Revised 2/12/2020 Communications Office dnbm

STUDENT REGISTRATION FORM • Alexandria City Public SchoolsPAGE 1 OF 2

Student’s Last Name: First Name: Middle Name:

Student and Primary Parent/Guardian Address: Street Apt #

City State Zip

Date of Birth: Month: Day: Year: Country of Birth: Grade:

Gender: r Male r Female Gender Identity: r Male r Female r Other Preferred Name:

Last School Attended: r Public r Private

Address: City State Zip

If not an Alexandria City school, has student EVER attended Alexandria City Public Schools? r Yes r No

If Yes, please provide the following: School: Year: Grade:

Is this student Hispanic or Latino? (choose only one)r o no is anic o atino r es is anic o atino e son o Cuban e ican ue o Rican ou me ican

Central American, or other Spanish culture or origin, regardless of race)

What is the student’s race? (choose one or more)r American Indian/Alaskanr Asian

r Black or African Americanr ative a aiian o O e aci c s ande

r i e a e son avin o i ins in an o e o i ina peoples of Europe, the Middle East or North Africa)

Do you live/reside in the City of Alexandria? r Yes r o o as an e ce tion o o ic been a oved r Yes r No

Primary Parent/Guardian:This is the parent/legal guardian with whom the student lives most of the week, and the main contact regarding the student.

ome one ) - Is your home phone a cell phone?

Ce one ) -

Email Address:

ome one ) - Is your home phone a cell phone?

Ce one ) -

Email Address:

r Father r Stepfather r Legal Guardianr Mother r Stepmother r Foster Parent

O e ease indica e e ations i

Parent/Guardian’s preferred language of communication?r English r Spanish r Amharic r Arabic r O e ease s eci

Last Name: First Name: r Male r Female

Employer:

Work Address:

o one ) - Ext:

Parent/Guardian #2:

r Father r Stepfather r Legal Guardianr Mother r Stepmother r Foster Parent

O e ease indica e e ations i

Address: r Address is the same as student and primary parent/guardian’s address above

Street Apt #

City State Zip

Last Name: First Name: r Male r Female

Employer:

Work Address:

o one ) - Ext:

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

r Yesr No

r Yesr No

Revised 2/12/2020 Communications Office dnbm

Name Birth Date Sex School

1.

2.

3.

4.

5.

Does your child have a current IEP for Special Education services or 504 Plan? r Yes r No

If Yes, has documentation been provided to the school? r Yes r No

Has your child been expelled from attending school at a private or public school in Virginia or another state, for an offense in violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person? r Yes r No

STUDENT BACKGROUND

STUDENT’S SIBLINGS

PRE-KINDERGARTEN EXPERIENCE Only for students enrolling into kindergartenPlease list at least two people we may call to make emergency decisions and/or pick up your

c i d om sc oo i e a en s / ua dian s canno be eac ed in e even o an eme enc

By signing this form I am verifying that the information contained herein is correct.

Parent/Guardian Signature: Date:

During the year before kindergarten, my child attended (choose one):

i inia esc oo nitiative ea o d program at:r e and ia Ci ub ic c oo s Cr Campagna Centerr C i d and ami e o Cen e C Cr ALIVE! Child Development Centerr C eative a c oo

Another pre-K program:r a C i d ood ecia ducationr esc oo e s ea nin o e e r Head Startr Full-day Private Preschool/Daycarer Half-day Private Preschoolr Licensed Family Home Daycare Provider

r Department of Defense Child Development Program

Other:r a en /Re ativer C i d ca e ovide in m ome nann au

pair, etc.)r Other:

Specify:

Student ID School ID Sch/Res Att/Permit Code

Address/Transfer Permit Verified Grade Entry Code Entry Date Office Verification/Signature

Emergency Contact #1 (Other than Parent/Guardian):

Name:

Address: Street Apt #

City State Zip

Home Phone: Cell Phone:

Work Phone: Re ations i o s uden

Emergency Contact #2 (Other than Parent/Guardian):

Name:

Address: Street Apt #

City State Zip

Home Phone: Cell Phone:

Work Phone: Re ations i o s uden

Emergency Contact #3 (Other than Parent/Guardian):

Name:

Address: Street Apt #

City State Zip

Home Phone: Cell Phone:

