child. - Deed or Mortgage - Lease Paycheck€¦ · Tuition amounts for non-resident are established by the Commissioner of Education and are affirmed by local school district boards

Dear Families:

Welcome to Mexico Academy and Central School District! We are excited to be serving your child and we look

forward to fostering a strong home and school connection to support the educational needs and interests of your

child.

Students in New York State are entitled to a free and appropriate public education in the district in which they reside.

In the event that you elect to enroll your child in a school district other than your child’s district of residence,

Education Law requires school districts to collect non-resident tuition. Exceptions to this may be considered under the

provisions of the McKinney-Vento Act. We are asking all families to provide proof of residency when they register

their students and/or complete the residency questionnaire to determine your residency status.

Mexico CSD requires any new, permanently housed, registrants to provide proof of residency. The following items

required at time of registration:

One of the following:

- Deed or Mortgage

If you are not the owner of the house, but live with the owner - such as a grandparent of the child - please call 315-

963-8400 x 5406 for further instructions. You will need to provide additional documentation.

- Lease

If you rent an apartment or house, your child's name must appear on the lease or lease application. If the child's

name is not listed, then, in addition to the lease, you must also bring a letter from the landlord stating that the child

lives at that address. The letter must include the landlord's name and phone number.

- Contract to Build/Buy a Home (for September entrance only).

In addition to the above, two (2) more proofs of residency are required. Any two of the following are acceptable:

• Bank account and/or credit union statement

• Paycheck

• Automobile and/or homeowners/renters insurance policy

• Automobile registration (NOTE: A driver's license is not acceptable)

• Telephone, cable and/or utility bills

Documents must be current and original - they will be copied and returned to you immediately. Print-outs from online

accounts will be accepted if they show the name and address of the resident and have a current date.

In the event that you are not able to provide proof of residency, Mexico CSD will require that you pay non-resident

tuition or enroll your children in their district of residence.

Tuition amounts for non-resident are established by the Commissioner of Education and are affirmed by local school

district boards of education. Non-resident tuition for the 2017-2018 school year for students in grades K-6 has been

established as $6,289 and tuition for students in grades 7-12 has been established as $6,537.

If you have any questions regarding residency, please feel free to contact Mary Beth Horn at extension 5406. If you

have questions regarding the McKinney-Vento Act, please feel free to contact Carolyn Maloney at extension 3410.

MEXICO ACADEMY AND CENTRAL SCHOOL

MEXICO, NEW YORK 13114 STUDENT REGISTRATION FORM

______________________________________________________________________________________________________________________________

Student’s Name ________________________________________________________________________________________________________________ Last First Middle

Male _____ Female _____ Student’s Date of Birth ______________________ Parent Email Address ____________________________________ Month Day Year Residential Address _____________________________________________________ Mailing Address __________________________________________ Home Phone # ______________________________________ Cell Phone # __________________________________________ Was Student Born In US? _____Yes _____No Date Student Entered US ____________________ Country of Birth ______________________ Last Country of Residency _________________________ Name of Emergency Contact Person: _______________________________________________ Relationship to Student: ___________________________ Address of Emergency Contact Person: ______________________________________________________________________________________________ Phone # of Emergency Contact Person: _______________________________________ Student Lives With: (circle all that applies) Both Parents Mother Only Father Only Step-Parent Grandparent(s) Other Name of Parent/Guardian Student Resides With and Relationship to Student:

(i.e. mother, father, step-mother, step-father, grandparent, aunt, uncle, foster parent, brother, sister, unrelated male/female, etc.)

1.) _____________________________________________________________________ Relationship: _____________________________________ Place of Employment: __________________________________________________ Work #: __________________________________________

2.) _____________________________________________________________________ Relationship: _____________________________________

Place of Employment: ___________________________________________________ Work #:__________________________________________

Have Court Ordered Custody Papers Been Issued For This Student: ( ) Yes ( ) No Are Court Papers Attached for Student File: ( ) Yes ( ) No Other Parent Name and Address __________________________________________________________________________________________________ Other Parent Home Phone # _________________________________ Cell # ______________________________________________ List All Person(s) to Receive Correspondence _______________________________________________________________________________________ Did Parent(s) Serve in Military? _____Yes _____No Date Parent(s) Entered Armed Forces __________________________ Is Parent(s) Still Active? _____Yes _____No Date Parent(s) Became Inactive in Armed Forces ___________________________ Names and Birth Date of Other Children In Student’s Home:

1.) _____________________________________________________________________________________________________________________ Last First Middle Sex Birth Date





If there are additional children in the home, please attach a sheet and list their names, sex, and birth date.

