REGISTRATION PACKET Grade K

FRANKLIN REGIONAL SCHOOL DISTRICT

STUDENT REGISTRATION

3210 SCHOOL ROAD

MURRYSVILLE, PENNSYLVANIA 15668

http://www.franklinregional.k12.pa.us

Fax number 724-327-6149

E-mail – [email protected]

REGISTRATION PACKET

Grade K

Please call Sandy Stonebrook

(724) 327-5456 x7622

with any questions and

to make an appointment

Appointments accepted Monday through Friday

http://www.franklinregional.k12.pa.us/

Welcome to the 2013-2014 School Year!

Dear Parent(s)/Guardian(s),

Franklin Regional School District is now accepting registration for children

who will be entering Kindergarten in the 2013-2014 school year. Children must be (5) five years of age on or prior to September 1, 2013 to enter

school this year.

In order to register your child, the papers in the enclosed registration packet

must be completed in entirety and returned in person. You will not be able to register your child without the following information:

~ Child’s original birth certificate (with raised seal) or passport

~ Completed immunization record or printout from pediatrician

~ Proof of residency – (2) Two are required Current tax receipt

Utility bill Sales/Lease agreement

Closing settlement agreement ~ Valid PA Driver’s License

Kindergarten registrations will be accepted, by appointment, the

evenings of April 3rd, 4th, & 5th from 5:00 PM-7:45 PM. Heritage and

Newlonsburg registrations will be held at the Administration Conference room on the ground floor of Heritage Elementary. Sloan registrations will be

held at Sloan Elementary.

At the registration appointment, your child will also be scheduled to participate in the Brigance and Vision screenings that will be held at each

building. Again, screenings will be by appointment on the following dates: Newlonburg: May 31 or June 3, 2013

Heritage: May 31, June 3 or June 4, 2013 Sloan: June 3, 4 or 5, 2013

Revised 2/7/13

Beginning April 8th, those who could not attend during one of the dates noted above, may make an appointment to register their child

by calling Mrs. Sandy Stonebrook at 724-327-5456 (Extension: 7622). Registrations will continue to be accepted at the Franklin Regional

Administration Office during daytime hours (8:00 a.m. to 2:30 p.m.), until Friday, April 26, 2013.

Families are strongly encouraged to register prior to the April 26,

2013 cut off for formal registration. Please be aware that placements for the neighborhood school may not be guaranteed for any

registration taken after April 26 as school assignments are based on the classroom capacity in each building.

Included in this registration packet are dental and physical forms which must be completed and returned to your school nurse by November 30, 2013.

Examinations by the school’s physician and the school’s dentist will be scheduled for your child if these forms are not returned by the due date.

The entire Franklin Regional School District staff looks forward to working

with you as your child begins this educational journey with us. If you have any questions, please call us at 724-327-5456 X7622, or X7625.

Sincerely,

Linda Miller

Assistant Director of Financial Services 724-327-5456 X7625

Timeline of Kindergarten Transition Events Preparation for 2013-2014

Franklin Regional School District

PHASE 1

Preschool Parents Meeting ~ Orientation for Kindergarten (Meet Staff, Program Intro, Q/A, Appointments for Registration)

Incoming preschoolers to Heritage or Newlonsburg Elementary

March 20, 2013 @ 7:00 pm, Newlonsburg Cafeteria

Incoming preschoolers to Sloan Elementary:

March 21, 2013 @ 7:00 pm, Sloan LGI

PHASE 2

Kindergarten Registration (by appointment) (Parents bring completed forms from Registration Packet, Immunization Records,

Appointments for Student Screenings)

Incoming preschoolers to Heritage or Newlonsburg Elementary

Evenings of April 3, 4, 5, 2013 @ Administration Building (lower level of Heritage)


Evenings of April 3, 4, 5, 2013 @ Sloan Elementary

PHASE 3

Preschool Visitation @ Franklin Regional

Preschoolers and Staff from local centers (Delmont, Export, Murrysville) will

visit Newlonsburg, Sloan and Heritage on May 6 and May 8, 2013

PHASE 5

Kindergarten Meet & Greet (Parents bring children for School/Class Tour, meet their assigned Teacher, Bus Experience)

Incoming preschoolers to Newlonsburg Elementary

Wednesday, August 14, 2013 @ Newlonsburg (Time: TBA)


