central enrollment and parent information center · 2017. 3. 21. · central enrollment and parent...

Central Enrollment and Parent Information Center

Fitchburg Public Schools

376 South Street

Fitchburg, MA 01420

Telephone: 978-345-3200

Fax: 978-343-2129

WELCOME Parents / Guardians of incoming Kindergarten students to the Fitchburg Public Schools.

Please complete each form in the attached packet in order to register your child in

Kindergarten. Some information may be duplicated, but it is necessary that all of the forms be filled

out completely. The complete packet must be returned to the Central Enrollment and Parent

Information Center at 376 South Street. Do not return any of these forms directly to the schools.

The following documents will need to be included with the Enrollment Packet:

Your child’s birth certificate, with the raised seal. We will make a copy of it and return

the original back to you. Your child cannot be enrolled without it. Your child must be

five-years old on or before September 1st

of the kindergarten school year.

A completed immunization record and physical form from your child’s doctor.

Your child’s social security number (optional)

A copy of the I.E.P. (Individualized Education Plan), if applicable.

Please be sure to include the names and telephone numbers of friends and / or relatives who

we can call in an emergency if you cannot be reached. This is very important for the safety

of your child.

Proof of Fitchburg Residency. We can only accept one of the following:

Unitil bill (gas/electric), Cable bill (Comcast, Direct TV, Dish or FIOS),

Lease Agreement, Purchase and Sales Agreement (front page indicating name and

address) or Telephone bill (not cellular).

If you do not have proof of residency because you are living with a family member or a

friend and the bills are in their name, we need a notarized letter from the person with

whom you are living with stating that you and your child are living with them, along with

a copy of the proof of Fitchburg residency (bill) in their name.

If your child’s home language is other than English, the Enrollment Center personnel will

be contacting you to schedule English proficiency testing.

If you are the guardian, please provide the legal guardianship paperwork.

Please use black or blue ink to complete the forms

Thank you for your cooperation

The School Committee’s policy of nondiscrimination extends to students, employees, and the general public with whom it does business. Fitchburg Public

Schools does not discriminate on the basis of race, color, religion, creed, national origin, gender, sexual orientation, gender identity, age or disability in

admission to, access to, employment in, or equal treatment in its programs and/or activities in compliance with state and federal law. Questions related to this

policy must be addressed to: The Human Resources Director/Grievance Officer, 376 South Street, Fitchburg, MA 01420, (978) 345-3215.

Enrollment

Coordinator

Maria Ulloa-Hancock

Principal Secretaries:

Deborah Champagne

Jackie Ozores

Kindergarten Enrollment Check List

It is very important that each form is filled out completely. If a form is not filled out, then we must contact

you to do so, in order to have your child fully registered in the Fitchburg Public Schools.

The following is a checklist for your convenience to assure that all of the necessary

paperwork is complete.

You must return a completed:

Kindergarten Placement Form

Transportation & Child Care Form (Must be signed)

Home Language Survey (Must be signed)

Ethnicity Form

Family and Emergency Information (Must be signed)

Emergency Contact Form

Kindergarten Home Record

Kindergarten Transition Form

Release of Records Form (Must be signed)

Massachusetts Parental One Time Consent Form (Must be signed)

Acceptable Use of Technology (Must be signed)

Google Account (Must be signed)

Notice of Use of Student Information (Must be signed)

Transportation & Federal Grant Form (Must be signed)

Sibling Form

Temporary School Health Record

Over the Counter Medication (OTC) Form (Must be signed)

Health Examination Form

Immunization Record

You must include, with the completed packet:

Child’s Birth Certificate with the raised seal

Child’s Immunization (Shot) Record

Most Recent Physical Form from your child’s doctor

Proof of Fitchburg Residency

Individualized Education Plan (IEP), if applicable

Proof of Legal Guardianship, if you are the guardian

Also requested: Copy of Child’s Social Security Card (Optional)

FITCHBURG PUBLIC SCHOOLS

STUDENTS AND INSTRUCTION SECTION: 5000

STUDENT CONDUCT: 5400

POLICY#: 5410

POLICY SECTION #: 5410.03

POLICY NAME: SCHOOL BUS TRANSPORTATION

DATE FIRST READING: April 22, 2013

DATE SECOND READING: May 6, 2013

DATE ADOPTED: May 6, 2013

DATE REVISED/FIRST READING:

DATE REVISED SECOND READING:

DATE ADOPTED:

BUS TRANSPORTATION AND SAFETY POLICY

The major purpose of the Fitchburg Public Schools transportation policy is to aid students in

getting to and from their regularly assigned school in a safe and efficient manner.

Eligibility for Transportation

The following table sets forth the minimum distance from school that students must reside in

order to be provided with transportation by the District:

Grade Level Distance Eligible for Busing Transportation

K-4 Student must reside one (1) mile or more from

school

5-8 Student must reside one and one-half (1.5)

miles or more from school

9-12 Student must reside two (2) miles or more

from school

The above distances will be determined by an authorized vehicle driving from the school to

the student’s residence over the shortest traveled distance or electronic/technological means,

including mapping software or a similar internet-based program.