Has the Student Previously Attended Mexico School District ( ) Yes ( ) No If Yes, What Grade(s)? __________________________________________ Does the Student Have an IEP (Individual Educational Plan) or a Section 504 Accommodation Plan: ( ) Yes, Copies Attached ( ) No Does Your Child Currently Receive: (circle all that apply) AIS (Academic Intervention Services) Math, AIS (Academic Intervention Services) Reading Counseling Speech Physical Therapy Other School Transferring From: ______________________________________________________________________________________________________ Address of Previous School District: ______________________________________________________________________________________________ *****Please Note***** At time of registration the following paperwork is necessary: Birth Certificate, Immunization Records, Physical, Custodial Papers, Report Card, Proof of Residency (3 forms)

2/2017

MEXICO ACADEMY AND CENTRAL SCHOOL BUS INFORMATION

Check One:

( ) New Student

( ) Returning Student

( ) Current Student Changing Schools Within the District

Student’s Name: ____________________________________________________________________

Home Phone: ____________________ ( )Male ( )Female Date of Birth: ___________________

Residence Address: _________________________________________________________________

Mailing Address: ___________________________________________________________________

Looking at Your Home

-Who is your neighbor or what landmark is on your left?

__________________________________________________________________________________

-Who is your neighbor or what landmark is on your right?

__________________________________________________________________________________

Name of Adults in the Home

#1 ________________________________________Relationship ____________________________

#2 _________________________________________Relationship ____________________________

Name of Emergency Contact _____________________________ Phone# _____________________

Relationship_____________________________

Will Your Child be Bused to a Daycare Provider? ( )Yes ( )No

Name of Provider: ___________________________________________________________________

Address of Provider: _________________________________________________________________

Phone of Provider: _________________________ ( )AM Only ( )PM Only ( )Both AM & PM

FOR SCHOOL USE ONLY

Date Entered: _________ Student ID Number: ______________________________

Grade: _____ Teacher: ________________________________

Pick-up Bus Number: ________ Dismissal Bus Number: ________

( )Mexico Elementary ( )Palermo Elementary ( )New Haven Elementary

( )Mexico Middle School ( )Mexico High School

2/2017

MEXICO CENTRAL SCHOOL – DISMISSAL INFORMATION

Student Name ________________________________________________ Grade _______________________

Does your child go to a daycare provider? Before School: ( ) Yes ( ) No After School: ( ) Yes ( ) No

Provider’s Name ________________________________________________ Provider’s Phone Number ______________________

Provider’s Address___________________________________________________________________________________________

The following people have permission to pick up my child at any time (photo ID may be required):

1. _______________________________________Relationship________________________________Phone ___________

2. _______________________________________Relationship________________________________Phone____________



Early Dismissal Information

The Superintendent may find it necessary to close schools early when hazardous weather conditions or other emergencies threaten

the health and welfare of students. In addition, the district calendar has several ½ days, or Early Dismissal Days.

When school dismisses early for regularly scheduled ½ days or Early Dismissal Days, please send my child to the following

destination:

A. _____ Home on Bus # ______

or

B. _____ Alternate destination on Bus # _____

To ____________________________________________________________ Phone # _______________________ Address ______________________________________________________________________________________

When school dismisses early for hazardous weather conditions or other emergencies that threaten the health and welfare of

students, please send my child to the following destination:

A. _____ Same as Early Dismissal Days, Noted Above

or

B. _____ Alternative destination on Bus # _____

To ___________________________________________________________ Phone #_________________________ Address _______________________________________________________________________________________

Parent’s Signature Date

2/2017

AUTHORIZATION FOR

RELEASE/EXCHANGE OF INFORMATION

According to the Final Regulations – Family Education Rights and Privacy Act (Buckley Amendment) dated June 17, 1976,

it is no longer necessary to obtain written consent to release records between schools. It states that school officials,

including teachers within the educational institution and officials of other schools in the school system which the student may intend to enroll, may receive a student’s records without a written consent for such a release.

Student Name: ______________________________________________________________ has enrolled in

Grade: ________________ At the Following School: ________________________________ Date: _______________

Date of Birth: ____________________________

Please forward the following information:

Transcript of grades including Regents, RCT’s, and Proficiency Grades Standardized Test Scores

Psychological Evaluations Special Education Records Discipline Records

Medical Records Custody/Visitations Papers Birth Certificate

Regents Science Labs Completed for Year Attendance Records

This authorization forms allows the exchange of Special Education records, not limited to, but including: IEP, 504,

Functional Behavioral Assessments, Speech, OT, PT, etc.

Transferring From: _________________________________________________________________________

(School)

________________________________________________________________________________________

(School Address)

_______________________________________________________________________________________

(School Phone Number)

Terri Herrington, District Registrar (315)963-8400 ext. 5400 fax: (315)963-5801 2/2017

Dear Parent/Guardian:

Our school building is located within the ten-mile emergency-planning zone (EPZ) of the Nine

Mile Point Nuclear Power Plants. In January 2001, the Federal Nuclear Regulatory Commission

amended its policy on the availability and usage of the over-the-counter drug potassium iodide

(KI) during a radiological emergency. As a result, New York State also revised its policy regarding

providing KI to the general population in the 10-mile emergency planning zones surrounding the

Indian Point, Nine Mile Point, and Ginna commercial nuclear power sites.

