1. education
2. school

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Welcome Meeting Forms and Permissions
Greetings from Success Academy! We are excited to have you here. We will need some
important information and permissions from you regarding your child prior to the start of
school. Please carefully read, sign, and date each form and return them by mail, email, or by
bringing them to your next scheduled meeting. Below are brief descriptions of each required
form.
Department of Education Student Ethnic and Race identification
Federal law requires the New York City Department of Education to collect and record the ethnic
identity and race of public school students. This form requires that you check off the ethnicity and race
with which your child identifies.
1. Only complete your child’s name and date of birth in the top section designated for school staff.
2. In the ethnic identity boxes, if you select “Yes” to question 1 you do not need to complete question 2.
If you select “No” to question 1, you must check one of the 5 options in question 2.
3. Please sign and date at the bottom of the page and select your appropriate relationship to the
student.
Success Academy Media Release Form
Success Academy often takes photos and video of scholars during the school day that might be used
on our website or in other media. If you consent to your child being featured in such media, please
indicate your permission on this form. If you do not wish for your child to be featured in these materials,
please write a note on the form indicating that you do not give consent.
Success Academy Field Study Permission Form
Success Academy scholars make frequent field study trips around the city as part of our curriculum.
Instead of sending forms home before each field study, we provide one form that grants permission to
take your scholar on field studies throughout the year. You will be reminded of these field studies by
your school’s staff as they arise, so you will always know when your scholar is leaving school grounds.
Proof of Address
We have also included our guidelines for supplying Success Academy with a proof of address. All
Success Academy scholars must be legal New York State residents. These guidelines will help you know
what is an acceptable proof of residency.
Uniform Financial Assistance Request
Please only fill out this form if your family is experiencing a hardship that would qualify you for financial
assistance to help pay for your child’s uniform. Refer to the “Uniform Requirements and Cost” page of
this package for 2013-2014 uniform costs.
Health Exam Form
Each scholar must have a health exam form completed by a licensed health care provider in order to
attend school. You will want to make an appointment with a doctor soon so that you may have your
child’s physical completed.
Immunization Guideline
All children attending public schools must be up-to-date on required vaccinations. This guideline will list
vaccines and doses required.
Medical Administration Form
If your child requires a medication that would need to be administered by a Success Academy staff
member during a school day, this form gives consent for us to be able to do so.
Thank you in advance for completing these forms. Please complete them as timely as
possible and submit by mail, email or by bringing them to your next scheduled Success
Academy meeting.
2013 – 2014 IMPORTANT DATES We have provided the school start dates and vacation calendar so that you can begin planning. Please note that we begin earlier than traditional district schools and we have a different vacation
calendar. The first few days of school are exceptionally important and we cannot excuse absences
on those days. Please plan accordingly. August 2013
First Day of School………………………………........................................................................Monday, August 19
Kindergarten: Harlem 1 – 5, Bronx 1 & 2, Upper West, Bed-Stuy 1 & 2, Cobble Hill, Williamsburg
Gr 3: Harlem 1 – 5, Bronx 1 & 2, Upper West, Bed-Stuy 1
First Day of School………………….………......................................…....……………………...Thursday, August 22
Gr 1 & 2: : Harlem 1 – 5, Bronx 1 & 2, Upper West, Bed-Stuy 1 & 2, Cobble Hill, Williamsburg
First Day of School……………………….……….................................................................…..Monday, August 26
Kindergarten: Hell’s Kitchen, Union Square, Bronx 3, Fort Greene, Prospect Heights, Crown Heights
First Day of School……………….…………………………………….…………………………….Thursday, August 29
Gr 1: Hell’s Kitchen, Union Square, Bronx 3, Fort Greene, Prospect Heights, Crown Heights
September 2013
Labor Day (no school)…………....……………………………….........................................Monday, September 2
October 2013
Columbus Day (no school)…………...............................................................................…Monday, October 14
November 2013
Thanksgiving Break (no school)……………………………………….…………………………....November 25 – 29
December 2013
Winter Break (no school)………...............................................................................................December 23 – 31
January 2014
Winter Break (no school)………………………………………..………………………...…….………….January 1 – 3
MLK Day (no school)……………………………………………….……………………………....Monday, January 20
February 2014
President’s Day (no school)………………………………………….……………………….….Monday, February 17
No School………………………………………………………………………………………....…Tuesday, February 18
April 2014
K – Gr 2 Spring Break (no school)…………….…..……………………………………………………..…April 14 – 18
May 2014
Gr 3 Spring Break (no school)………………………………………………………………….….……….…..May 5 – 9
Memorial Day (no school)…………………………………………..............................…………....Monday, May 26
June 2013
Last Day of School………………………………………………………………..…...……………….…..Friday, June 13
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Forms and Permissions Packet
The forms in this packet must be filled out in order to continue in the
enrollment process. Please return these forms with this attached cover sheet.
After you have filled them out, you may return them by:
• Mailing them to:
Success Academy
Attn: Enrollment
310 Lenox Ave, 2nd Floor
New York, NY 10027
• Emailing completed and scanned copies to:
[email protected]
• Bringing them to your next scheduled meeting
Complete the following information and return with your forms:
Child’s Name:
Child’s Date of Birth:
Grade Entering Next Year:
Parent/Guardian Name:
Phone Number of Parent/Guardian:
Email of Parent/Guardian:
Please Remember:
You must submit the following for each child:
 The forms in this packet
 A New York State Proof of Residency
(guidelines included in this packet)
 A photocopy of the
child’s birth certificate
 A completed health form packet
THE New York City DEPARTMENT OF EDUCATION
FORM
PSE!
FEDERAL PARENT/GUARDIAN STUDENT ETHNIC & RACE IDENTIFICATION!
To the Parent/Guardian:
Federal law requires the New York City Department of Education to collect and record the ethnic
identity and race of public school students. This information is used to determine funding for your
school, among other things, and is kept secure and confidential.
We need your help to accomplish this task. Please respond to the ethnicity and race identification
questions on the back of this page. The first question provides an opportunity for you to indicate
whether your child is of Hispanic, Latino, or Spanish origin; the second question provides an
opportunity for you to indicate your child’s race(s). Please be sure to respond to both questions.
Students identified with more than race will be counted in the “two or more races” category.
Hispanic students of all races will be counted in the Hispanic category.
The New York City Department of Education understands the sensitive nature of this process.
The options provided by the federal government may not represent an accurate or complete
portrayal of your family’s own ethnic or race identification. We encourage you to provide
responses using your best judgment. If you decline to respond to either question, federal
guidelines require New York City Department of Education school staff to make an identification
of your child on your behalf.
Race and ethnicity information for students is protected by the confidentiality regulations cited at
the bottom of this page.
Thank you for your cooperation.
Parents and Guardians: Please complete the form on the reverse
side of this page and return it to your child’s school.
School staff: File the completed form in the student’s Cumulative
Record folder as confidential information.
Confidentiality Procedures and Regulations
The Family Educational Rights and Privacy Act (1974) and Regulations of the Chancellor A-820 prohibit
unauthorized access to student records and unauthorized release of any student record information identifiable by
either student name or student identification number.
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Race may be considered as a factor in school enrollment only where required by court order; gender is a factor
only in single-gender schools.
PSE FORM 08252010
FORM
THE New York City DEPARTMENT OF EDUCATION
PSE!
FEDERAL PARENT/GUARDIAN STUDENT ETHNIC & RACE IDENTIFICATION!
! - All students between 5 and 21 years of age have the right to a free public education.
- Federal law requires the New York City Department of Education to collect and record the ethnic
identity and race(s) of public school students.
- Children may not be refused admission to a public school because of race, color, creed, national
origin, gender, gender identity, pregnancy, immigration/citizenship status, disability, sexual
orientation, religion, or ethnicity.1
SCHOOL STAFF: PLEASE COMPLETE THIS SECTION
Borough
District
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Grade Code
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School
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Class Code
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English Only!
Name of
High School/
Mini School /Annex
NYC Student Identification Number
(HIGH SCHOOL ONLY 4-DIGIT)
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Date of Birth (Month/Day/Year)
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Student Name: Last, First, Middle Initial
PARENT/GUARDIAN: PLEASE COMPLETE THIS SECTION
PLEASE ANSWER BOTH QUESTIONS (1) AND (2). PLEASE READ THEM BEFORE YOU RESPOND.
For Question (1), check (√) the box that best describes your child.
1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Dominican, Mexican,
Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
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YES, Hispanic
NO, not Hispanic
For Question (2), check (√) all boxes that apply to your child.
2. Select one or more races from the following five racial groups.
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AMERICAN INDIAN OR ALASKAN NATIVE: A person having origins in any of the original peoples of North America and South America (including Central
America. (ATS Code: B)!
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ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Sub-Continent including for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (ATS Code: C)!
