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Required documents needed to register:
Birth Certificate
Immunization Records
Three proofs of residency
HARBOR CREEK SCHOOL DISTRICT
www.hcsd.iu5.org
Phone (814) 897-2100
Clark Elementary
3650 Depot Road
Erie, PA 16510
Fax: 897-8723
Klein Elementary
5325 East Lake Road
Erie, PA 16511
Fax: 580-5419
Rolling Ridge Elementary
3700 Ridge Parkway
Erie, PA 16510
Fax: 898-1916
Harbor Creek Jr./Sr. High
6375 Buffalo Road
Harborcreek, PA 16421
Jr. High Fax: 897-2121
Sr. High Fax: 897-2136
Website:
Newsletter & Alerts:
Twitter:
Facebook:
HCSD.iu5.org
request to receive at:
twitter.com/HCSDHuskie
facebook.com/HCSDHuskies
STAY CONNECTED WITH HCSD
ANNUAL PUBLIC NOTICE OF SPECIAL EDUCATION SERVICES &
PROGRAMS, SERVICES FOR GIFTED STUDENTS, & SERVICES FOR
PROTECTED HANDICAPPED STUDENTS
The Northwest Tri-County Intermediate Unit and its Member
School Districts, Charter Schools
and Private Rehabilitation Residential Institution (PRRI)
Conneaut School District Corry Area School District
Crawford Central School District Erie’s Public Schools
Fairview School District Fort LeBoeuf School District
General McLane School District Girard School District
Harbor Creek School District Iroquois School District
Millcreek Township School District
North East School District
Northwestern School District
PENNCREST School District
Union City Area School District
Warren County School District
Wattsburg Area School District
Erie RISE Leadership Charter School
Montessori Regional Charter School
Perseus House Charter School of Excellence
Tidioute Community Charter School
Robert Benjamin Wiley Community Charter School
Harborcreek Youth Services
Notice to Parents
According to state and federal special education regulations, annual public notice to parents of children who reside within
a school district is required regarding child find responsibilities. School districts, intermediate units and charter schools are
required to conduct child find activities for children who may be eligible for services via Section 504 of the Rehabilitation
Act of 1973. For additional information related to Section 504/Chapter 15 services, the parent may refer to Section 504,
Chapter 15, and the Basic Education Circular entitle Implementation of Chapter 15. Also, school districts are required to
conduct child find activities for children who may be eligible for gifted services via 22 PA Code Chapter 16. For
additional information regarding gifted services, the parent may refer to 22 PA Code Chapter 16. If a student is both gifted
and eligible for Special Education, the procedure in IDEA and Chapter 14 shall take precedence.
This notice shall inform parents throughout the school district, intermediate unit, and charter schools of the child
identification activities and of the procedures followed to ensure confidentiality of information pertaining to students with
disabilities or eligible young children. In addition to this public notice, each school district, intermediate unit and charter
schools shall publish written information in the handbook and on the website. Children ages 3-21 can be eligible for
special education programs and services.
If parents believe that the child may be eligible for special education, the parent should contact the school
district where the child attends or the Director of Special Education for the NW Tri-County Intermediate Unit
identified at the end of this public notice.
Children age three through the age of admission to first grade are also eligible if they have developmental delays
and, as a result, need special education and related services. Developmental delay is defined as a child who is
less than the age of beginners and at least three years of age and is considered to have a developmental delay
when one of the following exists: (i) The child’s score, on a developmental assessment device, on an assessment
instrument which yields a score in months, indicates that the child is delayed by 25 percent of the child’s
chronological age in one or more developmental areas, or (ii) The child is delayed in one or more of the
developmental areas, as documented by test performance of 1.5 standard deviations below the mean on
standardized tests.
Developmental areas include cognitive, communicative, physical, social/emotional and self-help. For additional
information you may contact the Early Intervention Department at the Intermediate Unit. (See Evaluation
Process below for contact info.)
Evaluation Process
Each school district, intermediate unit and charter schools have a procedure in place by which parents can
request an evaluation. For information about procedures applicable to your child, contact the school, which your
child attends. Parents of preschool age children, age three through five, may request an evaluation in writing by
addressing a letter to the Early Intervention Supervisor, NW Tri-County Intermediate Unit #5, 252 Waterford
St., Edinboro, PA 16412 or call 1-800-677-8461.
