June 2018

Grades 1-5 Enrollment Checklist

Enrollment Instructions

In order to help expedite your enrollment process, we need you to fill out the following paper work:

Grades 1-5 Enrollment Packet (one per student)

Contents of the Elementary Enrollment Packet are:

o Student Enrollment Form

o Minnesota Language Survey

o Enrollment Survey

o Student and Parent – Internet Use Agreement Form (2 pages)

o McKinney-Vento Questionnaire

o Are Your Kids Ready – Minnesota’s Immunization Law (2 pages)

o Student Immunization Form (2 pages)

o Request for Student Records

o Daycare/Alternate Address – link to Google Form

o Nutrition Services Overview

o Annual Health & Emergency Contact Form (2 pages)

Please bring the following items to the Enrollment Center, along with the completed packet:

Proof of Residency – rental agreement, purchase agreement, utility bill, etc.

IEP and Evaluation – if applicable.

* A teen parent is a student who has a minor child or children for which the teen parent has either custody or joint custody; or is pregnant. ** A displaced homemaker is a parent whose youngest dependent child will become ineligible to receive assistance under Part A of Title IV of the Social Security Act, not later than 2 years after the date on

which the parent applies for assistance under this title; and is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment. Rev 10/17

Office Use Only

School: First Day of Enrollment: Teacher (elementary only): Home Primary Language:

______ __ MARSS Code

Student ID #:

North St. Paul – Maplewood – Oakdale ISD #622 Student Enrollment LEGAL NAME, AS STATED ON BIRTH CERTIFICATE, REQUIRED FOR ENROLLMENT

Enrolling Grade: Student LAST Name: Student FIRST Name: Student MIDDLE Name (full):

Nickname: (optional) Student Date of Birth: Federal Ethnicity: (please mark one)

Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

YES □ NO □

State Race/Ethnicity: (please mark all that apply)

□ 1 American Indian or Alaskan Native

□ 2 Asian

□ 3 Black or African American

□ 4 Native Hawaiian or Other Pacific Islander

□ 5 White

Student Gender:

Male □ Female □

Previously attended #622

Schools? No □ Yes □

____ ________ Name of School

Address:__________________________________________________ Primary/Home Phone: (______)______________ STREET APT #

_________________________________________________________________________ CITY ZIP CODE COUNTY DATE STUDENT MOVED INTO THIS ADDRESS

Does another family live at this address? No □ Yes □ Name(s) of other family: ________________________________

Pick-Up/Daycare Address (if other than home) __________________________________________________________

List all schools student has attended (MOST RECENT SCHOOLS FIRST): Name of School City and State Grades Attended Dates Attended

Student Lives With: Both □ Mother □ Father □ Step Parent □ Foster Parent □ Other □ ________________________

Are there court orders that apply to custody of the student? No □ Yes □ (provide copy)

Parent/Guardian #1 Parent/Guardian #2 Parent/Guardian #3 (custodial/resides with student) (non-custodial/second mailing)

Name (First, MI, Last)

Gender (Male/Female)

Date of Birth (M/D/Y)

Relationship to Student (mother, stepfather, etc)

Street Address, City, Zip

E-Mail Address

Cell Phone #

Work Phone #

List all children residing in the home (including those not currently in school): First, MI, Last Name School Attending Grade Gender Birthdate Relationship to

Parent/Guardian#1 Relationship to

Parent/Guardian#2 Relationship to

Parent/Guardian#3

Is this student a Military Connected Youth? Relationship _________________ YES □ NO □

Does this student have Special Education Services (an IEP)? YES □ NO □

Does this student have a 504 Accommodation Plan? YES □ NO □

Students in secondary schools only: Is the student a teen parent? YES □ NO □ * (see below)

Is the student a displaced homemaker? YES □ NO □ ** (see below)

______________________________________________________Signature of Parent or Guardian Date Copy to: School, Info Svcs, Transportation

August 2017

Minnesota Language Survey

Minnesota is home to speakers of more than 100 different languages. The ability to speak and understand multiple languages is valued.

