brooklyn city school district preschool registration …

Effective Date March 1, 2010

BROOKLYN CITY SCHOOL DISTRICT PRESCHOOL

REGISTRATION PACKET

Student Registration is by appointment only. Please call 216-485-8112.

The Brooklyn Board of Education is located at 9200 Biddulph Road, Brooklyn, OH 44144. Only legal residents who are the parent or legal guardian of the child may complete the registration process.

PRESCHOOL REGISTRATION FEE ($20.00 non-refundable)

MUST BE PAID BEFORE STUDENT CAN START, NO EXCEPTIONS.

The following items are required for each student you are enrolling:

Birth Certificate

In the form of:

Original Certified Copy

Custody Papers (originals with court stamp)

In the form of:

Guardianship Custody

Divorce Decree/Shared Parenting

Agreement (if appropriate) Journal Entry

Medical Information

In the form of:

Immunization Records Physical Form (Preschool and Kindergarten)

Parent/Guardian Identification

In the form of:

Ohio Drivers License or State ID

School Records

In the form of:

Withdrawal Slip State Testing Information

Last Report Card/Grades in

Progress IEP/ETR/MFE (if applicable)

Transcripts (high school only) 504 Plan

Home Schooling Documentation Other:

Proof of Residency

HOME OWNERS You must provide each of the following

Deed or Truth-in-Lending

RENTERS You must provide each of the following

Valid Signed Lease/Rental Agreement

2 current utilities 2 current utilities

Notarized form Notarized form

NOTE: AN APPOINTMENT IS REQUIRED FOR REGISTRATION.

NOTARIZED FORMS: Two (2) affidavits are included in this packet and must be signed in the presence of a Notary Public before they are submitted to the Registrar. These forms are the OWNER/TENANT AFFIDAVIT and the RESIDENCYAND CUSTODY AFFIDAVIT.

Student Registration is by

appointment only.

Please call 216-485-8112.

New Re-entry Date_______________

Student Name

Last Name First Name Middle Name

Birth Date

Month Day Year / /

Entry Grade

Student Home Address

Number Street City Zip Code Up Down Apt. #

Parent/Guardian

Name Phone Number

Previous school attended Kindergarten include preschool if attended

Include homeschooling

Name of School School District City State

Is this student Hispanic/Latino?

No, not Hispanic/Latino

Yes, Hispanic/Latino

Race (choose one or

more)

White Black or African American Asian

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander How Identified: _________________

Gender

Male

Female

Citizenship

Dual National Non-Resident Alien Resident Alien U.S. Citizen Other please name:

Birthplace

City State Country

Native / Primary Language

English Other please name:

Student Lives With (check all that apply)

Mother Father Step-Parent Other (explain):

Guardian Spouse Self

Legal Custody (check all that apply)

Mother Father Foster Parent

Guardian CCDCFS Other (explain):

Court Journal Entry: ( / / ) Probate Court Juvenile Court

County: Restrictions:

District Bearing Cost(for Foster Children only):

Is the child in gifted or Advanced Placement? Yes No If yes, describe services:

Does the child have a 504 plan? Yes No If yes, describe services:

Has the child ever had an IEP? Yes No If yes, list year of most recent evaluation:

If yes, do you have a copy of the IEP? Yes No If yes, indicate program:

Is the child suspended? Yes No If yes, from what district?

Is the child expelled? Yes No If yes, from what district? End Date:

Birth Certificate Parent/Guardian Photo ID Consent for Records Release Report Card/Transcripts Home Language Survey Immunization Record Deed/Truth in Lending Lease Notarized Residency/Custody Affidavit Notarized Owner Affidavit Utility ____________________________ _____________________________ Proof of Custody/Guardianship: Divorce Decree and/or Certified Copy of 60 day Optional Enrollment Shared Parenting Journal Entry

BROOKLYN CITY SCHOOL DISTRICT STUDENT REGISTRATION FORM

1

PARENT(S) / GUARDIAN INFORMATION

Mother Single Married Divorced Separated Remarried Deceased

Residential Non-Residential

Dual Mailing: Yes No

Last Name First Name

Number Street City Zip Code Address

Workplace Email

Home Phone Work Phone Cellular Phone

Father Single Married Divorced Separated Remarried Deceased

Residential Non-Residential

Dual Mailing: Yes No



Workplace Email


Legal Guardian Step Parent Foster Parent Other:



Workplace Email


Social Worker (If Applicable):

Legal Guardian Step Parent Foster Parent Other:



Workplace Email


Social Worker (If Applicable):

PLEASE LIST ALL OTHER CHILDREN UNDER THE AGE OF 22 WHO LIVE AT THE HOME ADDRESS

Name Grade Date of Birth Gender Relationship To Student

I certify that I am a legal resident of Brooklyn, Ohio. I certify under penalty of perjury, that all the information provided is correct in all respects to the best of my knowledge. I understand that I am responsible for informing school officials of any changes that may occur pertaining to my address or legal custody/guardianship of my student. Enrollment of a child under false pretense subjects the parent/guardian to liability for tuition and/or other costs.

Date: Parent/Legal Guardian/Independent Student: Signature

BROOKLYN CITY SCHOOL DISTRICT

For the purpose of establishing school residence and custody (To be completed by parent or legal guardian)

SIGN ONLY AFTER CAREFULLY READING AND SIGNING IN THE PRESENCE OF A NOTARY.

THE UNDERSIGNED, FIRST BEING DULY SWORN ACCORDING TO LAW, STATE THAT:

I, ________________________________, certify that I am the custodial parent/legal guardian of (Parent’s or Legal Guardian’s Full Name) (Student’s Name)

and that I have established residency at (Street Number, Name, Apt. #) (City) (State) (Zip Code)

Date of Occupancy: Lease End Date (if applicable):

I, , certify that I am a resident of the above residence located within the Brooklyn City School District. The registrar

has explained to me that legal residency is determined by certain conditions, among them are that mail delivery, voting residence, and payroll city tax deductions are based on the Brooklyn City School District address and also, that the residence where meals are taken, and where the resident parent sleeps must be the Brooklyn residence. (Photo identification, such as an Ohio Driver’s License with your most recent address, is required for identification)

List the names of ALL people, both adults and children, who reside at the above address. Also, please indicate their school (if applicable) and “status” (i.e., homeowner, lessee, renter, parent, guardian, student, preschooler, grandparent, etc.) Attach a separate piece of paper, if needed.

