For All Grades: Certified Birth Certificate

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1 To be enrolled as a student in Dover City Schools, school personnel must have the following documents before the student is permitted to attend classes. Please take the following items to your child s school. For All Grades: Certified Birth Certificate Custody Papers (In the event the student does not live with both biological parents. House Bill 130 requires grandparents to produce a notarized Power of Attorney or Caregiver Authorization Affidavit from the court in order for a child to be enrolled in the school district.) Child s immunization records (Shots must be up to date and on file by the time the student starts school.) Proof of Dover residency (utility bill with name and address) or, if an Open Enrollment student, a copy of the Open Enrollment Acceptance Letter. Home Language Survey Please use Home Language Survey in this document For High School Students In the event the student is over the age of 18 and does not live with the custodial parent, the student must also provide the following in place of custody papers: Letter and/or pay stub from an employer stating the amount of income earned by the student to determine if the student is self-supporting. The superintendent will determine final entrance approval. For Kindergarten and Preschool (in addition to above) A copy of your child s health history, including Please use Medical Health form in this document physical forms completed by medical provider A copy of your child s oral assessment Please use Oral Assessment form in this document

2 HOME LANGUAGE SURVEY Information about the language background of each student is necessary to determine the possible need for language development assistance. Date Name of Student Grade Date of Birth / / Place of Birth Month Day Year City State Country Name of Parent/Guardian Family Name First Name Home Address City Zip Code Home Phone Work Phone Is there a language other than English spoken at home? Yes No If yes, what language? What language did your son/daughter learn first? What language do the adults at home most often speak? Do any adults at home read English? Yes No How long has your son/daughter attended school in the United States? Thank you for your help. Parent or Guardian Signature For School District Personnel: If the answer to any question above is a language other than English, indicate the student's native/home language to EMIS Student Data Element ( ), and send a copy of this form to the Curriculum Director.

3 HOME LANGUAGE SURVEY ENCUESTA DE LENGUAJE Informacion a cerca del lenguaje primario es necessario para determinar si necesita ayuda. Fecha Nombre del Estudiante Fecha de Nacimiento Mes day ano Nombre de los padres Apellido Primer Nombre Domicilio Ciudad codigo postal Telefono de su casa Telefono de su trabajo Se habla otro lenguaje a parte del Ingles en su casa? Si No Si respondio si, cual lenguaje? Cual lenguaje aprendio su hijo primero? Cual lenguaje se habla mas en casa entre los adultos? Hay algun alduto en casa que pueda leer Ingles? Si No Por cuanto tiempo ha asistido su hijo a la escuela en los Estados Unidos? Gracias por su ayuda Firma de la madre o padre

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

5 Does the student require any special procedures and/or treatments for their health condition(s)? Yes 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 DOVER CITY SCHOOLS Ohio Department of Health School and Adolescent Health Physical Examination Student's Name Sex Male Female Height Weight BMI percentile BP Date of Birth Screening Tests Vision Hearing Postural Date performed Date performed Date performed Distance Acuity R L Pure Tone No abnormality noted Muscle Balance Pass Fail Right ear Pass Fail Screening not done Left ear Pass Fail Stereopsis Pass Fail Referral made Child wears hearing aid? Yes No Color Pass Fail Child under the care of Comments Child wears glasses? Yes No a hearing specialist? Yes No Tested with glasses? Yes No Referral made? Yes No Referral made? Yes No Speech/Language Speech assessment completed Yes No Child has no discernible speech problem Yes No Speech evaluation recommended Yes No Child has possible problem with Lead Poisoning Date Type C V Results g/dl Date Type C V Results g/dl Tuberculin Test Date Type Results Health History (Serious or chronic illnesses/injuries/surgeries) Physical Examination Date of most recent examination Essentially normal Abnormalities as follows Is this child able to participate fully in: Classroom and academic activities Yes No Physical education classes Yes No Competition athletics Yes No Contact and collision sports Yes No If limitations are advised, please specify Does this child have any physical, developmental or behavioral issues that may affect his/her educational process? Health Care Provider's Signature Print Name Phone ( ) Address Date City State Zip HEA /10

7 Ohio Department of Health School and Adolescent Health Immunization Report (Requirements for kindergarten are marked with an "*".) Student's name Sex Male Female Date of birth Students are required to be immunized in accordance with Ohio law (Ohio Revised Code / ). A copy of the child's immunization record may be attached or dates may be entered below. Please note, the month, day, and year for each immunization should be on record. Vaccine Record complete dates (month, day, year) of vaccine doses given Diphtheria, Tetanus, Pertussis (DTP) DTaP, Tdap DT, Td Polio *4 doses Hepatitis B (HBV) *3 doses Measles, Mumps, Rubella (MMR) *2 doses Varicella (Chickenpox) *2 doses Varivax or verification of the Disease Hepatitis A Meningococcal (MCV4, MPSV4) Pneumococcal (PCV) Measles (Rubeola) only Rubella only Mumps only Haemophilus influenza Type b (Hib) Influenza Other This information was provided by Health Care Provider Parent/Guardian Other Signature Print Name Date HEA /10

8 DOVER CITY SCHOOLS Ohio Department of Health School and Adolescent Health Oral Assessment Student's name The following services have been performed (please check all that apply) Date of birth Examination Fluoride application Oral prophylaxis (cleaning) Prescription for fluoride supplement Orthodontic assessment Radiographs Dental sealant Treatment (restoration, pulp therapy) Other The following oral hygiene instruction was provided (please check all that apply) Toothbrushing Flossing Dietary counseling Use of fluoride mouth rinse Other The following statements are applicable (please check all that apply) All necessary preventive services have been performed. (Fluoride treatment, prophylaxis) No restorative services are required at this time. Further treatment is indicated. (See comments) Further appointments have been arranged. (Orthodontic, restorative) Routine recall visits recommended. Comments Dentist's Signature Print Name Phone ( ) Address Date City State Zip HEA /10

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