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Student Registration Packet WATERLOO CENTRAL SCHOOL DISTRICT
Waterloo Central School District REGISTRATION PACKET
____________________________________
Welcome to WCS! It is our goal to make this transition as quick and positive
as possible. Please complete the attached enrollment packet and take a
moment to gather the following items:
• Proof of child’s age (birth certificate, passport, medical card, certificate of baptism, or other acceptable proof of age)
• Proof of residency (lease/deed, rental contact, utility bill, letter from landlord, letter from person you are living with, other)
• Proof of custody or guardianship (if applicable)
• Immunization records (Most Recent)
All applications are considered incomplete until all documentation listed has been provided.
If you have any questions or need assistance, please do not hesitate to contact us. ~~~~~~~~
Central Registrar: Heather Elisofon Direct Line 315-539-1502 / Fax: 315-539-1504
[email protected] 109 Washington Street, Waterloo, NY 13165
Last updated 11/22/19
Rev. 9/8/17 SCHOOL USE ONLY: Student qualifies for M.V.______________ Student does not qualify__________
NOTE TO SCHOOLS/LEAS: Please assist students and families fill out this form. Do not simply include this form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required to submit proof of residency and other required documents that may be part of the registration
packet.
Name of School bldg:
Female Month Day Year (preschool-12) (optional)
Address: Phone:
The answer you give below will help the district determine what services you or your child may be able to
receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are
entitled to immediate enrollment in school even if they don’t have the documents normally needed, such
as proof of residency, school records, immunization records, or birth certificate. Students who are
protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please check one box.)
In a shelter
With another family or other person because of loss of housing or as a result of economic hardship
(sometimes referred to as “doubled-up”)
In a hotel/motel
Other temporary living situation (Please describe):
In permanent housing
Print name of Parent, Guardian, or Signature of Parent, Guardian, or
Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth)
Date
If the student is NOT living in permanent housing, proof of residency and other documents normally needed
for enrollment are not required and the student is to be immediately enrolled. The district’s LEA liaison is
required to assist the student in obtaining any necessary documents, including immunization or school records
after the student has been enrolled.
NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a
Designation Form is completed.
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
_____________________ ________________ ________________ _________________________ ______________ Student Number Grade Counselor Teacher Advisement
_____________________ ________________ ____________ _________________ __________ __________ Bus Number a.m. Bus Number p.m. Locker Number Locker Combination Year of Grad. Cohort
_____________________ Date of Entrance
Date of Birth: Place of Birth: City State Country
Parent/Guardian Name _______________________ Child lives with this Parent/Guardian? Y____ N____
Address:_____________________________________ Phone (Primary) ________________________
Address:_____________________________________ Phone (Primary) ________________________
Are there custody or guardianship papers? Yes No If yes, current papers must be attached.
Comments on custody/guardianship: _______________________________________________________
Has the student ever been enrolled in this Waterloo Central School district? Yes No
If yes, please list grade and year of last attendance: ______________________________________
Name of School Student is Leaving: Grade:
Location of previous school:
If yes, please explain: ______________________________________
WATERLOO CENTRAL SCHOOL DISTRICT NEW STUDENT REGISTRATION FORM
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
Special Education
Has your Child ever been referred for a special education evaluation in the past? Yes No If yes, please explain? ____________________________________________________
Does the student have an IEP? Yes No
Does the student have a 504? Yes No
Does the student receive special services in school NOT associated with an IEP or 504? Yes No If yes, please list? ____________________________________________________ ____
Has the student ever been retained? Yes No If yes, what grade(s)?
OTHER
Is the student a Foreign Exchange student? Yes No If yes, from what country?
Is the student currently placed in Foster Care? Yes No If yes, through what County?
Is the student’s parent/guardian on active military duty? Yes No If yes, describe?
Has anyone in your family worked or looked for work at an agricultural job or farm work within the past 3 years? Yes No If yes, describe?
In what language would you like to receive information from the school? (Check all that apply) English Spanish Chinese Other________________________
Would you like an interpreter available to you for better communication with the school? Yes No If yes, please list language/comment?
Permission
I grant permission for this student’s photo and name to be used for school-related publicity in such media as newspapers, newsletters, websites, television and videos. _______________________
Parent/Guardian Signature
Please List Any Siblings:
___________________________ __________ ___________________________ __________ Name DOB Name DOB
___________________________ __________ ___________________________ __________ Name DOB Name DOB
___________________________ __________ ___________________________ __________ Name DOB Name DOB
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
Receives Mailings ok to call if student is NOT in school ----------------------------------------------------------------------------------------------------------------------------------
ADULT INFORMATION (CONTACT PRIORITY #2)
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
Receives Mailings ok to call if student is NOT in school
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
___________________________________________________________________________________
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
Receives Mailings ok to call if student is NOT in school
WATERLOO UNIVERSAL PRE K REGISTRATION (Only) STUDENTS NAME_____________________________ Please indicate your preference: _________ _________ __________ AM PM Either
Dear UPK Parents: There are openings for 4-year-old PreK students that live in the Waterloo Central School District for the 2021-2022 school year. If you are interested in your child attending, please complete this registration packet and return to the district office at 109 Washington Street.
NOTEWORTHY/REQUIREMENTS:
• This is a half-day program with no cost to families.
• Child must live in the Waterloo Central School District.
• Child must be 4 years old on or before December 1, 2021.
• New York State requirements must be met for immunizations, dental screenings and physicals before the student can start.
• There is NO transportation to and from this program. (DO NOT complete the transportation sheet in in the packet)
I have read and understand the obligations of UPK and my child meets the above requirements.
Signature
20/21 School Year ____
21/22 School Year ____
Waterloo Central School District Transportation Department
D'Allah Laffoon, Director Tracy Nobles, Secretary 1719 North Rd., Waterloo, New York 13165
Phone (315) 539-1515 Fax (315)539-1578
Telephone: (315)-539-1515 • Fax: (315)-539-1578
Which hand does your child use? Right____ Left____
Are there any children your child should be seperated from?
Do you feel your child has any special learning needs? Please Explain
Is there any additional information that you would like to share?
Take turns and share? Finish one activity before starring another?
Please help us make appropriate educational choices for your child. Please consider the following questions carefully and place and "X" in the appropriate box
Cooperate with adults?
