Enrollment Packet 2014 -2015 Arlington community schools Tammy Mason, Superintendent July 29, 2014 Arlington Elementary & Donelson Elementary Arlington Middle School 7:30 a.m. – 11:30 a.m. & 3:00 p.m. – 6:00 p.m. ! Arlington High New Students: 7:30 a.m. – 11:30 a.m. & 1:00 p.m. – 6:00 p.m. Grades 11 & 12: 8:00 a.m. – 9:30 a.m. Grades 9 & 10: 9:30 a.m. – 11:30 a.m. ! ! ! ! Required Documents Are Enclosed: Registration Information Items Accepted for Proof of Residency Student Enrollment Form Primary Home Language Survey Immunization Exemption Form Confidential Student Health Information Form Medication Authorization Form ! Arlington)Community)Schools)offers)educational)and)employment)opportunities)without)regard)to)race,)color,)creed,)national) origin,)religion,)sex,)age,)or)disability)and)adheres)to)the)provisions)of)the)Family)Education)Rights)and)Privacy)Act)(FERPA).) Registration day: July 29, 2014 Arlington Community Schools Arlington & Donelson Elementary 7:30 – 11:30 a.m. & 3:00 – 6:00 p.m. Arlington Middle 7:30 – 11:30 a.m. & 3:00 – 6:00 p.m. Arlington High New Students: 7:30 – 11:30 a.m. & 1:00 – 6:00 p.m. Grades 11 & 12: 8:00 – 9:30 a.m. Grades 9 & 10: 9:30 – 11:30 a.m. All students not able to attend their assigned times must register between 11:30 a.m. and 6:00 p.m. Bus transportation is not provided for Registration Day. AHS Students must have a completed Parking Form and Class Schedule to receive a parking permit. Self-Contained Special Education Students in self-contained Special Education classes will register on August 4, 2014, the first full day of school, and do not need to be present on Registration Day. Parents are encouraged to contact the school and speak with the Special Education Secretary to confirm enrollment prior to the first day of class. Items Needed for Enrollment if student DID NOT attend the registration nights in March or April *Proof of Residence: Parents/guardians must provide TWO of the following items showing the parent/guardian’s name and address to prove residency: 1. Most recent MLGW or municipal water bill of the owner, renter or lessee of the home in which the student will reside during the current school year; 2. Mortgage statement or deed of the owner of the home in which the student will reside during the current school year; 3. Lease of the lessee of the home in which the student will reside during the current school year; 4. Rental Agreement of the renter of the home in which the student will reside during the current school year; 5. Real Estate tax receipt; 6. Public assistance/government benefits check, card, or papers; 7. In the event that two (2) of the items listed above cannot be provided, residency may be established by submitting other documentation deemed to be appropriate proof of residence by the department responsible for verifying residency. Immunization Records NEW IMMUNIZATION REQUIREMENTS: K-12 students must have a TN School Immunization Certificate showing: Two (2) doses of Varicella Four (4) doses of DTPTwo (2) doses of MMR Four (4) doses of Polio or proof of Chickenpox Hib-Td (all students) Two (2) doses of Tdap Booster Three (3) doses of Hepatitis Hepatitis A (Grade K); (7th Grade Entry Only) B (Grade K & 7) For more on state-required immunizations, please refer to the Immunization Requirements at the following state website: https://health.state.tn.us/ceds/required.htm. New Student Enrollment Students who have previously enrolled in another school system in Tennessee may enroll pending receipt of their academic and health records. Students transferring into the system from an out of state school or from a nonpublic school must provide a Tennessee Department of Health Immunization Certificate that includes a physical ! exam. The following documents are required: 1. Proof of Residence: Same as above. Proof of residence is required of all students at enrollment and may be required of any student during the school year. 2. Social Security Number: Bring student’s Social Security Card. (T.C.A. 49-6-5102) 3. Tennessee Department of Health Immunization Certificate: Contact the school for additional information. 