eastport-south manor central school district student ......anterior(es) no residen en esta...

Eastport-South Manor Central School District Student Admission Form/Formulario de admisión de estudiantes

OFFICE USE ONLY Registration Appt. Date: Registration Complete: Entered in Schooltool:

New Student Re-Entry Student

Student ID No.:

Building: Grade:

Special Education 504 Plan

Homeless Foster

Custody Issue

English Proficient

Transportation Request

Entered in Raptor

Documents Uploaded

Guidance Counselor

Parent Portal Account

Home District (Tuition)

STUDENT INFORMATION/INFORMACIÓN DEL ESTUDIANTE

First Name/Primer nombre:

MI: Last Name/Apellido:

Date of Birth/Fecha de nacimiento: Place of Birth/Lugar de nacimiento: [ ] Male/Masculino

[ ] Female/Femenino

RACE/RAZA: Check all that apply/Marque todas las que apliquen White/Blanca Black or African American/Negra o Afroamericana Asian/Asiática Native Hawaiian/Other Pacific Islander/Nativo de Hawai/Isleño del Pacifico

Hispanic or Latino/Hispano o Latino: YES/SÍ NO

Grade Entering in ESM: ESM SCHOOL:

PARENT/GUARDIAN INFORMATION/INFORMACIÓN DEL PADRE/TUTOR Mother/Guardian Name Custodial Parent? Yes/Sí Nombre de Madre/Tutor ¿Padre con custodia? No Address Dirección Mailing Address (PO BOX ONLY) Dirección de envío (Solamente correo postal) Home Phone Cell Phone Teléfono de casa Teléfono celular Email Address/Dirección de correo electrónico: Employer Name Work Phone Nombre del Empleador Teléfono del trabajo

Father/Guardian Name Custodial Parent? Yes/Sí Nombre de Padre/Tutor ¿Padre con custodia? No Address Dirección Mailing Address (PO BOX ONLY) Dirección postal Home Phone Cell Phone Teléfono de casa Teléfono celular Email Address/Dirección de correo electrónico: Employer Name Work Phone Nombre del Empleador Teléfono del trabajo

MILITARY SERVICE Is a parent/guardian of child in active military service: NO YES/SÍ ¿Está un padre / tutor del niño en servicio militar activo? If yes, what branch of the military? ____________________________________________ En caso afirmativo, ¿qué rama de las fuerzas armadas?

GUARDIANSHIP/CUSTODY INFORMATION

Guardians of the student must be identified to ensure each party’s rights are respected. If an order exists affecting guardianship rights or custody or access rights, a copy of the order will be required to be placed in the student record. Los tutores del estudiante deben ser identificados para garantizar que se respeten los derechos de cada parte. Si existe una orden que afecta los derechos de tutela o la custodia o los derechos de acceso, se requerirá una copia de la orden que se colocará en el registro del estudiante. Please indicate if any such document(s) exist: YES/SÍ NO Por favor indique si existe algún documento de este tipo Type of legal document Tipo de documento legal

Custody Custodia

Guardianship Tutela

Order of Protection Orden de protección

Other Otro

PREVIOUS EDUCATION INFORMATION Has this child ever been enrolled in the Eastport-South Manor Central School District? NO YES, year ________ ¿Se ha matriculado alguna vez este niño(a) en el Distrito Escolar Central de Eastport-South Manor? Sí, año ________ Previous School District/Distrito escolar anterior

Date of last day of attendance at previous school Fecha de último día de asistencia a la escuela anterior

Has this child ever been retained? NO YES, year/grade: __________________ ¿Ha sido retenido este niño(a) alguna vez? Sí, año/grado: __________________

HOME LANGUAGE/IDIOMA DEL HOGAR

Language spoken at home/Idioma hablado en casa _____________________________ Do you need correspondence and phone calls in a language other than English? ¿Necesita correspondencia y llamadas telefónicas en un idioma que no sea inglés? YES/SÍ NO If yes, what language? En caso afirmativo, ¿qué idioma? ________________________

