warsaw elementary school...community unity school district #316 340 south 11th street warsaw, il...
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Warsaw Elementary School 220 Underwood St.
Warsaw, IL 62379
217-256-4614
Dear Parents/Guardian:
Illinois law requires a health examination for students entering Pre K, Kindergarten,
& 6th
grades and all students entering or transferring into an Illinois school. A dental
exam is required for students entering Kindergarten, 2nd
, and 6th
grades. A new state
health requirement is an eye exam. All children enrolling in kindergarten or upon first
entry into an Illinois school beyond kindergarten (i.e., grades 1-12) are required to have
an eye examination. Examinations must be performed by a licensed optometrist or
medical doctor who performs eye exams He/she shall complete and sign the Eye
Examination Report form. These examinations should be completed before school
registration in August. A “Live Birth Certificate” copy must also be submitted for all Pre
K and Kindergarten students as well as any student new to the district.
Immunizations required are:
DPT (Diphtheria/Pertussis/Tetanus) – Four or more doses of DPT with the last
booster received after age 4. Any child entering 6th
grade shall show proof of receiving
one dose of Tdap (tetanus, diphtheria, acellular pertussis) vaccine regardless of the
interval since the last Tdap, DT or Td dose.
POLIO (TOPV or IPV) – Three or more doses with the last dose being a booster
given after 4 years of age.
MMR (Measles, Mumps, Rubella) – Two doses, first dose at 12-15 months,
second dose 4-6 years before start of school.
Hepatitis B – Three dose series, the 2nd
dose should be given 1 month after the 1st
dose, and the 3rd
dose at least 4 to 6 months after the 2nd
dose.
Chicken Pox Vaccine- Beginning with school year 2014-2015, any child entering
kindergarten, sixth grade, or ninth grade for the first time shall show proof of having
received two doses of varicella vaccine, the first dose on or after the first birthday and the
second dose no less than four weeks (28 days) after the first dose, or proof of prior
varicella disease or laboratory evidence of varicella immunity.
A lead-screening test/questionnaire must be submitted for each pre k and
kindergarten student prior to admission. If the test/questionnaire was completed in pre-
school, and the results were normal, it does not need to be repeated in kindergarten.
However a copy of the lead screening test/questionnaire results must be on file in school.
Thank you for your cooperation and we hope your students’ experiences with Warsaw
Elementary School will be happy and successful ones.
Sincerely,
Brad Froman, Principal
Warsaw Elementary School
Community Unity School District #316
340 South 11th
Street
Warsaw, IL 62379
(217) 256-4282
2014-2015
STUDENT FEES
(Required)
Pre-K No Fee
Grades K – 6 $35.00
Grades 7 – 8 Nauvoo
Grades 9 – 12 $70.00 (Includes $10 technology fee)
Driver’s Education $100.00
High School PE Uniforms $15.00
STUDENT REGISTRATION 2014 – 2015
Please fill out the information below.
Parent or Guardian Name: _______________________________________________________
Address: _____________________________________________________________________
City: ______________________ Zip: _______________ Phone #: _____________________
Student Name Date of
Birth
Grade Student
Fees
PE
Uniform
Drivers Ed (if applicable)
Lunch
(Optional)
TOTALS
TOTAL ENCLOSED: ______________________
Make checks payable to : Community Unit School District #316
COMPLETED FORMS ARE DUE NO LATER THAN AUGUST 8th
, 2014. PLEASE
MAIL OR BRING COMPLETED FORMS WITH PAYMENT TO THE ELEMENTARY
OR HIGH SCHOOL OFFICE.
EMERGENCY CONTACT AND MEDICAL INFORMATION FORM
WARSAW ELEMENTARY SCHOOL STUDENT EMERGENCY FORM
Student’s Last Name _____________________ Middle ___________ First _________________
Grade _____ Date of Birth _______ City of Birth ________________State ______ Male Female
Mother/Guardian
Name ______________________________________ Relationship _______________________
Address _____________________________________ City ______________ Zip Code ________
Home Phone # ________________Work #________________Cell #_______________________
E-mail _______________________________________________________________________
Father/Guardian
Other Parent/Guardian:__________________________________________________________
Address_____________________________________City________________Zip Code________
Home Phone #_________________Work #________________Cell #______________________
E-mail _______________________________________________________________________
Persons (OTHER THAN YOURSELF)) to be notified in case of emergency if you can not be reached.
CALL FIRST:Name________________________________Relationship_____________________
Home Phone #__________________Cell #_________________Work #____________________
CALL SECOND:Name______________________________Relationship_____________________
Home Phone #__________________Cell #__________________Work #___________________
MEDICAL INFORMATION
Hospital/Clinic Preference_________________________________________________________
Physician’s Name_______________________________________Phone #__________________
Dentist’s Name_________________________________________Phone #__________________
Allergies/Special Health Considerations______________________________________________
If you and the physician of choice as indicated above cannot be reached in an emergency and, if in the judgment of the school
authorities, immediate medical and/or hospital attention is indicated, do you authorize responsible school authorities to send
your child (properly accompanied) to an available hospital or physician? YES N0
----------------------------------------------------------------------------------------------- -----------------------------------------------
Parent/Guardian Signature Date
Warsaw C.U.S.D. #316 7:270-E Page 1 of 2
7:270-E-Students
School Medication Authorization Form
To be completed by the child’s parent{s}/guardian{s}. A new form must be completed every school year. Keep in the
school nurse’s office or, in the absence of a school nurse, the Building Principal’s office.
