lake placid elementary school...• an affidavit (written statement signed under oath) saying that...

Lake Placid Elementary School 318 Old Military Road Lake Placid, New York 12946

518-523-3640 Fax: 518-523-4314 www.lpcsd.org

Dear Parent/Guardian,

Enclosed is our registration packet. In it, you will find the following documents to be completed and returned: 1. RequestforRecordsfrompreviousschool2. LakePlacidCentralSchoolRegistrationForm(2pages)3. EnrollmentForm–ResidencyQuestionnaire4. HealthHistory5. PhysicalExamforSchoolHealthRecords(2pages‐completedbyyourchild’sdoctorand

returnedpriortostartingschool)6. DentalHealthCertificate(tobecompletedbyyourchild’sdentistat

his/her next dental visit and returned).

Please submit the following with the above completed information: 1. BirthCertificate2. ProofofResidency‐copymustbecurrentandshowphysicaladdress:

a. utilityorotherbillb. currentleaseorproofofhomeownershipc. paystubsd. incometaxformse. documentsissuedbyfederal,stateorlocalagencies(suchasasocialserviceagency)

If you have any questions, please feel free to contact the office at (518)523-3640 ext 4501.

Michele Kulina Administrative Assistant

School Principal Sonja Franklin

Ext. 4502

CSE Chairperson Sarah Allen Ext. 4011

School Psychologist Melinda Frazer

Ext. 4504

School Counselor DeAnna Brown

Ext. 4533


518-523-3640 Fax: 518-523-4314 www.lpcsd.org

Date: _________________________ To: _________________________________________________________________________________

(previous school) __________________________________________________ recently enrolled in our school. (Student’s name) We are requesting the following records:

1. Academic Records 2. Special Education Records (if applicable) 3. Health Records 4. Birth Certificate

Has this student been recommended for any special services? If yes, please name the service(s): __________________________________________________________________________________________

Please send all records requested (by mail or fax) as soon as possible to:

Lake Placid Elementary School Attn: Principal

318 Old Military Road Lake Placid, New York 12946

Fax: (518) 523-4314 ****************************************************************************************************************** I hereby give consent for release of all information concerning my child to the Lake Placid Elementary School, Lake Placid, New York. ________________________________________ ____________________________ Parent Signature Date


Ext. 4502



Ext. 4504


Ext. 4533

1

LAKEPLACIDCENTRALSCHOOLREGISTRATIONFORM

StudentPersonalData

LastName:_________________________________________________FirstName:________________________________M.I.________DateofBirth:_______________________________________Sex:MorF(circle)Grade:__________________________________

PlaceofBirth:___________________________________________________________________(City&StateorCountry)EthnicBackground: (Chooseallapplicable) _______AmericanIndianorAlaskaNative _______Asian _______BlackorAfricanAmerican _______HispanicorLatino

_______NativeHawaiianorotherPacIslander _______White

Student’sPhysicalAddress(notaPOBox):___________________________________________________________________________Student’sMailingAddress(ifdifferent):______________________________________________________________________________MainPhoneNumber:___________________________________________(thisnumberwillbeusedforourdistrict’sOneCallSystem)FAMILYINFORMATION:Currentlylivingwith:_______Mother&Father(biological)_______motheronly_______fatheronly_____legalguardianFather’sName:_________________________________________________________________________________________________________ PhoneNumber:_____home______cell_____work:___________________________________________________________ PhoneNumber:_____home______cell_____work:___________________________________________________________ MailingAddress(ifdifferentfromStudent’s):______________________________________________________________ EmailAddress:________________________________________________________________________________________________Mother’sName:________________________________________________________________________________________________________ PhoneNumber:_____home______cell_____work:___________________________________________________________ PhoneNumber:_____home______cell_____work:___________________________________________________________ MailingAddress(ifdifferentfromStudent’s):______________________________________________________________ EmailAddress:________________________________________________________________________________________________

2

Or,LegalGuardian’sName:____________________________________________________________________________________________ PhoneNumber:_____home______cell_____work:___________________________________________________________ PhoneNumber:_____home______cell_____work:___________________________________________________________ MailingAddress(ifdifferentfromStudent’s):______________________________________________________________ EmailAddress:________________________________________________________________________________________________Persontocallorhavepick-upstudentinanemergency/illnessifparentsorguardiansareunavailable: Name:____________________________________________Relationship:____________________Phone#_________________ Name:____________________________________________Relationship:____________________Phone#_________________

______________________________________________________________________ParentorGuardianSignature Date

LAKEPLACIDCENTRALSCHOOL

ENROLLMENTFORM–RESIDENCYQUESTIONNAIRE

NameofStudent:___________________________________________________________________________ Last First MiddleGender:_______Male_______FemaleDateofBirth:______/______/______Grade:_____ MMDDYear

StreetAddress:_____________________________________________________________________

Town,State,ZipCode:_____________________________________________________________

PhoneNumber:_____________________________________________________________________

TheansweryougivebelowwillhelpthedistrictdeterminewhatservicesyouoryourchildmaybeabletoreceiveundertheMcKinney-VentoAct.StudentswhoareprotectedundertheMcKinney-VentoActareentitledtoimmediateenrollmentinschooleveniftheydon’thavethedocumentsnormallyneeded,suchasproofofresidency,schoolrecords,immunizationrecordsorbirthcertificate.StudentswhoareprotectedundertheMcKinney-VentoActmay

alsobeentitledtofreetransportationandotherservices.

Whereisthestudentcurrentlyliving?(Pleasecheckonebox): _______Inashelter _______Withanotherfamilyorotherpersonbecauseoflossofhousing orasaresultofeconomichardship(sometimesreferredtoas “doubledup”) _______Inahotel/motel _______Inacar,park,bus,trainorcampsite _______Othertemporarylivingsituation,pleasedescribe: _______Inpermanenthousing__________________________________________ __________________________________________ PrintnameofParent,Guardianor SignatureofParent,GuardianorStudentStudent(forunaccompaniedhomelessyouth) (forunaccompaniedhomelessyouth________________________Date

A GUIDE TO THE NEW RULES FOR SCHOOL REGISTRATION

understandingTo enroll in school:You (the parent, guardian, or caregiver) have to show that the youth is living with you and that you have total and permanent custody and control. To do this, you can show the school district:

• proof of custody or guardianship

OR

• an affidavit (written statement signed under oath) saying that you have “total and permanent custody and control” over the child

OR

• other proof such as documentation that the child has been placed with a sponsor by a federal agency.

Enrollment requirements:

NYS Education DepartmentOffice of Student Support Services(518) 486-6090

Enrollment of immigrant children and youth:

NYS Education DepartmentOffice of Bilingual Education &World Languages(718) 722-2445

Enrollment of children and youth in temporary housing:

NYS Technical and Education Assistance Center for Homeless Students (NYS-TEACHS) (800) 388-2014

NYS Education DepartmentState Coordinator for Homeless Education(518) 473-0295

This pamphlet is a summary of the applicable regulatory provisions and is intended for informational purposes only. For further information on the applicable regulatory requirements, please consult an attorney or see 8 NYCRR section 100.2(x) and 100.2(y), as amended effective July 1, 2015,

August 2015

WHAT IF…the youth is not living with a parent?

the parents are separated or divorced? For more information:

➡There are different requirements for youth in temporary housing (this may include, for example, youth who have run away or been kicked out of their homes).

For more information about temporary housing and enrollment, call NYS-TEACHS at 800-388-2014.

Did you know:• Your child must be enrolled within one day

of your request.• Children and youth can get a free public

education, even if they are undocumented or are not citizens.

• Schools cannot ask you for your social securi-ty card or social security number at the time of or as a condition of enrollment.

• Schools cannot ask about immigration status at the time of or as a condition of enrollment (but after enrollment they may ask about which country your child was born in).

• There are many different ways to show residency. Schools must give you choices and cannot only ask for a lease or a deed.

• Your child can be enrolled in school even if you don’t have his or her birth certificate.

• Youth may enroll in school under certain circumstances even if they are not living with their parents.

Ways you can show residency:

• Lease or deed• Affidavit (a written statement signed under

oath) from the person you pay rent to, saying you live there

• A letter from the person you pay rent to saying you live there

• A letter from another person saying you live at your address

• Other documentation, such as: Pay stub showing your address Income tax form that shows your ad-

dress Utility bill or other bill in your name Membership documents based on

residency, such as a local library card Voter registration card Driver’s license, or permit, or

non-driver ID State or other government issued ID Documents from government agencies

such as a social service agency or the federal Office of Refugee Resettlement

Custody or guardianship papers

If the school district decides your child can’t go to school in the district because he or she is not a resident, the district must give you a letter within two business days explaining its decision and how to appeal the decision.

Ways to show a child’s age:

• Certified Birth Certificate (from any country)

• Baptismal record (from any country)• A Passport (from any country)

If you don’t have a Birth Certificate, baptismal record, or passport, you can use other documents if you’ve had them for at least two years, such as:

• Driver’s license• State or governmental ID• School photo ID with date of birth• Consulate ID card• Hospital or health records• Military dependent ID card• Other documents from federal/state/local

agencies (examples: Department of Social Services, Office of Refugee Resettlement)

• Court orders• Native American tribal document• Records from international aid agencies or

voluntary agencies

Do you know how to show that you live in the district where you are enrolling your children?

Do you know how to prove your children’s ages? ➡

To enroll in school, you have to show:• that you live and intend to remain in the school

district. This is called showing you are a “resident.”

AND

• your child’s age.

➡

Children and youth in temporary housing can enroll in school without the documents normally needed to enroll. Children and youth are temporarily housed or homeless if they lack a fixed, regular, and adequate nighttime residence which includes, for example:– living in a shelter or, – sharing the home of a relative or a friend

because they lost their home or were evicted.


518-523-3640 Fax: 518-523-4314 www.lpcsd.org

Dear Parent/guardian, We would like for your child to gain the most from his/her school experience. In order for us to assist in accomplishing this, it is necessary to have a current health history. Please complete this form and return it to the school nurse. Thank you. Accidents: * Serious head injury_________________ * Loss of Consciousness______________

* Other(specify)____________________

Eye Difficulties: * “Lazy eye”_______________________ * Glasses/Contact lenses_____________

* Other___________________________

Ear/Throat Problems: * Ear infections_____________________ * Tubes___________________________ * Hearing loss______________________ * Throat infections__________________

* Other___________________________

Heart Problems: * Heart murmurs____________________ * Congenital heart disease_____________ * Rapid heartbeat___________________

* Other___________________________

Respiratory difficulties: * Asthma_________________________ * Asthma triggers__________Peak Flow________ * Bronchitis/Pneumonia_______________

* Other___________________________

Kidney/Bladder disease: * Kidney disease____________________ * Bladder infections__________________ * Enuresis(bedwetting)_______________ * Encopresis(fecal soiling)_____________ * Constipation______________________ * Hernia__________________________ * Undescended/one testicle____________

Parents Signature & Date:_______________

Musculoskeletal/Orthopedic problems: * Joint pain/swelling_________________ * Limitation of movement_____________ * Fractures________________________ * Braces/adaptive equip.______________ * Poor coordination__________________

* Other___________________________

Birth Defects(specify)________________

Hospitalizations(specify)______________

Operations(specify)__________________ Illness with a high fever(103+)__________ * Seizures_________________________ * Staring spells_____________________

* Other___________________________ Allergies(specify to what and type of reaction)__________________________ _________________________________

Currently/Regularly taking medication: * Name___________________________ * Reason__________________________

* Needed during school?_______________

Skin Conditions(specify)______________

Tuberculosis TB contact______________

Anemia___________Mono____________

Diabetes__________Hepatitis_________

Thyroid disease_______Speech________

Emotional problems__________________

Special Educational Needs_____________

Medical exams by specialists___________

________________________________


Ext. 4502



Ext. 4504


Ext. 4533

Lake Placid Central School District

Health and Dental Examination Requirements

Dear Parents/Guardians,

New York State law requires a health examination for all students entering the school district for the first time and when entering Pre‐K or K, 2nd, 4th, 7th, and 10th grade. The examination must be completed by a New York State licensed physician, physician assistant or nurse practitioner. A dental certificate which states your child has been seen by a dentist or dental hygienist is also asked for at the same time. The school will provide you with a list of dentists and registered dental hygienists who offer dental services on a free or reduced cost basis if you ask for it. A copy of the health examination must be provided to the school within 30 days from when your

child first starts at the school, and when your child starts K , 2nd ,4th ,7th , & 10th grades. If a copy is not given to the school within 30 days, the school will contact you.

If your child has an appointment for an exam during this school year that is after the first 30 days of school, please notify the Health Office with the date.

For your convenience, a physical exam form and dental certificate for your health care providers is enclosed.

Communication between private and school health staff is important for safe and effective care at school. Your healthcare provider may not share health information with school health staff without your signed permission. Please talk to your provider about signing their consent form for the school at the time of your child’s appointment for the examination.

We suggest you make copies of the completed forms for your own records before sending them to the school health office. Forms may also be faxed to the number below.

Sincerely, Elise Stosiek RN, BSN 518. 523‐3640 ext 4505 F: 518. 523‐4314

SAMPLE

Dental Health Certificate- Optional

Parent/Guardian: New York State law (Chapter 281) permits schools to request an oral health assessment in the following grades: school entry, K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your registered dentist or registered dental hygienist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist/dental hygienist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.

Section 1. To be completed by Parent or Guardian (Please Print) Child’s Name: Last First Middle

Birth Date: / / Month Day Year

Sex: Male Female

Will this be your child’s first oral health assessment ? Yes No

School: Name

Grade

Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No

I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below. Parent’s Signature______________________________________________________________ Date

Section 2. To be completed by the Dentist/ Dental Hygienist

I. The dental health condition of _______________________________ _______ on__________ (date of assessment) The date of the assessment needs to be within 12 months of the start of the school year in which it is requested. Check one:

Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools. No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.

NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.

Dentist’s/ Dental Hygienist’s name and address

(please print or stamp) Dentist’s/Dental Hygienist’s Signature

Optional Sections - If you agree to release this information to your child’s school, please initial here. II. Oral Health Status (check all that apply).

Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].

Yes No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].

Yes No Dental Sealants Present Other problems (Specify):_______________________________________________________________________________

II. Treatment Needs (check all that apply) No obvious problem. Routine dental care is recommended. Visit your dentist regularly.

May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.

Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

Note:

Name: DOB: Gender: M F

School: Grade: Exam Date:

Asthma: Intermittent Persistent

Diabetes: Type I Type 2 Hyperlipidemia Hypertension

Seizures Type:

Allergies: Non Life-Threatening Life-Threatening

Allergen(s):

Positive Negative Not Done Date

Height: Weight: BP: Pulse:Right Left Referral

Degree of deviation: Yes No

Distance acuity with lenses Yes No

Yes No

85th - 94th Pass Fail Yes No

95th - 98th Right Left Referral

Yes No

Check developmental stage (ONLY for Athletic Placement Process for 7th & 8th graders): Tanner: I II III IV V

No Grade

HEALTH HISTORY

Appendix A Sample Recommended Form Updated June 2015 - Page 1 of 2STUDENT HEALTH EXAMINATION FORM (To be completed by private health care provider or school medical director)

NYSED requires a physical exam for new entrants and students in Grades pre-K or K, 2, 4, 7 & 10, interscholastic sports and working papers.

IMMUNIZATIONS Immunization record attached Immunizations received today:

Hx of Anaphylaxis: Last occurrence:

Last Occurrence:

Asthma Action Plan Attached

Emergency Care Plan Attached

Diabetes Medical Mgmt Plan Attached

Type: Food Insect Latex Medication Seasonal/Environmental Other:

Emergency Care Plan Attached

Immunizations reported on NYSIIS

No immunizations received today Will return on: to receive:

Angle of trunk rotation via scoliometer:

Distance acuity

PHYSICAL EXAMINATION

Respirations:

Scoliosis: Negative Positive Vision

Treatment prescribed: None Antihistimine Epinephrine Autoinjector

Diagnostic Tests

Sickle Cell Screen

PPD

Elevated Lead:

Significant Medical/Surgical Information:

Vision one eye only One functioning kidney One testicle Concussion - Last occurrence:

Vision - color perception

20 db sweep screen both ears or

Hearing

Vision - near vision Weight Status Category (BMI Percentile):

99th & higher

Name: DOB: Page 2 of 2

ICD Code Route Time

Date:

Phone #: ( )

Fax #: ( )

School: Phone #: ( ) Fax: ( ) Date:

Please list names of prescribed or OTC medications used on a routine basis at home

Full Activity without restrictions including Physical Education and Athletics.

MEDICATION HISTORY (optional)

Other Specific Restrictions:

Brace/Orthotic Athletic Cup

Hearing Aides

Insulin Pump/Insulin SensorMedical /Prosthetic Device

PacemakerSports Safety Goggles

PROVIDER REQUEST FOR MEDICATION REQUIRED DURING SCHOOL/SCHOOL SPONSORED EVENTS - VALID 1 YEAR

Restrictions/Adaptations. Please base restrictions/modifications on the following Interscholastic Sports Categories.

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

School Nurse:

Provider Address:

No Contact Sports includes: basketball, baseball, field hockey, ice hockey, lacrosse, soccer, football, softball, volleyball, competitive cheerleading and wrestlingNo Non-Contact Sports includes: archery, bowling, cross-country, golf, gymnastics, rifle, swimming and diving, skiing, tennis, track & field, fencing, badminton

Accommodations / Protective Equipment: Other:

HEALTH CARE PROVIDER

REQUIRED PARENT/GUARDIAN PERMISSION FOR MEDICATION USE AT SCHOOL

All information contained herein is valid through the last day of the month for 12 months from the date below.

Return to:

Medical Provider Signature:

Provider Name: (please print)

Independent Carry and Use Option: NYS law requires both provider attestation that the student has demonstrated they can effectively self-administer inhaled respiratory rescue medication, epinephrine autoinjector, insulin, glucagon and diabetes supplies, or other medications requiring rapid administration along with parent/guardian permission to allow this option in schools. Required Independent Carry and Use Attestation documentation is attached.

Parent/Guardian Permission: I request the school nurse give the medications listed on this plan; or after the nurse determines my child can take their own medications, trained staff may assist my child to take their own medications. I will provide the medication in the original pharmacy or over the counter container. This plan will be shared with staff caring for my child

Parent/Guardian Signature:

Diagnosis DoseMedication Name

Student Health Examination -2.pdfSheet1