Wednesday, August 14, 2013 @ Sloan Elementary (Times: TBA)

Incoming preschoolers to Heritage Elementary:

Wednesday, August 14, 2013 @ Heritage Elementary (Times: TBA)

PHASE 6

Staggered Start (sign up @ Meet & Greet) (Small Groups of Parents/Students attend an abbreviated day/Curriculum, School Routines)

One of the First Three Academic Days of 2013-2014

Tentatively: August 26, 27 or 28 of 2013

~ All students at their home building with their homeroom teacher ~

Abbreviated Day: 10:30 a.m. to 12:15 p.m.

PHASE 4

Kindergarten Screen (by appointment) (Parents bring children for Brigance and Vision Screenings)

Incoming preschoolers to Newlonsburg Elementary

May 31, 2013 or June 3, 2013


June 3, 4, 5, 2013 @ Sloan Elementary

Incoming preschoolers to Heritage Elementary:

May 31, June 3 & 4 @ Heritage Elementary

(Letters will be mailed to homes in the summer with

Teacher Assignments for each building as well as Meet & Greet details)

RESIDENCY QUALIFICATION In order for your child to attend school in the Franklin Regional School

District, you must reside in the Franklin Regional School District or be in the

process of building or buying a home within the boundaries of the District.

NON-RESIDENT/PRE-RESIDENT STATUS

Families not yet living in the District but who are in the process of building or buying a home in the district and would like to register their children to

begin school are required to pay tuition until their residency is established.

1. You must write a letter to the Superintendent attaching a copy of lease agreement or builder’s agreement to the letter.

2. The Business Office will then send you a letter stating the

amount of tuition due and the date it is due.

3. A copy of the District Policy #8304 is available on the

website.

MULTIPLE OCCUPANCY

If you are sharing a residence with another family within the Franklin Regional School District you must file a NOTARIZED Certificate of Multiple

Occupancy. Forms are available from Sandy Stonebrook at the Franklin Regional Administration Building or on the website.

To: Prospective Kindergarten Parent(s) and/or Guardian(s) From: The Franklin Regional Team

Re: Kindergarten Registration Forms

Date: School Year 2013-2014

PLEASE BRING THE COMPLETED FORMS AND REQUIRED

INFORMATION WITH YOU - ALL FORMS MUST BE COMPLETED IN FULL AND PRESENTED AT REGISTRATION.

District Forms – Included in Packet

Student Entry Information Form – Please complete and sign

Student Custody Form – (Complete only if applicable)

Special Services Form – Please complete and sign

Home Language Survey – Please complete this form in its entirety

Internet Use Agreement – You may sign for your child

Census Enumeration – Please complete this form in its entirety

Authorization for Verification of Address

Forms Parent(s) are to provide:

Your child’s ORIGINAL birth certificate or Passport

Proof of residency in the Franklin Regional School District (see below) - At least two of the following (must show CORRECT address)

Current tax receipt

Utility bill

Sales/Lease agreement

Closing settlement statement

Valid PA Driver’s license with Franklin Regional address

Most current well-visit report from the pediatrician

Immunization Record/Print Out from Pediatrician

Additional Forms (only as needed – available at Administration office or online)

Certification of Multiple Occupancy – Only if residing with another family within the Franklin Regional School District.

NOTE: We will not be able to register your child if any of this information is missing. Thank you.

Full /Half Day FRANKLIN REGIONAL SCHOOL DISTRICT Resident_________

Student ID_________ OFFICE OF CHILD ACCOUNTING Non- Resident_____

STUDENT ENTRY INFORMATION PLEASE PRINT OR TYPE ALL INFORMATION

STUDENT INFORMATION

Race Code: Please chose a code and enter above: A = Asia/Pacific Islander B = African American EI = Indian I = American Indian W = White O = Other Ethnicity: Please chose a code and enter above: H = Hispanic or Latino O = Not Hispanic or Latino

HOME ADDRESS______________________________________________________________________________ ( ) __________________ Street # Street Name City State Zip Area Code Phone # CITY OF BIRTH_________________________STATE OF BIRTH ____________________COUNTRY OF BIRTH ________________________ PREVIOUS PRESCHOOL/SCHOOL’S NAME_______________________________________________________________________________ PREVIOUS SCHOOLS ADDRESS___________________________________PHONE ( ) ________ FAX ( )_______________