Do you need an interpreter for meetings? ¿Necesita un intérprete para las reuniones? YES/SÍ NO

SIBLING INFORMATION/INFORMACIÓN DE HERMANOS Name Nombre Date of Birth

Fecha de nacimiento

Name Nombre Date of Birth Fecha de nacimiento



SPECIAL EDUCATION INFORMATION/INFORMACIÓN DE EDUCACIÓN ESPECIAL Does your child receive Special Education or related services? ¿Recibe su hijo(a) servicios de educación especial o servicios relacionados? NO YES/Sí If yes, please indicate below and provide a copy of the student’s IEP (Individualized Education Program)/En caso afirmativo, indique a continuación y proporcione una copia del IEP (Programa de educación individualizada) del estudiante Resource Room Special Class Speech Counseling Other _____________________ Aula de recursos Clase especial Habla Asesoramiento Otro

UNACCOMPANIED YOUTH/ EMERGENCY CONTACT INFORMATION JOVEN NO ACOMPAÑADO/INFORMACIÓN DE CONTACTO DE EMERGENCIA

If the student is an UNACCOMPANIED YOUTH, give the address and telephone number of any living natural parent/guardian in the space below. Si el estudiante es un JOVEN NO ACOMPAÑADO, indique la dirección y número de teléfono de cualquier padre natural vivo/tutor en el espacio abajo. Name/Nombre Relationship

Relación

Address/Dirección Home Phone # Teléfono de casa

FOSTER CHILD/HIJO(A) ADOPTIVO Is child a Foster Child? NO YES/SÍ If yes, Form DSS-2999 must be provided. ¿Es el nino(a) de acogida? En caso afirmativo, se debe proporcionar el formulario DSS-2999. Foster Agency/Agencia de crianza: ________________________________________Telephone/Teléfono_______________________________

Address/Dirección:_____________________________________________________________________________________________________

Case Worker/El asistente social: ____________________________________________________

EMERGENCY CONTACT INFORMATION if parents cannot be reached (STUDENT WILL NOT BE RELEASED TO ANYONE NOT LISTED BELOW)

INFORMACIÓN DE CONTACTOS DE EMERGENCIA si los padres no pueden ser localizados (EL ESTUDIANTE NO SERÁ ENTREGADO A CUALQUIER PERSONA QUE NO ESTE EN LA LISTA ABAJO)

Name/Nombre Relationship Relación


Cell Phone # Teléfono celular










Under penalty of perjury, the statements contained in this application are true. I understand that the statements in this application are subject to verification by the school district, and that false statements could subject me to retroactive transportation and/or tuition charges where applicable.

I also understand that it is my responsibility to notify the school district of any changes or circumstances involving my residency. Bajo pena deperjurio, las declaraciones contenidas en esta solicitud son verdaderas. Entiendo que las declaraciones en esta solicitud están sujetas a verificación por parte del distrito escolar, y que las declaraciones falsas podrían someterme a cargos retroactivos de transporte y / o matrícula cuando corresponda. También entiendo que es mi responsabilidad notificar al distrito escolar sobre cualquier cambio o circunstancia que involucre mi residencia. ____________________________________________________________ _________________________________________Parent/Guardian Signature Date Firma del Padre/Tutor Fecha

Eastport-South Manor Central School District RESIDENCY REQUIREMENTS/REQUISITOS DE RESIDENCIA

The Board of Education requires that positive proof of residency be submitted when students are enrolled in the district. All proofs of residency must be current, within 30 days of registration. La Junta de Educación requiere que se presente comprobantes positivos de residencia cuando los estudiantes estén inscritos en el distrito. Todas las pruebas de residencia deben estar al día, dentro de 30 días de matriculación.

Do you own your home? Yes/Sí If yes, how long have you lived at this address? ___________________ ¿Eres dueño de tu casa? Si es así, ¿cuánto tiempo has vivido en esta dirección?