Work Phone: Re ations i o s uden

FOR OFFICE USE ONLY

EMERGENCY CONTACTS

STUDENT REGISTRATION FORM • Page 2 of 2 Alexandria City Public Schools

Office of English Learner Services 1340 Braddock Place Alexandria, VA 22314

Telephone: 703-619-8022 E-mail: ELOffice@acps.k12.va.us

Home Language Survey

Parent/Guardian: Federal regulations require school systems to survey all enrolling students regarding the students’ home language and any other languages the students may speak. Based on the information provided below, the student may be assessed for English proficiency as required by federal regulations. Based on the results of the assessment, the student may be eligible for supplemental instruction through the English Learner (EL) program. Parents/guardians will be informed about the assessment results and if the student is eligible for supplemental services, the parents will have the opportunity to accept or refuse the supplemental EL services. Padre, madre o tutor legal: Las leyes federales requieren que los sistemas escolares encuesten al inscribirse a todos los alumnos sobre el idioma que se habla en el hogar y sobre cualquier otro idioma que puedan hablar los alumnos. Con base en la información proporcionada a continuación, el alumno pudiera ser evaluado para determinar su competencia en el idioma inglés tal como lo exigen las normas federales. Con base en los resultados de la evaluación, el alumno pudiera ser elegible para recibir instrucción suplementaria mediante el programa de Aprendizaje del Idioma Inglés (EL). Se informará a los padres o tutores legales sobre los resultados de la evaluación y si el alumno es elegible para recibir servicios suplementarios, los padres tendrán la oportunidad de aceptar o rechazar los servicios suplementarios de EL. ወላጅ/ አሳዳጊ፤ አዲስ የሚመዘገቡ ተማሪዋች በቤታቸው ስለሚናገሩት ቋንቋ እና ተማሪው ስለሚናገረው ሌላ ቋንቋ የትምህርት ቤት አስተዳደሮች መጠይቅ እንዲያዘጋጁ የፌደራል ሕግ ይጠይቃል። እታች በተገለፀው መረጃ ላይ ተመሰርቶ የፌደራል ሕግ በሚጠይቀው መሰረት የተማሪውን የእንግሊዘኛ ቋንቋ ብቃት ምዘና ይካሄዳል። ከሚካሄደው ምዘና በሚገኘው ውጤት መሰረት ተማሪው በእንግሊዘኛ ቋንቋ ትምህርት (ኢ ኤል) ፕሮግራም ተጨማሪ የቋንቋ ትምህርት ለመውሰድ ብቁ ሊሆን ይችላል። ወላጆች/ አሳዳጊዋች ስለምዘና ውጤት እና ተማሪው ለተጨማሪ ድጋፍ አገልግሎት ብቁ ስለመሆኑ መረጃ የሚደርሳቸው ሲሆን ወላጆችም በተጨማሪነት የሚሰጠውን የኢ ኤል አገልግሎት የመቀበል ወይም ያለመቀበል እድል ያገኛሉ።

لب وأية لغات أخرى قد يتحدثها الطلاب. وعلى ضوء تتطلب اللوائح الفيدرالية قيام الأنظمة التعليمية بإجراء إستبيان لجميع الطلاب المسجلين فيما يتعلق باللغة المستخدمة في منزل الطا /الوصي الشرعي:الطالبأمرولي موجب اللوائح الفيدرالية. واستنادًا إلى نتائج التقييم، قد يكون الطالب مؤهلاً للحصول على تعليم إضافي من خلال برنامج متعلمي المعلومات المقدمة أدناه، يمكن تقييم كفاءة الطالب في اللغة الإنجليزية وكما هو مطلوب ب

ELلأولياء الأمور فرصة قبول أو رفض تلقي خدمات (. سيتم إبلاغ أولياء الأمور/ الأوصياء الشرعيون بنتائج التقييم وفيما إذا كان الطالب مؤهلاً للحصول على خدمات تكميلية، حيث ستتاحELاللغة الإنجليزية ) التكميلية.

Student Name: __________________________________________________________________ Date of Birth: _________________ Nombre del alumno Fecha de nacimiento የተማሪው ስም የትውልድ ቀን፤ تأريخ الميلاد :أسم الطالب Parent/Guardian Name: ___________________________________________________________ Telephone: ___________________ Nombre del padre, madre o tutor legal Teléfono የወላጅ/አሳዳጊ ስም ስልክ رقم الهاتف أسم ولي الأمر/ الوصي الشرعي 1. What is the primary language used in the home, regardless of the language spoken by the student? __________________________ ¿Cuál es el idioma principalmente utilizado en el hogar, independientemente del idioma que el alumno hable? በቤት ውስጥ የሚነገር የመጀመሪያ ዋነኛ ቋንቋ ምንድን ነው ተማሪው ሌላ ቋንቋ የሚናገር ቢሆንም እንኾ? ماهي اللغة الأساسية المستخدمة في البيت، بغض النظر عن اللغة التي يتحدث بها الطالب؟ 2. What is the language most often spoken by the student? ____________________________________________________________ ¿Cuál es el idioma que el alumno habla con más frecuencia? ተማሪው ብዙ ጊዜ የሚናገረው ቋንቋ ምንድን ነው? ماهي اللغة التي يتحدث بها الطالب غالبا؟ً 3. What is the language that the student first acquired? _______________________________________________________________ ¿Cuál es el idioma que el alumno aprendió primero? የተማሪው የአፍ መፍቻ ቋንቋ ምንድን ነው ? ماهي اللغة التي تعلمها الطالب لأول مرة؟ In which language do you prefer to receive communication from the school? � English � Español � አማርኛ � العربية ¿En qué idioma prefiere recibir comunicación de la escuela? ከትምህርት ቤት የሚላከውን መረጃ መለዋወጫ መገናኛ እንዲሆን የትኛው ቋንቋ ይመርጣሉ? ماهي اللغة التي تفضل التواصل بها مع المدرسة؟ � Other: ________________________________ Otro ሌላ أخرى Parent/Guardian Signature: ______________________________________________________________ Date: __________________ Firma del padre, madre o tutor legal Fecha የወላጅ/አሳዳጊ ፊርማ ቀን التأريخ توقيع ولي الأمر/الوصي الشرعي

