birth certificate immunization records three proofs of residency · 2018. 6. 14. · evaluation...
TRANSCRIPT
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STAY CONNECTED WITH HCSD
Required documents needed to register:
Birth Certificate
Immunization Records
Three proofs of residency
HARBOR CREEK SCHOOL DISTRICT
www.hcsd.iu5.org
Phone (814) 897-2100
Clark Elementary
3650 Depot Road
Erie, PA 16510
Fax: 897-8723
Klein Elementary
5325 East Lake Road
Erie, PA 16511
Fax: 898-0225
Rolling Ridge Elementary
3700 Ridge Parkway
Erie, PA 16510
Fax: 898-1916
Harbor Creek Jr./Sr. High
6375 Buffalo Road
Harborcreek, PA 16421
Jr. High Fax: 897-2121
Sr. High Fax: 897-2136
.HCSD September 3, 2015 Page 1 of 3
ANNUAL PUBLIC NOTICE OF SPECIAL EDUCATION SERVICES Sc. PROGRAMS,
SERVICES FOR GIFTED STUDENTS, & SERVICES FOR PROTECTED
HANDICAPPED STUDENTS
CHILD FIND
Harbor Creek School District
Notice to Parents
According to state and federal special education regulations, annual public notice to parents of children who reside
within a school district is required regarding child find responsibilities. School districts, intermediate units and
charter schools are required to conduct child find activities for children who may be eligible for services via Section
504 of the Rehabilitation Act of 1973. For additional information related to Section 504/Chapter 15 services, the
parent may refer to Section 504, Chapter 15, and the Basic Education Circular entitle Implementation of Chapter 15.
Also, school districts are required to conduct child find activities for children who may be eligible for gilled services
via 22 PA Code Chapter 16. For additional information regarding gifted services, the parent may refer to 22 PA Code
Chapter 16. If a student is both gifted and eligible for Special Education, the procedure in IDEA and Chapter 14 shall
take precedence
This notice shall inform parents residing in the Harbor Creek School District of the child identification activities and
of the procedures followed to ensure confidentiality of information pertaining to students with disabilities or
eligible young children. In addition to this public notice, the Harbor Creek School District shall publish written
information in the handbook and on the website. Children ages 3-21 can be eligible for. special education programs
and services. If parents believe that the child may be eligible for special education, the parent should contact the
Director of Special Education. Children age three through the age of admission to first grade are also eligible if they
have developmental delays and, as a result, need special education and related services. Developmental delay is
defined as a child who is less than the age of beginners and at least three years of age and is considered to have a
developmental delay when one of the following exists: (i) The child's score, on a developmental assessment device,
on an assessment instrument which yields a score in months, indicates that the child is delayed by 25 percent of the
child's chronological age in one or more developmental areas, or (ii) The child is delayed in one or more of the
developmental areas, as documented by test performance of 1.5 standard deviations below the mean on
standardized tests. Developmental areas include cognitive, communicative, physical, social/emotional and self-
help. For additional information regarding Early Intervention Services, you may contact IU#5 734-5610 x 8461 or
toll-free 1-800-677-5610 x. 8461.
Evaluation Process
Each school district, intermediate unit and charter school has a procedure in place by which parents can request an
evaluation. For information about procedures applicable to your child, contact the school, which your child attends.
Parents of preschool age children, age three through five, may request an evaluation in writing by addressing a
letter to the Early Intervention Supervisor, NW Tri-County Intermediate Unit #5, 252 Waterford St, Edinboro, PA
16412 or call 1-800-677-5610, ext. 8461.
HCSD September 3, 2015 Page 2 of 3
Screening
Kindergarten screening activities include a review of informal social and health history, developmental areas,
functional vision and hearing, and speech and language. Further screenings are conducted through the
Instructional Support Teams in each school for any student that may be in need of special education services.
Parents who wish to request screening and evaluation for their child may do so by contacting the principal or
counselor in their child's school building.
Consent
School entities cannot proceed with an evaluation or reevaluation, or with the initial provision of special
education and related services, without the written consent of the parents. For additional information related to
consent, please refer to the Procedural Safeguards Notice which can be found at the PaTTAN website at
www.pattan.net. Once written parental consent is obtained, the Harbor Creek School District will proceed with
the evaluation process. If the parent disagrees with the evaluation, the parent can request an independent
education evaluation at public expense.
