Special Education / 504 / SAT Disclosure

Welcome to the Española Public Schools where our mission is to provide and continuously improve a quality education for all students in a safe environment by implementing an educational program that insures students are prepared to meet educational and life-long challenges.

Attached are the required forms and list of required documentation. Please complete all forms

and return to your child’s school. We look forward to registering and educating your child.

Special Education / 504 / SAT Disclosure

My Child Currently has an IEP Qualifying Condition:

My Child Currently has a 504 Plan Qualifying Condition:

My Child Currently has a SAT Plan Area(s) of Concern:

I believe that my child may have a disability or qualifying condition that qualifies my child for IEP, 504, or SAT accommodations, and I request a review of his/her case.

• Suspected Disability:
• Area(s) of Concern:

Special Programing Considerations

My child is a migrant student. A migratory child is a child who is, or whose parent, spouse, or guardian is, a migratory agricultural worker or migratory fisher, and who, in the preceding 36 months, has moved from one school district to another, to obtain or accompany such parent, spouse, or guardian, in order to obtain temporary or seasonal employment in agricultural or fishing work as a principal means of livelihood. Please consider my child for Migrant Education Program Services (Title I, Part C).

My child is homeless. The McKinney-Vento Act defines homeless children as "individuals who lack a fixed, regular, and adequate nighttime residence." This may include: Children and youth sharing housing due to loss of housing, economic hardship or a similar reason; Children and youth living in motels, hotels, trailer parks, or camp grounds due to lack of alternative accommodations; Children and youth living in emergency or transitional shelters; Children and youth abandoned in hospitals; Children and youth awaiting foster care placement; Children and youth whose primary nighttime residence is not ordinarily used as a regular sleeping accommodation (e.g. park benches, etc); Children and youth living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations; and Migratory children and youth living in any of the above situations. Please consider my child for assistance and services offered via the McKinney-Vento Homeless Education Assistance Act

Parent/Guardian Signature Date:

Española Public SchoolsReturning Student Registration 2016/2017

STUDENT INFORMATION FORM

In addition to parents, who is authorized to pick up your child? Please provide a complete list with contact information.

¿Además de los padres, quien está autorizado para recoger a su hijo? Proporcione un lista complete con información de contacto.

Completed by/Completado por: ______Date/Fecha:

RELEASE FORM

In order to comply with FERPA (Family Educational Rights and Privacy Act) and the No Child Left Behind Act of 2001, it will be necessary to obtain parental permission in order to publish or release your child’s name and/or address.

Photo Release (Check One)

I give my permission for my child to be interviewed, photographed, or videotaped by media representatives.

I DO NOT give my permission for my child to be interviewed, photographed, or videotaped by media representatives.

Student Art Work Permission Slip

I give my permission for my child’s artwork to be displayed and/or published in EPS publications.

I DO NOT give my permission for my child’s artwork to be displayed and/or published in EPS publications.

School Web Sites

I give my permission to allow my child’s photo to be published on the EPS District websites.

I DO NOT give my permission to allow my child’s photo to be published on the EPS District websites. Directory

Information (Check One) HIGH SCHOOL ONLY

I want my child’s education records to be disclosed.

I DO NOT want my child’s education records to be disclosed.

Military Recruiter 11th and 12th Grade ONLY

I give my permission for my child to be contacted by a military recruiter.

I DO NOT give my permission for my child to be contacted by a military recruiter.

Signature of Parent/Guardian ______Date_____

This form will remain on file in the Main Office for the current school year.

Date

Española Public SchoolsReturning Student Registration 2016/2017

Code of Conduct - Prohibited Behavior Infractions

DIRECTIONS: Parents please review with your child and sign and return immediately. Thank you.

Behaviors marked with an * indicate behaviors for which referral to law enforcement is either (1) required by law; (2) based on the totality of the circumstances, severe enough to merit referral to law enforcement upon the first occurrence; or (3) merit referral to law enforcement if the behavior is repeated. Referral to law enforcement may result in a secondary referral by law enforcement to Juvenile Probation, the District Attorney, or Children’s Court.

Behavior Interventions & Consequences

We have reviewed the behavior infractions and consequences.

Parent’s SignatureDateStudent’s SignatureDate

Student Computer Use and Internet Access Release Form

As a condition to use of the School District’s computer system, including access to and use of the Internet, I understand and agree to the following:

1. To abide by the School Board’s Policy on Acceptable Use and its Computer and Internet Code of Conduct.

2. School Site and district level administrators have the right to review any materials

created or stored in any files I may create and to edit or remove any material which they, in their sole discretion, believe may be unlawful, obscene, abusive, or otherwise objectionable and I hereby waive any right of privacy which I may otherwise have to such material.

3. That the Espanola Public School District will not be liable for any direct or indirect, incidental or consequential damage due to information gained and/or obtained via use of the School District’s computer system including, without limitation, access to public networks.

4. That the Espanola Public School District does not warrant that the functions of the School District computer system or any of the networks accessible through the system will meet any specific requirements you may have, or that the School District computer system will be error-free or uninterrupted.

5. That the Espanola Public School District shall not be liable for any direct or indirect,

incidental, or consequential damages (including lost data or information) sustained or incurred in connection with the use, operation, or inability to use the School District computer system.

6. That the use of the School District computer system, including use to access public

computer networks, is a privilege which may be revoked by School District administrators at any time for violation of the district's Acceptable Use Procedures and Code of Conduct. School District administrators will be the sole arbiter(s) of what constitutes a violation of the policy or Code of Conduct.

7. In consideration for the privilege of using the School District computer system and in consideration for having access to the public networks, I hereby release Espanola Public School District, the School Board, its members, administrators and employees, including its computer operators, and any institutions with which they are affiliated from any and all claims and damages of any nature arising from my use, or inability to use, the School District computer system.

I hereby certify that we have reviewed the policy and my child will abide by the conditions set forth in this document, the School District's Acceptable Use Procedures and Computer and Internet Code of Conduct.

Parent’s SignatureDateStudent’s SignatureDate

A copy of this signed form shall be maintained in the Students file.

Bilingual Education Program Parent Notification

To the Parents or Guardians EPS Students:

The State of New Mexico provides financial support so that the students can receive bilingual education in the public school. The Espanola Public Schools applies and receives these funds in order to include bilingual education in their curriculum. The students receive instruction in English, Spanish, or Tewa.

As part of our regular program of instruction, you son/daughter may participate in a bilingual program, which gives them the opportunity to learn and develop the English language fluently and also maintain, develop and enrich their native language, which may be Spanish or Tewa.

You are cordially invited to visit the school, observe the program meet, and converse with your son/daughters teacher.

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Para los padres o tutores de estudiantes de EPS:

El Estado de Nuevo Mexico provee fondos para que los alumnos reciban una educación bilingüe en las escuelas públicas. Las escuelas Públicas de Española solicitan y reciben estos fondos estatales para proveer instrucción bilingüe en su currículo. Los alumnos reciben instrucción en Inglés, español o Tewa.

Su hijo-hija participa en el programa de educación bilingüe para darle la oportunidad de hablar y desarrollar en Ingles con fluidez, para mantener, desarrollar y enriquecer su idioma nativo, el Español o Tewa.

Ustedes están cordialmente invitados a visitar la escuela y el programa bilingüe, para que conozcan y conversen con el/la maestro(a).

Note: This form is due: Upon registration and at the beginning of each school year.

Signature of Parent/Guardian ______Date___

EMERGENCY MEDICAL AUTHORIZATION FORM

PURPOSE: To enable parents or guardians to AUTHORIZE emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached. Upon completion, parents must return this form to the school. The original form and any copies thereof may be used to identify the medical options of the undersigned parent.

ALTERNATE EMERGENCY CONTACTS (Local people to contact if parents cannot be reached)

In addition to parents, who is authorized to be an Emergency Contact and pick up your child? Please provide a complete list. ¿Además de los padres, en un emergencia quien está autorizado para recoger a su hijo? Proporcione un lista complete.

INSURANCE INFORMATION

EMERGENCY CONSENT

In case of an emergency involving my child and I cannot be reached, I hereby give consent to transport my child to the following medical care providers and hospital, and authorize these providers and hospital to give any reasonable and customary medical and health care deemed necessary:

Doctor Phone

Dentist Phone

Nurse Practitioner/Physician Assistant: Phone

Hospital Phone

If, for any reason, the listed medical care providers or hospital cannot be reached, I authorize appropriate transport and medical care of my child to any appropriate medical care provider, hospital or medical facility. This authorization does not cover major surgery unless one other doctor/dentist concur to the need.

Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts to comply with this section. It is understood that I will be financially responsible for all emergency care.

Signature of Parent/Guardian ______Date ______

ADMINISTRATION OF MEDICATION

I give permission for my child to take the following over-the-counter medication at school, (students may not carry medication at school), with the supervision of the nurse. Dosages will be administered in accordance with Age/weight per the dosing directions.

• Acetaminophen (Tylenol) Regular Strength (325 mg) Yes No
• Acetaminophen (Tylenol) Extra Strength (500 mg) Yes No
• Ibuprofen (Motrin/Advil) Regular Strength Yes No
• Pepto-Bismol/Tums Yes No
• Midol/Pamprin Yes No
• Allergy Medication (Claritin, Zyrtec, Generic Brand) Yes No
• Cough Syrup/Cough Drops/Throat Spray Yes No
• Saline Eye Drops Yes No
• Triple Antibiotic Cream Yes No
• Hydrocortisone Cream Yes No

Notes:______

______

______

Signature of Parent/Guardian ______Date

MEDICAL HISTORY & INFORMATION

Please indicate if student has had or is currently under treatment for any of the following conditions:

Give year or age when problem occurred.

Please indicate if student has had or is currently under treatment for any of the following conditions:

YES / NOAsthma. Current Inhaler? YES / NO

YES / NODiabetes. On insulin? YES / NO

YES / NOEar/Hearing Problem. Type:

YES / NOEmotional Problem.Type:

YES / NOSeizures Type:

YES / NOHigh Blood Pressure

YES / NOHeart Problems. Type:

YES / NOHepatitis. Type:

YES / NOSeasonal Allergies.

YES / NOFood Allergies. Type: Epi-Pen? YES / NO YES / NO Medication Allergies. Type: Epi-Pen? YES / NO

YES / NOReactions to medicine/injections Type:

YES / NOMeningitis

YES / NOMigraine Headaches

YES / NOMuscular Weakness or Paralysis

YES / NOBleeding Disorders. Type:

YES / NOInfectious Disease.Type:

YES / NOHospitalized or serious illness, surgery or accidents? When/For what?

YES / NOVision? Corrected Wears glasses Wears contact lenses

YES / NOLong Term Medications? Name:

What/dose/time?

YES / NOImmunizations Current?