Parents are also responsible for insuring their child is in possession of a valid Fitchburg

Public Schools Bus Pass.

Students who choose to attend a school other than their regularly assigned school (i.e.,

choosing to attend a different elementary or middle school or the alternative high

school) will not be provided with transportation.

FITCHBURG PUBLIC SCHOOLS

Kindergarten Placement Form

Student’s Name: __________________________________________________________________Gender: Female Male Last First Middle

Address: __________________________________________________________Home Phone # /Cell#: ____________________ Street Apt. # City

Date of Birth: _______________Age ______Place of Birth: _________________________ Primary Language_____________ City State/Country

Parent/Guardian Name: ________________________________________________________________________________ Last First Middle

E-mail: ______________________________________________________________________________________

Who does the child live with? (Please check appropriate boxes.)

Both Parents Mother Father Grandparent Stepmother Stepfather Foster Parent

Other __________________________

Who has legal custody? Mother Father Joint Guardian DCF Other______________________

Has this child ever attended a school in Fitchburg or in Massachusetts before? NO YES Where__________

School of Preference 1. ____________________2. ___________________3.___________________4.________________

SUPPORT SERVICES

Has this child been enrolled in Special Education?: NO YES

Is there an I.E.P.? NO YES School/Headstart/? __________________________________________________

Has this child been enrolled in a Bilingual, ESL or English Immersion Class?: NO YES

School? ___________________________________________________________________________________________

Where?___________________________________________________________________________________________

Other_____________________________________________________________________________________________

SIBLINGS

BROTHER(S) NAME: Date of Birth GRADE NAME OF SCHOOL (IF ATTENDING)

_________________________________ ___________ _______ __________________________________

_________________________________ ___________ _______ __________________________________

_________________________________ ___________ _______ __________________________________

SISTER(S) NAME: Date of Birth GRADE NAME OF SCHOOL (IF ATTENDING)

_________________________________ ___________ _______ __________________________________

_________________________________ ___________ _______ __________________________________

_________________________________ ___________ _______ __________________________________

Are there any other persons living with the family? No Yes If yes, please write the names and the

relationship to the child: _________________________________________________________________________

1

Fitchburg Public Schools Transportation & Child Care Information – GR K-8

School Bus Eligibility:

Child’s Name : ________________________________________________________

First Name Last Name (Grade) Child’s Home Address: __________________________________________________

Please check (√) one of the following regarding your child’s transportation:

Walkers:

□ My child is a walker.

□ My child is a walker, and interested in the MART BUS (There is a fee for the

MART Bus, and parents make those arrangements directly with MART 978-345-7711.)

Parent or Private Transportation Arrangements:

□ My child will be transported by parent or private transportation:

□Morning Only □After School Only □ Morning AND After School

School Bus Transportation:

□ My child will be transported by school bus:

□Morning Only □After School Only □ Morning AND After School □ My child attends child care and will need to be transported by school bus to and

from the following location: (Child care must be in Fitchburg)

□Morning Only □After School Only □ Morning AND After School

Name of Child Care Facility: _______________________________________________

Name of Child Care Provider / Sitter: ________________________________________

Address of Child Care / Sitter: ______________________________________________

Telephone of Child Care / Sitter: ____________________________________________

Signature of Parent / Guardian: ______________________________ Date: ______________

Please Note: Transportation arrangements affect school assignment. If your child care arrangements change, the school

assignment may need to change as well. It is important that you call the Fitchburg Public Schools, Enrollment Center if

you are moving or changing child care arrangements, 978-345-3200

Grade: K-4 Over 1 Mile between school and home

Grade: 5-8 Over 1 ½ Miles between school and home

2

Home Language Survey Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the

language (s) spoken in each student’s home in order to identify their specific needs. This information is essential in order

for schools to provide meaningful instruction for all students. If a language other than English is spoken at home, the

District is required to do further assessment of your child. Please help us meet this important requirement by answering

the following questions. Thank you for your assistance.

Student Information

_________________________________________________________________________________ Gender F M First name Middle Name Last Name

Date of Birth ____________ Country of Birth __________________ Date left____________ Date arrived_________

Indicate Status: US Citizen Immigrant Refugee Migrant

Child’s language background: (Please list all the languages that your child can speak)

Native language ______________Other: _________________Other:______________ Other: _______________

First year in the U.S. school? Yes No

Is this your child’s first year in the United States? Yes No

Questions for parents

1. What language did your son/daughter learn when he/she first began to talk? ________________________

2. What language does your son/ daughter speak at home? _______________________________________

3. What language does your child use when speaking to other children?_____________________________

4. What language is most spoken by the adults at home? _________________________________________

Mother’s language background: Native language ______________ Speak Read Write

Other: _____________________ Speak Read Write

Other: _____________________ Speak Read Write

Father’s language background: Native language ______________ Speak Read Write

Other: ______________________ Speak Read Write

Other: ______________________ Speak Read Write

Parent requests WRITTEN communication from the school in: English Native language

Parent requests ORAL communication from the school in: English Native language

Other Information: ____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Signature of Parent/Guardian: ________________________________________ Date: ___________________

