mes step 2

Meadowlark Elementary School

On-‐Line Enrollment Step 2 Document 2011/2012

WELCOME BACK TO

MEADOWLARK ELEMENTARY

New Students Enroll

Monday, August 8 (8 a.m. to 12 p.m. & 1 p.m. to 4 p.m.) (in the Meadowlark Office)

Returning Students Enroll Tuesday, August 9 (12:30 p.m. to 7 p.m.)

(in the Meadowlark Office)

Meet Your Teacher Night Tuesday, August 16 (5:30 p.m. to 6:30 p.m.)

First Day - Grades 1st thru 5th

Thursday, August 18 (8:35 a.m.)

First Day - Kindergarten (Monday, August 22) All Day 8:35a.m. to 3:35 p.m.

Half Day 11:35 p.m. to 3:35 p.m.

Kindergarten Screening Thursday, August 18

Friday, August 19

Office Use: Amount $_______________Check#_____________Cash__________Online__________

2011-2012 Meadowlark Elementary

Student Name:

Grade:

Required Fees $65.00 - Half Day Kindergarten Textbook Fee

$75.00 - All Day Kindergarten, 1st thru 5

th Grade

$25.00 - All Day Kindergarten, 1st thru 5

th Grade

$12.50 - Half Day Kindergarten Technology Fee

Elective Fees $100.00/1 student - Transportation Fee (for all students who live less than 2.5 miles from their school and choose to ride

the bus)

$150.00/family - Transportation Fee (for all students in one family who live at the same address)

$275.00 – Monthly Fee for All Day Kindergarten

Food Service Fees $1.50 – Breakfast

$2.05 – Lunch

$0.40 – Snack Milk (kindergarten only)

Required Fee Payment Options • Check or money order payable to Meadowlark Elementary School• Pay online at www.usd385.org

Elective Fee Payment Options • Check or money order payable to USD• Pay online at www.usd385.org

Food Service Payment Options • Check or money order payable to USD #385 Food Service• Pay online at www.usd385.org

Applications for free and reduced fee assistance are

The following forms will need to be printed off and returned to the school off

complete. Please check off that you are returning the following forms:

_____ Request for Transcript (new students

_____ Placement Information (new students only)

_____ Proof of Residence (new students only)

_____ School Directory Form (optional)

_____ PTO Committees (optional)

_____ Request for Paper Copy of Newsletter (optional)

_____ Free & Reduced Application (if applicable)

_____ Student Requiring Special Meals (if applicable

_____ Birth Certificate (new students only)

Amount $_______________Check#_____________Cash__________Online__________

Elementary Fees

Half Day Kindergarten Textbook Fee

Grade Textbook Fee

Grade Technology Fee

Half Day Kindergarten Technology Fee

for all students who live less than 2.5 miles from their school and choose to ride

(for all students in one family who live at the same address)

or All Day Kindergarten

payable to Meadowlark Elementary School

payable to USD #385

payable to USD #385 Food Service

Applications for free and reduced fee assistance are available online.

The following forms will need to be printed off and returned to the school office

Please check off that you are returning the following forms:

new students only)

(new students only)

(new students only)

opy of Newsletter (optional)

applicable)

if applicable)

Amount $_______________Check#_____________Cash__________Online__________

for all students who live less than 2.5 miles from their school and choose to ride

(for all students in one family who live at the same address)

ice before enrollment is

Volunteer Sign-up Sheet

All Meadowlark parents and staff are members of the school’s Parent-Teacher Organization (PTO). The PTO coordinates more than 30

different school activities and services which cannot happen without our wonderful Meadowlark parent volunteers! Please consider being

involved. Mark the box next to the committees you could help with. Thank you!

Name:_______________________________________Primary/Secondary Phone Numbers: _____________________________________

E-mail address:________________________________Name of Child/Children & grade(s)_______________________________________

General Volunteer Receive e-mails when help is needed for any PTO activity. Help when you can.

Home Room Parent Become the home room parent in your child’s class; plan the fall and spring parties with other parents’ help.

Helping Hands

Greet and direct students to their class and to/from the bus on the first few days of school. Help in the

lunchroom during the first week of school.

Welcome Wagon

Help plan the September Welcome Wagon Coffee to welcome all families back to Meadowlark for another

great year. Greet new families during the year at PTO meetings.