Potassium iodide (KI) is an over the counter drug that protects the thyroid from exposure to

radioactive iodine. KI only protects one organ against one radioactive substance. It is not an

alternative to evacuation or sheltering (See attached KI information sheet) In fact, evacuation and

sheltering remain New York’s primary public protective action in the event of an accident at any

nuclear power site.

Should the County and/or State Department of Health recommend the use of KI during an

emergency, the Mexico High School, Mexico Middle School, Mexico Elementary School, New

Haven Elementary and Palermo Elementary School will have KI available on-site for your child.

Evacuation from the ten-mile EPZ remains our primary protective radiological action. In the event

that evacuation is not immediately possible and/or County and/or State health officials recommend

KI use, and appropriate dose of KI will be available for your child.

If you do not want the school to provide your child with KI in a radiological emergency, you must

sign and return the enclosed form to the main office in your child’s school. This form will remain

in effect as long as your child attends this school building, unless you notify us in writing that you

now want your child to be provided with KI. Please note that if you do not return the enclosed

form and KI is recommended by health officials, your child will receive KI.

If you have any further questions about the school’s program please contact your child’s school or

the Oswego County Emergency Management Office at 591-9150.

Sincerely

Sean Bruno

Superintendent

SB/th

Potassium Iodide (KI) Questions & Answers For Parents

1. What is potassium iodide (KI)?

Potassium iodide is a U.S. Food and Drug Administration (FDA) approved over the counter drug that can be used to protect the thyroid gland from immediate and

future radiation injury caused by radioactive iodine released during a nuclear accident.

2. How does KI work?

KI saturates the thyroid gland with stable (non-radioactive) iodine, thus preventing or reducing the amount of radioactive iodine that will be taken up by the

thyroid. Radiological emergencies may release radioactive iodine in the environment. Since iodine concentrated in the thyroid gland, inhalation of air or ingestion

of food contaminated with radioactive iodine can lead to injury to the thyroid – including an increased risk of thyroid cancer.

3. Does KI protect individuals from all types of radiation?

No. KI is only effective against exposure to radioactive iodine. KI does not protect against other types of radiation.

4. Does KI protect organs other than the thyroid?

No. KI does not protect body organs or tissues other than the thyroid.

5. Is a prescription necessary?

No. KI is a FDA approved over the counter drug.

6. Should some people avoid KI?

Yes. According to the FDA, people with known iodine sensitivity, thyroid diseases, clusters of itchy skin blisters (dermatitis, herpetiformis), and/or an inflammation

in blood vessels involving the skin or multiple organs of the body (hypocomplementemic vasculitis) should avoid the use of KI. A physician should be consulted

before an event occurs with individual concerns on whether to take KI in an emergency.

7. What are the possible side effects to KI?

According to the FDA, the benefits of taking KI far exceed the risks. The possible side effects may include stomach upset and minor rash.

8. When is KI most effective?

To be most effective, KI should be taken shortly before or shortly after exposure to radioactive iodine. Even if taken three to four hours after exposure, it would

still reduce radioactive iodine from being absorbed by the thyroid and still have a substantial effect.

9. How long is KI effective in the body?

The protective effects of KI last approximately 24 hours.

10. Is KI an alternative to evacuation?

No. Evacuation remains the primary protective action in a radiological emergency.

11. What happens if the ten-mile EPZ cuts through the school district?

Only school building located within the ten-mile EPZ will receive KI from the NYS Emergency Management Office (SEMO).

12. Who may administer the KI to children?

13. If a child has problems swallow pills?

The pill can be dissolved in water or it may be crushed and take with juice, applesauce, etc.

14. How will schools be notified that events warrant the administration of the KI to children?

The State Department of Health and/or County Department of Health are charged with issuing the recommendation to administer KI in the event radioactive is

released into the environment.

15. Will the adults in the school building also be provided with KI?

Yes, KI will be provided to all adults in school buildings located within the 10-mile EPZ. However, according to the FDA, it is not necessary for persons over 40 years

of age to take KI in a radiological emergency.

16. Is a physician’s order necessary for KI administration in a radiological emergency?

No. KI administration in a school is part of an emergency protocol to deal with a radioactive iodine release into the environment.

2/2017

Potassium Iodide (KI)

I understand that potassium iodide (KI) may be given to my child if recommended by the

County and/or State Department of Health in a radiological emergency.

I have read and understand the Parent/Guardian letter, potassium iodide (KI) Parent Q&A’s

and Department of Health KI information sheet. I also understand that this permission is

granted until I revoke it in writing.

I DO want my child to be given potassium iodide (KI) in the event of

a radiological emergency.