4. Kindergarten Students must be 5 years old on or before August 15, 2014, and the following items must be provided: A. Certified copy of Birth Certificate B. Proof of recent medical examination C. Tennessee Department of Health Immunization Certificate with proof of a physical exam within 12 months prior to enrollment. D. Social Security Card E. If applicable, custody papers and parent plan Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age, or disability and adheres to the provisions of the Family Education Rights and Privacy Act (FERPA). Items Accepted for Proof of Residence 2014-15 Arlington Community Schools Please provide two (2) of the following seven (7) items showing the parent/guardian’s name and address to prove residence: 1. Most recent MLGW or municipal water bill of the owner, renter or lessee of the home in which the student will reside during the current school year; 2. Mortgage statement or deed of the owner of the home in which the student will reside during the current school year; 3. Lease of the lessee of the home in which the student will reside during the current school year; 4. Rental Agreement of the renter of the home in which the student will reside during the current school year; 5. Real Estate tax receipt; 6. Public assistance/government benefits check, card, or papers; ! 7. In the event that two (2) of the items listed above cannot be provided, residency may be established by submitting other documentation deemed to be appropriate proof of residence by the department responsible for verifying residency. Any child up to the eighteenth birthday whose parents are bona fide residents of Arlington or Lakeland is entitled to attend Arlington Community Schools. Only the residence of the parent with legal custody may be used for registration. (T.C.A.§49-6-3103) In cases where parents have joint custody, only the address of the parent named as the primary custodian or designated primary responsibility to determine educational issues may be used for registration. The parent whose residence qualifies the child to be registered is the parent the school personnel will consider as the custodial parent. The noncustodial parent may receive school records when a written request is given to the school principal in compliance with T.C.A.§49-6-902 or T.C.A.§36–6–104. Any child who has been legally adopted by persons who are bona fide residents of Arlington or Lakeland is entitled to attend Arlington Community Schools (ACS Board Policy 6.204). Wards of the Juvenile Court who have been placed in custody of a bona fide resident of Arlington or Lakeland are entitled to attend Arlington Community Schools (ACS Board Policy 6.204). Any child approved under the non-resident policy is entitled to attend Arlington Community Schools (ACS Board Policy 6.204). ! Arlington Community Schools’ policy prohibits the enrollment of any student other than the above described. “Any parent, guardian, or other legal custodian who enrolls an out-of-district student in a school district and fraudulently represents the address for the domicile of the student for enrollment purposes is liable for restitution to the school district for an amount equal to the local per pupil expenditure identified by the Tennessee Department of Education for the district in which the student is fraudulently enrolled. Any parent, guardian, or other legal custodian who enrolls an out– of-state student in a school district and fraudulently represents the address for the domicile of the student for enrollment purposes is liable for restitution to the school district for an amount equal to the state and local per pupil expenditure identified by the Tennessee Department of Education for the district in which the student is fraudulently enrolled… .” Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age, or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA). Check place of residency: Student Enrollm ent Form ___ Arlington city limits ___ Lakeland city limits ___ Other 2014-15 Arlington Community Schools For School Use Only: Proof of Residence: Birth Cert ________ Physical ________ Immunization Cert ________ SS Card ________ ______ Mortgage ______ Lease ______ Rental Agreement ______ Sales Contract ______ Real Estate Tax ______ MLGW ______ Public Assistance Docs ____ Military Housing Letter ____ Other deemed appropriate by school admin (list) _________________ Proof of residence if living with someone else: ______ Notarized Proof of Residence Form Completed ______ Administrative Approval Teacher __________________________ Date of enrollment ________________ Bus RT# ______________ Daycare ________ Car ________ Walker ________ Has student ever attended another Tennessee Public School? Yes Has student ever attended a Shelby County (or Memphis City) school? Yes No No! Last School Attended School Name Student Social Security Number Gender Male Address Student’s Legal Last Name Federal Ethnic Category: First Name City State Birth Date (mm/dd/yyyy) Generation (Jr, II, etc.) Federal Race Category: Mark one or more races to indicate what you consider your