Spring Fund Raiser Help organize and work the fundraiser in April.

GAD Parade Help design and build the float for the Greater Andover Days Parade on October 1, 2011.

Parent/Teacher Conferences Provide food and other items for teacher meals during conferences in October and February.

Box Tops/Tyson

Help to collect, count and forward box tops to General Mills and Tyson labels to Tyson. This is a great

fundraiser for the school. All money received from Boxtops goes to the Staff Grant Program.

Family Fun Night Help plan and work at a fun school social in September.

Bulletin Board Help decorate the PTO bulletin board in the front lobby monthly or as needed.

Book Fair Help to set up and sell books at one or more shifts during the 2011 Scholastic Book Fair in October.

Picture Day Help photographer and school staff take pictures of students in the fall and spring.

Librarian Helper

Assist librarians throughout the year, shelving books and other duties as needed. Commitment could be once or

twice per month, once per week or other schedules.

Sunshine Committee Help recognize staff members on their birthdays throughout the year.

Holiday Staff Meal Provide items (drinks, food, paper products) to create a nice meal for the staff in December.

Staff Appreciation Week Help organize and provide food, decorations and gifts the first week in May.

All Star Reading

With a staff member, watch students on the playground at the extra 15 minute recesses at the end of each

quarter. Help with the All Star Reading T-shirt design contest in the spring.

Holiday Caring & Sharing

Help organize the collection of toys and money for the under-privileged in Andover starting after Thanksgiving

and finishing before Christmas break.

Office Helper Help office staff with getting Friday folders out and other duties as necessary. Serve once per month or more.

Art Helper Help Art Teacher hang artwork in the school hallways throughout the year.

Music Helper Help decorate for school music programs (all grades) and make signs and create costumes as needed.

Year Book

Help take and gather pictures for the school yearbook throughout the year. At least one picture chairperson per

grade level is needed.

T-Shirts Design, order and sell Meadowlark T-shirts, especially during August and September.

Nurse Helper Help nurses check in students for dental check up day, height/weight day and other duties as needed.

Counselor Helper

Help as needed with Drug Free Red Ribbon week in the fall, Careers on Wheels day in the spring and

Counselor Appreciation Day in February.

Reading Lab Helper Help Reading Specialist plan and work during Read Across America activities in early March.

PE Helper Help PE teacher with Fun in the Sun Field Day in May and sometimes other PE events throughout the year.

Outdoor Habitat Help maintain our beautiful outdoor habitat by volunteering to weed and plant as needed.

Future All-Stars Playgroup Be notified of upcoming playgroups for future Meadowlark students.

Recycling Help with the recycling program at Meadowlark throughout the year.

Staff Grant Program

Serve once per year or more on the monthly rotating committee to vote on staff applications for PTO-funded

classroom projects.

MEADOWLARK ELEMENTARY DIRECTORY PERMISSION

Dear Parents,

A 2011-12 school directory will be published for parents containing Meadowlark student contact

information. Please fill out this permission form and return it to the school office with your

enrollment packet. Students who do not have a permission form turned in will not be in the

school directory. Ordering information will go home with students at a later date. Even if you

will not be ordering a directory, we still need this form from you. If you have a child who has

more than one household, please fill out two forms and indicate the difference between the

addresses. If you have any questions, please contact Chris Steward, PTO President, at

[email protected].

Thank you for your help!

MEADOWLARK ELEMENTARY SCHOOL DIRECTORY FORM

Name(s) of

Child: _____________________________________

Grade: _____

Child: _____________________________________

Grade: _____

Child: _____________________________________

Grade: _____

Child: _____________________________________

Grade: _____

Parents Name(s):

______________________________________________________________________

Address: ______________________________________________________________

City, State, Zip: _________________________________________________________

Home or Primary Phone #: (____)____________________________

Check one of the following:

_____I give permission for my address and family names to be published in the

Meadowlark Elementary School Directory.

_____I do not wish to have my address or family names published in the Meadowlark

Elementary School Directory.

__________________________________________ _________________

Signature Date

WE ARE ON THE WEB!

In an effort to reduce the time and expense involved in distributing

paper copies of school notes and newsletters, we will be posting links

to each classroom or department. Teachers have been asked to post

their class information, such as schedules, newsletters, and

handbooks. The Elementary Family Handbook will be available on our

school website as well. The monthly parent newsletter will be posted

on the school website along with a lunch menu.