I DO NOT want my child given potassium iodide (KI) in the event of

a radiological emergency.

Child’s Name_______________________________________________________________

Teacher/Homeroom _________________________________________________________

Grade ________ School _____________________________________________________

Parent/Guardian Signature ____________________________________________________

Date ____________ Telephone Number____________________________________

IF YOU DO NOT RETURN THIS FORM AND KI USE IS RECOMMENDED BY HEALTH OFFICIALS,

YOUR CHILD WILL RECEIVE POTASSIUM IODIDE (KI).

2/2017

MEXICO ACADEMY & CENTRAL SCHOOL DISTRICT

ENROLLMENT FORM - RESIDENCY QUESTIONNAIRE INFORMATION

All school districts are required by law to identify students experiencing homelessness. Mexico Academy & Central School District fulfills this requirement by having families complete a Residency Questionnaire when enrolling in school or for those students who have a change of address. This form should be completed by the student’s parent, person in parental relation, or in the case of an unaccompanied youth, by the student directly.

Purpose The purpose of gathering the information is to ensure that students in temporary housing arrangements are provided with the rights and services to which they are entitled under the McKinney-Vento Act. These rights and services include:

1. The right to stay in the same school the student had been attending before losing his/her housing or the last school attended (both known as the school of origin)

2. The right to immediate enrollment for students who decide to transfer schools, even if the student does not have all of the documents normally for enrollment

3. Transportation services if the student continues to attend the school of origin 4. Categorical eligibility for Title I services 5. Categorical eligibility for free meals 6. Access to services provided with McKinney-Vento funds

Confidentiality Student housing information will be kept confidential to the maximum extent possible. This information will only be shared with staff members who need information about housing status to ensure that the student’s educational needs are met. This may include the Homeless Liaison, the District Registrar, and the student’s teachers, and the guidance counselor. Completing the Form If a parent, person in parental relation, or unaccompanied youth enrolling in school indicates that a student is living in one of the five temporary housing arrangements, the school may not require proof to verify where the student is living before enrolling the student. After the student is enrolled and attending classes, the school will verify the student’s housing arrangements, which may include a home visit. If the parent, person in parental relation, or unaccompanied youth declines to complete the Enrollment Form - Residency Questionnaire, the district registrar will note on the form accordingly. The five temporary housing arrangements are listed below:

1. In a shelter 2. With another family or other person (sometimes referred to as “doubled-up”) 3. In a hotel/motel 4. In a car, park, bus, train, or campsite 5. Other temporary living situation

Definitions of Temporary Housing Arrangements “With another family or other person” (also referred to as “doubled-up”)”: Students who are sharing the housing of others are eligible for services under the McKinney-Vento Act and State law, if sharing housing is due to loss of housing, economic hardship, or a similar reason.

“Other temporary living situation”: In addition to the four examples of temporary housing, students who lack a “fixed, adequate, and regular” nighttime residence are also covered as homeless under the McKinney-Vento Act and State law. This may include unaccompanied youth who have fled their homes or were forced to leave their homes and who do not otherwise meet the definition of “doubled-up.”

“In permanent housing”: Permanent housing means that the student’s living arrangements are “fixed, regular, and adequate.”

Next Steps for LEAs with Students Living in Temporary Housing Arrangements If the parent, person in parental relation, or unaccompanied youth indicates that a student is living in temporary housing, the District must complete a Designation Form. If the District believes additional information is needed before reaching a final decision on the student’s eligibility under McKinney-Vento, enrollment should not be delayed and a Designation Form should still be filled out. For more information about determining eligibility see the National Center on Homeless Education’s Determining Eligibility Brief, available at: www.serve.org/nche/downloads/briefs/det_elig.pdf

http://www.serve.org/nche/downloads/briefs/det_elig.pdf

STUDENT RESIDENCY QUESTIONNAIRE

Name of Student:

Last First Middle

Name of School:

Gender: Male Date of Birth: / / Grade: ____

___Female Month Day Year

Address: _____________ Phone: ___________

____________________________________________________

The answer you give below will help the district determine what services you or your child may be able to receive under

the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate

enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records,

immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled

to free transportation and other services.

Where is the student currently living? (Please check only one box.)

In a shelter

With another family or other person (sometimes referred to as “doubled-up”)

In a hotel/motel

In a car, park, bus, train, or campsite

Other temporary living situation (Please describe):

In permanent housing

Print name of Parent, Guardian, or Student Signature of Parent, Guardian, or Student

(if unaccompanied homeless youth) (if unaccompanied homeless youth)

Date

Forward to: Carolyn Maloney – New Haven Elementary

I certify the above named student qualifies for services under the provisions of the McKinney-Vento Act.

__________________________________________________ ________________________

McKinney-Vento Liaison Signature Date

2/2017

STUDENT RACIAL AND ETHNIC IDENTIFICATION

To the Parent/Guardian:

The Mexico School District is required to collect and record the ethnic identity of students, in accordance with the

federal categories and definitions. The information will be used to:

- Report information to the State and Federal Education Departments, as required.