The information you provide will be used by the school district to see if your student is multilingual. In Minnesota, students who are multilingual may qualify for a Multilingual Seal upon high school graduation. Additionally, the information you provide will determine if your student should take an English proficiency test. Based upon the results of the test, your student may be entitled to English language development services. Access to services are required by federal and state law. As a parent or guardian, you have the right to decline English Learner services at any time.

Every enrolling student must be provided with the Minnesota Language Survey during enrollment. Information requested on this form is important to us to be able to serve your student. Your assistance in completing the Minnesota Language Survey is greatly appreciated.

Student Information Student’s Full Name: (Last, First, Middle)

Birthdate or Student ID:

Check the phrase that best describes your student: Indicate the language(s) other than English in space provided:

1. My student firstlearned:

___ language(s) other than English.

___ English and language(s) other than English.

___ only English.

2. My student speaks: ___ language(s) other than English.

___ English and language(s) other than English.

___ only English.

3. My studentunderstands:

___ language(s) other than English.

___ English and language(s) other than English.

___ only English.

4. My student hasmeaningful andconsistent exposure to:

___ language(s) other than English.

___ English and language(s) other than English.

___ only English.

Language use alone does not identify your student as an English learner. If a language other than English is indicated, your student will be screened for English language proficiency.

Parent/ Guardian Information

Parent/Guardian Name (printed):

Parent/Guardian Signature: Date:

* All data on this form is private. It will only be shared with district staff who need the information to best serveyour student and for legally required reporting about home language and service eligibility to the MinnesotaDepartment of Education. At the district and at the Minnesota Department of Education, this information will notbe shared with other individuals or entities, except if they are authorized by state or federal law to access theinformation. Compliance with this request for information is voluntary.

March 2017

Enrollment Survey

Please answer to the best of your ability. Yes No

1. Has this student ever been retained? If so, what grade?

2. Has this student ever been absent more than 10 days per year?

If yes, why?

3. Has this student ever received special help for any subject?

If yes, what type of help or program?

4. Has this student ever been tested by educational specialists for

which parental permission was obtained?

5. Has this student participated in ESL or ELL programs?

If yes, which grade(s)?

6. Is an interpreter needed for family/student communication?

7. Has this student participated in an AVID program? If so, which grade(s)?

8. Was this student ever placed in a special program? IEP? Y/N

If yes, please indicate:

☐ECSE ☐LD ☐EBD ☐DCD ☐504 ☐Speech

☐Hearing Impaired ☐Visually Impaired ☐Other

9. Has the student ever been tested for or participated in a gifted and talented

program? Has the student skipped a grade level or been accelerated in a

subject area? If yes, please indicate:

☐Tested ☐Participated ☐Skipped a grade, which grade?

☐Accelerated in a subject, which subject(s)?

10. Are there any known problems of academic, social, physical, or

emotional adjustments? Has the student been receiving counseling

services? If yes, please list:

11. Does the student have a probation officer?

If yes, please provide name and phone number:

12. Has there been any discipline issues (suspension, expulsion)?

If yes, please explain:

Parent/Guardian Signature Date

*Please see back side of this user agreement for required student and parent signatures

Student and Parent/Guardian User Agreement

Internet/Bring Your Own Technology (BYOT)

Important Parent/Guardian Information

Acceptable Use Policy

It is expected that all parents/guardians review the Internet Acceptable Use Policy with their student prior tosigning this Internet/Bring Your Own Technology User Agreement. Policy EM-020.21 is available online athttp://www.isd622.org under About Us District Policies Ends, and is included under General Information inthe printed District Calendar, which is mailed to each household prior to the start of the school year. Papercopies of policy EM-020.21 are also available upon request from the main office at your child’s school.

Parent/Guardian Responsibility

Outside of school, parents/guardians bear responsibility for the same guidance of Internet use as they exercisewith information sources such as television, telephones, radio, movies and other possibly offensive media.Parents/guardians are responsible for monitoring their student’s use of the school district system and of theInternet if the student is accessing the School District from home or a remote location.