3

Race and Ethnicity Identification Not Hispanic or Latino Hispanic or Latino

One race

White 01 33

Black or African American 02 34

Asian 03 35

American Indian or Alaska Native 04 36

Native Hawaiian or Other Pacific Islander 05 37

Combination of Two Races

White & Black or African American 06 38

White & Asian 07 39

White & American Indian or Alaska Native 08 40

White & Native Hawaiian or Other Pacific Islander 09 41

Black or African American & Asian 10 42

Black or African American & American Indian or Alaska Native 11 43

Black or African American & Native Hawaiian or Other Pacific Islander 12 44

Asian & American Indian or Alaska Native 13 45

Asian & Native Hawaiian or Other Pacific Islander 14 46

American Indian or Alaska Native & Native Hawaiian or

Other Pacific Islander 15 47

Combination of Three Races

White & Black or African American & Asian 16 48

White & Black or African American & American Indian or Alaska Native 17 49

White & Black or African American & Native Hawaiian or Other Pacific Islander 18 50

White & Asian & American Indian or Alaska Native 19 51

White & Asian & Native Hawaiian or Other Pacific Islander 20 52

White & American Indian or Alaska Native & Native Hawaiian or


Black or African American & Asian & Native Hawaiian or Other Pacific Islander 22 54

Black or African American & Asian & American Indian or Alaska Native 23 55

Black or African American & Native Hawaiian or

Other Pacific Islander & American Indian or Alaska Native 24 56

Asian & Native Hawaiian or Other Pacific Islander &

American Indian or Alaska Native 25 57

Combination of Four Races

White & Black or African American & Asian & American Indian or Alaska Native 26 58

White & Black or African American & American Indian or

Alaska Native & Native Hawaiian or Other Pacific Islander 27 59

White & Asian & American Indian or Alaska Native &

Native Hawaiian or Other Pacific Islander 28 60

White & Black or African American & Asian & Native Hawaiian or


Black or African American & Asian & American Indian or


Combination of Five Races

White & Black or African American & Asian & American Indian or


4

FITCHBURG PUBLIC SCHOOLS Grades Pre-K-8 Family and Emergency Information

Child’s Name: _______________________________________________________________ Gender F M GR:____ Last First Middle

Address: __________________________________________________________________________ DOB:______________

Home Phone #______________________ Parent/Guardian E-mail address: ________________________________________

Child Care Provider _____________________________________________________________________________________ Name Address Phone #______________________ Does your child attend: Before School After School Both

Who does the student live with? Both Parents Mother Father Grandparent Stepmother Stepfather Foster Parent

Other_____________________

Who has legal custody? Mother Father Joint Guardian DCF Other _________________

Father’s Name: _____________________________________________________________________________________ Last First Middle

Birth Place:______________________________________ Cell phone #: ____________________________________

Father’s Home Address (if different from child’s):___________________________________________________________

Home Telephone # (if different from child’s): ______________________________ Work #:_________________________

Employer: ____________________________________________ Occupation:____________________________________

Mother’s Name: ____________________________________________________________________________________ Last Maiden First Middle

Birth Place:_______________________________________ Cell phone #: ___________________________________

Mother’s Home Address (if different from child’s): _________________________________________________________

Home Telephone # (if different from child’s): _______________________________ Work #: _______________________

Employer: ____________________________________________ Occupation: ___________________________________

GUARDIAN INFORMATION:

Guardian(s) Name: _____________________________________________________________________ Last First Middle Relationship to Child: _____________________________________________ Cell phone: _____________________________ EMERGENCY INFORMATION: List two (2) people who could be contacted in your absence, who could assume care and transportation

for you child, in case of illness. 1. ______________________________________________________________________________________________________________________________ Name Address Relationship to Student Phone

2. ______________________________________________________________________________________________________________________________ Name Address Relationship to Student Phone

In case of accident or serious injury and I cannot be reached at the numbers above, I hereby authorize the school to arrange for

emergency transportation to the nearest hospital emergency room to be treated by the physician on duty.

Signature of Parent / Guardian: _______________________________________________ Date: __________________

Insurance Plan: ___________________________________________Policy #: ___________________________________

Name of Family Physician________________________________ Name of Family Dentist_________________________

Please state any health problems or disabilities that the school should be aware of:

□Seizure Disorder □Heart Disease □Allergic to Insect Bites □Medication Allergy □Food Allergy

□Asthma □Diabetes □Other Please, give details: _________________________________________________

Do you have a family member, living in your household, who is on active duty in the armed forces? YES □ NO □

Do you have a family member, living in your household, who is a member of the armed forces or veteran, who has been

medically discharged or has been retired for 1 year or less? YES NO Do you have a family member who died on Active Duty? YES NO Relationship _______________________

5

Fitchburg Public Schools Emergency Contact Information

Name: ___________________________________Relationship to child: _____________________________

Address: _________________________________________________________________________________

Telephone: __________________________ Work telephone: ______________________________________


Address: _________________________________________________________________________________

Telephone: __________________________ Work telephone:______________________________________

Name: ___________________________________Relationship to child:______________________________

Address: _________________________________________________________________________________

Telephone: __________________________Work telephone: _______________________________________


Address: _________________________________________________________________________________