- Plan educational programs and make sure that they are readily available to all students.

- Study the movement of students in different ethnic groups as they move from school to school.

- Analyze the difference in academic performance, attendance and completion of school.

We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions and put a check (√)

in the box for the categories which best describe your child. The Mexico School District understands the sensitive

nature of this information and wishes to assure you that it will be kept secure and confidential in accordance with all

State and Federal student privacy laws and regulations. The Family Educational Rights and Privacy Act (1974)

prohibits unauthorized access to student records and unauthorized release of any student record information

identifiable by either student name or student identification number. If the information requested is not provided

on this form on behalf of your child, a student records officer from the school or district will be required to identify

the group to which the student appears to belong, identifies with, or is regarded in the community as belonging.

Thank you for your cooperation.

STUDENT RACIAL AND ETHNIC IDENTIFICATION

All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of

race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.

Student Name: Last, First, Middle: _________________________________________________________ Date of Birth: _______________ Name of School: ______________________________________________________________________ Grade Level: ___________

PLEASE ANSWER QUESTIONS 1 AND 2. PLEASE READ THEM BEFORE YOU RESPOND. (For question #1, check (√ ) the line that best

describes your child.) Check only ONE line.

1. Is the student Hispanic, Latino, or of Spanish origin? (Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto

Rican, Central or South American, or other Spanish culture or origin, regardless of race.

_____ YES, Hispanic

_____ NO, not Hispanic

2. Select one or more races from the following five racial groups (For question #2, Check (√) all groups that apply to your child. Check (√)

at least ONE line.)

_____ American Indian or Alaska Native: a person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition. e.g. Cherokee, Mohawk, Inuit. _____ 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, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. _____ Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. _____ Black: A person having origins in any of the black racial groups of Africa. _____ White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

____________________________________________ ____________________________

Signature of Parent/Guardian/Other Date

Relationship to Student (please check one below)

_____ Mother _____ Father _____ Guardian _____Other (Specify): _________________

2/2017

Medicaid Consent This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's Individualized Education Plan (IEP). This consent allows the School District to bill for covered health-related services and to release information to the school district’s Medicaid Billing Agent for that purpose. I, ________________________________________________________ as the guardian/parent of _________________________________________________________. Have received a written notification from the School District that explains my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services. I understand and agree that the School District may access Medicaid to pay for special education and related services provided to my child, and that this consent extends to any eligible services provided in prior school years. I understand that providing consent will not impact my child’s/my Medicaid coverage. Upon request, I may review copies of records disclosed pursuant to this authorization. Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid. I have the right to withdraw consent at any time; and the School District must give me annual written notification of my rights regarding this consent. I also give my consent for the School District to release the following records/information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared.

-IEP -Evaluation Reports -Medication Administration Report

-Written Order/Referral -Session Notes -Special Transportation Log

-Other Personally Identifiable Information

-Any Other Specific Records Pertaining to the Student’s Services or Program

I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me. Parent/Guardian Signature: __________________________________________________ Print Name: _________________________________________ Date: _____________________

Authorization for Treatment

As a parent or legal guardian of __________________________________________, I give

the Mexico Central School District permission to care for my child at school in accordance

with the District’s established medical and first aid guidelines. I grant the school nurse

permission to exchange medical information about my child with my child’s physician and

current teachers as necessary.

This consent is valid indefinitely from this date unless revoked by the parent or guardian.

Parent/Guardian Signature

_______________________________________________________

Date _________________________________________

2/2017

Student Name _______________________________________ School _______________________________

Dear Parents,

All students who transfer to the Mexico Central School District or students entering grades Pre-K, K, 2, 4, 7, and 10 are

required by New York State Law to have a physical exam by a NYS licensed health care provider. This health exam must have

taken place within 12 months prior to entering, and proof of this is required by the school within 30 days of starting school.

If the health exam is more than 12 months old when your child starts school, you will need an updated physical exam. This

can be completed by your own physician or our School Physician. Please note that in the event that the documentation of a

current physical is not provided to the school within 30 days of starting school, then we are required by law to have our

School Physician conduct this physical exam. You would first receive notification of this and then it would take place in the

nurse’s office at your child’s school.

Please choose from the following:

( ) I will have a physical completed by our family physician. I understand that I must provide this documentation

(Mexico Central School Health Appraisal Form) within 30 days of the start of school or the School Physician will conduct this

physical, upon written notification to me.

( ) I give permission for the designated School Physician to complete a school physical examination as required by

NYS Education Law. I understand this will be performed at the school my child attends and that there is no charge for the

school physical. School physicals will begin in October and are conducted periodically throughout the year.

This consent form is valid from the date noted below unless revoked by the parent or guardian. If custody or guardianship

changes in the future, it is your responsibility to notify the school district of such a change.

