Female Month Day Year (preschool-12) (optional)
Address: Phone:
The answer you give below will help the district determine what services you or your child may be able to
receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are
entitled to immediate enrollment in school even if they don’t have the documents normally needed, such
as proof of residency, school records, immunization records, or birth certificate. Students who are
protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please check one box.)
In a shelter
With another family or other person because of loss of housing or as a result of economic hardship
(sometimes referred to as “doubled-up”)
In a hotel/motel
Other temporary living situation (Please describe):
________________________________________________
In permanent housing
Print name of Parent, Guardian, or Signature of Parent, Guardian, or
Student (for unaccompanied homeless youth) Student (for unaccompanied homeless youth)
Date
FULTON CITY SCHOOL DISTRICT
Nombre de la Escuela: _____________________________________________________________________
Género: Hombre Fecha de Nacimiento: _____ / _____ / ______ Grado:______ ID#: _______
Mujer Mes Día Año (jardín de infantes – 12) (opciónal)
Dirección: _______________________________________________ Teléfono: _____________________
Su respuesta abajo permitirá al distrito escolar definir los servicios que puede aprovechar su
hijo/hija según el Acto de McKinney-Vento. Los estudiantes elegibles tienen derecho a la
inscripción inmediata en la escuela, aun si ellos no tienen los documentos necesarios tales como:
prueba de residencia, documentos escolares, documentos de inmunización, o partida de
nacimiento. Los estudiantes elegibles según el Acto de McKinney-Vento tienen además derecho
al transporte gratuito y otros servicios que ofrece el distrito escolar.
¿Donde está el estudiante viviendo actualmente? (Por favor marque una caja.)
En un refugio
Con otra familia o otra persona debido a la pérdida del hogar o a dificultades económicas
En un hotel/motel
Otra vivienda temporal (Por favor describa):
__________________________________________________________________________
Nombre de Padre, Guardián, o Firma de Padre, Guardián, o
Estudiante (para jóvenes sin acompañamiento) Estudiante (para jóvenes sin acompañamiento)
____________________________
Fulton City School District
Forms Needed for Registration
Pertain to
Completed by
Student Registration Word Format All Students Parent/Guardian
Ethincity Questionnaire (optional) All Students Parent/Guardian
Home Language Questionnaire PDF Format All Students Parent/Guardian
Migrant Education Services (optional) All Students Parent/Guardian
Parent/Guardian Statement All Students Parent/Guardian
Kindergarten Students Only K students only Parent/Guardian
Physical Consent PDF Format All new students Parent/Guardian
Health Appraisal PDF Format All new students & Students K,2,4,7&10 Physician
Student Health History All Students Physician
Health Record Update PDF Format All Students Parent/Guardian
Dental Health Certificate (optional) PDF Format Students K,2,4,7&10 Parent & Dentist
Directory Information Disclosure (optional) All Students Parent/Guardian
Original Birth Certificate All Students
Up-to-date Immunization Records All Students Physician
Proof of Residency (see below for acceptable forms)
All Students
All Students
Reduced/Free Lunch All Students
IEP/504 Plan Special Education Students Parent - Complete Papers in Special Education Office
Custody Agreement and/or Court Papers Divorced/Separated Court/Parent/ Guardian
Acceptable Primary Forms of Proof of Residency:
Residential tax bill for residential property within the District, in the name of parent or guardian.
Signed purchase agreement for residential real property within the District.
Residential mortgage instrument, or deed, duly recorded in Oswego County Clerk’s Office in the name of parent or guardian, which describes real
property with a residential address within the District.
Lease agreement in the name of parent or guardian for real property within the District with name, address and telephone number of landlord.
Rental receipt in the name of parent or guardian for real property within the District with name, address and telephone number of landlord.
Notarized letter from owner of the house stating the parent or guardian and student(s) are residing with them, including the address of the
property.
DSS Form 2999 School District Notification of Foster Child Placed in a Foster Family, Agency Boarding or Group Home.
Utility bill for service at the residential address within the District being billed in the name of parent or guardian.
Bank statement in the name of parent or guardian addressed to the residential address within the District.
Social Services correspondence or statement in the name of parent or guardian, addressed to a residential address within the District.
US Postal Service verification of change of address to a residential address within the District, in the name of parent or guardian.
Federal or NYS income tax documentation with preprinted name and address in the name of parent or guardian addressed to residential address
within the District, such a W2 form, preprinted label from government, or income tax return check with preprinted address.
A policy or binder of homeowner’s or residential renter’s insurance for residential real property within the District addressed and/or issued in the
name of parent or guardian.
Other proof acceptable to a District administrator that would demonstrate that the child actually resides (defined as the primary place where the
child predominately sleeps, has a physical presence as an inhabitant, changes clothes, and has a base of operations for their care, custody and
living arrangements in the school district).
Fulton City School District
Starting Date Home Language Proof of Immunization Questionnaire Residency Records
Residency Form Birth Certificate Physical Exam IEP/504 Plan Dental Exam
Records Release/Discipline Rcv’d Custody Papers Reduced/Free Lunch Form Date Called previous school / Entered into ST / /
Counselor Notes:
DO NOT WRITE ABOVE THIS LINE – OFFICE USE ONLY
Student’s Last First Middle Student Name Sex M F Grade
Date of Birth Place of Birth
Street Address City
Home Address (if different) Home Phone (if different) Cell Phone
Email
Home Address (if different) Home Phone (if different) Cell Phone
Email
Student’s Parents are Married Separated Divorced Never Married
Student is currently living with Father Mother Step-Father Step-Mother Grandfather Grandmother Foster Parent Legal Guardian Other Specify
Are there custody papers or order of protection? Yes No If yes, copy required
Note: Under Fulton City School District Policy unless court papers are on file with the district, both parents have equal access to their child(ren) and school records.