Telephone: __________________________ Work telephone: ______________________________________


Address: _________________________________________________________________________________

Telephone: __________________________ Work telephone: _____________________________________

6

KINDERGARTEN HOME RECORD

Child’s Name: ________________________________________________________________ Male Female Last First Middle

Address: __________________________________________________________________________________________

Birth Date: ___________________ Age: _____ Telephone #: __________________________

Parent / Guardian Name _____________________________________________________________________________

DEVELOPMENT ---- Give age at which your child:

A. Rolled over _______________________ G. Sat alone _______________________

B Crawled __________________________ H. Walked _________________________

C. Uttered first word __________________ I. Uttered first three words ____________

D. Rode tricycle ______________________ J. Counted to ten ____________________

E. Fed self completely _________________ K. Was toilet-trained _________________

F. Dress self ________________________

Is a language other then English spoken in the home? YES NO If so, specify ________________________

HEALTH HABITS:

Is the child allergic to anything? YES NO ___________________________________________________________

Is the child a sound sleeper? YES NO Take a nap? YES NO _______________________________

How much sleep does he / she get a night? _____________________________________________________________

What does he / she say when he / she wants to go to the bathroom? _________________________________________

How many toilet accidents? ____________________

Does he / she speak clearly? YES NO Stutter ________________ Lisp ____________

Difficulty with special letters? YES NO If so, which ones? __________________________________

PLAY AND SPECIAL INTERESTS: What does he / she enjoy most? (Dolls, trucks, crayons, music, books, etc…) _________________________________

PERSONALITY CHARACTERISTICS:

Is he / she shy with grown-ups? _____________________ With children? _________________

Does he / she have any special habits, which disturb you? __________________________________________________

Does he / she have any special abilities? ________________________________________________________________

Does he / she take responsibility easily? ________________________________________________________________

Dress him /herself? ______________ Put away his /her toys? ___________ Do errands? ________________

What do you especially hope he / she will get from school? __________________________________________________

__________________________________________________________________________________________________

Under whose medical supervision? Doctor: ______________________________Telephone: ______________________

Whom to call, other than parent, in an emergency:

__________________________________________________________________________________________________ Name Relation to Student Address Telephone #

7

KINDERGARTEN TRANSITION FORM

Child’s Name: _________________________________________________________________________ Last First Middle

Date of Birth: ________________________________________ Male Female

Has this child ever attended one of the following?

Child care arrangements: (please check all that apply)

o Home With Parents/Guardian

o Group Child Care/Child Care Center (which one?)__________________________________________

o Family Child Care (Home-based)

o Relative Care

Preschool: (please check all that apply)

o Public School Integrated Preschool Program – Which one?_________________________________

o Head Start – Which one?____________________________________________________________

o Private Preschool -Which one? _______________________________________________________

How long did this child attend preschool: ___________________

Before Kindergarten, how was this child MOSTLY cared for during the day?

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Special Services: Has your child ever received any of the following services?

o Vision Referral/Glasses

o Early Intervention

o Hearing Referral

o Receives therapy? (What kind?) ________________

What else would you like your child’s teacher to know about your child?

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

____________________________________________________________________________________________________

8

Central Registration and Parent Information Center


376 South Street

Fitchburg, MA 01420

Telephone: 978-345-3200

Fax: 978-343-2129

KINDERGARTEN RELEASE OF RECORDS FORM

__________________________________________________________________________________________________________

Name of Former School/Early Education and Childcare Program

__________________________________________________________________________________________________________

Telephone # Fax #

________________________________________________________________________________________ Address

_______________________________________________________________________________________ City State Zip Code

I hereby authorize the RELEASE OF RECORDS for the following student:

Student’s Name_________________________________________________________________________________________

Date of Birth: _________________________________

Please fax or mail the records to: (For school office use only)

School ___________________________________

Address__________________________________

City _____________State______Zip Code______

Information Requested:

1. Transcript and Grade Placement Information

2. Health and Immunization records

3. Birth Certificate

4. Current or most recent Individualized Education Program (IEP)

5. Current Attendance and Discipline Records

6. Most recent Report Card

7. SASID# (State Assigned Student Identifier)

8. Most recent Educational Assessments/ Evaluation Information/ State Standardized Testing

9. WIDA Model, ACCESS for ELLs. Idea Proficiency Test Results (IPT) and any other English language

proficiency assessments

10. 504 Plan

Parent/ Guardian Signature: ______________________________________________Date: __________________

Address: __________________________________________________________Phone #: ______________________ The School Committee’s policy of nondiscrimination extends to students, employees, and the general public with whom it does business. Fitchburg Public Schools does not discriminate on the basis of race, color, religion,

creed, national origin, gender, sexual orientation, gender identity, age or disability in admission to, access to, employment in, or equal treatment in its programs and/or activities in compliance with state and federal law.

Questions related to this policy must be addressed to: The Human Resources Director/Grievance Officer, 376 South Street, Fitchburg, MA 01420, (978) 345-3215.