Student lives with: (circle one) Both Parents Father Mother Other _________________

Parent(s)/Guardian that the student lives with:

LAST NAME_______________________ FIRST NAME____________________ (Father) LAST NAME_______________________ FIRST NAME____________________ (Mother) LAST NAME _______________________ FIRST NAME ____________________ (OTHER) (EXP: STEP FATHER, GUARDIAN ETC)

ADDRESS__________________________________________________________________________________________________ HOME PHONE ( ) ________________ WORK PHONE ( ) ________________(Father) CELL PHONE ( ) _______________(Father) WORK PHONE ( ) _______________(Mother) CELL PHONE ( ) _______________ (Mother)

EMAIL ADDRESS____________________________(Father) EMAIL ADDRESS________________________________________(Mother) If Student does not live with both parents, yet both parents are to receive mailings, please list additional mailing information below:

LAST NAME_________________________________ FIRST NAME_______________________ Relationship___________________ ADDRESS__________________________________________________________________________________________________ HOME PHONE ( ) __________________ WORK PHONE ( ) ____________________ CELL PHONE ( ) __________________ EMAIL ADDRESS______________________________________________

PARENT/GUARDIAN SIGNATURE___________________________DATE______________________________ CHILD ACCOUNTING USE ONLY:

PRIOR ATTENDANCE: Last year attended ________ SME # ___________ LUNCH/PIN # _____________ IMMUN. CERT. __________ BIRTH CERTIFICATE/PASSPORT PROOF OF RESIDENCY ___________ ___________ MULTIPLE OCCUPANCY _________________ IS THERE A CUSTODY ORDER? Yes________ No _______ IF YES, HAS A COPY OF THE ORDER BEEN PROVIDED? _____________ ENTRY DATE_______________ENTRY CODE__________ BUILDING ___________________________ GRADE_____________ AM BUS #____________PM BUS #______________ BUS STOP # _________ BUS STOP LOCATION ___________________

COPY SENT TO: SENIOR_____MIDDLE_____HERITAGE______NEWLONSBURG_______SLOAN_____ RECORDS REQUESTED______________RECORDS RECEIVED______________

LAST NAME

FIRST NAME

MIDDLE

GRADE

BIRTHDATE

SEX

RACE CODE

ETHNICITY

Student Custody Form Franklin Regional School District

3210 School Road Murrysville, PA 15668 Main: 724-327-5456 Fax: 724-327-6149

(This form must be completed if the student(s) parents reside at different residences)

Name of Enrolling Parent/Guardian___________________________________________ (Please print) Address _________________________________________________________________ (Please print) City ________________________State _________________ Zip ___________________ (Please print)

List full name(s) of child(ren) affected by this Student Custody Form. . Last name ____________________First name __________________School________________ Last name ____________________ First name _________________ School________________ Last name ____________________ First name _________________ School________________ Please check one: _____ I have full custody of the child(ren) listed on this form as described in the most recent Court Order of custody (attach Court Order). _____I have joint custody of the child(ren) listed on this form as described in the most recent Court Order of custody (attach Court Order) _____Parents do not have a legal custody agreement. Parent Signature _________________________________Date___________________


3210 School Road

Murrysville, Pennsylvania 15668

SPECIAL SERVICES – REGISTRATION FORM

My child has an I.E.P. or a 504 Service Agreement on file at the previous school

attended.

If your child currently has an IEP, please check area/areas of exceptionality.

Autistic Support

Learning Disability

Gifted

Vision

Physical Disability

Mental Retardation

Speech/Language

Hearing

Physical Therapy

Occupational Therapy

Special Transportation Needs (related to disability)

Emotionally Disturbed

Neurological Impairment

Other Health Impairment

Other (Please specify) _________________

Multidisciplinary Evaluation in Progress (MDE)

My child does not need any special education services.

_____________________________

Parent Signature

_____________________________

Date

*HOME LANGUAGE SURVEY*

The Office of Civil Rights (OCR) requires that school districts/charter schools/full day

AVTS identify limited English proficient (LEP) students in order to provide appropriate

language instructional programs for them. Pennsylvania has selected the Home

Language Survey as the method for the identification.

