Jonathan Y. Scammon Elementary

English Enrollment Packet School Year 2020-2021

Rev. 07/2014

Chicago Public Schools School Enrollment Form

School Name__________________________________________________________________________

Student Information

Student’s siblings’ names if currently enrolled in CPS: ___________________________ ___________________________ ___________________________

___________________ Student ID#

School Use Only: Prevent duplicate student records. Search in SIM for an existing Student ID before creating a new one.

___________________________ ______________________ __________________ ___________________ Last Name First Name Middle Name Generation (Jr., etc) ______________ _______________________________ _________________________________________ Gender Birth date (mm/dd/yyyy) Registration Grade Level (when first entering CPS)

Personal, Immigrant, and Refugee Information

To Parent/Guardian:

CPS is required to keep a count of immigrant students for Federal and State Guidelines in order to determine if additional resources and services for students are needed.

Note that this is not an inquiry on citizenship status, and all information will be kept confidential.

Y / N _______________________________________________________ Birth Certificate on File Birth Verification Type __________________________ ________________________________ ____________________________ * Birth Country Birth State Birth City

* Complete if student was not born in the United States (US) or one of its Territories:

Date of first enrollment in any US School: ____________________________

Full Years completed school in US: _________________________________ Student has refugee status: Y / N Country of refugee:_____________________________________

School Use Only: Note that “Date of first enrollment in any US School” becomes a required field in SIM if “Birth Country” is not the US or one of its Territories.

Student Address/Phone

Physical (Home) Address

Mailing Address (if different than Home)

__________________________________ ______ _________________ _________________ ___________ Street Number and Name Apt. City State Zip Code __________________________________ ______ _________________ _________________ ___________ Street Number and Name Apt. City State Zip Code Home Phone Number______________________________

Demographic, Home Language,

Parent/Guardian Contacts, Emergency/Health Information

Federal Ethnic and Race Categories: (Enter information into SIM from the Race and Ethnicity Survey form)

Home Language Survey: (Enter information into SIM from the Home Language Survey form)

Parent/Guardian Contacts: (Enter information into SIM from the Request for Emergency and Health Information form)

Emergency/Health Information: (Enter information into SIM from the Request for Emergency and Health Information form)

Enrollment Enrollment Status Codes:

01 – No Former School 02 – Chicago Public School (to incl. Charter/Contract) 03 – Chicago Private School 04 – IL Public Schl, not Chicago 05 – IL Private Schl, not Chicago 06 – US Public Schl, not Illinois 07 – US Private Schl, not Illinois 08 – Not in USA

_______________________________________________________________ __________________________________ *School Transferring From ((if not a Chicago Public, Charter or Contract School) City and State

*Is the student in good standing? Y / N (Instructions to school: for out-of-state public school or any private school students, a certification of “good standing” should be received from the Parent/Guardian. Refer to CPS Policy 10-0623-PO1 for more information.)

Last Chicago Public, Charter, or Contract School Attended _____________________________________________ Is the student receiving any type of Special Education services? Y / N (Instructions to school: if yes, please notify the Case Manager.) Student Enrolled by ____________________________________________________________________________ (Print Name and Relationship) _________________________________________________________ ________________________________ Signature of Parent/Guardian Date of Enrollment

School Use Only: Enrollment Status Code (insert a # from the left) ______ Grade Level_______ Homeroom/Division #____________

ChicagoPublic

Schools

HOME

LANGUAGE

SURVEY

HLS 1 of 2SpanishPolish

ChineseArabicBosnianCroatianSerbian

Urdu

HLS 2 of 2Romanian

YorubaAssyrianGujaratiTagalogKorean

Office ofLanguage

andCultural

Education

RevisedMay 2016

____________________________________________________ ____________________________________________________ Signature of School Official Date Signature of Parent/Guardian Date

Notes:• If the parent/guardian does not speak English and the school does not have staff who speaks the parent/guardian’s

language, identify the language spoken by the parent/guardian through any assistance available in the school.• If exact name of the language cannot be determined, enter “Other” as a temporary entry. If you entered “Other,” the

exact language must be determined within two weeks after enrollment. • If the language spoken by the parent is not reflected in this HLS, please visit the OLCE Forms page on the Knowledge

Center at bit.ly/OLCEforms and click on Home Language Survey in Additional Languages.

Complete this Home Language Survey at the student’s initial enrollment in a Chicago Public School.This form must be kept in the student’s folder.