9

Enrollment

Coordinator

Maria Ulloa-Hancock


Deborah Champagne

Jackie Ozores

Massachusetts Parental Notice with One-Time Consent to Allow the School District To Access MassHealth (Medicaid) Benefits

Fitchburg Public Schools 0097

Dear Parent/Guardian: The purpose of this letter is to ask your permission to bill MassHealth for the cost of special education services that the district provides your child under the IEP that we developed with you. If you agree, MassHealth will reimburse the cost of services that they cover, such as therapy services as well as the cost of time spent by providers of such services to participate in Team meetings. We cannot send records and information about your child and your child’s IEP services to MassHealth to ask for reimbursement without your consent and without first notifying you of the following:

1. The school district cannot require you to sign up for MassHealth in order for your child to receive the special education services to which your child is entitled;

2. The school district cannot require you to pay anything towards the cost of your child’s special education services. This means that the school district cannot require you to pay a co-pay or deductible so that it can bill MassHealth. The school district can agree to pay the co-pay or deductible if any such cost is expected.

3. If the school district receives your consent: a. Your consent will not decrease your child’s available lifetime coverage or other MassHealth benefit; nor

will it in any way limit your own family’s use of MassHealth benefits outside of school.

b. Your consent does not affect your child’s special education services or IEP rights in any way.

c. Your consent will not lead to any changes in your child’s MassHealth rights; and

d. Your consent will not lead to any risk of losing eligibility for other Medicaid or MassHealth funded

programs.

4. If you consent, you have the right to change your mind and withdraw your consent at any time.

5. If you withdraw your consent, or refuse to agree to allow the school district to share your child’s records and information with MassHealth for the purpose of billing the cost of his/her IEP services, the school district will continue to be responsible for providing your child the special education services in his/her IEP at no cost to you.

I have read the notice and understand it. I have had my questions, if any, answered. I agree to give my consent to the school district to share records and information concerning my child and his/her IEP services as necessary to bill MassHealth to obtain federal reimbursement for the cost of the IEP services that MassHealth covers. Parent/Guardian Signature: _________________________________________ ____________ Date

Massachusetts ESE Mandated Form 28M/13 Developed June 2013

10

Student Name: DOB: SASID:

User Agreement for Participation

in the


Electronic Communications System

This user agreement must be renewed each academic year.

Users Name:__________________________________________________________

Grade level: _____________________________________________________

School:_________________________________________________________

I have read the district’s Acceptable Use Policy and Administrative Procedures and agree to abide by their provisions. I

understand that violation of these provisions may result in disciplinary action including but not limited to suspension or

revocation of privileges, suspension or expulsion from school, termination of employment and criminal prosecution.

Signature: ___________________________________________Date:______________________

Parent/Guardian Sponsor

I have read the district’s Acceptable Use Policy and Administrative Procedures. In consideration for the privilege of using the district’s system/network, and in consideration for having access to the public networks, I hereby release the district, its operators, and institutions with which they are affiliated from any all claims and damages of any nature arising from my child’s use of, or inability to use, the system/network, including, without limitation, the type of damage identified in the district’s policy and administrative procedures

I give permission for my child to participate in the district’s system/network.

I do not give permission for my child to participate in the district’s system/network.

I give permission for my child’s name to appear on their student web page should one be developed.

I give permission for my child’s photo to appear on their student web page should one be developed.

Signature of parent/guardian:______________________________________Date:________________________

**************************************************************************************************

This space reserved for system administrator.

Last Name _______________________________First Name: ______________________________MI:_________

School___________________________________Room:__________________________________Date:_______

Assigned by: _____________________________Training Date:_________________________

Assigned Username:____________________________________

Assigned Password:_____________________________________

11


Parental Permission for student Google Account

The Fitchburg Public Schools is implementing student Google Apps for Education accounts.

These accounts will be used to give students access to valuable educational tools. The suite of

Google Apps for Education includes:

• Docs, which allows students to work collaboratively with teachers and other students on

assignments

• Drive, which allows students to save work and access it from any computer or device

with an internet connection

• Gmail: which allows students to communicate with teachers to ask questions and receive

feedback

In addition, Google accounts will be used to access online tools such as Khan Academy, a self-

paced learning tool that provides feedback to both the student and their teachers as to their

academic progress.

These accounts will be hosted by the school district and will remain under the control of the

district. District officials will be able to monitor and access data on these accounts in the event

that there is concern about their use. The use of these accounts is subject to the Acceptable Use

Policy as put forth in the Student Handbook. If you have questions or concerns, please contact,

your child's school.

In order to benefit fully in classroom activities, it is crucial that all students have access to these

tools. Please return the following permission form so that we can establish a Google account (at

no cost) to be used by your child.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Google Apps for Education Permission: I give permission for the Fitchburg Public School

District to establish a Google Apps for Education account for my child.

Student Name _______________________________________________________Grade_____ (Print Only)

Homeroom Teacher_____________________________________ School__________________ (Print Only)

Parent Name_____________________________________________________________ OR (Print Only)

___________ I do not want my child to have an individual e-mail account.

Parent Signature ______________________________________________Date ____________

12

Notice of Use of Student Information/Media Release

Occasionally, students are recognized for activities, sports, honors, awards and class projects in local

or school newspapers/newsletters, Fitchburg Access Television or on the District’s Internet Websites.