Our school website can be accessed by going to www.usd385.org. By

going to the district website, you will have access to all our

Meadowlark links, lunch menu, district calendar, Powerschool and

much, much more!

If you do not have access to the internet, please return the completed

form below to the school office. A paper copy of any information you

may need will be sent home with your child.

I do not have access to the internet and will need a paper copy

of the newsletters, handbooks, and school notes.

Parent Name__________________________________________________

(Please print)

Name of Children

_________________________ Teacher__________________ Grade____

_________________________ Teacher__________________ Grade____

_________________________ Teacher__________________ Grade____

_________________________ Teacher__________________ Grade____

Kindergarten #2 Pencil (6)

Crayola crayons – 24 ct. (2) Crayola Classic thick washable markers - 8 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (4) Fiskar sharp scissors – 5” (1) Pocket only folder – any color (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (1) Black Sharpie (Fine pt.-Art) (1) Pop-up wipes (1) Backpack

1st Grade #2 Dixon Ticonderoga pencils -24ct. Pink bevel eraser (2) Crayola crayons – 24 ct. (2) Crayola Classic thick washable markers 8 ct. (1) Crayola 8 color washable watercolors (1) Chisel tip dry erase marker – black (4) Glue stick (4) Fiskar sharp scissors – 5” (1) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – yellow (1) Pocket only folder – green (1) Pocket only folder – blue (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (2) 12 ct. colored pencils (Art) 1 disinfecting wipes backpack

2nd Grade #2 Dixon Ticonderoga pencil (12)

Pink bevel eraser (1) Highlighter – fluorescent yellow (1) Chisel tip dry erase marker – black (3) Crayola crayons – 24 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (3) Fiskar sharp scissors – 5” (1) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – green (1) Pocket & brad folder – blue (1) Pocket & brad folder – yellow (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (2) Clorox Wipes Sharpie Extra Fine – black 1 (Art) Crayola Markers Classic Colors (10 ct) Backpack

3rd Grade #2 Pencil (24) Pink bevel eraser (1) Bic medium stick pen – red (2) Pen style highlighter – yellow (1) Chisel tip dry erase marker – black (4) Crayola crayons – 24 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Ross glue stick – 1.23 oz. (2) Fiskar sharp scissors – 7” (1) Filler paper wide rule – 200 ct. (2) Spiral comp. book wide rule – 70 ct. (2) Pocket & brad folder – red (1) Pocket & brad folder – green (1) Pocket & brad folder – blue (1) Pocket & brad folder-orange (1) Pocket & brad folder --yellow (1) Kleenex – approx. 120 ct. (2) 8 ct. Crayola Markers (Art) Glue Bottle Backpack

4th Grade # 2 pencil (12) Pink bevel eraser (1) Pen style highlighter – pink (1) Pen style highlighter – yellow (1) Sharpie Fine marker – black (1) Sharpie Extra Fine marker – black (1) Chisel tip dry erase markers – 4 pk (black or assorted color) 1 Crayola Classic thick washable markers – 8 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (2) Fiskar sharp scissors – 7” (1) Ruler – 12” clear plastic (1) 3 x 5 ruled index cards – 100 ct. (1) Filler paper wide rule – 100 ct. (2) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – yellow (1) Pocket & brad folder – green (1) Clip board – standard letter size (1) Kleenex – approx. 120 ct. (1) Crayola crayons – 24 ct. 1 (Art) 13 pocket expandable folder Backpack

5th Grade #2 pencil (24)

Bic medium stick pen – blue (3) Sharpie Fine marker – black (1) Pen style highlighter – yellow 2 Chisel tip dry erase marker – black (4) Crayola Classic thick washable markers – 8 ct. (1) Crayola 7” colored pencils – 24 ct. (1) Ross glue stick – 1.23 oz. (1) Fiskar sharp scissors – 8” (1) Ruler – 12” clear plastic (1) 3 x 5 plain index cards – 100 ct. (1) Filler paper wide rule – 200 ct. (2) Spiral comp. book wide rule – 70 ct. (2) Pocket & brad folder – assort. colors (6) Pencil bag – 8 x 10 see- thru plastic (1) Kleenex – approx 120 ct. (2) Glue bottle-4oz. (2) Clorox wipes Sandwich sized baggies zip close hand sanitizer paper towels Backpack