No If No, I rent/live in the home owned by: _________________________ Si no, alquilo/vivo en la casa propiedad de:

You must provide at least one item from Section A and two items from Section B below: Debes proveer por lo menos un artículo de la Sección A y dos artículos de la Sección B abajo:

Section A/Sección A Section B/Sección B

Deed, Tax Bill or Mortgage Statement Escritura, factura de impuestos o declaración de hipoteca

Photo Identification (Driver’s license, government issued identification, passport) Identificación con foto (licencia de conducir, identificación emitida por el gobierno, pasaporte).

Real Estate Closing Statement Declaración de cierre de bienes raíces

Current Utility Bill (PSEG, Cable, Water, Oil/Fuel) indicating the address of residence. Factura actual de servicios públicos (PSEG, cable, agua, aceite / combustible) que indica la dirección de residencia.

Lease or Rental Agreement* Contrato de arrendamiento o alquiler*

*Registration Affidavit Form. This form must accompanythe Lease or Rental Agreement. *Formulario dedeclaración jurada de registro. Este formulario debeacompañar el contrato de arrendamiento o alquiler.

The Registration Affidavit Form IS NOT required if you reside in Pine Hills. No se requiere el Formulario de Declaración Jurada de Registro si vive en los Apartamentos Pine Hills.

Documents issued by Federal, State or local agencies (Voter Registration, Federal Office of Refugee Resettlement, local social service agency). Documentos emitidos por agencias federales, estatales o locales (Registro de votantes, Oficina Federal de Reasentamiento de Refugiados, agencia local de servicios sociales).

OFFICE USE ONLY Homeowner Renter

Mortgage Statement Tax Bill Deed

Lease Registration Affidavit

Photo Identification Utility Bill

EASTPORT-SOUTH MANOR CENTRAL SCHOOL DISTRICT Central Registration

149 Dayton Avenue – Administration Office, Manorville, NY 11949

Phone: (631) 801-3045 / Fax: (631) 874-6750

REGISTRATION AFFIDAVIT

STATE OF NEW YORK COUNTY OF SUFFOLK

I, _________________________________________________________: Print Owner/Landlord’s Name

▪ Reside at _________________________________________________________________________________,

▪ My contact telephone number is ____________________________

▪ I am the owner of the residence located at ________________________________________________________,New York, which is within the boundaries of the Eastport-South Manor Central School District, and have thefollowing person(s) residing in said residence for a period of ______ years, beginning ___/___/___ and ending___/___/___. (Please include the names of everyone living at the residence):

_______________________________________ __________________________________________

_______________________________________ __________________________________________

_______________________________________ __________________________________________

_______________________________________ __________________________________________

I understand that it is my responsibility to inform the District if/when the conditions set forth above terminate or change. In the event the Eastport-South Manor Central School District determines that the above person(s) do not reside at this address or have moved and remained registered, these students will be dropped from the atte ndance register of the Eastport-South Manor Central School District. I also understand that as the homeowner, I may be liable for tuition and/or transportation costs for each student listed above that received services from or attended the Eastport-/South Manor Central School District.

************************************************************************************************** You as deponent understand that this affidavit is made under oath; that the statements are true; that the Eastport-South Manor Central School District Board of Education will rely thereon, and that any misstatements made could result in criminal (perjury) charges being brought against the person whose signature appears hereon.

