SALEM  PUBLIC  SCHOOLS  SCHOOL  HEALTH  SERVICES  

MEDICAL  INFORMATION  SHEET    

Student’s  Name:______________________________________  Date  of  birth:_______________  

Parent/Guardian  Name:__________________________________________________________  

Address:  _____________________________________________________________________  

Phone:________________________________  Cell:  ____________________________________  

Parent/GuardianName:___________________________________________________________  

Address:  ______________________________________________________________________    

Phone:  __________________________________Cell:  __________________________________  

Pediatrician:  ______________________________________    MD  Phone:  ___________________  

Dentist:  ___________________________________________DMD  Phone:  _________________  

Prescribed  Medications:    ______________________________________________________  

Health  Insurance  Name:    _______________________________________________________  

Does  your  child  have  any  allergies?    _________YES      _______  NO    

If  yes,  please  specify:  

Foods:  _______________________________________  Insects/Bees:  ____________________  

Medicines:  __________________________     Animals:  ___________________________  

Seasonal/environmental  allergies:  ______________  Other:  ____________________________  

Allergy  medication  used:  _____________________________________________  

Describe  any  reaction;  include  date(s)  of  reaction(s):  

______________________________________________________________________________

______________________________________________________________________________  

What  treatment  was  given  to  your  child?  

______________________________________________________________________________  

 Has  your  child  ever  been  given  an  Epi-­‐Pen?  ________Does  your  child  have  an  Epi-­‐Pen?______  

Has  your  child  been  seen  by  an  allergist,  if  so  when:____________________________________  

Allergy  doctor:_______________________________________Phone:_____________________  

   

Does  your  child  have  any  health  conditions?          ________YES  ________  NO     asthma      

Nebulizer   ______  yes   ______  no  

Inhaler     ______  yes   ______  no    

________YES  ________  NO    headaches  

________YES  ________  NO    constipation  

________YES  ________  NO     heart  condition  

________YES  ________  NO     sickle  cell  

________YES  ________  NO    diabetes  

________YES  ________  NO    ADHD  

________YES  ________  NO     urinary  tract  infections  

________YES  ________  NO    bedwetting  

________YES  ________  NO     seizures      

________YES  ________  NO     food  intolerances  

________YES  ________  NO     short  attention  span  

________YES  ________  NO     temper  tantrums  

________YES  ________  NO    celiac  disease  

________YES  ________  NO    hearing  difficulty    hearing  aid?   ______yes     ____no  

________YES  ________  NO     difficulty  seeing     wear  glasses?      ______  yes   ____  no  

________  YES  ________  NO     speech  problems  

 Has  your  child  ever  been  hospitalized  or  had  surgery?     ______yes   ______  no  If  yes,  please  explain_____________________________________________________________    ____________________________________________________________________________________________________________________________________________________________            Is  there  anything  else  you  think  we  should  know  about  your  child?        

 

Salem Public Schools City of Salem Parent Information Center

__________________________________________________________________________________ 29 Highland Avenue, Salem, Massachusetts 01970 (978) 740-1225 Fax (978)740-1176

Registration Document Checklist

In order to properly register your child for school, you must provide the Parent Information Center with the following documents:

Required Forms Assignment Application Form (please complete & sign)

Home Language Survey Household Information Survey, and Acknowledgement Form

Birth Certificate (one of the following documents) § Child’s birth certificate (original or certified copy) ��� § Passport ��� § I-94 Card ��� § Resident Alien Card

Immunization Records (Please provide your child's most recent physical examination and immunizations. If your child has an appointment during the summer, send a copy of the updated information to PIC attention Paula Dobrow, RN. By law, children cannot be admitted to school until the documentation has been received). Medical Information Sheet & Emergency form Proof of Parent/Guardian’s Identity – provide one of the following:

§ Massachusetts Driver’s License, § Massachusetts Photo ID § Passport

Proof of Address in Salem (two of the following documents) § Lease or mortgage statement in parent’s/guardian’s name, current electric, gas, cable, water, or

telephone bills in parent’s/guardian’s name § If you do not have any utilities under your name and you reside with a family member or

friend: please provide a notarized letter from the person you live with and two proofs of address under that person’s name.

Special Education Individualized Educational Plan (IEP), if applicable 504 Plan, if applicable

Proof of address Residency fraud is a violation of Massachusetts state law and is subject to per diem fines for every day that a student attends school outside the district in which s/he legally resides.

Legal guardianship Legal guardianship requires additional documentation from a court or agency. Homeless families The McKinney-Vento Act requires schools to enroll homeless children and youth immediately, in the absence of the normally required documents, please talk to a PIC staff member.

Escuelas Públicas de Salem Ciudad de Salem Centro de Información para Padres

__________________________________________________________________________________ 29 Highland Avenue, Salem, Massachusetts 01970 (978) 740-1225 Fax (978)740-1176

Lista de Verificación para Inscripción

Para matricular a su niño/a en la escuela, debe proveer al Centro de Información para Padres los siguientes documentos:

Documentos Requeridos Aplicación de Asignación (completada y firmada) Encuesta del Idioma Hablado en el Hogar Encuesta de Información Familiar y Forma de Reconocimiento

Acta de Nacimiento (uno de los siguientes documentos) § Certificado de nacimiento (original o copia certificada) § Pasaporte § Tarjeta I-94 § Tarjeta de residencia

Vacunas (incluya el examen físico y las vacunas más recientes de su hijo. Si su hijo tiene una cita durante el verano, envíe una copia de la información actualizada a Paula Dobrow, RN. Por ley, los niños no pueden ser admitidos a la escuela hasta que la documentación haya sido recibida).

Hoja de Información Médica & Formulario de Emergencia Prueba de Identidad del Padre/Tutor (uno de los siguientes documentos)

§ Licencia de conducir de Massachusetts § Identificación con foto de Massachusetts § Pasaporte

Prueba de Dirección en la Ciudad de Salem (dos de los siguientes documentos) § Arrendamiento o estado de hipoteca en nombre de los padres/tutor, factura de electricidad, gas, cable,

agua, o teléfono a nombre de los padres/tutor § Si usted no tiene ninguna prueba de dirección bajo su nombre y vive con un familiar o

amigo/a: Necesitamos una carta de la persona con quien vive, certificada por un notario, acompañada de dos pruebas de dirección con el nombre de esa persona.

Plan Educacional Individualizado (PEI), si aplica

Plan 504, si aplica

Comprobante de domicilio El fraude de residencia es una violación a las leyes estatales de Massachusetts y está sujeto a multas diarias por cada día que un estudiante asista a una escuela fuera del distrito en el cual él/ella reside legalmente. La tutela legal La custodia legal requiere documentación adicional de un tribunal o agencia. Familias sin hogar La Ley McKinney-Vento ordena que las escuelas matriculen a niños y jóvenes sin hogar de inmediato, aún si no posee los documentos normalmente requeridos, por favor hable con un miembro del personal del Centro de Información para Padres.

Salem Public Schools School Health Services

Dear Parent / Guardian,

Massachusetts State Law, Chapter 76, s. 15 requires that all children receive these immunizations before the first day of Kindergarten. Your child’s health records for Kindergarten entry must contain:

_____ Physical Examination (must be within 6 months of entering school)

All immunizations

_____ DTP #1 #2 #3 #4 #5

_____ Polio #1 #2 #3 #4

_____ MMR #1 #2

_____ Hepatitis B #1 #2 #3

_____ Varicella #1 #2

_____ or physician’s documentation of having had chicken pox disease

_____ Lead Test

____ Health Questionnaire

______Vision Screening including stereopsis screening

Please contact your health care provider to schedule the required physical and/or immunization visit(s). Vaccines are available, free of charge, at the Lydia Pinkham Clinic, 250 Derby Street, Salem, MA on Tuesday and Thursday afternoons from 1 PM until 4 PM.

All health forms must be reviewed by the school nurse before the start of Kindergarten. Children will not be allowed to be in school until the documentation has been received. If you have any questions, please contact your school nurse.

Please submit any health information completed during the summer to the Parent Information Center at Collins Middle School, 29 Highland Ave, attention Paula Dobrow, RN.

Thank you for your prompt attention. Paula J. Dobrow, RN, MSN Director of Nursing and Health Services 978-825-5500

Salem Public Schools - Assignment Application Date of Application:__________________ School Year: 2015-2016 Date of Enrollment: September 2015

Student Information

Child’s Full Name: ________________________________________________________________ Grade Entering: Kindergarten First Full Middle Last

Address: _________________________________________________________________ Age_________ Male Female Place of Birth:______________________________________________________________Date of Birth: _____________________ City Country

If born in another country, date of arrival in USA: ________________________Is your child repeating Kindergarten? No Yes

Name of last school /daycare of attendance:____________________City/State: ________________Last day attended: ____________

Parent/Guardian Information

I am the child’s Parent Legal Guardian E-mail: _________________________ Home Phone: _______________________

Mother’s Name: ____________________________________ child lives with Yes No Mobile Phone: ______________________

Father’s Name: _____________________________________ child lives with Yes No Mobile Phone: ______________________

Mother’s Work #:________________________________________ Father’s Work #: __________________________________

Guardian’s Name: _____________________________________________ Relationship: _________________________________

Parent’s address, if different from student’s:_____________________________________ Home Phone: ______________________

Contact’s Name: ____________________________________ child lives with Yes No Phone #: __________________________ (if parents are not available)

Ethnic/Racial Group: Primary Home Language

Hispanic or Latino: Yes No AND check all that apply: English Spanish Vietnamese

Asian American Indian or Alaskan Native Russian Portuguese Albanian

Black White Other________________

Hawaiian/Pacific Islander In which language would you prefer your school notification sent? ______________________

Is student receiving special services? Yes No If Yes IEP 504 Plan

Is student receiving the following services? Title 1 LEP (English Lang. Learner)

Medical Concerns/Daily Medications Yes No _________________________________________________________________________ (If not in violation of confidentiality)

Special Circumstances: Homeless Other: _________________________________________________________________________ Siblings: Name Date of Birth School Attending Grade ________________________________ ______________________________ _______________________ ________________ ________________________________ ______________________________ _______________________ ________________ ________________________________ ______________________________ _______________________ ________________

My Household qualifies for Free/Reduced Meals Yes No Staff Initials ________

Opt IN to the Bentley Academy Charter school lottery Yes No

Parent’s School Choices 1.___________________________ 2.___________________________ 3.__________________________

Would you like information about the Parent-Child Home Program for 2 and 3 year olds? Yes No Parent’s signature:_________________________________________________ Date: ______________________________________________ Office Use Only

School Assignment: Prog.: Reg. ____ ESL___ Dual ___ NCP___ SEI ____SPED_________

Sibling Preference: Yes ___ No ___ If YES school: SASID # :

Sibling Attending SPS: Yes ___ No ___ If YES school: School Closest to Home:

Language Eval: Yes ___ No ___ If YES level: Free Transportation: Yes ___ No ___ Proximity:_______________

Waiting List: Yes ___ No ___ If YES which school: Free/Reduced meals: Yes ___ No ___

Salem Public Schools City of Salem Parent Information Center

_______________________________________________________________________________________ 29 Highland Avenue, Salem, Massachusetts 01970 (978) 740-1225 Fax (978)740-1176

HOUSEHOLD INFORMATION SURVEY

Please complete, sign and return this application to the address above.

INSTRUCTIONS: Complete this survey and return to your child’s school or mail to the address listed above. These se lec t ions must be comple ted by the Head o f Househo ld or Des ignee

1. SIZE OF FAMILY - Indicate the total number of individuals living in your household, including all adults and children:_______ 2. STUDENT INFORMATION - Complete for each student Pre-K through 12th grade

Last Name

First Name

Birth Date MM-DD-YY

School

Identify H if Homeless M if Migrant R if Runaway F if Foster

1.

2.

3.

4.

5.

6.

7.

8.

If you need additional lines, attach a second sheet to this survey or attach a copy of this survey clearly marked as Page 2 3. TOTAL MONTHLY HOUSEHOLD INCOME – Report Income for all members of household excluding foster children. If you have reported a case number above, you

do not need to complete this section; proceed to section 4.

Type of Income Income Circle if No Income

1. Gross Monthly Earnings: Wages, Salary, Commissions $ None

2. Monthly Welfare Payments, Child Support, Alimony $ None

3. Monthly Payments from Pensions, Retirement, Social Security $ None

4. Monthly Dividends or Interest on Savings $ None

5. Monthly Worker’s Compensation, Unemployment, Strike Benefit $ None

6. Other Monthly Income (SSI, VA, Disability, Farm, other) $ None

Tota l Month ly Househo ld Income (Add lines 1-6) $

4. SIGNATURE I certify (promise) that all information on this application is true and that all income is reported. I understand the school will be eligible for certain federal and/or state funds based on the information I give. Sign Here: X________________________________________________ Print Name:______________________________________ Date____________________ Address City Zip Code

Home Phone Work Phone Email Address: By providing your email address, you may be contact via email by the district

For Of f i ce Use On ly : C i rc le One

QUALIF IES DOES NOT QUALIFY

PROCESSED BY:

IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES M A S N AP o r M A TA FD C be ne f i t s , PROVIDE THE AGENCY IDENTIFICATION NUMBER* LOCATED ON THE DEPARTMENT OF TRANSITIONAL ASSISTANCE (DTA) BENEFIT LETTER. Then proceed to Section 4. If no one receives these benefits, start with Section 1. Name:___________________________________________________ 10-Digit Case Number:________________________________

Home Language Survey Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.

Student Information F M First Name Middle Name Last Name Gender

/ / / / Country of Birth Date of Birth (mm/dd/yyyy) Date first enrolled in ANY U.S. school (mm/dd/yyyy)

School Information / /20 ______ Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade

Questions for Parents/Guardians What is the native language(s) of each parent/guardian? (circle one)

(mother / father / guardian)

(mother / father / guardian)

Which language(s) are spoken with your child? (include relatives -grandparents, uncles, aunts,etc. - and caregivers)

seldom / sometimes / often / always

seldom / sometimes / often / always What language did your child first understand and speak? Which language do you use most with your child?

Which other languages does your child know? (circle all that apply)

speak / read / write

speak / read / write

Which languages does your child use? (circle one)

seldom / sometimes / often / always

seldom / sometimes / often / always Will you require written information from school in your native language? Y N

Will you require an interpreter/translator at Parent-Teacher meetings? Y N

Parent/Guardian Signature:

X / /20 Today’s Date: (mm/dd/yyyy)

Salem Public Schools City of Salem

______________________________________________________________________________________________________________"29"Highland"Avenue,"Salem,"Massachusetts"01970" """"""""""""""""""""(978)"740?1225""""""""Fax"(978)740?1176"

Acknowledgement Eligibility for Free/Reduced Price Meals: How Information Will Be Used

Parent Name:____________________________ Student Name: _____________________________ I acknowledge and agree to release to the Salem Public Schools’ Parent Information Center and further acknowledge and agree that the Salem Public Schools’ free and reduced price meals officials may give to the Salem Public Schools’ Parent Information Center information concerning my child’s eligibility or non-eligibility for price meal benefits. I acknowledge and agree that the Salem Public Schools’ Parent Information Center may use this information to help determine the placement of my child. I understand that both the Salem Public Schools’ and I free and reduced price meals officials will be releasing eligibility information to the Salem Public Schools’ Parent Information Center from the Price Meal Benefit Form for my child. I give up my rights to confidentiality for this purpose only. I understand that I am not required to release this information and that my declining to sign this form will not affect my child’s eligibility and participation for price meal benefits or non-eligibility for price meal benefits. I understand that if I elect not to release this information, the Salem Public Schools’ Parent Information Center will consider my child non-eligible for free and reduced price meals only for purpose of determining school placement for my child.

! I am choosing to release my eligibility for free or reduced price meal benefits and am attaching a copy of our meals application. ! I am electing not to release this information and/or my family is not eligible for this benefit. I have read this release and understand its terms and sign it voluntarily.

___________________________________ Parent/Guardian Signature

___________________________________ Date Please Note: This voluntary disclosure is used in the registration process only. When your child begins school, you must submit your formal application for the federal free and reduced price lunch program and be determined to be eligible to receive free or reduced price meals.

"