Last Name First Name School (If Applicable)






Please read each statement and then place your initials to the left of the statement. ____ I/we certify that the information provided in this document and registration packet is true and no information has been withheld,

concealed, or misrepresented for the purpose of circumventing the school attendance laws of the State of Ohio in order to enroll named students in the Brooklyn City School District.

____ I/we understand that I/we are responsible for informing school officials of any change(s) in the residence of any parent, legal guardian, or other responsible adult. If I change my present address to another address that is within the Brooklyn City School District, I will immediately file another residency and custody affidavit with the Board of Education of the Brooklyn City School District. I further understand that if the above noted address ceases to be my legal residence and my new residence is outside the boundaries of the Brooklyn City School District, I will withdraw my child(ren) from the district and will enroll my child(ren) in the new district of residence.

____ I/we are also responsible for informing school officials of any changes to the legal custody or guardianship of the child(ren).

____ I/we have provided the Brooklyn City School District with an official copy of any and all current court orders from the Domestic Relations, Juvenile, Probate or any other court which has exercised jurisdiction over the custody or residency of the children being enrolled as per Ohio Revised Code 3313.672.

____ I/we acknowledge the student who is being registered has not been expelled or excluded from any other school pursuant to O.R.C. Sections 3301.121 and 3313.662.

____ I/we understand that if the student attends school while not being eligible to do so tuition free, the student and all responsible parties will be liable for tuition at a rate set by the Ohio Department of Education according to the Ohio Revised Code 3317.08 (the tuition rate for Brooklyn City Schools is $10,587.51 for FY 2017) plus interest at a rate of 1.5% per month, administrative costs, court costs, and any attorney fees incurred in the collection of those sums and the student will immediately be withdrawn from the Brooklyn City School District.

____ I/we understand that the Brooklyn City School District may use whatever legal means it has at its disposal to verify my residency. I/we hereby waive my rights to confidentiality of information relative to my/our residence and give permission to the Brooklyn Ctiy School District, the City tax Administrator, and the Regional Income Tax Agency (RITA) to release selected information such as name, social security number, and current and former addresses to confirm or deny my residency for the current or prior years.

NOTE: Be sure you have read this statement carefully before you sign. Giving false information under oath is punishable as a criminal offense under the Ohio Revised Code 2921.13 and 2921.21, a misdemeanor of the first degree with a maximum fine of $1,000 and/or a jail term of six months. In cooperation with the City Prosecutors, each violation may be thoroughly and vigorously prosecuted.

Signature(s) Parent/Legal Guardian/Custodian:

Student 18 years of age or older:

County of Cuyahoga ) ) SS: State of Ohio )

Before me, a Notary Public of the State of Ohio, came the above-named who said that he/she/they did understand the statements set forth above and did adopt said statements and the information, herein as his/her/their own, as true to the best of his/her knowledge of the consequences and penalties of falsification, and did affix his/her signature in my presence, This ____________________day of _____________________________, 20____ _____________________ Notary Public

RESIDENCY AND CUSTODY AFFIDAVIT

BROOKLYN CITY SCHOOL DISTRICT

O.R.C. 3313.64

I, __________________________________________,certify that I am the owner of the home/apartment located

at , BROOKLYN , OH 44144 (Address) I further certify that the below listed tenants have established permanent residence in the aforementioned residence/apartment with me and, to the best of my knowledge, are not maintaining a separate residence elsewhere. Attach a separate piece of paper, if needed.

_____________________________________ __________________________________ (Adult and Relationship) (Child and Relationship)



__________________________________ (Child and Relationship) Please read each statement and then place your initials to the left of the statement. ____ I understand that it will be my responsibility to notify the Brooklyn City School Distrtict Registration (216-485-8112) when the above-named

family no longer resides in my home/residence.

____ I understand that should any of the above statements be false, I am liable for any penalties including, but not limited to, the collection of any money owed for tuition purposes for which the law provides under the pertinent criminal code (the tuition rate of $10,587.51 for the FY 2017), plus interest at a rate of 1.5% per month, administrative costs, court costs, and any attorney fees incurred in the collection of those sums.

____ I agree to, and stipulate, that Brooklyn City School District may use whatever legal means it has at its disposal to verify my residency, including having an attendance officer visit my home to ensure that the family named above, resides at this address.

Signatures: NOTE: SIGN ONLY IN THE PRESENCE OF A NOTARY PUBLIC

_________________________________________ _____________________________________ (Signature of Owner/Tenant) (Date)

_________________________________________ _____________________________________ (Printed Name of Owner/Tenant) (Phone Number of Owner/Tenant) State of Ohio ) SS ) County of Cuyahoga ) Before me, a Notary Public of the State of Ohio, came the above-named who said that he/she/they did understand the statements set forth above and did adopt said statements and the information, herein as his/her/their own, as true to the best of his/her knowledge of the consequences and penalties of falsification, and did affix his/her signature in my presence. This ________ day of ____________, 20_________. ______________________________ Notary Public

NOTE: Be sure you have read this statement carefully before you sign. Giving false information under oath is punishable as a criminal offense under the Ohio Revised Code 2921.13 and 2921.21, a misdemeanor or the first degree with a maximum fine of $1,000 and/or a jail term of six months. In cooperation with the city of Brooklyn, each violation may be thoroughly and vigorously prosecuted.

OWNER AFFIDAVIT

Brooklyn Board of Education

9200 Biddulph Road • Brooklyn, Ohio 44144 • (216) 485-8191 • FAX: (216) 485-8118 www.brooklyn.k12.oh.us

ATTENTION RENTERS

All renters not living at the Westbrook Village Apartments, Parkview Apartments

or Terraces of Northridge Oval must provide the following information (please

print clearly):

Landlord’s name_____________________________________________________

Landlord’s phone number _____________________________________________

If at any time your residency is in question, Brooklyn City School’s reserves the

right to verify your lease/rental agreement with the above contact information.

http://www.brooklyn.k12.oh.us/

BROOKLYN CITY SCHOOL DISTRICT Date:______________

Federal guidelines require that this form be completed for all enrolled students.