School: ________________________________ Room: _____ School ID #: __________ Network: __________________

Student Name: ________________________________________ Student IS #: ___________________________________

Rev. 07/2017 Chicago Public Schools

Request for Emergency and Health Information

School Name: _____________________________________________________________________________________ PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a change in this information, immediately notify the school in writing. ___________________ __________________________________________________________________________________________ __________________ Student ID# Last Name First Name Middle Name Homeroom # ______________________ ___________________________________________________________________________________ _____________________ Birth Date (mm/dd/yyyy) Student Home Address Student Home Phone #

Confidential Information Box 1 Complete this box only if (1) it reflects your child’s current living situation; OR (2) it reflects your living situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff with enrollment and may enable the student to receive additional services.) Check one box:

in a car/park/other public place

doubled-up in a hotel/motel in a shelter in transitional housing

Confidential Information Box 2 Is there a current Order of Protection or No Contact Order which concerns this student? Yes No

School Note: If any box is checked, see the CPS Policy 702.5.

Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed.

Parent/Guardian Contact Parent/Guardian Contact

Contact Name

Relationship to Student

Check all that apply: Lives With Gets Mailings Emergency Permission to Pickup

Lives With Gets Mailings Emergency Permission to Pickup

Home Address, if different from student’s

Home Phone Number, if different from student’s

Cell Phone Number

Email Address

Name and Address of Employer

Work Phone Number

* Communication Language

* CPS communicates via phone calls. Select the language that should be used to communicate with you. Languages available for mass communication at this time are English and Spanish (note: other languages upon availability).

List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student: _________________________________________________________________________________________________________________________________ Name Home Address Telephone # Relationship

Family Doctor’s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency.

____________________________________________________________________________________________________________________________________

Student Health Insurance: (select only one of the three)

Illinois Medical Card/All Kids: provide student’s medical ID # __________________________________________(9-digit number located on back of card)

No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No

Private/Employer Health Insurance: no additional information needed

Children of Military Personnel (optional) As the Parent or Guardian, are you a member of a branch of the armed forces of the United States? Yes No

If yes, are you either deployed to active duty or expect to be deployed to active duty during the school year? Yes No

I certify that the information on this form is correct:

____________________________________________________________________________(Parent/Guardian Signature)___________________________(Date)

School Note: If “Yes,” follow CPS Policy 704.4 procedures. Enter information in Legal Alert field and update contact information, as needed, in SIM.

11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

State of Illinois Certificate of Child Health Examination

Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.

Student’s Name Last First Middle

Birth Date Month/Day/Year

Sex Race/Ethnicity School /Grade Level/ID#

Address Street City Zip Code

Parent/Guardian Telephone # Home Work

IMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication. REQUIRED Vaccine / Dose

DOSE 1

MO DA YR

DOSE 2

MO DA YR

DOSE 3

MO DA YR

DOSE 4

MO DA YR

DOSE 5

MO DA YR

DOSE 6

MO DA YR

DTP or DTaP

Tdap; Td or Pediatric DT (Check specific type)

�Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT �Tdap�Td�DT

Polio (Check specific type)

� IPV � OPV � IPV � OPV � IPV � OPV � IPV � OPV � IPV � OPV � IPV � OPV

Hib Haemophilus influenza type b

Pneumococcal Conjugate

Hepatitis B

MMR Measles Mumps. Rubella

Comments: Varicella

(Chickenpox)

Meningococcal conjugate (MCV4)

RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose Hepatitis A

HPV

Influenza

Other: Specify Immunization Administered/Dates

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here. Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result. *MEASLES (Rubeola) MO DA YR **MUMPS MO DA YR HEPATITIS B MO DA YR VARICELLA MO DA YR 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title 3. Laboratory Evidence of Immunity (check one) �Measles* �Mumps** �Rubella �Varicella Attach copy of lab result. *All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence. **All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.

Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________ Physician Statements of Immunity MUST be submitted to IDPH for review.

Birth Date Sex School Grade Level/ ID

# Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other)

Yes No

List: MEDICATION (Prescribed or taken on a regular basis.)

Yes No

List:

Diagnosis of asthma? Child wakes during night coughing?

Yes No Yes No

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

Yes No Birth defects? Yes No Hospitalizations?

When? What for? Yes No

Developmental delay? Yes No

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

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

Yes No

Diabetes? Yes No Serious injury or illness? Yes No

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

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

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

Dizziness or chest pain with exercise?

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

Yes No

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

Dental � Braces � Bridge � Plate Other

Ear/Hearing problems?

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

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

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

Skin Endocrine

Ears Screening Result: Gastrointestinal

Eyes Screening Result: Genito-Urinary LMP

Nose Neurological

Throat Musculoskeletal

Mouth/Dental Spinal Exam

Cardiovascular/HTN Nutritional status

Respiratory � Diagnosis of Asthma Mental Health

Currently Prescribed Asthma Medication: � Quick-relief medication (e.g. Short Acting Beta Agonist) � Controller medication (e.g. inhaled corticosteroid)

Other

NEEDS/MODIFICATIONS required in the school setting

DIETARY Needs/Restrictions

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

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

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

Address Phone

Scammon Elementary

One complete, please contact Mrs. Toledo at

ytoledo@cps.edu to set up a virtual appointment.

Thank you for completing the enrollment packet.

Stay safe!