ACPS Staff Members: This form must be completed for all students registering in Alexandria City Public Schools. It should be the first document provided to the parent/guardian during the registration process. Please ensure that all questions are answered completely. If a language other than, or in addition to, English is listed in response to question 1, 2, or 3, the student should be referred to the Office of English Learner Services (EL Office) for registration and assessment. Families and staff can contact the EL Office at 703-619-8022 with any questions. Rev. 8/8/18

1 July, 2018

Residency Verification & Enrollment Form

Part I : Student/Family Information Please complete A, B or C.

A. I am the Parent who is enrolling ___________________________________________in school. (student full name)

B. I am the Legal Guardian/Primary Caregiver enrolling _______________________________________ in school (must provide official documentation). (student full name)

C. I am the adult student (18 years or older) enrolling myself, __________________________________ in school. (student full name)

I, the parent/legal guardian/caregiver and/or adult student, affirm that I/we reside at the following domicile*: Full Address: _____________________________________________________________________________________________________ Street name Apt. # City State Zip Code Phone Number Part II: Parent/Guardian/Caregiver or Adult Student Sworn Statement I understand that enrollment of the student in Alexandria City Public Schools is based on my affirmation that I am (Part I) the parent/legal guardian of the student and a resident of the City of Alexandria, (Part II) this sworn statement of City of Alexandria residency and (Part III) my presentation of residency verification documentation (see page 3 - category A, B, or C). I affirm I reside with the student at the address noted in this document. If this sworn statement is false, I understand that I may be liable for payment of retro-tuition for the student, and that the student will be withdrawn from Alexandria City Public Schools. Please be advised that according to the Code of Virginia § 22.1-264.1, it is a Class 4 misdemeanor to knowingly misrepresent residency for the purpose of enrollment in a school outside the attendance zone in which the student resides. I hereby waive my rights to confidentiality of information relative to my residence and understand that the Alexandria City Public Schools will use whatever legal means it has at its disposal to verify my residence. I also agree to notify the school of any change of residence for myself and/or the student with in three (3) business days of such change. _______________________________________________________________ _____________________ Printed Name of Parent/Legal Guardian/Caregiver or Adult Student Phone Number _______________________________________________________________ ______________________ Signature of Parent/Legal Guardian/Caregiver or Adult Student Date *A bona fide residence/domicile is defined as where a person lays their head each night. Owning or renting a property is not enough to claim residency in the City of Alexandria. The student and legal guardian must sleep in the City of Alexandria nightly.

*** ACPS STAFF OFFICAL USE ONLY - DO NOT COMPLETE BELOW THIS LINE***

2 July, 2018

Part III: Residency Verification Registering adult must provide photo identification, student birth certificate & the following three (3) documents: All documents must be the original copy (current-within the past 60 days) & clearly notes the parent/legal guardian or adult student name & Alexandria City address. See reverse for further explanation of documents. Category A – one (1) document: � Lease Agreement � Deed (with copy of property

tax) � Mortgage contract

Category B - two (2) supporting documents: � Utility bill (water, gas, electric, cable, and/or landline phone) � Current personal Alexandria City property tax bill/receipt � Mailed letter from a government agency (TANIF, HUD, ARHA, IRS, etc. � Current pay stub (noting Alexandria address & Virginia tax withholding) � 2 u l � l u y l

� u u l y y

l � ly l 0 y y l u

Category C: � Lack of Housing � DSS/Foster Care Services

Shared Housing Residents: If the parent/guardian is living in a shared housing a notarized A/B form will be required with a copy of the homeowner’s mortgage, Deed or a copy of the lease with whom the student and parent are living. Additionally, you will be required to provide two supporting documents (in the parent/legal guardian’s name) as listed above. A home visit maybe completed in cases of questionable residency. A/B FORM EXPIRATION: ___________ (Registrar - enter date into PowerSchool). I certify that I personally reviewed all the documents presented and affirm that the information represented above is true and factual to the best of my knowledge, information, and belief. I also affirm that copies of all required documentation will be attached to this document and placed in the student’s file. _____________________________________________________________________________________________ School Official Name (Print) School Official (Signature) Date

3 July, 2018

List of Acceptable Residency Verification Documentation All documents must note the registering parent/legal guardian or adult student’s full name and Alexandria City

address

Category A: (One document from this list to verify residency) � Lease or Rental Agreement: The original lease must be current (not expired) indicating the dates, names

and property address for the parent/legal guardian who is enrolling the student. If the lease is a private generated agreement with the landlord the lease must be notarized.

� Deed: The property deed must be accompanied by a copy of the owner’s personal property tax. This may be obtained (free of charge) at http://realestate.alexandriava.gov/index.php?action=address. The deed must be in the parent/legal guardian name.