Consent
School entities cannot proceed with an evaluation or reevaluation, or with the initial provision of special
education and related services, without the written consent of the parents. For additional information related to
consent, please refer to the Procedural Safeguards Notice which can be found at the PaTTAN website at
www.pattan.net. Once written parental consent is obtained, the school district, intermediate unit, charter schools,
or PRRIs will proceed with the evaluation process. If the parent disagrees with the evaluation, the parent can
request an independent education evaluation at public expense.
Program Development
Once the evaluation process is completed, a team of qualified professionals and the parents determine whether
the child is eligible. If the child is eligible, the individualized education program (IEP) team meets, develops the
program, and determines the educational placement. Once the IEP team develops the program and determines
the educational placement, school district staff, intermediate unit staff or charter school staff will issue a notice
of recommended educational placement/prior written notice. Your written consent is required before initial
services can be provided. The parent has the right to revoke consent after initial placement.
HCSD October 27, 2020 Page 1 of 3
Confidentiality of Information
The school districts, intermediate units, charter schools and PRRIs maintain records concerning all children
enrolled in the school, including students with disabilities. All records are maintained in the strictest
confidentiality. Your consent, or consent of an eligible child who has reached the age of majority under State
law, must be obtained before personally identifiable information is released, except as permitted under the
Family Education Rights and Privacy Act (FERPA). The age of majority in Pennsylvania is 21. Each
participating agency must protect the confidentiality of personally identifiable information at collection, storage,
disclosure, and destruction stages. One official at each participating agency must assume responsibility for
ensuring the confidentiality of any personally identifiable information. Each participating agency must maintain,
for public inspection, a current listing of the names and positions of those employees within the agency who
have access to personally identifiable information.
For additional information related to student records, the parent can refer to the FERPA at the following URL:
http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html.
This notice is only a summary of the special education services, evaluation and screening activities, and rights
and protections pertaining to children with disabilities, children thought to be disabled, and their parents. For
more information or to request evaluation or screening of a preschool or school aged child, public or private,
contact the school or district where your child attends. Additionally one may contact the name and number or e-
mail listed below:
Christine Carucci
Director of Special Education
Northwest Tri-County Intermediate Unit #5 252 Waterford Street
Edinboro, PA 16412
1-800-677-5610
The school district, intermediate unit and charter school will not discriminate in employment, educational
programs, or activities based on race, color, national origin, age, sex, handicap, creed, marital status or because a
person is a disabled veteran or a veteran of the Vietnam era. No preschool, elementary or secondary school pupil
enrolled in a school district, intermediate unit, or charter school program shall be denied equal opportunity to
participate in age and program appropriate instruction or activities due to race, color, handicap, creed, national
origin, marital status or financial hardship.
HCSD October 27, 2020 Page 2 of 3
HCSD October 27, 2020 Page 3 of 3
Harbor Creek School District STUDENT REGISTRATION
Student Registration Updated 2021.05.11
Integrated Pest
Management Dear Parent(s) or Guardian(s)
The Harbor Creek School District uses an Integrated Pest Management (IPM) approach for managing insects, rodents and
weeds. Our goal is to protect every student from pesticide exposure by using an IPM approach to pest management. Our
IPM approach focuses on making the school building and grounds an unfavorable habitat for these pests by removing food
and water sources and eliminating their hiding and breeding places. We accomplish this through routine cleaning and
maintenance. We routinely monitor the school building and grounds to detect any pests that are present. The pest monitoring
team consists of our building maintenance, office, and teaching staff and includes our students. Pest sightings are reported
to our 1PM coordinator who evaluates the "pest problem" and determines the appropriate pest management techniques to
address the problem. The techniques can include increased sanitation, modifying storage practices, sealing entry points,
physically removing the pest, etc.
From time to time, it may be necessary to use chemicals to manage a pest problem. Chemicals will only be used when
necessary, and will not be routinely applied. When chemicals are used, the school will try to use the least toxic products
when possible. Applications will be made only when unauthorized persons do not have access to the area(s) being treated.
Notices will be posted in these areas 72 hours prior to application and for two days following the application.