Under state and federal law, the District may release names, photographs or images, and other

personally identifiable information from students’ education records. See FERPA Policy in

Student/Parent Handbooks.

Please check the appropriate line(s):

_____ No, I do not consent to the release any information about my child for publication in local or

school newspapers/newsletters, FATV and the District’s Internet Websites.

_____ Yes, I consent and authorize the school to include my child’s name, class, photograph or image,

participation in school activities, honors and awards in any pertinent releases to local newspapers.


participation in school activities, honors and awards in any school newspaper/newsletter or other

publication.


participation in school activities, honors and awards as part of programming on Fitchburg Access Television

(FATV).


participation in school activities, honors and awards on the District’s Internet Websites.

Print Name of Parent/Guardian:_____________________________________________

Signature of Parent/Guardian:_________________________ Date:_________________

Signature of Student:________________________________ Date:_________________

(for middle and high school students)

13

FITCHBURG PUBLIC SCHOOLS INCOME APPLICATION FOR TRANSPORTATION ELIGIBILITY AS WELL AS STATE AND FEDERAL GRANTS-RELATED REPORTING

PART 1. ALL HOUSEHOLD MEMBERS List all household members including children and both parents of children living in home. Also, include other relatives and friends living in home if you live as a single economic unit.

NAME OF ALL HOUSEHOLD MEMBERS

(First, Middle Initial, Last) NAME OF SCHOOL CHILD ATTENDS

CHILD’S DATE OF BIRTH (MONTH/DAY/YEAR)

CHECK IF A FOSTER

CHILD (LEGAL RESPONSIBILITY OF

WELFARE AGENCY OR COURT)

PART 2. TOTAL HOUSEHOLD GROSS INCOME (BEFORE DEDUCTIONS). List all income on the same line as the person who receives it. Check the box for how often it is received. RECORD EACH INCOME ONLY ONCE.

1. NAME

(LIST ONLY HOUSEHOLD

MEMBERS WITH INCOME)

2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED

Earnings from work

before deductions.

Wee

kly

Ever

y 2 W

eeks

Tw

ice

Mo

nth

ly

Mo

nth

ly

Welfare, child

support, alimony

Wee

kly

Ever

y 2 W

eeks

Tw

ice

Mo

nth

ly

Mo

nth

ly

Pensions, retirement, Social Security, SSI, VA

benefits

Wee

kly

Ever

y 2 W

eeks

Tw

ice

Mo

nth

ly

Mo

nth

ly

All other income (you must indicate how much

and how often)

(Example) Jane Smith $200 $150 $0 $0

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

PART 3. SIGNATURE

A parent or caretaker adult must sign the application. I certify (promise) that all information on this application is true and that all income is

reported. I understand that if I purposely give false information, my children may lose benefits. An adult household member must sign the

application.

Sign here: Print Name: Date:

Address: City: State: Zip Code:

Phone Number: Cell Phone Number:

DO NOT FILL OUT THIS INFORMATION-FOR SCHOOL USE ONLY

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

Only annualize income if there are multiple pay frequencies

Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: __________

Dual Eligibility: Foster child(ren) – Free _________ Non-foster child(ren) – Free ________ Reduced ________ Denied ___________

Categorical Eligibility: ____ Date Withdrawn: ________ Eligibility: Free____ Reduced____ Denied_____ Reason: __________________

Determining Official’s Signature: ________________________________________________ Date: ________________

14

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http:// www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected].

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).

USDA is an equal opportunity employer.

15

FEDERAL ELIGIBILITY INCOME CHART 2016-2017

Household size Yearly Monthly Weekly

1 $21,978 $1,832 $423

2 $29,637 $2,470 $570

3 $37,296 $3,108 $718

4 $44,955 $3,747 $865

5 $51,614 $4,385 $1,012

6 $60,273 $5,023 $1,160

7 $67,951 $5,663 $1,307

8 $75,647 $6,304 $1,455

Each additional person:

7,696 642 148

mailto:[email protected]

Central Enrollment and Parent Information Center

Fitchburg Public Schools 376 South Street

Fitchburg, MA 01420 Telephone: 978-345-3200

Fax: 978-343-2129

SIBLINGS Student Name _______________________________________________________________________ School ____________________________________________________ Grade ________________

Address ____________________________________________________________________________

Home Phone ____________________ Cell Phone ____________________

Parent / Guardian Names _____________________________________________________________

Brother(s) Name___________________________________________________ Date of Birth ____________ Name of School (if applicable) ______________________________________________ Grade_________ Name___________________________________________________ Date of Birth ____________ Name of School (if applicable) _____________________________________________ Grade_________ Name___________________________________________________ Date of Birth ____________ Name of School (if applicable) _____________________________________________ Grade_________

Sister(s) Name___________________________________________________ Date of Birth ____________ Name of School (if applicable) ______________________________________________ Grade_________ Name___________________________________________________ Date of Birth ____________ Name of School (if applicable) ______________________________________________ Grade_________ Name___________________________________________________ Date of Birth ____________ Name of School (if applicable) _____________________________________________ Grade_________

The School Committee’s policy of nondiscrimination extends to students, employees, and the general public with whom it does business. Fitchburg Public Schools does not discriminate on the basis of race, color, religion,