� Mortgage: The resident may present a mortgage bill prepared by the lender (including date, Alexandria address and lender name) within 60 days of registration or the initial mortgage contract with current copy of the owner’s property tax. This may be obtained for free at http://realestate.alexandriava.gov/index.php?action=address

� I am living in shared housing and the lease/deed or mortgage is not in my name. Please complete a Shared Housing (A/B) Form and attach the lease/deed or mortgage of the person with whom you reside.

AND

Category B: (Two documents from this list to verify residency) � Utility bill (water, gas, electric, cable and/or landline phone bill). The bill must be dated within the past

30 days. If all utilities are covered in your leasing contract and you do not have any other bills please provide a letter from your property manager on company letter head that notes water, gas, sewer, electric are all included in the monthly rent.

� Current Alexandria City Personal Property Tax (vehicle, RV, boat). Please note: Virginia Department of Motor Vehicles requires all personal property must be registered to the current address within 60 days of relocation.

� Mailed letter from a government agency (TANIF, HUD, ARHA, IRS, etc.) The letter must be addressed to the parent/legal guardian or adult student.

� Current pay stub (with Alexandria City address and noting Virginia tax withholding) � Latest federal/state income tax return noting the Alexandria City address � 2 consecutive bank statements mailed to the Alexandria City address. � Current homeowner or renter’s insurance policy noting an Alexandria City address

OR

Category C: Please confer with the school registrar if either of the following apply. � Lack of housing, in transition or are experiencing homelessness. � Foster Care/DSS: Provide verification that the student is in the custody of the Department of Social

Services, in the form of a court order or official documentation from the Department of Social Services.

Revised 2/2 /201 Communications Office dnbm

STUDENT HEALTH CONDITIONS Check all boxes that apply to the student.

ALLERGIES Yes No

FOOD RESTRICTIONS Yes No

ASTHMA Yes No

DIABETES Yes No

SEIZURE DISORDER Yes No

Allergy Type:

r Food List food(s):

r edication is medication s

r ee stin s o insec bi es

r O e

Date of last severe reaction:

Date of last hospital or emergency room visit due to allergies:

Currently prescribed medications and treatments for allergies: r O a anti is amine enad e cr ine ine r Has Epi-Pen

r Ot e

Currently prescribed medications and treatments for asthma: r ai con o evention medicationr s needed escue medication

Date of last hospital or emergency room visit due to asthma:

r ue o as oin estina i estive dis ess is ood s

r ue o e i ious o o e e e ences is ood s

STUDENT HEALTH INFORMATION FORM • e and ia Ci ub ic c oo s

Student’s Last ame: First Name:

Date of Birth: Grade: School Year:

PAGE 1 OF 2

Date of last sei ure:

Date of last hospital or emergency room visit due to sei ure:

Date of last hospital or emergency room visit due to diabetes:

Does the student’s sei ure disorder re uire medication I SCHOOL?

r No

r Yes is medication s

Does the student’s diabetes re uire medication and/or blood testing I SCHOOL? r No r Yes is medication s

Revised 2/2 /201 Communications Office dnbm

In the case of an emergency, school staff will call 11. Every attempt will be made to contact a parent, legal guardian or emergency contact. Students will be transported to the nearest Emergency Room unless the parent is on the school premises to assume responsibility for the child.

e a en / ua dian is es onsib e o ovidin e sc oo i an medication s ecia ood su ies o e ui men a e s uden e ui es du in e sc oo da C ec i e sc oo nu se o e is a o ob ain co ec medication and ocedu a o ms an

individua sc oo ea ca e an is indica ed e a en / ua dian is es onsib e o ovidin e sc oo nu se i necessa medica in o mation a o ia e au o i ation o ms and i en consen o e c an e in o mation i e c i d s sician

(do ) (do not au o i e m c i d s ea ca e ovide and desi na ed ovide o ea ca e in e sc oo se n o discuss m c i d s ea conce ns and/o e c an e in o mation e ainin o is o m

This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record.

a en / ua dian i na u e Date:

VISION CONDITIONS Yes No

HEARING CONDITIONS Yes No

r Glasses

r Contacts

r on co ec ab e

r O e

r ea in aid s

r on co ec ab e

r O e

Does the student have health insurance? r No r es ame o ea insu ance com an

ame o s uden s ima ca e doc o Phone:

Does the student have dental insurance? r No r es ame o den a insu ance com an

ame o s uden s dentis Phone:

STUDENT HEALTH CARE AND HEALTH COVERAGE

PARE /G ARDIA A HORI A IO

OTHER HEALTH CONDITIONS Yes No

r ADHD

r utism

r Ce eb a a s

r eve o men a e a

r Con eni a ea e ec

r emo i ia

r ic e Ce isease

r C stic ib osis

r Cance

r C onic n ection e atitis C

r Con eni a /C omosoma iso de s

r e ession

r Obs uctive ee nea

r u itiona iso de

r Physical Disability

r c ema

r O e sica o men a ea conditions

Does the student’s condition re uire I SCHOOL SE of the following?

