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: _________________________________________________________________________
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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
Other Pacific Islander 21 53
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
Other Pacific Islander 29 61
Black or African American & Asian & American Indian or
Alaska Native & Native Hawaiian or Other Pacific Islander 30 62
Combination of Five Races
White & Black or African American & Asian & American Indian or
Alaska Native & Native Hawaiian or Other Pacific Islander 31 63
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: ______________________________________
Name: ___________________________________Relationship to child: _____________________________
Address: _________________________________________________________________________________
Telephone: __________________________ Work telephone:______________________________________
Name: ___________________________________Relationship to child:______________________________
Address: _________________________________________________________________________________
Telephone: __________________________Work telephone: _______________________________________
Name: ___________________________________Relationship to child: _____________________________
Address: _________________________________________________________________________________
Telephone: __________________________ Work telephone: ______________________________________
Name: ___________________________________Relationship to child: _____________________________
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
Fitchburg Public Schools
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
Principal Secretaries:
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
Fitchburg Public Schools
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
Fitchburg Public Schools
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.
_____ 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 school newspaper/newsletter or other
publication.
_____ Yes, I consent and authorize the school to include my child’s name, class, photograph or image,
participation in school activities, honors and awards as part of programming on Fitchburg Access Television
(FATV).
_____ Yes, I consent and authorize the school to include my child’s name, class, photograph or image,
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
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,
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
16
Enrollment Coordinator:
Maria Ulloa-Hancock
Principal Secretaries:
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,
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 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