___________________________________ Signature of Deponent (Owner/Landlord)

Sworn to before me this________

day of _______________, 20____

____________________________ Notary Public:

Eastport-South Manor Central School District 149 Dayton Avenue - Oficina de Administración, Manorville, NY 11949

Teléfono: (631) 801-3045 / Fax: (631) 874-6750

Declaración jurada de registro

ESTADO DE NUEVA YORK, CONDADO DE SUFFOLK

Yo, _________________________________________________: Nombre del dueño/propietario

▪ Resido en __________________________________________________________________________,

▪ Mi número de teléfono de contacto es ___________________________

▪ Soy el dueño de la residencia ubicada en______________________________________________, NewYork, que se encuentra en los límites del Distrito Escolar Central de Eastport-South Manor, y tengo la(s)siguiente(s) persona(s) que reside(n) en dicha residencia por un período de _____ años, comenzando___ / ___ / ___ y terminando ___ / ___ / ___. (Incluya los nombres de todas las personas que viven en

la residencia).

_________________________________ ___________________________________ _________________________________ ___________________________________ _________________________________ ___________________________________ _________________________________ ___________________________________

Entiendo que es mi responsabilidad informar al Distrito si/cuando las condiciones establecidas anteriormente terminen o cambien. En el caso de que el Distrito Escolar Central de Eastport-South Manor determine que la(s) persona(s)anterior(es) no residen en esta dirección o se hayan mudado y permanezcan inscritos, estos estudiantes seráneliminados del registro de asistencia del Distrito Escolar Central de Eastport-South Manor. También entiendo que, comopropietario de vivienda, puedo ser responsable de los costos de matrícula y/o transporte para cada estudiantemencionado anteriormente que recibió servicios del Distrito Escolar Central de Eastport-South Manor o asistió a él.

******************************************************** ***************************************** Como deponente entiende que esta declaración jurada se hace bajo juramento; que las afirmaciones son ciertas; que la Junta de Educación del Distrito Escolar Central de Eastport/South Manor se basará en ello, y que cualquier declaración errónea podría dar lugar a cargos penales (perjurio) contra la persona cuya firma aparece aquí.

______________________________ Firma del Declarante (Arrendador)

Jurado ante mí este________ día de _______________, 20____ ____________________________ ____________________________ Notario público:

EASTPORT-SOUTH MANOR CENTRAL SCHOOL DISTRICT

NAME OF CHILD/Nombre del niño(a): ____________________________________________

HEALTH HISTORY INFORMATION/INFORMACIÓN DE HISTORIA DE SALUD

Has your child ever had any of the following? □ Yes/Sí □ No

¿Alguna vez su hijo(a) ha tenido alguno de los siguientes?

□ Pneumonia □ Whooping Cough □ Tonsillitis Neumonía Tos ferina Amigdalitis □ Tuberculosis □ German measles □ Frequent Colds Sarampión alemán Resfriados frecuentes □ Rheumatic Fever □ Asthma □ Hearing Loss Fiebre reumática Asma Pérdida de la audición □ Epilepsy □ Diabetes □ Vision Problems Epilepsia Problemas de la vista

□ Chicken Pox □ Anemia or Sickle Cell □ Heart Trouble Varicela Anemia o células falciformes Problemas del corazón

□ Measles □ Mononucleosis □ Skin Disorder Sarampión Trastorno de la piel

□ Mumps □ Kidney Trouble □ Hernias Paperas Problemas de riñón Is there anything concerning the eyes, ears, or health of this child which the school should know in order to provide special care? ¿Hay algo relacionado con los ojos, oídos o salud de este niño que la escuela debe saber para brindar atención especial? ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

ALLERGY SCREENING/EXAMEN DE ALERGIA

If your child has an allergy (such as food, medication, or environmental) please answer the following questions: Si su hijo(a) tiene una alergia

(como alimentos, medicamentos o el medio ambiente), responda las siguientes preguntas:

1. Is your child allergic to anything? □ YES/SÍ □ NO ¿Esta su hijo(a) alérgico a alguna cosa? *Please include any food, medication or environmental allergies* *Por favor incluye alergias alimentales, a medicamentos o

ambientales* Please specify allergen and your child’s reaction (i.e. hives, rash, shortness of breath, etc.): Por favor especifique el alérgeno y la reacción

de su hijo(a) (es decir, urticaria, sarpullido, falta de respiro, etc.): _________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

2. Does your child have a prescribed EpiPen for this allergy? □ YES/SÍ □ NO ¿Tiene su hijo(a) un EpiPen recetado para esta alergia?

3. Is your child at risk of a life-threatening allergic reaction? □ YES/SÍ □ NO ¿Está su hijo(a) en riesgo de una reacción alérgica potencialmente mortal?

4. Has your child’s allergy been identified through allergy testing? □ YES/SÍ □ NO

¿Se ha identificado la alergia de su hijo(a) a través de pruebas de alergia? 5. Please check circumstances in which reaction could occur:

Por favor marque las circunstancias en las cuales podría ocurrir una reacción: □ Contact □ Ingestion □ Airborne Contacto Ingestión Aerotransportado

ASTHMA/ASMA

If your child has asthma, please answer the following questions: Si su hijo(a) tiene asma, por favor conteste las siguientes preguntas:

1. Does your child have asthma? □ YES/SÍ □ NO

¿Su hijo(a) tiene asma? 2. Does your child use an inhaler or a nebulizer at home? □ YES/SÍ □ NO

¿Usa su hijo(a) un inhalador o un nebulizador en casa? 3. Will medication be required for use during school hours? □ YES/SÍ □ NO ¿Se requerirá la medicación durante las horas escolares?

ILLNESS, INJURY OR OPERATION/ENFERMEDAD, LESION U OPERACION

Has your child, during the past year had any illness, injury or operation? If so, please write name and date of illness below. ¿Durante el año pasado ha tenido su hijo(a) alguna enfermedad, lesión u operación? Si es así, escriba el nombre y la fecha de la enfermedad a continuación. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICATIONS/MEDICAMENTOS

Please list any medications your child is presently taking. Por favor enumere cualquier medicamento que su hijo(a) esté tomando al presente. ________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________ *If your child requires an over the counter medication or prescription medication during school hours, a doctor’s order along with parent/guardian consent must be obtained. *Si su hijo(a) requiere un medicamento de venta libre o un medicamento recetado durante el horario escolar, se debe obtener una orden del médico junto con el consentimiento del padre / tutor. •The medication must be brought to school by a parent/guardian in the original container.

El padre/tutor debe traer el medicamento a la escuela en el envase original.

•Medication cannot be transported on the school bus. La medicación no puede ser transportada en el autobús escolar. In the event of an emergency where a parent cannot be reached, I give permission for my child to receive medical treatment. En el caso de una

emergencia en la que no se pueda contactar a un padre, doy permiso para que mi hijo(a) reciba tratamiento médico.

PHYSICAL EXAMINATION/EXAMEN FÍSICO

A physical examination by a private physician or the school physician, on entry of school and routinely at grades PreK or K, 1, 3, 5, 7, 9, & 11 is compulsory. Un examen físico realizado por un médico privado o el médico de la escuela, al ingresar a la es cuela y rutinariamente en los grados Pre-K, K, 1, 3, 5, 7, 9 y 11 es obligatorio. Please check the appropriate item:/Por favor marque el artículo apropiado: _____ I wish to have my child examined by the family physician at my expense and will submit a report to the school by October 15th or 30

days after entry for students newly enrolled in the district. If the results of your child’s examination have not been received by this date, the school physician will examine your child. Deseo que mi hijo(a) sea examinado por el médico de familia a mi costa y presentará un

informe a la escuela a más tardar el 15 de octubre o 30 días después de entrada para los estudiantes de nuevo ingreso en el distrito. Si los resultados del examen de su hijo(a) no se han recibido por estas fechas, el médico de la escuela lo examinará.

_____ I wish to have my child examined without cost by the school physician. Deseo que mi hijo(a) sea examinado sin costo por el médico

escolar.