edications: r No r es is medication s

Special procedures: r No r es is ocedu e s

Special e uipment: r No r es is e ui men

STUDENT HEALTH INFORMATION FORM • a e 2 o 2 Alexandria City Public Schools

MCH 213G reviewed 03/2014 1

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

Part I – HEALTH INFORMATION FORM State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your child’s entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _______________________

Student’s Name: _________________________________________________________________________________________________________________________ Last First Middle Student’s Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________

Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________

Name of Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Name of Parent or Legal Guardian 2: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Condition Yes Comments Condition Yes Comments Allergies (food, insects, drugs, latex) Diabetes Allergies (seasonal) Head injury, concussions Asthma or breathing problems Hearing problems or deafness Attention-Deficit/Hyperactivity Disorder Heart problems Behavioral problems Lead poisoning Developmental problems Muscle problems Bladder problem Seizures Bleeding problem Sickle Cell Disease (not trait) Bowel problem Speech problems Cerebral Palsy Spinal injury Cystic fibrosis Surgery Dental problems Vision problems

Describe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,

etc.):__________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

List all prescription, over-the-counter, and herbal medications your child takes regularly:

_______________________________________________________________________________________________________________________________________

Check here if you want to discuss confidential information with the school nurse or other school authority. � Yes � No

Please provide the following information:

Name Phone Date of Last Appointment Pediatrician/primary care provider

Specialist

Dentist

Case Worker (if applicable)

Child’s Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record. Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________

Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______

MCH 213G reviewed 03/2014 2

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM

Part II - Certification of Immunization

Section I

To be completed by a physician or his designee, registered nurse, or health department official. See Section II for conditional enrollment and exemptions.

A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form. Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box. Certification of Immunization 11/06

Student’s Name: Date of Birth: |____|____|____|

Last First Middle Mo. Day Yr.

IMMUNIZATION

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

*Diphtheria, Tetanus (DT) or Td (given after 7 years of age)

1 2 3 4 5

*Tdap booster (6th grade entry) 1

*Poliomyelitis (IPV, OPV)

1 2 3 4

*Haemophilus influenzae Type b (Hib conjugate) *only for children <60 months of age

1 2 3 4

*Pneumococcal (PCV conjugate) *only for children <60 months of age

1 2 3 4

Measles, Mumps, Rubella (MMR vaccine)

1 2

*Measles (Rubeola)

1 2 Serological Confirmation of Measles Immunity:

*Rubella

1 Serological Confirmation of Rubella Immunity:

*Mumps

1 2

*Hepatitis B Vaccine (HBV) � Merck adult formulation used

1 2 3

*Varicella Vaccine

1 2 Date of Varicella Disease OR Serological Confirmation of Varicella Immunity:

Hepatitis A Vaccine 1 2

Meningococcal Vaccine 1

Human Papillomavirus Vaccine

1 2 3

Other 1 2 3 4 5

Other 1 2 3 4 5

Other 1 2 3 4 5

* Required vaccine I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child care or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Reference Section III). Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):___/___/____

MCH 213G reviewed 03/2014 3

Student’s Name: Date of Birth: |____ |_ ___|___ _|

Section II Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

Certification of Immunization 03/2014

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ] This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next immunization due on __________________. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site at

http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published by

the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),

otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)). (Requirements are subject to change.)

Section III Requirements

MCH 213G reviewed 03/2014 4

Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth. Student’s Name: _______________________________________________ Date of Birth: _____/_____/__________ Sex: □ M □ F

Hea

lth A

sses

smen

t

Date of Assessment: _____/_____/_______

Weight: ________lbs. Height: _______ ft. ______ in.

Body Mass Index (BMI): ___________ BP____________

� Age / gender appropriate history completed

� Anticipatory guidance provided

Physical Examination

1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment

1 2 3 1 2 3 1 2 3

HEENT □ □ □ Neurological □ □ □ Skin □ □ □ Lungs □ □ □ Abdomen □ □ □ Genital □ □ □ Heart □ □ □ Extremities □ □ □ Urinary □ □ □

TB Screening: □ No risk for TB infection identified □ No symptoms compatible with active TB disease □ Risk for TB infection or symptoms identified Test for TB Infection: TST IGRA Date:_______ TST Reading _____mm TST/IGRA Result: □ Positive □ Negative CXR required if positive test for TB infection or TB symptoms. CXR Date: __________ □ Normal □ Abnormal EPSDT Screens Required for Head Start – include specific results and date: Blood Lead:___________________________________________ Hct/Hgb ____________________________________________

Dev

elop

men

tal

Scre

en

Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation Emotional/Social

Problem Solving

Language/Communication

Fine Motor Skills

Gross Motor Skills

Hea

ring

Sc

reen

� Screened at 20dB: Indicate Pass (P) or Refer (R) in each box. 1000 2000 4000

R L

� Screened by OAE (Otoacoustic Emissions): □ Pass □ Refer

□ Referred to Audiologist/ENT □ Unable to test – needs rescreen

□ Permanent Hearing Loss Previously identified: ___Left ___Right

□ Hearing aid or other assistive device

Visi

on

Scre

en

� With Corrective Lenses (check if yes) Stereopsis � Pass � Fail � Not tested Distance Both R L Test used: 20/ 20/ 20/ � Pass