Student’s Name: __________________________________________Birth Date: ___________________________________
Address: _____________________________________________________________________________________________
Home Phone: ________________________Emergency Phone: ________________________________________________
School: _____________________________Grade: ______Teacher: ____________________________________________
To be completed by the student’s physician, physician assistant, or advanced practice RN:
Physician’s Printed Name: _______________________________________________________________________________
Office Address: ________________________________________________________________________________________
Office Phone: ______________________________________Emergency Phone: __________________________________
Medication Name: ______________________________________________________________________________________
Purpose: _____________________________________________________________________________________________
Dosage: ______________________________________________Frequency: _____________________________________
Time medication is to be administered or under what circumstances:___________________________________________
Prescription date: _________________Order date: _________________Discontinuation date: ______________________
Diagnosis requiring medication: __________________________________________________________________________
Is it necessary for this medication to be administered during the school day: Yes _____________No ________________
Expected side effects, if any: ____________________________________________________________________________
Time interval for re-evaluation: ___________________________________________________________________________
Other medications student is receiving: ___________________________________________________________________
____________________________________________________________________
Physician’s signature Date
Asthma Inhalers Parent{s}/Guardian{s}: Please attach prescription label here:
Warsaw C.U.S.D. #316 7:270-E Page 2 0f 2 Student Name: ______________________________________________________
For only parents/guardians of students who need to carry asthma medication or an EplPen®:
I authorize the School District and its employees and agents, to allow my child or ward to possess and use his/her asthma medication and/or epinephrine auto-injector: (1) while in school, (2) while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after normal school activities, such as while in before-school or after-school care on school-operated property. Illinois law requires the School District to inform parent(s)/guardian(s) that it, and its employees and agents, incur no liability, except for willful and wanton conduct, as a result of any injury arising from a student’s self-administration of medication or epinephrine auto-injector (105 ILCS 5/22-30). If you agree please initial: _________________________________ Parent(s)/Guardian(s) For all parent(s)/Guardian(s): By signing below, I agree that I am primarily responsible for administering medication to my child. However, in the event that I am unable to do so or on the event of a medical emergency, I hereby authorize the School District and its employees and agents, in my behalf, to administer or to attempt to administer to my child (or to allow my child to self-administer, pursuant to State law, while under the supervision of the employees and agents of the School District), lawfully prescribed medication in the manner described above. I acknowledge that it may be necessary for the administration of medications to my child to be performed by an individual other than a school nurse and specifically consent to such practices, and I agree to indemnify and hold harmless the School District and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the administration or the child’s self-administration of medication. __________________________________________ _______________________________________ Parent/Guardian printed name Parent/Guardian printed name Address: (if different from Student’s) _________________________________________________ Phone: ______________________________Emergency Phone: _______________________________ _______________________________________ ______________________________________ Parent/Guardian signature* Parent/Guardian signature* *Both parents and/or guardians, if available, should sign. Approved January 24, 2001
Warsaw Elementary School Pre-K
220 Underwood
Warsaw, IL. 62379
Transportation Information
Child’s Name____________________________________________
Child’s Home Address_____________________________________
Parent /Guardian_________________________________________
Home Phone ________________Work Phone_________________
Message /alternate contact name and phone number
Name__________________________________________________
Phone number___________________________________________
____My Child will come to school by bus and will be picked up at
____ I, or another adult will bring my child to school
____When my child leaves school, I will pick him/her up
____ After school, my child will ride the bus to
My child has a sibling at Warsaw Elementary who he/she will ride the bus home with
____My child is in AM Pre-K ____ My Child is in PM Pre-K
Start date______________
Parent /Guardian
Signature_____________________________________________________________________________
SCHOOL REACH Instant Parent Contact
To whom it may concern:
In our effort to improve communication between parents and school, we are instituting a telephone broadcast
system that will enable school personnel to notify all households and parents by phone within minutes of an
emergency or unplanned event that causes an early dismissal, school cancellations or late start. The service
may also be used from time to time to communicate general announcements or reminders. School Reach, a
company specializing in school-to-parent communications, provides this service. We will report school
closings due to snow or weather on the usual radio and TV stations and will use this system as an overlay to the
public.
When used, this service will simultaneously call all listed phone numbers in our contact list and will deliver a
recorded message from school personnel. The service will deliver the message to both live answer and
answering machines. No-answers and busy signal calls will be retried two times in 15-minute intervals after the
initial call.