Questions related to this policy must be addressed to: The Human Resources Director/Grievance Officer, 376 South Street, Fitchburg, MA 01420, (978) 345-3215

16

Enrollment Coordinator:

Maria Ulloa-Hancock


Deborah Champagne

Jackie Ozores

KINDERGARTEN TEMPORARY SCHOOL HEALTH RECORD

STUDENT NAME: _____________________________________________________________________________________________ GENDER: _____

Last First Middle ADDRESS: ______________________________________________________________________________ HOME/CELL #: _____________________

Street City Zip Code

BIRTH DATE: _______________ BIRTH PLACE: ___________________________________ PRIMARY LANGUAGE: __________________ City State

NAME OF FAMILY PHYSICIAN: ___________________________________________ TELEPHONE: ________________________

NAME OF FAMILY DENTIST:______________________________________________ TELEPHONE: ________________________

IN CASE OF EMERGENCY, if you cannot be reached, give name, address, and phone number of person to be contacted:

NAME: __________________________________________________ TELEPHONE: _____________________________

ADDRESS: _________________________________________________________________________________________

DOES THE CHILD HAVE ANY BROTHERS OR SISTERS ATTENDING FITCHBURG SCHOOLS?

NAME GRADE SCHOOL

HEALTH HISTORY: Give dates / explanation

Food Allergy: No□ Yes □ __________________ Medication Allergy: No□ Yes □ __________________

Insect Stings Allergy: No□ Yes□ ____________ Seizure Disorder: No□ Yes □ Heart Disease: No□ Yes □

Operations: No□ Yes□ ____________ Accidents: No□ Yes□ _________ Chicken pox: No□ Yes□

Diabetes: No□ Yes□ Asthma: No□ Yes□ Pneumonia: No□ Yes□ Ear Infections: No□ Yes□

Frequent Headaches: No□ Yes□ Strep Throat: No□ Yes□ Bone or Joint Disease or Injury: No□ Yes□

Other: _____________________________________________

Wears glasses? No□ Yes□ Contacts?: No□ Yes□ Doctor’s Name: _________________________

Hearing Problems?: No□ Yes□ ____________________________________ Doctor’s Name: _________________________

Is this student on medication regularly? No□ Yes □ If yes, complete items below:

Medication Dosage Diagnosis Time Doctor

Does your child have any present physical limitations that may require program modification or restrictions? No□ Yes□

Please explain. (A doctor’s note may be required.) __________________________________________________________________

IMPORTANT NOTICE Massachusetts State Law-states that no child shall be admitted to school except upon presentation of a physician or clinic’s certificate stating that

the child has been immunized against:

DIPTHERIA, PERTUSSIS, TETANUS (DTP): 5 Doses DTaP/DTP or 4 doses if last dose is given after age 4

MEASLES, MUMPS, RUBELLA (MMR): 2 Doses

POLIO: 4 Doses Minimum*

HEPATITIS B: 3 Doses

VARICELLA: 2 Doses or Physician certification of disease history

YOUR CHILD WILL NOT BE ADMITTED TO SCHOOL WITHOUT PROOF OF THESE REQUIREMENTS

School Nurse to determine if documented immunizations meet entry requirements

17

OVER-THE-COUNTER MEDICATIONS (OTC)

PARENT PERMISSION FORM

The school physician for Fitchburg Public Schools, in compliance with Massachusetts Department of Public Health Regulations (105

CMR 210.00) has authorized the district’s school nurses to administer the following over-the counter medications during the school

day:

IBUPROFEN (Advil, Motrin)—for headaches, body aches or menstrual cramps

ACETAMINOPHEN (Tylenol)—for headaches, body aches or menstrual cramps

BENADRYL—for general allergy symptoms or mild insect stings

TUMS —for upset stomach or indigestion

EUCERIN - cream/lotion OR Aloe Vera Gel —for mild inflammation/dryness of skin

To assure safe administration of OTC medications to students during the school day, the school nurse will:

Assess the student’s condition, current medication profile, history of allergies and evaluate the need for medication.

Review the signed parent permission form, which is valid for one school year.

Call the parent/guardian to confirm, when necessary, the time of the last dose given.

Administer the correct dosage according to the physician’s written protocols.

Document the medication administration in the health office visit log.

Contact parent/guardians who have requested notification following OTC medication administration during the school day.

School Health Services will provide the over-the-counter medications listed below.

I give my consent to the school nurse to administer the following medications as needed during the school day.