Undecided____
Sit quietly for an entire story? Frighten easily? Use pencil,crayons, scissors, and glue correctly? Use toilet independently? Dress unassisted? Can write name?
Talk back to adults? Have temper tantrums? Show aggressive behavior? Demand a lot of attention?
Waterloo Central School District
Student Racial and Ethnic Identification
All students between 5 and 21 years of age have the right to a free public education. Children may not be refused
admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.
Name of School: WATERLOO CENTRAL SCHOOL DISTRICT
School District Student Identification Number: Date of Birth (Month/Day/Year):
/ /
DIRECTIONS TO PARENT/GUARDIAN
Please answer questions (1) and (2). Please read them before you respond. [For question (2) check (√) the box that best
describes your child.] Check (√) only ONE box.
1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican,
Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
YES, Hispanic NO, not Hispanic
2. Select one or more races from the following five racial groups [For question (2) check (√) all groups that apply to your child;
check (√) at least ONE box.]:
AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North America
and who maintains cultural identification through tribal affiliation or community recognition, e.g. Cherokee, Mohawk, Inuit.
ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the ORIGINAL PEOPLES
OF Hawaii, Guam, Samoa, or other Pacific Islands.
BLACK: A person having origins in any of the black racial groups of Africa.
WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Relationship to Student (please check one box below):
Mother Father Guardian Other (Specify): ___________________________
_________________________________________________________ ____________________
Signature of Parent/Guardian/Other Date
To School Staff: This form will be filed in the student’s permanent record as confidential information
To the Parent/Guardian: The information which you have provided on this form is confidential. It is protected by the
Confidentiality Regulations cited below.
The Family Educational Rights and Privacy Act (1974) prohibit unauthorized access to student records and unauthorized release of
any student record information identifiable by either student name or student identification number.
CONFIDENTIAL PROCEDURES AND REGULATIONS
1 ENGLISH
Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.
STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12
Lissette Colón-Collins, Assistant Commissioner
55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB
Brooklyn, New York 11217 Albany, New York 12234
Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948
Home Language Questionnaire (HLQ)
H O M E L A N G U A G E C O D E
Language Background (Please check all that apply.)
1. What language(s) is(are) spoken in the student’s home or residence?
English Other
specify
2. What was the first language your child learned? English Other
_________________________________________ specify
3. What is the Home Language of each parent/guardian? Mother Father specify specify
Guardian(s) specify
specify
5. What language(s) does your child speak? English Other Does not speak
specify
6. What language(s) does your child read? English Other Does not read
specify
7. What language(s) does your child write? English Other Does not write
specify
TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::
Please write clearly when completing this section. S T U D E N T N A M E :
First Middle Last
D A T E O F B I R T H : G E N D E R :
Male Female Month Day Year
P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :
Last Name First Name Relation to Student
S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T
I N F O R M A T I O N S Y S T E M :
District Name (Number) & School Address
2 ENGLISH
Educational History
8. Indicate the total number of years that your child has been enrolled in school _____________
9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write in English or any other language? If yes, please describe them.
Yes* No Not sure *If yes, please explain:____________________________________________________________________________
How severe do you think these difficulties are? Minor Somewhat severe Very severe
10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below
10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .
Age at which services received (Please check all that apply):
Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)
10c. Does your child have an Individualized Education Program (IEP)? No Yes
11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)
12. In what language(s) would you like to receive information from the school? _________________________________________________
Month: Day: Year:
Signature of Parent or of Person in Parental Relation Date
OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ
NAME: POSITION:
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:
NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW
NAME: POSITION:
**DATE OF INDIVIDUAL INTERVIEW:
NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL
NAME: POSITION:
MO. DAY YR.
FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:
WATERLOO CENTRAL SCHOOL DISTRICT DISTRICT OFFICES
109 WASHINGTON STREET WATERLOO, NEW YORK 13165 STUDENT RECORDS REQUEST
School Name: (Prior school) ______________________________________________ School Address: ______________________________________________ School City, State, Zip: ______________________________________________ School Telephone: ______________________School Fax: ______________________ School Email: ____________________________________________________________
PERMISSION IS HEREBY GIVEN TO WATERLOO CENTRAL SCHOOL DISTRICT TO RECEIVE INFORMATION REGARDING:
Student Name: __________________________________________
PLEASE SEND A COPY OF THE FOLLOWING:
x Birth Certificate x Achievement Test Scores x Report Card x Transcript & Attendance Report x Immunization and Health Records x Discipline Records
PLEASE SEND TO:
______ ______ ______ ______ Shaun Merrill, Principal Vincent Vitale. Principal Terri Goodman, Guidance Sec. Lafayette Intermediate School Waterloo Middle School Waterloo Senior High School 71 Inslee Street 65 Center Street 96 Stark Street Waterloo, NY 13165 Waterloo, NY 13165 Waterloo, NY 13165 Phone: 315-539-1530 Phone: 315-539-1540 Phone: 315-539-1552 Fax: 315-539-1529 Fax: 315-539-1534 Fax: 315-539-1536 Email: Email: Email:
Sherri Monell, Principal Skoi Yase Primary School 65 Fayette Street Waterloo, NY 13165 Phone: 315-539-1520 Fax: 315-539-1527 Email: [email protected] [email protected] [email protected] [email protected]
___________________________________ ________________ Signature of Parent/Guardian Date
109 WASHINGTON STREET WATERLOO, NEW YORK 13165 STUDENT RECORDS REQUEST FOR STUDENTS WITH SERVICES
School Name: (Prior school) ______________________________________________ School Address: ______________________________________________ School City, State, Zip: ______________________________________________ School Telephone: ______________________School Fax: ______________________ School Email: ____________________________________________________________
PERMISSION IS HEREBY GIVEN TO WATERLOO CENTRAL SCHOOL DISTRICT TO RECEIVE INFORMATION REGARDING:
Student Name: __________________________________________
DOB: ___________________ Grade Last Attended: _____________
PLEASE SEND A COPY OF THE FOLLOWING: IEP, 504 Plan or Declassification Notes Psychological/Psychiatric Evaluations OT, PT, Speech, Vision, Hearing, etc. Evaluations IEP Goals Progress Reports OT, PT, Speech Scripts Parental Consent for Special Education Services Transcripts
PLEASE SEND TO: WATERLOO CSE OFFICE 109 WASHINGTON STREET WATERLOO, NY 13165 Phone: 315-539-1503 Fax: 315-539-1537 [email protected]
___________________________________ ________________ Signature of Parent/Guardian Date
Waterloo Central School District
Committee on Special Education
Medicaid Consent
Dear Parent/Guardian:
This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related
services that are on your child's Individualized Education Plan (IEP).