Student Use of Electronic Communications

District 622 is a Google Apps for Education District. In order for students to have full access to these collaborativetools an individual Google account will be issued to each student.

Alternative Educational Activities Option

Parents/Guardians have the option to request alternative educational activities not requiring Internet and/orGoogle Apps for Education access.

Student BYOT Information

In an effort to enhance their educational experience, students of the North St. Paul-Maplewood-Oakdale School District 622 are invited to bring their own personal technology to school. Technology includes, but is not limited to, a wireless network capable device. This agreement outlines the District expectations on the use of personal technology. Students must also adhere to the School Board approved, EM-020.21 Internet Acceptable Use Policy & Internet Use Agreement.

1. Use of personal devices in the classroom is at the teacher’s discretion.

2. Students are not permitted to connect any personal devices to the District 622 wired network.

3. Personal device use must support the instructional activities currently occurring in the classroom/lab.

4. Students are responsible for their devices at all times while at school. District 622 is not responsible for any lost,

stolen or damaged personal devices.

5. Use of personal mobile WiFi hotspots on school grounds in District 622 is prohibited.

6. It is not permissible to circumvent the District 622 Web content filter.

7. No district level technical support will be available for personal devices.

8. Students are allowed to use District 622 provided Gmail only, for email communication, while using the district

network.

9. Website block/unblock requests will only be reviewed when made by faculty or staff and for instructional

purposes.

10. Violations to these guidelines/agreement or misuse of a personal device could result in the loss of networking

privileges and/or disciplinary actions.

11. Any use of a personal device that interferes with or disrupts the normal procedures of the school or classroom is

prohibited. This prohibition extends to activities that occur off school property and outside of the school day if

the result of that activity causes a substantial disruption to the educational environment.

Student Internet/BYOT User Agreement

I have read and understand the School District policy related to safety and acceptable use of the School District computer system and the Internet and agree to abide by it. I further understand that should I commit any violation, my access privileges and/or device may be revoked, school disciplinary actions may be taken, and/or appropriate legal action may be taken.

User’s Full Name (please print):

User Signature: _____________ Date:

Student ID: ___________________________________________ Graduation Year: __________________________

Parent/Guardian Internet BYOT User Agreement

As the parent or guardian of this student, I have read the School District policies related to safety and acceptable use of the School District computer system and the Internet. I understand that this access is designed for educational purposes. The School District has taken precautions to eliminate controversial material. However, I also recognize it is impossible for the School District to restrict access to all controversial materials and I will not hold the School District or its employees or agents responsible for materials acquired on the Internet. Further, I accept full responsibility for supervision if and when my student’s use is not in a school setting. I hereby give permission to issue an account for my child and certify that the information contained on this form is correct.

Parent or Guardian’s Name (please print):

Parent or Guardian’s Signature: _______ Date:

12/9/2016

McKinney-Vento Eligibility Questionnaire Homeless Education Liaison: 651-621-1900

Your child may be eligible for additional educational services through Title I Part A, and/or Federal McKinney-Vento Assistance. Eligibility can be determined by completing this questionnaire. The purpose of this information is to ensure the rights of your children and youth under the McKinney-Vento law. This information is confidential. Please contact the number listed above with questions.

Presently, are you and/or your family in any of the following situations? (Check all that apply)

❏ Staying in a shelter (youth, domestic violence, or family shelter)

❏ On the street

❏ Sharing the housing of others due to loss of housing, economic hardship, similar reason; doubled-up

❏ Living in a car, park, campground, public space, abandoned building, substandard housing or similar

❏ Temporarily living in a motel or hotel due to loss of housing, economic hardship or similar reason

❏ Migrant worker

❏ Living in one of the situations listed above and without a guardian (unaccompanied youth)

You do not need to complete this form if you have not checked any of the above boxes. If you lose your housing during the school year please contact your child’s social worker or counselor for assistance.

