Greenwood Lake Union Free School District New Registrant Household Form

GREENWOOD LAKE ELEMENTARY SCHOOL

P.O. BOX 8

GREENWOOD LAKE, NY 10925

(845) 477-2411FAX: (845) 477-3180

MARIA BOLLER

Elementary School Principal

February 2017

Dear Parents,

Registration of children who will enter Kindergarten in September 2017 will take place Wednesday, March 8th, Thursday, March 9th and Friday, March 10, 2017. Registration hours will be 9:00 a.m. to 11:00 a.m. and 2:00 p.m. to 3:00 p.m. each day. Children entering Kindergarten must reach the age of five years on or before November 30, 2017.

Parents should register their child at the Greenwood Lake Middle School, 1247 Lakes Road, Monroe, NY. The registration packet is attached, and is also available at the Greenwood Lake Elementary School, Greenwood Lake Middle School or online at

The following items MUSTbe presented at the time of registration:

Completed Registration Packet

Original Birth Certificate

Two Proofs of Residencyverifying that the child’s legal parent/guardian resides in the Greenwood Lake Union Free School District (refer to the Registration Packet for acceptable proofs of residency)

Certificate of Immunization validated by your Physician

Valid parent/guardian photo I.D.

***Current Physical (must be submitted to the School Nurse by October 1st or the school physician will do the examination).

Please feel free to contactTheresa Finn, Registrar at 845-782-8678ext. 51103, if you have any questions or need assistance.

Sincerely,

Maria Boller

ElementarySchool Principal

GREENWOOD LAKE UNION FREE SCHOOL DISTRICT

New Registrant Household Form

Student NameSurname of the Household______

(Last name of Primary Parent/Guardian)

Home Phone # ______Contact Priority______

Address______City______State______Zip______

Mailing Address, if different______

Dominant Home Language______

Residence Type: Lease Own Rent Unknown

Proofof Residency (minimum of 2 required): Utility Bill Mortgage Statement Property Tax Bill Lease

Income Tax Form Real Estate Statement Voter’s Registration Official DMV ID State/Gov’t ID Other

PARENTS/GUARDIANS WITH WHOM CHILD RESIDES:

Name ______

(Last) (First) (Middle)

Relationship______

Phone 1______Phone Type Cell HomeOffice Contact Priority______

Phone 2______Phone Type Cell HomeOffice Contact Priority

Email address______

Employer’s Name ______Employer’s Phone # ______Priority______

Employer’s Address ______

(City) (State/Zip)

Name ______

(Last) (First) (Middle)

Relationship______

Phone 1______Phone Type Cell Home Office Contact Priority

Phone 2______Phone Type Cell Home Office Contact Priority

Email address______

Employer’s Name ______Employer’s Phone # ______Priority______

Employer’s Address ______

(City) (State/Zip)

SIBLINGS WHO RESIDE IN HOUSEHOLD:

Name ______DOB______Gender Male Female

Name ______DOB______Gender Male Female

Name ______DOB______Gender Male Female

Name ______DOB______Gender Male Female

Only to be filled out if Parent/Guardian lives outside the household

Name ______

(Last) (First) (Middle)

Relationship______

Address______Correspondence Yes No

(City) ( State/Zip)

Phone1______Phone Type Cell Home Office Contact Priority

Phone2______Phone Type Cell Home Office Contact Priority

GREENWOOD LAKE UNION FREE SCHOOL DISTRICT

New Registrant Pupil Form

Student Name _____ Gender: Male Female

(Last) (First) (Middle)

Are you Hispanic: Yes No

Race (Choose all that apply):

It is required by law for us to report this data, if you do not indicate your choice it will be necessary for us to make the selection.

Asian African American (Black) Native American/Native Alaskan Pacific Islander Caucasian (White)

Date of Birth ______

Place of Birth (City, State) ______Country, if place of birth not in US______

Emergency Contact Info: (OTHER THAN pARENT/gUARDIAN)

Name______Gender ______Resides in Same Household: Yes No

(Last) (First) (Middle)

If different household: Address______City______State______Zip______

Phone______Phone Type: Cell Home Office

Relationship to the Student______

Name______Gender ______Resides in Same Household: Yes No

(Last) (First) (Middle)

If different household: Address______City______State______Zip______

Phone______Phone Type: Cell Home Office

Relationship to the Student______

Pre K Experience: Yes No

Has pupil ever attended school in this District? Yes No If yes, which school ______Grade(s) ______