Evaluations
Parents who wish to request screening and evaluation for their child may do so by contacting the principal or
counselor in their child's school building. Parents are encouraged to meet with school staff to address concerns. A
multidisciplinary evaluation (NOE) will be conducted by a multidisciplinary team (MDT). The team shall be
composed of the parents, persons familiar with the child's development, persons knowledgeable in such areas of
suspected exceptionality, persons trained in the appropriate evaluation techniques and, if possible, persons
familiar with the child's cultural background. All information gathered through the screening and/or reevaluation
process is considered confidential under the Family Education Rights and Privacy Act (FERPA).
Program Development
Once the evaluation process is completed, a team of qualified professionals and the parents determine whether
the child is eligible. If the child is eligible, the individualized education program (IEP) team meets, develops the
program, and determines the educational placement. Once the 1EP team develops the program and determines
the educational placement, school district staff will issue a notice of recommended educational placement/prior
written notice. Your written consent is required before initial services can be provided. The parent has the right to
revoke consent after initial placement.
Confidentiality of Information
The Harbor Creek School District maintains records concerning all children enrolled in the school, including
students with disabilities. All records are maintained in the strictest confidentiality. Your consent, or consent of an
eligible child who has reached the age of majority under State law, must be obtained before personally
identifiable information is released, except as permitted under the Family Education Rights and Privacy Act
(FERPA). The age of majority in Pennsylvania is 21. Each participating agency must protect the confidentiality of
personally identifiable information at collection, storage, disclosure, and destruction stages. One official at
each participating agency must assume responsibility for ensuring the confidentiality of any personally
identifiable information. Each participating agency must maintain, for public inspection, a current listing of
Harbor Creek School District STUDENT REGISTRATION
Student Registration Updated 2019.003.28
HCSD September 3, 2015 Page 3 of 3
the names and positions of those- employees within the agency who have access to personally identifiable
information.
For additional information related to student records, the parent can refer to the FERPA at the following URL:
https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.htm
This notice is only a summary of the special education services, evaluation and screening activities, rights and
protections pertaining to children with disabilities, children thought to be disabled, and their parents. For more
information or to request evaluation or screening of a preschool or school aged child, public or private, contact
the school or district where your child attends. Additionally, one may contact a school representative listed
below:
Brenda Evans
Director of Special Education
Harbor Creek School -District
6375 Buffalo Road
Erie, PA 16421
814-897-2100 x 1244
The Harbor Creek School District will not discriminate in employment, educational programs, or activities based
on race, color, national origin, age, sex, handicap, creed, marital status or because a person is a disabled veteran
or a veteran of the Vietnam era. No preschool, elementary or secondary school pupil enrolled in a Harbor Creek
School District program shall be denied equal opportunity to participate in age and program appropriate
instruction or activities due to race, color, handicap, creed, national origin, marital status or financial hardship.
Harbor Creek School District STUDENT REGISTRATION
Student Registration Updated 2019.003.28 Integrated Pest Management Revised 7-16 pg Form 09-A16
Integrated Pest
Management Dear Parent(s) or Guardian(s)
The Harbor Creek School District uses an Integrated Pest Management (IPM) approach for managing insects, rodents and
weeds. Our goal is to protect every student from pesticide exposure by using an IPM approach to pest management. Our
IPM approach focuses on making the school building and grounds an unfavorable habitat for these pests by removing
food and water sources and eliminating their hiding and breeding places. We accomplish this through routine cleaning and
maintenance. We routinely monitor the school building and grounds to detect any pests that are present. The pest
monitoring team consists of our building maintenance, office, and teaching staff and includes our students. Pest sightings
are reported to our 1PM coordinator who evaluates the "pest problem" and determines the appropriate pest management
techniques to address the problem. The techniques can include increased sanitation, modifying storage practices, sealing
entry points, physically removing the pest, etc.
From time to time, it may be necessary to use chemicals to manage a pest problem. Chemicals will only be used when
necessary, and will not be routinely applied. When chemicals are used, the school will try to use the least toxic products
when possible. Applications will be made only when unauthorized persons do not have access to the area(s) being treated.
Notices will be posted in these areas 72 hours prior to application and for two days following the application.