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February 2012

The policies of the Board of Education of USD 385 prohibit discrimination on the basis of race, color, national origin, disability, religion and sex in all programs and activities of the district. Additionally, discrimination on the basis of age is prohibited in employment.. Equal Opportunity Employer. Approved 3/14/11


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October 2011 August

8 New Students Enroll (8 am to 12 pm & 1-4 pm) 9 Returning Students Enroll (12:30 pm to 7 pm) 10-11 New Teachers Report 12 .1.0 Flex Work Day (Outside of Contract time) 15-17 All Teachers Report—Building/District Inservice 18 First Day-Grades 1st-5th, 6th, & 9th 19 First Day For Grades 7th, 8th, 10th, 11th & 12th 22 First Day for Early Childhood and Kindergarten

September 5 All Schools Closed-Labor Day 26 Building/District Inservice

October 14 End of 1st Quarter (40 days) 17 No School - Morning Building Inservice/ Afternoon Flex Work Day 31 All Schools Closed - Conference Credit Day

November 23-25 All Schools Closed-Thanksgiving Break

December 21 End of 2nd Quarter (43 Days) Dismiss 2 hrs. early (meet teacher credit time) 22 .5 Flex Work Day 22-Jan 2 All Schools Closed-Holiday Break

January 3 School Resumes 16 Inservice All Day/MLK Day

February 20 All Schools Closed-President’s Day

March 8 End of 3rd Quarter (46 Days) 9 No School - Morning Building Inservice/ Afternoon Flex Work Day 19-23 All Schools Closed-Spring Break April 6 No School—Conference Credit Day 8 Easter May 20 Commencement ACHS & AHS 23 Dismiss 2 Hrs. Early for building Inservice Last Day for Students End of 4th Quarter (47days) 24 Morning Flex Work Day Last Day For Teachers

Legend Yellow-School in Session Red-All Schools Closed, Teachers Inservice White-All Schools Closed, Teachers off Duty Blue-All Schools Closed, Teachers Flex Day Brown-All Schools Closed, Conference Credit Day

District Office Mark A. Evans, Superintendent Dr. Andrew Koenigs, Associate Superintendent Tom Ostrander, Assistant Superintendent. Jim Freeman, Business Manager/Treasurer Keturah Austin, Communications (316) 218-4660

Andover High Robert Baier, Principal Gary Merritt, Asst. Principal Amanda Grier, Asst. Principal (316) 218-4600

Andover Central High Cheryl Hochhalter, Principal Doug Carr, Asst. Principal Brian Gregoire, Asst. Principal (316) 218-4700

Andover Middle Brett White, Principal Brent Jones, Asst. Principal (316) 218-4610

Andover Central Middle Tim Hayden, Principal Debra Regier, Asst. Principal (316) 218-4710

Cottonwood Elementary Shari Rooks, Principal (316) 218-4620

Robert M. Martin Elementary Dr. Crystal Hummel, Principal (316) 218-4720

Meadowlark Elementary Jody Baker, Principal (316) 218-4630

Prairie Creek Elementary Shelley Jonas, Principal (316) 218-4830

Sunflower Elementary Rita Decker, Principal (316) 218-4730

Wheatland Elementary Elton Armbrister, Principal (316) 218-4820

Food Service Ann Katt, Director (316) 218-4603

Transportation Julie Clopton, Director (316) 218-4621

Operations Bruce Sanderson/Exec Dir. of Operations (316) 218-4604

Technology Rob Dickson, Director (316) 733-3686

2011-2012 USD 385 PROFESSIONAL CALENDAR

Visit us online at www.usd385.org!


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July 2012

The following pages

only apply to

students new to

Andover Public Schools.

ANDOVER USD #385 PROOF OF RESIDENCE

This form must be accompanied by a verification of residency. Acceptable forms of

verification are: Utility Bills, Lease Agreement or Homeowner Contract

Date: _______________________ School: ________________ Student(s) Name(s): Grade: ______________________________________ ______________ ______________________________________ ______________ ______________________________________ ______________ ______________________________________ ______________ I, ___________________________________, the parent/guardian declare that the above students reside with me at the following address:

Street Address: ______________________________________________________________

City, Zip: ____________________________________________________________________

I understand that the accuracy of the above information is important to the continued enrollment of my child(ren).