This consent allows the School District to bill for covered health-related services and to release information to the school district’s
Medicaid Billing Agent for that purpose.
I, ________________________________as the parent/guardian of , have received a
written notification from the School District that explains my federal rights regarding the use of public benefits or insurance to pay
for certain special education and related services.
I understand and agree that the School District may access Medicaid to pay for special education and related services provided to my
child.
• Providing consent will not impact my child’s/my Medicaid coverage;
• Upon request, I may review copies of records disclosed pursuant to this authorization;
• Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid;
• I have the right to withdraw consent at any time; and
• The school district must give me annual written notification of my rights regarding this consent.
I also give my consent for the school district to release the following records/information about my child to the State’s Medicaid
Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be
shared.
Records to be shared (such as records or information about services your child receives)
IEP Medication Administration Report
Evaluation Reports Other Personally Identifiable Information
Session Notes Any Other Specific Records Pertaining to the Student’s Services
or Program
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to
receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to
provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.
Parent/Guardian Signature: __________________________________________
Print Name: __________________________________________ Date: ____________________
*Please provide your child’s Medicaid CIN# from their personal Medicaid card: ____________________
(The CIN# is the Alphanumeric ID Number located above the sex and DOB on your child’s Medicaid card.
It starts with 2 letters, followed by 5 numbers, and ends with 1 letter.)
Waterloo Central School District DISTRICT OFFICES 109 Washington Street Waterloo, NY 13165
STUDENT HEALTH INFORMATION
Student Name__________________________________ School____________ *New registrants are required by law to provide the school with a Health Examination form completed by the child’s physician and a Dental Health form completed by the child’s dentist within the past 12 months. PLEASE CHECK ONE: ____ I will provide the school’s Health office with the completed health and dental forms within the next 30 days. (Please note: IF THE REQUIRED FORMS ARE NOT RECEIVED BY THE SCHOOL DISTRICT IN THE 30 DAYS, THE SCHOOL PHYSICIAN WILL COMPLETE THE EXAM WITHOUT FURTHER NOTIFICATION TO THE PARENT/GUARDIAN.) ____ The school physician may conduct my child’s physical examination. If you are unable to provide us with this current health information then our school physician (Life Care Medical Associates) with perform a physical examination for your child in the school’s health office, during school hours, at no cost to you. You would be informed of any health concerns related to this physical examination via a medical screening referral form. Signature of Parent/Guardian______________________ Date___________ I give permission for the school nurse to share any pertinent medical information with other school personnel on a need to know basis. Signature of Parent/Guardian______________________ Date___________
Student’s Doctor: _________________________ Phone: ____________ Student’s Dentist: _________________________ Phone: ____________
Last updated 11/19/17
Please have your health care provider send health forms to your child’s school: Waterloo High School 96 Stark St. Waterloo, NY 13165 phone 315-539-1555 fax 315-539-1536 Waterloo Middle School 65 Center St. Waterloo NY 13165 phone 315-539-1545 fax 315-539-1534 Lafayette Intermediate School 71 Inslee St. Waterloo, NY 13165 phone 315-539-1535 fax 315-539-1529 Skoi Yase Primary School 65 Fayette St. Waterloo, NY 13165 phone 315-539-1525 fax 315-539-1527
STUDENT HEALTH INFORMATION (Page 2)- Student DOB___________
Child’s Medical History
Illness Date Illness Date TB/Contact with TB _____ Lead Poisoning _____ Head Injury/concussion _____ Asthma _____ Anxiety _____ ADD/ADHD _____ Depression _____ Bipolar _____ Sickle Cell Anemia _____ ODD/OCD _____ Whooping cough _____ Autism/Asperger _____ Meningitis _____ Heart Disease/Murmur _____ Chicken Pox _____ Diabetes _____ Pneumonia _____ Kidney Disease _____ Recurrent Sore Throats Seizure Disorder _____ and/or Ear infections _____ Bleeding Disorder _____ Other illness or disease _____ Missing Organs _____
Explanation of any of the above listed illnesses: ____________________________________________________________ ____________________________________________________________
Does your child have any allergies? YES NO If yes, please list_________________
Is your child taking any medications? YES NO If yes, please list_______________
Does your child have EMERGENCY medication they may need at school? YES NO If yes, please list________________________________
Have you ever suspected that your child may have poor eyesight? YES NO If so, has he/she ever been seen by an optometrist or eye specialist? YES NO If so, what were the results? ________________________________________
Have you ever suspected that your child may have a hearing problem? YES NO If so, has he/she been evaluated by a doctor: YES NO If so, what were the results? ________________________________________
Have you suspected that your child may have a speech or language problem? YES NO If so, has he/she had a speech or language evaluation: YES NO If so, what were the results? _________________________________________
Has your child had any other screenings or evaluations? YES NO (psychological, educational, allergy testing, physical therapy, occupational therapy, etc.) If so, what were the results? _________________________________________
Has your child been hospitalized? YES NO If so, please explain? _____________________________________________
Has your child ever seen a dentist? YES NO If so, for what reasons? __________
Is there any condition that limits classroom or physical education activities: YES NO If so, please explain? _____________________________________________
STUDENT HEALTH INFORMATION (Page 3)- Student Name___________ Other Medical issues that you would like to bring to the school’s attention: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ _____________ ______________________________________ Date Signature of Parent / Guardian
Last updated 11/22/19
2020-2021 Application for Free and Reduced Price School Meals
To apply for free and reduced-price meals for your children, read the instructions on the back, complete only one form for your household, sign your name and return it to the address listed below. Call 315-539-1464, if you need help. Additional names may be listed on a separate paper.
Return Completed Applications to: WATERLOO CENTRAL SCHOOL DISTRICT 96 STARK STREET WATERLOO, NY 13165 ATTN: BRIAN COREY
1. List all children in your household who attend school:
Student Name School Grade/Teacher
2. SNAP/TANF/FDPIR Benefits: If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 4 and sign the application. Name: ______________________________________ CASE #: __________________________________Must list a Valid Case # for application to be approved
3. Report all income for ALL Household Members (Skip this step if you answered ‘yes’ to step 2) All Household Members (including yourself and all children that have income). List all Household members not listed in Step 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any other source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
Name of household member Earnings from work before deductions Amount / How Often
Child Support, Alimony Amount / How Often
Pensions, Retirement Payments Amount / How Often
Other Income, Social Security Amount / How Often
No Income
*Last Four Digits of Social Security Number: XXX-XX- __ __ __ __
*When completing section 3, an adult household member must provide the last four digits of their Social Security Number (SS#) or mark the “I do not have a SS# box” before the application can be approved.
4. Signature: An adult household member must sign this application before it can be approved. I certify (promise) that all the information on this application is true and that all income is reported. I understand that the information is being given so the school will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and federal laws, and my children may lose meal benefits. Signature: ___________________________________________________ Date: ___________________ Email Address: ________________________________________________ Home Phone: _____________________ Work Phone: _________________________ Home Address:____________________________________________
5. Ethnicity and Race are optional; responding to this section does not affect your children’s eligibility for free or reduced-price meals.
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race:(Check one or more) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Island White
DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLY
Annual Income Conversion (Only convert when multiple income frequencies are reported on application)
Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X 24; Monthly X 12
SNAP/TANF/Foster
Free Meals Reduced Price Meals Denied/Paid Signature of Reviewing Official________________________________________________________ Date Notice Sent:________________
I do not have a
SS#
2
APPLICATION INSTRUCTIONS
To apply for free and reduced price meals, complete only one application for your household using the instructions below. Sign the application and return the application to, WATRLOO CSD, 96 STARK ST., WATERLOO NY 13165. ATTN: FOOD SERVICE DEPT. If you have a foster child in your household, you may include them on your application. A separate application is not needed. Call the school if you need help: 315-539-1464. Ensure that all information is provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application.
PART 1: ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE APPLICATION FOR YOUR HOUSEHOLD. (1) Print the names of the children, including foster children, for whom you are applying on one application. (2) List their grade and school. (3) Check the box to indicate a foster child living in your household, or if you believe any child meets the description for homeless, migrant, runaway (a school staff will confirm this eligibility). PART 2 HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 4. (1) List a current SNAP, TANF or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in your household. The case number is provided on your benefit letter. Contact your local Dept of Social Services to obtain your valid case number. (2) An adult household member must sign the application in PART 4. SKIP PART 3. Do not list names of household members or income if you list a SNAP case number, TANF or FDPIR number. PART 3 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 4. (1) Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are applying for, all other children,
your spouse, grandparents, and other related and unrelated people in your household. Use another piece of paper if you need more space. (2) Write the amount of current income each household member receives, before taxes or anything else is taken out, and indicate where it came from, such
as earnings, welfare, pensions and other income. If the current income was more or less than usual, write that person’s usual income. Specify how often this income amount is received: weekly, every other week (bi-weekly), 2 x per month, monthly. If no income, check the box. The value of any child care provided or arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income for this program.
(3) Enter the total number of household members in the box provided. This number should include all adults and children in the household and should reflect the members listed in PART 1 and PART 3.
(4) The application must include the last four digits only of the social security number of the adult who signs PART 4 if Part 3 is completed. If the adult does not have a social security number, check the box. If you listed a SNAP, TANF or FDPIR number, a social security number is not needed.
(5) An adult household member must sign the application in PART 4. OTHER BENEFITS: Your child may be eligible for benefits such as Medicaid or Children’s Health Insurance Program (CHIP). To determine if your child is eligible, program officials need information from your free and reduced price meal application. Your written consent is required before any information may be released. Please refer to the attached parent Disclosure Letter and Consent Statement for information about other benefits.
USE OF INFORMATION STATEMENT Use of Information Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not submit all needed information, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the primary wage earner or other adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We may share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.
DISCRIMINATION COMPLAINTS
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632- 9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or (3) email: [email protected]. This institution is an equal opportunity provider.
Residency Questionnaire waterloo
New Student Registration Request For Transportation-2019
pre k-k student input form
Sheet1
CSE Records Request Form 11-1-19
CSE info 6-18
medicaid consent waterloo
STUDENT HEALTH INFORMATION
STUDENT HEALTH INFORMATION
2018-2019 free-reduce application
Child’s Medical History
UPK Page for registation.pdf
Grade Level:
Text141:
Text142:
Text143:
Text144:
S T U D E N T N A M E Row1:
First Middle Last:
G ENDER:
D A T E O F B I R T H Row1:
undefined_40: Off
Male Female:
P A R E N T P E R S O N I N P A R E N T A L R E L A T I O N I N F O Row1:
English: Off
Other_3: Off
Other_4: Off
English_2: Off
specify_4:
S C H O O L D I S T R I C T I N F O R M A T I O N Row1:
S T U D E N T ID N U M B E R I N NYS S T U D E N T I N F O R M A T I O N S Y S T E M Row1:
8 Indicate the total number of years that your child has been enrolled in school:
If yes please explain:
Age at which services received Please check all that apply:
No_7: Off
Birth to 3 years Early Intervention: Off
3 to 5 years Special Education: Off
6 years or older Special Education: Off
10c Does your child have an Individualized Education Program IEP: Off
11 Is there anything else you think is important for the school to know about your child eg special talents health concerns etcRow1:
11 Is there anything else you think is important for the school to know about your child eg special talents health concerns etcRow2:
12 In what languages would you like to receive information from the school:
Mother_2: Off
Father_2: Off
Other_9: Off
OUTCOME OF INDIVIDUAL INTERVIEW ADMINISTER NYSITELL ENGLISH PROFICIENT REFER TO LANGUAGE PROFICIENCY TEAM:
NAME_3:
ADMINISTRATION:
Session NotesRow1:
Any Other Specific Records Pertaining to the Students Services or ProgramRow1:
ParentGuardian Signature 2:
Date_10:
Waterloo Central School District REGISTRATION PACKET
____________________________________
Welcome to WCS! It is our goal to make this transition as quick and positive
as possible. Please complete the attached enrollment packet and take a
moment to gather the following items:
• Proof of child’s age (birth certificate, passport, medical card, certificate of baptism, or other acceptable proof of age)
• Proof of residency (lease/deed, rental contact, utility bill, letter from landlord, letter from person you are living with, other)
• Proof of custody or guardianship (if applicable)
• Immunization records (Most Recent)
All applications are considered incomplete until all documentation listed has been provided.
If you have any questions or need assistance, please do not hesitate to contact us. ~~~~~~~~
Central Registrar: Heather Elisofon Direct Line 315-539-1502 / Fax: 315-539-1504
[email protected] 109 Washington Street, Waterloo, NY 13165
Last updated 11/22/19
Rev. 9/8/17 SCHOOL USE ONLY: Student qualifies for M.V.______________ Student does not qualify__________
NOTE TO SCHOOLS/LEAS: Please assist students and families fill out this form. Do not simply include this form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required to submit proof of residency and other required documents that may be part of the registration
packet.
Name of School bldg:
Female Month Day Year (preschool-12) (optional)
Address: Phone:
The answer you give below will help the district determine what services you or your child may be able to
receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are
entitled to immediate enrollment in school even if they don’t have the documents normally needed, such
as proof of residency, school records, immunization records, or birth certificate. Students who are
protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please check one box.)
In a shelter
With another family or other person because of loss of housing or as a result of economic hardship
(sometimes referred to as “doubled-up”)
In a hotel/motel
Other temporary living situation (Please describe):
In permanent housing
Print name of Parent, Guardian, or Signature of Parent, Guardian, or
Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth)
Date
If the student is NOT living in permanent housing, proof of residency and other documents normally needed
for enrollment are not required and the student is to be immediately enrolled. The district’s LEA liaison is
required to assist the student in obtaining any necessary documents, including immunization or school records
after the student has been enrolled.
NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a
Designation Form is completed.
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
_____________________ ________________ ________________ _________________________ ______________ Student Number Grade Counselor Teacher Advisement
_____________________ ________________ ____________ _________________ __________ __________ Bus Number a.m. Bus Number p.m. Locker Number Locker Combination Year of Grad. Cohort
_____________________ Date of Entrance
Date of Birth: Place of Birth: City State Country
Parent/Guardian Name _______________________ Child lives with this Parent/Guardian? Y____ N____
Address:_____________________________________ Phone (Primary) ________________________
Address:_____________________________________ Phone (Primary) ________________________
Are there custody or guardianship papers? Yes No If yes, current papers must be attached.
Comments on custody/guardianship: _______________________________________________________
Has the student ever been enrolled in this Waterloo Central School district? Yes No
If yes, please list grade and year of last attendance: ______________________________________
Name of School Student is Leaving: Grade:
Location of previous school:
If yes, please explain: ______________________________________
WATERLOO CENTRAL SCHOOL DISTRICT NEW STUDENT REGISTRATION FORM
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
Special Education
Has your Child ever been referred for a special education evaluation in the past? Yes No If yes, please explain? ____________________________________________________
Does the student have an IEP? Yes No
Does the student have a 504? Yes No
Does the student receive special services in school NOT associated with an IEP or 504? Yes No If yes, please list? ____________________________________________________ ____
Has the student ever been retained? Yes No If yes, what grade(s)?
OTHER
Is the student a Foreign Exchange student? Yes No If yes, from what country?
Is the student currently placed in Foster Care? Yes No If yes, through what County?
Is the student’s parent/guardian on active military duty? Yes No If yes, describe?
Has anyone in your family worked or looked for work at an agricultural job or farm work within the past 3 years? Yes No If yes, describe?
In what language would you like to receive information from the school? (Check all that apply) English Spanish Chinese Other________________________
Would you like an interpreter available to you for better communication with the school? Yes No If yes, please list language/comment?
Permission
I grant permission for this student’s photo and name to be used for school-related publicity in such media as newspapers, newsletters, websites, television and videos. _______________________
Parent/Guardian Signature
Please List Any Siblings:
___________________________ __________ ___________________________ __________ Name DOB Name DOB
___________________________ __________ ___________________________ __________ Name DOB Name DOB
___________________________ __________ ___________________________ __________ Name DOB Name DOB
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
Receives Mailings ok to call if student is NOT in school ----------------------------------------------------------------------------------------------------------------------------------
ADULT INFORMATION (CONTACT PRIORITY #2)
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
Receives Mailings ok to call if student is NOT in school
I hereby certify that the above statements are true and accurate.
Signature: ______________________________________ Date: _______________________
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
___________________________________________________________________________________
________________ ______________________ ______ _________________________ First Last Gender Relationship to Student
Physical Residence: __________________________________________________________________
Employer: ____________________________________________________________________
Email: _______________________________________________________________________
Check all that apply: OK to pick up student Lives with student Legal Custody
Receives Mailings ok to call if student is NOT in school
WATERLOO UNIVERSAL PRE K REGISTRATION (Only) STUDENTS NAME_____________________________ Please indicate your preference: _________ _________ __________ AM PM Either
Dear UPK Parents: There are openings for 4-year-old PreK students that live in the Waterloo Central School District for the 2021-2022 school year. If you are interested in your child attending, please complete this registration packet and return to the district office at 109 Washington Street.
NOTEWORTHY/REQUIREMENTS:
• This is a half-day program with no cost to families.
• Child must live in the Waterloo Central School District.
• Child must be 4 years old on or before December 1, 2021.
• New York State requirements must be met for immunizations, dental screenings and physicals before the student can start.
• There is NO transportation to and from this program. (DO NOT complete the transportation sheet in in the packet)
I have read and understand the obligations of UPK and my child meets the above requirements.
Signature
20/21 School Year ____
21/22 School Year ____
Waterloo Central School District Transportation Department
D'Allah Laffoon, Director Tracy Nobles, Secretary 1719 North Rd., Waterloo, New York 13165
Phone (315) 539-1515 Fax (315)539-1578
Telephone: (315)-539-1515 • Fax: (315)-539-1578
Which hand does your child use? Right____ Left____
Are there any children your child should be seperated from?
Do you feel your child has any special learning needs? Please Explain
Is there any additional information that you would like to share?
Take turns and share? Finish one activity before starring another?
Please help us make appropriate educational choices for your child. Please consider the following questions carefully and place and "X" in the appropriate box
Cooperate with adults?
Undecided____
Sit quietly for an entire story? Frighten easily? Use pencil,crayons, scissors, and glue correctly? Use toilet independently? Dress unassisted? Can write name?
Talk back to adults? Have temper tantrums? Show aggressive behavior? Demand a lot of attention?
Waterloo Central School District
Student Racial and Ethnic Identification
All students between 5 and 21 years of age have the right to a free public education. Children may not be refused
admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.
Name of School: WATERLOO CENTRAL SCHOOL DISTRICT
School District Student Identification Number: Date of Birth (Month/Day/Year):
/ /
DIRECTIONS TO PARENT/GUARDIAN
Please answer questions (1) and (2). Please read them before you respond. [For question (2) check (√) the box that best
describes your child.] Check (√) only ONE box.
1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican,
Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
YES, Hispanic NO, not Hispanic
2. Select one or more races from the following five racial groups [For question (2) check (√) all groups that apply to your child;
check (√) at least ONE box.]:
AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North America
and who maintains cultural identification through tribal affiliation or community recognition, e.g. Cherokee, Mohawk, Inuit.
ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the ORIGINAL PEOPLES
OF Hawaii, Guam, Samoa, or other Pacific Islands.
BLACK: A person having origins in any of the black racial groups of Africa.
WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Relationship to Student (please check one box below):
Mother Father Guardian Other (Specify): ___________________________
_________________________________________________________ ____________________
Signature of Parent/Guardian/Other Date
To School Staff: This form will be filed in the student’s permanent record as confidential information
To the Parent/Guardian: The information which you have provided on this form is confidential. It is protected by the
Confidentiality Regulations cited below.
The Family Educational Rights and Privacy Act (1974) prohibit unauthorized access to student records and unauthorized release of
any student record information identifiable by either student name or student identification number.
CONFIDENTIAL PROCEDURES AND REGULATIONS
1 ENGLISH
Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.
STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12
Lissette Colón-Collins, Assistant Commissioner
55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB
Brooklyn, New York 11217 Albany, New York 12234
Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948
Home Language Questionnaire (HLQ)
H O M E L A N G U A G E C O D E
Language Background (Please check all that apply.)
1. What language(s) is(are) spoken in the student’s home or residence?
English Other
specify
2. What was the first language your child learned? English Other
_________________________________________ specify
3. What is the Home Language of each parent/guardian? Mother Father specify specify
Guardian(s) specify
specify
5. What language(s) does your child speak? English Other Does not speak
specify
6. What language(s) does your child read? English Other Does not read
specify
7. What language(s) does your child write? English Other Does not write
specify
TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::
Please write clearly when completing this section. S T U D E N T N A M E :
First Middle Last
D A T E O F B I R T H : G E N D E R :
Male Female Month Day Year
P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :
Last Name First Name Relation to Student
S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T
I N F O R M A T I O N S Y S T E M :
District Name (Number) & School Address
2 ENGLISH
Educational History
8. Indicate the total number of years that your child has been enrolled in school _____________
9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write in English or any other language? If yes, please describe them.
Yes* No Not sure *If yes, please explain:____________________________________________________________________________
How severe do you think these difficulties are? Minor Somewhat severe Very severe
10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below
10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .
Age at which services received (Please check all that apply):
Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)
10c. Does your child have an Individualized Education Program (IEP)? No Yes
11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)
12. In what language(s) would you like to receive information from the school? _________________________________________________
Month: Day: Year:
Signature of Parent or of Person in Parental Relation Date
OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ
NAME: POSITION:
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:
NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW
NAME: POSITION:
**DATE OF INDIVIDUAL INTERVIEW:
NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL
NAME: POSITION:
MO. DAY YR.
FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:
WATERLOO CENTRAL SCHOOL DISTRICT DISTRICT OFFICES
109 WASHINGTON STREET WATERLOO, NEW YORK 13165 STUDENT RECORDS REQUEST
School Name: (Prior school) ______________________________________________ School Address: ______________________________________________ School City, State, Zip: ______________________________________________ School Telephone: ______________________School Fax: ______________________ School Email: ____________________________________________________________
PERMISSION IS HEREBY GIVEN TO WATERLOO CENTRAL SCHOOL DISTRICT TO RECEIVE INFORMATION REGARDING:
Student Name: __________________________________________
PLEASE SEND A COPY OF THE FOLLOWING:
x Birth Certificate x Achievement Test Scores x Report Card x Transcript & Attendance Report x Immunization and Health Records x Discipline Records
PLEASE SEND TO:
______ ______ ______ ______ Shaun Merrill, Principal Vincent Vitale. Principal Terri Goodman, Guidance Sec. Lafayette Intermediate School Waterloo Middle School Waterloo Senior High School 71 Inslee Street 65 Center Street 96 Stark Street Waterloo, NY 13165 Waterloo, NY 13165 Waterloo, NY 13165 Phone: 315-539-1530 Phone: 315-539-1540 Phone: 315-539-1552 Fax: 315-539-1529 Fax: 315-539-1534 Fax: 315-539-1536 Email: Email: Email:
Sherri Monell, Principal Skoi Yase Primary School 65 Fayette Street Waterloo, NY 13165 Phone: 315-539-1520 Fax: 315-539-1527 Email: [email protected] [email protected] [email protected] [email protected]
___________________________________ ________________ Signature of Parent/Guardian Date
109 WASHINGTON STREET WATERLOO, NEW YORK 13165 STUDENT RECORDS REQUEST FOR STUDENTS WITH SERVICES
School Name: (Prior school) ______________________________________________ School Address: ______________________________________________ School City, State, Zip: ______________________________________________ School Telephone: ______________________School Fax: ______________________ School Email: ____________________________________________________________
PERMISSION IS HEREBY GIVEN TO WATERLOO CENTRAL SCHOOL DISTRICT TO RECEIVE INFORMATION REGARDING:
Student Name: __________________________________________
DOB: ___________________ Grade Last Attended: _____________
PLEASE SEND A COPY OF THE FOLLOWING: IEP, 504 Plan or Declassification Notes Psychological/Psychiatric Evaluations OT, PT, Speech, Vision, Hearing, etc. Evaluations IEP Goals Progress Reports OT, PT, Speech Scripts Parental Consent for Special Education Services Transcripts
PLEASE SEND TO: WATERLOO CSE OFFICE 109 WASHINGTON STREET WATERLOO, NY 13165 Phone: 315-539-1503 Fax: 315-539-1537 [email protected]
___________________________________ ________________ Signature of Parent/Guardian Date
Waterloo Central School District
Committee on Special Education
Medicaid Consent
Dear Parent/Guardian:
This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related
services that are on your child's Individualized Education Plan (IEP).
This consent allows the School District to bill for covered health-related services and to release information to the school district’s
Medicaid Billing Agent for that purpose.
I, ________________________________as the parent/guardian of , have received a
written notification from the School District that explains my federal rights regarding the use of public benefits or insurance to pay
for certain special education and related services.
I understand and agree that the School District may access Medicaid to pay for special education and related services provided to my
child.
• Providing consent will not impact my child’s/my Medicaid coverage;
• Upon request, I may review copies of records disclosed pursuant to this authorization;
• Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid;
• I have the right to withdraw consent at any time; and
• The school district must give me annual written notification of my rights regarding this consent.
I also give my consent for the school district to release the following records/information about my child to the State’s Medicaid
Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be
shared.
Records to be shared (such as records or information about services your child receives)
IEP Medication Administration Report
Evaluation Reports Other Personally Identifiable Information
Session Notes Any Other Specific Records Pertaining to the Student’s Services
or Program
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to
receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to
provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.
Parent/Guardian Signature: __________________________________________
Print Name: __________________________________________ Date: ____________________
*Please provide your child’s Medicaid CIN# from their personal Medicaid card: ____________________
(The CIN# is the Alphanumeric ID Number located above the sex and DOB on your child’s Medicaid card.
It starts with 2 letters, followed by 5 numbers, and ends with 1 letter.)
Waterloo Central School District DISTRICT OFFICES 109 Washington Street Waterloo, NY 13165
STUDENT HEALTH INFORMATION
Student Name__________________________________ School____________ *New registrants are required by law to provide the school with a Health Examination form completed by the child’s physician and a Dental Health form completed by the child’s dentist within the past 12 months. PLEASE CHECK ONE: ____ I will provide the school’s Health office with the completed health and dental forms within the next 30 days. (Please note: IF THE REQUIRED FORMS ARE NOT RECEIVED BY THE SCHOOL DISTRICT IN THE 30 DAYS, THE SCHOOL PHYSICIAN WILL COMPLETE THE EXAM WITHOUT FURTHER NOTIFICATION TO THE PARENT/GUARDIAN.) ____ The school physician may conduct my child’s physical examination. If you are unable to provide us with this current health information then our school physician (Life Care Medical Associates) with perform a physical examination for your child in the school’s health office, during school hours, at no cost to you. You would be informed of any health concerns related to this physical examination via a medical screening referral form. Signature of Parent/Guardian______________________ Date___________ I give permission for the school nurse to share any pertinent medical information with other school personnel on a need to know basis. Signature of Parent/Guardian______________________ Date___________
Student’s Doctor: _________________________ Phone: ____________ Student’s Dentist: _________________________ Phone: ____________
Last updated 11/19/17
Please have your health care provider send health forms to your child’s school: Waterloo High School 96 Stark St. Waterloo, NY 13165 phone 315-539-1555 fax 315-539-1536 Waterloo Middle School 65 Center St. Waterloo NY 13165 phone 315-539-1545 fax 315-539-1534 Lafayette Intermediate School 71 Inslee St. Waterloo, NY 13165 phone 315-539-1535 fax 315-539-1529 Skoi Yase Primary School 65 Fayette St. Waterloo, NY 13165 phone 315-539-1525 fax 315-539-1527
STUDENT HEALTH INFORMATION (Page 2)- Student DOB___________
Child’s Medical History
Illness Date Illness Date TB/Contact with TB _____ Lead Poisoning _____ Head Injury/concussion _____ Asthma _____ Anxiety _____ ADD/ADHD _____ Depression _____ Bipolar _____ Sickle Cell Anemia _____ ODD/OCD _____ Whooping cough _____ Autism/Asperger _____ Meningitis _____ Heart Disease/Murmur _____ Chicken Pox _____ Diabetes _____ Pneumonia _____ Kidney Disease _____ Recurrent Sore Throats Seizure Disorder _____ and/or Ear infections _____ Bleeding Disorder _____ Other illness or disease _____ Missing Organs _____
Explanation of any of the above listed illnesses: ____________________________________________________________ ____________________________________________________________
Does your child have any allergies? YES NO If yes, please list_________________
Is your child taking any medications? YES NO If yes, please list_______________
Does your child have EMERGENCY medication they may need at school? YES NO If yes, please list________________________________
Have you ever suspected that your child may have poor eyesight? YES NO If so, has he/she ever been seen by an optometrist or eye specialist? YES NO If so, what were the results? ________________________________________
Have you ever suspected that your child may have a hearing problem? YES NO If so, has he/she been evaluated by a doctor: YES NO If so, what were the results? ________________________________________
Have you suspected that your child may have a speech or language problem? YES NO If so, has he/she had a speech or language evaluation: YES NO If so, what were the results? _________________________________________
Has your child had any other screenings or evaluations? YES NO (psychological, educational, allergy testing, physical therapy, occupational therapy, etc.) If so, what were the results? _________________________________________
Has your child been hospitalized? YES NO If so, please explain? _____________________________________________
Has your child ever seen a dentist? YES NO If so, for what reasons? __________
Is there any condition that limits classroom or physical education activities: YES NO If so, please explain? _____________________________________________
STUDENT HEALTH INFORMATION (Page 3)- Student Name___________ Other Medical issues that you would like to bring to the school’s attention: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ _____________ ______________________________________ Date Signature of Parent / Guardian
Last updated 11/22/19
2020-2021 Application for Free and Reduced Price School Meals
To apply for free and reduced-price meals for your children, read the instructions on the back, complete only one form for your household, sign your name and return it to the address listed below. Call 315-539-1464, if you need help. Additional names may be listed on a separate paper.