Does your child have frequent absences? Yes No If yes, please explain
Is your child receiving Academic Intervention Services? Yes No If yes, please check services ELA Math Science Social Studies Other Specify
Does your child currently have a Section 504 Accommodation Plan? Yes No
Does your child have an Individual Education Plan (IEP)? Yes No If yes, please check services Consultant Teacher Resource Room Speech Therapy Occupational Therapy Physical Therapy Special Class BOCES Medical Other Specify
If parent is not available, in case of illness or emergency, call Name Phone
Address
Relationship to child
Please list brothers and sisters Name School Grade Date of Birth Sex M/F
If this student is transferring from another school *including: Preschool/Nursery School/previous UPK*, please complete the following information
School Name
School Address
Phone Number Fax Number
Has student attended Fulton City School District in the past? Yes No If yes, when
Is student an United State citizen? Yes No If no, please give date of immigration to the US
I certify that the above information is accurate to the best of my knowledge and that I have legal custody of the above-named child. Signature of parent/guardian Date
Ethnicity Questionnaire
By completing this part of the packet, you will help us to receive any additional
State Aid that will be made available to our district based on these factors.
Please answer both questions 1 and 2. Please read them before you respond.
1. Is the student Hispanic, Latino or of Spanish origin? Hispanic, Latino or of Spanish origin means a
person of Cuban, Mexican, Puerto Rican, Central of South America, or other Spanish culture or
origin, regardless of race. Please check the box that best describes your child.
Yes, Hispanic No, not Hispanic
2. Select one or more races from the following five racial groups. Check all the groups that apply to
your child. You must check at least one box.
American Indian or Alaska Native (A person having origins in any of the original peoples of North America and who maintains cultural
identification through tribal affiliation or community recognition.)
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian
subcontinent.)
Native Hawaiian or Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.)
Black (A person having origins in any of the black racial groups of Africa.)
White (A person having origins in any of the original peoples of Europe, North Africa or the Middle East.)
1 ENGLISH
Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.
STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12
Lissette Colón-Collins, Assistant Commissioner
55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB
Brooklyn, New York 11217 Albany, New York 12234
Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948
Home Language Questionnaire (HLQ)
H O M E L A N G U A G E C O D E
Language Background (Please check all that apply.)
1. What language(s) is(are) spoken in the student’s home or residence?
English Other
specify
2. What was the first language your child learned? English Other
_________________________________________ specify
3. What is the Home Language of each parent/guardian? Mother Father specify specify
Guardian(s) specify
specify
5. What language(s) does your child speak? English Other Does not speak
specify
6. What language(s) does your child read? English Other Does not read
specify
7. What language(s) does your child write? English Other Does not write
specify
TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::
Please write clearly when completing this section. S T U D E N T N A M E :
First Middle Last
D A T E O F B I R T H : G E N D E R :
Male Female Month Day Year
P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :
Last Name First Name Relation to Student
S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T
I N F O R M A T I O N S Y S T E M :
District Name (Number) & School Address
2 ENGLISH
Educational History
8. Indicate the total number of years that your child has been enrolled in school _____________
9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write in English or any other language? If yes, please describe them.
Yes* No Not sure *If yes, please explain:____________________________________________________________________________
How severe do you think these difficulties are? Minor Somewhat severe Very severe
10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below
10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .
Age at which services received (Please check all that apply):
Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)
10c. Does your child have an Individualized Education Program (IEP)? No Yes
11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)
12. In what language(s) would you like to receive information from the school? _________________________________________________
Month: Day: Year:
Signature of Parent or of Person in Parental Relation Date
OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ
NAME: POSITION:
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:
NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW
NAME: POSITION:
**DATE OF INDIVIDUAL INTERVIEW:
NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL
NAME: POSITION:
MO. DAY YR.
FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:
1
SPANISH
STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12
Lissette Colon-Collins, Assistant Commissioner Office of Bilingual Education and World Languages
55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB Brooklyn, New York 11217 Albany, New York 12234 Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948
Cuestionario de Idioma del Hogar (“HLQ” por sus siglas en inglés)
C Ó D I G O D E L I D I O M A D E L H O G A R
Conocimientos de idiomas (Por favor, marque todas las opciones que sean aplicables)
1. ¿Qué idioma(s) se habla(n) en el hogar o residencia del estudiante? Inglés Otro
especifique
2. ¿Cuál fue el primer idioma que su hijo(a) aprendió? Inglés Otro _________________________________________
especifique 3. ¿Cuál es el idioma primario de cada padre / tutor? Madre Padre
especifique especifique Tutor(es) especifique
4. ¿Qué idioma o idiomas entiende su hijo(a)? Inglés Otro especifique
5. ¿Qué idioma o idiomas habla su hijo(a)? Inglés Otro No sabe hablar especifique
6. ¿Qué idioma o idiomas lee su hijo(a)? Inglés Otro No sabe leer especifique
7. ¿Qué idioma o idiomas escribe su hijo(a)? Inglés Otro No sabe escribir especifique
TO BE COMPLETED BY THE DISTRICT IN WHICH THE STUDENT IS REGISTERED
PARA LLENAR POR EL DISTRITO EN EL QUE EL ESTUDIANTE SE HA INSCRITO
Por favor escriba con claridad al completar esta sección. N O M B R E D E L E S T U D I A N T E : Nombre Segundo nombre Apellido
F E C H A D E N A C I M I E N T O : G É N E R O : Masculino
Femenino Mes Día Año
I N F O R M A C I Ó N D E L O S P A D R E S / P E R S O N A E N R E L A C I Ó N P A R E N T A L
Apellido Primer Nombre Relación con el estudiante
S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T I N F O R M A T I O N S Y S T E M :
District Name (Number) & School Address
Estimados padres o tutores: Con el fin de proporcionar la mejor educación posible a su hijo(a), necesitamos determinar el nivel del habla, lectura, escritura y comprensión en el inglés, así como conocer su educación previa e historial personal. Por favor, llene con su información las secciones “Conocimientos de idiomas” e "Historial educativo". Apreciamos mucho su colaboración respondiendo a estas preguntas. Gracias.
2
SPANISH
Relación con el estudiante: Madre Padre Otra: _______________________________________________________________________________________________________________________________________________________
Historial Educativo
8. Indique con un número el total de años que su hijo(a) lleva inscrito en una escuela: _____________
9. ¿Cree usted que su hijo(a) pueda tener dificultades, interferencias o problemas educacionales que le afecten su capacidad para entender, hablar, leer o escribir en inglés o en cualquier otro idioma? En caso afirmativo, por favor descríbalos. Sí* No No se sabe * En caso afirmativo, por favor explique :_____________________________________________________________ ¿Qué gravedad considera usted que tienen estas dificultades educacionales? Poca gravedad Algo grave Muy grave
10a. ¿Alguna vez se ha recomendado a su hijo(a) a tener una evaluación de educación especial? No Sí* * Por favor, llene 10b. 10b. *Si se le ha recomendado alguna vez una evaluación, ¿ha recibido su hijo(a) alguna vez alguna forma de educación especial? No Sí – Explique, que forma o formas de educación especial recibió: ______________________________________________________________________________________________________________________ . Edad en la que recibió la intervención o forma de educación especial (favor de marcar todas las opciones que sean aplicables): De nacimiento a 3 años (Intervención Temprana) 3 a 5 años (Educación Especial) 6 años o mayor (Educación Especial) 10c. ¿Tiene su hijo(a) un Programa de Educación Individualizada (“IEP” por sus siglas en inglés)? No Sí 11. ¿Considera que hay alguna otra información importante que la escuela deba saber sobre su hijo(a)? (Por ejemplo, talentos especiales, problemas de salud, etc.) 12. ¿En qué idioma(s) quiere usted recibir la información de la escuela? _________________________________________________
Mes: Día: Año: Firma del padre/madre o de la persona en relación paternal Date
OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ NAME: POSITION:
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:
NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW NAME: POSITION:
ORAL INTERVIEW NECESSARY: NO YES
**DATE OF INDIVIDUAL INTERVIEW:
OUTCOME OF INDIVIDUAL INTERVIEW:
MO DAY YR.
DATE OF NYSITELL ADMINISTRATION:
MO. DAY YR.
FOR STUDENTS WITH DISABILITIES, LIST ACCOMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:
Oswego County BOCES 179 County Route 64 Migrant Education Outreach Program Mexico, NY 13114 Paul Gugel, Migrant Education Coordinator 315-963-4265 or 1-800-474-1632
Eligibility screen for Migrant Education services
*** Migrant Education Program services are free of charge and may include tutoring, assistance with health needs, educational field trips, summer programs, parent involvement activities, adult education, emergency
assistance and referrals to other services as needed. ***
Has your family moved to a different school district in the last 3 years? YES _______ NO _______ In the last 3 years has a parent or guardian (or an older child) worked in agricultural activities such as: dairy, planting, picking/harvesting fruits or vegetables, food processing or packaging, logging or tree farming? YES _________ NO ________
If you can answer YES to BOTH of the above questions, your family MAY qualify for Migrant Education services. To be contacted by a Migrant Education recruiter, please complete the information below.
Child’s name _______________________________ D.O.B. ____________Grade__________
Child’s name _______________________________ D.O.B. ____________Grade__________
Child’s name _______________________________ D.O.B. ____________Grade__________
Child’s name _______________________________ D.O.B. ____________Grade__________
Parents/ Guardians
Mother’s name __________________________ Father’s Name ___________________________ Home Address __________________________ Home Phone #____________________ (Street Address) _____________________________ Work or Message # _______________ (city, town or village) (Zip)
School District__________________________ School Building______________________________
School Contact Person_______________________________ Contact Number __________________
___________________________________________________________________________________ ___________________________________________________________________________________
To submit this referral please fax to the Oswego BOCES at (315) 963-4242 or mail to the address above. For more information please call the Migrant Program at 963-4265 or
1-800-474-1632. Thank you for your assistance.