Parents or guardians of students enrolled in the school may request prior notification of specific pesticide applications made
at the school. To receive notification, you must be placed on the school's notification registry. If you would like to be placed
on this registry, please notify your building principal in writing. Please include your email address if you would like to be
notified electronically.
If a chemical application must be made to control an emergency pest problem, notice will be provided by telephone to any
parent or guardian who has requested such notification in writing. Exemptions to this notification include disinfectants and
antimicrobial products; self-containerized baits placed in areas not accessible to students, and gel type baits placed in
cracks, crevices or voids; and swimming pool maintenance chemicals.
Each year the district will prepare a new notification registry. If you have any questions, please contact Mike Oleski,
IPM Coordinator at 897-2100 or by e-mail at [email protected] .
Sincerely,
Kelly Hess
Superintendent of Schools
Harbor Creek School District
Integrated Pest Management Revised 10-2020 mm Form 09-A16
Harbor Creek School District
Student Registration Updated 2020.10.27 mm
FOOD SERVICE INFORMATION
The Harbor Creek Food Service Department welcomes you to our School District. The following
information is to help with your child's lunch account,
If you would like an application for free or reduced lunches, you may obtain one from your school office
or on our Website. Just click on free or reduced application's under the news and announcements section
on the home page. Be assured all financial information is kept private. You may send the completed and
signed application to your child's school office or mail to:
Harbor Creek School District Food Service
6375 Buffalo Road
Harborcreek, PA 16421
You are also able to review your child's lunch account activity and make payments online. Simply go to the
Harbor Creek School District webpage and click on HAC & Meals Plus then select the directions and
information link for our Meals Plus program. We encourage you to use the Meals Plus system to keep money
on your child's account to help make a smooth transition through the lunch line each day, as well as, to
review your child's account for accuracy.
If you have any questions, feel free to contact me, Patricia Stadler, at 897-2100 extension 2132.
Thank you.
Patricia Stadler
Harbor Creek School District STUDENT REGISTRATION
Student Registration Updated 2021.05.11
Welcome to Harbor Creek! The following documentation is required to be completed and submitted before a student
can be admitted: (Please note that additional documentation will be required for Foster Children or Other Children who are
residing with a resident adult who is not their parent.)
Proof of Age [24 P.S §13-1304] a. Original or certified official birth certificate or; b. Original or certified baptismal certificate
Immunization Records [24 p.s. §13-1303a] – Certificate of immunization issued in accordance with the rules and regulations of the Pennsylvania Secretary of Health and the Advisory Health Board. Students who are not immunized as required by the PA Dept. of Health, or who are not medically or religiously exempt may not be admitted to school. Children in all grades (K-12) need the following immunizations to attend school:
4 doses of tetanus*(1 dose on or after 4th birthday) 4 doses of diphtheria* (1 dose on or after 4th birthday) 3 doses of polio 2 doses of measles** 2 doses of mumps** 1 dose of rubella (German measles) ** 3 doses of hepatitis B 2 doses of varicella (chickenpox) or evidence of immunity
*Usually given as DTP or DT or Td **Usually given as MMR
Students in 7th Grade also need the following immunizations: 1 dose meningococcal conjugate vaccine (MCV)
1 dose of tetanus, diphtheria, acellular pertussis (Tdap) [if five years have elapsed since last tetanus immunization]
The only exceptions to the school laws for immunization are medical, Philosophical/Strong Moral Ethical Conviction and religious beliefs. If your child is exempt from immunizations, your child may be removed from school during a disease outbreak.
Parental Disclosure Statement [24 P.S. §13-1304a] Parent attestation to whether the student has been or is suspended or expelled for offenses involving drugs or alcohol, weapons or violence. (Page 4 of this packet)
Proof of Residency and Affidavit [24 P.S. §13-1302] Application for registration must be accompanied by three proofs of residency from the following Lists. Proof of Residency documents must indicate the physical address of residence and the name(s) of property owner(s). A child shall be considered a resident of the school district in which his parent or guardian resides, and will be enrolled in the school building he/she would normally attend in accordance with established school district attendance areas.