Parent/Guardian Signature Date

Firma del Padre/Tutor Fecha

EASTPORT-SOUTH MANOR CENTRAL SCHOOL DISTRICT 149 Dayton Avenue – Administration Office, Manorville, NY 11949

Phone: (631) 801-3045 / Fax: (631) 874-6750

CONSENT FOR RELEASE OF SCHOOL RECORDS Consentimiento para la divulgación de registros escolares

STUDENT NAME: ____________________________________________________________________________________ Nombre del estudiante

Date of Birth: ______________________________________ Current/Entering Grade: _________________________ Fecha de nacimiento Grado actual/de entrada

The above listed student enrolled in the Eastport-South Manor Central School District on ________________. Please send all applicable records pertaining to this student TO THE SCHOOL LISTED BELOW. El estudiante indicado arriba se matriculo en el Distrito Escolar Central de Eastport-South Manor en la fecha ________. Por favor manda todos los registros aplicables relativas al estudiante A LA ESCUELA INDICADA ABAJO.

□ Cumulative Academic Record – Registro académico acumulativo □ Standardized Test Data/NYS Assessments – Datos de exámenes estandarizadas/Evaluaciones del Estado

de New York □ Most Recent Report Card, Transcript – Tarjeta de calificaciones más recientes/Expediente académico □ NYSESLAT/NYSITELL Scores - Calificaciones de NYSESLAT/NYSITELL □ Health Records (Immunizations, Current Physical) – Registros de salud (vacunas, físico actual) □ Attendance Records – Registros de asistencia □ Discipline Records – Registros disciplinarios □ Special Education Records (including but not limited to) – Registros de educación especial (incluyendo,

pero no limitándose a: ✓ Current Individualized Education Program (IEP) – Programa de educación individualizada actual ✓ Psychological Records – Registros psicológicas ✓ Evaluations (Speech and Language, Medical) – Evaluaciones (de habla y lenguaje, y de medica) ✓ Social History – Historia social

----------------------------------------------------------------------------------------------------------------------------- ----------------------------------- I hereby agree to the release of school records from/Al presente, estoy de acuerdo con la liberación de archivos escolares de: School/Escuela: ________________________________________________________________________ Address/Dirección: ________________________________________________________________________ Telephone Number: ____________________________ Fax Number: ____________________________ Número de teléfono Número de fax Eastport Elementary School Dayton Avenue Elementary School Tuttle Avenue Elementary 390 Montauk Highway 151 Dayton Avenue 1 Tuttle Avenue Eastport, NY 11941 Manorville, NY 11949 Eastport, NY 11949 Fax: 631-325-1066 Fax: 631-878-6404 Fax: 631-325-1952 South Street Elementary School Eastport-South Manor Junior-Senior High School 130 South Street 543 Moriches Middle Island Road

Manorville, NY 11949 Manorville, NY 11949 Fax: 631-878-4954 Fax: 631-874-6790

________________________________________________ _______________________________________________

Parent/Guardian Signature Date Principal/Counselor/Registrar Date Firma del Padre/Tutor Fecha

EASTPORT-SOUTH MANOR CENTRAL SCHOOL DISTRICT RESIDENCY QUESTIONNAIRE/CUESTIONARIO DE RESIDENCIA

Name of LEA: EASTPORT-SOUTH MANOR CENTRAL SCHOOL DISTRICT Nombre de LEA

School Building : Edificio escolar

Name of Student: Nombre de estudiante Last Name/Appellido First Name/Primer Nombre

Gender: [ ] Male/Masculino Date of Birth: / / Grade: ______________ [ ] Female/Femenino Fecha de nacimiento Grado

Street Address/Dirección: _____________________________________________Phone: _____________________ City/Ciudad: ____________________________, Teléfono de casa

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. La respuesta que usted da a continuación ayudará al distrito a determinar qué servicios usted o su hijo(a) tal vez pueda recibir bajo el acto de McKinney-Vento. Los estudiantes que están protegidos bajo el acto de McKinney-Vento tienen derecho a la matriculación inmediata en la escuela, incluso si no tienen los documentos normalmente necesarios, tales como prueba de residencia, registros escolares, registro de vacunación, o certificado de nacimiento. Los estudiantes que están protegidos bajo el acto de McKinney-Vento también pueden tener derecho a transporte gratuito y otros servicios.