child to be. (Even if “Hispanic or Latino” has been chosen for ethnicity, the child must be recorded as being one or more of the following races.) Hispanic or Latino Asian American Indian or Alaska Native Female Not Hispanic or Latino White Student’s Physical Address (Address of Parent/Legal Guardian) Street Number Middle Name Grade Level Black/African-American Native Hawaiian and Other Pacific Islander Street Name Apartment City State Zip Parent/Legal Guardian #1 Title (Mr., Mrs, etc.) Preferred Language English Last Name Spanish Home Phone Work Phone Relationship Student Lives With First Name Middle Name Other Generation Translator Needed? Cell Phone Mother Both Father Other Employed By Yes No Yes No Yes No Email Federal Employee Yes No Parent/Legal Guardian or Other Contact #2 Title (Mr., Mrs, etc.) Preferred Language English Last Name Spanish Home Phone Work Phone Relationship Student Lives With First Name Middle Name Other Generation Translator Needed? Cell Phone Mother Both Father Other Employed By Email Federal Employee Yes No Emergency Contact #1 Title (Mr., Mrs, etc.) Preferred Language English Home Phone Last Name Spanish First Name Middle Name Other Generation Translator Needed? Work Phone Cell Phone Email ! Relationship Name Birth Date Gender Grade School List siblings attending Arlington Community Schools Are there any Legal Alerts the school needs to be aware of? Yes No If Yes, please explain and provide appropriate documents (for example, court orders). Has the student ever been enrolled in a Special Education/Resource/504/Gifted Program? Yes No If yes, what type of program? Where? When? Student’s Birth Place (City) Birth State Birth Country If Immigrant, Date Entered U.S. Year Started School (mm/dd/yyyy) Mother’s Maiden Name Is English primary language spoken by student? First Date Enrolled in U.S. School (yyyy) (mm/dd/yyyy) Birth County Yes No Is English language limited? Birth City Yes No List Home Language Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age, or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA). ! ! Primary Home Language Survey 2014-15 Arlington Community Schools The parent or legal guardian should complete this form during registration. Date _______________ Student Name _________________________ Sex _____ Date of Birth ___________________ School _______________________________ Grade ______Student # __________________ Home Telephone _______________________ Cell Phone:________________________ The native/home language of each student must be recorded in his/her permanent record. ! Please answer the following questions about your child’s language background: 1. What is the first language this child learned to speak? ________________________________ 2. What language does this child speak most often outside of school? _____________________ 3. What language do people usually speak in the child’s home? __________________________ Listing another language other than English to any of the questions above DOES NOT qualify a student as an English language learner. It does require, however, that the student participate in an approved language proficiency assessment to determine language proficiency and possible ESL classification based on these assessment results. If any question is answered with another language other than English, a copy of this form should be forwarded to the local school ESL teacher for language assessment testing. ! Collected for Funding Purposes Only: Was this child born in the United States? _____Yes _____No ! If no, what is the country of birth? _____________________________________________ Date entered the United States: ______________________________________ Date entered schools in the United States: ________________________________ Has this student ever been enrolled in an ESL program? _____Yes _____No In what language do you want correspondence sent to you from school? _____________________ Signature of Parent/Guardian Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA). Revised'02/2014' !! Immunization Exemption Form 2014-15 Arlington Community Schools Coordinated School Health Received date___________ Entered in PowerSchool under Special Medical Considerations: By ____________________ Date___________________ ! Student Name (print) ! Date of Birth ! Parent/Guardian Name ! Address ! Phone ! ! Please circle 2014-15 grade level: pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 Waiver of Immunization Requirements State Law (T.C.A. 49-6-5001) provides waiver of immunization requirements under the following conditions: 1. In the absence of epidemic or threat of epidemic, parents may object in writing when immunization conflicts with the teachings and practice of a well recognized religious denomination to which the parents adhere. However, if an epidemic or threat of epidemic occurs, objections on behalf of religious teaching are invalid. 