List A (Must Provide 1) List B (Must Provide 2)
Mortgage Document Current Utility Bill (gas, water, electric, or cable, phone or cell phone) Lease Agreement Driver’s License
Tax Bill Vehicle Registration Current Credit Card Bill
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2021.05.11
Residency /Multiple Family Affidavit Parent or Guardian Own/Rent/Live with a Harborcreek Resident
Student’s Name __________________ Completed by Parent/Guardian or Harborcreek Resident
*Parent or Guardian is to complete only ONE of the following sections and provide all necessary residency documents. (see reverse side)
Parent/Guardian Owns a Home in Harborcreek
To be completed by registrants who own or are purchasing a home in Harborcreek Section A
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee. I/We, __________________________________________________ currently reside at ___________________________________________
Registrant Parent/Guardian Legal Name Address
Parent/Guardian Signature: ___________________________________________________________ Date: _______/__________/__________
Parent/Guardian Rents/Leases in Harborcreek
To be completed by registrants who are renting a home in Harborcreek Section B
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee. I/We, __________________________________________________ currently reside at ___________________________________________
Registrant Parent/Guardian Legal Name Address
Parent/Guardian Signature: ___________________________________________________________ Date: _______/__________/__________
Parent/Guardian Lives with a Harborcreek Resident Section C To be completed by the parent/guardian of the student and the Harborcreek resident with whom a family will reside
Per 24 P.S. §13-1302, a person who knowingly provides false information in the above statement for the purpose of enrolling a child in a school district for which the
child is not eligible commits a summary offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three hundred dollars ($300)
for the benefit of the school district in which the person resides or to perform up to two hundred forty (240) hours of community service, or both. In addition, the
person shall pay all court costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in accordance with 42561 during the
period of enrollment.
(Registration to attach all relevant Residency Documentation)
This form must be renewed by July 1st of each year for Section C only, and is subject to Central Office approval.
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason, it is the
responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law
and will hold all parties responsible for a non-resident fee.
I / We, ____________________________________________________ currently reside at _________________________________________________________________
Parent/Guardian Name Harbor Creek Resident’s Address
which is owned leased by __________________________________________ (________________________________________________________________)
Harbor Creek Resident’s Name Relationship
Through our notarized signature, we understand that the school district, pursuant to guidelines issued by the Department of Education and their own written policy, may require other
reasonable information to be submitted to confirm this sworn statement.
______________________________________________________________ _______/_______/_______
Parent or Guardian’s Notarized Signature Date
_____________________________________________________________________ _______/_______/________
Harbor Creek Resident’s Notarized Signature Date
_____________________________________________________________________ _______/_______/_______
Notary’s Signature Date
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2021.05.11
COMPLETE FOR ALL SECTIONS
THE FOLLOWING ITEMS MUST BE PROVIDED BY ALL RESIDENTS AND/OR PARENTS RESIDING IN HCSD TO COMPLETE STUDENT REGISTRATION:
Proof of Residency [24 P.S. §13-1302 Application for registration must be accompanied by 3 proofs of residency from the following lists. Proof of Residency
documents must indicate the physical address of residence and the name(s) of property owners(s). A child shall be considered a resident of the school district in
which his parent or guardian resides, and will be enrolled in the school building he/she would normally attend in accordance with established school district
attendance areas.
List A (Must Provide 1) List B (Must Provide 2) Mortgage Document Current Utility Bill
Resident Lease Agreement Driver’s License
Tax Bill Vehicle Registration Current Credit Card Bill
Parent / Guardian Lives with a Harborcreek Resident
PROOF OF RESIDENCE IN HARBORCREEK:
HCSD requires evidence that a student resides in the district before the student can be enrolled. If your family is living with another Harborcreek resident
temporarily, you may enroll your child by completing & having this Residency Affidavit notarized, which requires both the parent/guardian of the child and the
resident to appear before the Central Registration office (or designee). The resident needs to provide the above documents, plus the parent/guardian needs to
proved one of the below documents.
Parent List B (Must Provide 2) Living with a Drivers’s License
Harborcreek Vehicle Registration
Resident Cell Phone Bill Current Credit Card Bill
ACKNOWLEDGEMENT:
I acknowledge and agree to the following statements (initial each one below):
_____ My child resides with me ____ days per week at the address proven, which is my primary residency.
_____ I agree to notify HCSD within five (5) days when I change my residence either within or outside HCSD.
_____ Home visitation and/or other residency verification are part of a periodic process to confirm current residency status.
_____ The District will actively investigate all cases when it has reason to believe that residency status has changed and/or believe that false information has
been provided. Verification may include home visits.