School District: ________________________ Date:___________________

School: _______________________________

Student’s Name: ________________________ Grade: _________________

1. What is/was the student’s first language? __________________________

2. Does the student speak a language(s) other than English?

(Do not include languages learned in school.)

Yes No

If yes, specify the language(s): ___________________________________________

3. What language(s) is/are spoken in your home? ______________________

4. Has the student attended any United States school in any 3 years during

his/her lifetime?

Yes No

If yes, complete the following:

Name of School State Dates Attended

______________________ _____________ __________________

______________________ _____________ __________________

______________________ _____________ __________________

Person completing this form (if other than parent/guardian):____________________

Parent/Guardian Signature: _______________________________________________


Policy 7008 Internet and Computer Usage

The Franklin Regional School district makes every effort to provide a secure and productive computing environment. It supports confidentiality of information through the Family

Educational Rights and Privacy Act (FERPA) and Internet Content Filtering guidelines through

the Child Internet Protection Act (CIPA). In no way will the Franklin Regional School District assume responsibility for its students and staff for computer misconduct resulting from inappropriate use or redirection of bandwidth and unauthorized charges or fees. This Acceptable Use Policy will be reviewed annually with students and staff and revised as needed. 1. The Internet will be used to support the functions of the Franklin Regional School District,

its curriculum, the educational community, and projects between schools, communication and research for school district administrators, teachers and students. 2. The Internet and computer technology will not be used for illegal activity, transmitting offensive materials, hate mail, discriminatory remarks or obtaining, transmitting or otherwise communicating indecent, obscene or pornographic material. Sending harassing, abusive, intimidating, discriminatory or other offensive e-mails is strictly prohibited. 3. The Internet and computer network will not be used for sending or initiating chain-mail,

playing non-instructional games, downloading and storage of unauthorized multimedia files, and peer-to-peer file sharing systems such as KaZaa, Croakster, or similar systems. 4. The use of unauthorized chat, instant messaging systems, or discussion boards is strictly prohibited.

5. The Internet and computer technology will not be used for profit purposes, lobbying or advertising on behalf of any individual or employee of the Franklin Regional School District. 6. Use of the Franklin Regional School District’s computer technology or the Internet for

fraudulent or illegal copying, communication, taking or modification of material or any other activity in violation of the law is prohibited and will be referred to the proper authorities. 7. In no event shall the Franklin Regional School District be liable for any damage, whether direct, indirect, special or consequential, arising out of the use of the Internet, accuracy or correctness of databases or information contained therein or related directly or indirectly, to any failure or delay of access to the Internet.

8. The Franklin Regional School District may terminate the availability of the Internet and Network accessibility at its sole discretion. 9. From time to time, the Franklin Regional School District will make determination on whether specific uses of the Internet and Network are consistent with this policy and notify users of the same. 10. The Franklin Regional School District, in its discretion, reserves the right to log Internet use in terms of time and content and to monitor file server disk space utilization by users. It

also reserves the right to process grievances against individuals who use the Internet in a manner inconsistent with this policy. 11. The Franklin Regional School District reserves the right to remove a user account on the Internet and Network to prevent further unauthorized activity as specified in this document. 12. The Network shall not be used to disrupt the work of others; hardware or software shall not be destroyed, modified or abused in any way. 13. Network accounts are to be used only by the authorized owner of the account for the

authorized purpose. 14. Diligent effort must be made by the user to delete mail daily from personal mail directories to avoid unnecessary use of file server disk space. 15. Diligent effort must be made by the user to periodically delete obsolete files from the Network file server. 16. Users shall not intentionally seek information, obtain copies of or modify files, other data,

or passwords belonging to other users, or misrepresent other users in the Network. 17. Uploading, downloading, installation, or use of unauthorized games, programs, files or

other electronic media is prohibited. 18. The illegal use of copyrighted software is prohibited. 19. In order to maintain a high level of security on the Local Area Network, all Network users may need to update their passwords as needed. 20. The user shall be responsible for damages to the Franklin Regional School District’s

equipment, systems and software resulting from deliberate or willful acts. 21. The Internet, Network and e-mail are not guaranteed to be private. People who operate the systems do have access to all e-mail and files. Messages relating to, or in support of, illegal activities may be reported to the authorities. 22. Confidential information shall never be transmitted to unauthorized sources. This includes health records, academic records, financial information, social security numbers or passwords.