Parent/Guardian Signature: _________________________________________________

Meadowlark Elementary USD # 385

1411 N. Main – Andover, KS 67002

Ms. Jody Baker – Principal Phone: 316-218-4630

Mrs. Tammy Clarkson – Counselor Fax: 316-218-1000

Request for Transcript

Date: _________

Student: ___________________________________ Grade: ________

Registrar:

Please send us at your earliest convenience, all official records, transcript of grades,

cumulative records, birth certificate, test results, health records, athletic eligibility,

psychological test results and any other data directly related to this student.

Thank you for your time.

Former School: _____________________________________

_____________________________________

_____________________________________

Parent/Guardian Signature: ___________________________________

Send Records To:

Meadowlark Elementary school

1411 N. Main

Andover, KS 67002

Parental permission is no longer required when records are requested by authorized school personnel.

Family Education Rights and Privacy Act, Final Rule on Education Records, Federal Register

June 17, 1976, Vol. 41, No. 118, page 24673

MEADOWLARK ELEMENTARY New Student Placement Information Form

2011-2012 School Year

Student Name: ___________________________________________ Male or Female

(Please circle)

To better help us place your student, please provide the following information:

1. Was your child ever retained? If so, which grade(s)?

2. How was your child performing academically at his/her previous school?

3. Was your child involved in any special programs and what were they?

(Example: Title I reading, and math programs, speech, language, learning

disabilities, special classroom placement, gifted, enrichment, etc.)

4. Please describe your child’s personality. (Is he/she excitable, creative, very

active, quiet, etc.)

5. Would you say your child would benefit from (please circle):

A. A structured classroom

B. A flexible classroom

C. Either type of classroom

Please use the back of this form to add any additional information about your child that

would help with your child’s placement. Thank you.

___________________________________________ _________________

Parent/Guardian Signature Date

USD 385 DEPARTMENT OF HEALTH SERVICES

ANDOVER, KANSAS

IMMUNIZATION STATEMENT Please sign and return with enrollment forms.

Name of Student: _________________________________________ Date of Birth: _____________________________________________

I have been notified that Kansas Law (K.S.A. 72-5208, 72-5209, 72-5210, 72-5211 and 72-5211a) requires every pupil enrolling in any school for the first time, prior to admission, to present proof from a physician or local health department that the pupil has received such tests and inoculations as are deemed necessary.

In USD 385, proof of each inoculation received must be presented prior to admission. Also, mandatory booster inoculations in all required series must be received (within 30 days for students admitted after September 1). If transferring into USD #385, it is the parents obligation to make sure proof of inoculations are received within 30 days. Required inoculations include the following:

DTP, DTaP and/or DT/Td Additions for Early Childhood OPV or IPV Hib MMR PCV7 (pneumococcal) Hepatitis B Hepatitis A Varicella

Parents will be notified of any additional requirements.

Parent/Guardian Signature Indicating Receipt of Notice:

_______________________________________Date:_________________ Student is transferring from: _____________________________________ Name of School City St.

Date Student Entered USD #385: _______________________________

KANSAS CERTIFICATE OF IMMUNIZATIONS (KCI)This record is part of the student's permanent record and shall be transferred from one school to another as defined in Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.)

Student Name:

Parent or Guardian Name:

Address:

Birthdate (MM/DD/YYYY): SEX: [ ] MALE [ ] FEMALE

Phone:

CountyRace: Ethnicity:

RECORD THE MONTH, DAY, AND YEAR THAT EACH DOSE OF VACCINE WAS RECEIVEDVACCINE

7th6th5th4th3rd2nd1st

If additional doses are added,

please initial the dose and sign

below:

Polio Required for school entry.

HEP B (Hepatitis B) Required for school entry through Grade 10 for 2010-

2011 school year. Recommended for all children.

Varicella (Chickenpox) Required for school entry through Grade 10 for

2010-2011 school year. Recommended for all children.

MMR (Measles, Mumps, and Rubella combined) Required for school entry.

HIB (Haemophilus Influenzae Type B) Required < 5 years of age for preschool

or child care operated by a school.

PCV7 (Pneumococcal Conjugate) Required < 5 years of age for preschool or

child care operated by a school.

HEP A (Hepatitis A) Required < 5 years of age for preschool or child care

operated by a school.

Physician Signature:

MCV4 (Meningococcal) Recommended at 11 years of age. Not required for

school entry.

DTaP/DT/Td/Tdap (Diphtheria, Tetanus, Pertussis) Required for

school entry.

HPV (Human Papillomavirus) Recommended for females and provisionally

recommended for males at 11 years of age. Not required for school entry.

Rotavirus Recommended < 8 mo. Not required for school entry.

Hx of Disease:

State Type

Influenza (Flu) Recommended annually for ages 6mo - 18 yrs. Not required

for school entry.

I certify I reviewed this student's vaccination record and transcribed it accurately.

Agency Name:

1. "Annual written statement signed by a licensed physician (Medical Doctor/M.D. or Doctor of Osteopathy/D.O.) stating the physical

condition of the child to be such that the tests or inoculations would seriously endanger the life or health of the child." Medical exemption

shall be validated annually by physician completion of KCI Form B and attachment to the KCI.

KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf

2. "Written statement signed by one parent or guardian that the child is an adherent of a religious denomination whose religious

teachings are opposed to such tests or inoculations."

DateParent/Legal Guardian's Signature

I give my consent for information contained on this form to be released to the Kansas Immunization

Program for the purpose of assessment and reporting.

KANSAS IMMUNIZATION PROGRAM

1000 SW Jackson, Suite 210, Topeka, KS 66612-1274

PHONE 785-296-5591 FAX 785-296-6510

WEB SITE www.kdheks.gov/immunizeRev. 02/01/2010

Date:

q

Authorized Representative:

Address:

The record presented was:

qq

Kansas Immunization Record

Other Immunization Record (Specify)

DOCUMENTATIONKCI MAY ONLY BE SIGNED BY A PHYSICIAN (MD/DO), HEALTH DEPT, OR SCHOOL.

LEGAL ALTERNATIVES TO VACCINATION REQUIREMENTS "KSA 72-5209"

KANSAS IMMUNIZATION REQUIREMENTS: Based on age of child as of September 1 of current school year.

As per Kansas Statute 72-5209, all children upon entry to school must be appropriately vaccinated. In each column below, vaccines are required for all ages listed in that column.

Ages 0-4

Recommended Schedule

Birth

2 Months

4 Months

6 Months

12-15 Months

HEP B

DTaP/DT

POLIO

HIB

PCV7

ROTAVIRUS

DTaP/DT

POLIO

HEP B

HIB

PCV7

ROTAVIRUS

DTaP/DT

MMR

VAR

HIB

PCV7

HEP A

DTaP/DT

POLIO

HEP B

HIB

PCV7

ROTAVIRUS

Ages 5-6 Ages 7 and Older

DTaP/*DT: 5 doses

4 week minimum interval between doses, with at least 6 months between dose 3

and dose 4.

4 doses acceptable if dose 4 given on or after the 4th birthday.

If dose 4 is administered before the 4th birthday, a 5th dose must be given at 4-6

years of age.

If 1st DT dose given at <12 months of age, 4 doses recommended; acceptable

only when Pertussis component is contraindicated by the physician.

If 1st DT dose given at 12 months or older, 3 doses complete primary series;

acceptable only when Pertussis component is contraindicated by the physician.

a)

b)

c)

*

*

POLIO:

4 doses of POLIO are acceptable IF:

3 doses of POLIO (all IPV) are acceptable IF:

4 week minimum interval between doses, regardless of age given.

† - The ACIP Schedules may be accessed at: http://www.cdc.gov/vaccines/recs/schedules

Vaccine doses given up to 4 days before the minimum interval or age may be considered valid.

With the exception of Hepatitis B vaccine, immunizations given before 6 weeks of age are not considered valid.

Half doses or reduced doses of vaccine are not considered valid.

PARENTS AND/OR GUARDIANS ARE NOT AUTHORIZED TO COMPLETE KCI FORMS.

A ROSTER WITH THE NAMES OF ALL EXEMPT STUDENTS SHOULD BE MAINTAINED. PARENTS OR GUARDIANS OF EXEMPT CHILDREN SHOULD BE INFORMED THAT

THEIR CHILDREN SHALL BE EXCLUDED FROM SCHOOL IN THE EVENT OF AN OUTBREAK OR SUSPECTED CASE OF A VACCINE-PREVENTABLE DISEASE.

KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf

BLANK VERSION OF KCI FORM is available at http://www.kdheks.gov/immunize/download/KCI_Form.pdf

Recommendations are based

on the ACIP recommended

schedule.†

The limit for DTaP vaccine is 6 doses, regardless of schedule.

a)

4 week minimum interval between each dose, with 1 dose given on or after the

4th birthday.

a)

The limit for POLIO vaccine is 5 doses, regardless of schedule.

Single antigen measles vaccine will not meet requirements without the addition of

mumps and rubella vaccine.

First dose must be on or after the 1st birthday.

4 week minimum interval between doses.

a)

b)

MMR: 2 doses

a)

b)

c)


None required if prior varicella disease verified.

Two doses are recommended for all children.

VARICELLA: 2 doses required for Kindergarten and Grade 1 for 2010-11 school

year; 1 dose required for Grades 2-10 for 2010-11 school year

a)

b)

c)

d)

4 week minimum interval between dose 1 and dose 2.



Dose 3 must be given after 24 wks of age.

HEPATITIS B: 3 doses required through Grade 10 for 2010-11 school year




Dose 3 must be given after 24 wks of age.

a)

b)

c)

d)

HEPATITIS B: 3 doses required through Grade 10 for 2010-11 school year

a)

b)

c)


None required if prior varicella disease verified.

Two doses are recommended for all children.

VARICELLA: 1 dose required through Grade 10 for 2010-11 school year


4 week minimum interval between doses.

a)

b)

MMR: 2 doses

The limit for POLIO vaccine is 5 doses, regardless of schedule.

4 week minimum interval between each dose, with 1 dose given on or after the

4th birthday.

a)


4 week minimum interval between doses, regardless of age given.a)


POLIO - All IPV or OPV Schedule

Booster dose of Tdap is required at 7th grade if more than 2 yrs since previous dose

of Td. Tdap booster required 10 years after the completion of the primary series or

previous dose. Only one dose of Tdap is needed during adolescence. KCI Form B

Medical Exemption should be completed by a physician if pertussis is contraindicated.


6 month interval between dose 2 and dose 3.

a)

b)

Tdap/Td: 3 doses if DTaP/DT series not completed previously†

One of the doses must be Tdap if student is without a Pertussis

medical exemption.

POLIO - IPV/OPV Combination Schedule


4 week minimum interval between each dose, regardless of age given. Three

doses of a combination schedule are NOT acceptable.

a)

ANDOVER PUBLIC SCHOOLS USD 385

HEALTH EXAMINATION REPORT

Pupil’s Name_____________________________________ SS#__________________ Birth Date_____________ Grade___________

Last First

To Parents: For maximum health your child should have a periodic health

examination. If your child is entering Kindergarten (or is new to Kansas

Schools and is under 9 years of age) please obtain an examination of

your child by your family doctor. Gender: M______F_______

Height_____ Weight_____ BP_____ T_____ P_____ R_____

Central Nervous System________________________________________

Epilepsy?__________ Emotional Disturbance?______________

Cardio-Vascular System________________________________________

Heart Disease?____________________ Limitation?__________

EENT (Eye, Ear, Nose & Throat)_________________________________

Myringotomy?____________________ Glasses?____________

Endocrine System_____________________________________________

Diabetes Mellitus?_____________________________________

Gastrointestinal System________________________________________

Nutritional Status______________________________________

Genitourinary System__________________________________________

Musculo-Skeletal System_______________________________________

Scoliosis?____________________ Arthritis?________________

Respiratory System____________________________________________

Asthma?_____________________ Allergies?_______________

Social Development (family, peer, school if appropriate)______________

Recommendations:____________________________________________

Physician’s Signature__________________________________________

Immunization – Please attach green Kansas

Certificate of Immunization (KCI) with all dates

for DPT, Polio, MMR, Varicella, and Hepatitis B

recorded - with Physician Signature and Date.

Optional other vaccines or tests:____________________

Are routine medications prescribed? Yes No

NOTE: If medication is to be given at school, please

provide written physician/parental request.

Physical Education:

Regular_______________________________________

Limited (explain)_______________________________

None (explain)_________________________________

Date__________________________________________

MAY USE BACK OF CARD FOR ADDITIONAL SPACE

mes step 2

Documents

day kindergarten

day kindergarten payable

transcript new students

monthly fee

day grades

family transportation

birth certificate new

reduced fee assistance