List all children or youth living in the situation marked above:

First Middle Last School (if known)

The undersigned certifies that according to information provided above, the students listed meet eligibility under the McKinney- Vento Act (Subtitle B, Sect. 725) of July 1, 2002.

________________________________________________________________________________________________________________

Print Parent/Guardian Name Signature Date

(Student and District Liaison in case of unaccompanied youth.)

Enrollment Center Staff Use Only ❏ School(s): ________________________________________________________________________________❏ Copy of McKinney-Vento Questionnaire and School Enrollment Form Sent to Homeless Program Specialist❏ Copy of McKinney-Vento Questionnaire and School Enrollment Form Sent to School

Are Your Kids Ready?Minnesota’s Immunization Law

Immunization Requirements

Use this chart as a guide to determine which vaccines are required to enroll in child care, early childhood programs, and school (public or private).Find the child’s age/grade level and look to see if your child had the number of shots shown by the checkmarks under each vaccine. The table on the back shows the ages when doses are due.

Polio

MMR

Varicella

Varicella

Varicella

Early childhood programs & Child care

Birth through 4 years

For Kindergarten

Age: 5 through 6 yearsFor 1st through 6th

grade

Age: 7 through 11 yearsFor 7th through 12th

grade

Age: 12 years and older

Not required after 24 months.If the child has already had chickenpox disease, varicella shots are not required. If the disease occurred after 2010, the child’s doctor must sign a form confirming disease. First graders who are 6 years old and younger must follow the polio and DTaP/DT schedules for kindergarten. Fifth shot of DTaP not needed if fourth shot was after age 4. Final dose of DTaP on or after age 4.Fourth shot of polio not needed if third shot was after age 4. Final dose of polio on or after age 4.Need proof of at least three tetanus and diphtheria containing doses. If up to date on DTaP/DT series, no additional doses needed.An alternate two-shot schedule of hepatitis B may also be used for kids age 11 through 15 years. One dose of Tdap is required beginning at 7th grade. Also need proof of at least two tetanus and diphtheria containing doses (DTaP/DT/Td). If a child received Tdap prior to 7th grade, another dose of Tdap is not needed.One dose is required beginning at 7th grade. The booster dose is usually given at 16 years.

To enroll in child care, early childhood programs, and school in Minnesota, children must show they’ve had these immunizations or file a legal exemption.Parents may file a medical exemption signed by a health care provider or a non-medical exemption signed by a parent/guardian and notarized.

Exemptions

Hepatitis B

Hepatitis B

Hepatitis B (Hep B)

Hepatitis A (Hep A)

Hib

Meningococcal  & booster

Influenza Annually for all children age 6 months and older

Pneumococcal

Human papillomavirus At age 11 -12 years

Immunizations recommended but not required:

For copies of your child’s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-3980.

Looking for Records?

RotavirusFor infants

DTaP/DT

tetanus and diphtheria containing doses

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Minnesota law requires children enrolled in school to be immunized against certain diseases or file a legal medical or conscientious exemption.

Student Immunization Form FOR SCHOOL USE ONLY( ) Complete; booster required in ___________( ) In process; 8 mos. expires _____________( ) Medical exemption for _________________( ) Conscientious objection for _____________( ) Parental/guardian consent _____________

Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13)

Student Name _________________________________________________

Birthdate _____________________Student Number __________________

Additional exemptions: • Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the minimum

requirements of the law.• Students in grades 7-12: A Tdap at age 11 years or later is required for students in grades 7-12. If a child received Tdap at age

7-10 years another dose is not needed at age 11-12 years. However, if it was only a Td, a Tdap dose at age 11-12 years is required.• Students 11-15 years of age: A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the

alternative 2-dose schedule.• Students 18 years of age or older: Do not need polio vaccine.