_____ The District may refer cases in which false information has been intentionally provided to our solicitor for further investigation.
_____ Investigations that reveal students have enrolled on the basis of providing false information will lead to immediate withdrawal and billing for
non-resident fee.
_____ I understand that a person who knowingly provides false information for the purpose of enrolling a child in a school district for which the child is not
eligible commits a summary offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three hundred dollars
($300) for the benefit of the school district in which the person resides or to perform up to two hundred forty (240) hours of community service, or both.
_____ I understand that the person shall pay all court costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in
accordance with 24 P.S. 25-2561 during the period of enrollment.
________________________________________ ______/______/_____ ___________________________________________ ______/________/______
Parent/Guardian Signature Date Resident Signature Date
A RESIDENCY AFFIDAVIT FOR SECTION C IS VALID FOR THE CURRENT SCHOOL YEAR ONLY AND MUST BE RENEWED BY
JULY 1ST OF EACH SCHOOL YEAR. FAILURE TO RENEW THIS FORM WILL DELAY CONTINUED ENROLLMENT.
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2021.05.11
FO
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200
Student Number Registration Date PA Secure ID # Building Enrolled Building Code Entry Code Grade
First Day Attendance Agency Name Agency Phone Social Worker
Homeless
Homebound Foreign Exchange Student (239A) Guardianship (1302)
Foster Child (1305) Institutionalized Child (1306) Special Education
Has the student previously attended the HC School District? Y N
Student Information
Student Last Name, First Name, Middle Initial Date of Birth Grade Entering Male
Female
Is there a Court Order involving this student? Y N (If YES, please provide a copy to the school office, otherwise we are unable to abide by its contents.)
Ethnicity
Hispanic Not Hispanic
Race
American Indian/ Alaskan Native Black/ African American Native Hawaiian/ Pacific Islander
Asian Multi-racial Hispanic White/Caucasian
Street Address:
Apt or Lot # City: Zip Code: Home Phone #:
Name of Previous School: Address of Previous School: (street, city, state, zip) Phone #:
Date of US Entry: Date of PA Entry: Date of 9th Gr. Entry: Parent(s) in Military Yes No
Is this student currently receiving SPECIAL EDUCATION services? Yes No
Student Program Information Check ALL services that your child is currently receiving:
Individualized Education Plan (Special Education Services)
Gifted Individualized Education Plan (Gifted Education Services)
Section 504/Chapter 15 Service Agreement (Special Accommodations for Health/Physical needs)
Early Intervention Program
Autistic Support Blind/Visually Impaired
Deaf or Hearing Support Emotional Support
ESL (English as a Second Language) IST (Instructional Support Team)
Life Skills Support Physical Support
Remedial Math (Extra Help) Remedial Reading (Extra Help)
Speech/Language Support Other
FOR OFFICE USE ONLY
Please complete this section:
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2021.05.11
FO
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200
Parent/Guardian Information
Number of Parents in Household (please choose one): 1 2 Child Resides
With (Check all that apply)
Parent #1 Name: Mr. Mrs. Ms. Dr. Parent #1 Address, City, State, Zip (if different from student):
Parent #1 Cell #: Home #: Work #: Email: Circle priority #
Parent #2 Name: Mr. Mrs. Ms. Dr. Parent #2 Address, City, State, Zip (if different from student):
Parent #2 Cell #: Home #: Work: Email: Circle priority #
Guardian Name: Mr. Mrs. Ms. Dr. Guardian Address, City, State, Zip (if different from student): Relationship to Student
Guardian Cell Cell#: Home#: Guardian Alt #: Guardian Email: Circle priority #
Emergency Contact #1 Mr. Mrs. Ms. Dr. Name:
Relationship to Student
Emergency Contact
Cell#: Home#: Alt. #
Emergency Contact #2 Mr. Mrs. Ms. Dr. Name:
Relationship to Student
Emergency Contact
Cell#: Home#: Alt. #
Other Adults or Children in Residence
Name Birthdate
(mm/dd/year) Grade School
Signature of Parent or Guardian: Date:
Harbor Creek School District
Student Registration Updated 2021.05.11
PA1304 F
OR
M
6375 Buffalo Road, Harborcreek, PA 16421 www.hcsd.iu5.org
(814)897-2100
Parental Disclosure Statement
Student Name
Date of Birth Grade
Parent or Guardian Name
Address
Telephone Number
Pennsylvania School Code §13-1304-A states in part “Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration provide a sworn statement or affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an action of offense involving a weapon, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.”
