New Students, Please Complete All Paperwork & Return to Shelley at TIS Along with a Copy Of

*NEW STUDENT*

TIS REGISTRATION

2017-2018

New students, please complete all paperwork & return to Shelley at TIS along with a copy of:

ü  Birth Certificate

ü  Immunization Records

ü  Proof of Residency

ü  $25 iPad fee, payable to “TIS”

Please check all that apply to your child:

Individualized Learning Plan

504 Plan

Read Plan

Advanced Learning Plan (Gifted/Talented)

Speech

Shelley Schuler

Telluride Intermediate School

717 West Colorado

Telluride, CO 81435

Phone: 970-369-4719

Fax: 970-728-9496

“This institution is an equal opportunity provider.”

Parent / Student Handbook

2017-2018

By signing this form, you acknowledge that you have read and understand the documents below. These documents are contained within the TIS Student-Parent Handbook which is found online at: http://tis.tellurideschool.org/. Hard copies may also be obtained from the TIS Office.

Student-Parent Handbook: We have reviewed and accept the conditions of the online version of the Student-Parent Handbook.

Technology Acceptable Usage Policy and iPad insurance fee: We have reviewed the online version of the Technology Acceptable Usage Policy within the Student-Parent Handbook and have paid TIS the $25.00 iPad insurance fee.

Field Trip Permission: During the course of the school year, students take a number of academic field trips. Signing this one form gives your child permission of attend all of these field trips. Communication regarding upcoming field trips will come directly from the classroom teachers.

Student

Signature: Date:

Printed Name:

Parent/Guardian

Signature: Date:

Printed Name:

FOR NEW STUDENTS ONLY!

TELLURIDE INTERMEDIATE SCHOOL

717 West Colorado Avenue

Telluride, CO 81435

970-369-4719

Fax: 970-728-9496

REQUEST FOR TRANSCRIPTS

To: Registrar

Previous School District Name

Previous School’s Name

Address Phone#

City/State/Zip Fax #

Name of Student: Birthdate Current Grade

PLEASE FORWARD THE FOLLOWING RECORDS TO:

Telluride Intermediate School

717 West Colorado Avenue

Telluride, Co 81435

1.  Standardized Test Data

2.  Scholastic Achievement Data

3.  Birth Certificate, Immunization/Medical Data

4.  Complete Transcripts with Grades to Date

5.  Additional Services Provided (ELL, Gifted/Talented, etc.)

PLEASE FORWARD ALL SPECIAL EDUCATION RECORDS TO:

Uncompahgre Board of Cooperative Services (UnBOCS)

P. O. Box 728

Ridgway, CO 81432

Phone – 970-626-2977

Fax – 970-626-2978

Parent/Guardian Date

Official School Signature Date

Student Registration

TIS-2017-2018

Student Information:

Legal Name on Birth Certificate: ______

Nickname: ______Gender: ______

Grade for 2017-2018 School Year: ______Previous School: ______

Birthdate: ______Social Security #: ______Home Phone #: ______

Student Email Address: ______Student Cell #: ______

Ethnicity: Do you consider your student to be of Hispanic/Latino origin? Yes No

Which of the following groups describes your student’s race? (Please circle at least one category)

Latin or American Indian Alaska Native Asian Black White Pacific Islander

Has your family ever qualified for the Migrant Education Program? Yes No

Household Information:

Mother Household Father Household Other Household

Name:
Mailing Address:
Physical Address:
Email: (Most communication is sent by email only)
Home Phone:
Cell Phone:
Work/Other Phone:
Student Lives With:
Please send weekly emails to:(all that apply)
Please send USPS mailings to:(all that apply)

Sibling Information: (Only for siblings enrolled in TSD for 2017-2018 School Year)

Sibling 1 Sibling 2 Sibling 3 Sibling 4

Name:
Grade 2016-2017
Cell Phone:

Any additional non-medical information (not covered above) that the TIS front desk should know regarding your family situation?

Emergency Contact Information:

Contact 1 Contact 2 Contact 3

Name:
Relationship:
Cell Phone:
Home Phone:
Work/Other Phone:

Residency Requirement:

______Student resides within Telluride R1 School District and can provide proof of residency.

Neighborhood student lives in: ______(Telluride, Lawson Hill, Mtn. Village, Placerville, etc)

______Student is from Out of District. Student lives in ______District.

Opt Out:

Please opt my student out of the following: _____ Directory Listings _____Photo/Video

Student Medical Information

TIS 2017-2018

Student Name: ______

Primary Care Physician: ______Phone #:______

Dentist: ______Phone #:______

Medical Alerts: (please list any allergies and/or special needs:

Insurance Company: ______Policy #:______

Prescription & over-the-counter drugs are administered only when the appropriate forms are completed and both the forms & the medication (in the original container) have been brought to the Front Desk.

_____My student DOES NOT need medication at school

_____My student needs medication at school

_____If medication needed I have filled out the appropriate paperwork (Student Medical Permission Form) with the School Nurse

By signing this Student Medical Information form, I hereby authorize the principal or designee, into whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and provides authority and power to the Telluride R-1 School District to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. This authorization shall remain effective until revoked in writing and delivered to Telluride R-1 School District. I understand that Telluride R-1 School District, its administrators, teachers, and staff assume no liability of any nature in relation to the transportation of the student. I further understand that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be my sole responsibility as the student’s parent/guardian.

______

Parent/Guardian Signature Date

New Students Only

Telluride School District 2017-2018

Home Language Questionnaire

Student: ______

First name middle name family name/s

Grade _____ Date of Birth ______/______/______Country of Birth ______

Parent or Guardian Names: ______

Phone Numbers: (home/work/cell) ______

Please answer these questions and return this form with your enrollment packet.

Please contact your English as a Second Language specialist, with questions. Intermediate school 970-369-4719, or

MS/HS 970 728 4377.

What is the native language/s of each parent/guardian? (Indicate one)

English only English + ______Other ______

What languages are spoken in your home? (Indicate one)

English only English + ______Other ______

What language/s did your child learn first? (Indicate one)

English only English + ______Other ______

What language does your child use most frequently at home? (Indicate one)

English only English + ______Other ______

What language do the parents most frequently speak to the child? (Indicate one)

English only English + ______Other ______

What other languages does your child understand and use?

School Spanish Other ______

Describe the language your child is able to READ.

_____ Not in any language.

_____ Only in another language.

_____ In another language and some English.

_____ In English and another language equally.

_____ Mainly in English and some of another language.

_____ Only in English.

Describe the language your child is able to WRITE:

_____ Not in any language.

_____ Only in another language.

_____ In another language and some English.

_____ In English and another language equally.

_____ Mainly in English and some of another language.

_____ Only in English.

______

Parent or Guardian Signature Date

Uncompahgre Board of Cooperative Services

Student Health Inventory

Year 2017 Grade______School Telluride Public SchoolRidgway Public SchoolWest End Public SchoolOuray Public SchoolNorwood Public School

To assist in providing health services at school, please complete the following and return to the school nurse. Please call

Christine Tschinkel at 369-4719, #7224 with any questions or concerns.

(Circle one)

Student Name ______Birthdate ______M F

Last First Middle

Does student have private health insurance? Yes No Medicaid? Yes No

If your child is covered under Medicaid, do we have ID#______

permission to bill for health related services? Yes No CHIP______

If your child does not have health insurance, do you grant the school district Nurse permission to share this

information with Medicaid/CHP+ enrollment counselor? Yes No

Name of parent or guardian ______Daytime phone ______

Doctor’s name ______Date of last physical ______

Dentist’s name ______Date of last exam ______

Is student under an orthodontist’s care Yes No Doctor’s name ______

Does student have any of the following?

Allergies Yes No To drugs, food, insects, pollen? Please list______

Has the allergy required emergency action in the past? Yes No

If yes, was an Epinephrine pen prescribed? Yes No

If yes, can student administer injection on his/her own? Yes No

Comments ______

Bee Sting Yes No Describe reactions ______

Difficulty breathing? Yes No Need emergency medication? Yes No

Asthma Yes No Triggered by? ______Medication or treatment______

Diagnosed by doctor______Date ______

Date of last episode______

Does student require medication to be given at school? Yes No

Diabetes Yes No Takes Insulin? Yes No Date diagnosed ______

Does student require medication to be given at school? Yes No

Does student know how to use own medication? Yes No

Epilepsy/ Yes No Describe seizure______

Seizures Date of last seizure______Medication______

Is student currently under doctor care for seizures? Yes No

Does student require medication to be given at school? Yes No

Tuberculosis Yes No Diagnosed by doctor______Date______

Speech Yes No Describe______

Problems

Heart Yes No Describe______

condition List physical restrictions ______

Bone/Joint Yes No Describe______

problems or List physical restrictions ______

arthritis

Chicken Pox Yes No Date of contraction______

Check all the following regarding health concerns that pertain to student:

Eyes: Ears: Hearing Aids:

Date last seen by eye doctor ______known hearing loss __ right

__ Glasses __ Contacts __ frequent infections __ left

Date of last prescription ______tubes __ wear at school

__ reading __ hearing difficulties, explain: __ other

__ distance ______concerns______

__ contacts ______

__ difficulty seeing ______

__ lazy eye

__ concerns ______

Other:

__ menstruation __ requires catheterization __ ADD/ADHD

__ blood disorder __ lungs __ head Injury

__ blood pressure __ neurological __ dental

__ nosebleeds __ headaches __ bedwetting

__ eating __ bowel __ skin

__ sleeping __ requires diapering __ other______

__ bladder __ phobias __ other______

Medication:

Is student taking daily medication at home? Yes No At school? Yes No Emergency Only? Yes No

Name of medication and reasons for taking:

______

If student requires medication at school, please obtain the appropriate form found in the school office.

List serious illness or injuries______

List any operations______Conditions that prevent PE participation?

Explain: ______

If student requires a change in PE participation, please obtain the appropriate form found in the school office.

Check services student currently receives:

__ Special Education services (i.e., resource room)

__ Speech/Language __ OT/PT services __ Counselor __ Title I __ Special diet

__ requires special health care, please explain: ______

Any other health concerns: ______

______

Signature of legal parent/guardian Date

UnBOCS Student Health Inventory