School:______________________________________________Grade:___________Gender: Male Female Student Name:____________________________________________ Birthdate:______________ Country of Birth:________________ Home Address:_______________________________________________________________________________________________ (Street) (City) (ZIP)

Parent/Guardian Name:________________________________________________________________________________ Home Phone:_____________________ Cell Phone:_____________________ Work Phone:_____________________ Please answer the following questions:

1. What language did your child speak when first learning to talk?

2. What language does your child speak most often at home?

3. What language do you use most frequently when communicating with your child?

4. List the language(s), other than English, spoken by your child

5. List the language(s), other than English, spoken in the home.

PARENT/GUARDIAN SIGNATURE:

Continue ONLY if your answer was any language other than English to questions 1-5. If your answer was any language other than English to questions 1-5, please answer the following questions.

6. What is the Parent/Guardian’s native language? Mother_____________ Father ___________ Guardian___________

7. Does your child: speak English read English write English (Check all that apply.)

8. Which adults in the home speak English? Mother Father Guardian

9. Which adults in the home read English? Mother Father Guardian

10. Do you need an interpreter? Yes No If yes, do you have one available? Yes No

11. Interpreter’s Name (If available): __________________________________________ Phone #:__________________

12. When did your child first attend school in the United States? Date:______________________

13. List the schools your child attended in the United States

School Name City/State Grade Dates Enrolled

14. List the schools your child attended in another country

School Name City/Country Grade Dates Enrolled

Effective Date March. 1, 2010

Home Language Survey

SCHOOL PERSONNEL: If any of the answers to question 1-5 on reverse is a language other than English, indicate the student’s native/home language in EMIS Student Data Element (G-1270) and proceed to assess the student’s English language proficiency.

English Language Assessment

Communication Skill Proficiency Level

Listening: Pre-functional Beginning Intermediate Advanced Advanced Proficient

Speaking: Pre-functional Beginning Intermediate Advanced Proficient

Reading: Pre-functional Beginning Intermediate Advanced Proficient

Writing: Pre-functional Beginning Intermediate Advanced Proficient

Comprehension:* Pre-functional Beginning Intermediate Advanced Proficient

Composite:** Pre-functional Beginning Intermediate Advanced Proficient

*The Comprehension level is derived from Listening and Reading.

**The Composite level is derived from Listening, Speaking, Reading, Writing, and Comprehension.

Assessment instrument(s) used:____________________________________________________________Date:_________ Does the student qualify as LEP? Yes________ If yes, ________L or _________M No____________ Indicate the student’s status as LEP or not LEP in EMIS Student Data Element (G1230) If the student has been in the U.S. schools for less than three years, is the student eligible for extended accommodations for statewide academic assessments? Yes________ No _________ ______________________________________________________ __________________ Signature of District Personnel Date

PRESCHOOL INFORMATION

To: PreSchool Parents/Guardians

From: Clinic

ALL Preschool students will be required to have:

1. Physical Form completed by physician

2. Dental Form completed by dentist

3. Health History completed by parent

4. Immunization Record. Immunizations must be up to date at the start of the

school year, otherwise students can be excluded from school. 5. Emergency Contact Card. Please update numbers throughout the year as they change.

These are the only numbers that can be called from the clinic.

Any student requiring medication MUST have a Medication Form on file at school. This

includes both Prescription (signed by physician) and Over the Counter Medications. ***Cough

drops are considered medication.

If your child has a Chronic Health Condition such as severe allergies requiring an Epi-Pen;

Asthma-needing an inhaler; Diabetes or anything you feel needs to be brought to the attention of

the School Nurse, please contact the nurse at 485-8179.

When to KEEP YOUR CHILD HOME:

1. Fever of 100 or higher. Must be Fever Free for 24 hours without medication.

2. Vomiting/diarrhea. Please keep home 24 hours after last episode.

3. Undiagnosed rash. You will need a physician’s note to return to school.

4. Strep Throat. Must complete 24 hours of antibiotic.

5. Severe Cough/Cold, especially with green/yellow nasal drainage.

6. Red, watery, burning, itchy eyes or yellowish drainage

7. Nits/Lice. Must be cleared by the Clinic.

The above symptoms/conditions may mean the start of a communicable disease or nuisance

condition that could affect many other children in your child’s classroom. Your child may also

be too sick to learn in school that day. In fairness to ALL children, keep your child home until

you can determine what else may be developing.

Contact your school nurse at 485-8187 if you have any questions.

*See Immunization Requirements on reverse page.

PRESCHOOL IMMUNIZATION REQUIREMENTS

DTaP/DTP/DT/Tdap/Td: (Diphtheria, Tetanus, Pertussis) 4 doses of DTaP/DPT or DT or any combination Polio: 3 doses of OPV or IPV or any combination of OPV or IPV MMR: (Measles, Mumps, Rubella)1 dose of MMR administered on or after the first birthday Hib: 3 or 4 doses depending on the vaccine type administered (Haemophilus Influenzae Type b) Hep B: (Hepatitis B) 3 doses of Hepatitis B Varicella: (Chicken Pox) 1 dose of varicella vaccine (Required for Kindergarten thru 7th grade) A complete Immunization Record is required for entrance into the Preschool. Children who do not meet this requirement can be excluded from school.

OHIO SCHOOL HEALTH RECORD

PHYSICIAN’S REPORT

Child’s Name _____________________________ Male ____ Female ____ Age ____ Date _____________

OBJECTIVE DATA

Height ______________ ( %) Weight ________________ ( %) B.P. ______/______

SCREENING TESTS: Date Done _________ Date Done_______________

Vision Hearing Audiometric thresholds:

Distance Acuity R _____ L _____ R – ear pass fail not done

Muscle Balance pass fail not done L – ear pass fail not done

Farsightedness pass fail not done Other tests (specify) _____________________

Color pass fail not done ______________________________________

Child wears glasses? yes no Child wears hearing aid? yes no

Tested with glasses? yes no Tested with hearing aid? yes no

Referral made? yes no Referral made: yes no

SPEECH/LANGUAGE

Speech assessment: done not done

Child has no discernible speech problem:

Child has possible problem with:

Disorders: (check) Articulation Rhythm Voice Language

Speech evaluation recommended: yes no

LABORATORY TESTS

Hct/Hgb ______ Lead level _____ Urine protein/blood ______ Urine glucose _____ Other _____

PHYSICAL EXAMINATION

Date examined ______________ Essentially normal: yes no

Abnormalities as follows:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Allergies:_________________________________________________________________________________

Is this child able to participate fully in the following?

A. Classroom and academic activities? yes no

B. Physical education classes? yes no

C. Competitive athletics? yes no

D. Contact and collision sports? yes no

If limitations are advised, please specify those limitations:

__________________________________________________________________________________________

__________________________________________________________________________________________

If this child has any physical, developmental, or behavioral problems, how can the school assist with special

programs, placement, or attention?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

PHYSICIAN’S ASSESSMENT

Problem List Recommendation for school management

1.

1.

2.

2.

3.

3.

IMMUNIZATION RECORD

DPT ________ ________ ________ ________ ________

IPV ________ ________ ________ ________

Hep B ________ ________ ________ ________

Hib ________ ________ ________ ________

MMR ________ ________

Varicella ________ ________

Other ________ ________ ________

PLEASE PRINT OR STAMP

Physician’s Name ______________________________ Physician’s Signature ________________________

Address _________________________________________________________________________________

Phone ______________________________________ Date signed _________________________________

1/2011

OHIO SCHOOL HEALTH HISTORY (Both sides to be completed by parent or guardian)

Child’s Name_________________________________________________________________________ (Last) (First) (Middle)

Male Female Date of Birth ________________________________ (month) (day) (year)

Child’s Address ________________________________________________________________________________

Mother’s Name ________________________________________________________________________________

Address (if different from child’s) __________________________________________________________

Home Phone __________________________________ Work Phone _____________________________

Father’s Name _________________________________________________________________________________

Address (if different from child’s)__________________________________________________________

Home Phone _________________________________ Work Phone _____________________________

With whom does your child live? __________________________________________________________________

(name) (relationship)

Who is this child’s legal guardian? _________________________________________________________________

Please list this child’s brothers and sisters:

FAMILY HISTORY

Name Birth Year Sex Name Birth Year Sex

1.

5.

2

6.

3.

7.

4.

8.

IMMUNIZATIONS

DPT #1_________ #2_____ ____ #3_________ #4_________ #5_________

IPV #1_________ #2_________ #3_________ #4_________

Hep B #1_____ ____ #2_____ ____ #3_____ ____ #4_________

Hib #1_________ #2_________ #3_________ #4_________

MMR #1_________ #2_________

Varicella #1_________ #2_________

Other _________ _________ _________

DEVELOPMENTAL HISTORY

Please give the approximate age at which this child:

walked alone _______ was toilet trained _______ spoke in sentences _______ dressed self _______

How does this child’s development compare to other children, such as his or her brothers/sisters or playmates?

about the same slower faster

I. HEALTH CONDITIONS - Please check any that this child has had:

Abnormal spinal curvature (scoliosis, etc.) Hepatitis

Allergies or hay fever Kidney disease - type ________________

Anemia Measles (“old fashioned” or “ten day”)

Arthritis Meningitis or encephalitis

Asthma or wheezing Multiple ear infections (3 or more)

Bedwetting at night Mumps

Behavior problem Near-drowning or near-suffocation

Birth or congenital malformation Nervous twitches or tics

Cancer – type _________________ Poisoning

Chicken pox Poor hearing

Chronic diarrhea or constipation Pregnancy

Concern about relationship with siblings or friends Rheumatic fever

Cystic fibrosis Seizures or epilepsy

Diabetes Sickle cell disease

Eczema Stool soiling

Emotional problems Substance abuse (alcohol, drugs)

Eye problems, poor vision Suicide attempt

Frequent headaches Toothaches or dental infections

Frequent skin infections Urinary tract infection

Frequent sore throat infections Wetting during day

Heart disease – type ____________________

II. ALLERGIES – Please list and describe allergies or reactions to:

Medicines/drugs ____________________________________________________________________________

Foods/plants/animals/other ____________________________________________________________________

Recommended treatment, if allergy is severe ______________________________________________________

III. INJURIES AND ILLNESSES – Please list any severe injuries or illnesses:

Injuries/Illnesses Age of Child If Hospitalized (check)

___________________________________ ____________ _________________________________

___________________________________ ____________ _________________________________

___________________________________ ____________ _________________________________

Does this child always wear seatbelts in cars? Yes No

IV. ADDITIONAL INFORMATION:

What medications are given daily? _____________________________________________________________

What medications are given frequently, but not daily? ______________________________________________

This child is usually: very active normally active rather inactive

Do you have any concern about how your child gets along with other children?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Do you have other comments or concerns about this child’s health, development, behavior, family or home life that

you would like the school to be aware of? If yes, explain briefly _________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Completed by: ______________________________________

Relationship to child: ________________________________

2/2010

Child’s Name:_____________________

OHIO SCHOOL HEALTH RECORD

DENTIST’S REPORT

The following services have been performed:

______ Examination

______ Diagnosis

______ Radiographs

______ Oral prophylaxis

______ Prescription for fluoride supplements

______ Topical application of fluoride

The following oral hygiene instruction was provided:

______ Toothbrushing

______ Flossing

______ Diet counseling reflecting relation of diet to dental health

______ Home/school use of fluoride mouth rinse

The following statements are applicable:

______ All necessary services have been performed

______ No restorative services are required at this time

______ Further treatment is indicated

______ Further appointments have been arranged

COMMENTS:__________________________________________________________________________

______________________________________________________________________________________

________________________________________________________________________

PLEASE PRINT OR STAMP

Dentist’s name _________________________________________________________________

Address _______________________________________________________________________

Phone _________________________________________________________________________

Dentist’s signature _______________________________________

Date signed ______________________

2/2010

PRESCHOOL APPLICATION

Dear Parents/Guardians:

In order for your child to be considered for participation in

the Brooklyn City School District Preschool Program, you must

complete and return these items to the Brooklyn City School

District Board of Education Office:

Registration Packet

Registration Fee (non-refundable)

Proof of Residency

Application Form

Parent/Guardian Acknowledgment Form

Brooklyn City School District

Preschool Program

Program

Staffed by certified teachers and classroom assistants

Curriculum aligned with Ohio’s Early Learning and Developmental Standards

Monday through Thursday 9:00 a.m. – 11:30 a.m. or 12:20 p.m. – 2:50 p.m.

Participation Requirements

Children must be three years old by September 30th to attend, or 4 or 5 years of

age and not yet in kindergarten.

Students must be residents of the Brooklyn City School District.

Students must be toilet trained unless identified with a disability.

Compliance with preschool regulations, which require parent conferences at least

one (1) time per school year

Compliance with Communicable Disease Policy (see attachment) including all

requirements for immunizations and physical examinations prior to school

entrance

Parents provide transportation

Tuition (please see scholarship form for possible reduction):

1. Registration fee of $20.00 (non-refundable) payable in cash or money

order made out to Brooklyn City Schools with completed registration

packet. Registration fee must be paid before student will be permitted to

start attending preschool.

2. Tuition fee of $1,800.00** payable at the start of school or in two

payments of $900.00 each due September 1st and January 1st OR

$200.00** per month, due on the first of each month September through

May.

After 15 days, if tuition payment has not been made, a reminder letter is sent home to the

parents for non-payment. At 30 days, a letter is sent home with the balance not paid

indicating if the tuition is not paid in full within the next 15 days the child will be

withdrawn from preschool for lack of payment. A final notice letter is sent home after

45 days with a final attendance date at the end of the month.

Application Procedure

Read explanation of Brooklyn City School District’s Preschool Programs

Turn in registration information to the Board of Education office. (See packet

cover)

All applicants will be notified regarding a meeting for the fall preschool classes

FOR MORE INFORMATION CONTACT:

Mrs. Paula Jones, Director of Pupil Services @ (216) 485-8136 _______________________________

** Fees subject to yearly review.

BROOKLYN CITY SCHOOLS

Brooklyn Preschool Program

for Typical Peers

APPLICATION FORM

Child’s Name:_____________________________ Date of Birth: __________________

Social Security Number: ____________________ Gender: ______Male ______Female

Address: _______________________________________________________________

_______________________________________________________________________

Child lives with:__________________________________________________________

Father’s Name: __________________________ Mother’s Name: _________________

Home Phone: ____________________________ Home Phone: ___________________

Work Phone: ____________________________ Work Phone: ____________________

_____________________________________________ _______________

Signature of Parent/Guardian Date

_____________________________________________ _______________

Signature of Parent/Guardian Date

(For School Use Only)

Date Received: ____________________________ Time: ___________ (a.m./p.m.)

_____________________________________________________

Signature of Brooklyn Employee

BROOKLYN CITY SCHOOLS Brooklyn Preschool Program

Parent/Guardian Acknowledgement Form

I understand:

1. Ongoing parent/teacher collaborative activities enhance my child’s

preschool experience and will be mutually planned and arranged. This

collaboration is particularly important in the event that concerns arise.

2. I must comply with the Communicable Disease Policy

3. The need to maintain current child information (address, telephone, etc.)

and will update these items as necessary

4. I am responsible for transporting my child to and from the Brooklyn

Preschool Program

5. A Registration fee of $20.00 (non-refundable) payable in cash or money

order made out to Brooklyn City Schools is due at time of registration.

The Registration fee must be paid before student will be permitted to start

attending preschool.

6. Tuition payment is due prior to the beginning of the year/semester/month.

I understand that tuition (without scholarship) is:

$1,800.00** per year (school calendar year) if paid annually or bi-

annually (two payments of $900.00 each, September 1st, and

January 1st), or

$200.00** per month, due at the beginning of each month

beginning in September and continuing through May.

After 15 days, if tuition payment has not been made, a reminder letter is sent home to the

parents for non-payment. At 30 days, a letter is sent home with the balance not paid

indicating if the tuition is not paid in full within the next 15 days the child will be

withdrawn from preschool for lack of payment. A final notice letter is sent home after

45 days with a final attendance date at the end of the month.

_______________________________________________________________________

Parent/Guardian Signature Date

_______________________________________________________________________

Parent/Guardian Signature Date

_______________________________________________________________________

Student Name (Please Print)

________________________________

** Fees subject to yearly review

MANAGEMENT OF COMMUNICABLE DISEASES

If your child is ill when at home, do NOT send him/her to school. It is not fair to

expose other children to disease; neither will your child benefit from the experience.

We are not equipped to handle sick children, and you will be asked to pick them up

immediately.

Please call (216) 485-8127 if your child will be absent from the integrated or KATS

classroom.

Should your child become ill while at the school, we will isolate him/her from the rest of

the children and make him/her as comfortable as possible. We will contact you to pick

your child up as soon as possible. Remember, if someone other than the registering

parent will be picking up a child, staff members will require identification and your prior

notice, preferably in writing.

You child will be isolated and discharged to you immediately if these symptoms appear:

1. diarrhea more than once

2. severe coughing

3. difficult or rapid breathing

4. yellowish skin or eyes

5. tearing, inflamed eyes

6. temperature of 100 degrees Fahrenheit when taken by auxiliary method

7. untreated skin rash

8. dark urine or light stool

9. stiff neck

10. unusual spots

11. sore throat/vomiting

12. evidence of lice

Children who have fevers should return to school 24 hours after the fever is gone.

Children on antibiotics should remain at home until they have been receiving medication

for 24 hours.

Brooklyn Board of Education

9200 Biddulph Road • Brooklyn, Ohio 44144 • (216) 485-8191 • FAX: (216) 485-8118 www.brooklyn.k12.oh.us

Scholarships for Preschool Students

Dear Parent/Guardian: As a parent of a student attending the Brooklyn City School’s Preschool program, we are sending you information in advance to qualify for the scholarship through Universal Pre-Kindergarten (UPK) for the 2017-18 school year. Depending if and how you qualify, the monthly tuition of $200 would be reduced to either $100 or $130 based on the following:

Families whose annual gross income is below 200% of the Federal Poverty Level will receive a 50% reduction making the monthly tuition $100.

Families whose gross income is above 200% but below 400% will receive 1/3 off their fee making the monthly tuition $130.

Please see the attached guidelines and should you qualify:

1. Please complete the enclosed paperwork – this is required each school year even if your child was in Preschool the previous school year.

2. Do not forget to include either a copy of your 2016 tax return OR W2 for the parent(s)/guardian(s) of the student attending preschool.

Please drop this paperwork off at the Brooklyn Board of Education office as soon as possible. This is a wonderful opportunity to help make it more affordable for your family and we hope that you take advantage of this program. The scholarships will be awarded on a first come, first served basis until the funds are exhausted. Thank you, Department of Pupil Services Attachments

http://www.brooklyn.k12.oh.us/

Revised 3/2017

Original to: Child’s file Copy to: Invest in Children, 310 W. Lakeside Ave., #565, Cleveland, OH 44113

UPK Scholarship Income & Residency Verification Form 2017-18 This form is required to document the parents’ eligibility for a UPK scholarship based on their gross income and to document that families receiving scholarship assistance are residents of Cuyahoga County. Please attach the document(s) used to verify the parents’ income and residency.

Provider:___________________________________ Child name:________________________________ Date:______________________________________ Document used to verify Parents’ Total Family Gross Income (please attach) Check one: Weekly_____ Monthly____ Annually_____ Check one:

_____ Two most recent check stubs (PREFERRED) _____ Prior year’s tax return AND IRS Form W – 2 _____ Documentation for all unearned income (award letter and/or summary statement) _____ Statement/documentation of self-employment _____ A copy of the child care authorization letter for subsidized care If parent did not provide child care authorization letter, residency was documented by (please attach): Check one: _____ Most recent check stub with home address _____ Current form of identification with address _____ Current utility bill Total Family ANNUAL Gross Income: Family Size: (Calculated from above OR Based on Line 22 from IRS 1040 Tax Return)

______________________________________ _________ Indicate where the parents’ ANNUAL GROSS income falls on the Federal Poverty Level Scale (refer to table below) Check one _____ Below 100% FPL

_____ Below 200% FPL _____ Below 300% FPL _____ Below 400% FPL _____ Above 400% FPL

2017 Federal Poverty Guidelines – Annual Gross Income

*Add $4,180 for each person over 8

Persons in

Household 100% 200% 300% 400%

1 $12,060 $24,120 $36,180 $48,240

2 $16,240 $32,480 $48,720 $64,960

3 $20,420 $40,840 $61,260 $81,680

4 $24,600 $49,200 $73,800 $98,400

5 $28,780 $57,560 $86,340 $115,120

6 $32,960 $65,920 $98,880 $131,840

7 $37,140 $74,280 $111,420 $148,560

8 $41,320 $82,640 $123,960 $165,280

Note: Annual Family Gross Income and family size must be entered into COPA.

I attest that all income and residency information is true and accurate and I will inform the

provider of any changes. I understand that by submitting this information my child is entitled to

scholarship assistance of one-half of the parent fee if my income is below 200% of the FPL or one-

third of the parent fee if my income is more than 200% FPL but less than 400% of the FPL.

X______________________________________________________ Parent Signature

Universal Pre-Kindergarten COPA Application

Application Date: ______________

Child’s Name: ____________________________________ Birth Date: _____________________

Gender: (Circle One) Male Female Social Security Number: _____________________

Language: __________________ Ethnicity: (Circle One) Hispanic Latino Neither

Race: (Circle One) African American Asian Bi-Racial/Multi-racial Caucasian

Native American Other Pacific Islander Unspecified

Disability (if applicable): ___________________ Circle Any Plan Applicable: IEP/IFSP/NCP

Primary Caregiver:

Parent/Guardian Name: ______________________________ Birth Date: ___________________


Address: ___________________________________________________________________________

City: ______________________________ State: __________ Zip Code: ____________________

Home Phone Number: _____________________ Cell Phone Number: _____________________

Education Level: _____________________ Employment Status: _________________________

Employer/School Name: __________________________ Income: _________________________

Employer/School Phone Number: ____________________________________________________

# in Family: ______ # in Household: _______ Disability: (Circle One) Yes No

Medical Insurance Carrier: __________________________________________________________

Current Housing: (Circle One) Homeless Own Rent Other

Current Housing Date: ____________ Caregiver Relationship to Child: ________________

Is there a Secondary Caregiver/ Parent/ Guardian? (Circle One) Yes No

If there is a Secondary Caregiver, complete the next section on Page 2 and sign the

verification section. If there is no Secondary Caregiver in the home, then skip the next

section and proceed to verification section.

PLEASE FILL OUT FORM

COMPLETELY AND SIGN

Universal Pre-Kindergarten COPA Application

Secondary Caregiver:

Parent/Guardian Name: ______________________________ Birth Date: ___________________


Address: ___________________________________________________________________________

City: ______________________________ State: __________ Zip Code: ____________________

Home Phone Number: _____________________ Cell Phone Number: _____________________

Education Level: _____________________ Employment Status: _________________________

Employer/School Name: __________________________ Income: _________________________

Employer/School Phone Number: ____________________________________________________

Language: _____________________________ Disability: (Circle One) Yes No

Medical Insurance Carrier: __________________________________________________________

Caregiver Relationship to Child: __________________

Verification Section:

I verify that the information on this application is correct.

Parent/Guardian Name : (Print) _______________________________________

Signature: _____________________________________ Date: _______________

Staff Name: (Print) ____________________________________________________

Staff Signature: ________________________________ Date: ________________

Cuyahoga County

Invest in Children

310 W. Lakeside Ave., #565

Cleveland, OH 44113

(216) 698 – 2215

ACKNOWLEDGEMENT OF RECEIPT OF THE

NOTICE OF PRIVACY PRACTICES

Acknowledgement of Receipt of Privacy Practices: I, the undersigned, acknowledge that I have

received and have been given the opportunity to review the Cuyahoga County Universal Pre-

Kindergarten (UPK) Program Notice of Privacy Practices. I understand that I will be given

additional copies of this Notice of Privacy Practices any time at my request.

Please list children enrolled ages 3 to 5 years (not in kindergarten)

First Name Middle Name Last Name Date of Birth

Name of Parent/Guardian __________________________________________________

Address ________________ ________________

___________________ ___________________

Telephone ( ) ______ -__ ____ ( ) _____ -____ ___ Home Work

________________________________________________________

Signature

________________________________________________________

Print Name

________________________________________________________

Date

Original: UPK Site File Copy: Copy: Parent

Starting Point

Attn: Julia Garber

4600 Euclid Avenue, Suite 500

Cleveland, OH 44103

Cuyahoga County Universal Pre-Kindergarten (UPK) Program

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOUR CHILD’S EXPERIENCE IN THE

CUYAHOGA COUNTY UPK PROGRAM, ADMINISTERED BY THE OFFICE OF EARLY CHILDHOOD,

MAY BE USED AND DISCLOSED. PLEASE REVIEW THIS INFORMATION CAREFULLY. If you have

questions about this notice or wish to request addition copies, please contact the Office of Early

Childhood at (216) 443-2215.

I. Who is subject to this notice: This notice describes the practices of the UPK program and

that of:

1) Cuyahoga County’s Office of Early Childhood

2) Starting Point

3) The individual UPK provider that your child attends

4) Case Western Reserve University (business associate)

5) Pascal Learning Inc./Ready Rosie

II. Our pledge: We understand that information about your child’s experience in the UPK

program is personal and we are committed to protecting that information. A record of

your child’s UPK experience is created in order to provide your child with a high quality

experience and to help us make improvements to the program. This notice applies to all

records created by your child’s UPK provider. This notice will tell you about the ways in

which we use the information gathered on your child.

III. Examples of the types of information we collect:

1) Age, gender and race of your child

2) Street Address

3) Email Address

4) Attendance and enrollment information

5) Assessments of your child

6) Parent involvement in UPK activities

7) Child’s special needs, if applicable

8) Other

IV. Uses:

Information collected about your child and their UPK experience may be used and disclosed as

follows:

1) By his/her teacher to create a unique learning plan for your child -

2) By your provider to prepare regular invoices to you for UPK services

3) By your provider to prepare invoices to the OEC to be reimbursed for the services

provided to your child

4) By your provider to refer your child to additional services in the community

5) By the OEC, and their business associate at CWRU, to run the program and make

improvements

6) By Starting Point to plan support for your UPK provider and to help your UPK provider

make improvements to the programs and services you and your child receives

7) Email addresses only: By the OEC, and their business associate Pascal Learning

Inc./Ready Rosie, to provide parents with brief videos that will help them prepare their

children for school. Parents may unsubscribe from the electronic delivery of these

emails at any time.

V. Your Rights Regarding Your Child’s UPK records

1) You are allowed to inspect and make copies of any records created about your child

2) You are allowed to amend your child’s record if you feel that there is information in

it that is wrong

3) You are allowed to request restrictions or limitations on the uses of the information

collected about your child. To request restrictions, you must make your request in

writing to the Director of the Office of Early Childhood. All parent requests will be

responded to in writing.

VI. Changes to This Notice

We reserve the right to make changes to this notice. If this notice is changed, you will be

advised and furnished with a copy of the revised notice.

VII. Effective Date of This Notice

1) The effective date of this notice is August 1, 2015.

Questions/Concerns Contact:

Cuyahoga County

Invest in Children

Attn: Evaluation Manager

310 W. Lakeside Ave., #565

Cleveland, OH 44113

(216) 698 – 2215

CUYAHOGA COUNTY Invest in Children

Universal Pre-Kindergarten Health Screening Resources

1

Pediatric Dental Provider Name Address Phone Number Payment Method CWRU School of Dental Medicine Early Childhood Dental Program*

2124 Cornell Rd., Cleveland, OH 44106 216-368-0665

Private PPO and All County Medicaid Plans or Check or Money Order for set amount (call for exact amount)

Tri-C’s Dental Hygiene Clinic

2900 Community College Ave., MetroHealth Careers and School (MHCS), Rm.127, Cleveland, OH 441155

216-987-4413 Cash only, No insurance accepted $10- Children 17 yrs. and younger; $15- ages 18 and up; Periodic free cleaning and sealants by appt. only

MetroHealth Medical Center

•Main Campus- Dental Clinic, 2500 MetroHealth Dr., Cleveland, OH 44109 •Lee-Harvard Clinic, 4071 Lee Rd., Ste.260, Cleveland, OH •Broadway Clinic, 6835 Broadway Ave., Cleveland, OH

216-778-4725 216-957-1222 216-957-1850

Private insurance, Medicaid; credit cards; financing options, call 216-778-4737 or 216-778-7294

Northeast Ohio Neighborhood Health

Services, Inc.