Please complete the following: I hereby swear or affirm that my child was was not previously suspended or expelled, or is is not
presently suspended or expelled from any public or private school of this Commonwealth or any other state for an act
or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of
violence committed on school property. I make this statement subject to the penalties of 24 P.S. §13-1304-A(b) and
18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities, and the facts contained herein are true and
correct to the best of my knowledge, information and belief.
If this student has been or is presently suspended or expelled from another school, please complete:
Name of the school from which student was suspended or expelled:
Dates of suspension or expulsion:
(Please provide additional schools and dates of expulsion or suspension on back of this sheet.)
Reason for suspension/expulsion (optional)
(Signature of Parent or Guardian)
(Date)
Any willful false statement made above shall be a misdemeanor of the third degree.
This form shall be maintained as part of the student’s disciplinary record.
An equal rights and opportunities school district.
Harbor Creek School District
Student Registration Updated 2021.05.11
200A FO
RM
The Office of Civil Right (OCR) requires that school districts/charter schools/full day AVTS identify limited English
Proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has
selected the Home Language Survey as the method for the identification.
Please complete the following:
_______________________ Signature of Parent/Guardian
Or
_________________________
Signature of person completing this form (if other than parent/guardian):
*The Harbor Creek School District has the responsibility under federal law to serve students who are limited English
proficient and need English instructional services. Given this responsibility, Harbor Creek School District has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and
identify ELLs, the school district may conduct screenings or ask for related information about students who are already enrolled in the district as well as from students who enroll in the school district in the future.
PLEASE RETURN THIS COMPLETED FORM TO YOUR CHILD’S SCHOOL.
Home Language Survey Pink
HCSD Home Language Survey
Date
Student’s Name
School
Grade
1. What is the language that your child first learned to speak?
2. Does the student speak a language other than English?
(Do not include languages learned in school.)
Yes/No If yes, what language
3. Is a language other than English spoken in the child’s home?
4. Has the student attended any United States school in any 3 years during his/her lifetime?
If the answer to #4 is Yes please complete the following.
Name of School State Dates Attended
Harbor Creek School District
Student Registration Updated 2021.05.11
216 F
OR
M
Release of records
To Whom it May concern: The below listed student has registered with the Harbor Creek School District effective __________. Please forward his/her school records to highlighted school below. School records should include transcript of grades, materials from both categories such as grades earned this year and/or withdrawal grades, standardized test scores, attendance, birth certificate, IEP, psychological records, speech, dental, health and immunization records, intake/ discharge summaries, drug and alcohol treatment and any other pertinent information.
Student’s Name: (Last, First, Middle)
Student’s PA Secure ID #
DOB: Grade:
Previous School or Agency:
Address:
Phone # Fax:
You are hereby authorized to release copies of the following requested records:
STANDARD RECORDS SPECIAL EDUCATION RECORDS
Transcripts Most Recent IEP
Attendance Evaluation/Re-evaluation Reports
Discipline 504 Plan (Protected Handicapped)
Test Scores Gifted Program
Withdrawal Grades
Health Records
339 Documentation
Records are to be sent to the HCSD school listed below: Clark Elementary Klein Elementary Rolling Ridge Elem. HC Jr./ Sr. High
Attn: Office Attn: Office Attn: Office Attn: Guidance Office
3650 Depot Rd. 5325 East Lake Rd. 3700 Ridge Parkway 6375 Buffalo Rd.
Erie, PA 16510 Erie, PA 16511 Erie, PA 16510 Harborcreek, PA 16421 Phone:
814-897-2100 x 5500 Phone:
814-897-2100 x 4100 Phone:
814-897-2100 x 3300 Phone:
814-897-2100 x 1211 FAX: 814-897-8723 FAX: 814-580-5419 FAX: 814-898-1916 FAX: 814-897-2136
Please note:
Any information received by the Harbor Creek School District will be placed in a file to which parents have access and the capacity to release to a third independent agency. The professional staff of the Harbor Creek School District
monitors this access. Information will be destroyed when it is no longer useful for educational purposes.