� Referred to eye doctor

� Unable to test – needs rescreen

D

enta

l Sc

reen

� Problem Identified: Referred for treatment

� No Problem: Referred for prevention

� No Referral: Already receiving dental care

Rec

omm

enda

tions

to (P

re) S

choo

l , C

hild

Car

e, o

r Ea

rly

Inte

rven

tion

Per

sonn

el

Summary of Findings (check one): □ Well child; no conditions identified of concern to school program activities □ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________ _____________________________________________________________________________________________________________________________

___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________ Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epinephrine auto-injector □ other: ________________

___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)

___ Restricted Activity Specify: _________________________________________________________________________________________________

___ Developmental Evaluation □ Has IEP □ Further evaluation needed for: ___________________________________________________________

___ Medication. Child takes medicine for specific health condition(s). □ Medication must be given and/or available at school.

___ Special Diet Specify: ______________________________________________________________________________________________________

___ Special Needs Specify: ______________________________________________________________________________________________________

Other Comments: _____________________________________________________________________________________________________________

Health Care Professional’s Certification (Write legibly or stamp) □ By checking this box, I certify with an electronic signature that all of

the information entered above is accurate (enter name and date on signature and date lines below). Name: _____________________________________ Signature: ________________________________________ Date: ____/_____/______

Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________

Phone: _______-_______-____________________ Fax: _______-_______-______________ Email: ______________________________________________

AlexandriaCityPublicSchoolsTransportationDepartment

AlternateAuthorizedPersonsforKindergarten/SpecialEducationRelease

Date:______________ StudentName: StudentID#:

HomeAddress: Apt: Zip:

Parent/GuardianName(s): LanguageSpokenbyParent/Guardian:

PhoneNumbers: Home: Work: Cell:

School:

AuthorizedPersonsforPickUp(otherthanlegalguardians).Only3authorizednamesallowed.

NameofAuthorizedPersons Relationship TelephoneNumber(s)

Parent/GuardianSignature: Date:

PrincipalSignature:

ForOfficeUseOnly:

Receivedby:_______________________Date:______________________Time:____________________

Pleasenote:Thisformmustbesubmittedby12p.m.inordertobeeffectiveimmediately.Ifsubmittedafter12p.m.,changewillgointoeffectthefollowingschoolday.PrincipalsMUSTapproveinordertobeprocessed.

/ /201 Communications Office dnbm

Section 1: S DE I OR A IO

Section 2 E PLOY E I OR A IO : CIVILIA S O LY working on federal property

S DE PARE S RVEY

Student Name: Last First Middle Student ID

Address: Number & Street City State Zip Code

Name of School Grade Birth Date Home Phone

If the above property is federal property, please enter the name of the property

Parent/Guardian Name: Last First MI Employer Name

m o e dd ess sica ocation ui din umbe ee Ci a e i Code

Federal Property Name (see bac side for list of eligible federal properties

Federal Property Address Number & Street City State Zip Code

n e in o mation in is section i ei e a en / ua dian as on active du in e ni o med e vices o e ni ed a es on e su ve da e bo a en s in e ouse o d a e in e mi i a a e time o e su ve da e ease ou a second o m

n e in o mation in is section i ei e a en / ua dian as on active duty on the survey date no s i is section

a en / ua dian ame as i s and o ei n ove nmen ame

i i a Ran / ade anc o e vice

is in o mation is used o su o ou e ues o ede a unds unde e m ac id o am i e o e emen a and econda c is in o mation ma be ovided o e e a men o ducation i ou a ication o ede a unds is audi ed is o m mus be si ned and da ed o C o eceive i ai s a e o ede a unds

By signing this form, I am certifying that all typed and written information on his form is accurate and complete as of the survey date.

Section 3 PARE /G ARDIA E PLOY E I OR A IO : I OR ED SERVICES PARE /G ARDIA

Section 4 PARE /G ARDIA E PLOY E I OR A IO : OREIG ILI ARY

Survey Date 10/30/2019Each Section S be Completely illed in Where Applicable

C ma eceive ede a an unds o en o in s uden s o a e ede a connec ed no a en o ua dian in ou ouse o d ives o o s on ede a o e ease com e e ection 1 and si n and da e a e bo om o e o m

r uden is no mi i a connec ed o no com e e an u e in ection

Branch of Active Service:r Air Force r Army r Coast Guard r Marine Corps r Navyr e Commissioned Co s o e ationa Oceanic and mos e ic dminis ation Or e Commissioned Co s o e o e ub ic ea e vices

r ationa ua d o Rese ves mobi i ed b esidentia ecutive O de 1 22 o /1 /2001 and i e 10 C ac Co o ctivation O de s

r ationa ua d Rese ve

r Rese ve uden is a de enden o a membe o e Rese ve o ces m av i o ce a ine Co s o Coas ua d

a en / ua dian ame as i s and

i i a Ran / ade

i na u e o a en / ua dian Date [mm/dd/yyyy]