Oswego County BOCES 179 County Route 64 Migrant Education Outreach Program Mexico, NY 13114 Paul Gugel, Migrant Education Coordinator 315-963-4265 or 1-800-474-1632
Cuestionario de Eligibilidad para Servicios de Educación Migrante
*** Servicios del Programa de Educación Migrante son gratuitos y pueden incluir tutoría, ayuda con necesidades de salud, viajes educacionales, programas del verano, actividades de involuncrar a los padres,
educación para adultos, ayuda de emergencia y referidos a otros servicios como necesario. ***
¿Ha mudado su familia a un districto escolar diferente en los ultimos 3 años? Sí ____ NO _______ ¿En los ultimos 3 años ha trabajado un padre o guardian en actividades agriculturales como: lecheria, plantando, cosechando frutas o legumbres, el procesamiento o empacar de comida, corta de arboles o cultivo de arboles? Sí_____ _ NO_______
Si Usted contestó que Sí a AMBOS pregunatas de arriba, su familia PUEDA calificar para servicios de Educación Migrante. Para estar contactado por una reclutadora del Programa de Educación Migrante, favor de llenar la infomación de abajo. Nombre del niño(a) __________________________ Fecha de Nacimiento___________Grado______
Nombre del niño(a) _________________________ Fecha de Nacimiento __________Grado______
Nombre del niño(a) _________________________ Fecha de Nacimiento __________Grado_______
Nombre del niño(a) _________________________ Fecha de Nacimiento __________Grado_______
Padres/ Guardianes
Nombre de la Mamá _____________________ Nombre del Papá _________________________ Dirección de la Casa _____________________ Numero de teléfono en casa____________________ (Dirección de la Calle) _____________________________ # de teléfono del trabajo o de Mensaje______________ (Ciudad o Pueblo) (Codigo Postal)
Distrito escolar _________________________ edificio escolar ______________________________
Persona para contactar____________________ numero para contactar _________________________
___________________________________________________________________________________
___________________________________________________________________________________
Para someter este referido, favor de mandarlo por fax al BOCES de Oswego a (315) 963-4242 o mandar por correo al dirección de arriba. Para más información, favor de
llamar al Programa Migrante a 963-4265 o a 1-800-474-1632. Gracias.
BOARD OF EDUCATION
167 SOUTH FOURTH ST
FULTON, NEW YORK 13069
Important Student Information Notice
The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that The Fulton City School District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s education records. However, the Fulton City School District may disclose appropriately designated “directory information” without written consent, unless you have advised the District to the contrary in accordance with District procedures. The primary purpose of directory information is to allow the Fulton City School District to include this type of information from your child’s education records in certain school publications.
Directory information, which is information that is generally not considered harmful or an invasion of privacy if released, can also be disclosed to outside organizations without a parent’s prior written consent. Outside organizations include, but are not limited to, colleges and universities, military recruiters, the media and prospective employers.
The Fulton City School District has designated the following information as “Student Directory Information” for students in grades pre-kindergarten (Pre-K) through twelfth (12th) grade: the student’s name, name of the student’s parent or guardian, school currently attending, grade in school, participation in officially recognized activities and sports, awards received, a student’s works (written or otherwise), photographs including the student and video and/or audio clips of students. “Student Directory Information” for students in grades nine (9) through twelve (12) includes the following additional information: the student’s address, electronic mail address (email), telephone listing, date and place of birth, major field of study, weight and height of members of athletic teams, dates of attendance and the most receive previous educational institution attended by the student.
Examples of publications that may contain directory information include, but are not limited to, the following:
A playbill, showing your student’s role in a drama production
Newspaper articles
Honor roll or other recognition lists
Graduation programs
Sports activity sheets, such as for football, showing weight and height of team members
BOARD OF EDUCATION
167 SOUTH FOURTH ST
FULTON, NEW YORK 13069
DIRECTORY INFORMATION DISCLOSURE
If you do NOT want the Fulton City School District to disclose directory information from your child’s education records without your prior written consent, you must notify the District in writing within twenty (20) days. You may use the form below to provide such notification.
___________________________________ ___________________________________
___________________________________ ___________________________________
Grade _________________ Date of Birth ____________________
Health Care Provider _________________________ Dentist ____________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
**Note: NYS law requires all medications that need to be administered in school have
written instructions from the health care provider, written parent permission and
the medication to be brought to school in its original pharmacy container, even if child is self-administering.
4. Please provide signed proof from your health care provider for immunizations
(ex- DTAP or Tdap, IPV, MMR etc)
5. Is your child seen by a doctor regularly? Yes/No Weekly/Monthly Other __________________________________
Why? _________________________________________________________________________________________
6. Please list any special concerns for classroom, physical education or dietary restrictions. All restrictions need written
orders from health care provider.
______________________________________________________________________________________________
7. Were your child’s eyes examined by a doctor or optometrist during the past year? Yes/No
Name of Eye Doctor _____________________ Corrective lens prescribed? Yes/No
Reading only? Yes/No Wear full time? Yes/No Take off for Physical Education? Yes/No
8. Did your child have a dental exam and/or orthodontics this past year? Yes/No Dentist ______________________
If you have any additional information that you feel the school nurse should know about, or need to further
describe any conditions listed above, please use the back of this page.
I give permission for confidential and discreet use of health information to meet my child’s health needs while
he/she is in school.
Phone Number _______________________________________________________
Fulton, NY 13069
Student’s Name ____________________________________ DOB______________________
I understand that proof of New York State required immunizations for polio, mumps, diphtheria,
hepatitis and rubella from a physician or clinic is required for admission to school. Failure to file either
proof of immunizations or exemptions will result in the exclusion of the pupil until such time as an
appropriate immunization statement is submitted.