I may revoke this release at any time except to the extent that the person who is to make the disclosure has already acted on it. Except as noted above, this release will expire one year from now unless revoked earlier in writing., All information released or obtained will be handled confidentially in compliance with the Family Education Rights and Privacy Act (FERPA).
______________________ ______________ _________________________
Parent/Guardian Signature Date Witness Signature
_____________________________________________ ______________ _____________________
Student Signature (14 years or older for Mental Health Records) Age Date (18 years or older for Educational Records)
Consent to obtain/release confidential Revised 2020.10.27 mm Form # 216 - Yellow
Ed./Med./Health Info
Harbor Creek School District
Updated 2019.03.28
Annual Health Assessment
Please complete both sides of this form and return to school
Student Name: __________D.O.B: ____ _______Grade: ___________
Preferred hospital in emergency: ___________________Does your student have health insurance? YES NO The school nursing staff has non-aspirin pain medication and antacid that may be given at the nurse’s discretion. Please
indicate which type of medication your child is permitted to have and sign below. The school has standing orders, which includes
a list of approved treatments and medications recommended by our school physician.
Tylenol (Acetaminophen) Yes No
Motrin (Ibuprofen) Yes No
Antacid (Tums) Yes No
Parent/guardian signature:
Please list any medications, dosage and reason for medication taken on a daily basis:
Medication Name Dosage Reason for Medication
Please read the following & CIRCLE any health concerns/conditions that your child has.
If you CIRCLE any of the following, please send in supporting documentation from your physician. Include any diagnoses,
medication orders, activity restrictions, action plans, or special accommodations needed for the school environment.
***************************************************************************************************
LIFE-THREATENING ALLERGIES/REACTIONS: Yes No
If yes, to what? ______________________________________________________________________________________
Type of Reaction (circle): Mild Moderate Severe
Please describe reaction: ______________________________________________________________________________
Is an Epi-Pen prescribed: Yes No *************************************************************************************************************************
ASTHMA: Yes No Is an inhaler prescribed for school? Yes No ADD/ADHD: Yes No Is medication prescribed during school hours? Yes No EPILEPSY/SEIZURE DISORDER: Yes No Date of last seizure: ________________ Emergency seizure medication prescribed: Yes No Medication Name: ___________________________________________
Please Complete Reverse side
FO
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Harbor Creek School District
Updated 2019.03.28
Does your child currently have or had in the past any of the following conditions (please circle and describe
below if needed):
Autism Spectrum Kidney/Bladder Disorder Concussion/Brain Injury
Recent Hospitalization Stomach/Bowel Neuro/Muscular Condition
Heart condition Skin Condition Diabetes/Thyroid issue
Cancer/Blood disorder Anxiety /Mood Disorder Other Respiratory Condition
Hearing Difficulty/Hearing Aides Vision Problems/Glasses Recent Injury/Illness/Surgery
Please describe any of the above conditions you circled:
__________________
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Dental Exams: Complete ONLY for Grades 1, 3, and 7:
The Pennsylvania School Code provides for periodic dental examinations in grades 1, 3, and 7. The school dentist will be
performing dental exams in the fall of each school year. Please indicate your preference below.
My child receives a regular dental exam. I will provide a copy for the school health record. Exam date: ______________ Dentist Name: _________________________________________ I give my permission for my child to be examined by the school dentist.
Signature for permission for school dentist to examine your child: __________________________________________
Physical Exams: Complete ONLY for Grades K, 6, and 11: The Pennsylvania School Code provides for periodic physical examinations in grades 6 and 11. If your child has not had
either an athletic or annual physical within one year of the current school year, the school physician will provide a
physical examination, free of charge, at a date to be determined. Please indicate your preference below.
My child received a physical exam by our family physician. I will provide a copy for the school health record. Exam date: ____________ Physician Name:________________________________________ My child received a sports physical within the last school year (Sport: ___________________________________)
I give my permission for my child to be examined by the school physician.
Signature for permission for school physician to examine your child: __________________________________________
Please sign below if the medical and health information on this form can be shared with your child’s teachers, bus drivers, coaches,
and other school staff as deemed necessary to best provide for your child during school hours.
Parent/Guardian Signature: Date: __________________________