2. Certificate in writing from a physician stating that such immunization would be harmful to the child involved is provided to the school for the student’s permanent file. EXEMPTIONS If your child has not received all the required immunizations, complete the appropriate section and return this form to your child’s school. Medical Exemption The following immunizations are medically contraindicated and constitute a threat to the child’s health. Please check the appropriate vaccine below: Dtap HIB Hepatitis B Polio Varicella (Chickenpox) MMR Hepatitis A S. Pneumo Physician’s Signature _____________________________________________Date_________________________ ! Religious Exemption Parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to such immunizations. State your reason for requesting a religious exemption: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Parent/Guardian Signature __________________________________Date________________ Important: Students exempted from immunizations may be excluded from school if one of these vaccine-preventable diseases is identified in the school. Children excluded from school will be prohibited from attending school until either the child is immunized and the danger of outbreak is past, or the child contracts the disease and completely recovers. Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age, or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA). Revised 2/2014 ! ! Confidential Student Health Information Form 2014-15 Arlington Community Schools Please&Print&Below& & Student!Name_____________________________________________! !!!2014015!Grade____________! ! Gender!!!!!M!or!F!!!!!!!!!!!!!Date!of!Birth!!!__________________! ! School!_____________________________________________________!!!!!!!!!!!!!!!!!!!!!!Homeroom!Teacher__________________________! General&Information& ! The! request! for! identifiable! health! information! will! enable! us! to! provide! safe! and! appropriate! health! care! if! your! child!becomes!ill!or!injured!at!school!or!on!the!bus.!The!information!that!you!provide!will!be!maintained!confidentially!and!is! limited! to! individuals! that! work! with! your! child! within! the! school! setting! with! a! legitimate! need! to! know.! If! you! have! any! questions! or! would! like! to! discuss! specific! health! issues! with! Health! Services! staff,! please! call! your! school! directly! during! school!hours.! Release&of&Health&information&(Please&initial&only&one&below)& ! Parent!gives!permission!to!release!health!information!to!appropriate!school!system!staff!for!medical!alert! notification!and!health!care!management.! ! Parent!prohibits!disclosure!of!sensitive!health!information!to!school!staff!unless!medically!necessary!without! specific!request!and!school!nurse!involvement.!! ! Parent/Guardian&Information&& Last!Name! First!Name! Relationship! Phone! ! ! ! ! ! ! ! ! ! ! ! Emergency&Contacts&& Last!Name! First!Name! Relationship! Phone! ! ! ! ! ! ! ! ! ! ! ! Physician&Contacts& Physician!Name!or!Office! Clinic/Practice!Name!and!Address! Phone! ! ! ! ! ! ! ! ! Please&Review&The&Following&List&and&Check&Any&And&All&That&Apply.& ! ADHD! ! Cystic!Fibrosis! ! Kidney!Problems! ! Anemia! ! Diabetes! ! Leukemia! ! Anxiety!attack! ! Depression! ! Low!Blood!Pressure! ! Arthritis! ! Dialysis! ! Meningitis! ! Artificial!joints! ! Fractures!(Skull)! ! Menstrual!cramps! ! Artificial!valves!! ! Glasses! ! Migraine!Headache! ! Asthma! ! Headaches! ! Nosebleeds! ! Back!Problems! ! Hearing!Problems! ! Panic!attacks! ! Broken!bones! ! Heart!Problems! ! Reflux! ! Cancer! ! Hemophilia! ! Rheumatic!Fever! ! Contact!lenses! ! High!Blood!Pressure! ! Scoliosis! ! Concussion! ! Hypoglycemia! ! Seizures! ! Other,!including!health!procedures:! If!any!are!checked,!please!provide!specific!information:!! & & PLEASE&COMPLETE&REVERSE&SIDE& ! ! ! ! ! ! ! ! ! ! ! ! Sickle!Cell!anemia! ! Sinus!Problems! Stroke! Vision!Problems! Vomiting! Procedure!Below:! Catheterization! Tube!Feeding! Equipment!Below:! Crutches! Walker! Wheelchair! Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA). Revised 02/2014 ! ! !!!!!!!!!!!!!!!!!!& ALLERGY&INFORMATION:&&IS&YOUR&CHILD&ALLERGIC&TO&ANY&OF&THE&FOLLOWING?& & Medication!(Name)! Environmental! (Trees,!Grass)! Does!your!child!require!an!epinephrine! for!an!allergic!reaction?! ! Food!(Tree!nuts,!Peanuts,! Fish,!Milk,!Egg)! ! Insects!(Bees,!Wasps)! ! Latex! ! Dyes!(Red,!Yellow)! Other! !!!!!!!!!!!!!!!!!!!!!Yes!!or!!No! ! If!yes,!what!type!and!dose!level:! & & & Name!of!medications!your! child!takes!in!addition!to!the! Epinephrine!to!treat!an! allergic!reaction:! & & & & MEDICATION&INFORMATION:&&DOES&YOUR&CHILD&ROUTINELY&TAKE&MEDICINE&AT&HOME&OR&SCHOOL?&&&Y&&OR&&N& IF#YES,#PLEASE#PROVIDE#INFORMATION#BELOW:# # DIAGNOSIS!FOR! WHICH! MEDICINE!IS! GIVEN! NAME!OF! MEDICATION! FORM!(PILL,! LIQUID,! INHALER)! DOSAGE! SPECIFIC!TIME(S)! TO!BE!GIVEN! GIVEN!AT! HOME! GIVEN!AT! SCHOOL! # # # # # # # # # # # # # # # # # # # # # # # # # # # # # PARENT/GUARDIAN& ACKNOWLEDGEMENT:& & I!acknowledge!that!my!child!may!be!allowed!to!take!his/her!medication! according!to!Board!policy.!I!also!understand!that!I!must!personally!bring!all!medications!that!are!deemed!medically!necessary! for! administration! during! the! school! day! to! the! office! and! complete! a! Parent! Authorization! Form! for! Administration! of! Medication.!This!document!will!be!placed!in!the!school!office.! ! I!understand!that!although!a!reasonable!attempt!will!be!made!to!remind!the!student!about!medications,!it!is!expected!that!the! student!will!be!responsible!for!obtaining!his/her!medication!if!required!for!self0administration!during!the!school!day.! ! I!agree!to!indemnify!and!hold!harmless!ACS!and!its!employees!from!claims!relating!to!the!possession!or!self0administration!of! asthma!inhalers,!and!understand!that!ACS,!its!employees!and!agents!shall!incur!no!liability!as!a!result!of!injury!to!a!student!or! any!other!person!as!a!result!of!possession!or!self0administration!of!asthma!inhalers.! ! I! also! authorize! the! school! nurse! and! district! health! services! staff! to! consult! with! the! prescribing! physician! to! clarify! medication! orders,! or,! in! the! interest! of! the! student’s! health,! to! discuss! his/her! response! to! the! prescribed! medication.! ! All! health!information!will!be!kept!confidential.! ! ! ________________________!! _______________________________________________________!!!!!!!!!!!!!!!!!!!!!!!!!!______________________________________! !!!!!!!!!!!!Date!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Parent/Guardian!Signature!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Telephone! ! ! ! ! !! FOR&SCHOOL&STAFF&ONLY& & Note:!!The!School!Nurse!will!review!this!form!to!determine!the!level!of!disclosure!and!appropriate!action:! ! Medical!Alert_______!!!!!!!! ! IHP!to!be!developed_______! ! Other___________________________________________________________! ! School!Nurse!review!date!and!signature:!__________________________________________________________________________! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA). Revised 02/2014 ! ! Medication Authorization 2014%15' Arlington'Community'Schools' ' ! Student’s!Name!___________________________________________________________________!School________________________________! Homeroom!Teacher_______________________________________________________________!Grade________________________________! Name!of!Medication_______________________________________________________________!Expiration'Date____________________' ''''''''''''''''''''''''''''''''''''''''Is!medication!given!by!inhaler?!!!Yes_______!!!!No_______' If!yes,!do!you!wish!inhaler!kept!with!your!child?!!Yes_______!!!!No_______! Purpose____________________________________________________________________________________________________________________! Dosage__________________________________________________!!!!Time!to!be!administered_____________________________________! Possible!side!effects_______________________________________________________________________________________________________! This'certifies'that'I,'the'undersigned'parent/guardian,'am'aware'of'the'terms'of'the'above' authorization'and'hereby'request'that'they'be'carried'out'accordingly.' Signed___________________________________________________________!!!!Date___________________________________________________! Home!Phone_____________________________________________________!!!Work!Phone__________________________________________! Cell!Phone________________________________________________________!!!Other!contact________________________________________! ! Please'do'not'write'below'this'line.''For'office'use'only' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ! ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ! Arlington Community Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age or disability and adheres to the provisions of the Family Rights and Privacy Act (FERPA).