Permission is hereby granted to Fulton City School District to obtain all health records from my physician
and scholastic records from previously attended school(s) as well as transfer records to a new school in
the event of a move to another district or state.
I certify that the information provided is accurate to the best of my knowledge and that I have legal
custody of the above named child.
Parent/Guardian Signature ______________________________________ Date ___________________
Fulton City School District
SCHOOL PHYSICAL CONSENT FORM
School ______________________________________ Grade _________________________
Please check the appropriate box. Sign and return to the school nurse.
I give permission for the designated school physician or nurse practitioner to
complete a physical examination as per school policy and as required by
NYS Education Laws.
I do NOT give permission for the designated school physician or nurse practitioner
to complete a physical examination as per school policy and as required by
NYS Education Laws. I will have a physical completed by our family physician.
This consent is valid from this date unless revoked by the parent or guardian. If custody or
guardianship changes in the future, it is the responsibility of the parent or guardian to notify
the school district of such a change.
________________________________________ ______________________
Rev. 5/4/2018 Page 1 of 2
REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR
Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or
Committee on Pre-School Special education (CPSE).
STUDENT INFORMATION
School: Grade: Exam Date:
Food Insects Latex Medication Environmental
Asthma No
Intermittent Persistent Other : ___________________________
Yes, indicate type Type: __________________________ Date of last seizure: ______________
Diabetes No Medication/Treatment Order Attached Diabetes Medical Mgmt. Plan Attached
Yes, indicate type Type 1 Type 2 HbA1c results: ____________ Date Drawn: _____________ Risk Factors for Diabetes or Pre-Diabetes:
Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.
Hyperlipidemia: No Yes Hypertension: No Yes
PHYSICAL EXAMINATION/ASSESSMENT
TESTS Positive Negative Date Other Pertinent Medical Concerns
PPD/ PRN One Functioning: Eye Kidney Testicle
Sickle Cell Screen/PRN Concussion – Last Occurrence: __________________________
Lead Level Required Grades Pre- K & K Date Mental Health: ________________________________
Other: Test Done Lead Elevated > 10 µg/dL
System Review and Exam Entirely Normal
Check Any Assessment Boxes Outside Normal Limits And Note Below Under Abnormalities
HEENT Lymph nodes Abdomen Extremities Speech
Dental Cardiovascular Back/Spine Skin Social Emotional
Neck Lungs Genitourinary Neurological Musculoskeletal
Assessment/Abnormalities Noted/Recommendations: Diagnoses/Problems (list) ICD-10 Code
_________________________ _____________
_________________________ _____________
_________________________ _____________
Name: DOB:
Distance Acuity 20/ 20/ Yes No
Distance Acuity With Lenses 20/ 20/
Vision – Near Vision 20/ 20/
Vision – Color Pass Fail
Pure Tone Screening Yes No
Scoliosis Required for boys grade 9 Negative Positive Referral
And girls grades 5 & 7 Yes No
Deviation Degree: Trunk Rotation Angle:
Recommendations:
Full Activity without restrictions including Physical Education and Athletics.
Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications
No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling
No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, Skiing, swimming and diving, tennis, and track & field
Other Restrictions:
Developmental Stage for Athletic Placement Process ONLY
Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports
Student is at Tanner Stage: I II III IV V
Accommodations: Use additional space below to explain
Brace*/Orthotic Colostomy Appliance* Hearing Aids
Insulin Pump/Insulin Sensor* Medical/Prosthetic Device* Pacemaker/Defibrillator*
Protective Equipment Sport Safety Goggles Other: *Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.
Explain: _____________________________________________________________________________
MEDICATIONS
List medications taken at home:
IMMUNIZATIONS
HEALTH CARE PROVIDER
Provider Address:
Phone:
Fax:
Please Return This Form To Your Child’s School When Entirely Completed.
STUDENT'S HEALTH HISTORY IN ORDER FOR YOUR CHILD TO ENTER SCHOOL, THIS FORM MUST BE COMPLETED,
SIGNED & ON FILE PRIOR TO ADMISSION AT THE SCHOOL YOUR CHILD WILL ATTEND.
Student Name Parent Name Date DATE OF MEDICAL/HEALTH EXAMINATION (Must be within last 12 months)
IMMUNIZATION HISTORY/MINIMUM RECOMMENDATIONS Enter the MONTH, DAY & YEAR the child received each does of the following vaccines
TYPE OF VACCINE 1st DOSE 2nd DOSE 3rd DOSE 4th DOSE 5th DOSE DPT or DTAP
Diphtheria
Tetanus
Pertussis
Tdap
Pneumococcal Conjugate (PCV)
STUDENT'S HEALTHCARE PROVIDERS:
Physician
Dentist
Phone
Phone
I CERTIFY THAT THE RECOMMENDED NUMBER OF IMMUNIZATIONS HAVE BEEN RECEIVED FOR SCHOOL ADMISSION
SCHOOL NURSE OR PHYSICIAN SIGNATURE DATE
4/16/2014
@ 593-5514 to set up transportation for your child.
A 24-hour advance notice is required for all busing requests.
