West Plains Elementary School

PARENT CONSENT TO RELEASE OR OBTAIN RECORDS

Fax: 417-256-2358

Date______________

STUDENT’S LEGAL NAME

Last____________________ First____________________ Middle________________ Nickname_________________

Date of Birth: ____ /____ /____ Grade _______

Previous School’s Name/City, St. ____________________________________________________________________

My child has received special services (IEP/504) at his/her former school. Yes No

Please send the following information:

Transcript State Assessment Test Scores/NCLB requirement Withdrawal Grades Attendance Discipline Records Immunizations/Health Records Special Services Records/IEP/Psychological Records MOSIS Number ________________________

_________________________________________________________________________________________________ Print Name Parent/Guardian Signature of Parent/Guardian Relationship to Student

_________________________________________________________________________________________________ Address City, State, Zip Phone

Please fax, email, or send student records to: West Plains Elementary 1136 Allen West Plains, MO 65775 Attn: Amy Smotherman Phone: 417-256-6158 Fax: 417-256-2358 Email: amy.smotherman@zizzers.org This consent may be modified or revoked by me at anytime upon written request to the party releasing the information, except to the extent that action has already been taken in reliance on

this authorization. I understand that this information may not be forwarded to another individual, agency or organization without my written consent. I understand that I have the right to

inspect, copy and challenge the information contained in the records received. I certify that I am the parent or legal guardian of the above named student and have the authority to sign this

release. I understand that failure to consent to such release of information may have an impact on the quality of services to be provided, but will not be grounds for termination of services by

West Plains R-VII School District.

WEST PLAINS STUDENT INFORMATION

Public Schools 2017-2018 PLEASE PRINT Form Version 101217

STUDENT’S LEGAL NAME Enrollment Date__________________

Last____________________ First____________________ Middle________________ Nickname_________________

Gender: Female Male Date of Birth: ____ /____ /____ Grade _______ Student Cell Phone______________

Who has legal custody?: Both Parents Father Mother Other _____________________________

Are there legal documents concerning custody, educational decision making, etc. associated with this student? Yes No

If yes, please provide a copy of the legal document to the school. Legal Documents Provided: Yes No NA

High School ONLY – What school district do you live?

Fairview Glenwood Howell Valley Junction Hill Richards West Plains

RACE/ETHINICITY/HOME LANGUAGE Please check all that apply:

Is the student Hispanic/Latino? Yes No American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

PREVIOUS EDUCATIONAL INFORMATION

Last Date in School ______________ Last School Attended ___________________________________________

Has student ever attended West Plains School District before Yes No If yes, what grade?________

Has student ever attended a Missouri school before? Yes No

Has this student been retained? ……………………………………………………………... Yes No

If yes, what grade?__________

Have you been enrolled in a gifted program? ……………………………………………… .. Yes No

Have you been enrolled in Special Education classes (includes Speech) or have a 504 Plan?..... Yes No

Behavior/Discipline

Is this student currently under suspension, or expulsion, from another school district?............. Yes No

If yes, please answer the following:

1. Reason for suspension/expulsion ___________________________________

2. Date of suspension/expulsion ______________________________________

3. Name of School_________________________________________________

4. School’s Address: City ______________________State______ Zip_________

Has this student ever at any time been involved with juvenile/law enforcement authorities?.... Yes No

If yes, please explain ______________________________________________________

High School ONLY - Have you been enrolled in the Missouri A+ program?.......................... Yes No

By my signature below, I certify the information I provided on and in connection with this form is true, accurate and complete.

Parent/Guardian Signature____________________________________________Date_________________

OFFICE USE ONLY

Did parents/guardians mark “yes” to any of the McKinney-Vento information on Household Form? Yes No If yes, please document when Dr. Ross was contacted: (date)_____________Initials_______ If “yes” was given on any of the questions above, please document who was notified and the date.:

Contacted _____________________about ____________________________ on (date)_____________Initials_____

Contacted _____________________about ____________________________ on (date)_____________Initials_____

Verified by counselor: Signature_______________________________________________ Date________________

WEST PLAINS R-7 SCHOOL MEDICATION FORM

Student Legal Name: Last____________________ First____________________ Nickname_________________

Gender: Female Male Date of Birth:____ /____ /____ Grade _______

Parent/Guardian_____________________________Home Phone________________Work Phone__________________

