BOLTON CENTER SCHOOL
ENROLLMENT INFORMATION
2015-2016
Student Name: ______
(First) (Middle) (Last)
Home Address: ______
(Street) (City, State) (Zip Code)
Home
Phone: ______Grade and Teacher: ______
D.O.B. ______Age: ______
PARENT/GUARDIAN INFORMATION
___ OK to pick-up
Mother’s Name: ______Lives with
Home Address: ______Receives mailings
(if different from above – include Street, City, State and Zip Code)
Home Cell Other
Phone #: ______Phone #: ______Phone #: ______
Work
Place of employment: ______ Phone # ______
E-Mail Address: (Home)______(Work) ______
------
___ OK to pick-up
Father’s Name: ______Lives with
Home Address: ______Receives mailings
(if different from above – include Street, City, State and Zip Code)
Home Cell Other
Phone #: ______Phone #: ______Phone #: ______
Work
Place of employment: ______ Phone # ______
E-Mail Address: (Home) ______(Work) ______
------
Emergency Contacts: (1) ______
(Name and phone number)
(2) ______
(Name and phone number)
PLEASE COMPLETE REVERSE SIDE
EARLY DISMISSAL INFORMATION
This will be used for scheduled and unscheduled early dismissals; e.g. parent/teacher conference days, inclement weather, etc.
Student’s Destination: Same as regular day ____ Yes ____No
(If no, please complete the information below for the location your child will go to)
Name: ______Address: ______
Telephone #______
Please list people who are authorized to pick up your child during the school year. No child will be released in the custody of any individual who is not listed below. If you have given permission for an individual other than the ones listed, please call the main office. Any individual picking your child up should present identification to main office personnel upon arrival and sign the child out in the appropriate ledger.
Name ______ Relationship ______
Address ______ Phone Number ______
Name ______ Relationship ______
Address ______ Phone Number ______
Name ______Relationship ______
Address ______ Phone Number ______
Name ______ Relationship ______
Address ______ Phone Number ______
Name ______ Relationship ______
Address ______ Phone Number ______
Name ______ Relationship ______
Address ______ Phone Number ______
Student SASID # ______
BOLTON PUBLIC SCHOOLS
CUMULATIVE RECORD REGISTRATION FORM
Date of Date of Date Records Date Records
Registration: ______Entry ______Requested ______Received ______
Name and Address of
Grade Entering ______School last attended ______
Is this student presently receiving any Special Education or 504 Services? _____ Yes _____ No
______(If Yes, please attach latest IEP or 504 Plan)
(Including elementary, pre-school/nursery or Head Start)
Student Information Male ____ Female ____
Student’s Name ______Date of Birth ______
(First) (Last)
Address______(Street, City, State, Zip Code)
Home Telephone ______Birthplace ______
Student cell phone ______Student email ______
Social Security Number ______
Is the student a U.S. Citizen? ____ Y ____N Is student covered by health insurance? ______Y ______N
State and Federal law requires that the questions below pertaining to race, ethnicity, and language be answered. Your participation is
appreciated. If you do not provide these answers, the laws allow for appropriate school personnel to determine this information.
Is the student Hispanic or Latino? ____Yes ____No
Is the student one or more of the following races (choose ALL that apply)
American Indian or Black or Native Hawaiian or
Alaskan Native ____; Asian ____; African American ____; Other Pacific Islander ____; White ____
What was the first language the student learned to speak? ______
What is the primary language spoken by those who live in the student’s home? ______
What is the language the student usually speaks at home? ______
Parent/Guardian Information
Mother’s
Name ______Address ______
(If not same as student)
Employment ______Work # ______
Email ______Cell # ______
Joint Custody* *(If parents are divorced and/or student lives with other
Single _____ Married _____ Divorced _____ Y ___ N___ than both parents, legal papers supporting custody
Widowed ______Remarried _____ Deceased _____ and/or guardianship must be filed with the school)
Please indicate if both parents should receive school mailings _____Yes _____No
PLEASE COMPLETE REVERSE SIDE
Father’s
Name ______Address ______
(If not same as student)
Employment ______Work # ______
Email ______Cell # ______
Joint Custody* * (If parents are divorced and/or student lives with other
Single _____ Married _____ Divorced _____ Y ___ N___ than both parents, legal papers supporting custody
Widowed ______Remarried _____ Deceased _____ and/or guardianship must be filed with the school)
Student lives with: Both Parents _____ Mother _____ Father _____
Guardian _____ (Name) ______
Educational Status (Mother): Elem. School High School College Tech School
Degrees (specify) ______
Educational Status (Father): Elem. School High School College Tech School
Degrees (specify) ______
Sibling Information M F
Date
Name:______of Birth: ______
School: ______Grade: ______
M F Date
Name:______of Birth: ______
School: ______Grade: ______
M F Date
Name:______of Birth: ______
School: ______Grade: ______
M F Date
Name:______of Birth: ______
School: ______Grade: ______
Others in home: Yes ______No ______
Name & Relationship ______
Student’s Interests, Distinctions and Memberships:
______
______
Bolton Center School
Student Registration
Physical and Health Review
Name of Child Date of Birth
I. To ensure the well-being and safety of your child in school, please complete
both sides of this form.
