EVSC Prek - 8th Grade Enrollment Form

Student’s Name: __________________________________________________ Grade: _______ First Middle Last Suffix

Male ____ Female ____ Date of Birth: ____________ Primary Phone: _______________________

Student’s Birthplace (City, State and Country): ________________________________________________

Home Address: _________________________________________________________________________ Street Address City State Zip Do you currently own or rent your home?

Last School Attended:

Parents/Guardians 1:Name 1: _______________________ Name 2: _______________________ Cell # 1: ______________________ Cell # 2: ________________________Workplace: ____________________ Workplace: ______________________Work # 1: _____________________ Work # 2: _______________________Email*: _______________________ Email*: _________________________Address: _______________________________________________________Relationship to student _____________________________

DO NOT WRITE BELOW THIS LINE – FOR SCHOOL USE ONLYEntry date: __________ Grade: _________ Room _________ Teacher: ____________________ EVSC ID No. ___________________ Bus No.: ____________ Records sent for: __________________ Records received: _________________State Test Number (STN): _____________________________ Entry Code: _________________

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Please list emergency contacts other than parents. Include additional contact numbers on a separate sheet, if needed.

Emergency Contact 1: ________________________ Relationship: ____________ Phone: _______________ Emergency Contact 2: ________________________ Relationship: ____________ Phone: _______________

Emergency Contact 3: ________________________ Relationship: ____________ Phone: _______________ Emergency Contact 4: ________________________ Relationship: ____________ Phone: _______________

Is there anyone, by court order, who is not allowed to pick up this student? If so, who?* ______________________ ______________________

* The school must have legal documents on hand in order to enforce if the person listed is a parent.

List parents/guardians living with student (i.e. mom & dad or mom & stepdad, etc.)

If enrolling in the summer, list future grade

Parents/Guardians 2:Name 1: _______________________ Name 2: ______________________ Cell # 1: ______________________ Cell # 2: ________________________Workplace: ____________________ Workplace: ______________________Work # 1: _____________________ Work # 2: _______________________Email*: _______________________ Email*: _________________________Address: _______________________________________________________Home Phone: _______________________ Relationship to student _____________________________

(Other Parent Household, if applicable)

(mom & dad/mom & stepdad, etc.)

(mom & stepdad, dad and stepmom etc.)

How will student normally:Arrive at school: ___ Bus

___ EVSC Daycare

___ Walk

___ Car rider

Go home:___ Bus

___ EVSC Daycare ___ Walk

___ Car rider

* Only two emails per student

School Name City State Country

Rev. 2/2020

Yes No

Student Name: _______________________________________________________1. Does this student have school-aged brothers and sisters living in the same household? If so, please list their names and schools they attend. (If more space is needed, please use a separate piece of paper.) ________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________

2. Is this student’s parent(s) a current duty member of any branch of the armed forces? ____ Yes ____ No

3. Within the last 3 years, has your child(ren) moved from one school district to another within the United States, with a parent, relative or guardian so that person could look for seasonal or temporary work in agriculture? ____Yes ____No

4. If enrolling in fourth grade or higher from another Indiana school: Did your student pass Indiana IREAD? ___Yes ___No List school, including city where student took the IREAD test: _____________________________

5. If enrolling in PreK or Kindergarten: Is your child currently attending or has your child attended one of the preschool programs listed below. ____ Yes ___ NoIf yes, which one*? If no, leave blank

6. If born outside U.S. - Date Enrolled in U.S. School: ________________________________________ Name of School: ________________________________________

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I confirm that the above information is true, correct and complete to the best of my knowledge. Parent Signature: _________________________________________ Date: _______________

7. Does your student have or receive: ___ 504 ___ Individual Education Plan (IEP) (Special Education) ___ High Ability Services ___ Speech ___ English as a Second Language (ESL)

8. Is the student currently under expulsion/suspension from another school? ____ Yes ____ No

* If your student attended more than one of the programs listed above, mark the one he/she most recently attended.

___ EVSC Preschool Programs___ Arc Child Life Center___ CAPE Head Start___ Carver___ Central Child Care___ Deaconess

___ Fairlawn Children’s Center___ Highpoint___ Kindergate___ La Petite (St. Vincent)___ Methodist Temple

___ Milestones___ Mt. Pleasant___ Oak Hill Baptist___ St. Mark’s___ St. Vincent’s___ USI Children’s Center

Home Language Survey (HLS)

The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in

each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students

as outlined Plyler v. Doe, 457 U.S. 202 (1982).

The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district / charter school. The HLS is administered one time, upon initial enrollment, and remains in the student's cumulative file. If original HLS is received, then the original version must be filed with student record.

Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the

survey questions below, the W-APT will be administered to determine whether or not the student will qualify for additional English

language development support.

Por favor tenga en cuenta que las respuestas a la encuesta corresponden solamente a su hijo/a. Si en alguna de las tres preguntas escritas abajo,

usted identifica un idioma diferente al inglés, la escuela administrará la Prueba del Desarrollo del Inglés (W-APT) para determinar si su hijo/a

calificará para el programa de desarrollo del idioma inglés.

Jouj im lale ke uwaak ko ilo kein jonak eo ilal rej ekkar nan kajjojo ri-jikuuļ. Ne ej rekoot juon kajin me ejjab Kajin Pālle ikijjien JABDEWŌT iaan

kajjitōk ko ilo kein jonak eo ilal, jenaaj leļọk W-APT eo nan kile ne ri-jikuuļ eo ej ekkar nan bōk bar jipan nan kōwōnṃaanļọk ilo Kajin Pālle.

Please answer the following questions regarding the language spoken by the student:

Por favor responda las siguientes preguntas acerca del idioma(s) hablado por su estudiante:

Jouj im uwaake kajjitōk kein ilal ikijjien kajin eo ri-jikuuļ eo ej kōjerbale:

1. What is the native language of the student? ¿Cuál es el idioma o el dialecto nativo del estudiante?

Etan lukkuun kajin eo an ri-jikuuļ eo?

2. What language(s) is spoken most often by the student? ¿Cuál es el idioma(s) más hablado por el estudiante?

Etan kajin eo/ko me eļaptata an ri-jikuuļ eo kōjerbale?

3. What language(s) is spoken by the student in the home? ¿Cuál idioma(s) habla el estudiante en casa? Etan kajin eo/ko me ri-jikuuļ eo ej kōjerbale ilo ṃweo iṃōn?

Student Name: Grade: Nombre del estudiante / Etan Ri-jikuuļ eo Grado / Kilaaj

Parent/Guardian Name: Nombre del padre, madre o guardián / Etan jinen, jemen ak ri-lale

Parent/Guardian Signature:__________________________________________Date: Firma del padre, madre o guardián / An jinen, jemen ak ri-lale jain Fecha / Raan

By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has

been identified, your student will be tested to determine if they qualify for English language development services. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.

Al firmar aquí, usted certifica que las respuestas a las tres preguntas mencionadas arriba corresponden a su hijo/a. Usted entiende que si se ha identificado un

idioma diferente al inglés, su hijo/a tendrá un examen para determinar si él o ella califica para el programa de desarrollo del idioma inglés. Si entra en el programa de desarrollo del idioma inglés, su hijo/a, tendrá derecho a servicios que lo ayudarán a aprender el idioma inglés y tendrá un examen cada año para

determinar su nivel de inglés.

Ilo aṃ jain ijin, kwōj kaṃool ke uwaak ko nan kajjitōk ko jilu itulōn rej ekkar nan ri-jikuuļ eo nājūṃ wōt. Kwōj meļeļe ke elanne kwaar jitōne juon kajin me ejjab

Kajin Pālle, jenaaj teej ri-jikuuļ eo nājūṃ nan kile elanne ej ekkar nan bōk jipan nan kōwōnṃaanļọk ilo Kajin Pālle. Elanne ej deļọn būrookraaṃ in

kōwōnṃaanļọk ilo Kajin Pālle, enaaj wōr an ri-jikuuļ eo nājūṃ maron in bōk jipan āinwōt juon ri-ekkatak Kajin Pālle im jenaaj teeje kajjojo iiō nan kile an jeļā Kajin Pālle.

For School Use Only: School personnel who administered and explained the HLS and the placement of a student into an English language development program if a language other than English was indicated:

Name:_________________________________________________ Date:___________________________

Student Name: _______________________________________________________________ Ethnicity – Please answer both questions. 1. Is your child Hispanic or Latino? (Please mark only one.) ____ No, my child is not Hispanic or Latino. ____ Yes, my child is Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. 2. What is your child’s race? (At least one must be marked, but please mark all that apply.) ____ American Indian or Alaska Native – A person having origins in any of the original peoples of North and South American (including Central America) and who maintains tribal affiliation or community attachment. ____ Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, e.g. Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

____ Black or African American – A person having origins in any of the black racial groups of Africa.

____ Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Island.

____ White: A person having origins in any of the original peoples of Europe, the Middle East, or

North Africa.

I affirm that the foregoing information is true, correct and complete to the best of my information and belief. Parent Signature: _________________________________________ Date: _______________

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Revised:3/2017

To Parents/Guardians: The Office of Health Services and Wellness of the Evansville Vanderburgh School Corporation highly recommends that every child have at least three physical examinations during his or her school career. One examination should be given at the time the child first enters school, most often this is upon entering Kindergarten. Students transferring from other school systems at any grade level should also have a physical examination or a report of a recent physical examination. The other grade levels where physical examinations are recommended are at the beginning of sixth grade and at the beginning of ninth grade.

We ask you to take the “Physical Examination Record” (Form #75.880), included with

this letter, to your physician and return it to the school nurse on the first day of

school. The record of immunizations is to be completed by a physician and returned with the examination record. For students who plan to participate on a high school athletic team during the school year, the Indiana High School Athletic Association (IHSAA) form must also be completed by the physician and the parent after April 1st. It is helpful to schedule this examination during the summer to avoid the last minute rush in August. Beginning in 2010, Indiana Code requires that immunization records be entered into the State Immunization Registry (CHIRP) for all Indiana students. A parental consent to

release your child’s shot record to this Registry may also be attached: If this form is attached and you give consent, please sign and return it also. If it is necessary for this student to be excused from physical education, please contact the school nurse for the appropriate form to be completed by the physician. If you are financially unable to take your child to the doctor, please be aware that there are agencies available that can provide services on a sliding-fee-scale, based on your income. Please contact your school nurse for information.

Sincerely,

School Nurse

75.870 Rev. 2004, 2007, 2010, 2013, 2014, 2016

StudentHealth&AuthorizationForm

Student’sName:__________________________________________BirthDate:__________Sex:______Grade:____________Address:_________________________________________________________Homeroomteacher:_________________________

HealthInformation(Checkallthatapplyandincludeanyothernecessaryinformation)Allergies ChronicConditions Food:_________________________________________ Asthma*:_________________________________________ Medications:___________________________________ Diabetes*:________________________________________ Other:________________________________________ Seizures*:________________________________________ Other:___________________________________________Operations Injuries Type&Date:______________________________________ Type&Date:_________________________________________Type&Date:______________________________________ Type&Date:_________________________________________

SpecialRestrictions Mobility:______________________________________ Emotional:________________________________________ Vision(glasses,contacts):______________________________ Speech:__________________________________________ Hearing:______________________________________ Other:___________________________________________

Diseases&ConditionsPleaselistanydiseasesorconditionsyourstudentwasdiagnosedwithandthedate.Includethingssuchaswhoopingcough,chickenpox,hepatitis,epilepsy,nosebleeds,highfevers,faintingspells,Tuberculosis,etc.Disease:________________________ Date:_______________ Disease:_____________________ Date:___________Disease:________________________ Date:_______________ Disease:_____________________ Date:___________

Medications*Medicine:_____________________ Dosage:________ Medicine:_________________________ Dosage:_____________Medicine:_____________________ Dosage:________ Medicine:_________________________ Dosage:_____________

HealthcareInformationDoctor’sName:___________________________________ Phone:_______________________ Dentist’sName:___________________________________ Phone:_______________________ HospitalPreference:_______________________________ Doyouhavehealthinsurance? Yes: No: Doyouhavedentalinsurance Yes: No: * Please contact your school nurse to create a care plan.

1. IN CASE OF AN EMERGENCY INVOLVING YOUR CHILD, THE EVSC WILL TAKE APPROPRIATE MEASURES TO CARE FOR YOUR CHILD AND THEN CALL THE PARENT/GUARDIAN. IN THE EVENT THE PARENT/GUARDIAN CANNOT BE REACHED, OR IF AN INJURY IS LIFE THREATENING, THE EVSC WILL CALL 911 FOR EMERGENCY HELP AND THEN CALL THE PARENT/GUARDIAN.

2. EVSC WILL KEEP YOUR MEDICAL INFORMATION AS CONFIDENTIAL AS POSSIBLE, BUT FOR HEALTH AND EMERGENCY PURPOSES, INFORMATION ON THIS FORM MAY BE SHARED WITH EVSC PERSONNEL.

NOTE: IF AT THE END OF THE SCHOOL DAY, YOUR CHILD IS ILL OR HAS NOT BEEN PICKED UP AND YOU OR YOUR EMERGENCY

CONTACT DESIGNEE(S) CANNOT BE REACHED, EVSC MAY CALL CHILD PROTECTIVE SERVICES IF OTHER ARRANGEMENTS CANNOT BE MADE.