Signature: ____________________________________________ Date: ___________________

Parent or Legal Guardian

If you have any questions, please call your school’s nurse at the extension below.

Mexico High School – Deborah Wallace – 963-8400 ext. 5052

Mexico Middle School – Carolee McCoy –963-8400 ext. 4205

Mexico Elementary – Shannon Main – 963-8400 ext. 2307

Palermo Elementary – Darlys Forbes – 963-8400 ext. 1019

New Haven Elementary – Jill LaRock – 963-8400 ext. 3502

2/8/2017

Mexico Central Schools Health History

Name: _________________________________________________ Date of Birth: _________________ Sex: ( ) Male ( ) Female School: ( ) Mexico Elementary ( ) Palermo Elementary ( ) New Haven ( ) Mexico Middle School ( ) Mexico High School

Birth and Developmental History:

Birth Weight: ___________ Developmental Milestones: ____________ Sat up __________ Walked __________Started Talking

Medical History Does your child have any serious medical problems? (Ex: Asthma, Diabetes, Heart or Kidney Problems, Seizures, Broken Bones, Head Injuries, Migraines, etc.)

Surgical History

Has your child ever had any operations? (Ex. Tonsillectomy, Adenoids, Hernia, Ear Tubes, Dental, Appendectomy, Broken Bones, etc.)

Family History

Is there any family history (siblings, parents, grandparents) of diabetes, high blood pressure, heart disease, cancer, tuberculosis, asthma?

Does your child have any allergies? (food, medicine, bee stings, environmental)

Does your child take any prescription medications (daily or as needed)? Please list.

Will your child need any medication during school hours? ( ) Yes ( ) No If yes, name of medication: ______________________________________________________________

Written permission from the parent/guardian and your child’s health care provider is required. The medication must be delivered to school in the original container.

HEALTH HISTORY CONTINUED Does your child wear glasses/contacts ( ) Yes ( ) No Has your child seen an eye doctor? ( ) Yes ( ) No Does your child have a hearing problem? ( ) Yes ( ) No If yes, when? ___________________________________________________________________ Does your child have braces? ( ) Yes ( ) No Has your child visited a dentist? ( ) Yes ( ) No If yes, when? ___________________________________________________________________ Do you have any concerns about your child’s growth (height or weight)?

Emergency Information: Child’s Health Care Provider: _____________________________________________________________ Phone Number: _______________________________________________________________________ In case your child is ill or injured at school or if there is an urgent situation, please list in order of priority, the adult that should be contacted first: Name: ______________________________________________ Phone: __________________________ Name: ______________________________________________ Phone: __________________________ Name: ______________________________________________ Phone: __________________________

2/2017

MEXICO ACADEMY AND CENTRAL SCHOOLS

Authorization for Use or Disclosure of Protected Health Information

In order to share protected health information with the school district, your healthcare provider may require completion of the form below to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). Please complete, sign and give the form to your healthcare provider and/or to your school nurse to avoid delays in care for your child.

I, __________________________________________ authorize my child’s healthcare provider(s) listed below: Name___________________________________________Phone__________________FAX________________Name___________________________________________Phone__________________FAX________________Name___________________________________________Phone__________________FAX________________

to release the medical records of my child, ___________________________________, DOB ______________ to the district’s: Medical Director School Nurse Athletic Trainer (AT) Counselor Occupational Therapist (OT) Physical Therapist (PT) Psychologist Social Worker Speech Therapist (ST) other __________________________________________________________________________________________

The healthcare provider may disclose the following information: (Parent/School: check all that apply) Immunizations Health Appraisals Past/Current Medical Conditions and impact on attendance, athletics, or school programming or therapy Other_____________________________________________

The Protected Health Information may be used, disclosed or received for the following purpose(s): (Parent/School: check all that apply) To develop care or therapy plans for routine and emergent school management To design appropriate educational, school, or athletic programs To assess the impact of the medical condition(s) on school programming and/or attendance To share school observations/concerns surrounding behavior To assess a medical basis for modification of transportation and/or home tutoring Medication delivery or therapy prescriptions At patient’s request with no specified purpose Other___________________________________________________________________________________

This authorization is valid for the entire duration of attendance within the school district unless otherwise specified by parent/guardian.

I acknowledge that I have the right to revoke this authorization at any time by sending written notification to the Privacy Officer at my healthcare provider’s office and to the District Administration Building. I understand that the revocation of this authorization is not effective if the Healthcare Provider or District has used the authorization for disclosure of the Protected Health Information before receiving my written revocation notice. I understand that any Protected Health Information disclosed as a result of this Authorization to anyone not covered by the state and federal privacy laws and regulations may be subject to re-disclosure and may no longer be protected by federal or state law. I understand that my child’s treatment is not dependent on my agreement to release or withhold information. I acknowledge that the district will share relevant school information with my healthcare providers and when applicable with those governmental agencies as required for reimbursements. I give permission for the school representatives above to share and disclose information as indicated above with the health care provider listed.