Here is some specific information you should know:
Caller ID: The caller ID will display a school phone number
(217) 256-4614 – Elementary School
(217) 256-4281 – High School
(217) 256-4282 – District Office
Live Answers: There is a short pause at the beginning of the message. Answer your phone as
you normally would and wait for the message to begin. Multiple “hellos” will
delay the message.
Answering Machines: The system will detect that your machine has answered and will play the
recording. Maximum number of rings is 5, before the system will hang up.
Attendance: We will use the system to notify you when your child is absent, unless you
call the school before 9:00 a.m.
Cell Phones: We need to know your carrier (US Cellular, Sprint, etc) to allow the service to
go directly to your voice mail. Otherwise, it may “time out” and you may only
get part of the message.
Please fill out the information below so that we can get all the information we need into our system. This
service will allow up to 3 numbers per student to be called. This form needs to be filled out and returned even if
there are no changes from the last year.
STUDENT NAME: ______________________________________________ GRADE: _____________
1st Number to Call (with area code): ___________________________________ Carrier: ______________
2nd
Number to Call (with area code): __________________________________ Carrier: _______________
3rd
Number to Call (with area code): ___________________________________ Carrier: _______________
Note: Carriers are only needed for cell phone numbers.
Illinois Department of Public Health Childhood Lead Risk Assessment Questionnaire
ALL CHILDREN 6 MONTHS THROUGH 6 YEARS OF AGE MUST BE ASSESSED FOR LEAD POISONING
(410 ILCS 45/6.2)
Name ___________________________ Today’s Date_________________________________ Age _____________ Birthdate ________________ ZIP Code _________________ Respond to the following questions by circling the appropriate answer. R E S P O N S E 1. Is this child eligible for or enrolled in Medicaid, Head Start, All Kids
or WIC? Yes No Don’t Know 2. Does this child have a sibling with a blood lead level of10 mcg/dL or higher? Yes No Don’t Know 3. Does this child live in or regularly visit a home built before 1978? Yes No Don’t Know 4. In the past year, has this child been exposed to repairs, repainting or renovation of a home built before 1978? Yes No Don’t Know 5, Is this child a refugee or an adoptee from any foreign country? Yes No Don’t Know 6. Has this child ever been to Mexico, Central or South America, Asian
countries (i.e., China or India), or any country where exposure to lead from certain items could have occurred (for example, cosmetics, home
remedies, folk medicines or glazed pottery)? Yes No Don’t Know
7. Does this child live with someone who has a job or a hobby that may involve lead (for example, jewelry making, building renovation or repair, bridge construction, plumbing, furniture refinishing, or work with automobile batteries or radiators, lead solder, leaded glass, lead shots, bullets or lead fishing sinkers)? Yes No Don’t Know
8. At any time, has this child lived near a factory where lead is used (for example, a lead smelter or a paint factory)? Yes No Don’t Know
--------------------------------------------------------------------------------------------------------------------------------------------
If there is any “Yes” or “Don’t Know” response; and • there has been no change in the child’s living conditions; and • the child has proof of two consecutive blood lead test results (documented below) that are
each less than 10 mcg/dL (with one test at age 2 or older), a blood lead test is not needed at this time.
Test 1: Blood Lead Result_____mcg/dL Date _____ Test 2: Blood Lead Result_____mcg/dL Date _____
Please discuss any questions or concerns with your child’s health care provider. For more information, call:
Illinois Department of Public Health Childhood Lead Poisoning Prevention Program
800-545-2200 or 217-782-0403 TTY (hearing impaired use only) 800-547-0466
________________________________________ Signature of Doctor/Nurse Date
Childhood Lead Poisoning 1. What is lead? Lead is a naturally-occurring metal that is unsafe at any level in the body. 2. What is lead poisoning? Lead poisoning is the presence of too much lead in the body. 3. What are the symptoms of lead poisoning?
Children with lead poisoning usually have no obvious signs or abnormal symptoms.
4. How does lead poisoning affect children? Lead decreases children’s ability to learn and may lead to behavior problems. 5. Who gets lead poisoning?
People of any age, race or economic level, but children are at the greatest risk because of oral behaviors and hand contamination.
6. What are sources of present lead exposure?
• Dust and paint chips from deteriorating lead-based paint in homes built before 1978
• Soil contaminated with lead • Imported glazed pottery or other products made outside the United States
that contain lead • Food, medicines or folk remedies from foreign countries that contain lead • Family members who have occupations or hobbies involving lead • Drinking water from plumbing containing lead
7. How can I tell if my child has lead poisoning?
The only way to diagnose lead poisoning is through a blood test. The blood sample is sent to a laboratory to find out how much lead it contains.
8. When should I have my child assessed or tested?
• A child should be assessed for lead exposure at every well child visit between 6 months and 6 years of age.
• Blood lead tests are recommended at 12 and 24 months of age. • When a high risk of lead exposure exists. • All children eligible for or enrolled in Medicaid, Head Start, All Kids or WIC
are required to have blood lead testing.
Printed by Authority of the State of Illinois P.O. # 507345 2M 5/07
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