Where is the student currently living? (Please check one box.) ¿Dónde reside el estudiante actualmente? (por favor marque una casilla.):

□ In a shelter/En un refugio

□ With another family or other person (sometimes referred to as “doubled-up”)/Con otra familia u otra

persona

□ In a hotel or motel/En un hotel o motel

□ In a car, park, bus, train, or campsite/En un automóvil, parque, autobús, tren o campamento

□ Other temporary living situation (Please describe):

Otra situación de vivienda temporal (Por favor describa):

□ In permanent housing/En vivienda permanente

Print name of Parent/Guardian Signature of Parent/Guardian Escriba nombre de Padre/Tutor Firma de Padre/Tutor

Date/Fecha: ________________________

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

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

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 homeor 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 Fatherspecify specify

Guardian(s)specify

4. What language(s) does your child understand? English Other

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

Home Language Questionnaire (HLQ)—Page Two

Relationship to student: Mother Father Other:

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 inEnglish 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:

ORAL INTERVIEW NECESSARY: NO YES

**DATE OF INDIVIDUAL INTERVIEW:

OUTCOME OF

INDIVIDUAL

INTERVIEW:

ADMINISTER NYSITELL

ENGLISH PROFICIENT

REFER TO LANGUAGE PROFICIENCY TEAMMO DAY YR.

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL

NAME: POSITION:

DATE OF NYSITELLADMINISTRATION:

PROFICIENCY LEVEL

ACHIEVED ON

NYSITELL: ENTERING EMERGING TRANSITIONING EXPANDING COMMANDING

MO. DAY YR.

FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:

Dental Health Certificate- Optional Parent/Guardian: New York State law (Chapter 281) permits schools to request an oral health assessment at the same time a health examination is required. 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 registered dentist or registered dental hygienist for an assessment. If your ch ild had a dental

check-up before he/she started the school, ask your dentist/dental hygienist 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 oral health assessment? 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 activit ies? 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 servic es 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/ Dental Hygienist

I. The dental health condition of _______________________________ _______ on__________ (date of assessment) The date of the assessment 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 designat ion 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/ Dental Hygienist’s name and address

(please print or stamp) Dentist’s/Dental Hygienist’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 s mooth 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):_______________________________________________________________________________

II. 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.

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

Name: Sex: M F DOB:

School: Grade: Exam Date:

HEALTH HISTORY

Allergies ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached

☐ Food ☐ Insects ☐ Latex ☐ Medication ☐ Environmental

Asthma ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Asthma Care Plan Attached

☐ Intermittent ☐ Persistent ☐ Other : ___________________________

Seizures ☐ No ☐ Medication/Treatment Order Attached ☐ Seizure Care Plan Attached

☐ 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

Height: Weight: BP: Pulse: Respirations:

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

_________________________ _____________

_________________________ _____________

_________________________ _____________

☐ Additional Information Attached _________________________ _____________

Rev. 5/4/2018 Page 2 of 2

Name: DOB:

SCREENINGS

Vision Right Left Referral Notes

Distance Acuity 20/ 20/ ☐ Yes ☐ No

Distance Acuity With Lenses 20/ 20/

Vision – Near Vision 20/ 20/

Vision – Color ☐ Pass ☐ Fail

Hearing Right dB Left dB Referral

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:

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

☐ 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

☐ Order Form for Medication(s) Needed at School attached

List medications taken at home:

IMMUNIZATIONS

☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No

HEALTH CARE PROVIDER

Medical Provider Signature: Date:

Provider Name: (please print) Stamp:

Provider Address:

Phone:

Fax:

Please Return This Form To Your Child’s School When Entirely Completed.