Please Check All That Apply:

IBUPROFEN No Yes ACETAMINOPHEN No Yes BENADRYL No Yes

TUMS No Yes EUCERIN No Yes Aloe Vera Gel No Yes

School___________________________________

Student’s Name: _______________________________________________DOB____________________

Parent’s Signature: _____________________________________________Date: ____________________

Parent’s Phone Numbers: (Work)____________________ (cell)____________________ (home)____________________

Please notify me when OTC medication is administered to my child during the school day. Yes________ No__________

Comments: ______________________________________________________

Fitchburg Public Schools School Health Services 140 Arn How Farm Rd. Fitchburg, MA 01420 Ph: 978-343-2134 Fax: 978-345-3260

The School Committee’s policy of nondiscrimination extends to students, employees, and the general public with whom it does business. Fitchburg Public Schools does not discriminate on the basis of race, color, religion,


Questions related to this policy must be addressed to: The Human Resources Director/Grievance Officer, 376 South Street, Fitchburg, MA 01420, (978) 345-3215 18

Name Male Female Date of birth: ______

Medical History Pertinent Family History

Current Health Issues Y N Allergies: Please List: Medications Food Other History of Anaphylaxis to Epi-Pen

® Yes No

Asthma: Asthma Action Plan Yes No (Please attach) Diabetes: Type I Type II Seizure disorder: Other (Please specify)

Current Medications (if relevant to the student’s health and safety) Please circle those administered in school; a separate medication order form is needed for each medication administered in school.

Physical Examination Date of Examination Hgt: ( %) Wgt: ( %) BMI: ( %) Bp: (Check = Normal / If abnormal, please describe.) General Lungs Extremities Skin Heart Neurological HEENT Abdomen Other Dental/Oral Genitalia

Screening: (Pass) (Fail) (Pass) (Fail) (Pass (Fail) Vision: Right Eye Hearing: Right Ear Postural Screening: Left Eye Left Ear (Scoliosis/Kyphosis/

Stereopsis Lordosis

Laboratory Results: Lead Date Other

The entire examination was normal:

Targeted TB Skin Testing Med-to- High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors) TB Test Type: TST IGRA Date: Result: Positive Negative Indeterminate/Borderline Referred for evaluation to: Date: __________ Low risk (no TB test done)

This student has the following problems that may impact his/her educational experience: Vision Hearing Speech/language Fine/Gross Motor Deficit Emotional/Social Behavior Other

Comments/Recommendations:

Y N This student may participate fully in the school program, including physical education competitive sports. If no, please list restrictions:

Y N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System Certificate or other complete immunization record.

Signature of Examiner Circle: MD, DO, NP, PA Date Please print name of Examiner

Group Practice Telephone Address City State Zip code

Please attach additional information as needed for the health and safety of the student. MDPH 03/07/2017 19

MASSACHUSETTS SCHOOL HEALTH RECORD Health Care Provider’s Examination

Name: Date of Birth: Sex: M F

CERTIFICATE OF IMMUNIZATION

Please indicate vaccine type (e.g., DTaP-Hib, etc.)

I certify that this immunization information was transferred from the above-named individual’s medical records.

Doctor or nurse’s name (please print)___________________________________________________ Date: / /

Signature: ____________________________________________________________________________

Facility name: _________________________________________________________________________

Certificate of Immunization Massachusetts Department of Public Health 4/16 20

Vaccine Date Vaccine Type Vaccine

Date Vaccine Type

Hepatitis B

(e.g., HepB, HepB-Hib,

DTaP-HepB-IPV,

HepA-HepB)

1

Measles, Mumps,

Rubella

(e.g., MMR, MMRV)

1

2

2

3 Varicella

(Var, MMRV) 1

4

2

Diphtheria, Tetanus, Pertussis

(e.g., DTP, DTaP, DT,

DTaP-Hib, DTaP-HepB-

IPV, DTaP-IPV/Hib, DTaP-

IPV, Td, Tdap)

1 Meningococcal

Quadrivalent MenACWY-Conjugate

(MCV4) or Polysaccharide

(MPSV4)

1

2

2

3 Meningococcal

Serogroup B (Men B) MenB-FHbp MenB-4C

1

4

2

5

3

6 Seasonal Influenza

Inactivated

IIV4, IIV4-ID, IIV3, IIV3- ID,

IIV3-HD, RIV3-IM, CCIIV3-IM

Live Attenuated

LAIV, LAIV4 (quadrivalent)

1

7

2

8

3

Haemophilus influenzae

type b

(e.g., Hib, HepB-Hib, DTaP-Hib, DTaP- IPV/Hib, Hib-MenCY)

1

4

2

5

3

6

4

7

Polio

(e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP- IPV)

1 2009 H1N1 Influenza

Inactivated or Live 1

2

2

3 Pneumococcal

Polysaccharide

(PPSV23)

1

4

2

5 Hepatitis A

(HepA, HepA-HepB) 1

Pneumococcal Conjugate (PCV13, PCV7)

1

2

2 Human

Papillomavirus (9vHPV, 4vHPV, 2vHPV)

1

3

2

4

3

Rotavirus

(e.g., RV5: 3-dose series,

RV1: 2-dose series)

1 Zoster (shingles)

1

2 Other: 1

3

2

Serologic Proof of Immunity Check One

Test (if done) Date of Test Positive Negative

Measles / /

Mumps / /

Rubella / /

Varicella* / /

Hepatitis B / /

* Must also check Chickenpox History box.

Chickenpox History

Check the box if this person has a physician-certified reliable

history of chickenpox.

Reliable history may be based on:

• physician interpretation of parent/guardian description of chickenpox

• physical diagnosis of chickenpox, or

• serologic proof of immunity

central enrollment and parent information center · 2017. 3. 21. · central enrollment and parent...

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