Type of Vaccine DO NOT USE () or () 1st DoseMo/Day/Yr

2nd DoseMo/Day/Yr

3rd DoseMo/Day/Yr

4th DoseMo/Day/Yr

5th DoseMo/Day/Yr

Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT)• for children age 6 years and younger• final dose on or after age 4 years

Tetanus and Diphtheria (Td) • for children age 7 years and older• 3 doses of Td required for children not up to date with DTaP,

DTP, or DT series aboveTetanus, Diphtheria and Pertussis (Tdap)

• for children in 7th - 12th grade

Polio (IPV, OPV)• final dose on or after age 4 years

Measles, Mumps, and Rubella (MMR)• minimum age: on or after 1st birthday

Hepatitis B (hep B)

Varicella (chickenpox)• minimum age: on or after 1st birthday• vaccine or disease history required

Meningococcal (MCV, MPSV) • for children in 7th - 12th grade• booster given at age 16 years

RecommendedHuman Papillomavirus (HPV)

Hepatitis A (hep A)

Influenza (annually for children 6 months and older)

5th dose not required if 4th dose was given on or after the 4th birthday

4th dose not required if 3rd dose was given on or after the 4th birthday

School Personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it. Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space.

Parent/Guardian:You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption. Additionally, if a parent or guardian would like to give permission to the school to share their child’s immunization record with Minnesota’s immunization information system, they may sign section 3 (optional).For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.

Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13)

Student Name _______________________________________________Instructions, please complete:Box 1 to certify the child’s immunization status Box 2 to file an exemption (medical or concientious) Box 3 to provide consent to share immunization information (optional)

3. Parental/Guardian Consent to Share Immunization Information (optional):Your child’s school is asking your permission to share your child’s immunization documentation with MIIC, Minnesota’simmunization information system, to help better protect students from disease and allow easier access for you to retrieve yourchild’s immunization record. You are not required to sign this consent; it is voluntary. In addition, all the information you provide islegally classified as private data and can only be released to those legally authorized to receive it under Minnesota law.I agree to allow school personnel to share my student’s immunization documentation with Minnesota’s immunization informationsystem:

Signature of parent or legal guardian Date

A. Received all required immunizations:I certify that this student has received all immunizationsrequired by law.

Signature of Parent / Guardian OR Physician / Public Clinic

_______________ Date

B. Will complete required immunizations withinthe next 8 months:I certify that this student has received at least one doseof vaccine for diphtheria, tetanus, and pertussis (ifage-appropriate), polio, hepatitis B, varicella, measles,mumps, and rubella and will complete his/her diphthe-ria, tetanus, pertussis, hepatitis B, and/or polio vaccineseries within the next 8 months.

The dates on which the remaining doses are to be given are:

Signature of Physician / Public Clinic

_______________ Date

1. Certify Immunization Status. Complete A or B to indicate child’s immunization status.

A. Medical exemption:No student is required to receive an immunization if theyhave a medical contraindication, history of disease, orlaboratory evidence of immunity. For a student to receivea medical exemption, a physician, nurse practitioner, orphysician assistant must sign this statement:I certify the immunization(s) listed below arecontraindicated for medical reasons, laboratory evidenceof immunity, or that adequate immunity exists due toa history of disease that was laboratory confirmed(for varicella disease see * below). List exemptedimmunization(s):

Signature of physician/nurse practitioner/physician assistant _______________ Date

*History of varicella disease only. In the case of varicelladisease, it was medically diagnosed or adequatelydescribed to me by the parent to indicate past varicellainfection in ___________ (year)

Signature of physician/nurse practitioner/physician assistant (If disease occured before September 2010, a parent can sign.)