“I UNDERSTAND THAT AS PARENT/LEGAL GUARDIAN I MAY GIVE AUTHORIZATION FOR THE DISCLOSURE OF MY CHILD’S PROTECTED HEALTH INFORMATION. I UNDERSTAND THAT SUCH HEALTH INFORMATION IS PROTECTED BY FEDERAL REGULATIONS UNDER EITHER THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OR THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT OF 1974 (BUCKLEY AMENDMENT) AND MAY NOT BE DISCLOSED WITHOUT EITHER PARENT/LEGAL GUARDIAN AUTHORIZATION UNDER HIPAA OR CONSENT UNDER THE BUCKLEY AMENDMENT. I HEREBY GIVE PERMISSION TO EVSC TO SHARE INFORMATION RELEVANT TO MY CHILD’S HEALTH CONDITION WITH APPROPRIATE SCHOOL PERSONNEL OR HEALTH CARE PROVIDERS WHEN NEEDED TO MEET MY CHILD’S HEALTH AND SAFETY NEEDS. I ALSO GIVE PERMISSION TO EXCHANGE INFORMATION WITH MY CHILD’S PRIMARY HEALTH CARE PROVIDERS FOR THE PURPOSE OF REFERRAL, DIAGNOSIS AND TREATMENT. I UNDERSTAND THAT I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTIFICATION IN WRITING TO EVSC, BUT IF I DO, IT WILL NOT HAVE ANY EFFECT ON THE ACTIONS OF THOSE REPRESENTING EVSC PRIOR TO RECEIVING THE REVOCATION.” THISAUTHORIZATIONEXPIRESONEYEARAFTERTHEDATEDSIGNATURE.

PARENT/LEGALGUARDIANSIGNATURE_____________________________________________ DATE________________________________

Form 75.880 Rev. 05/00, 09/05, 08/07, 3/13

OFFICE OF HEALTH SERVICES & WELLNESS

Home Room Teacher ____

Physical Examination Record (To be filled out only by a physician)

Name Grade Date Address Phone No. Date of Birth Sex Family Physician Circle abbreviation of Immunization administered PHYSICAL EXAMINATION (Code: No Defect - 0; Defect - Note) 1. Height (in inches) Weight 2. Eyes: Vision (Snellen) Right

Left Glasses Right

Left 3. Ears: Right Left Hearing: Right Left 4. Teeth: Caries 5. Nose 6. Throat 7. Lymph Nodes 8. Thyroid 9. Heart 10. Blood Pressure 11. Lungs 12. Abdomen 13. Hernia 14. Orthopedic Impairments 15. Scoliosis Screening 16. Nutrition 17. Skin 18. Nervous Symptoms 19 Menstrual History 20. Ano-rectal 21. External Genitals 22. General Condition 23. History of severe illnesses, injuries or surgeries: 24. Ongoing Medical Concerns:

RECORD OF REQUIRED IMMUNIZATIONS DPT/DTaP 1. MMR 1. DPT/DTaP 2. 2. DPT/DTaP 3. 3. DPT/DTaP 4. DPT/DTaP 5. Hepatitis B DPT/DTaP 6. 1. 2. Td 1. 3.

2. Tdap 1. HIB 1. 2. _ 2. 3. Polio Vaccine 4. OPV/ IPV 1. OPV/ IPV 2. Prevnar1. OPV/ IPV 3. 2. OPV/ IPV 4. 3. OPV/ IPV 5. 4. OPV/ IPV 6.

Varicella Meningococcal 1. 1. MCV4 / MPSV4 2 2. Hep A 1.___________ HPV 1. 2. 2,______________ Other 1.___________ 3.______________ 2.___________ TESTS Tuberculin: Type Date Results: X-Ray Lead Screen : Date Results Sickle Cell Anemia: Yes No Results Urinalysis: Date Results Allergies:

Physician’s Recommendations

I recommend medical or dental attention to the following conditions: ________________________________ ______________________________________________________________________________________ Student physically fit to participate in physical education? Yes ________ No _________ _________________________________________ ________________________________________ Date Print Physician’s Name Signature of Physician

PLEASE RETURN TO THE SCHOOL NURSE

I, _________________________________, give ___________________________, permission (Parent/Guardian Name) (Name of School) to release the following information concerning my child, ________________________, to the (Name of Child) Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP):

CHILD’S NAME, DATE OF BIRTH, ADDRESS, ETHNICITY and IMMUNIZATION DATA

I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me or my child of my child’s immunization status or that an immunization is due according to recommended immunization schedules. I understand that my child’s information may be available to the immunization data registry of another state, a healthcare provider or a provider’s designee, a local health department, an elementary or secondary school, a child care center, the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, a licensed child placing agency, and a college or university. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3. I hereby consent to the release of such information. __________________________________________________ _______________________ Signature Date __________________________________________________ Printed Name of Parent or Guardian __________________________________________________ _(____)_________________ Address Telephone Number __________________________________________________ _______________________ Child’s Name Grade Level __________________________________________________ School

PLEASE RETURN COMPLETED / SIGNED FORM TO SCHOOL NURSE