Emergency Contact_______________________________Home Phone________________Work Phone_____________ Additional Phone Numbers___________________________________________________________________________ Drug/Food Allergies (BE SPECIFIC) ___________________________________________________________________ Significant Health Problems__________________________________________________________________________ Medications Taken at Home__________________________________________________________________________ The West Plains R-7 School District has my permission to administer the following Over-the-Counter medications checked: _____ Acetaminophen for temperatures, general discomfort- (not to exceed one dose per day)- (80mg) Grades Pre-K-2 four tablets, (325mg) grades 5-8 one tablet, grades 9-12 two tablets _____ Antacid regular strength for upset stomach/heartburn (not to exceed one dose per day) _____ Chloroseptic spray for sore throat, Canker sores, minor irritations gums/mouth (3) Sprays for PK-8 (5) for 9-12 (may repeat every two hours) _____ Anbesol for toothache pain, cold sores (may repeat every two hours as needed) _____ Camphonpenique for insect bites/chapped lips (not to exceed twice daily) _____ Sting kill swabs for insect bites/bee stings _____ Calamine Lotion for irritated/itching skin (not to exceed twice daily) _____ Clean abrasions/wounds with soap and water/Hydrogen Peroxide- Apply Antibiotic Ointment _____ Benadryl 12.5 mg FOR ALLERGIC REACTIONS ONLY! _____ Cough Drop (one given per day) Parent/Guardian Signature___________________________________________ Date____________________ West Plains R-7 District has my permission to administer the following medication: Medication _________________________________________________ Amount to give __________________ Doctor Prescribing_________________________________________ Time to give_______________________ Reason taking medication____________________________________________________________________ Parent/Guardian Signature__________________________________________ Date_____________________ *For medications to be given you must follow the medication protocol outline in the Handbook and attached to this note, or they WILL NOT be given. * Leslie Murray, LPN Sara Edelen, RN Amy Green, RN Jennifer Tidwell, RN Kati McKee, LPN High School Middle School Elementary Elementary South Fork 256-6150 ext. 4317 256-6150 ext. 4209 256-6150 ext. 4115 256-6150 ext. 4115 256-2836

Student Legal Name: Last____________________ First____________________ Nickname_________________

School Medication Policy

Student’s medication should be given at home if at all possible. This decreases the chance of errors such as missed or forgotten doses. Medication will only be given during school hours by complying with these guidelines.

1. Medication consent form must be completed and signed. 2. Prescription medication must be in the original bottle for use. Medications given on a regular basis

(inhalers, Ritalin…etc.) must have the newest refill and send no more than a month’s supply at a time. Medication will only be given during school time if prescription states: at noon, every four hours or every six hours. Three times a day will not be given during school hours.

3. Over-the-counter medication (other than those listed on the Medication Consent Form) muse come in the original container and a medication consent form signed by parent or guardian turned into the school nurse.

4. All medications must be turned in at the School Nurse’s Office along with a dated note giving permission for the nurse to administer the medication. Medications are NOT to be sent on the bus. Incidents regarding the transportation of controlled substances on the bus will be referred to law enforcement officials.

5. Medication bottles will be sent home when medication course is completed or expired.

*Please send cough drops for your child to keep in the teacher’s classroom*

Questions concerning this policy may be directed to your School Nurse. For medications to be given you must follow protocol outlined herein and in the hand book.

Family Doctor: ____________________________________________________________________________ Insurance Provider: ________________________________________________________________________ Parent Signature: ______________________________________________Date: ______________________ Leslie Murray, LPN Sara Edelen, RN Amy Green, RN Jennifer Tidwell, RN Kati McKee, LPN High School Middle School Elementary Elementary South Fork 256-6150 ext. 4317 256-6150 ext. 4209 256-6150 ext. 4115 256-6150 ext. 4115 256-2836

Administrative Office

305 Valley View Drive West Plains, MO 65775

417-256-6155 417-256-8616 (fax)

Zizzer Pride A Tradition of Excellence

Dr. John Mulford, Superintendent

Dr. Julie Williams, Assistant Superintendent Dr. Luke Boyer, Assistant Superintendent Dr. Scott Smith, Assistant Superintendent Dr. Jack Randolph, Senior High Principal Mr. Kevin Hedden, Assistant. Senior High Principal Mr. Lenny Eagleman, Assistant Senior High Principal Mr. Ronnie Harper, Dean of Students Mr. Jim Laughary, Director, South Central Career Center Dr. Josh Cotter, Assistant Director, South Central Career Center Dr. Wesley Davis, Middle School Principal Mrs. Erica Walker, Assistant Middle School Principal Mr. Donnie Miller, Elementary Principal Mr. Matthew Orchard, Assistant Elementary Principal Dr. Seth Huddleston, South Fork Principal Mr. Greg Simpkins, Athletic Director Dr. Amy Ross, Special Services Coordinator Mrs. Lana Snodgras, Director, Communications and Community Relations

BOARD OF EDUCATION Mr. Jimmy E. Thompson, President Mrs. Cindy Tyree, Vice-President Mr. Sam Riggs, Member Mr. Lee Freeman, Member Mr. Brian Mitchell, Member Mrs. Christena Silvey-Coleman, Member Mrs. Courtney Beykirch, Member Ms. Linda Y. Collins, Secretary Dr. Luke Boyer, Treasurer

Student Language Survey Student’s Name: ___________________________________________________ Person Completing Survey: ________________________________________________ Does anyone in your home speak a language other than English? IF YES, CONTINUE

IF NO, (STOP)

If yes, please circle the best answer to the following questions:

1. Was the first language the student learned English? Yes No 2. Can the student speak a language other than English? Yes No

If yes, what language? __________________________________ 3. Is any language other than English used at home? Yes No 4. Which language does the student most often when you speak to friends?

English Other (specify) _____________________________________________ 5. Which language does the student use when speaking to parents?

English Other (specify) _____________________________________________ 6. Has the student attended school in a country other than the U.S.? Yes No

If so, how long and what grades? _________________________________________________ 7. Has the student attended another school in the U.S.? Yes No

If so, where and how long? _____________________________________________________ 8. Has the student attended another school in Missouri? Yes No 9. Please provide any other related information that would help the school (for example, referral to Gifted or Special

Education programs in prior schools, etc.): ___________________________________________________________________________

*If the student’s survey indicated that another language is spoken, then it may be necessary to give fluency tests to see if she/he is limited in their English proficiency and in need of services to improve their proficiency in English. Student’s Date of Birth: ________________________ Grade: ___________________________ Parent’s Name: ____________________________________________________________________ Address: ___________________________________________________________________________ Home Telephone: ____________________________________ Cell Phone: __________________________ Parent’s Place of Employment: _____________________________________________________________ Parent’s Signature: _______________________________________________________________________ Note to school staff: This form should be given to all new and enrolling students. Any student that indicates use of a language other than English should be assessed as to English language proficiency.

Web: www.zizzers.org

West Plains

1136 Allen Street, West Plains, Missouri 65775 Mr. Donnie Miller, Principal

Elementary School

Ph. (417) 256-6158 Fax (417) 256-2358

Mr. . Mathew Orchard, Assistant Principal

West Plains Elementary

Permission Form

Date: ____________

I give permission for my child or ward, _________________________, to attend field trips, assemblies or any supervised activity sponsored by West Plains R-VII Schools for the 2017-2018 school year. ______________________________ Parent/Guardian Signature

Educating, Engaging, & Empowering Students

WEST PLAINS ELEMENTARY THERAPY DOG

Our school is home to a professional therapy dog, Lucy, who works in our building daily. Lucy visits the

classrooms with the school counselor and provides emotional support to students. If your child has an

allergy to dogs, plans will be made to keep the dog out of your child’s classroom.

Please feel free to contact Michelle Miller, school counselor, at 417-256-6158 with any questions you

may have about the role a therapy dog plays in the school setting. Please indicate below if your child has

an allergy to pet hair.

My child is not allergic to dog dander and may have contact with the West Plains Elementary therapy

dog.

My child is allergic to dog dander and should not be in the presence of the West Plains Elementary

therapy dog.

_____________________________________

Student name

Student’s teacher

_____________________________________________________________________________________

Parent or Guardian Signature Date

West Plains

1136 Allen Street, West Plains, Missouri 65775

Mr. Donnie Miller, Principal

Elementary School

Ph. (417) 256-6158 Fax (417) 256-2358