Name of last school attended______Grades attended in previous school______

Address of school last attended ______

TO BE COMPLETED BY SCHOOL PERSONNEL:

School Assignment Teacher ______Grade ______Homeroom # ______

Date of Enrollment ______Bus # Student ID # ______

Proof of Birth: Alien Card Baptismal Certificate Birth Certificate Passport

Greenwood Lake Union Free School District

Dear New Parents:

In order to determine the most appropriate program for your child, we screen and evaluate all incoming students. All new students receive an evaluation by the school nurse and speech/language therapist, as well as participate in academic screening. We may also contact your child’s previous school for additional information. It is very helpful for you to inform us of any testing evaluation and special class placement or services that your child received in his/her previous school.

If deemed necessary and appropriate, we may contact you for permission to do additional testing by our learning specialists or school psychologist. If the initial placement appears to be inappropriate for your child’s needs, we will contact you to share this information and review other possible placement alternatives.

Thank you for your cooperation and, again, welcome to our District.

Date: ______

I have read the above letter and understand that any screenings and evaluations deemed necessary for the appropriate placement of my child will be conducted by the appropriate staff.

______

Signature of Parent or Guardian

GREENWOOD LAKE UNION FREE SCHOOL DISTRICT

STUDENT EMERGENCY INFORMATION SHEET

Building (Circle One): Elementary Middle Date: ______

Child’s Full Name: ______DOB: ______Teacher: ______Grade: _____

EMERGENCY MEDICAL INFORMATION

PHYSICIAN INFORMATION

Family Physician: ______Physician’s Phone Number: ______

Address: ______City: ______State: _____ Zip: ______

If the School District is unable to reach the aforementioned Emergency Contacts in the order listed, we do hereby authorize the School District to call the family physician listed. In the event the physician cannot be reached, we do hereby authorize the school district to transport the child to a hospital emergency room if in the judgment of the school district such emergency treatment seems warranted. This authorization also includes authority to release pertinent medical records needed.

Date: ______Parent’s Signature: ______

Transportation Department

P.O. Box 8

70 Elm Street

Greenwood Lake, NY 10925

T: 845-477-2411 Ext. 54300 F: 845-477-3326

Greenwood Lake Union Free School District

To the Parents or Guardians of 2017/2018 Kindergarten Students:

The Transportation Department would like to welcome you and your child to the Greenwood Lake Union Free School District. Listed below are some details to help you understand transportation.

Everyone who is employed in our office, along with your child’s bus driver, understands that this is a big step in your child’s life. Now that your son/daughter has become a student of the Greenwood Lake Union Free School District, our goal is to make this transition as easy and as reassuring as possible.

The Transportation Department requests that an adult be present at the bus stop to receive your child home each day. If someone other than this designated person will be meeting your child at the bus stop, please call our office and let us know whom. We will notify the driver of this change.

Seat belts are available on all buses. If you wish to have your child wear a seat belt, please make sure they can operate the seat belt and you have instructed them to do so.

If your child will be going to a babysitter or an after school program, you are required to fill out an alternative stop form. In order to properly route buses, it is very important that this form be returned to the Registrar before July 1, 2017.

Busing information will be mailed home around the middle of August. Included in this information will be your child’s stop location, pickup and drop off time.

I thank you in advance for your cooperation. I know that by working together, we willprovide your child with a great school year.

The Transportation Department is open Monday - Friday from 6:00 am - 5:00 pm. If you have any questions or concerns, please call us at (845) 477– 2411 Extension 54300.

Sincerely,

Patricia Milburn

Patricia Milburn

Transportation Supervisor

GREENWOOD LAKE UNION FREE SCHOOL DISTRICT

2017 -2018 SCHOOL YEAR

TRANSPORTATION REQUEST SHEET

PLEASE PRINT

DATE______

STUDENT NAME______

LASTFIRST

SCHOOL ATTENDING:______GRADE AS OF SEPTEMBER 2017: ______

DATE OF BIRTH: ______/______/______MALE FEMALE

M D Y

PARENT/GUARDIAN NAME: FATHER______

LAST FIRST

MOTHER______

LAST FIRST

911 ADDRESS______

______

MAILING ADDRESS ______

CITY, STATE, ZIP CODE______

HOME TELEPHONE #______ALTERNATE CELL# ______

EMERGENCY CONTACT PERSON______

PHONE NUMBER______RELATIONSHIP______

X______

SIGNATURE OF PARENT OR GUARDIAN

Greenwood Lake union free school district

P.O. Box 8

Greenwood Lake, New York 10925

(845) 782-8678 Fax: (845) 845-782-8582

Website:

Dr. Christine Ackerman

Superintendent of Schools

Dear Parent or Guardian:

The New York State Education Law requires that every child in grades K, 2, 4, 7, 10 and allnewstudents have a health examination, which may be given by your family physician or the school doctor. Your family physician, who has a more complete understanding of your child, can interpret his findings directly to you and assist you in carrying out any recommendations, which may be indicated.

Therefore, we respectfully ask that you take your child to your family physician and have the Annual Health Examination Record (included) filled out and returned when your child enters school in the fall.

We are asking that all statements from the private physician be returned to the Nurse’s Office (no later than October 1st). If, by that time, we do not have the record of examination, it will be necessary to have the examination done by the school physician in order to have the record of the child’s physical condition on hand for reference.

NY State Law, Section 2164, requires proof of immunization for school attendance. Effective July 1, 2014, the following doses of vaccine must be given at an age and interval that is in accordance with the ACIP (Advisory Committee for Immunization Practices) schedule:

Entering Pre-K (2014 or after) (CPSE only), HIB: 3 doses < 15 months or 1 dose > 15 months

Entering Kindergarten – Grade 5 (2014 or after)

1.Polio: 3 – 5 doses (must include a dose after age 4)

2.Hepatitis B: 3 doses

3.Diphtheria/Tetanus/Pertussis: 4-5 doses (must include a dose after age 4)

4.Measles/Mumps/Rubella: 1 dose

5.Varicella (Chickenpox): 2 doses

6.DTaP/DTP/Tdap: 3 doses (must include a does after age 4)

Entering Grade 6 – Grade 12 (2014 or after)

1.DTaP/DTP: 3 doses

2.Varicella (Chickenpox): 2 doses

3.Polio: 3 – 5 doses (one after age 4)

4.MMR: 2 doses

5.Hepatitis B: 3 doses

6.Tdap: 1 dose

Please check with your health care provider to make sure your child has all the required immunizations for school attendance. Proof of immunization must be any 1 of these 3 items:

• An immunization certificate signed by your health care provider
• Immunization Registry report (NYSIIS) from your health care provider or health dept.
• A blood test (titer) lab report that proves your child is immune to the diseases.

(Varicella: note from health care provider that child had disease is acceptable.)

Please contact your child’s building principal or me if you have questions or concerns about the informationincluded in this letter.

Sincerely,

Christine Ackerman,

Superintendent of Schools

The Greenwood Lake Union Free School District is an Equal Opportunity Employer and does not discriminate on the basis of sex, race, religion, national origin, handicap, age or marital status; nor does it apply other arbitrary measure which would deprive persons of their constitutional rights.

GREENWOOD LAKE UNION FREE SCHOOL DISTRICT

Elementary845-477-2411 FAX 845-477-3180 Middle845-782-8678 Fax 845-782-2004

NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and

triennially for the Committee on Special Education (CSE).

HEALTH CERTIFICATE / APPRAISAL FORM

Name: Date of Birth:

School: Gender:  M  F Grade:

IMMUNIZATIONS / HEALTH HISTORY

 Immunization record attachedSickle Cell Screen: Positive Negative Not done Date:

 No immunizations given today PPD:Positive Negative Not done Date:

 Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done Date:

Dental ReferralYes  NoNot done Date:

Significant Medical/Surgical History:  See attached

Allergies: LIFE THREATENING  Food:  Insect: Other:

 Seasonal  Medication:

PHYSICAL EXAM

Height: ______Weight: ______Blood Pressure: ______Date of Exam:

Referral

Body Mass Index: ______. ____ / Vision - without glasses/contact lenses / R / L
Weight Status Category (BMI Percentile): / Vision - with glasses/contact lenses / R / L
 less than 5th  5th through 49th  50th through 84th / Vision - Near Point / R / L
 85th through 94th  95th through 98th  99th and higher / Hearing  Pass 20 db sc both ears or: / R / L

 EXAM ENTIRELY NORMAL Tanner: I. II. III. IV. V. Scoliosis:  Negative Positive:

Specify any abnormality (use reverse of form if needed):

MEDICATIONS

Medications (list all):  None  Additional medications listed on reverse of form

Name: ______Dosage/Time: ______

Name: ______Dosage/Time: ______

If AM dose is missed at home: ______

I assess this student to be self-directed  Yes  No Student may self carry and self administer medication  Yes  No

Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if the morning medication has not been given.

PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

 Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:

___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.

___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.

 Specify medical accommodations needed for school: ______ None

 Known or suspected disability:  Please monitor

 Restrictions:  Please monitor

 Protective equipment required:  Athletic Cup  Sport goggles/impact resistant eyewear  Other:

OPTIONAL INFORMATION, if known

Specify current diseases:  Asthma Diabetes:  Type 1  Type 2  Hyperlipidemia  Hypertension

 Other:

Provider’s Signature: Phone: (Stamp below)

Provider’s Name/Address: Fax:

Parent Signature: Date:

HEALTH HISTORY – To be completed by Parent

Has your child ever had (Please check)

YESNOYESNO

Medication Allergies Injury to Spine  

Environmental Allergies Infectious Mononucleosis  

Food Allergies Fracture/of any bone  

Bee sting Allergy Joint Dislocation/Injury  

Asthma Ligament Injury  

Anemia Torn/Pulled Muscle  

Arthritis Back Pain/Injury  

Bladder/Kidney Problems Neck Injury  

Cancer Knee Pain/Injury  

Convulsions/seizures Ankle Pain/Injury  

Chest Pain Prosthetic Appliances  

Heart Disease/Murmur Nose Bleeds/frequent or severe  

Rheumatic Fever Broken Nose  

Rapid Heart Beat Operations  

Elevated Blood Pressure One Kidney  

Diabetes One Testicle  

Ear Problems/Hearing Loss Orthopedic Appliance  

Vision in only one eye Braces  

Contact Lenses Capped Teeth/Bonded  

Emergency room visit Stomach Ulcer  

Fainting Spells Sudden Weight Loss/Gain  

Fainting during exercise Ill for five (5) consecutive days  

Headaches/frequent or severe Frequent Absences/lateness  

Head injury/Concussion Girls, Menstrual Period  

Hospitalization If yes, age started? ______

Tuberculosis If yes, heavy bleeding? ______

Chicken Pox If yes, Cramps? ______

Measles/German Measles Mumps  

Scarlet Fever Poliomyelitis  

Pneumonia Immunizations required  

If yes to the above questions, please provide details: dates, physicians, treatment, current status of problems

______

YESNO

Is your child under medical care now?  

Is student on medication on a regular basis?  

If yes, medication and reason ______

______

Did anyone in your immediate family below age fifty (50) die of a heart attack suddenly?  

Has your child been unconscious or lost memory from a blow on the head?  

Has your child ever had an illness, condition, or injury that required him/her to go to the hospital?

either as a patient overnight or in the emergency room or for x-rays or required an operation, or

caused your child to miss school?  

Is there any other information that the school should know in order to safeguard your child’s health?

______

I understand that this confidential information will be shared with the school personnel deemed appropriate by the health professional in my child’s building.

Parent/Guardian Signature: ______Date: ______

GREENWOOD LAKE UNION FREE SCHOOL DISTRICT
Dental Health Certificate - OPTIONAL
Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Child’s Name: Last First Middle
Birth Date: / /
Month Day Year / Sex:  Male
Female / Will this be your child’s first visit to a dentist? Yes No
School: Name / Grade
Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No
I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health.
I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below.
Parent’s Signature______Date
Section 2. To be completed by the Dentist
I. The Dental Health condition of ______on ______(date of exam) The date of the exam needs to be within 12 months of the start of the school year in which it is requested. Check one:
Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.
No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.
NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.
Dentist’s name and address (please print or stamp) Dentist’s Signature
Optional Sections -If you agree to release this information to your child’s school, please initial here.
II. Oral Health Status (check all that apply).
 Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].
 Yes  No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].
 Yes No Dental Sealants Present
Other problems (Specify):______
III. Treatment Needs (check all that apply)
 No obvious problem. Routine dental care is recommended. Visit your dentist regularly.
 May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.
 Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

**IMPORTANT**

PLEASE ANSWER THE QUESTIONS BELOW

STUDENT NAME:______