_________________________________________________________________________________________ Signature of Parent/Guardian or Student if over 18 Relationship Date

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION A SIGNED COPY OF THIS AUTHORIZATION MUST BE GIVEN TO THE ADULT PATIENT OR PARENT OF THE MINOR CHILD

2/2017

Contact Information

Name:

Home Address:

Home Phone:

Email Address: (This email address is required to obtain an account. It is and/or will be your primary email address with the district.)

Yes! I would like access to the School Tool Parent Portal System, and I verify that I am the legal

guardian of the child(ren) listed below and that I should have access rights to the parent portal. I agree that I will not share my password or allow anyone other than myself to use the account, including my own child(ren). I agree to protect any information printed or transferred to my computer or destroy any documentation generated from this site.

Student Name (First and Last Name) Grade Student Date of Birth

Parent/Guardian Signature:

Date:

Parent / Student Portal - Frequently Asked Questions

• Do I need any special software? To effectively access your Parent Portal account, you will need:

1. Computer or mobile device with a web browser & Internet access - A minimum dial-up modem speed of 56Kbs – a slower connection will work but not as well;

2. Adobe Reader™ – This is a free document reader available for download on the web at:

http://get.adobe.com/reader/. There are some Schooltool reports that require the Adobe Reader.

• How often do I need to fill out the parent portal application? You only need to fill out the application once to create the account. Younger siblings will become visible on the portal once they become school age and register for school. Accounts are carried over from year to year as long as you do not move out of the district.

• What happens if I forget my user ID or password?

You will NOT need to email us. Just use the “Forgot Password” feature at login. Simply enter your email address, with no password, and click the “login” button. You will then be presented with the “Forgot” link. Just follow that process to have your password emailed.

• What happens if my email address changes? Please notify your child’s school for any change of information. Once you have notified the school of a change to your email address, your parent portal user name will be updated to reflect the new email address as well. You should allow from 24 to 48 hours for any changes to be reflected in the system.

• How often is information updated in the parent portal? Demographic, attendance and discipline information is updated in real time. Teachers are expected to update assignments and grades within 10 business/school days.

• Can I access parent portal from anywhere (Home, Work, Library …)? Yes. As long as you meet the minimum computer and Internet access requirements. How do I add/change/correct my personal information including address, or telephone numbers? Please notify your child’s school for any change of information.

• What if a report card shows a wrong grade(s) for my child/children? Contact your child’s Guidance Counselor/Teacher.

Parent / Student Portal - Frequently Asked Questions

• Who can I talk to regarding Attendance related issues?

Call the Attendance Office at your child's school, but give them 24 to 48 hours before you call to report any errors.

• How do I view my child’s information? When you are on the Students tab, all enrolled children that you have permission to view are listed. To view the selected student’s information, click on the blue arrow to the left of the name. The student’s profile will come up along with a new group of tabs: Contact Tab: Lists all known contacts for the student as well as the siblings Schedule Tab: Displays the student’s schedule for each semester Attendance: Lists any absences, tardiness, or early dismissals for the selected year Grades: Lists marking period or if entered, progress report grades for the selected period and year. Assignments: Displays detailed information for specific assignments, as made available by teachers. Click on the tab that corresponds to the type of information you want to see.

• Can I change my password myself and if so, how? (PARENTS ONLY) You can change your password at anytime and as many times as you want. We cannot see what your password is set to so pick something you will remember.

1. When you first login to Schooltool your children’s demographic information is displayed. Above that is a row of tabs, click on the Account tab. 2. You will need to enter your old password. Once again, be careful to pay close attention to letters that are capitalized and any special characters that may make up your password. 3. Type in the password you want to start using next to New Password and again next to Confirm. 4. Click on the “Change Password” button.

Click on the Students tab once your password has been changed or if you decide not to change your password at this time.

Parent Portal Logging In:

In an email sent to your personal email account, you will find your login credentials. Use this information to log into School

Tool’s Parent Portal.

1. Open your email from Schooltool.

2. After the first sentence, there will be an eight (8)-digit password consisting of letters and numbers. Highlight the password

and copy it by pressing ctrl-c.

3. Minimize your email.

4. Use your web browser (Internet Explorer, for instance) to access the internet and go to the Schooltool web site…

https://mexicocsd.org

5. Select the SchoolTool icon to link to the program.

6. On the login page type your “Username” or your full email address.

7. Paste the password just copied from your email into the password box by pressing ctrl-v.

8. Click on the blue Login button. You should now be logged into Schooltool.

9. Now is a good time to change your password to a more comfortable one. To change this temporary password simply click

on the sub tab, enter the existing cryptic password, then the new desired password. Click on the Change Password button

to finalize the change.

