does not speak English and the school does not have staff who speaks the parent/guardian’s
language, identify the language spoken by the parent/guardian through any assistance available in the school.• If exact name of the language cannot be determined, enter “Other” as a temporary entry. If you entered “Other,” the
exact language must be determined within two weeks after enrollment. • If the language spoken by the parent is not reflected in this HLS, please visit the OLCE Forms page on the Knowledge
Center at bit.ly/OLCEforms and click on Home Language Survey in Additional Languages.
Complete this Home Language Survey at the student’s initial enrollment in a Chicago Public School.This form must be kept in the student’s folder.
School: ________________________________ Room: _____ School ID #: __________ Network: __________________
Student Name: ________________________________________ Student IS #: ___________________________________
Rev. 07/2017 Chicago Public Schools
Request for Emergency and Health Information
School Name: _____________________________________________________________________________________ PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a change in this information, immediately notify the school in writing. ___________________ __________________________________________________________________________________________ __________________ Student ID# Last Name First Name Middle Name Homeroom # ______________________ ___________________________________________________________________________________ _____________________ Birth Date (mm/dd/yyyy) Student Home Address Student Home Phone #
Confidential Information Box 1 Complete this box only if (1) it reflects your child’s current living situation; OR (2) it reflects your living situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff with enrollment and may enable the student to receive additional services.) Check one box:
in a car/park/other public place
doubled-up in a hotel/motel in a shelter in transitional housing
Confidential Information Box 2 Is there a current Order of Protection or No Contact Order which concerns this student? Yes No
School Note: If any box is checked, see the CPS Policy 702.5.
Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed.
Parent/Guardian Contact Parent/Guardian Contact
Contact Name
Relationship to Student
Check all that apply: Lives With Gets Mailings Emergency Permission to Pickup
Lives With Gets Mailings Emergency Permission to Pickup
Home Address, if different from student’s
Home Phone Number, if different from student’s
Cell Phone Number
Email Address
Name and Address of Employer
Work Phone Number
* Communication Language
* CPS communicates via phone calls. Select the language that should be used to communicate with you. Languages available for mass communication at this time are English and Spanish (note: other languages upon availability).
List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student: _________________________________________________________________________________________________________________________________ Name Home Address Telephone # Relationship
Family Doctor’s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency.
____________________________________________________________________________________________________________________________________
Student Health Insurance: (select only one of the three)
Illinois Medical Card/All Kids: provide student’s medical ID # __________________________________________(9-digit number located on back of card)
No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No
Private/Employer Health Insurance: no additional information needed
Children of Military Personnel (optional) As the Parent or Guardian, are you a member of a branch of the armed forces of the United States? Yes No
If yes, are you either deployed to active duty or expect to be deployed to active duty during the school year? Yes No
I certify that the information on this form is correct:
____________________________________________________________________________(Parent/Guardian Signature)___________________________(Date)
School Note: If “Yes,” follow CPS Policy 704.4 procedures. Enter information in Legal Alert field and update contact information, as needed, in SIM.
11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
State of Illinois Certificate of Child Health Examination
Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.
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. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication. REQUIRED Vaccine / Dose
DOSE 1
MO DA YR
DOSE 2
MO DA YR
DOSE 3
MO DA YR
DOSE 4
MO DA YR
DOSE 5
MO DA YR
DOSE 6
MO DA YR
DTP or DTaP
Tdap; Td or Pediatric DT (Check specific type)
�Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT
Polio (Check specific type)
� IPV � OPV � IPV � OPV � IPV � OPV � IPV � OPV � IPV � OPV � IPV � OPV
Hib Haemophilus influenza type b
Pneumococcal Conjugate
Hepatitis B
MMR Measles Mumps. Rubella
Comments: Varicella
(Chickenpox)
Meningococcal conjugate (MCV4)
RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose Hepatitis A
HPV
Influenza
Other: Specify Immunization Administered/Dates
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 (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result. *MEASLES (Rubeola) MO DA YR **MUMPS MO DA YR HEPATITIS B MO DA YR VARICELLA MO DA YR 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below verifies 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 3. Laboratory Evidence of Immunity (check one) �Measles* �Mumps** �Rubella �Varicella Attach copy of lab result. *All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence. **All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.
Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________ Physician Statements of Immunity MUST be submitted to IDPH for review.
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)
Yes No
List: MEDICATION (Prescribed or taken on a regular basis.)
Yes No
List:
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 BMI PERCENTILE 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. http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm. 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 Screening Result: Gastrointestinal
Eyes Screening Result: 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 � Modified �
Print Name (MD,DO, APN, PA) Signature Date
Address Phone
Scammon Elementary
One complete, please contact Mrs. Toledo at
[email protected] to set up a virtual appointment.
Thank you for completing the enrollment packet.
Stay safe!