Eligible ederal Properties

be an ede a Cou ouse 01 Cou ouse e and ia 22 1

ea e OC 1 o 1 0 ue Rid e oun ain Rd uemon 201

in on ationa Ceme e in on 22211

os e e Cou ouse 200 as in on e and ia 22 1

C an e Cam us 1000 Co onia a m Rd c ean 22101

ava u ace a a e Cen e 1 20 a en Rd a en 22

C RO 1 ee Rd C anti 201 1

O o 2 ea e e vice Rd e in 201

u es n e nationa i o 1 aa inen Ci e in 201

en a on inc ude b d ocation in s ee add ess in on 22202

i Rou e affic Con o Cen e 2 a e eesbu 201

Rona d Rea an ationa i o 1 viation Ci in on 22202

o omac R CO acin os a en on 201

Rona d Rea an ationa i o 2 01 mi v in on 22202

cadem abo a o 2 01 nvesti ation uantico 221

even dva a C 1 0 i and ace useum C anti 201 1

o e voi 10 ac oo o e voi 220 0

u ne ai ban RC 00 eo e o n i e c ean 22101

o e voi o 00 eoin in e d 221 0

m ationa ua d 111 eo e ason in on 2220

anconia OC 0 10 o 000 oisda e Rd in e d 221 0

m Rese ve Cen e 01 o e e a Rd e and ia 22 10

eo e c u C 000 in on v in on 2220

o ne s Office O 2100 amieson ve e and ia 22 1

eo e as in on emo ia a a 00 22101

Coas ua d Radio ation 2 e e a Rd e and ia 22 1

ende son a 1 ou a e Rd in on 2221

eo o ica u ve 12201 un ise a e Res on 201 2

um e s n inee Cen e 01 e e a Rd e and ia 22 1

a en on ainin Cen e i e 0 i madi n a en on 201

b a a e Office d 01 e e a Rd e and ia 22 0

a en on ainin Cen e i e 1 ea a o Rd a en on 201

oin ase e ende son a o e 22211

a en on ainin Cen e i e C 2 ume duc Rd Remin on 22

a ine Co s ase uantico 2 0 Ca in ve uantico 221

a en on ainin Cen e i e 2212 Con ede a e Rd ood 22 1

a Cen e ede a Office d 1 eau e a d e and ia 22 0

o a a m a 1 1 a Rd ienna 221 2

Revised 2/ /2020 Communications Office dnbm

2020-21 ACPS Signature FormPlease review both sides of this form.

Student Name: Grade:

School:

Parent/Guardian Name: Date Form Completed:

ac section be o e e s o ma e ia s ci ed on is o m in e C ami andboo ac s 12 va us/ ami andboo o in e C uden Code o Conduc ac s 12 va us/codeo conduc A er signing, please return to the student’s school upon

registration or within two weeks of the student’s first day of school in ACPS. his form must be completed each school year.

he Student Code of Conduct is made available to every family each school year. si nin is section and e u nin is o m a en s / ua dian s s a no be deemed o aive bu do e ess ese ve ei i s o o ec b e Consti ution o a s o e ni ed a es and/o e Common ea o i inia and s a ave e i o e ess disa eemen i e sc oo division s

o icies and o decisions e uden Code o Conduc e ui ed b a con ains uide ines and u es o Res onsib e Com u e s em se o ic o uden s Com u so c oo endance anda ds o uden Conduc ui and ce ence o ic u in

Re o tin o m and ono Code a en s/ ua dians ave a du o assis C sc oo s in en o cin e s anda ds o s uden conduc and com u so sc oo a endance a en s/ ua dians ave a es onsibi i o unde s and e Code o Conduc omo e o e s uden conduc assis e sc oo i e disci ine o e s uden and mee i sc oo officia s i e ues ed o discuss ma e s e a ed o disci ine and sc oo a endance e a a so e ui es a a en s/ ua dians si n a s a emen s o in a e no ei es onsibi ities

Parent/Guardian Signature:

Student Signature:

Section A: Student Code of Conduct

Section B1: Student Directory Information ( amily Educational Rights and Privacy Act / ERPA)

Section B2: P A Directories and School Related Organi ations

i ec o in o mation inc udes a s uden s name add ess sc oo o o a a a ds and ono s e c does no inc ude e s uden s socia secu i numbe e ima use o di ec o in o mation is o ub is s uden in o mation in sc oo affi ia ed ub ications u is o di ec o in o mation is avai ab e in e C ami andboo C ma disc ose di ec o in o mation i ou i en consen

un ess e a en / ua dian indica es be o a e s uden s in o mation ma no be e eased

Do O e ease e s uden s di ec o in o mation e ce as e ui ed b s a e o ede a a om the date this form is si ned unti e embe 1 2021. I understand this means that information about and photographs featuring the student will be excluded from school publications such as yearbooks, honor roll listings, and printed graduation/sports/theatrical programs.