Note: We recommend creating a new password that has the following characteristics:

• Greater than or equal to eight (8) characters.

• Combination of letters, number and symbols (including upper and lower case letters).

• Something that you can remembered easily.

Good passwords do not have to be hard to remember. “Late2School!”, for instance is a

good password that has upper and lowercase letters, a number, a symbol, and is greater

than 8 characters long but still easy to remember.

If you forget your password, just put your email address into the Username box and click Login. Then click the Forgot password

option to receive information on your new password.

If you have any questions regarding your passwords or using the Portal, please contact your buildings main office of assistance.

NYSED requires an annual physical exam for new entrants, students in Grades Pre-K, K, 2, 4, 7 and 10, sports, working permits and

triennially for the Committee on Special Education (CSE).

This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school medical director. Rev. 2/2016

MEXICO CENTRAL SCHOOLS HEALTH APPRAISAL FORM

Name: Date of Birth:

School: _________________________________________ Gender: M F Grade: ______________________________________

IMMUNIZATIONS / HEALTH HISTORY

Immunization record attached Sickle Cell Screen: Positive Negative Not done Date: No immunizations given today PPD: Positive Negative Not done Date: Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done Date:

Dental Referral Yes No Not done Date:

Significant Medical/Surgical History: See attached _____________________________________________________________________

______________________________________________________________________________________________________________________

Allergies: LIFE THREATENING Food: Insect: ________ Seasonal ____ Medication:

PHYSICAL EXAM

Height: ______ Weight: ______ Blood Pressure: _______ Referral

Body Mass Index: ____ ____ . ____ Vision - without glasses/contact lenses

R L

Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L

less than 5th 5th through 49th 50th through 84th Vision - Near Point R L

85th through 94th 95th through 98th 99th and higher Hearing Pass 20 db sc both ears or: R L

EXAM ENTIRELY NORMAL Tanner: I. II. III. IV. V. Scoliosis: Negative Positive:

Specify any abnormality (use reverse of form if needed):

MEDICATIONS

Medications (list all): None Additional medications listed on reverse of form

Name: ____________________________________________________ Dosage/Time: _________________________________________________

Name: ____________________________________________________ Dosage/Time: _________________________________________________

If AM dose is missed at home: ________________________________________________________________________________________________

I assess this student to be self-directed Yes No Student may self carry and self administer medication Yes No

Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if the morning medication has not been given.

PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION

Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:

___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball. ___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.

Specify medical accommodations needed for school: None

Known or suspected disability: Please monitor

Restrictions: Please monitor

Protective equipment required: Athletic Cup Sport goggles/impact resistant eyewear Other:

OPTIONAL INFORMATION, if known

Specify current diseases: Asthma Diabetes: Type 1 Type 2 Hyperlipidemia Hypertension Other: Provider’s Signature: Phone: (Stamp below)

Provider’s Name/Address: Fax:

Parent Signature: Date of Exam:

2/2017

Mexico Academy & Central School Athletics

3338 Main street, Mexico, NY 13 114 David Gryczka, Athletic Director

[email protected] 963-8400 x 5020 Kendra O’Connor, [email protected] ,963-8400 x 5019

Dear Mexico Athletic Families,

We are excited to announce that we are now offering the convenience of online registration through FamilyID

(www.familyid.com). FamilyID is a secure registration platform that provides you with an easy, user-friendly way to

register for our athletic programs. When you register through FamilyID, the system keeps track of your information in your

FamilyID profile. You enter your information only once for each family member for multiple sports. Registering your

athletes with FamilyID does away with the athletic packets that families have needed to fill out every season.

A parent/guardian should register by following this link:

Follow these steps:

l . To find your program, click on the link provided by the Organization above and select the registration form under

the word Programs.

2. Next click on the green Register Now button and scroll, if necessary, to the Create Account/Log In green buttons.

If this is your first time using FamilyID, click Create Account. Click Log In, if you already have a FamilyID account.

3. Create your secure FamilyID account by entering the account owner First and Last names

(parent/guardian), E-mail address and password. Select IAgree to the FamilyID Terms of Service. Click Create

Account.

4. You will receive an email with a link to activate your new account. (If you don't see the email, check your E-mail

filters (spam, junk, etc.).

5. Click on the link in your activation E-mail, which will log you in to FamilyID.com

6. Once in the registration form, complete the information requested. All fields with a red* are required to have an

answer.

7. Click the Save & Continue button when your form is complete.

8. Review your registration summary.

9. Click the green Submit button. After selecting 'Submit', the registration will be complete. You will receive a

completion email from FamilyID confirming your registration.

At any time, you may log in at www.familyid.com to update your information and to check your registration(s). To view a

completed registration, select the Registration' tab on the blue bar.

If you need assistance with registration, contact FamilyID at: [email protected] or 888-800-5583 x1.

Support is available 7 days per week and messages will be returned promptly.