23. Failure to follow the procedures listed above by students of the Franklin Regional School District may result in suspension or loss of the right to access the Internet, to use the Franklin Regional School District’ s computer technology, and be subject to other disciplinary actions, including but not limited to, expulsion.

24. Violations of this policy and procedures by employees of the Franklin Regional School District may result in discipline, including but not limited to, dismissal. 25. All students in 7th grade and above who wish to use the Internet, Network, and computer

technology tools must sign an Internet Agreement form which will be kept on file. Parents or guardians must sign for all students who are under the age of 18. Such signed agreements will be stored in the student’s permanent file. 26. All staff must sign an Internet Agreement that will be kept on file.

27. Electronic e-mail messages will be stored by the District for the duration prescribed by law. This policy covers the use of all company-owned electronic communications systems: e-mail, Internet access, district Intranet, district-wide telephone systems and all licenses software programs, whether or not they are associated with any of the above mentioned systems. Applicable Laws and Regulations/Policy History Adopted: 2/28/05/Amended/Effective: 2/28/05

As a student user of the FRSD network, I hereby agree to comply with the terms and conditions listed above:

Student name (printed legibly) ________________________________

Student signature__________________________________________

Date__________________________

As a parent or legal guardian of the minor student signing above, I grant permission for my son/daughter to access networked

computer services such as email and the Internet. I understand that individuals and families may be held liable for violations. I understand that some materials on the Internet may be

objectionable, but I accept responsibility for guidance of Internet use, setting and conveying standards for my son/daughter to follow

when selecting, sharing or exploring information and media. Parent name (printed legibly)

______________________________________

Parent signature__________________________________Date__________ Address_______________________________________________________

Phone_______________School Building__________________Grade_______

CENSUS ENUMERATION

Borough of Delmont Borough of Export Municipality of Murrysville


ADDRESS:____________________________________________________________________ ZIP CODE ____________

RESIDENCE CODE: 1 - OWN HOME Best number to reach you in the case of emergency:

2 - RENT HOME #___________________________

21 YEARS OF AGE OR OVER

LAST FIRST SEX BIRTHDATE E-MAIL ADDRESS EMPLOYER NAME

CHILDREN - UNDER 21 YEARS OF AGE (Admin use only)

LAST FIRST SEX BIRTHDATE GRADE FR SCH STU ID#

FAMILY

RELATIONSHIP SCHOOL

1 - Head of House 1 - Public

2 – Son/ Daughter 2 - Non-Public

3 - Foster Child 3 - Not In School

4 - Other 4 - Other

INFORMATION PROVIDED BY: ___________________________________ DATE: ______________________________ ADMINISTRATION USE ONLY: DWELLING # _________________ HOUSEHOLD # _______________ ELEMENTARY # ____________________


OFFICE OF CHILD ACCOUNTING AND STUDENT REGISTRATION

3210 SCHOOL ROAD

MURRYSVILLE, PENNSYLVANIA 15668

AUTHORIZATION FOR VERIFICATION OF ADDRESS

RELEASE OF INFORMATION AGREEMENT

I, _____________________________________________________________________,

Parent or Guardian Printed Name

Do hereby give the Franklin Regional School District authorization to contact any or all of the

following to obtain verification of my address which is on file, or which I have used in completing

the registration forms with them. I further authorize the agency or employer contacted to release

the requested information which will verify my address upon receipt of a photocopy or

electronically transmitted copy of this form.