Request hours: 7:30 am – 4:00 pm
Thank you,
167 SOUTH FOURTH ST
FULTON, NEW YORK 13069
Dear Parent/Guardian:
Fulton City School District would like to welcome you and your child/children. To insure that we have all the medical information necessary to provide your child with health care while at school, we request that you complete this packet of information. Attached you will find.
School Physical Consent Form Fulton City School District will provide any physical required by NYS Education Law IF consent is given by parent/guardian. Please check the appropriate box on the form and return to school nurse. (Whether or not you give consent, each student must have this form on file in the Health Office.)
Health Appraisal Form Physicals are required for new enterers and for students in Pre-K or K, 2, 4, 7 and 10. If you choose to have your own Health Care Provider complete the physical, please bring this form to the appointment and return it to the school nurse.
Health Record Update This form is completed upon entry and updated via student confidential Health form every fall to provide the nurse with current health information regarding your child and allows us the opportunity to plan appropriate healthcare during the school day.
School Policy on Medication, Health Procedures & NYS Immunization Requirements This is for your information only. Please read this information carefully and call with any questions.
Dental Health Certificate The form is optional but it is appreciated if completed.
If your child has any significant medical conditions/needs or will be taking medication during the school day, please contact the school nurse (listed below) prior to the child’s first day of school. There is an answering machine or voice mail at each of the buildings, so please leave a message and someone will return your call.
G. Ray Bodley High School 593-5400 x5414 Fulton Junior High School 593-5445 Fairgrieve Elementary 593-5558 Granby Elementary 593-5483 Lanigan Elementary 593-5473 Volney Elementary 593-5573
BOARD OF EDUCATION
167 SOUTH FOURTH ST
FULTON, NEW YORK 13069
HEALTH PROCEDURES
The health and safety of children in our schools are very important to all of us. Please keep this handout about our health procedures for future reference. If you have any questions during the year, please feel free to call your school nurse or your child’s teacher.
Medication in School
In step with NYS regulations, in order for the nurse to give any type of medication, the nurse’s office will need a written note from the doctor; medicine must be in a prescription/pharmacy bottle; and your written permission to administer the medication.
Medications prescribed to be taken three (3) times a day usually do not need to be taken during school time. (Before school, after school and at bedtime often give the best balance to three (3) times a day medication. Please check with your doctor on this point.)
Bee Sting Allergies (severe)
The Fulton City School District has recommended the use of EPI-PEN JR auto injection kit. This kit is a pre- measured injection kit designed for convenience, which leaves less chance for error in an emergency situation. This injection kit, like any other medication, cannot be administered to your child in school unless we have a written note from your doctor and your written permission.
Hepatic Prevention
Children are encouraged by the teachers to wash hands regularly with soap and water. Our custodians have been instructed to disinfect bathrooms, sinks, fountains, door knobs and other high contact areas.
You can help by reminding your child about hand washings, care at water fountains and not sharing food and drinks with others. With this in mind, party foods and snacks in school need be to store bought, wrapped food items.
Colds and Illness
Colds, flu, “pink-eye”, chicken pox and at times, head lice, affect school children. These and other communicable diseases can try the most patient parent.
Please keep your child home when they have severe colds, copious nasal discharge, red eyes with yellow drainage, diarrhea, vomiting and/or a fever. (If your child has a fever, please keep him/her home until his/her temperature is normal for at least 24 hours.) Children with diagnosed strep throat must be on their medication a minimum of 24 hours before returning to school. Rest, lots of fluids and mom and dad is what your child needs to get better, stay well and not infect his/her classmates.
Head lice can affect any child and is not a sign of being “dirty”. Follow the recommendations of your doctor and school nurse for treatment. Most cases respond quickly to treatment.
BOARD OF EDUCATION
167 SOUTH FOURTH ST
FULTON, NEW YORK 13069
SCHOOL POLICY ON MEDICATION
For the nurse to administer any medication to a student during school hours, the following rules must
be applied:
unless these steps are followed
1. Written permission from parent/guardian
2. Written note/instructions from child’s doctor stating:
Name of medication
Amount of dose
Length of administration
Doctor/Provider signature
Non-prescription medicine must be in an un-opened store package
that will be kept here at school (ex – Tylenol).
4. Parent/guardian brings medication to the nurse’s office
This refers to all medications, including over-the-counter (OTC) medications such as aspirin, Tylenol,
ibuprofen, cough syrups, cough drops, etc.
Medicine should never be sent to school in plastic bags or containers; only in the original packaging.
Your cooperation is appreciated.
167 SOUTH FOURTH ST
FULTON, NEW YORK 13069
__________________ _____________________ ______________________
I give the School Nurse permission to administer medication to my child for this school year.
Parent Name (please print) ___________________________________________________
Parent Name (please sign) ____________________________________________________
BOARD OF EDUCATION FULTON
CITY SCHOOL DISTRICT FULTON
SCHOOL HEALTH SERVICES
After September 1, 2008, Chapter 281 of the Education Law 903 in New York
State requires that the school district request a dental certificate for each of its
students who meet the following criteria:
New to the school district
In grades Pre-K or K, 1, 3, 5, 7, 9, 11.
There is a dental certificate attached for you to take to your child’s dentist and
once it is completed, it should be returned to your child’s School Nurse.
Failure to provide this document will not exclude your child from school.
Thank you for your cooperation in this new health endeavor. Our students
benefit when we work together to promote the health and achievement of all
students.
Please call the Health Office at your child’s school if you have any questions or
concerns.
Dental Health Certificate- Optional
Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Child’s Name: Last First Middle
Birth Date: / / Month Day Year
Sex: Male
Female
Will this be your child’s first visit to a dentist? Yes No
School: Name
Grade
Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No
I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below.
Parent’s Signature______________________________________________________________ Date
Section 2. To be completed by the Dentist
I. The Dental Health condition of _______________________________ on _________________ (date of exam) The date of the
exam needs to be within 12 months of the start of the school year in which it is requested. Check one:
Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.
No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.
NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.
Dentist’s name and address (please print or stamp) Dentist’s Signature
Optional Sections - If you agree to release this information to your child’s school, please initial here.
II. Oral Health Status (check all that apply).
Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a
tooth that is missing because it was extracted as a result of caries OR an open cavity].
Yes No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-
brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].
Yes No Dental Sealants Present
Other problems (Specify):_______________________________________________________________________________
III. Treatment Needs (check all that apply)
No obvious problem. Routine dental care is recommended. Visit your dentist regularly.
May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.
Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.
Vaccines Prekindergarten
Grade 5
Grades 11 and 12
4 doses
5 doses or 4 doses
if the 4th dose was received at 4 years or older or
3 doses if 7 years or older and the series was
started at 1 year or older
3 doses
Not applicable 1 dose
if the 3rd dose was received at
4 years or older
3 doses
4 doses or 3 doses if the 3rd dose was received at 4 years or
older
1 dose 2 doses
Hepatitis B vaccine6 3 doses 3 doses or 2 doses
of adult hepatitis B vaccine (Recombivax) for children who received the doses at least 4 months apart between the ages of 11 through 15 years
Varicella (Chickenpox) vaccine7
1 dose 2 doses 1 dose 2 doses 1 dose
Meningococcal conjugate vaccine (MenACWY)8
Grade 12: 2 doses
older
1 to 4 doses Not applicable
Pneumococcal Conjugate vaccine (PCV)10
2018-19 School Year
New York State Immunization Requirements for School Entrance/Attendance1
NOTES: Children in a prekindergarten setting should be age-appropriately immunized. The number of doses depends on the schedule recommended by the Advisory Committee on Immunization Practices (ACIP). For grades pre-k through 10, intervals between doses of vaccine should be in accordance with the ACIP-recommended immunization schedule for persons 0 through 18 years of age. (Exception: intervals between doses of polio vaccine DO NOT need to be reviewed for grades 5, 11 and 12.) Doses received before the minimum age or intervals are not valid and do not count toward the number of doses listed below. Intervals between doses of vaccine DO NOT need to be reviewed for grades 11 and 12. See footnotes for specific information for each vaccine. Children who are enrolling in grade-less classes should meet the immunization requirements of the grades for which they are age equivalent.
Dose requirements MUST be read with the footnotes of this schedule.
Department of Health
2370
1. Demonstrated serologic evidence of measles, mumps, rubella, hepatitis B, varicella or polio (for all three serotypes) antibodies is acceptable proof of immunity to these diseases. Diagnosis by a physician, physician assistant or nurse practitioner that a child has had varicella disease is acceptable proof of immunity to varicella.
2. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks)
a. Children starting the series on time should receive a 5-dose series of DTaP vaccine at 2 months, 4 months, 6 months and at 15 through 18 months and at 4 years or older. The fourth dose may be received as early as age 12 months, provided at least 6 months have elapsed since the third dose. However, the fourth dose of DTaP need not be repeated if it was administered at least 4 months after the third dose of DTaP. The final dose in the series must be received on or after the fourth birthday.
b. If the fourth dose of DTaP was administered at 4 years or older, the fifth (booster) dose of DTaP vaccine is not required.
c. For children born before 1/1/2005, only immunity to diphtheria is required and doses of DT and Td can meet this requirement.
d. Children 7 years and older who are not fully immunized with the childhood DTaP vaccine series should receive Tdap vaccine as the first dose in the catch-up series; if additional doses are needed, use Td vaccine. If the first dose was received before their first birthday, then 4 doses are required, as long as the final dose was received at 4 years or older. If the first dose was received on or after the first birthday, then 3 doses are required, as long as the final dose was received at 4 years or older. A Tdap vaccine (or incorrectly administered DTaP vaccine) received at 7 years or older will meet the 6th grade Tdap requirement.
3. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 7 years)
a. Students 11 years or older entering grades 6 through 12 are required to have one dose of Tdap. A dose received at 7 years or older will meet this requirement.
b. Students who are 10 years old in grade 6 and who have not yet received a Tdap vaccine are in compliance until they turn 11 years old.
4. Inactivated polio vaccine (IPV) or oral polio vaccine (OPV). (Minimum age: 6 weeks)
a. Children starting the series on time should receive a series of IPV at 2 months, 4 months and at 6 through 18 months, and at 4 years or older. The final dose in the series must be received on or after the fourth birthday and at least 6 months after the previous dose.
b. For students who received their fourth dose before age 4 and prior to August 7, 2010, 4 doses separated by at least 4 weeks is sufficient.
c. If the third dose of polio vaccine was received at 4 years or older and at least 6 months after the previous dose, the fourth dose of polio vaccine is not required.
d. Intervals between the doses of polio vaccine do not need to be reviewed for grades 5, 11 and 12 in the 2018-19 school year.
e. If both OPV and IPV were administered as part of a series, the total number of doses and intervals between doses is the same as that recommended for the U.S. IPV schedule. If only OPV was administered, and all doses were given before age 4 years, 1 dose of IPV should be given at 4 years or older and at least 6 months after the last OPV dose.
5. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months)
a. The first dose of MMR vaccine must have been received on or after the first birthday. The second dose must have been received at least 28 days (4 weeks) after the first dose to be considered valid.
b. Measles: One dose is required for prekindergarten. Two doses are required for grades kindergarten through 12.
c. Mumps: One dose is required for prekindergarten and grades 11 and 12. Two doses are required for grades kindergarten through 10.
New York State Department of Health/Bureau of Immunization health.ny.gov/immunization 2/18
d. Rubella: At least one dose is required for all grades (prekindergarten through 12).
6. Hepatitis B vaccine
a. Dose 1 may be given at birth or anytime thereafter. Dose 2 must be given at least 4 weeks (28 days) after dose 1. Dose 3 must be at least 8 weeks after dose 2 AND at least 16 weeks after dose 1 AND no earlier than age 24 weeks.
b. Two doses of adult hepatitis B vaccine (Recombivax) received at least 4 months apart at age 11 through 15 years will meet the requirement.
7. Varicella (chickenpox) vaccine. (Minimum age: 12 months)
a. The first dose of varicella vaccine must have been received on or after the first birthday. The second dose must have been received at least 28 days (4 weeks) after the first dose to be considered valid.
b. For children younger than 13 years, the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons 13 years and older, the minimum interval between doses is 4 weeks.
8. Meningococcal conjugate ACWY vaccine. (Minimum age: 6 weeks)
a. One dose of meningococcal conjugate vaccine (Menactra or Menveo) is required for students entering grades 7, 8 and 9.
b. For students in grade 12, if the first dose of meningococcal conjugate vaccine was received at 16 years or older, the second (booster) dose is not required.
c. The second dose must have been received at 16 years or older. The minimum interval between doses is 8 weeks.
9. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks)
a. Children starting the series on time should receive Hib vaccine at 2 months, 4 months, 6 months and at 12 through 15 months. Children older than 15 months must get caught up according to the ACIP catch-up schedule. The final dose must be received on or after 12 months.
b. If 2 doses of vaccine were received before age 12 months, only 3 doses are required with dose 3 at 12 through 15 months and at least 8 weeks after dose 2.
c. If dose 1 was received at age 12 through 14 months, only 2 doses are required with dose 2 at least 8 weeks after dose 1.
d. If dose 1 was received at 15 months or older, only 1 dose is required.
e. Hib vaccine is not required for children 5 years or older.
10. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks)
a. Children starting the series on time should receive PCV vaccine at 2 months, 4 months, 6 months and at 12 through 15 months. Children older than 15 months must get caught up according to the ACIP catch-up schedule. The final dose must be received on or after 12 months.
b. Unvaccinated children ages 7 through 11 months of age are required to receive 2 doses, at least 4 weeks apart, followed by a third dose at 12 through 15 months.
c. Unvaccinated children ages 12 through 23 months are required to receive 2 doses of vaccine at least 8 weeks apart.
d. If one dose of vaccine was received at 24 months or older, no further doses are required.
e. For further information, refer to the PCV chart available in the School Survey Instruction Booklet at: www.health.ny.gov/prevention/immunization/schools
For further information, contact:
Room 649, Corning Tower ESP Albany, NY 12237
(518) 473-4437
New York City Department of Health and Mental Hygiene Program Support Unit, Bureau of Immunization,
42-09 28th Street, 5th floor Long Island City, NY 11101
(347) 396-2433
TESTS:
1:
08 Asthma Other Notes:
09 Type Seizure Notes:
10 Results HgbA1c:
15 Lead Elevated 10 gdL: Off
16 Concussion Last Occurrence: Off
16 Mental Health: Off
18 HEENT: Off
18 Dental: Off
18 Neck: Off
20 DiagnosesProblems list 1:
20 DiagnosesProblems list 2:
20 DiagnosesProblems list 3:
20 DiagnosesProblems list 4:
20 ICD10 Code 1:
20 ICD10 Code 2:
20 ICD10 Code 3:
20 ICD10 Code 4:
07 Food: Off
07 Insects: Off
07 Latex: Off
07 Medication: Off
07 Environmental: Off
08 Asthma: Off
08 Intermittent: Off
08 Persistent: Off
09 Seizure Care Plan Attached: Off
09 Type Seizures: Off
10 Diabetes Medical Mgmt:
03 Right Near Vision:
03 Notes Near Vision:
03 Notes Vision Color:
09 Accommodations: Off
09 BraceOrthotic: Off
09 Protective Equipment: Off
09 Colostomy Appliance: Off
09 MedicalProsthetic Device: Off
09 Hearing Aids: Off
10 Order Form for Medications Needed at School attached: Off
10 List medications taken at home 1:
10 List medications taken at home 3:
10 List medications taken at home 4:
10 List medications taken at home 5:
11 Record Attached: Off
12 Date:
12 Provider Address:
12 Provider Phone:
03 Left Near Vision:
08 Tanner Stage: Off
11 Immunization Records Received: Off
Yes No20:
Yes No20_2:
NotesReferral:
NotesReferral_2: