FINNEYTOWN LOCAL SCHOOL DISTRICT Student Enrollment Data Form

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1 Student LAST Name Office Use Only Student # Address Zip Code Daytime Phone Number Grade Homeroom Mother's Maiden Name Called Name Teacher Date of Birth City of Birth State / Country of Birth Native Language Requirement for Enrollment Proof of Residency Circle One: Male Female FINNEYTOWN LOCAL SCHOOL DISTRICT Student Enrollment Data Form Information supplied on this form is required under provisions of Ohio Department of Education STUDENT INFORMATION FIRST Name MIDDLE Name Circle One: US citizen Non-US citizen/immigrant Foreign Exchange Student Lease Utility Is the student of Hispanic/Latino origin, regardless of race? Yes No Notarized Affidavit Circle all that apply: African American White Asian Alaskan/ Indian Native Hawaiian / Pacific Island Is either parent active or reserve Military? Yes No If yes, which parent? Mother Father Guardianship School Name PREVIOUS SCHOOL INFORMATION School District Parent Court Appointed Address of School City State Zip code Other forms / Records Is Student currently in special education, served on an IEP? Yes No Are fees paid and records available from previous school? Yes No Has student attended vocational school? Yes No If Yes, in what program? List the parent(s) / legal guardian with whom the student resides: Disability: FAMILY INFORMATION Has student attended Finneytown before? Yes Is student currently under an expulsion order in any school district? Yes No No Birth Certificate Immunization I. D. Court Docs Grades/Transcripts IEP ETR Circle one: Mother Grandparent Step Mother Foster Parent Other (describe): Name Place of employment Daytime Phone Circle one: Father Grandparent Step Father Foster Parent Other (describe): Name Place of employment Daytime Phone Enrolled by: COURT APPOINTED GUARDIANS: Please complete the following information Name of court appointed guardian Name of Agency Phone No. Agency Address School District of Residence County of Guardianship Name of Surrogate Parent Court Papers? Yes No Requested Phone No. I have completed the above form truthfully and to the best of my knowledge Signature of student's legal guardian Relationship to student Date

2 FINNEYTOWN LOCAL SCHOOL DISTRICT EMERGENCY MEDICAL AUTHORIZATION Finneytown Secondary Campus School Student Name (Please Print) School Year Date of Birth (MM/DD/YY) Age Grade Home Telephone Number Address including zip code Student s address CONTACT # where you can be reached between the hours of 7 am & 4 pm PURPOSE: TO enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under the school s authority, when parents or guardians cannot be reached. PARENT/GUARDIAN INFORMATION: Mother s Name: Mother s Daytime Phone # Mother s Mother s Cell Phone # Father s Name: Father s Daytime Phone # Father s Father s Cell Phone # Guardian s Name: Guardian s Daytime Phone # Guardian s Guardian s Cell Phone # Living with: Mother/Father Mother Father Guardian Exchange Student Stepmother/Father Mother/Stepfather Names of siblings, their ages and school they attend: If parent is unavailable try: #1 Emergency Contact Person: Name Relationship Daytime Phone # Cell Phone # #2 Emergency Contact Person: Name Relationship Daytime Phone # Cell Phone # STUDENT S MEDICAL INFORMATION: Facts concerning the child s medical history including allergies, medications being taken, and any physical impairment(s)/ condition(s) to which school personnel/physician should be alerted: Note: The above information will be shared with appropriate staff as necessary, unless notified in writing by parent. Hamilton County Public Health TB Control Unit requires documented TB (tuberculosis) testing of certain students. Check all that apply: I am a newly enrolled student who has been in the USA for 5 years or less. I am a currently enrolled student who traveled/plans to travel to a high-risk country (defined by the World Health Organization) in a non tourist over the summer, or during the current school year None of the above Questions should be directed to the District School Nurse PLEASE COMPLETE PAGE 2 Rev. 06/2017

3 ***PART l OR PART ll MUST BE COMPLETED AND SIGNED*** PART l (Must be completed to grant consent) Doctor s Name: Phone #: Dentist s Name: Phone #: Medical Specialist: Phone #: Local Hospital: Emergency Room Phone #: In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist, and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Date Signature of Parent/Guardian Printed Name of Parent/Guardian Address including zip code PART ll - REFUSAL TO CONSENT (Do NOT complete this portion if you completed Part l above) I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency room treatment, I wish the school authorities to take NO action or to: Date Signature of Parent/Guardian Printed Name of Parent/Guardian INSURANCE DISCLAIMER My son/daughter Check ONE of the following is NOT covered by accident and health insurance. I must purchase coverage. is FULLY COVERED by accident and health insurance. Insurance Company: Policy #: Phone: Person in whose name insurance is carried: Relationship: In the event of injury to my son/daughter while involved in travel to and from AND during extracurricular participation, I shall in no way hold Finneytown Local School District responsible for said injury. My family will assume complete responsibility for coverage for any and all injuries which may occur. Signed: Date: (Parent or Legal Guardian) Rev. 06/2017

4 Ohio Department of Health School and Adolescent Health Health History Student s name Sex Date of birth a Male a Female / / Family Health History Please list allergies, heart problems, diabetes, cancer or other serious health conditions. Father Mother Brothers and Sisters Birth and Developmental History a No unusual birth or developmental history Did the mother have any unusual physical or emotional illness during this pregnancy? a Yes a No Was infant born full term? a Yes a No Did the infant have any sickness or problems? a Yes a No Briefly explain illness or problems. How does the child s development compare to other children, such as his or her brothers/sisters or playmates? a About the same a Delayed a Advanced Student Health Conditions a YES,my child receives regular medical/health care for the following conditions: a NO medical conditions a Allergies a Diabetes a Seizure disorder a Asthma a Depression a Sickle cell anemia a ADD/ADHD a Ear problem/hearing difficulty a Skin conditions a Autism a Emotional concerns a Speech problems a Behavior concerns a Headaches a Traumatic brain injury a Birth/congenital malformations a Heart problems a Vision problems (glasses, contacts) a Bone/muscle/joint problems a Hemophilia a Other a Blood problems a Juvenile arthritis a Other a Bowel/bladder problems a Lead poisoning a Other a Cancer a Migraines a Other a Cystic fibrosis a Neuromuscular disorder a Other Please explain any conditions above or any reasons for hospitalizations. Please indicate any allergies your child may have. Allergy type Reaction School restrictions or recommended actions a Bee/Insect a Food a Medication a Other HEA /06

5 Health History continued Please list any prescription and over the counter medication that your child takes on a regular basis. Medication and dose Time Reason Do any health and/or medical conditions require school restrictions, modifications, and/or intervention? a Yes a No If YES, please explain. Does the student require any special procedures and/or treatments for their health condition(s)? a Yes a No If YES, please explain. Please indicate any other information about your child s health or development that you think would be helpful for the school to know. Form completed by Relationship to student Date / /

6 SCHOOL HISTORY Student: Date of Birth: Name of School City, State Grade Level(s) For Office Use Only

7 SPECIAL EDUCATION FORM Student Name: Date of Birth: Student is NOT currently receiving special education services Student IS currently receiving special education services and being served on an Individualized Education Program (IEP) and Evaluation Team Report (ETR) I have provided a current copy of the IEP and ETR I do not have a current copy of the IEP and ETR and understand that the student cannot be placed in a special education program until Finneytown Special Education Department receives a current copy of the student s IEP and ETR Student IS currently under a 504 Education Plan Student is NOT currently under a 504 Education Plan I have signed the record release form giving my permission to release special education information or 504 Education Plan information to the Special Education Department of Finneytown Local Schools Parent/Guardian Signature Date

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12 FINNEYTOWN LOCAL SCHOOL DISTRICT STUDENT NETWORK AND INTERNET ACCEPTABLE USE POLICY AGREEMENT Every student, regardless of age, must read and sign below: I have read, understand, and agree to abide by the terms of the Student Network and Internet Acceptable Use Policy. Should I commit any violation or in any way misuse my access to the Finneytown Local School District s computers, computer network, other technologies, and/or the Internet, I understand and agree that my access privileges may be revoked and disciplinary action may be taken against me as outlined in the applicable handbook or Student Code of Conduct. (Please print clearly) Student Name Phone Student Signature Date I am under 18 years of age I am 18 years of age or older If I am signing this Student Network and Internet Acceptable Use Policy Agreement when I am under 18, I understand that when I turn 18, this agreement will continue to be in full force and effect and I agree to abide by this agreement. Parent or Guardian Computer Network and Internet Agreement (To be read and signed by parent or guardian of student who is under 18 years of age) As the parent or legal guardian of this student, I have read, understand, and agree that my child or ward shall comply with the terms of the Finneytown Local School District s Student Network and Internet Acceptable Use Policy for access to the district s computers, computer network, other technologies, and the Internet. I understand that access is being provided for educational purposes only. However, I also understand that it is impossible for the Finneytown Local School District to restrict access to all offensive and controversial material. I understand that it is the responsibility of my child or ward to abide by the Student Network and Internet Acceptable Use Policy. I hereby give permission for my child or ward to use a building-approved account to access the Finneytown Local School District s computers, computer network, other technologies, and the Internet. (Please print clearly) Parent/Guardian Name Signature Phone Date

13 FINNEYTOWN LOCAL SCHOOL DISTRICT AUTHORIZATION TO RELEASE INFORMATION Student Last Name First Name M. I. Date of Birth Enrolling to enter grade Print- Parent/Guardian Name Relationship to Student Parent/Guardian Signature Former School Former School address Former School City, State, Zip Code Former School Phone Fax As the parent, guardian, or independent student (18 years or older), my signature authorizes the release of student records to Finneytown Local School District. The material provided is to be used for educational placement and will be maintained with all due safeguards as provided by the laws of Right and Privacy and will become part of the individual s education file subject to review by parents, the independent student, and other persons authorized under the law. Please release the following records: Transcript of subjects and grades Ohio Graduation Test results Standardized test results Health records Court orders (custody, restraining orders, etc.) Psychological or other individual test results ETR, IEP and Special Education records, if applicable Special Education EMIS form 504 or other Intervention Plans Attendance records Discipline records, including suspensions/expulsions The records may be released to: Finneytown Board of Education Enrollment Center, IRN Fontainebleau Terrace Cincinnati OH Phone Fax Registrar Date/Effective Start Date If records are not available, please return our request indicating the reason. No records available reason(s) Sending partial records reason(s)

14 VACCINES DTaP/DT Tdap/Td Diphtheria, Tetanus, Pertussis POLIO MMR Measles, Mumps, Rubella HEP B Hepatitis B Varicella (Chickenpox) MCV4 Meningococcal Immunization Summary for School Attendance Ohio FALL 2018 IMMUNIZATIONS FOR SCHOOL ATTENDANCE K Four (4) or more doses of DTaP or DT, or any combination. If all four doses were given before the 4 th birthday, a fifth (5) dose is required. If the fourth dose was administered at least six months after the third dose, and on or after the 4 th birthday, a fifth (5) dose is not required. * 1-12 Four (4) or more doses of DTaP or DT, or any combination. Three doses of Td or a combination of Td and Tdap is the minimum acceptable for children age seven (7) and up. Grades 7-12 One (1) dose of Tdap vaccine must be administered prior to entry. ** K-8 Three (3) or more doses of IPV. The FINAL dose must be administered on or after the 4 th birthday regardless of the number of previous doses. If a combination of OPV and IPV was received, four (4) doses of either vaccine are required. *** Grades 9-12 Three (3) or more doses of IPV or OPV. If the third dose of either series was received prior to the fourth birthday, a fourth (4) dose is required; If a combination of OPV and IPV was received, four (4) doses of either vaccine are required. K-12 Two (2) doses of MMR. Dose one (1) must be administered on or after the first birthday. The second dose must be administered at least 28 days after dose one (1). K-12 Three (3) doses of Hepatitis B. The second dose must be administered at least 28 days after the first dose. The third dose must be given at least 16 weeks after the first dose and at least 8 weeks after the second dose. The last dose in the series (third or fourth dose), must not be administered before age 24 weeks. K-8 Two (2) doses of varicella vaccine must be administered prior to entry. Dose one (1) must be administered on or after the first birthday. The second dose should be administered at least three (3) months after dose one (1); however, if the second dose is administered at least 28 days after the first dose, it is considered valid. Grades 9-12 One (1) dose of varicella vaccine must be administered on or after the first birthday. Grade 7-9 One (1) dose of meningococcal (serogroup A, C, W, and Y) vaccine must be administered prior to entry. Grade 12 Two (2) doses of meningococcal (serogroup A, C, W, and Y) vaccine must be administered prior to entry. **** NOTES: Vaccine should be administered according to the most recent version of the Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger or the Catch-up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind, as published by the Advisory Committee on Immunization Practices. Schedules are available for print or download at Vaccine doses administered 4 days before the minimum interval or age are valid (grace period). Doses administered 5 days earlier than the minimum interval or age are not valid doses and should be repeated as age-appropriate. If MMR and Varicella are not given on the same day, the doses must be separated by at least 28 days with no grace period. For additional information please refer to the Ohio Revised Code and for School Attendance and the ODH Director s Journal Entry (available at Immunization: Required Vaccines for Childcare and School). These documents list required and recommended immunizations and indicate exemptions to immunizations. Please contact the Ohio Department of Health Immunization Program at (800) or (614) with questions or concerns. * Recommended DTaP or DT minimum intervals for kindergarten students four (4) weeks between doses 1-2 and 2-3; six (6) month minimum intervals between doses 3-4 and 4-5. If a fifth dose is administered prior to the 4 th birthday, a sixth dose is recommended but not required. ** Pupils who received one dose of Tdap as part of the initial series are not required to receive another dose. Tdap can be given regardless of the interval since the last Tetanus or diphtheria- toxoid containing vaccine. DTaP given to patients age 7 or older can be counted as valid for the one-time Tdap dose. *** The final polio dose in the IPV series must be administered at age 4 or older with at least six months between the final and previous dose. **** Recommended MCV4 minimum interval of at least eight (8) weeks between dose one (1) and dose two (2). If the first (1 st ) dose of MCV4 was administered on or after the 16 th birthday, a second (2 nd ) dose is not required. If a pupil is in 12 th grade and is 15 years of age or younger, only 1 dose is required. Currently there are no school entry requirements for meningococcal B vaccine. ODH Immunization 11/30/2017 Imm Sum Sch Ohio docx

15 STUDENT DISCIPLINARY STATUS Dear Parent / Guardian, House Bill 64 went into effect in September, 1994 clearly stating that a student currently under an expulsion order from another school district may not register in a new school district until the expulsion expires. Therefore, we ask for the following information: Student name: Date of Birth: Is your child currently under an expulsion order or suspension order from any school district? Yes No As parent / Guardian of this student, you have my permission to obtain all information regarding disciplinary status to confirm the response above. Parent / Guardian: Date *** Failure to provide accurate information will result in immediate dismissal ***

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