fcps forms available from the warehouse · pdf filenote attached yes bus delayed no office ......

FCPS Forms Available From the Warehouse

1Updated: 01 April 2017

Admit Slip: 2-part NCR (5.5” x 3”)Inventory ID: 006051

100 per package

ADMIT SLIPDATE: CODE:

NAmE Of STuDENT

ArrivED AT SChOOl AT (TimE Of ArrivAl)

NOTE ATTAChED YES BuS DElAYED

{ NO

OffiCE SigNATurE:

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Bus Pass: Pad (5.5” x 4.25”)

Inventory ID: 00603450 sheets per pad

BUS PASS

Student:

Has permission to ride BUS#:

To/With:

On (Date):

Authorized Signature CS–SEP2011

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Detention Assignment: 2-part NCR (8.5” x 11”)

Inventory ID: 006035100 per package

CS/10‐11 White Copy to Student/Parent Canary Copy to File

DETENTION ASSIGNMENT

NAME __________________________________________________________ GRADE _____________

is to report for detention on _________________________________ as a result of ___________________________________

_______________________________________________________________________________________________________

IF THE ABOVE NAMED STUDENT MISSES ANY OF THE ASSIGNED DETENTIONS, IS LATE OR CAUSES A DISRUPTION, HE/SHE MAY

BE:

□ REFERRED TO AN ADMINISTRATOR

□ ASSIGNED TO SATURDAY SCHOOL

DETENTION RULES

1. Assigned detention will be from _______ a.m./p.m. to _______ a.m./p.m. and will be held in ________________________.

2. Students must report no later than ______ a.m./p.m. Students who arrive late may not be admitted and may be referred to

the appropriate administrator. Students are required to bring pens, pencils, books and school‐related assignments to

detention. Students are expected to be on task throughout the assigned time. Work may be assigned if the student brings

none. Students are expected to demonstrate appropriate behavior. Sleeping, talking, making noises, leaving an assigned seat

and other forms of behavior that distract others will not be tolerated. Eating and drinking are not allowed. All electronic

devices must be powered off.

3. If the student is absent on the day of scheduled detention, the student is required to:

□ attend detention on the day he/she returns to school □ reschedule through the administrator

4. Students may not reschedule detention dates. If rescheduling is necessary, the parent must contact the administrator prior

to the scheduled date.

5. Students may not be dismissed from detention for any school activities.

6. Other:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

TRANSPORTATION

Please note that school bus transportation is not provided for before‐ or after‐school detention. Transportation to and from the

detention assignment is the parent’s responsibility.

MY SIGNATURE BELOW INDICATES THAT I HAVE RECEIVED A COPY OF THIS DOCUMENT, HAVE REVIEWED IT WITH

AN ADMINISTRATOR, UNDERSTAND THE RULES AND AGREE TO SHOW THIS FORM TO MY PARENTS THIS EVENING.

__________________________________________ _____________________________

Student’s Signature Date

__________________________________________ _____________________________

Administrator’s Signature Date



Gate Receipt Reconciliation: 3-part NCR (8.5” x 11”)


GATE RECEIPTS RECONCILIATION FORMSCHOOL:DATE: EVENT:

I. TICKET REVENUE CALCULATION: A. AdultTickets EndingNumber BeginningNumber TotalSold X = (TicketRate) (AdultRevenue) B. StudentTickets EndingNumber BeginningNumber TotalSold X = (TicketRate) (StudentRevenue) C. No-ChargeTickets EndingNumber BeginningNumber TotalIssued X N/A = N/A

D. OtherTickets EndingNumber BeginningNumber TotalSold X = (TicketRate) (OtherRevenue)

I. TOTAL TICKET REVENUE $

II. CASH RECONCILIATION: Hundreds = X $100.00 = Fifties = X $ 50.00 = Twenties = X $ 20.00 = Tens = X $ 10.00 = Fives = X $ 5.00 = Ones = X $ 1.00 = FiftyCents = X $ .50 = Quarters = X $ .25 = Dimes = X $ .10 = Nickels = X $ .05 = Pennies = X $ .01 =

TotalCashinCashBox $

Less:BeginningCash –

II. CASH REVENUE $

III. TOTAL REVENUE $

LESS REVENUE FOR BOE PARTICIPATION FUND ($1 PER ADULT TICKET) – (ACCTCODE21340-10-0102-013--88-00000)

TOTAL REVENUE FOR ATHLETIC DEPARTMENT $

Administrator Cashier CashShort(I.ExceedsII.) OR CashOver(II.ExceedsI.)