Section C: edia Participationou ou e sc oo ea e s uden s sc oo o C ma an o s a e o o a s o videos o e s uden ic u es o is/ e

a o c ass o assa es om ei itin s o uo ations om c ass discussions o educationa esen ations is inc udes ima es on e C ebsi e in C videos in socia media in sc oo ub ications inc udin ea boo s and o ams o s a ed i i d

a ties inc udin bu no imi ed o oca o nationa media e evision on ine and in ub ications

Do O use e s uden s o o a ima e voice itin s c ass o o a o in an o e a s desc ibed above from e da e is o m is si ned unti e embe 1 2021

an sc oo s and sc oo e a ed o ani ations oduce an annua di ec o o ami ies o eve acco din o i inia a no sc oo ma disc ose e add ess e e one numbe o emai add ess o a s uden un ess e ui ed b a o as desc ibed in e C ami andboo un ess e a en / ua dian affi mative consen s in itin

YES, ACPS may e ease e s uden / ami telephone number and email address o s boos e o ani ations and o e sc oo e a ed o ani ations om e da e is o m is si ned unti e embe 1 2021.

Revised 2/ /2020 Communications Office dnbm

Section D: Responsible se for echnology and Social edia

Section E: Student Record Information

Section : Book Contract

Section G: School Bus Regulations

Section H: amily Life Education

e es onsib e use o icies o ec no o and socia media a e avai ab e in e uden Code o Conduc ease evie ese o icies and si n be o

Parent/Guardian Signature:

s a s uden a ee o com i e uide ines on ec no o and e n e ne as i en in e uden Code o Conduc

Student Signature:

( or High School Parents 11th and 12th Graders O LY)

ection 2 o e o C i d e e ind c o 2001 e ui es sc oo s s ems o ovide mi i a ec ui e s and insti utions o i e education i seconda s uden s names add esses and e e one istin s u on e ues o eve a en s/ ua dians o a s uden i

e/s e is 1 o a e a emanci a ed mino ma e ues a e s uden s name add ess and e e one istin s no be e eased iou io i en consen C is b is o m noti in ou o ou i o e ues a ou c i d s in o mation no be e eased ou do O c ec an o e o tions be o e s uden s in o mation i be e eased en e ues ed b a mi i a ec ui e os ec

tive em o e o an insti ution o i e education o sc oo ea 2020 21

ease c ec an o ese ou s i ou do O an em o eceive e s uden s in o mation

Do O e ease e s uden s in o mation o ilitary Recruiters

Do O e ease e s uden s in o mation o Colleges/Other Educational Institutions

Do O e ease e s uden s in o mation o Prospective Employers

e eb a ee o e ace o a o an o a e boo s o ib a boo s a ma be e ained des o ed os o misused as e as a a dama es caused b e e ao dina ea o use as assessed b e sc oo

Parent/Guardian Signature:

School bus regulations are provided in the ACPS amily Handbook. ave ead and unde s and e e u ations o s uden s idin a sc oo bus and a ee o assume u es onsibi i o e s uden s conduc on e sc oo bus

Parent/Guardian Signature:

ave ead and unde s and e e u ations o s uden s idin a sc oo bus and a ee as a assen e o abide b ese e u ations

Student Signature:

C e u ations e mi a s uden o o ou o e ami i e ducation ma e ia de ive ed ou ou e cou se o e sc oo ea essons a i be used in e o am a e avai ab e o evie in e ib a media cen e a eac sc oo and e C a es ea e Cen a ib a oca ed a 00 u e ee o ou i sc oo esou ces associa ed i is cu icu um a e e a C i iams i c oo and e C i iams innie o a d Cam us o evie an o ese esou ces ease con ac e ami i e

ducation e a men o stay in LE does not re uire any action on your part.

ease c ec be o i ou do O an e s uden o a tici a e in e ma e ia

Please exempt the student om a tici ation in e ami i e ducation ma e ia

a en / ua dian i na u e

When families are engaged in their children’s education,

EVERYBODY WINS!

The ACPS Family and Community Engagement Center (FACE Center) provides meaningful opportunities and resources for families to work with schools by hosting interactive workshops that support academic achievement, championing two-way communication between families and schools, and facilitating volunteerism that promotes student learning. We can’t wait to see your FACE this year!

www.acps.k12.va.us/face / @acpsFACE

WELCOME!

Parent Liaisons help connect

families to school staff and

resources — whether your

family is new to Alexandria

or has been here for years.

The FACE Center supports

Parent Liaisons at select

ACPS elementary schools

and all secondary schools

HANDS-ON

We could use your help

chaperoning a field

trip or lending a hand

at school.

Complete or renew your

volunteer application at

www.acps.k12.va.us/volunteer

PARENT POWERShare your daily

parenting triumphs and frustrations;

learn new strategies from other families.

Ask about bilingual parent programs provided by FACE for K-12 families

LINKED TO LEARNINGIt’s important for you to know what is taught in the classroom so you can support your child’s learning at home.Look out for flyers throughout the year about school Curriculum Nights or FACE Center workshops that are linked to student learning

PARENT COFFEESYou’re the expert on your child. Join ACPS school staff for coffee and discuss how we can work together to ensure your child succeeds.Every month, starting in October

Family and Community

Engagement Center (FACE)

703-619-8055 English/Español

703-927-7095 العربية

703-927-6866 አማርኛPARENT

INFO

LINES