1. Internal Revenue Service

2. Employer

3. Welfare Agency or related Health Service Agencies

4. Bureau of Motor Vehicles

5. U.S. Postal Service

6. Credit Reporting Agencies

7. Landlord of previous address __________________________________

8. Landlord of current address ___________________________________

_________________ _____________________________________

Date Signature of registering parent/guardian

_____________________________________

House # Street Name

________________________ ______________________________________

Area Code & Telephone City State Zip Code

Franklin Regional School District Student Health Identification Form

NAME__________________________GRADE_____DOB_________SEX____

HOME PHONE_________________ALTERNATE PHONE____________________

MEDICAL HISTORY: PLEASE CHECK IF YOUR CHLD HAS NOW OR IN THE PAST

NOW PAST NOW PAST

Allergic reaction requiring emergency

treatment

Asthma—treated with medication

Diabetes Seizures/Epilepsy

Heart problems Bone or joint problems

Vision problems Hearing problems

Migraine headaches Stomach problems

Skin disease Bladder/Kidney problems

Respiratory problems Cancer

Blood

disorder/anemia

ADD/ADHD

Other Other

Serious Accidents Operations

Wheelchair Walker Glasses Hearing Aide Speech Difficulty

PLEASE LIST ANY OTHER MEDICAL PROBLEMS NOT MENTIONED ABOVE:

LIST ANY SERIOUS ILLNESS OR INJURIES:

____________________________________________________________________

LIST ANY MEDICAL PROCEDURES THAT MUST BE PERFORMED AT SCHOOL: ____________________________________________________________________

LIST ANY MEDICATIONS THAT MUST BE GIVEN AT SCHOOL (MEDICATIONS CANNOT

BE ADMINISTERED UNTIL THE PROPER FORMS HAVE BEEN COMPLETED FOR EACH MEDICATON):

____________________________________________________________________

Parent/Guardian

Signature____________________________________Date______________

Dear Parent:

The Pennsylvania Department of Health requires children to be COMPLETELY

immunized prior to school entry. Therefore, no child will be enrolled without verification of

immunization or a proper exemption. The attached certificate of immunization must be

completed and returned for your child to be registered.

MINIMUM REQUIRED IMMUNIZATIONS

~ Diptheria/Tetanus – minimum of 4 doses with one given on or after

the 4th birthday

~ Polio – minimum of 3 doses

~ Hepatitis B – 3 doses, properly spaced

~ Measles, Mumps, Rubella – separately or combined as MMR after the

1st birthday. A second measles dose & mumps (preferably MMR) one

month or more after the first

~ Varicella (chickenpox) – 2 doses or history of disease

Included in this registration packet are dental and physical forms which must

be completed and returned to your school nurse by November 30, 2013. Examinations by the

school’s physician and the school’s dentist will be scheduled for your child if these forms are

not returned by the due date.

We look forward to working with you and your child. Please, if you have any questions

at anytime throughout your child’s education process, feel free to contact your child’s school

nurse.

Sincerely,

Beth Frydrych, RN, CSN Health Services Coordinator Middle School 724-327-5456 X2013 Fax 724-733-0949

Sandra Pianetti, RN, CSN Sr. High 724-327-5456 X5011 Fax 724-327-6147 Kristi Crawford, RN, CSN Heritage 724-327-5456 X7118

Fax 724-327-8298 Sloan 724-327-5456 X3026 Fax 724-733-5487 Newlonsburg 724-327-5456 X4003

Fax 724-327-4903

WELCOME FROM YOUR SCHOOL NURSES

You and your child are beginning an exciting thirteen-year journey and we would like to extend to you a special welcome and supply you with some information about the services we provide.

SCREENINGS; Vision: every year, K through 12

Hearing: K-3, 7, 11 - any time a problem is suspected; we can recheck hearing with the audiometer

and inspect the ear for wax blockage. Growth: every year, K through 12 Dental: K, 3, 7 (your dentist or at school) Physical: K, 6, 11 (your physician or at school) Scoliosis: 6-7

MEDICATIONS: At the beginning of each year we will furnish a list of available medications and treatments (standing orders by the school physician) for you to review. You may approve which medications and treatments that you would like your child to receive when needed for minor ailments such as upset stomach and headache.

If your child needs long or short-term medication other than those available at school, they must be approved IN WRITING BY YOUR PHYSICIAN. We have forms which must be completed before any other medication can be given. Otherwise we are not permitted to administer them.

ILLNESS: A sore throat; vomiting/diarrhea during the night; or a skin rash are reasons for keeping your child at home,

since these are things which may be passed on to others. If your child has had a fever (>100°F.), they should be

kept at home until their symptoms are gone and their temperature is normal for 24 hours without medication. Keep in mind that following a high fever the temperature sometimes falls below normal. IMMUNIZATIONS:

A record of the immunizations your child has received is required to enter school. Please keep us informed with SPECIFIC DATES of any boosters given after registration and we’ll note your child’s record. You will get the complete history when your child graduates.