COMMENTS:

Hall Pass: Pad (5.5” x 2.75”)


H A L L P A S S

NAME:_______________________________________ DATE_ISSUED:____________________

FROM:_________________________________ FROM:_ _______________________________

TO:____________________________________ TO:___________________________________

TIME:__________________________________ TIME:_ ________________________________

REASON:_____________________________________________________________________

_____________________________________ _____________________________________________________

SIGNATURE_ SIGNATURE_ CS–SEP2011

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Health Information Card: Single-sided form (8.5” x 11”)


Rev Apr 2011

CONFIDENTIAL HEALTH INFORMATION In case of an emergency, the school staff will contact 911.

Every attempt will be made to contact a parent, a guardian, or a designated emergency contact. STUDENT INFORMATION

Last: First: Middle:

Date of Birth: Gender M F

Grade

School Name: Does the student have health insurance? Does the student have dental insurance?

Private Medical Assistance No Insurance Y N

CURRENT HEALTH CONCERNS Please check the following health concerns that may impact the student’s educational day. This information may be shared with FCPS staff as appropriate.

The student does not have any medical concerns

ADD/ADHD

allergies (choose all that apply)

foods ______________________________________

bee sting/insect bite _________________________

medicines __________________________________

pesticides/chemicals*________________________

other ______________________________________

asthma: Has the student experienced an asthma episode in

the past 12 months? Yes No

blood disorder ________________________________

cancer

diabetes

hearing problems hearing aid(s)

heart problems _______________________________

mental health diagnosis_________________________

physical disability ______________________________

seizures

vision problems _______________________________

glasses contacts

other _______________________________________

This information is a change in health condition from the last school year

*FCPS uses the Integrated Pest management programs to identify and control pest problems in schools. Elementary schools must notify staff and parents/guardians of all students 24 hours before pesticides are to be applied inside the school building or on the grounds. Middle and high schools must notify only those parents, guardians or staff who have filed a written request for notification; forms are available at each school and must be updated every school year. See the FCPS Calendar Handbook for details, or contact your child’s school.

MEDICATIONS List all medications and dosages your child receives on a routine basis

Medications are not required at school

If the student requires over‐the‐counter or prescription medications or treatments at school, the health care provider and parent must complete and submit the appropriate authorization form(s). Obtain forms from the health staff at your child’s school or at http://www.fcps.org/ (click on Forms).

Medications: __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

I hereby give authorization and consent to the school, in the event that I cannot be contacted, to obtain emergency medical care and necessary emergency transportation to a healthcare facility. I understand and authorize that my child’s medical records or other medical information, furnished to the school, will be shared with FCPS/Frederick County Health Department staff and emergency personnel who have a legitimate medical/educational purpose for accessing such medical records and information. Parent/Guardian name (please print):_________________________________________________ Primary Contact Ph# _____________________ Signature of Parent / Guardian:____________________________________________________ Date _______________________

High School Admit/Attendance Slip: 2-part NCR (5.5” x 3”)Inventory ID: 006026

100 per package

ADMIT/ATTENDANCE SLIP TEACHER’S SIGNATURE BY PERIOD

Name:

Date Absent/Dismissed/Late:

Date Issued:

Code:

Time:

Authorized by:

STUDENT ASSISTANTS ARE NOT AUTHORIZED TO SIGN THIS PASS

CS–SEP2011

1.

2.

3.

4.

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Internal Deposit Slip: 3-part NCR (3.666” x 8.5”)


INTERNAL DEPOSIT SLIP

SCHOOL

Date

Account Name

Source of funds being deposited

Amount – Currency $

Coins

Checks

Total of Deposit $

Teacher signature

Bookkeeper signature

Please complete the following if the deposit consists of taxable sales.

Total Collected $

Taxable Sales $

Sales Tax Collected $ (6% of taxable sales)


SCHOOL

Date

Account Name



Coins

Checks

Total of Deposit $

Teacher signature



Total Collected $

Taxable Sales $



SCHOOL

Date

Account Name



Coins

Checks

Total of Deposit $

Teacher signature



Total Collected $

Taxable Sales $


InternalDepositSlip.indd 1 7/26/11 11:04 AM



Late Pass: 2-part NCR (4.25” x 2.75”)


LATE PASS

DATE

STUDENT

TIME

TEACHER

REASONCS–SEP2011

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Maryland Schools Record of Physical Examination: 4-page form, (2-sided, folds to 8.5” x 11”)




Permission to Report to Guidance: Pad (5.5” x 3.25”)


PERMISSION TO REPORT TO GUIDANCE OFFICEPlease show this to your teacher before reporting to the Guidance Office.

Date ___________________________ 20_______

____________________________________________________________ hasanappointment

with ________________________________________________ at(time):________________

Signatureapproval ____________________________________________________________

Theabove-namedstudentconferredwithmeandleftat(time): _________________________

Signature____________________________________________________________________CS–SEP2011

Generic_ReportToGuidancePass.indd 1 9/14/11 12:54 PM

Recess Detention Notice: 3-part NCR (8.5” x 5.5”)


RECESS DETENTION NOTICE

____________________________________________________________ ______________________________________ StudentName Date

_________________________________________________________________________________________________________________ ReferringTeacher HomeroomTeacher DetentionTeacher

REASON FOR DETENTION:

c Behavior:____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

c Academic: ___________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Please sign and return to teacher:

Student Signature ________________________________________________________________Date ___________________________________

Parent/Guardian Signature _________________________________________________________Date ___________________________________

White copy – Parent/Student Yellow copy – Teacher Pink copy – OfficeCS–SEP2011

Generic_Recess Detention Notice.indd 1 9/14/11 12:48 PM

Out of School Pass: 2-part NCR (5.5” x 3”)Inventory ID: 006052

100 per package

OUT-OF-SCHOOL PASS Date:______________________________

Name:________________________________________________________________ haspermissioN

toleaveschoolat:__________________________________________ (time)forthefollowiNg

purpose:____________________________________________________________________________

NotexpecteDtoreturNtoDay: ______________________________________________________

expecteDtoreturNat: __________________________________________________ (time)toDay

officesigNature:____________________________________________________________________

Generic_OutOfSchoolPass.indd 1 6/20/12 4:53 PM



Saturday School Contract: 2-part NCR (8.5” x 11”)


CS 10 11 White Copy to Student/Parent Canary Copy to File

SATURDAY SCHOOL CONTRACT

NAME ______________________________________________________ GRADE __________

is to report for Saturday School on _________________________________ as a result of ________________________

_________________________________________________________________________________________________.

SATURDAY SCHOOL GENERAL INFORMATION

1. Saturday School will be from _____ a.m. to ______ a.m. and will be held in ____________________________.Students are to report to ____________________________________ no later than ________ a.m. to gain entranceto the building. Students arriving late will not be admitted. Early dismissals are not allowed.

2. Saturday School is cancelled if school is closed all day or closes early on Friday due to inclement weather. SaturdaySchool is also cancelled if the snow emergency plan is in effect by 6 a.m. on Saturday.

SATURDAY SCHOOL RULES

1. Students are required to bring pens, pencils, books and school related assignments to detention. Work may beassigned if the student brings none. Students are expected to be on task throughout the assigned time.

2. Students are expected to demonstrate appropriate behavior. Sleeping, talking, making noises, leaving an assignedseat and other forms of behavior that distract others will not be tolerated. Electronic devices must be powered offand may be confiscated if they are not.

3. No food or drinks are permitted.4. Restroom privileges must be requested through the proctor.5. Use of library materials must be arranged with permission from staff.6. Absence from Saturday School is unacceptable unless the absence is certified in writing by a doctor.7. Other: ___________________________________________________________________________________

CONSEQUENCES

1. Refusal to follow the proctor’s requests and/or any disruptive behavior may result in immediate removal fromSaturday School. A reasonable attempt will be made to notify the student’s parent/guardian that the student hasbeen removed.

2. If the student fails to attend the assigned Saturday School, is late or causes a disruption, he/she may be suspendedout of school for a minimum of _______ days.

TRANSPORTATION

Please note that school bus transportation is not provided for Saturday School. Transportation to and from SaturdaySchool is the parent’s responsibility.

MY SIGNATURE BELOW INDICATES THAT I HAVE RECEIVED A COPY OF THIS DOCUMENT, HAVE REVIEWED IT WITH ANADMINISTRATOR, UNDERSTAND THE RULES OF SATURDAY SCHOOL AND AGREE TO SHOW THIS FORM TO MY PARENTSTHIS EVENING.

___________________________________________ __________________________________Student’s Signature Date

___________________________________________ __________________________________Administrator’s Signature Date

Student Absence, Late Arrival, Dismissal Change: Pad (5.5” x 8.5”)


STUDENT ABSENCE, LATE ARRIVAL, DISMISSAL CHANGE

School Office Notification

Student________________________________________________Grade_________

Teacher__________________________ Date______________ Time______________

ABSENT / LATE

c Absent_ c Tardy_ c Will_Arrive_Late_/_Time_Expected__________________

c Illness_ c Missed_bus_ c Dr._appt._ c Overslept_ c Car_trouble

c Religious_ _ Other_________________________________________________

DISMISSAL CHANGE

Dismiss_at_(time)_______________Returning_at_____________ /_c Not_returning

______Will_be_picked_up_by_ ______________________________________________

c Will_ride_bus#__________to/with_____________________________________

c Will_be_a_car_rider_with______________________________________________

c Will_be_a_walker_ c Other_ ________________________________________

PERMISSION FROM PARENT/GUARDIAN

c Called_ c Sent_Note_ c Other_ ______________________________

Rec’d_by_________________________ on_(date)_________ at_(time)_____________CS–SEP2011

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Student Detention Notice From Teacher: 3-part NCR (8.5” x 5.5”)


STUDENT DETENTION NOTICE FROM TEACHER

Student____________________________________________________________________________ Grade_ ___________________

Detention_Date_________________________________ Detention_Room_#_________________Detention_Time________________

Teacher________________________________________________Class__________________________________________________

Behavior Reasons:_ ____Late_to_class_ Academic Reasons:_ ____Failure_to_complete_class_assignment(s)

_ ____Disruptive_in_class_(see_note)_ _ ____Make-up_of_test

_ ____No_class_materials;_repeated_ _ ____Tutorial_help

_ ____Other_(see_note)_ _ ____Class_enrichment

_ _ _ ____Other_(see_note)NOTE:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

My signature below indicates that I have received a copy of this Detention Notice and agree to show this notice to my parents/

guardians this evening.

Student Signature _____________________________________________Date __________________________________________

White copy – Parent/Student Yellow copy – Teacher Pink copy – OfficeCS–SEP2011

Generic_Student Detention Notice.indd 1 9/14/11 12:49 PM



Student Referral Notice: 4-part NCR (8.5” x 5.5”)


FREDERICK COUNTY PUBLIC SCHOOLS STUDENT REFERRAL FORM

Student Name School Date/Time Referred School Phone # Period/Subject Referred ToGrade/Section Room # Referred By

REASON FOR REFERRAL:

PILLARS OF CHARACTER COUNTS! q Trustworthiness q Respect q Responsibility q Fairness q Caring q Citizenship

TEACHER ACTION PRIOR TO REFERRAL:

ADMINISTRATIVE ACTION TAKEN:

Reprimand and Warning Pupil Personnel Referral Discussion with Student Parent Contact–Call/Letter Suspension – Out-School/In-School Conference – Student/Parent Suspension Pending Parent Conference Extended Suspension Detention

Other

ADMINISTRATOR’S SIGNATURE: DATE: / /

PARENT’S SIGNATURE: DATE: / /(If Applicable)FORM # 01-11-7-10 Rev. 5/98 White – Teacher Canary – Parent Pink – Other Goldenrod – Administrator

Generic_Student Referral Form.indd 1 11/3/11 12:18 PM

Student Record Card 1:Double-sided form (11” x 8.5”)


STUDENT RECORDCARD 1 SIDE 1

Maryland StateDepartment of Education

Rev. 07/11

Sex of Studentc Malec Female

Race (check all that apply)c American Indian or Alaskan Nativec Asianc Black or African Americanc Native Hawaiian or Other Pacific Islanderc White

Evidence of Birth Verified (Name/Title/Date):

Evidence of Birth (check all that apply)c Birth Certificate c Hospital Certificatec Passport/Visa c Parent’s Affidavitc Physician’s Certificate c Birth Registrationc Baptism/Church Cert. c Other

1 Date: Month Day Year

Student Address

Responsible Adult for Student at Address

Relationship to Student

Parent/Guardian (If other than responsible adult above)

Name: Relationship:

Address:

Phone:


Student Address




Name: Relationship:

Address:

Phone:


Student Address




Name: Relationship:

Address:

Phone:


Student Address




Name: Relationship:

Address:

Phone:


Student Address




Name: Relationship:

Address:

Phone:


Student Address




Name: Relationship:

Address:

Phone:

FOR LOCAL USE

(For secondary students only) F-1 or J-1 Immigration Status

Proof of Residency (Include a copy of documents)

List languages spoken in the home:Hispanic.Latinoc Yes

c No

PERSONAL DATA

Legal Name LOCID SASID

Birth Date: Month Day Year

Completion of High School Program60 – High School Diploma62 – Maryland High School Certificate70 – Early College Admission

STUDENT RECORDCARD 1      SIDE 2

Maryland StateDepartment of Education

Rev. 07/11

SCHOOL ATTENDANCE INFORMATION

Legal Name  LOCID  SASID

Birth Date:  Month  Day  Year

Year Grade No. School Name Abs. Pres. Code Month Day From Code Mo. Day To

Withdrawal/CompletionEntryDaysLSS

Entry Status R – First Entry Into Any School E – Transferring from Another School N – Re-entry      06 – involuntary withdrawal - current 

reporting period      07 – voluntary withdrawal - current 

 reporting period

Withdrawal Status  T – Transfer to Another School W – Terminated Formal Education  C – Completed High School Program

Entry/Transfer Codes01 – First Entry02 – Continuing08 – Re-entry - involuntary w/d09 – Re-entry - voluntary w/d10 – Same LSS13 – MD public school14 – US public school15 – Local nonpublic school16 – MD nonpublic school17 – US nonpublic school18 – Foreign School21 – Evening High School22  – Maryland Institution24 – Home Schooling25 – Schools in Improvement26 – Unsafe School Choice27 – Homeless

Termination Codes30 – Illness  40 – Expulsion (under 16)31 – Academic  41 – Immaturity32 – Discipline  42 – Special Case33 – Lack of Interest  43 – Death34 – Employment  44 – Parenting35 – Marriage  46 – Expulsion (16 & over)36 – Military Service  50 – Whereabouts Unknown38 – Court Action  71 – Pregnancy39 – Economic Reasons



Student Record Card 3B:Single-sided form (11” x 8.5”)






Rev. 07/11

TEST INFORMATIONSTATE MANDATED TESTING

Legal Name Birth Date: Mo. Day Year

LEA ID# STATE ID#

Maryland School Assessments and Alternate Maryland School Assessments



Rev. 07/11

TEST INFORMATION

Legal Name Birth Date: Mo. Day Year

LEA ID# STATE ID#

Local School System Testing

fcps forms available from the warehouse · pdf filenote attached yes bus delayed no office ......

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