B. Conscientious exemption:No student is required to have an immunization thatis contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccinerecommendations may endanger the health or life of thestudent or others they come in contact with. In a diseaseoutbreak schools may exclude children who are not vac-cinated in order to protect them and others. To receivean exemption to vaccination, a parent or legal guardianmust complete and sign the following statement andhave it notarized:I certify by notarization that it is contrary to my conscien-tiously held beliefs for my child to receive the followingvaccine(s):

Signature of parent or legal guardian _______________ Date

Subscribed and sworn to before me this: _______ day of ______________________ 20______

Signature of notary

2. Exemptions to School Immunization Law. Complete A and/or B to indicate type of exemption.

Request for Student RecordsThe following student has registered at North Saint Paul-Maplewood-Oakdale ISD 622:

Anticipated Enrollment Date: Grade:

Student Name: Date of Birth:

Previous School Information

School Name:

School Address:

City: State: Zip Code:

School Phone: School Fax:

Parent/Guardian Signature Date

Previous School - Please complete the following:

□STEP 1: FAX the IEP/504 Plan, Evaluation and other assessments to 651-748-7558, attention: _______as soon as possible for appropriate placement.

□STEP 2: Send or FAX the following information to the school circled below, attention: _____________• Transcripts of records and grades - all academic records (Please fax ASAP)• Standard Test Results• MN Basic Standard Test Results• Legal Documents• Attendance Records• Discipline Records• Health Records – including Immunization and Sports Physical Records• ELL/ESL Records

Carver Elementary2680 Upper Afton RdMaplewood MN 55119651-702-8200651-702-8291 FAX

Castle Elementary6675 50th St NOakdale MN 55128651-748-6700651-748-6791 FAX

Cowern Elementary2131 N Margaret StNorth St Paul MN 55109651-748-6800651-748-6891 FAX

Eagle Point Elementary7850 15th St NOakdale MN 55128651-702-8300651-702-8391 FAX

Oakdale Elementary821 Glenbrook Ave NOakdale MN 55128651-702-8500651-702-8591 FAX

Richardson Elementary2615 1st St NNorth St Paul MN 55109651-748-6900651-748-6991 FAX

Skyview Elementary1100 Heron Ave NOakdale MN 55128651-702-8100651-702-8191 FAX

Weaver Elementary2135 Birmingham StMaplewood MN 55109651-748-7000651-748-7091 FAX

Webster Elementary2170 E 7th AveNorth St Paul MN 55109651-748-7100651-748-7191 FAX

John Glenn Middle1560 E County Rd BMaplewood MN 55109651-748-6300651-748-6391 FAX

Maplewood Middle2410 Holloway AveMaplewood MN 55109651-748-6500651-748-6591 FAX

Skyview Middle1100 Heron Ave NOakdale MN 55128651-702-8000651-702-8091 FAX

North High2416 E 11th AveNorth St Paul MN 55109651-748-6000651-748-6087 FAX

Tartan High828 Greenway Ave NOakdale MN 55128651-702-8600651-702-8691 FAX

Next Step Transition 2586 E 7th Ave North St Paul MN 55109 651-621-1900651-621-1991 FAX

Harmony Learning Center1961 E County Rd. CMaplewood MN 55109651-748-6200651-748-6251 FAX

Enrollment Center2520 E 12th AveNorth St. Paul MN 55109 651-748-7550651-748-7558 FAX

November 2015

October 2017

Daycare/Alternate Address

The Daycare/Alternate Address form is a Google form. Please click on the link below to complete the form. When you are done the form will automatically be delivered to Transportation Services. Daycare/Alternate Address form If you have any questions, contact Transportation Services at 651-621-1980.

Thank you!

ISD 622 Health Services Health & Emergency Information

(2018-2019)

Student: _______________________________________ Grade: ____ Gender: _____ Birthdate: ___/___/___ Last First MI

Primary Address: _______________________________________________ Phone: ____________________

Dear Parent/Guardian:

A student’s health may affect his or her learning. Therefore, updated health information is important. The following information will be held in confidence and disclosed to school personnel to the extent necessary to protect the health and safety of the student. This form should be completed each school year. Please complete this form and return it to the school Health Office as soon as possible.

Thank you ISD 622 Health Services

HEALTH INFORMATION Health Concerns Please put a ✔ if the student CURRENTLY HAS or HAS HAD IN THE PAST any of these health concerns:

No Health Concerns

Allergies (if yes, to what): ___________________________________________________________________

Anaphylactic/Life threatening? Yes *Needs care plan No

Asthma or breathing problems (if yes, see below):

● Has the student had episode(s) of wheezing in the last 12 months? Yes *Needs care plan No

● Has the student had to take medication to resolve breathing

problems in the last 12 months? Yes *Needs care plan No

Bladder/Bowel problems (if yes, describe): ______________________________________________________

Diabetes (if yes, see below): *Needs care plan

● Type (I or II): __________________________

● Managed by: Diet only Oral medication Insulin injections Insulin pump

Diagnosed diet restrictions/needs (if yes, describe): _______________________________________________

Heart problems (if yes, describe): _____________________________________________________________

Seizures (if yes, see below): *Needs care plan

● Type (describe) ________________________________ Date of last seizure: __________________

Social/Emotional/Mental Health concerns (if yes, describe): _________________________________________

Recent surgeries or hospitalizations (if yes, describe): _____________________________________________

Activity restrictions (if yes, describe): ___________________________________________________________ *Note: If yes, a current written note from your provider stating the restrictions and length of restrictions is needed in the health office

Autism

Blood disease

Cancer

Genetic/Congenital disorder

Vision impaired

Head injury/Concussion

Hearing impaired

Migraines

Other: ____________________

Complete for High School Students Grades 9-12 According to MS 121.222 (2005) a secondary student may possess and use non-prescription pain relief such as Tylenol or Motrin. Medications must remain in the original container and taken according to directions. Parent/Guardian permission must be given in order for students to “self-carry” non-prescription pain relievers.

I hereby give my child permission to “self-carry” non-prescription pain relievers. Signature: __________________________________

Parent(s)/Guardian(s) Note: The school district does not supply over-the-counter pain relievers to students.

Health Insurance The student HAS health insurance

The student DOES NOT HAVE health insurance. Would you like assistance with applying? Yes No

Health Care Providers

Primary Care Provider Clinic/Location Phone Number

Hospital Preference Address Phone Number

*Note: In case of an emergency, our procedure will be to attempt to contact the parent/guardian. Paramedics or local police may be called forassistance. Your student will be taken to the most appropriate hospital for emergency care if no other arrangements have been made.

Emergency Contacts Parent/Guardian 1: _________________________________________________________________________________

Print Name Primary Phone Number Work Phone Number

_________________________________________________________ Email Address

Parent/Guardian 2: _________________________________________________________________________________ Print Name Primary Phone Number Work Phone Number

_________________________________________________________ Email Address

Emergency Contact: ________________________________________________________________________________ Print Name Relationship Phone Number

Emergency Contact: ________________________________________________________________________________ Print Name Relationship Phone Number

Custody Issue Yes No *Note: If custodial issues are involved, a copy of decree must be on file at school.

This information is current and correct. I understand that it is my responsibility as the parent/guardian to notify the school of new or existing health concerns or any changes to contact information. I understand that this health history form must be updated every school year.

______________________________ ______________________________ _________________ Parent/Guardian Signature Printed Name Date

This institution is an equal opportunity provider

Free Reduced Meals ISD 622 encourages families to apply for free and reduced meals online. A new application is required each school year. Apply online at www.isd622.org/freereduced beginning August 1. About Our Meals Our schools provide healthy breakfast and lunch options every day. All of the menus are created using guidelines set by the United States Department of Agriculture (USDA) which means:

Students must take a fruit or vegetable with every meal

A variety of vegetables must be offered each week

A variety of meat/meat alternates, grains, fruits must also be offered each week

Most grains offered are whole grain

There are zero trans fats in all items, and saturated fat is limited to less than 10% of calories

Calorie ranges are within the minimum and maximum levels for each age group at breakfast and lunch

Pay for meals and get balance alerts online Nutrition Services uses the online account management system PayPAMS. There is no fee to use this service. Set up an account at www.Paypams.com.

Nutritional Information Breakfast and lunch menus, along with nutritional information, are posted on the district website at www.isd622.org/menus.

Look for these icons on the District 622 mobile app too. Download it today!