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NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, or other Pacific Islands. (ATS
Code: D)!
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BLACK: A person having origins in any of the Black racial groups of Africa. (ATS Code: E)!
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WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. (ATS Code: F)!
Signature of Parent/Guardian/Other/School Staff Observer:!
Date:!
Relationship to Student:!
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Parent!
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Guardian!
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Other (Specify):!
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School Staff Observer (Name):!
See reverse side for an important message to parents/guardians and
for confidentiality procedures and regulations!
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Permission and Consent/Release
I,
, hereby grant to Success Academy Charter
Schools, Inc. (“Success Academy”), any schools it operates and/or
manages, and any third parties to which Success Academy grants
permission to produce and/or use the Work (as defined below)(collectively,
the “Success Academy Parties”) the absolute permission and rights to use
any videotape, motion picture film, still photographs, digital image, and/or
voice of my son/daughter/ward, myself, and my son’s/daughter’s/ward’s
other parent(s)/guardian(s) in connection with any and all program(s)
produced by, on behalf of, or with the permission of Success Academy (the
“Work”). My consent allows the Success Academy Parties to use these
likenesses in any form in the editing, production, copyright, copying,
broadcast, publication, or distribution of such Work, or in any manner
related to the advertising and promotion of such Work, throughout the
world forever in any and all media now known or hereafter devised.
I hereby grant my full permission to the Success Academy Parties and
discharge the Success Academy Parties and each and all of their trustees,
officers, employees, agents, successors, and assigns, from any and all
causes of action and claims that may result from the use of the likeness or
voice of myself, my son/daughter/ward, and/or my
son’s/daughter’s/ward’s other parent(s)/guardian(s) in connection with the
result of photographing, videotaping, or recording said likeness and/or
voice. I also hereby waive any right to inspect and/or approve any use of
said likeness or voice in any draft, finished product, or advertising copy that
may be used in connection with production, copyright, copying,
advertising, or broadcast via cable, broadcast television, satellite, Internet,
or other media of said videotape or recording and that said permission
allows the Success Academy Parties’ contracted video producers full rights
to use any portion of this videotape or recording in any format as described
above in the editing and production of any videotape recording.
Child’s Name
Date
Parent/Guardian Signature
Phone Number
Street Address
City, State, Zip
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Field Studies
Field Study Consent Form for the 2013-2014 School Year
Dear Success Academy Families,
At Success Academy Charter Schools (“Success Academy”) we believe
that field trips (which we refer to as “field studies”), cultural outings, sports
competitions, and other school-related trips that take place outside of the
classroom are an important part of our school design. We are lucky to live
in New York City, where there are many opportunities to visit museums,
parks, performance art institutions, and much more. During the 2013-2014
school year, we plan to take all scholars on many school-related trips that
will reinforce what they study and do at school, and provide a meaningful
learning experience. These trips may take place during the school day
and/or before or after school hours, and they may also occur on weekends.
Some trips may require off-campus pickup by an approved adult. When a
school-related trip is scheduled for your scholar, you will receive a
notification flyer detailing the date and location of the trip.
To provide consent for your scholar to participate in all school-related trips
for the 2013-2014 school year, please fill in the blanks with the appropriate
information, sign and date, and return this completed Consent Form to your
scholar’s school.
My name is __________________________________, and I am the
parent/guardian of __________________________________ [Scholar’s Name]. I
consent to the full participation of my scholar in all school-related trips that
are planned, sponsored, and/or supervised by Success Academy and/or
one of its Schools. In consideration for my scholar being able to participate
in these school-related trips, I agree to release, indemnify, and hold
harmless Success Academy and the schools that it operates, and any of
their employees, contractors, board members, agents, volunteers, and
representatives, from any or all claims of liability, injury, or damage
occurring in connection with such trips.
Date: ___________________
Scholar Name (please print): _______________________________________
Parent / Guardian Name (please print): ________________________________
Parent / Guardian Signature: ________________________________________
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Guide to Proofs of Residency
Acceptable Proofs:
• A utility bill (cable, gas, landline phone, electric) in the resident’s
name:
o Issued by National Grid, Con Edison, or the Long Island Power
Authority, etc.
• Documentation or letter on letterhead from a federal, state, or local
government agency showing the resident’s name and address:
o This includes the Internal Revenue Service (IRS), City Housing
Authority, Human Resources Administration (HRA), The
Administration for Children’s Services (ACS), Medicaid,
Medicare, Child Health Plus, etc.
• An original lease agreement, rent statement, deed or mortgage
statement showing the name and address
• A current property tax bill for the residence
• A water bill for the residence
• Official payroll documentation from an employer
o This includes forms submitted for tax withholding purposes or
payroll receipt, W-2, paystubs showing name and address.
Unacceptable Proofs*:
• A letter on the employer’s letterhead in place of payroll documents
• Driver's License
• Bank statements or documents
• Hospital or clinic forms
• Private health insurance mail (vs. public health insurance listed
above, such as Medicaid)
• Non-utility bills (Cell phone, furniture deliveries, etc.)
• Social Security Card
* Proofs from the unacceptable list cannot be accepted, even if notarized.
Note: Students in transitional housing or who are homeless do not need to
provide proof of address.
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Residency Questionnaire
ENROLLMENT(FORM(*(RESIDENCY(QUESTIONNAIRE(
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Name!of!School:!
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Name!of!Scholar:!!
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Gender:!
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Last!! !
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First! !
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Middle!
Male!!
Date!of!Birth:!!
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Female! !
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Month& &Day&
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!!!!Grade:!!
&Year&
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Phone:!!
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(preschool212)&
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Address:!
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The(answer(you(give(below(will(help(the(school(determine(what(services(you(or(
your(child(may(be(able(to(receive.((Your(child(may(be(entitled(to(immediate(
enrollment(in(school(even(if(he(or(she(does(not(have(the(documents(normally(
needed,(such(as(proof(of(residency,(school(records,(immunization(records,(or(
birth(certificate.((Your(child(may(also(be(entitled(to(free(transportation(and(
other(services(depending(on(his(or(her(housing(status.(
(
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Where(is(the(scholar(currently(living?!(Please&check&one&box.)!
((In!a!shelter!
((Temporarily!with!another!family!or!other!person!because!of!loss!of!
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housing!or!as!a!result!of!economic!hardship!!
((In!a!hotel/motel!
((In!a!car,!park,!bus,!train,!or!campsite!
( Other!temporary!living!situation!(Please!describe):!! !
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_________________________________________________________________________________________!
( In!permanent!housing!
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Print!name!of!Parent,!Legal!Guardian,!or!
Scholar!(for!unaccompanied! !
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homeless!youth)!
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Signature!of!Parent,!Legal!Guardian,!or!
Scholar!(for!unaccompanied!!!!!!!
homeless!youth)(
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Date
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Uniform Financial Assistance Request
If your family is experiencing a hardship that would qualify you for financial assistance to help
pay for your child’s uniform, please fill out Option 1 or Option 2 below. Remember that a
uniform is the only financial contribution we ask you to make toward your child’s education.
Success Academy Charter Schools provides all field studies, school supplies, and every
breakfast and lunch for FREE every school day for every child. If at all possible, please make
every effort to pay for your child’s uniform.
Parent/Guardian Name:
Child’s Name:
Address:
Phone Number:
Address:
Please complete Option 1 or Option 2 below.
OPTION 1
List the current Food Stamp case number or TANF/FDPIR number from your benefit letter.
Food Stamp Case Number
TANF/FDPIR Case Number
________________________________________
_______________________________________
OPTION 2
List your current household income.
Adult Name
Gross Income
_________________
_____________  Weekly
 Monthly
 Yearly
_________________
_____________  Weekly
 Monthly
 Yearly
Total number of people living in household: ___________
Name of Employer: __________________________________________________
Employer phone number:
The foregoing information is true and accurate and based upon my own personal
knowledge.
Print Name: _________________________ Signature: ___________________________
Date: _______________________________
Please
CHILD & ADOLESCENT HEALTH EXAMINATION FORM Print Clearly
NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE
—
DEPARTMENT OF EDUCATION
Press Hard
STUDENT ID NUMBER
OSIS
TO BE COMPLETED BY PARENT OR GUARDIAN
Child’s Last Name
First Name
! Female
! Male
Date of Birth (Month/Day/Year )
__ __ / ___ ___ / ___ ___ ___ ___
Hispanic/Latino? Race (Check ALL that apply) ! American Indian ! Asian ! Black ! White
! Yes ! No
! Native Hawaiian/Pacific Islander ! Other ____________________________
Child’s Address
City/Borough
State
Zip Code
District
__ __ Phone Numbers
Number __ __ __ Home _____________________
School/Center/Camp Name
Health insurance
! Yes ! Parent/Guardian Last Name
(including Medicaid)? ! No ! Foster Parent
! Uncomplicated
! Premature: ________ weeks gestation
! Complicated by
_______________________________
Allergies
! None
! Epi pen prescribed
! Drugs (list)
! Foods (list)
Cell ______________________
First Name
Work ______________________
TO BE COMPLETED BY HEALTH CARE PROVIDER
Birth history (age 0-6 yrs)
If “yes” to any item, please explain (attach addendum, if needed)
Does the child/adolescent have a past or present medical history of the following?
! Asthma (check severity and attach MAF/Asthma Action Plan): ! Intermittent ! Mild Persistent ! Moderate Persistent ! Severe Persistent
If persistent, check all current medication(s): ! Inhaled corticosteriod ! Other controller ! Quick relief med ! Oral steroid ! None
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Attention Deficit Hyperactivity Disorder
Chronic or recurrent otitis media
Congenital or acquired heart disorder
Developmental/learning problem
Diabetes (attach MAF)
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Orthopedic injury/disability
Seizure disorder
Speech, hearing, or visual impairment
Tuberculosis (latent infection or disease)
Other (specify) ___________________
Medications (attach MAF if in-school medication needed)
! None
! Yes (list below)
Dietary Restrictions
! None
! Yes (list below)
! Other (list)
Explain all checked items above or on addendum
PHYSICAL EXAMINATION
General Appearance:
Height ____________________ cm
( ___ ___ %ile)
Weight ____________________ kg
( ___ ___ %ile)
____________________ kg/m2
BMI
Sex
Middle Name
( ___ ___ %ile)
Head Circumference (age ≤2 yrs) ______________ cm ( ___ ___ %ile)
Blood Pressure (age ≥3 yrs)
Nl Abnl
Nl Abnl
Nl Abnl
! ! HEENT ! ! Lymph nodes
! ! Dental ! ! Lungs
! ! Neck
! ! Cardiovascular
Describe abnormalities:
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Nl Abnl
Abdomen
Genitourinary
Extremities
Nl Abnl
Skin
Neurological
Back/spine
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! ! Psychosocial Development
! ! Language
! ! Behavioral
_________ / __________
DEVELOPMENTAL (age 0-6 yrs)
! Within normal limits
SCREENING TESTS
Date Done
If delay suspected, specify below
Blood Lead Level (BLL)
! Cognitive (e.g., play skills) ____________________________
(required at age 1 yr and 2 yrs
and for those at risk)
__ __ / ___ ___ / ___ ___
_________ µg/dL
__ __ / ___ ___ / ___ ___
_________ µg/dL
__ __ / ___ ___ / ___ ___
! At risk (do BLL)
! Not at risk
__ __ / ___ ___ / ___ ___
! Normal
! Abnormal
Lead Risk Assessment
! Communication/Language _________________________
(annually, age 6 mo-6 yrs)
! Social/Emotional __________________________________
Hearing
! Pure tone audiometry
! OAE
! Adaptive/Self-Help ________________________________
! Motor ___________________________________________
IMMUNIZATIONS – DATES
Date Done
Results
Tuberculosis
Only required for students entering intermediate/middle/junior or high school
who have not previously attended any NYC public or private school
PPD/Mantoux placed
__ __ / ___ ___ / ___ ___
Induration ______mm
PPD/Mantoux read
__ __ / ___ ___ / ___ ___
! Neg
! Pos
Interferon Test
__ __ / ___ ___ / ___ ___
! Neg
! Pos
Chest x-ray
(if PPD or Interferon positive)
__ __ / ___ ___ / ___ ___
—— Head Start Only ——
Hemoglobin or
Hematocrit (age 9–12 mo)
__________ g/dL
__________ %
__ __ / ___ ___ / ___ ___
CIR Number
of Child
Results
Vision
(required for new school entrants __ __ / ___ ___ / ___ ___
and children age 4–7 yrs)
! with glasses
! Nl
! Abnl
! Not
Indicated
Acuity Right ___ / ___
Left ___ / ___
Strabismus ! No ! Yes
Influenza
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
MMR
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Rotavirus
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Varicella
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
DTP/DTaP/DT
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Td
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Tdap
Hep A
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Hep B
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Hib
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Meningococcal
__ __ / ___ ___ / ___ ___
PCV
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
HPV
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Polio
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___
Other, specify: ____________
__ __ / ___ ___ / ___ ___ ;
_______________
__ __ / ___ ___ / ___ ___
RECOMMENDATIONS
! Full physical activity
ASSESSMENT
! Full diet
! Restrictions (specify) ___________________________________________________________________________
Follow-up Needed
Referral(s):
! Other
! No
! None
! Yes, for _________________________ Appt. date:
! Early Intervention
! Special Education
! Dental
Telephone
! Vision
CH-205 (5/08)
_____________________________________________________________
__ __ __ __ __
_____________________________________________________________
__ __ __ __ __
DOHMH PROVIDER
ONLY
I.D.
Fax
State
TYPE OF EXAM:
NAE Current
NAE Prior Year(s)
Comments
National Provider Identifier (NPI)
City
( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___
__ __ __ __ __
__ __ / ___ ___ / ___ ___
Provider License No. and State
Facility Name
ICD-9 Code
_____________________________________________________________
Date
Health Care Provider Name and Degree (print)
Address
! Diagnoses/Problems (list)
__ __ / ___ ___ / ___ ___
________________________________________________________________________
Health Care Provider Signature
! Well Child (V20.2)
Zip
Date
Reviewed:
( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___
Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian
I.D. NUMBER
__ __ / ___ ___ / ___ ___
REVIEWER:
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Guide to Immunizations
IMMUNIZATION REQUIREMENTS FOR ALL STUDENTS
2013-2014
Children cannot attend school if they do not meet the immunization
requirements below, as mandated by law.
Your child’s immunization records must be submitted to Success Academy.
There are three ways to submit vaccination information from your health
care provider:
1) In the Physical Health Examination Form
2) In the health department vaccination card
3) On a print out from your health care provider’s office
Immunization
Doses Required
Diptheria, Tetanus, Pertussis/ Whooping Cough
(DTap)
4
Polio
(IPV)
3
Measles, Mumps, Rubella/ German Measles
(MMR)
2
Hepatitis B
(HB, Hep B)
3
Varicella
(Chickenpox)
1
NOTE: Parent signature required on reverse side of this form. Current photograph of student MUST be attached to upper left corner of this form.
MEDICATION ADMINISTRATION FORM
Student’s Name (Last, First, Middle)
Authorization for Administration
of Medication to Students for
School Year 2012–2013
DOE District
1.
Diagnosis
ASTHMA
Choose Severity:
! Intermittent
! Mild Persistent*
Male ! Female !
School (PS, IS, etc. and Name)
Date of Birth
I.D. Number
Grade
Class
School Address
! Yes ! No
! Moderate Persistent*
! Severe Persistent*
Borough
Zip Code
Instructions for lack of
improvement or adverse reaction
Choose all that apply
Choose all that are appropriate
! Standard order. 2 puffs q 4 hrs. via MDI and
If improved, but not enough ! Student may carry medication
and may self-administer.
to return to class, call parent.
(PARENT MUST INITIAL REVERSE SIDE).
If significant respiratory
distress persists, call 911
! Store medication in medical room
and notify parent and PMD.
and student to self-administer
May provide additional puffs
under observation.
as needed until EMS
! Store medication in medical
room and nurse to administer.
URI sx can include: Itchy watery eyes, nasal drainage and/or arrives.
spacer prn cough, wheeze, tightness in chest,
difficulty breathing or shortness of breath. May
*National guidelines recommend inhaled corticosteroids
repeat in 15 mins x 2 if no improvement (3 total).
for children with persistent asthma.
! Pre exercise. 2 puffs via MDI with spacer 15-30
Stock supply only available for Ventolin HFA. (see back)
minutes before exercise.
Choose One:
! URI or recent asthma flare (within 3 days).
! Ventolin HFA (may be provided by school for
2 puffs @ noon via MDI inhaler and spacer for 3-5 days.
shared usage).
! _________________ HFA (to be provided by parent).
ADD MEDICATION NAME
" May substitute stock ventolin
" May not substitute stock ventolin
INDICATE HOME MEDS IN BOTTOM LEFT BOX.
2. Diagnosis: Anaphylaxis
Select One:
! EpiPen Auto-Injector: 0.3 mg/0.3 ml [1:1000]
! EpiPen Jr. Auto-Injector: 0.15 mg/0.3 ml [1:2000]
Intramuscularly into anterolateral aspect
of thigh
911 will be called immediately
3.
congestion, sneezing, sore throat, cough, headache
Asthma flare: sx can include: Shortness of breath, chest
tightness or pain, coughing, wheezing
Check one:
! prn
Conditions under which
medication should not be
given:
specific signs, symptoms or situations
Dose/Route
! Diagnosis substantially controlled with medication.
! Diagnosis not substantially controlled with medication.
List medication(s) student takes at
home and at what time:
Conditions under which
medication should not be
given:
HCP/Clinic Tel. No.
HCP Signature
Medicaid No.
HCP/Email
! Student may carry medication
(includes epi pen and MDI) and
may self-administer.
(PARENT MUST INITIAL REVERSE SIDE).
and student to self-administer
under observation.
! Store medication in medical
room and nurse to administer.
FOR DOHMH USE: Revisions per DOHMH
after consultation with prescribing provider
FIRST NAME
HCP/Clinic Fax No.
(PARENT MUST INITIAL REVERSE SIDE).
NOT FOR CONTROLLED SUBSTANCES.
ICD9: ______________________
HCP/Clinic Address
(includes epi pen and MDI) and
may self-administer.
! Store medication in medical room
Time interval: q ______ hours as needed
Any repeats if
no improvement? ! Yes, in _____ hr/mins, max _____ times
LAST NAME
! Student may carry medication
and student to self-administer
under observation.
! Store medication in medical
room and nurse to administer.
specific signs, symptoms or situations
Health Care Practitioner (HCP) Name (PLEASE PRINT)
! No
! Store medication in medical room
ICD9: ______________________
! prn
! Yes
NOT FOR CONTROLLED SUBSTANCES.
Any repeats if
_____ mins, max _____ times
no improvement? ! Yes, in
AND/OR
Medication/Preparation/Concentration
their personal MDI on school trips.
ICD9: ______________________
! Standing daily dose. Specify time(s): ______________
Diagnosis
! Can this student self administer
NPI No.
! IEP
NYS Registration No. Date
(Required)
INCOMPLETE PROVIDER INFORMATION WILL DELAY IMPLEMENTATION OF MEDICATION ORDERS
MEDICATION ADMINISTRATION FORM (MAF): PARENT/GUARDIAN'S CONSENT AND AUTHORIZATION
2012-2013
I hereby authorize the storage and administration of medication, as well as the storage and use of necessary equipment to administer the
medication, in accordance with the instructions of my child's physician. I understand that I must provide the school with the medication and
equipment necessary to administer medication, including non-Ventolin inhalers. Medication is to be provided in a properly labeled original
container from the pharmacy (another such container should be obtained by me for my child's use outside of school); the label on the
prescription medication must include the name of the student, name and telephone number of the pharmacy, licensed prescriber's name, date
and number of refills, name of medication, dosage, frequency of administration, route of administration and/or other directions; over the counter
medications and drug samples must be in the manufacturer's original container, with the student's name affixed to that container. I understand
that if I provide an asthma inhaler, it must be supplied in its original and UNOPENED medication box. I further understand that I must
immediately advise the principal and/or his/her designee(s) especially the school nurse of any change in the prescription or instructions stated
above.
I understand that no student will be allowed to carry or self-administer controlled substances.
I understand that this Authorization is only valid until the earlier of: (1) June 28, 2013 (This prescription may be extended through August if the
student is attending a New York City Department of Education (the “Department”) sponsored summer instruction program); or (2) such time that
I deliver to the principal or his/her designee(s) and nurse a new prescription or instructions issued by my child's physician regarding the
administration of the above-prescribed medication. By submitting this MAF, I am requesting that my child be provided with specific health
services by the Department and the New York City Department of Health and Mental Hygiene (“DOHMH”) through the Office of School Health
(“OSH”). I understand that part of these services may entail an assessment by an OSH physician as to how my child is responding to the
prescribed medication. Full and complete instructions regarding the provision of the above-requested health service(s) are included in this
MAF. I understand that the Department, DOHMH and their agents, and employees involved in the provision of the above-requested health
service(s) are relying on the accuracy of the information provided in this form. It is my intention that my child will be provided with health
service(s) according to the information and instructions that are provided in this MAF. I further understand that the Department, DOHMH and
their agents are not responsible for any adverse reaction to this medication.
I recognize that this form is not an agreement by the Department or DOHMH to provide the services requested, but, rather, my request,
consent and authorization for such services. If it is determined that these services are necessary, a Student Accommodation Plan may also
be necessary and will be completed by the school.
I hereby authorize the Department, DOHMH and their employees and agents, to contact, consult with and obtain any further information
they may deem appropriate relating to my child's medical condition, medication and/or treatment, from any health care provider and/or
pharmacist that has provided medical or health services to my child.
SELF-ADMINISTRATION OF MEDICATION: Initial this paragraph for use of an Epi-Pen, asthma inhaler and other approved
self-administered medications):
I hereby certify that my child has been fully instructed and is capable of self-administration of the prescribed medication. I
further authorize my child's carrying, storage and self-administration of the above-prescribed medication in school. I acknowledge that
I am responsible for providing my child with such medication in containers labeled as described above, for any and all monitoring of my
child's use of such medication, as well as for any and all consequences of my child's use of such medication in school. I further hereby
authorize the Department, DOHMH, their agents and employees; including the principal, his/her designee(s), school nurse and my
child's teacher(s), to administer such medication in accordance with the instructions of my child's physician should my child be
temporarily incapable of self-administering such medication. I understand that the school nurse will confirm my child’s ability to self
carry and self administer in a responsible manner with the school. In addition, I agree to provide “back up” medication in a clearly
labeled bottle to be kept in the medical room in the event my child does not have sufficient medication to self administer.
______ I also authorize the principal, his/her designee(s) and school nurse to store and/or administer to my child such medication in
the event that my child is temporarily incapable of self-storage and self-administration of such medication.
______ I hereby certify that I have consulted with my child’s health care provider and that I authorize the Office of School
Health to administer stock Ventolin in the event that my child’s asthma prescription medication is unavailable.
You must send your child’s Personal Metered Dose Inhaler (MDI) with your child on a school trip day in order that he/she has it
available. The stock Ventolin is only for use while your child is in the school building.
Please Print Parent/Guardian’s Name & Address Below:
_________________________________________________
Parent/Guardian's Signature
_________________________________________________
Date Signed
Daytime Telephone No.
__________________________________________________________
__________________________________________________________
__________________________________________________________
Home Telephone No.
(DO NOT WRITE BELOW - FOR DOE AND DOHMH ONLY)
Student’s Name:______________________________________
Received by: ___________________________
Name
OSIS No: ________________________________________
________
Date
Reviewed by: _________________________
Name
Referred to School 504 Coordinator
Services provided by:
MH Public Health Adv.
Signature and Title:
(RN OR MD)
12-13
Self-Administers/Self-Carries:
Health Center
_____________________________________________
(Date school notified and form forwarded to DOE Liaison)
__________
Date
!
!
Uniform Requirements and Cost
Success Academy is a uniform school. We believe uniforms keep our scholars
focused and eliminate distractions. Scholars are required to wear their uniform every
day of school, beginning on the first day. Success Academy offers all our families
free school supplies, free field studies, and free lunch, breakfast and snacks. Your
child’s uniform is the only item we ask you to purchase*. Uniform costs are listed
below by grade. Please factor the cost into your budget now.
You will have the opportunity to have your child measured in late June by our
uniform vendor, Flynn & O’Hara.
Accepted Scholars: Uniform payment is due at the time of your Uniform Fitting in late
June! Acceptable forms of payment are cash, credit, debit, and money order.
Wait Listed Scholars: if you remain on the wait list at the time of Uniform Fitting, no
payment will be required at that time. Please continue to factor uniform costs into
your budget in the event your child is accepted at a Success Academy after Uniform
Fitting.
2013 Flynn & O’Hara Uniform Packages and Prices
Girls Kindergarten – 3rd grade ($210):
• 2 jumpers
• 2 short-sleeve polo shirts
• 1 long-sleeve polo shirt
• 1 cardigan
• 2 pairs of lycra shorts
• 1 pair of tights
• 1 orange sport shirt
• 1 Success Academy backpack
Boys Kindergarten ($161):
• 2 pairs of pull-on elastic pants
• 2 short-sleeve polo shirts
• 1 long-sleeve polo shirt
• 1 v-neck pullover
• 2 pairs of socks
• 1 orange sport shirt
• 1 Success Academy Backpack
Boys 1st – 3rd grade ($200):
• 2 pairs of navy twill pants
• 2 short-sleeve oxford shirts
• 1 long-sleeve oxford shirt
• 2 orange ties
• 1 v-neck pullover
• 2 pairs of socks
• 1 orange sport shirt
• 1 black belt
• 1 Success Academy Backpack
* Assistance is available in cases of financial hardship. Please fill out and submit the Uniform Financial Assistance
Request form found in your Welcome Meeting packet. You may email the completed form to
[email protected] or mail to: Success Academy, Attn: Enrollment 310 Lenox Ave NY, NY 10027.