Parents or guardians of students enrolled in the school may request prior notification of specific pesticide applications
made at the school. To receive notification, you must be placed on the school's notification registry. If you would like to
be placed on this registry, please notify your building principal in writing. Please include your email address if you would
like to be notified electronically.
If a chemical application must be made to control an emergency pest problem, notice will be provided by telephone to
any parent or guardian who has requested such notification in writing. Exemptions to this notification include
disinfectants and antimicrobial products; self-containerized baits placed in areas not accessible to students, and gel type
baits placed in cracks, crevices or voids; and swimming pool maintenance chemicals.
Each year the district will prepare a new notification registry. If you have any questions, please contact Mike Oleski,
IPM Coordinator at 897-2100 or by e-mail at [email protected].
Sincerely,
Kelly Hess
Superintendent of Schools
Harbor Creek School District
Harbor Creek School District
Student Registration Updated 2019.03.28 PG
FOOD SERVICE INFORMATION
The Harbor Creek Food Service Department welcomes you to our School District. The following information is to help with your child's lunch account,
If you would like an application for free or reduced lunches, you may obtain one from your school office or on our Website. Just click on free or reduced application's under the news and announcements section on the home page. Be assured all financial information is kept private. You may send the completed and signed application to your child's school office or mail to:
Harbor Creek School District Food Service 6375 Buffalo Road Harborcreek, PA 16421
You are also able to review your child's lunch account activity and make payments on line. Simply go to the Harbor Creek School District webpage and click on HAC & Meals Plus then select the directions and information link for our Meals Plus program. We encourage you to use the Meals Plus system to keep money on your child's account to help make a smooth transition through the lunch line each day, as well as, to review your child's account for accuracy.
If you have any questions, feel free to contact me, Patricia Stadler, at 897-2100 extension 2132.
Thank you.
Patricia Stadler
Harbor Creek School District STUDENT REGISTRATION
Student Registration Updated 2019.003.28
Welcome to Harbor Creek! The following documentation is required to be completed and submitted before a student
can be admitted: (Please note that additional documentation will be required for Foster Children or Other Children who are
residing with a resident adult who is not their parent.)
Proof of Age [24 P.S §13-1304] a. Original or certified official birth certificate or; b. Original or certified baptismal certificate
Immunization Records [24 p.s. §13-1303a] – Certificate of immunization issued in accordance with the rules and regulations of the Pennsylvania Secretary of Health and the Advisory Health Board. Students who are not immunized as required by the PA Dept. of Health, or who are not medically or religiously exempt may not be admitted to school. Children in all grades (K-12) need the following immunizations to attend school:
4 doses of tetanus*(1 dose on or after 4th
birthday) 4 doses of diphtheria* (1 dose on or after 4
th birthday)
3 doses of polio 2 doses of measles** 2 doses of mumps** 1 dose of rubella (German measles) ** 3 doses of hepatitis B 2 doses of varicella (chickenpox) or evidence of immunity
*Usually given as DTP or DT or Td **Usually given as MMR
Students in 7th Grade also need the following immunizations: 1 dose meningococcal conjugate vaccine (MCV)
1 dose of tetanus, diphtheria, acellular pertussis (Tdap) [if five years have elapsed since last tetanus immunization]
The only exceptions to the school laws for immunization are medical, Philosophical/Strong Moral Ethical Conviction and religious beliefs. If your child is exempt from immunizations, your child may be removed from school during a disease outbreak.
Parental Disclosure Statement [24 P.S. §13-1304a] Parent attestation to whether the student has been or is suspended or expelled for offenses involving drugs or alcohol, weapons or violence. (Page 4 of this packet)
Proof of Residency and Affidavit [24 P.S. §13-1302] Application for registration must be accompanied by three proofs of residency from the following Lists. Proof of Residency documents must indicate the physical address of residence and the name(s) of property owner(s). A child shall be considered a resident of the school district in which his parent or guardian resides, and will be enrolled in the school building he/she would normally attend in accordance with established school district attendance areas.
List A (Must Provide 1) List B (Must Provide 2)
Mortgage Document Current Utility Bill (gas, water, electric, or cable, phone or cell phone) Lease Agreement Driver’s License
Tax Bill Vehicle Registration Current Credit Card Bill
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2019.003.28
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason, it is the
responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law
and will hold all parties responsible for a non-resident fee.
I / We, ____________________________________________________ currently reside at _________________________________________________________________
Parent/Guardian Name Harbor Creek Resident’s Address
which is owned leased by __________________________________________ (________________________________________________________________)
Harbor Creek Resident’s Name Relationship
Through our notarized signature, we understand that the school district, pursuant to guidelines issued by the Department of Education and their own written policy, may require other
reasonable information to be submitted to confirm this sworn statement.
______________________________________________________________ _______/_______/_______
Parent or Guardian’s Notarized Signature Date
_____________________________________________________________________ _______/_______/________
Harbor Creek Resident’s Notarized Signature Date
_____________________________________________________________________ _______/_______/_______
Notary’s Signature Date
Residency /Multiple Family Affidavit Parent or Guardian Own/Rent/Live with a Harborcreek Resident
Student’s Name __________________ Completed by Parent/Guardian or Harborcreek Resident
*Parent or Guardian is to complete only ONE of the following sections and provide all necessary residency documents. (see reverse side)
Parent/Guardian Owns a Home in Harborcreek
To be completed by registrants who own or are purchasing a home in Harborcreek Section A
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee. I/We, __________________________________________________ currently reside at ___________________________________________
Registrant Parent/Guardian Legal Name Address
Parent/Guardian Signature: ___________________________________________________________ Date: _______/__________/__________
Parent/Guardian Rents/Leases in Harborcreek
To be completed by registrants who are renting a home in Harborcreek Section B
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee. I/We, __________________________________________________ currently reside at ___________________________________________
Registrant Parent/Guardian Legal Name Address
Parent/Guardian Signature: ___________________________________________________________ Date: _______/__________/__________
Parent/Guardian Lives with a Harborcreek Resident Section C To be completed by the parent/guardian of the student and the Harborcreek resident with whom a family will reside
Per 24 P.S. §13-1302, a person who knowingly provides false information in the above statement for the purpose of enrolling a child in a school district for which the
child is not eligible commits a summary offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three hundred dollars ($300)
for the benefit of the school district in which the person resides or to perform up to two hundred forty (240) hours of community service, or both. In addition, the
person shall pay all court costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in accordance with 42561 during the
period of enrollment.
(Registration to attach all relevant Residency Documentation)
This form must be renewed by July 1st of each year for Section C only, and is subject to Central Office approval.
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2019.003.28
COMPLETE FOR ALL SECTIONS
THE FOLLOWING ITEMS MUST BE PROVIDED BY ALL RESIDENTS AND/OR PARENTS RESIDING IN HCSD TO COMPLETE STUDENT REGISTRATION:
Proof of Residency [24 P.S. §13-1302 Application for registration must be accompanied by 3 proofs of residency from the following lists. Proof of Residency
documents must indicate the physical address of residence and the name(s) of property owners(s). A child shall be considered a resident of the school district in
which his parent or guardian resides, and will be enrolled in the school building he/she would normally attend in accordance with established school district
attendance areas.
List A (Must Provide 1) List B (Must Provide 2) Mortgage Document Current Utility Bill
Resident Lease Agreement Driver’s License
Tax Bill Vehicle Registration Current Credit Card Bill
Parent / Guardian Lives with a Harborcreek Resident
PROOF OF RESIDENCE IN HARBORCREEK:
HCSD requires evidence that a student resides in the district before the student can be enrolled. If your family is living with another Harborcreek resident
temporarily, you may enroll your child by completing & having this Residency Affidavit notarized, which requires both the parent/guardian of the child and the
resident to appear before the Central Registration office (or designee). The resident needs to provide the above documents, plus the parent/guardian needs to
proved one of the below documents.
Parent List B (Must Provide 2) Living with a Drivers’s License
Harborcreek Vehicle Registration
Resident Cell Phone Bill
Current Credit Card Bill
ACKNOWLEDGEMENT:
I acknowledge and agree to the following statements (initial each one below):
_____ My child resides with me ____ days per week at the address proven, which is my primary residency.
_____ I agree to notify HCSD within five (5) days when I change my residence either within or outside HCSD.
_____ Home visitation and/or other residency verification are part of a periodic process to confirm current residency status.
_____ The District will actively investigate all cases when it has reason to believe that residency status has changed and/or believe that false information has
been provided. Verification may include home visits.
_____ The District may refer cases in which false information has been intentionally provided to our solicitor for further investigation.
_____ Investigations that reveal students have enrolled on the basis of providing false information will lead to immediate withdrawal and billing for
non-resident fee.
_____ I understand that a person who knowingly provides false information for the purpose of enrolling a child in a school district for which the child is not
eligible commits a summary offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three hundred dollars
($300) for the benefit of the school district in which the person resides or to perform up to two hundred forty (240) hours of community service, or both.
_____ I understand that the person shall pay all court costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in
accordance with 24 P.S. 25-2561 during the period of enrollment.
________________________________________ ______/______/_____ ___________________________________________ ______/________/______
Parent/Guardian Signature Date Resident Signature Date
A RESIDENCY AFFIDAVIT FOR SECTION C IS VALID FOR THE CURRENT SCHOOL YEAR ONLY AND MUST BE RENEWED BY
JULY 1ST OF EACH SCHOOL YEAR. FAILURE TO RENEW THIS FORM WILL DELAY CONTINUED ENROLLMENT.
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2019.003.28
FO
RM
200
Student Number Registration Date PA Secure ID # Building Enrolled Building Code Entry Code Grade
First Day Attendance Agency Name Agency Phone Social Worker
Homeless
Homebound Foreign Exchange Student (239A) Guardianship (1302)
Foster Child (1305) Institutionalized Child (1306) Special Education
Has the student previously attended the HC School District? Y N
Student Information
Student Last Name, First Name, Middle Initial Date of Birth Grade Entering Male
Female
Is there a Court Order involving this student? Y N (If YES, please provide a copy to the school office, otherwise we are unable to abide by its contents.)
Ethnicity
Hispanic Not Hispanic
Race
American Indian/ Alaskan Native Black/ African American Native Hawaiian/ Pacific Islander
Asian Multi-racial Hispanic White/Caucasian
Street Address:
Apt or Lot # City: Zip Code: Home Phone #:
Name of Previous School: Address of Previous School: (street, city, state, zip) Phone #:
Date of US Entry: Date of PA Entry: Date of 9th
Gr. Entry: Parent(s) in Military Yes No
Is this student currently receiving SPECIAL EDUCATION services? Yes No
Student Program Information
Check ALL services that your child is currently receiving:
Individualized Education Plan (Special Education Services)
Gifted Individualized Education Plan (Gifted Education Services)
Section 504/Chapter 15 Service Agreement (Special Accommodations for Health/Physical needs)
Early Intervention Program
Autistic Support Blind/Visually Impaired
Deaf or Hearing Support Emotional Support
ESL (English as a Second Language) IST (Instructional Support Team)
Life Skills Support Physical Support
Remedial Math (Extra Help) Remedial Reading (Extra Help)
Speech/Language Support Other
FOR OFFICE USE ONLY
Please complete this section:
Harbor Creek School District STUDENT REGISTRATION FORM
Student Registration Updated 2019.003.28
FO
RM
200
Parent/Guardian Information Number of Parents in Household (please choose one): 1 2 Child Resides
With (Check all that apply)
Parent #1 Name: Mr. Mrs. Ms. Dr. Parent #1 Address, City, State, Zip (if different from student):
Parent #1 Cell #: Home #: Work #: Email: Circle priority #
Parent #2 Name: Mr. Mrs. Ms. Dr. Parent #2 Address, City, State, Zip (if different from student):
Parent #2 Cell #: Home #: Work: Email: Circle priority #
Guardian Name: Mr. Mrs. Ms. Dr. Guardian Address, City, State, Zip (if different from student): Relationship to Student
Guardian Cell Cell#: Home#: Guardian Alt #: Guardian Email: Circle priority #
Emergency Contact #1 Mr. Mrs. Ms. Dr. Name:
Emergency Contact Address, City, State, Zip: Relationship to Student
Emergency Contact
Cell#: Home#: Alt. #
Emergency Contact #2 Mr. Mrs. Ms. Dr. Name:
Emergency Contact Address, City, State, Zip: Relationship to Student
Emergency Contact
Cell#: Home#: Alt. #
Other Adults or Children in Residence
Name Birthdate
(mm/dd/year) Grade School
Signature of Parent or Guardian: Date:
Harbor Creek School District
Student Registration Updated 2019.003.28
PA1304 F
OR
M
6375 Buffalo Road, Harborcreek, PA 16421 www.hcsd.iu5.org
(814)897-2100
Parental Disclosure Statement
Student Name
Date of Birth Grade
Parent or Guardian Name
Address
Telephone Number
Pennsylvania School Code §13-1304-A states in part “Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration provide a sworn statement or affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an action of offense involving a weapon, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.”
Please complete the following: I hereby swear or affirm that my child was was not previously suspended or expelled, or is is not
presently suspended or expelled from any public or private school of this Commonwealth or any other state for an act
or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of
violence committed on school property. I make this statement subject to the penalties of 24 P.S. §13-1304-A(b) and
18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities, and the facts contained herein are true and
correct to the best of my knowledge, information and belief.
If this student has been or is presently suspended or expelled from another school, please complete:
Name of the school from which student was suspended or expelled:
Dates of suspension or expulsion:
(Please provide additional schools and dates of expulsion or suspension on back of this sheet.)
Reason for suspension/expulsion (optional)
(Signature of Parent or Guardian)
(Date)
Any willful false statement made above shall be a misdemeanor of the third degree.
This form shall be maintained as part of the student’s disciplinary record.
An equal rights and opportunities school district.
Harbor Creek School District
Student Registration Updated 2019.003.28
200A FO
RM
The Office of Civil Right (OCR) requires that school districts/charter schools/full day AVTS identify limited English Proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has
selected the Home Language Survey as the method for the identification.
Please complete the following:
_______________________ Signature of Parent/Guardian
Or
_________________________
Signature of person completing this form
(if other than parent/guardian):
*The Harbor Creek School District has the responsibility under federal law to serve students who are limited English
proficient and need English instructional services. Given this responsibility, Harbor Creek School District has the right to
ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district may conduct screenings or ask for related information about students who are already
enrolled in the district as well as from students who enroll in the school district in the future.
PLEASE RETURN THIS COMPLETED FORM TO YOUR CHILD’S SCHOOL. Home Language Survey Reviewed 05/15 pg Pink
HCSD Home Language Survey
Date
Student’s Name
School
Grade
1. What is the language that your child first learned to speak?
2. Does the student speak a language other than English?
(Do not include languages learned in school.)
Yes/No If yes, what language
3. Is a language other than English spoken in the child’s home?
4. Has the student attended any United States school in
any 3 years during his/her lifetime?
If the answer to #4 is Yes please complete the following.
Name of School State Dates Attended
Harbor Creek School District
Student Registration Updated 2019.003.28
216 F
OR
M
Release of records
To Whom it May concern: The below listed student has registered with the Harbor Creek School District effective __________. Please forward his/her school records to highlighted school below. School records should include transcript of grades, materials from both categories such as grades earned this year and/or withdrawal grades, standardized test scores, attendance, birth certificate, IEP, psychological records, speech, dental, health and immunization records, intake/ discharge summaries, drug and alcohol treatment and any other pertinent information.
Student’s Name: (Last, First, Middle)
Student’s PA Secure ID #
DOB: Grade:
Previous School/Agency:
Address:
Phone # Fax:
You are hereby authorized to release copies of the following requested records:
STANDARD RECORDS SPECIAL EDUCATION RECORDS
Transcripts Most Recent IEP
Attendance Evaluation/Re-evaluation Reports
Discipline 504 Plan (Protected Handicapped)
Test Scores Gifted Program
Withdrawal Grades
Health Records
339 Documentation
Records are to be sent to the HCSD school listed below: Clark Elementary Klein Elementary Rolling Ridge Elem. HC Jr./ Sr. High
Attn: Office Attn: Office Attn: Office Attn: Guidance Office
3650 Depot Rd. 5325 East Lake Rd. 3700 Ridge Parkway 6375 Buffalo Rd.
Erie, PA 16510 Erie, PA 16511 Erie, PA 16510 Harborcreek, PA 16421 Phone:
814-897-2100 x 5500 Phone:
814-897-2100 x 4100 Phone:
814-897-2100 x 3300 Phone:
814-897-2100 x 1211 FAX: 814-897-8723 FAX: 814-898-0225 FAX: 814-898-1916 FAX: 814-897-2136
Please note:
Any information received by the Harbor Creek School District will be placed in a file to which parents have access and the capacity to release to a third independent agency. The professional staff of the Harbor Creek School District
monitors this access. Information will be destroyed when it is no longer useful for educational purposes.
I may revoke this release at any time except to the extent that the person who is to make the disclosure has already acted on it. Except as noted above, this release will expire one year from now unless revoked earlier in writing., All information released or obtained will be handled confidentially in compliance with the Family Education Rights and Privacy Act (FERPA).
______________________ ______________ _________________________
Parent/Guardian Signature Date Witness Signature
_____________________________________________ ______________ _____________________
Student Signature (14 years or older for Mental Health Records) Age Date (18 years or older for Educational Records)
Consent to obtain/release confidential Revised 2019.02.14 pg Form # 216 - Yellow
Ed./Med./Health Info
Harbor Creek School District
Updated 2019.03.28
Annual Health Assessment
Please complete both sides of this form and return to school
Student Name: __________D.O.B: ____ _______Grade: ___________
Preferred hospital in emergency: ___________________Does your student have health insurance? YES NO The school nursing staff has non-aspirin pain medication and antacid that may be given at the nurse’s discretion. Please
indicate which type of medication your child is permitted to have and sign below. The school has standing orders, which includes
a list of approved treatments and medications recommended by our school physician.
Tylenol (Acetaminophen) Yes No
Motrin (Ibuprofen) Yes No
Antacid (Tums) Yes No
Parent/guardian signature:
Please list any medications, dosage and reason for medication taken on a daily basis:
Medication Name Dosage Reason for Medication
Please read the following & CIRCLE any health concerns/conditions that your child has.
If you CIRCLE any of the following, please send in supporting documentation from your physician. Include any diagnoses,
medication orders, activity restrictions, action plans, or special accommodations needed for the school environment.
***************************************************************************************************
LIFE-THREATENING ALLERGIES/REACTIONS: Yes No
If yes, to what? ______________________________________________________________________________________
Type of Reaction (circle): Mild Moderate Severe
Please describe reaction: ______________________________________________________________________________
Is an Epi-Pen prescribed: Yes No *************************************************************************************************************************
ASTHMA: Yes No Is an inhaler prescribed for school? Yes No ADD/ADHD: Yes No Is medication prescribed during school hours? Yes No EPILEPSY/SEIZURE DISORDER: Yes No Date of last seizure: ________________ Emergency seizure medication prescribed: Yes No Medication Name: ___________________________________________
Please Complete Reverse side
FO
RM
216
Harbor Creek School District
Updated 2019.03.28
Does your child currently have or had in the past any of the following conditions (please circle and describe
below if needed):
Autism Spectrum Kidney/Bladder Disorder Concussion/Brain Injury
Recent Hospitalization Stomach/Bowel Neuro/Muscular Condition
Heart condition Skin Condition Diabetes/Thyroid issue
Cancer/Blood disorder Anxiety /Mood Disorder Other Respiratory Condition
Hearing Difficulty/Hearing Aides Vision Problems/Glasses Recent Injury/Illness/Surgery
Please describe any of the above conditions you circled:
__________________
__________________________________________________________________________________________
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Dental Exams: Complete ONLY for Grades 1, 3, and 7:
The Pennsylvania School Code provides for periodic dental examinations in grades 1, 3, and 7. The school dentist will be
performing dental exams in the fall of each school year. Please indicate your preference below.
My child receives a regular dental exam. I will provide a copy for the school health record. Exam date: ______________ Dentist Name: _________________________________________ I give my permission for my child to be examined by the school dentist.
Signature for permission for school dentist to examine your child: __________________________________________
Physical Exams: Complete ONLY for Grades K, 6, and 11: The Pennsylvania School Code provides for periodic physical examinations in grades 6 and 11. If your child has not had
either an athletic or annual physical within one year of the current school year, the school physician will provide a
physical examination, free of charge, at a date to be determined. Please indicate your preference below.
My child received a physical exam by our family physician. I will provide a copy for the school health record. Exam date: ____________ Physician Name:________________________________________ My child received a sports physical within the last school year (Sport: ___________________________________)
I give my permission for my child to be examined by the school physician.
Signature for permission for school physician to examine your child: __________________________________________
Please sign below if the medical and health information on this form can be shared with your child’s teachers, bus drivers, coaches,
and other school staff as deemed necessary to best provide for your child during school hours.
Parent/Guardian Signature: Date: __________________________