Return Completed Applications to: WATERLOO CENTRAL SCHOOL DISTRICT 96 STARK STREET WATERLOO, NY 13165 ATTN: BRIAN COREY
1. List all children in your household who attend school:
Student Name School Grade/Teacher
2. SNAP/TANF/FDPIR Benefits: If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 4 and sign the application. Name: ______________________________________ CASE #: __________________________________Must list a Valid Case # for application to be approved
3. Report all income for ALL Household Members (Skip this step if you answered ‘yes’ to step 2) All Household Members (including yourself and all children that have income). List all Household members not listed in Step 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any other source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
Name of household member Earnings from work before deductions Amount / How Often
Child Support, Alimony Amount / How Often
Pensions, Retirement Payments Amount / How Often
Other Income, Social Security Amount / How Often
No Income
*Last Four Digits of Social Security Number: XXX-XX- __ __ __ __
*When completing section 3, an adult household member must provide the last four digits of their Social Security Number (SS#) or mark the “I do not have a SS# box” before the application can be approved.
4. Signature: An adult household member must sign this application before it can be approved. I certify (promise) that all the information on this application is true and that all income is reported. I understand that the information is being given so the school will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and federal laws, and my children may lose meal benefits. Signature: ___________________________________________________ Date: ___________________ Email Address: ________________________________________________ Home Phone: _____________________ Work Phone: _________________________ Home Address:____________________________________________
5. Ethnicity and Race are optional; responding to this section does not affect your children’s eligibility for free or reduced-price meals.
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race:(Check one or more) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Island White
DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLY
Annual Income Conversion (Only convert when multiple income frequencies are reported on application)
Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X 24; Monthly X 12
SNAP/TANF/Foster
Free Meals Reduced Price Meals Denied/Paid Signature of Reviewing Official________________________________________________________ Date Notice Sent:________________
I do not have a
SS#
2
APPLICATION INSTRUCTIONS
To apply for free and reduced price meals, complete only one application for your household using the instructions below. Sign the application and return the application to, WATRLOO CSD, 96 STARK ST., WATERLOO NY 13165. ATTN: FOOD SERVICE DEPT. If you have a foster child in your household, you may include them on your application. A separate application is not needed. Call the school if you need help: 315-539-1464. Ensure that all information is provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application.
PART 1: ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE APPLICATION FOR YOUR HOUSEHOLD. (1) Print the names of the children, including foster children, for whom you are applying on one application. (2) List their grade and school. (3) Check the box to indicate a foster child living in your household, or if you believe any child meets the description for homeless, migrant, runaway (a school staff will confirm this eligibility). PART 2 HOUSEHOLDS GETTING SNAP, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 4. (1) List a current SNAP, TANF or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in your household. The case number is provided on your benefit letter. Contact your local Dept of Social Services to obtain your valid case number. (2) An adult household member must sign the application in PART 4. SKIP PART 3. Do not list names of household members or income if you list a SNAP case number, TANF or FDPIR number. PART 3 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 4. (1) Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are applying for, all other children,
your spouse, grandparents, and other related and unrelated people in your household. Use another piece of paper if you need more space. (2) Write the amount of current income each household member receives, before taxes or anything else is taken out, and indicate where it came from, such
as earnings, welfare, pensions and other income. If the current income was more or less than usual, write that person’s usual income. Specify how often this income amount is received: weekly, every other week (bi-weekly), 2 x per month, monthly. If no income, check the box. The value of any child care provided or arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income for this program.
(3) Enter the total number of household members in the box provided. This number should include all adults and children in the household and should reflect the members listed in PART 1 and PART 3.
(4) The application must include the last four digits only of the social security number of the adult who signs PART 4 if Part 3 is completed. If the adult does not have a social security number, check the box. If you listed a SNAP, TANF or FDPIR number, a social security number is not needed.
(5) An adult household member must sign the application in PART 4. OTHER BENEFITS: Your child may be eligible for benefits such as Medicaid or Children’s Health Insurance Program (CHIP). To determine if your child is eligible, program officials need information from your free and reduced price meal application. Your written consent is required before any information may be released. Please refer to the attached parent Disclosure Letter and Consent Statement for information about other benefits.
USE OF INFORMATION STATEMENT Use of Information Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not submit all needed information, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the primary wage earner or other adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We may share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.
DISCRIMINATION COMPLAINTS
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632- 9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or (3) email: [email protected]. This institution is an equal opportunity provider.
Residency Questionnaire waterloo
New Student Registration Request For Transportation-2019
pre k-k student input form
Sheet1
CSE Records Request Form 11-1-19
CSE info 6-18
medicaid consent waterloo
STUDENT HEALTH INFORMATION
STUDENT HEALTH INFORMATION
2018-2019 free-reduce application
Child’s Medical History
UPK Page for registation.pdf
Grade Level:
Text141:
Text142:
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S T U D E N T N A M E Row1:
First Middle Last:
G ENDER:
D A T E O F B I R T H Row1:
undefined_40: Off
Male Female:
P A R E N T P E R S O N I N P A R E N T A L R E L A T I O N I N F O Row1:
English: Off
Other_3: Off
Other_4: Off
English_2: Off
specify_4:
S C H O O L D I S T R I C T I N F O R M A T I O N Row1:
S T U D E N T ID N U M B E R I N NYS S T U D E N T I N F O R M A T I O N S Y S T E M Row1:
8 Indicate the total number of years that your child has been enrolled in school:
If yes please explain:
Age at which services received Please check all that apply:
No_7: Off
Birth to 3 years Early Intervention: Off
3 to 5 years Special Education: Off
6 years or older Special Education: Off
10c Does your child have an Individualized Education Program IEP: Off
11 Is there anything else you think is important for the school to know about your child eg special talents health concerns etcRow1:
11 Is there anything else you think is important for the school to know about your child eg special talents health concerns etcRow2:
12 In what languages would you like to receive information from the school:
Mother_2: Off
Father_2: Off
Other_9: Off
OUTCOME OF INDIVIDUAL INTERVIEW ADMINISTER NYSITELL ENGLISH PROFICIENT REFER TO LANGUAGE PROFICIENCY TEAM:
NAME_3:
ADMINISTRATION:
Session NotesRow1:
Any Other Specific Records Pertaining to the Students Services or ProgramRow1:
ParentGuardian Signature 2:
Date_10: