registration & residency requirements - indian...

Registration & Residency Requirements

All students must register each year in the school that they will be attending.

When a child is registering in District 204 for the first time, a parent or guardian must provide

proof of identity and age by providing one of the following documents:

original or certified copy of a birth certificate (which will be copied and original returned

to parent or guardian),

valid passport, or

other record recognized by a court of law.

In addition, the parent or guardian must provide disease immunization records as required by

State law, the required physical examination signed by the student’s physician, vision

examination, and dental examination.

Proof of residency is also required for all new students and whenever a change of address occurs.

To meet the proof of residency requirements, a parent / guardian must submit one document

from each of the following groups (for a total of three documents):

Group A: Title evidence, mortgage statement, lease agreement, or tax bill

Group B: Utility bill such as an electric bill, gas bill, or home phone bill, (a cell phone

bill is not a utility bill and will not be accepted)

Group C: Illinois Driver’s License, Illinois State Identification Card, other acceptable

photo identification, voter’s registration card, loan payment book, home insurance policy,

bank account paperwork, medical card, permanent resident card

Transfer students must provide student records and a "good standing" letter from the transfer

school.

The building principal or designee is responsible for collecting this information before

enrollment.

Please submit the required documents to the school office where the student will be attending. If

you have questions about these documents or other registration and enrollment procedures,

please do not hesitate to contact the school office or the IPSD 204 Crouse Education Center at

630.375.3798.

2014 – 2015 Student Registration

School: ______________________________ Grade: ______ Entry Date: ____/____/_______

Student Information Student Name First Middle Last Jr., Sr. III Mother’s Maiden Name:

Sex: F M Circle one

Birthday _____/_____/_____

Birth Place

Country of Birth

First Date Enrolled in a US School _____/_____/________

Has this student attended a District 204 school before? Y N

Circle one

Previous School Attended Name:_________________________________________ Address:_________________________________________ City/State/Zip:_________________________________________ Telephone:_________________________________________

Household/ Parent/ Guardian Information

Physical Address Address / Apartment:

Subdivision:

City, State and Zip:

Mailing Address Is same as Physical Address?

Y N Circle one

Address / Apartment:

Subdivision:


Parents/Guardians Parent/Guardian Name: First Middle Last

Home Phone: (______) ________ - __________ Mobile Phone: (______) ________ - __________ Work Phone: (______) ________ - __________ E-Mail :___________________________________

Do you wish the home phone to be kept private: Y N

Circle one

Relationship to Student:

Lives with student? Y N

Circle one

Employer Name:

Parent/Guardian Name: First Middle Last

Home Phone: (______) ________ - __________ Mobile Phone: (______) ________ - __________ Work Phone: (______) ________ - __________ E-Mail :___________________________________

Do you wish the home phone to be kept private:

Y N Circle one


Lives with student? Y N

Circle one

Employer Name:

O F F I C E U S E O N L Y

Birth Certificate

Residency

Medical

IPEF

Handbook

Fees

Internet

Home Language Survey

Milk

Technology

SSN

ISBE

Permission

Records Request Sent Received District ID State ID Rev: October 2014

2014 – 2015 Student Registration

Emergency Contact Information Please list at least 2(two) contacts in the immediate area to call if you are unavailable.

Contact Name: First Last

Phone: (______) _________ - ____________ Alternate Phone: (______) ________ _- ____________


Contact Name: First Last

Phone: (______) _________ - ____________ Alternate Phone: (______) _________ - ____________


Child Care / Day Care Provider Provider Name: Phone: (______) _________ - ____________

Alternate Phone: (______) _________ - ____________

Address:


Contact Type

Brothers & Sisters (Include Pre-School)

Name: Birthday ____/_____/________

School Grade

Name: Birthday ____/_____/________

School Grade

Name: Birthday ____/_____/________

School Grade

Connect ED Automated Phone System District 204 uses the Connect ED automated notification system for school-to-parent communications. This allows the district to send phone and text messages in an emergency and also provides principals with a way to keep parents informed by sending non-emergency email, phone and text messages to families. Help ensure that we can reach you by providing your most current contact information below. Please note, the system cannot dial an extension, so make sure the numbers you provide are direct numbers with no extensions. Please designate a phone number where you want to receive Connect ED non-emergency phone calls and text messages (information about school activities, testing schedules, parent reminders, etc.). This can be your home, work or cell number. Emergency phone calls and text messages (snow days, transportation updates, etc.) will be placed to all phone numbers in the system. Connect ED non-emergency phone: ( ) ________- ____________ If you would like to receive text-enabled alerts from Connect ED, enter up to two 10 digit guardian numbers and one student number. Carrier charges may apply. Connect ED primary text: ( ) ________- ____________ Connect ED student text: ( ) ________- ____________ Connect ED secondary text: ( ) ________- ____________

Children of US Military Personnel (This section is optional)

Parent or Guardian is a member of a branch of the armed forces of the United States.

Y N

Circle one

Parent or Guardian is either deployed to active duty or expects to be deployed to active duty during the school year.

Y N Circle one

Additional Information Use this space to add any student, Household, Guardian or Emergency Contact Information.

Illinois State Board of Education

U.S. Department of Education Race and Ethnicity Data Standards Student Name:_______________________________ Date of Birth:_____ /_____ /_____ Attending School:_____________________________ Grade:________ eSchoolPlus ID #:_________________ (to be completed by school) INSTRUCTIONS: This form is to be completed and signed by the student’s parent or guardian and both questions must be answered. Part A asks about the student’s ethnicity and Part B asks about the student’s race. If you decline to respond to either question, the school district is required to provide the missing information by observer identification. PART A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Choose only one. No, not Hispanic/Latino Yes, Hispanic/Latino The question above is about ethnicity, not race. No matter which answer you selected, continue and respond to the question below by marking one or more boxes to indicate what you consider this student’s race to be. PART B. What is the student’s race? Choose one or more.

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, 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 including, for example, 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 Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

Parent/Guardian Signature Date Observer Identification Note: Data collected on this form must be maintained by the school district for three years. However, when there is litigation, a claim, an audit, or another action involving this record, the original responses must be retained until the completion of the action.

Home Language Survey

Dear Parent/Guardian, The Federal NCLB-Title III Act and the Illinois School Code require that each school district

administer a Home Language Survey to every student entering the district’s schools for the first time. This information is used to report to the state the number of students whose families speak a language other than English. It also helps to identify the need for English Language Learning services in the schools. Your cooperation in helping us meet this important legal requirement is appreciated. Student Name_____________________________________________ Grade___________

School__________________________ Birthdate_________________ Gender__________

Country of Birth __________________ Home Phone Number_______________________

1. Is a language other than English spoken in your home? YES NO

If yes, what language? ________________________________

2. Does your child speak a language other than English? YES NO Note: Foreign languages the student has learned in school do not count. What language, other than English, does your child speak? ____________________________

Can your child read this language? YES NO Can your child write this language? YES NO

3. Which language is spoken most often in your home? _________________________________ Please be specific. (Example: Mandarin, not Chinese)

4. Does your child ……

…understand English? YES NO … speak English? YES NO

…read English? YES NO … write in English? YES NO

5. Which language does your child speak most often with his/her parents? ________________________

6. Which language does your child speak most often with his/her friends? ________________________

7. Where did your child attend school last year? ______________________________________________

8. Was your child in a bilingual or ELL/ESL program during the last school year? YES NO

9. Was your child ever in a Bilingual or ELL/ESL program? YES NO

If yes, what grade(s)? _____________ Where (school/city)? ___________________________________ 10. If you speak a language other than English, would you be willing to occasionally translate at school if needed?

YES NO

_______________________________________________ ______________________ Parent/Guardian Signature Date

O F F I C E U S E O N L Y HOME LANGUAGE on student’s language record will match language listed in question 3.

OTHER LANGUAGE on the student’s language record will match language listed in question 1.

**** If the answers to question #1 AND # 2 are both NO, you may stop here. If the answer to EITHER question is YES, please continue. If the answer to EITHER question is YES,

the law requires the school to assess your child’s English language proficiency****

Permissions Student Name _______________________________________ School _______________________________

ATTENTION PARENTS From time to time, your student's photograph/picture and/or name may appear in various in-district and out-of-district publications such as newsletters, school newspapers and yearbooks, web pages, communications to parents or guardians, textbooks, newspapers, and/or videos. This also applies to PTA and Indian Prairie Educational Foundation publications. While the district limits access to buildings by outside media, it has no control over the news media or other entities that may publish a picture of a named or unnamed student. If you do NOT wish to have your student’s information/picture appear in district publications, please mark the appropriate boxes below. Marking YES, gives permission to use the student’s information. Marking NO, denies permission to use the student’s information. If all boxes remain unchecked for a statement, you will be giving permission to have your student’s information appear in district sponsored publications or websites and the school PTA directory.

PERMISSIONS DISTRICT PUBLICATIONS:

My student’s picture and/or name may appear in District 204 publications. YES NO

My student’s picture and/or name may appear on District 204 web pages. YES NO

My student’s work may appear on District 204 web pages.

YES NO

INFORMATION RELEASE FOR MILITARY RECRUITMENT Federal Law requires the district to release directory information, including a student’s name, address, and telephone

number, to military recruiters unless the parent objects in writing. If you do NOT want this information released to military recruiters, check the NO box below. My student’s directory information may be released to military recruiters. YES NO

SCHOOL NEWSLETTER AVAILABILITY

Instead of mailing me a copy of the latest school newsletter, please notify me via E-mail that it is available to read on the school’s website. If you check the “Yes” box, Please be sure to write your Email address on the “Registration” form.

YES NO

__________________________________________ ___________________ Parent/Guardian Signature Date

PERMISSIONS RELATING TO PTA DIRECTORY

Student Name School The PTA for your child’s school may publish a contact directory for the convenience of parents and students attending the school. By signing this form, you give your permission for the School District to release information to the PTA, and for the PTA to publish the information in its directory. Please note that PTA directories may be published as booklets, and/or in electronic format via downloadable smart-phone apps. This form provides permission for both types of publications. Permissions: I hereby authorize the School District to release the following information to the PTA for my child’s school. In addition, I hereby authorize the school’s PTA to publish the information in the directory to be distributed by the PTA.

If you do not wish some or all of the information listed below to be released to the PTA, check the “opt out” box for the items of information that should not be released.

Opt Out

Student’s Name

Student’s Address

Parent/Guardian Name

Parent/Guardian Telephone Number

Parent/Guardian Email Address

Parent/Guardian Signature Date

Dear Parents and Guardians: Technology resources are a valuable part of the education process at IPSD. The use of electronic networks is available to district students. The uses of technology resources are outlined in the Board of Education Policies (6:235 Access to Electronic Networks & 6:220 Bring Your Own Technology) and the IPSD Acceptable Use Guidelines for BYOT and Electronic Networks. These policies and guidelines can be viewed on the district website under Tech Services->Polices and Guidelines (http://tech.ipsd.org). As part of Google Apps for Education, all secondary students are issued a district-assigned email account. Middle school Google accounts have limited access to the outside world while high school accounts have full access. For more information please visit http://goo.gl/qh8uuJ.

An opt-out policy is used for technology. Please verify these permissions during registration.

Specifically, students will be able to access internet resources at school and use personal technologies unless a parent/guardian chooses to opt-out by contacting the main office at the child’s school.

Yours truly, Mr. Stan Gorbatkin, Assistant Superintendent of Technology Services Dr. Stacey Gonzales, Director of Instructional Technology

http://tech.ipsd.org/

http://goo.gl/qh8uuJ

Elementary School Fee Statement School _______________________ 2014-15 School Year

Student Name: Grade: Parent/Guardian Name:

Address:

City:

Zip:

Instructions: 1. Place a check mark after the applicable Required Fees and after the Optional Fees you select. 2. Total the fees. 3. Make payment by check or money order to IPSD 204, or set up an online MyPaymentsPlus Account

(www.MyPaymentsPlus.com). Instructions available on the www.ipsd.org web site (on-line is only available to returning IPSD students).

4. Sign your name and date this statement. 5. Return statement and payment to the elementary school. Check here if you have made your payment through MyPaymentsPlus.

6. Insurance fees are separate. See the insurance packet for further instructions.

REQUIRED FEES*: ()

Grades 1 – 5 (Includes $30 technology fee.)

$105.00

Kindergarten – Half Day (Includes $15 technology fee.)

$53.00

Kindergarten – Full Day (Includes $30 technology fee.)

$105.00

OPTIONAL FEES: Indian Prairie Educational Foundation $25.00

TOTAL: Parent/Guardian Signature: ________________________________ Date: _______________________ *If you believe your child may qualify for fee waiver, please complete the Fee Waiver Application. All applications must be returned no later than July 28, 2014 to ensure fee waiver status is determined by the first day of school. The application form will be made available online at www.ipsd.org no later than July 1st. The Indian Prairie Educational Foundation fee is a tax-deductible donation to support educational enrichments including teacher grants, artist-in residence programs, the annual science fair, STEM nights, and the Fine Arts Festival.

http://www.ipsd.org/

Middle School Fee Statement Select Middle School 2014-15 School Year Crone Fischer Granger Gregory Hill Scullen Still Student Name: Grade: Parent/Guardian Name:

Address:

City:

Zip: ID #:

Phone Number:



4. Sign your name and date this statement. 5. Return statement and payment to the middle school. Check here if you have made your payment through MyPaymentsPlus.


REQUIRED FEES*: () Grades 6-8 (Registration $95 and Technology $45) $140.00

OPTIONAL FEES:

Indian Prairie Educational Foundation $25.00 TOTAL: (check or money order payable to IPSD 204)

Parent/Guardian Signature: ___________________________________ Date: ____________________ Note: **Lab fees as well as the appropriate athletic and activity fees will also be collected according to school instructions. ** Athletic fees are charged per sport or at $125 each. The maximum charge is $250, regardless of the number of sports in which the student is involved. Additional fees for uniform cleaning/replacement and Solo and Ensemble contest participants will also be collected by the appropriate staff. * If you believe your child may qualify for fee waiver, please complete the Fee Waiver Application. All applications must be returned no later than July 28, 2014 to ensure fee waiver status is determined by the first day of school. The application form will be made available online at www.ipsd.org no later than July 1st. The Indian Prairie Educational Foundation fee is a tax-deductible donation to support educational enrichments including teacher grants, artist-in-residence programs, the annual science fair, STEM nights, and the Fine Arts Festival.


Course Number Course Name Current Fee

ART0600 Art 1 - Grade 6 $5.00ART0700 Art 1 - Grade7 $5.00ART0701 Art 2 - Grade 7 $10.00ART0800 Design & Sculpture $10.00ART0801 Drawing & Painting $10.00

FACS0600 6th Grade FACS $5.00FACS0700 7th Grade FACS $10.00FACS0801 Sewing $10.00FACS0800 Foods $10.00

PLTW1006 Design and Modeling $5.00PLTW1014 Automation Robotics $10.00PLTW1016 Energy and the Environment $10.00TEE0802 Manufacturing Technology and Engineering $10.00

Course Number Course Name Cost

SPAN0700 7th Grade Spanish $15.00SPAN0800 8th Grade Spanish $15.00FREN0700 7th Grade French $18.50FREN0800 8th Grade French $18.50

MIDDLE SCHOOL LAB FEES 2014-15

MIDDLE SCHOOL STUDENT WORKBOOKS 2014-15

Technology and Engineering

FACS

Art

OFFICE USE: Check/MyPayPlus _______________________Amount _________ Dated ___________ Received __________

High School Fee Statement Select High School 2014-15 School Year Metea Valley Neuqua Valley Waubonsie Valley

Student Name: Grade: Parent/Guardian Name:

Address:

City:

Zip: ID #: Phone Number:



4. Sign your name and date this statement. 5. Return statement and payment to the appropriate high school. Check here if you have made your payment through MyPaymentsPlus.


REQUIRED FEES*: () Grades 9-12 (Registration $105 and Technology $50) $155.00

OPTIONAL FEES:

Athletic Activity Ticket (provides entrance to all home athletic events excluding regional, sectional, state contests and tournaments.)

$15.00

Indian Prairie Educational Foundation $25.00 TOTAL: (check or money order payable to IPSD 204)

Parent/Guardian Signature: __________________________________ Date: ______________________ Note: Lab fees as well as the appropriate music and activity fees will also be collected according to school instructions. Athletic fees ($200/$400 max) will be collected according to school instructions. * If you believe your child may qualify for fee waiver, please complete the Fee Waiver Application. All applications must be returned no later than July 28, 2014 to ensure fee waiver status is determined by the first day of school. The applications form will be made available online at www.ipsd.org no later than July 1st. The Indian Prairie Educational Foundation fee is a tax-deductible donation to support educational enrichments including teacher grants, artist-in-residence programs, the annual science fair, STEM nights, and the Fine Arts Festival.


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Course Number Course Name Current Fee

ArtART1001 2D Art and Design $20.00ART1004 3D Art and Design $20.00ART2000 Printmaking $20.00ART1015 Drawing 1 $20.00ART2003 Drawing 2 $20.00ART2005 Drawing 3 $20.00ART2007 Painting 1 $20.00ART2009 Painting 2 $20.00ART1017 Ceramics 1 $20.00ART2010 Ceramics 2 $20.00ART2012 Ceramics 3 $20.00ART2014 Jewelry $20.00ART3000I Art Independent Study (AIS) $20.00ART3002A AP Studio Art $50.00ART2002 Computer Graphics 1 $10.00ART2015 Computer Graphics 2 $10.00ART4000D Digital Photography $20.00BusinessBUS1030 Essential Technology $7.00BUS1031 e-Business & Financial Technology $7.00BUS1032 Marketing Technology $7.00BUS1033 Visual Media $7.00BUS3000 Advertising $7.00BUS3017 Finance $7.00BUS1034 Emerging Technology $7.00BUS1035 Multimedia Innovations $7.00BUS1036 Web Design $7.00BUS3002 Marketing $7.00BUS3020 Virtual Enterprises International (VEI) $14.00FACSFACS1001 Intro to Culinary Arts $30.00FACS4000D Senior Foods $30.00FACS1005 Pastry Arts $30.00FACS3002 Catering and Hospitality $30.00FACS2002 International and Regional Foods $30.00FACS3003I Independent Study (Culinary Arts) $30.00ZFACS1008 Home Maintenance $25.00MusicMUSIC Band & Orchestra Instrumental Music Fee $108.00

HIGH SCHOOL LAB FEES 2014-15

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Technology and EngineeringTEE3007 A+ Computer Repair $20.00TEE3001D Architectural Drafting $10.00TEE2005 Auto Maintenance $10.00TEE3003 Auto Mechanics $20.00TEE4001B Auto Servicing $25.00TEE3002 Computer Aided Drafting & Design $10.00TEE3008 Computer Networking $20.00TEE2003 Drafting and Design $10.00TEE2006D Electricity $20.00TEE3005 Electronics $20.00TEE1001 Engineering Technology 1 $15.00TEE1002 Engineering Technology 2 $15.00TEE1004 Power Mechanics $15.00TEE1003 Woods Fabrication 1 $20.00TEE2001 Woods Fabrication 2 $20.00TEE2002 Intro to Construction $15.00TEE1014D Media Commnication and Production 1 $20.00TEE2007D Broadcast Journalism and Production 2 $20.00TEE3013 Broadcast Journalism and Production 3 $20.00

TEE4005ITEE Independent Study - Manufacturing/Construction $20.00

TEE4002I TEE Independent Study - Communication $20.00TEE4003I TEE Independent Study - Transportation $25.00TEE4004I TEE Independent Study - Energy $20.00PLTW2000 Introduction to Engineering Design (IED) $20.00PLTW2001 Principles of Engineering (POE) $20.00PLTW2002D Digital Electronics (DE) $20.00PLTW2003 Civil Engineering & Architecture (CEA) $20.00PLTW2004 Engineering Design & Development (EDD) $20.00Physical EducationPE1100 P.E. 1 Freshman (CPR Unit) $10.00PE1052D Lifeguarding $40.00DRVR2000 Driver Education (BTW) $350.00

Course Number Course Name CostTEE2003 Drafting & Design $18.00TEE3001D Architectural Drafting $10.00TEE3003 Automotive Mechanics $15.00TEE4001B Automotive Servicing $19.00TEE2005 Automotive Maintenance $17.00BUS3004 College Test Prep $75.00BUS4002A AP Microeconomics $25.00BUS2001 Accounting 1 $41.00BUS2001 Accounting 1 $31.00BUS2001 Accounting 1 $31.00BUS3016H Honors Accounting 2 $43.00BUS3016H Honors Accounting 2 $36.00

HIGH SCHOOL STUDENT WORKBOOKS 2014-15

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BUS4003A AP Macroeconomics $25.00PE1052D Lifeguarding $32.00MUSC2001A AP Music Theory $40.95WLAN1001 French 1 $19.00WLAN1002 French 2 $19.00WLAN1003 French 3 $19.00WLAN1004 French 4 $14.00WLAN1004A AP French $39.00WLAN2001 German 1 $14.00WLAN2002 German 2 $14.00WLAN2003 German 3 $15.00WLAN2004A AP German $41.00WLAN3001GWLAN3001

Spanish 1 $15.00

WLAN3002 Spanish 2 $15.00WLAN3003 Spanish 3 $15.00WLAN3004 Spanish 4 $14.00WLAN3004A AP Spanish $31.00WLAN4001GWLAN4001

Chinese 1 $30.00

WLAN4002 Chinese 2 $30.00WLAN4003WLAN4004H

Chinese 3Honors Chinese 4

$30.00

Crouse Education Center 780 Shoreline Drive Aurora, IL 60504 630-375-3562 www.ipef204.org

Dear Parents, Since 1988, the Indian Prairie Educational Foundation has supported students attending District 204 schools. Thanks to the generosity of private donations, the Foundation has been able to fund program enrichments that aren’t typically financed with tax dollars. As we look back over our first 25 years, we celebrate our accomplishments in providing over $3 million in “educational extras” that make the difference between a good school system and an excellent one. The IPEF has supported:

• Young Hearts for Life Cardiac Screening Program, an initiative providing free ECG screenings to high school students to combat sudden cardiac death. More than 16,864 students have received free screenings since the program was introduced in 2009.

• STEM related program funding in middle and high school classrooms including the annual District 204 Science Fair and VEX Robotics Tournament.

• Artist-in-Residence has brought in 199 artists into classrooms to enhance learning for thousands of students in the areas of art, literature and music. Financial support of this program is more than $245,000.

• IPEF Teacher Grants have been awarded for 603 teacher driven initiatives providing enrichments in all areas of curriculum, at all grade levels. Grants awarded total more than $435,000.

• Fine Arts Festival, an annual showcase featuring the artistic and musical talents of students throughout our district features more than 80 musical performances from 9,000 students and 12,000 pieces of visual arts.

I am extremely grateful to our parents for past contributions that have helped support the Foundation. Your donation allows us to provide incredible opportunities to students throughout the district. With your on-going assistance, we can continue to fund programs that enrich our students’ educational experience. On your registration form, please consider making a $25 contribution to the Indian Prairie Educational Foundation. If you would like more information on the Foundation you can visit our web site at www.ipef204.org or call me at 630-209-2101. Thank you and have a wonderful year. Sincerely,

Kent Duncan Chairman

Dear Parent/Guardian: Welcome to Indian Prairie School District. The purpose of this letter is to inform you of the health examination and immunization requirements in Illinois and the policy of the school district. Indian Prairie School District will follow the mandates of the Illinois Department of Public Health with regards to required immunizations for our students.

• Students entering preschool, kindergarten, sixth, and ninth grades, and new students to the district, must present proof of the required state of Illinois physical examination and immunizations. The student history portion of the examination form must be completed and signed by the parent. If this is not completed, the student will be excluded from school on October 15, 2014. Out-of-state physical examinations written on approved forms, which meet current state of Illinois requirements, are acceptable if they are less than one year old.

• An out-of-state transfer student may, at the time of registration, provide an appointment card showing these requirements will be completed within thirty days. At the end of the thirty day period, if the completed forms have not been presented to health services, the student will be excluded from school.

• All students entering kindergarten, second, and sixth grades are required to present proof of an oral health examination completed by a licensed dentist. This will be due prior to May 15th of that academic year.

• A vision examination is required of all students entering kindergarten or enrolling in an Illinois public school for the first time. Written proof of having been examined by a physician licensed to practice medicine in all of its branches or a licensed optometrist will be required.

• Students, who were enrolled last school year in District 204, should not need a new physical exam unless he/she is entering kindergarten or grade six or nine. Returning students who need immunization(s) will receive individual letters notifying the parent of the immunization(s) needed. The DuPage (630-682-7400) and Will (815-727-8480) County Health Departments offer immunizations at their clinics for a nominal fee. Please contact them directly to schedule an appointment.

• Please note that a current physical is required to try out for any interscholastic sport (grades 7-12). A physical is not required for intramural sports (grades 6-12).

If a physical, dental, or vision exam is needed, check with your health care provider to see if he/she has the mandated Illinois form. If he/she does not have the Illinois form, it will be available at www.ipsd.org. The District’s Medication Policy is found in the Parent/Student Handbook and at www.ipsd.org. Please reference the section on School Board Policy. A student, who has asthma or allergies, is allowed to carry necessary medication while at school. Physician orders or a photocopy of the pharmaceutical label on the medication box for rescue inhalers must be on file with the nurse. Enclosed in the registration packet, you will find an emergency medical card, which must be filled out, signed, and returned to your child’s school. This card is kept in the nurse’s office and used in the event of an emergency. This card is needed in the nurse’s office prior to your child starting school. If you have any questions, please do not hesitate to call your school health office. Sincerely, Linda Herwaldt RN, BSN, MS, PEL-CSN Coordinator of Health Services


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2014-2015 REVISED/ADOPTED RULES FOR SCHOOL IMMUNIZATION REQUIREMENTS

PART 665 CHILD HEALTH EXAMINATION CODE SUBPART B: HEALTH EXAMINATION

Section 665.240 Basic Immunization

d) Rubella 2) Beginning with the school year 2014-2015, children entering school at any grade level

(kindergarten through 12) shall show proof of having received two doses of live rubella virus vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first dose, or other proof of immunity described in Section 665.250(c).

3) For students attending school programs where grade levels (kindergarten through 12) are not

assigned, including special education programs, proof of two doses of live rubella virus vaccine as described in subsection (d)(2) shall be submitted prior to the school years in which the child reaches the ages of five, 11 and 15.

e) Mumps 2) Beginning with the school year 2014-2015, children entering school at any grade level

(kindergarten through 12) shall show proof of having received two doses of live mumps virus vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first dose, or other proof of immunity described in Section 665.250(c).


assigned, including special education programs, proof of having received two doses of live mumps virus vaccine as described in subsection (e)(2) shall be submitted prior to the school years in which the child reaches the ages of five, 11 and 15.

g) Hepatitis B

2) Children entering the sixth grade shall show proof of having received three doses of hepatitis B vaccine, or other proof of immunity described in Section 665.250(f). The first two doses shall have been received no less than four weeks (28 days) apart. The interval between the second and third doses shall be at least two months. The interval between the first and third doses shall be at least four months. Proof of prior or current infection, if verified by laboratory evidence, may be substituted for proof of vaccination (see Section 665.250(f)).

h) Varicella

3) Beginning with school year 2014-2015, any child entering kindergarten, sixth grade, or ninth grade for the first time shall show proof of having received two doses of varicella vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first dose, or proof of prior varicella disease as described in Section 665.250(g), or laboratory evidence of varicella immunity.


assigned, proof of having received at least two doses of varicella vaccine or other proof of immunity as described in subsections (h)(2), (3) and (4) shall be submitted prior to the school year in which the child reaches the ages of five, 11 and 15.

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i) Invasive Pneumococcal Disease 1) Any child under two years of age entering a child care facility or school program below the

kindergarten level shall show proof of immunization that complies with the pneumococcal vaccination schedule in Appendix F.

2) Children 24 to 59 months of age who have not received the primary series of pneumococcal

conjugate vaccine, according to the recommended vaccination schedule, shall show proof of receiving one dose of pneumococcal vaccine.

3) Any child who has reached his or her fifth birthday shall not be required to provide proof of

immunization with pneumococcal conjugate vaccine.

j) The requirements of this Section also apply to children who transfer into Illinois child care facilities, school programs, and schools from other states, regardless of the age or grade level at which the child transfers.

of 3

SCHOOL YEAR 2015-2016

“PROPOSED” MENINGOCOCCAL

CONJUGATE VACCINE (MCV4)

PROPOSED REQUIREMENT WILL BE FOR 6TH AND 12TH

GRADE ENTRY 6th Grade Entry

Must show proof of receiving one dose of meningococcal conjugate vaccine (MCV4) on or after 11 years of age

12th Grade Entry

Must show proof of receiving two doses of meningococcal conjugate vaccine (MCV4) The second dose of MCV4 must be > 16 years of age If the first dose of MCV4 was administered > 16 years of age, then only 1 dose of MCV4 is required at 12th grade entry

State of Illinois

Certificate of Child Health Examination

IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

Student’s Name Last First Middle

Birth Date Month/Day/Year

Sex Race/Ethnicity School /Grade Level/ID#

Address Street City Zip Code

Parent/Guardian Telephone # Home Work

IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication.

Vaccine / Dose 1 MO DA YR

2 MO DA YR

3 MO DA YR

4 MO DA YR

5 MO DA YR

6 MO DA YR

DTP or DTaP

Tdap; Td or Pediatric DT (Check specific type)

TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT

Polio (Check specific type)

IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV

Hib Haemophilus influenza type b

Hepatitis B (HB)

Varicella (Chickenpox)

COMMENTS:

MMR Combined Measles Mumps. Rubella

Single Antigen Vaccines

Measles Rubella Mumps

Pneumococcal Conjugate

Other/Specify Meningococcal, Hepatitis A, HPV, Influenza

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date MO DA YR (Attach copy of lab result)

VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN

Date Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts

Age/ Grade

R L R L R L R L R L R L R L R L R L

Vision Hearing

FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013

Birth Date Sex School Grade Level/ ID

# Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.)

Diagnosis of asthma? Child wakes during night coughing?

Yes No Yes No

Loss of function of one of paired organs? (eye/ear/kidney/testicle)

Yes No Birth defects? Yes No Hospitalizations?

When? What for? Yes No

Developmental delay? Yes No

Blood disorders? Hemophilia, Sickle Cell, Other? Explain.

Yes No Surgery? (List all.) When? What for?

Yes No

Diabetes? Yes No Serious injury or illness? Yes No

Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No

Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No

Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No

Dizziness or chest pain with exercise?

Yes No Family history of sudden death before age 50? (Cause?)

Yes No

Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)

Dental Braces Bridge Plate Other

Ear/Hearing problems?

Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date Bone/Joint problem/injury/scoliosis? Yes No

PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P

DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered ? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm ______________ Blood Test: Date Reported / / Result: Positive Negative Value ______________ LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Sickle Cell (when indicated) Urinalysis Developmental Screening Tool

SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Endocrine Ears Gastrointestinal

Eyes Amblyopia Yes No Genito-Urinary LMP Nose Neurological

Throat Musculoskeletal Mouth/Dental Spinal Exam

Cardiovascular/HTN Nutritional status

Respiratory Diagnosis of Asthma Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid)

Other

NEEDS/MODIFICATIONS required in the school setting

DIETARY Needs/Restrictions

SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal

EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited

Print Name (MD,DO, APN, PA) Signature Date

Address Phone

(Complete Both Sides)

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

State of IllinoisIllinois Department of Public Health

To be completed by dentist:

Oral Health Status (check all that apply)

� Yes � No Dental Sealants Present

� Yes � No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it wasextracted as a result of caries OR missing permanent 1st molars.

� Yes � No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of thewalls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retainedroot, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-ered sound unless a cavitated lesion is also present.

� Yes � No Soft Tissue Pathology

� Yes � No Malocclusion

Treatment Needs (check all that apply)

� Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

� Restorative Care — amalgams, composites, crowns, etc.

� Preventive Care — sealants, fluoride treatment, prophylaxis

� Other — periodontal, orthodontic

Please note____________________________________________________________________________________

Signature of Dentist _________________________________________ Date of Exam ____________________

Address ___________________________________________________ Telephone _______________________Street City ZIP Code

Illinois Department of Public Health, Division of Oral Health217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us

Printed by Authority of the State of Illinois

Student’s Name: Last First Middle Birth Date:/ /

Address: Street City ZIP Code Telephone:

Name of School: Grade Level: Gender:� Male � Female

Parent or Guardian: Address (of parent/guardian):

(Month/Day/Year)

IOCI 0600-10

State of IllinoisEye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eyeexaminations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school forother children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinoisschool system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

Student Name ________________________________________________________________________________________________(Last) (First) (Middle Initial)

Birth Date ____________________ Gender ______ Grade _____(Month/Day/Year)

Parent or Guardian ____________________________________________________________________________________________(Last) (First)

Phone ______________________________(Area Code)

Address _____________________________________________________________________________________________________(Number) (Street) (City) (ZIP Code)

County ____________________________________________

To Be Completed By Examining Doctor

Case HistoryDate of exam ________________

Ocular history: � Normal or Positive for ___________________________________________________________________

Medical history: � Normal or Positive for ___________________________________________________________________

Drug allergies: � NKDA or Allergic to ____________________________________________________________________

Other information _____________________________________________________________________________________________

ExaminationDistance NearRight Left Both Both

Uncorrected visual acuity 20/ 20/ 20/ 20/Best corrected visual acuity 20/ 20/ 20/ 20/

Was refraction performed with dilation? �Yes � No

Normal Abnormal Not Able to Assess CommentsExternal exam (lids, lashes, cornea, etc.) � � � __________Internal exam (vitreous, lens, fundus, etc.) � � � __________Pupillary reflex (pupils) � � � __________Binocular function (stereopsis) � � � __________Accommodation and vergence � � � __________Color vision � � � __________Glaucoma evaluation � � � __________Oculomotor assessment � � � __________Other _________________________ � � � __________NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis� Normal � Myopia � Hyperopia �Astigmatism � Strabismus �Amblyopia

Other _______________________________________________________________________________________________________

Continued on backPage 1

State of IllinoisEye Examination Report

Recommendations1. Corrective lenses: � No �Yes, glasses or contacts should be worn for:

� Constant wear � Near vision � Far vision� May be removed for physical education

2. Preferential seating recommended: � No �Yes

Comments ________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Recommend re-examination: � 3 months � 6 months � 12 months

� Other ____________________________________

4. _________________________________________________________________________________________________________

5. _________________________________________________________________________________________________________

Print name____________________________________________ License Number_____________________________________Optometrist or physician (such as an ophthalmologist)

who provided the eye examination � MD � OD � DO

Address ____________________________________________

____________________________________________

Phone ____________________________________________

Signature ____________________________________________ Date ___________________

(Source: Amended at 32 Ill. Reg. _________, effective ___________)

Consent of Parent or GuardianI agree to release the above information on my childor ward to appropriate school or health authorities.

(Parent or Guardian’s Signature)

(Date)

Page 2Printed by Authority of the State of Illinois

6/09IOCI1271-09

Indian Prairie Community Unit School District 204 7:270-E

STUDENT MEDICATION FORM (PARENT/GUARDIAN AND PHYSICIAN)

Student Name: ________________________________________________

Student’s Address: ____________________________________________

Date of Birth: ________________________________________________

Grade: ______________________________________________________

ADMINISTRATION OF MEDICATION BY DISTRICT PERSONNEL

The undersigned, being the parent or guardian of the above-named student, hereby request that School District 204 administrative personnel administer prescription medication ordered by the student’s Physician, Physician Assistant or Advanced practice R.N. in accordance with the completed information on this form.

I recognize that it is not always practical or possible for medication to be administered by a school nurse, and, therefore, consent to administration of medication to the student by administrative personnel in addition to the school nurse.

I understand that I am to bring the medication to the school office in a pharmaceutical container labeled with the student’s name, name of medication, dosage and all pertinent instructions.

I hereby release School District 204, its officers, directors, agents, employees and assigns from any and all liability arising from the administration of medication to the above named student.

Parent/Guardian Signature: ________________________________ Phone # ______________________

TO BE COMPLETED BY PHYSICIAN/PROVIDER

Name of Medication: __________________________________________________________________

Dosage and Time to be Administered: _____________________________________________________

Purpose of Medication: _________________________________________________________________

Diagnosis: ___________________________________________________________________________

Possible Side Effects: __________________________________________________________________

Signature of Physician/Provider: _____________________________________ Date: _______________

Street Address: _______________________________________________________________________

City/State: _______________________________________________________ Zip: ________________

Office Phone #: _____________________________ Emergency Phone #: ________________________

Indian Prairie Community Unit School District 204 7:270-E

STUDENT SELF-ADMINISTRATION FORM (PARENT/GUARDIAN AND PHYSICIAN)

Student Name: ________________________________________________

Student’s Address: ____________________________________________

Date of Birth: ________________________________________________

Grade: ______________________________________________________

STUDENT SELF-ADMINSTRATION OF MEDICATIONS

The undersigned, being the parent or guardian of the above-named student, authorizes the School District to permit the student to self-administer his or her asthma medication or other medication. I acknowledge that the School District and its employees and agents will incur no liability, except for willful and wanton conduct, as a result of any injury arising from the student’s self-administration of the medication. I agree to indemnify and hold harmless the School District and its employees and agents against any and all claims, except claims based on willful and wanton conduct, arising out of the self-administration of medication by the student.

A Physician, Physician Assistant, or Advanced Practice RN must complete the information at the bottom of this form.

Parent/Guardian Signature: ________________________________ Phone # ______________________

TO BE COMPLETED BY PHYSICIAN/PROVIDER:

Name of Medication: __________________________________________________________________

Dosage and Time to be Administered: _____________________________________________________

Purpose of Medication: _________________________________________________________________

Diagnosis: ___________________________________________________________________________

Possible Side Effects: __________________________________________________________________

Signature of Physician/Provider: _____________________________________ Date: _______________

Street Address: _______________________________________________________________________

City/State: _______________________________________________________ Zip: ________________

Office Phone #: _____________________________ Emergency Phone #: ________________________

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