HEALTH SERVICES STAFF;

Certified School Nurses: Health Room Assistants: Beth Frydrych, RN, CSN Paulette Wilson, RN

Sandy Pianetti, RN, CSN Cindy Leyh, RN Kristi Crawford, RN, CSN Annette Smiach, CNRP Kristen Petrazzi, RN


GRADE K-12

PHYSICAL EXAM FORM

IMMUNIZATIONS

REQUIRED for attendance in ALL GRADES, students need the following:

4 doses DTaP (1 to be administered after 4th birthday) #1_________ #2 _________ #3___________ #4__________

3 doses of polio #1_________ #2 _________ #3___________

2 doses MMR #1_________ #2 _________

3 doses of HEPATITIS B #1_________ #2 _________ #3___________

2 doses of VARICELLA (chickenpox) #1_________ #2 _________ OR documentation of disease _____date

REQUIRED for attendance into 7th grade year:

1 dose of Tdap #1_________

1 dose of Meningococcal Conjugate vaccine (MCV) #1_________

Pennsylvania’s school immunization requirements can be found in 28 Pa CODE CH.23 (school immunizations)

PHYSICAL

PART 1

VITALS: B.P._____/_____, _____/_____ PULSE_____/_____ HEIGHT________ WEIGHT________

VISION: R_____ L_____ (Glasses, Contacts)

SYSTEMS; NORMAL COMMENTS IF ABNORMAL

ORTHO _____ _________________________________________________________________

NEURO _____ _________________________________________________________________

SCOLIOSIS _____ _________________________________________________________________

PART II

ENT/ SKIN _____ _________________________________________________________________

HEART _____ _________________________________________________________________

LUNGS _____ _________________________________________________________________

ABDOMEN _____ _________________________________________________________________

HERNIA _____ _________________________________________________________________

PHYSICIAN SIGNATURE___________________________________ DATE ______________

NAME ____________________

GRADE___________________

MALE/FEMALE

HEALTH HISTORY QUESTIONNAIRE

FAMILY HISTORY YES NO

1. Has any family member died of heart problems or sudden death before age 50? (excluding accidents) . . ____ ____

2. Does any close family member have: diabetes, migraines, asthma, heart trouble, elevated cholesterol? . . ____ ____

STUDENT HISTORY

3. Have you EVER been unable to participate in a particular sport or told you should not participate in

the future? Please explain below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ____

4. Have you EVER had any:. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . ____ ____

____Mono ____TB ____Diabetes ____Thyroid disorder

____Hepatitis ____Anemia or bleeding problem ____Stomach ulcer ____Hernia

____Asthma ____Headaches ____Eye injuries or temp. loss of vision

STUDENT HISTORY IN THE PAST YEAR - If answer is “YES” please circle reason

5. Have you been hospitalized or had surgery? . . . . . . . . . . . . . . . . . . . . . . . . . ____ ____

6. Have you had any chronic or recurring illness lasting more than 1 week? . . . . . . . . . . . . . ____ ____

7. Do you have any allergies: hay fever, hives, asthma, bee sting or medication? . . . . . . . . . . ____ ____

8. Are you currently taking any medication or any OTC meds or herbs? . . . . . . . . . . . . . . ____ ____

9. Have you passed out or felt dizzy during exercise? . . . . . . . . . . . . . . . . . . . . . . ____ ____

10. Have you had any heart trouble: murmur, racing, skipped beats, chest pain, or BP problems? . . . . . ____ ____

11. Have you had a concussion, skull fracture, loss of memory or consciousness, seizure or headaches? . . ____ ____

12. Have you injured (sprained, dislocated, fractured, etc. ... DURING THE PAST YEAR (please date)

Please specify left (L) or right (R) ____neck ____ back ___ chest ____shin/calf ____testicle ____spleen ____ ____

____hand ____elbow ___ hip ____ankle ____ovary ____clavicle

____wrist ____arm ____thigh ____foot ____kidney

____forearm ____ shoulder ____knee ____eye ____lung

13. Have you had ____Hearing loss ____Perforated eardrum ____Recurrent ear infections? . . . . . ____ ____

14. Do you have any skin problems: (recurrent rash, fungal infection, ringworm, athlete’s foot, boils)? ____ ____

15. Do you have any dentures, bridges, braces, tooth caps, dental implants or appliances? . . . . . ____ ____

16. Do you smoke, drink alcohol, take drugs? . . . . . . . . . . . . . . . . . . . . . . . . . ____ ____

17. GIRLS When was your first period? _____________. Any menstrual problems? . . . . . . . . . ____ ____

I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE INFORMATION HEREIN IS TRUE AND COMPLETE AND

GRANT PERMISSION FOR MEDICAL STAFF TO RELEASE ANY OF THE INFORMATION TO THOSE

INDIVIDUALS DEEMED NECESSARY.

(Signature of parent /Legal guardian)________________________ (Date) ___________

PHYSICAL EXAM CANNOT BE DONE BY SCHOOL PHYSICIAN WITHOUT COMPLETION

OF THIS FORM AND PARENT SIGNATURE!

PLEASE CIRCLE AND FILL IN DETAILS OF ANY “YES” ANSWER IN

SPACE AT BOTTOM OF PAGE

IF YOU ANSWERED “YES” TO ANY OF THE ABOVE QUESTIONS PLEASE EXPLAIN

Forms & Information for the Clearances mentioned

above may be located at:

www.franklinregional.k12.pa.us/sites/h

umanresources

(Hard copies may be obtained at any school office or the Administrative Offices)

VOLUNTEERS are always WELCOME! FRSD Policy 7407

As part of our continuous effort to maintain a safe, secure environment for all of our students,

the Franklin Regional School District has clearly defined the levels of volunteer service within

our schools and refined its policy on clearances required for those who wish to serve our

students more frequently.

GUEST: A visitor or volunteer who makes a rare appearance in the school one (1) or two

(2)times per year and who will work under the direct supervision/direction of a teacher or

administrator employed by the Franklin Regional School District.

NO CLEARANCES REQUIRED.

LEVEL 1 VOLUNTEER:

A volunteer who intends to be involved in the school setting three (3) or more times per year

and who will assist and work directly under the supervision and direction of a teacher or

administrator employed by the Franklin Regional School District. Level 1 volunteers do not

provide direct services to students or have unsupervised contact with students.

Examples: Homeroom parent/guardian, clerical aides, involvement with performances/ushers,

volunteers who assist with functions related to an athletic event or extra-curricular activity

CLEARANCES REQUIRED:

Criminal History from the Pennsylvania State Police (Act 34 ~ $10.00)

Child Abuse Clearance from the Pennsylvania Dept of Child Welfare (Act 151 ~ $10.00)

LEVEL 2 VOLUNTEER:

A volunteer who intends to be involved in the school setting three (3) or more times per year

and works under the supervision and direction of a teacher or administrator employed by the

Franklin Regional School District. Level 2 volunteers may have reasonable expectations to

have unsupervised contact with students.

Examples: Volunteer tutors, volunteer coaches, trip chaperones or those who may provide

health-related services or counseling to students

CLEARANCES REQUIRED:

Criminal History from the Pennsylvania State Police (Act 34 ~ $10.00)

Child Abuse Clearance from the Pennsylvania Dept of Child Welfare (Act 151 ~ $10.00)

Federal Criminal History from the Federal Bureau of Investigation (Act 114 ~ $28.75)

Date ___________________

FULL DAY HALF DAY (Please circle one)

2013-2014 KINDGERGARTEN PARENT CHECKLIST

Student’s Name____________________________________Phone ____________________

Registration Form

Original Birth Certificate (raised seal) or Passport

Proof of Residency – (2 Required)

Utility Bill

Tax Receipt

Rental/Lease Agreement

Closing Settlement

Sales Agreement that indicates completion date of home

Driver’s License

Custody Order – (If applicable a copy must be made)

Special Needs Form

IEP/GIEP

ER/Psychological Evaluation

Home Language Survey

Internet Use Agreement

Census Form (must include everyone living in house)

Authorization for Verification of Address

Student Health Needs Identification Form

Immunization Card – Current Record/Print out from Pediatrician

Physical Exam Form (if completed)

Dental Card (if completed) (Administrative Use)

Building Assignment (circle) Newlonsburg Sloan Heritage Intake (initial) _____________________

Documents

REGISTRATION PACKET Grade K