(See Medical Services below – NEON does provide pediatric dental services -details below)

Care Alliance Health Care

(See Medical Services below – Care Alliance Central Clinic does provide pediatric dental services -details below)

St. Luke’s Dental Practice 1201 Shaker Blvd. Cleveland, OH 44104 216-368-7238 Medicaid, Private Insurance and financing options

Vision Name Address Phone Number Payment Method Prevent Blindness Ohio-Northeast OH Chapter* (trains providers on how to screen)

Hillcrest Medical Building#1, 6803 Mayfield Rd., Suite 111, Cleveland, OH 44124

800-331-2020 Or 440-720-1285

**does not provide vision screening to individuals; works with centers

Easter Seals Northern Ohio*

1929 A East Royalton Rd., Broadview Hts., OH 44147 440-838-0990 Medicaid; Private Insurance; sliding scale

Hearing & Speech Name Address Phone Number Payment Method Cleveland Hearing & Speech Center

•11635 Euclid Ave., Cleveland, OH 44106 •4257 Mayfield Rd., S. Euclid, OH 44121 •7000 Town Dr.#200, Broadview Hts., OH 44147

216-231-8787 216-382-4520 440-838-1477

Medicaid; Private Insurance; Call for appointment and financing options

Easter Seals Northern Ohio

1929 A East Royalton Rd., Broadview Hts., OH 44147** 14701 Detroit Ave., Lakewood, OH 44107

440-838-0990 **Central Intake phone #

Medicaid; Private Insurance; sliding scale

CUYAHOGA COUNTY Invest in Children

Universal Pre-Kindergarten Health Screening Resources

2

Medical Services (Immunizations, Lead Screening, Well Child Visits)

Name Address Phone Number

Payment Method

Cleveland Department of Public Health Services: Immunizations and Lead Screening

The City of Cleveland Health Centers: •J. Glen Smith Health Center 11100 St. Clair Ave., Cleveland, OH 44108 •Thomas F. McCafferty Health Center 4242 Lorain Ave., Cleveland, OH 44113 •Miles-Broadway Health Center 9127 Miles Ave., Cleveland, OH 44105** www.clevelandhealth.org

216-249-3600 216-957-4848 216-664-3609

FREE FOR EVERYONE! Call for appointments *Immunizations only at Miles-Broadway

Cuyahoga County Board of Health Services: Immunizations and Lead Screening

5550 Venture Rd., Parma, OH 44130 216-201-2041 Medicaid accepted Call for an appointment and information regarding non-Medicaid payment options (Lead screening once a month by appointment)

Northeast Ohio Neighborhood Health Services, Inc. Services: Dental Immunizations Lead Screening Provides all medical services (functions as a medical home)

•East Cleveland Health Center, 15201 Euclid Ave., East Cleveland, OH 44112 •Superior Health Center, 12100 Superior Ave., Cleveland, OH 44106 •Southeast Health Center, 13301 Miles Ave., Cleveland, OH 44105 •Norwood Health Center, 1468 E. 55th St., Cleveland, OH 44103 •Hough Health Center, 8300 Hough Ave., Cleveland, OH 44103 •Collinwood Health Center, 15322 St. Clair Ave., Cleveland, OH 44110 • Miles-Broadway Health Center 9127 Miles Ave., Cleveland, OH 44105

216-541-5600 216-851-2600 216-751-3100 216-881-2000 216-231-7700* 216-851-1500 216-664-7487

Medicaid, private insurance and has a discounted fee structure based on family size and income (No lead screening or dental at Miles/Broadway *Central Intake 216-231-7700

Care Alliance Health Care Services: Dental, immunizations,Lead Screening Provides all medical services (functions as a medical home)

2916 Central Ave. Cleveland, OH 44115

216-535-9100 Medicaid and sliding scale

* Resources that will train staff and/or come to your location to conduct tests and screenings on children.

Please remember to call 2-1-1 for additional information on resources available in Cuyahoga County.

Please call providers listed above for additional information.

Office of Early Childhood/Invest in Children 310 W. Lakeside Avenue – Suite 565, Cleveland, Ohio 44113, (216) 443-7575, Ohio Relay Services 711

Revised 8/2015

Universal Pre-Kindergarten Health Screening Requirement Acknowledgement Form

Dear Parent(s)/Caregiver, As part of the Universal Pre-Kindergarten program your child must have certain health screenings. These screenings may help prevent future problems with your child’s health. Some of these screenings may be offered by your child’s preschool. If not, a list of resources is attached for those screenings that may not be provided by your child’s preschool.

Thank you!

Below is a list of required screenings Lead screening Hematocrit/Hemoglobin screening Dental screening Vision screening Hearing screening

Your signature below verifies that you are aware of the medical screenings your child needs; confirms that you received the necessary forms for your doctor or dentist to complete; and confirms that you received the list of local resources available to assist you with completing the medical screenings. Child’s Name

__________________________________________ _________________ Parent/Caretaker Date

__________________________________________ _________________ Site Manager/Representative Date

Original to Parent Copy to Child’s File

BCSD EMERGENCY MEDICAL AND STUDENT RELEASE AUTHORIZATION EMERGENCY CONTACTS: In case of an emergency with your student, the school office will call and notify you at the primary number provided. If you are not reached at the primary number, phone calls will be made to the contacts and phone numbers listed below in the order given until someone is notified.

STUDENT’S NAME DOB _______ GRADE

First, Middle, Last

ADDRESS ___ BROOKLYN, OH 44144

Contact Name

Phone

Resides @ same address

as Primary Contact

(for YES)

Can authorize medical

treatment (for YES)

Can release student to this person

(for YES)

Authorized to receive

Educational Records

(for YES)

PRIMARY CONTACT/Relationship to child Name: Email address:

C W H

2nd Contact Name/Relationship to child

C W H

3rd Contact Name/Relationship to child

C W H

4th Contact Name/Relationship to child

C W H

TO GRANT CONSENT In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of treatment deemed necessary by the below named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist: and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

(Physician) Dr. Phone

(Dentist) Dr. Phone

Local Hospital Phone

Emergency Room Phone

Facts concerning the child’s medical history including allergies, medication being taken, and any physical impairments to which a physician or nurse should be alerted:

Date Signature of Parent/Guardian

STUD

ENT LA

ST NA

ME___

_______

______

________

________

______

FIRST N

AM

E______

______

________

________

_____ G

RA

DE___

____ SC

HO

OL Y

EAR

______

REFUSAL TO CONSENT

In the event reasonable attempts to contact me at the numbers given have been unsuccessful, I DO NOT give my consent for

emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school

authorities to take no action, or to:

Date Signature of Parent/Guardian

*OTHER COMMENTS -

Effective August, 1 2017

brooklyn city school district preschool registration …

Documents