Please respond to each item listed below:
CIRCLE
1. Allergies to foods, bees, drugs, environmental/seasonal Yes No
2. Asthma Yes No
3. Diabetes, heart or kidney disease Yes No
4. Frequent ear infections, ear tubes, hearing aids Yes No
5. Speech problems Yes No
6. Vision problems Yes No
7. Epilepsy/seizures Yes No
8. Frequent colds or sore throats Yes No
9. Skin conditions Yes No
10. Physical limitations or orthopedic problems Yes No
11. Taking prescription medication Yes No
12. Problems sleeping Yes No
13. Any dietary concerns Yes No
II. Explain in this area any symptoms and/or forms of treatment for areas you
responded” Yes” to above. Please also list any other medical concerns you may have.
______
______
PLEASE COMPLETE REVERSE SIDE
III. Has your child had any accidents, illnesses, or experiences that would help us to understand him or her better?
______
IV. Please list any other information concerning your child’s health which would be helpful
to the school.
______
______
Parent/ Guardian’s Signature Date
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
IMMUNIZATION REQUIREMENTS FOR ENROLLED STUDENTS IN CONNECTICUT SCHOOLS 2015-2016 SCHOOL YEAR
PRESCHOOL
DTaP: 4 doses (by 18 months for programs with children 18 months of age)
Polio: 3 doses (by 18 months for programs with children 18 months of age)
MMR: 1 dose on or after 1st birthday
Hep B: 3 doses, last one on or after 24 weeks of age
Varicella: 1 dose on or after 1st birthday or verification of disease
Hib: 1 dose on or after 1st birthday
Pneumococcal: 1 dose on or after 1st birthday
Influenza: 1 dose administered each year between August 1st-December 31st
(2 doses separated by at least 28 days required for those receiving flu for the first time)
Hepatitis A: 2 doses given six calendar months apart, 1st dose on or after 1st birthday
KINDERGARTEN
DTaP: At least 4 doses. The last dose must be given on or after 4th birthday
Polio: At least 3 doses. The last dose must be given on or after 4th birthday
MMR: 2 doses separated by at least 28 days, 1st dose on or after 1st birthday
Hep B: 3 doses, last dose on or after 24 weeks of age
Varicella: 2 doses separated by at least 3 months-1st dose on or after 1st birthday; or verification of disease
Hib: 1 dose on or after 1st birthday for children less than 5 years old
Pneumococcal: 1 dose on or after 1st birthday for children less than 5 years old
Hepatitis A: 2 doses given six calendar months apart, 1st dose on or after 1st birthday
GRADES 1-3
DTaP/Td: At least 4 doses. The last dose must be given on or after 4th birthday. Students who start the series at age 7 or older only need a total of 3 doses.
Polio: At least 3 doses. The last dose must be given on or after 4th birthday
MMR: 2 doses separated by at least 28 days, 1st dose on or after 1st birthday
Hep B: 3 doses, last dose on or after 24 weeks of age
Varicella: 2 doses separated by at least 3 months-1st dose on or after 1st birthday; or verification of disease
Hepatitis A: 2 doses given six calendar months apart, 1st dose on or after 1st birthday
GRADE 4
DTaP/Td: At least 4 doses. The last dose must be given on or after 4th birthday. Students who start the series at age 7 or older only need a total of 3 doses.
Polio: At least 3 doses. The last dose must be given on or after 4th birthday
MMR: 2 doses separated by at least 28 days, 1st dose on or after 1st birthday
Hep B: 3 doses, last dose on or after 24 weeks of age
Varicella: 2 doses separated by at least 3 months-1st dose on or after 1st birthday; or verification of disease
GRADES 5-6
DTaP/Td: At least 4 doses. The last dose must be given on or after 4th birthday. Students who start the series at age 7 or older only need a total of 3 doses.
Polio: At least 3 doses. The last dose must be given on or after 4th birthday
MMR: 2 doses separated by at least 28 days, 1st dose on or after 1st birthday
Hep B: 3 doses, last dose on or after 24 weeks of age
Varicella: 1 dose on or after 1st birthday; or verification of disease
GRADES 7-11
Tdap/Td: 1 dose for students who have completed their primary DTaP series. Students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine, one of which must be Tdap
Polio: At least 3 doses. The last dose must be given on or after 4th birthday
MMR: 2 doses separated by at least 28 days, 1st dose on or after 1st birthday
Meningococcal: 1 dose
Hep B: 3 doses, last dose on or after 24 weeks of age
Varicella: 2 doses separated by at least 3 months-1st dose on or after 1st birthday; or verification of disease
GRADE 12
Td/Tdap: At least 3 doses. The last dose must be given on or after 4th birthday Students who start the series at age 7 or older only need a total of 3 doses one of which should be Tdap.
Polio: At least 3 doses. The last dose must be given on or after 4th birthday
MMR: 2 doses separated by at least 28 days, 1st dose on or after 1st birthday
Hep B: 3 doses, last dose on or after 24 weeks of age
Varicella: 1 dose on or after 1st birthday; or verification of disease (2 doses separated by at least 28 days for any unvaccinated student)
Important Reminders:
· DTaP vaccine is not given on or after the 7th birthday and may be given for all doses in the primary series.
· Tdap can be given in lieu of Td vaccine for children 7 years and older unless contraindicated. Tdap is only licensed for one dose.
· Hib is not required for children 5 years of age or older.
· Pneumococcal is required for all Pre-K and K students born on or after 1/1/2007 and less than 5 years of age.
· Hep A requirement for school year 2015-16 applies to all Pre-K, K, 1st , 2nd and 3rd graders born 1/1/2007 or later.
· Hep B requirement for school year 2015-2016 applies to all students in grades K-12. Spacing intervals for a valid Hep B series: at least 4 weeks between doses 1 and 2; 8 weeks between doses 2 and 3; at least 16 weeks between doses 1 and 3; dose 3 should not be given before 24 weeks of age.
· Second MMR for school year 2015-2016 applies to all students in grades K-12.
· If two live virus vaccines (MMR, Varicella, MMRV, Intranasal Influenza) are not administered on the same day, they must be separated by at least 28 days (there is no 4 day grace period for live virus vaccines). If they are not separated by at least 28 days, the vaccine administered second must be repeated.
· Lab confirmation of immunity is only acceptable for Hep B, Hep A, Measles, Mumps, Rubella, and Varicella.
· VERIFICATION OF VARICELLA DISEASE: Confirmation in writing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.
· For the full legal requirements for school entry visit www.ct.gov/dph/cwp/view.asp?a=3136&Q=467374&PM=1
New Entrant Definition:
*New entrants are any students who are new to the school district, including all preschoolers and all students coming in from Connecticut private, parochial and charter schools located in the same or another community. All pre-schoolers, as well as all students entering kindergarten, including those repeating kindergarten, and those moving from any public or private pre-school program, even in the same school district, are considered new entrants. The one exception is students returning from private approved special education placements–they are not considered new entrants.
Commonly Administered Vaccines:
Vaccine: Brand Name: Vaccine: Brand Name:
DTaP-IPV-Hib Pentacel MMRV ProQuad
DTaP-HIB TriHibit PCV7 Prevnar
HIB-Hep B Comvax PCV13 Prevnar 13
DTaP-IPV-Hep B Pediarix DTaP-IPV Kinrix
Hepatitis A Havrix, Vaqta Influenza Fluzone, FluMist, Fluviron, Fluarix, FluLaval
BOLTON CENTER SCHOOL
______
Mary E. Grande Darryl T. Giard
Principal Assistant Principal
Permission to Send/Receive Records
I give permission for Bolton Public School to send ____ receive ____ records as checked
below for ______.
Student Name Grade level
□ Transcript of courses, grades
□ Standardized test results
□ Health Records
□ Psychological Evaluations
□ Educational Evaluations
□ Social Work Records
□ Individual Education Program (IEP) Records
□ Other ______
______
This student’s last day of school will be ______
This student’s first day of school will be ______
______Signature of Parent/Guardian Date
The above records should be sent to: ______
______
______
The above records should be received from: ______
______
______
______
108 Notch Road Bolton, Connecticut 06043 Phone: (860) 643-2411 Fax: (860) 646-4860
6/9/2015