BLOOMINGDALE ELEMENTARY SCHOOLS ______________________________________________________________________________

DU PAGE SCHOOL DISTRICT 13 MR. MARK J. DWYER DU JARDIN SCHOOL Principal 166 Euclid Ave.

Bloomingdale, IL 60108-1586 MRS. STACY JOHNSTON (630) 894-9200 Assistant Principal FAX (630) 894-9545 www.sd13.org Dear Parents: Welcome to DuJardin School and the Kindergarten Registration process for 2016-2017. The documents that need to be completed for registration are enclosed. Registration will take place at DuJardin School the week of February 15th. Listed below are the dates and times: Tuesday, February 16 8:00 – 4:00 p.m. Wednesday, February 17 8:00 – 6:00 p.m. Thursday, February 18 8:00 – 4:00 p.m. Friday, February 19 8:00 – 4:00 p.m. All parents must also bring their child’s certified birth certificate to Kindergarten Registration. Completing these forms at home will reduce the amount of time it will take you to complete the registration process. If you have any questions, please call me at 894-9200. Sincerely, Mr. Mark Dwyer Principal

BLOOMINGDALE SCHOOL DISTRICT 13

2016-2017 KINDERGARTEN REGISTRATION CHECKLIST

*Please return this sheet with completed documents to the school office. Student’s Legal Name _____________________________ ___________________________________ School ___________________________________________ __________________________________

Proof of Residency Three documents are required as shown on the “Proof of Residency” form. A child cannot start until the residency requirement is complete.

Certified Birth Certificate. Please have the parent contact the appropriate county office vital records department to obtain the official birth record for their child. Phone numbers for surrounding counties are: DuPage County – 630-682-7400; Cook County – 866.252.8974; Kane County – 630-232-5950; Lake County – 847-377-2400. The parent can also go to a local Currency Exchange to obtain a birth certificate.

Seven registration forms: Proof of Residency Sheet

Student Registration & Emergency Consent Form Ethnicity/Race Letter and Form Class Placement Background Information Sheet

Language Survey Medical Information/Release Form

Military Letter

Student fees. These fees are current fees that should be paid as part of registration. If fees are paid at a later date, they will be next ye ar’s fees.

Student textbook fees ($50.00) – mandatory

Student technology Fee ($50.00) – mandatory Student milk fees ($22.00) – optional Student bus fees ($375.00) – when applicable

Optional Forms. Affidavit Fee Waiver

BLOOMINGDALE SCHOOL DISTRICT 13 2016-2017 PROOF OF RESIDENCY FORM

(Students must be District residents as of August 17, 2016)

ALL DOCUMENTS ACCEPTED FOR PROOF OF RESIDENCY MUST HAVE THE SAME ADDRESS:

Category I: Provide one of the following documents:

� Illinois Driver’s License � Illinois State ID � Other Photo ID

Category II: Provide one of the following documents:

� Current mortgage statement or closing statement from bank or lender � Real estate tax bill from current school year � Current lease showing the name, address and phone number of landlord

� Notarized Affidavit of Residency Form including names of students living in the residence

Category III: Provide one of the following documents:

� Current electric, water, gas or cable/internet bill in your name � Valid Illinois vehicle registration � Current pay stub from your employer

� Current public aid card or document from DHS or DCFS that includes your name

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

This proof of residency form is to attest that the child is not enrolling in the District solely for school purposes

and is living on a permanent basis with the person having complete custody and control. Registration of a

student who is not a resident is a fraudulent act. Any student found to have been fraudulently registered will

be dropped from the attendance rolls immediately. Parents or guardians making a fraudulent registration

will be subject to the payment of retroactive tuition charged for non-resident students, not to exceed 110%

of the per capita cost. A person who knowingly or willfully presents the District with any false information

regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in the District

shall have committed a Class C misdemeanor and shall be prosecuted by the District. National

Investigations, Inc. will be conducting a home visit if fraud is suspected.

I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.

Parent/Guardian Signature ___________________________________ Date ___________________

Parent/Guardian Address _________________________________ Telephone ______________

Name of Student _______________________________________ School __________________

Name of Student _______________________________________ School __________________

Name of Student _______________________________________ School __________________

Name of Student _______________________________________ School __________________

BLOOMINGDALE ELEMENTARY SCHOOL DISTRICT 13REGISTRATION AND EMERGENCY CONSENT FORM

164 S. Euclid Avenue - Bloomingdale, IL 60108-1634 - 630-893-9590

Bus Paid Book Paid AMOUNT

=

CASH CHECK # TOTAL PAID

Father First and Last Name Father Daytime Phone 1 CIRCLE ONE

Father Daytime Phone 2

Mother First and Last Name Mother Daytime Phone 1

Mother Daytime Phone 2Mother Maiden Name

District 13 uses an automated communication system to notify parents and guardians through phonecalls and texts of school closings, emergencies, and other important information. In the box below,please provide us with a phone number for these notifications. This number must be a direct line (noextension).

Name School(Circle one)

OTHER CHILDREN IN DISTRICT 13

EMERGENCY CONSENT

If the parents or guardians cannot be contacted in case of a serious injury or illness, I authorize the school districtto take such emergency action as may be deemed necessary, including the transportation of the student to ahospital or medical center. As a parent/guardian, I authorize the treatment by a licensed medical doctor of theabove named minor in the event of a medical emergency which, in the opinion of the attending physician, mayendanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authorityis granted only after a reasonable effort has been made to reach me.

THIS AUTHORIZATION IS TO CONTINUE FROM YEAR TO YEAR UNLESS REVOKED IN WRITING

SIGNATURE OF PARENT OR GUARDIAN TO VERIFY THE INFORMATION ON THIS FORM

DATE

X

E

E

E

DJ W

DJ W

DJ W

home cell work

home cell work

home cell work

home cell work

Student Full Legal Last Name Student Full Legal First Name Student Full Legal Middle Name Sex (M/F) Birth Date Home Phone

LOCAL EMERGENCY CONTACTS, OTHER THAN PARENTS

Name Phone

PhoneName

01/05/2016

B - Both ParentsM - Mother F - FatherG - Guardian O - Other

Parent E-Mail Address Guardianship

SID Number ID Number Entry Date School Grade Bus RouteBus Status* Textbook FeeMilk FeeBus Fee

*W - No Bus F - Free P - Pay H - Free/Hazard

DO NOT WRITE ABOVE THIS LINE - OFFICE USE ONLY

Native Language Spoken in the Home

Street Address City Zip Code (See Language Codes sheet in packet)

Lives with

I authorize Bloomingdale School District 13 to use a photo of my child in the school newsletter or on theDistrict's web page.

Yes No

Technology Fee

Milk Paid Tech Paid

Code Language Code Language Code Language Code Language Code Language000 English 034 Vietnamese 068 Hmong 102 Gaelic (Irish) 136 Kashi (Uyghur) 001 Spanish 035 Russian 069 Kanuri 103 Akan (Fante, Asante) 137 Tibetan 002 Greek 036 Cebuano (Visayan) 070 Icelandic 104 Tuluau 138 Maori 003 Italian 037 Gujarati 071 Ga 105 Amharic 139 Kache (Kaje, Jju) 004 Polish 038 Latvian 072 Menominee 106 Oulof (Wolof) 140 Mina (Geser-Goram) 005 German 039 Sioux (Dakota) 073 Cambodian (Khmer) 107 Balinese 141 Mongolian 006 Algonquin 040 Norwegian 074 Lao 108 Chamorro 142 Kpelle 007 Serbian 041 Danish 075 Shona 109 Tigrinya (Tigrigna) 143 Ilonggo (Hiligaynon) 008 Korean 042 Albanian, Gheg (Kosovo/Macedon) 076 Afrikaans (Taal) 110 Assamese 144 Efik 009 Pilipino (Tagalog) 043 Comanche 077 Nepali 111 Eskimo 145 Sourashtra (Saurashtra) 010 Arabic 044 Finnish 078 Marathi 112 Bagheli 146 Mien (Yao) 011 Japanese 045 Slovak 079 Oneida 113 Hakka (Chinese) 147 Chaochow/Teochiu (Chinese) 012 French 046 Swahili 080 Hausa 114 Welsh 148 Fukien/Hokkien (Chinese) 013 Samoan 047 Taiwanese/Formosan/Min Nan 081 Hemba 115 Guyanese 149 Hainanese (Chinese) 014 Hindi 048 Creek 082 Pima 116 Bisaya (Malaysia) 150 Shanghai (Chinese) 015 Burmese 049 Haitian-Creole 083 Isoko 117 Chechen 151 Croatian 016 Yiddish 050 Chippewa/ Ojibawa/ Ottawa 084 Pueblo 118 Pampangan 152 Bosnian 017 Lithuanian 051 Gbaya 085 Ibo/Igbo 119 Konkani 153 Albanian, Tosk (Albania) 018 Ukrainian 052 Ewe 086 Telugu (Telegu) 120 Krio 154 Tongan 019 Hungarian 053 Panjabi (Punjabi) 087 Choctaw 121 Kurdish 155 Uzbek 020 Czech 054 Bemba 088 Winnebago 122 Lingala 156 Jamaican 021 Cantonese (Chinese) 055 Bulgarian 089 Kikamba (Kamba) 123 Luganda 157 Dinlea (Turkish) 022 Thai 056 Apache 090 Yoruba 124 Luyia (Luhya) 158 Chaldean 023 Portuguese 057 Gaelic (Scottish) 091 Maltese 125 Lunda 159 Kanjobal 024 Swedish 058 Macedonian 092 Luo 126 Yombe 160 Palauan 025 Assyrian (Syriac, Aramaic) 059 Malay 093 Romany (Gypsy) 127 Okinawan 161 Hawaiian 026 Armenian 060 Malayalam 094 Tamil 128 Oriya 162 Maay or Mai Mai 027 Romanian 061 Navajo 095 Hopi 129 Orri (Oring) 163 Krahn (Liberia, Cote 'de Ivoire) 028 Dutch/Flemish 062 Indonesian 096 Slovenian 130 Ilocano 164 Somali 029 Hebrew 063 Kannada (Kanarese) 097 Cherokee 131 Pashto (Pushto) 165 American Sign Language 030 Mandarin (Chinese) 064 Estonian 098 Crow 132 Sikkimese 031 Farsi (Persian) 065 Chichewa (Nyanja) 099 Other 133 Sindhi 032 Turkish 066 Kashmiri 100 Mandingo (Mandinka) 134 Sinhalese 033 Urdu 067 Bengali 101 Mende 135 Sotho

Native Language Codes

ISBE 05/01/08

CLASS PLACEMENT BACKGROUND INFORMATION SHEET

Student's Name Date of Birth________________ Date School _____________ Last G rade Completed ___________

Yes No

Was the student last enrolled in a regular education classroom? If no, please list type of classroom:

Was the student ever enrolled in a special education program? If yes,

Was it a full day class?

Was it a partial day class?

Was it for Learning Disabilities?

Was it for Speech?

Was it another type of class?

Does the student have special needs in:

Learning?

Communication?

Physical?

Health?

Social?

Has the student been in a gifted and/or talent program?

Has the student been in a Title I Program?

Has the student been in a Bilingual Education Program?

3/2010

STUDENT LANGUAGE SURVEY Indicate the best answer to each question: 1. Was English the first language the student learned? Yes No 2. If no is the answer to question # 1. What was the first language learned by

the child? ______________________________ 3. Can the student speak a language other than English? Yes No 4. Code number of language spoken in the home, if other than English. ______ 5. What language is spoken in the home? ________________________________ 6. What language do you most often use to speak to your child?

_________________________________ 7. What language does the student use most often when speaking to parents?

(Specific language spoken) ___________________________________________

8. What language does the child use most often with friends outside the home? _____________________________________

9. Please circle the number that corresponds with your appropriate race.

1. American Indian or Alaska Native 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Island 5. White

10. Can an adult family member or extended family member speak English?

______________________ If yes, who can speak English? _______________ Can they read English? ___________________

Prior Schooling: 11. When did your child first enter school in the USA? In what state?

_____________________________________

12. Was the student enrolled in a bi-lingual or ESL program? Yes No (over)

13. If #11 is yes, give the name and location of the school where the student

received the bi-lingual instruction. 14. Did the student exit the program? ____________ Exit Date: ______________ 15. What country was the student born in? 16. What is the student’s native country? 17. How many years has the student been in the United States? 18. What is the father’s native country? 19. What is the mother’s native country? Parent/Guardian Signature

3/2010

MEDICAL INFORMATION/RELEASE FORM Return to Health Office

*** THIS FORM MUST BE SIGNED and DATED ***

THIS FORM IS IMPORTANT IN THE CARE OF YOUR STUDENT WHILE AT SCHOOL, and IF YOUR CHILD SHOULD NEED IMMEDIATE EMERGENCY CARE, IT WOULD BE NECESSARY FOR THE HEALTH OFFICE TO HAVE THIS INFORMATION AVAILABLE IMMEDIATELY. PLEASE REMEMBER TO PROVIDE UPDATED INFORMATION TO THE NURSE WHEN HEALTH CHANGES OCCUR AND UPDATED INFORMATION TO THE SCHOOL OFFICE WHEN CONTACT INFORMATION CHANGES.

STUDENT NAME: DOB: GENDER: SCHOOL: GRADE: HEALTH/MEDICAL INFORMATION: Any known health conditions (please be specific): Current treatment: Any illnesses, injuries, or surgery within this last year: YES NO (If yes, please explain.)

Does your child need an asthma inhaler during the school day or for sports? YES NO

(If yes, please note any restrictions, include a copy of the emergency plan, and complete the medication authorization form. This form must be completed by both physician and parent. )

Does your child have any vision or hearing difficulties? If yes, please specify:

Please circle corrective devices your child may need at school: Glasses Contacts Hearing aid Orthopedic aides Other:

Is there anything about your child’s health (physical or emotional) that you would like the teacher or nurse to know? If yes, please specify:

ALLERGIES: Insects/Bees: Localized: YES NO Severe: YES NO Epi-Pen required? YES NO Benadryl required? YES NO Foods (please list): Epi-Pen required? YES NO Benadryl required? YES NO

(If yes, please note any restrictions, include a copy of the emergency plan, and complete the medication authorization form. This form must be completed by both physician and parent. )

Medication allergies (please list): MEDICATIONS: Medication taken at HOME on a regular basis:

Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason:

Medication needed at SCHOOL on a regular basis: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason:

IF NEITHER PARENT/GUARDIAN CAN BE CONTACTED, I AUTHORIZE THE SCHOOL ADMINISTRATION TO TAKE SUCH EMERGENCY ACTION AS NEEDED. DATE: SIGNATURE OF PARENT/GUARDIAN: PRINTED NAME OF PARENT/GUARDIAN: PHONE:

BLOOMINGDALE SCHOOL DISTRICT 13 2016-2017 AFFIDAVIT OF RESIDENCY FORM

(Students must be District residents as of August 17, 2016)

*The Bloomingdale School District 13 resident must also submit residency documents from Category I and

Category III along with this form. These documents must come from the resident, not the person who will be

living with the resident.

I, ________________________________________, the parent or legal guardian of

(Printed Name of Parent/Legal Guardian)

__________________________________________, being first duly sworn, state on oath that

(Printed Name of Student or Students)

the named student(s) above is/are under my custody, but we will be residing with

_______________________________________ at ___________________________________

(Printed Name of Resident) (Address)

for the 2016-2017 school year. The reason that the student must reside at this address is

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

This affidavit of residency form is to attest that the above child is not enrolling in the District solely for school

purposes and is living on a permanent basis with the person having complete custody and control. Registration of

a student who is not a resident is a fraudulent act. Any student found to have been fraudulently registered will be

dropped from the attendance rolls immediately. Parents or guardians making a fraudulent registration will be

subject to the payment of retroactive tuition charged for non-resident students, not to exceed 110% of the per

capita cost. A person who knowingly or willfully presents the District with any false information regarding the

residency of a pupil for the purpose of enabling that pupil to attend any school in the District shall have

committed a Class C misdemeanor and shall be prosecuted by the District. National Investigations, Inc. will be

conducting a home visit if fraud is suspected.

I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.

SUBSCRIBED AND SWORN TO _________________________ before me this _________ day Parent Signature of _____________, 20______

_________________________ Telephone __________________________ Notary Public _________________________

Owner of Property Signature (Stamp)

_________________________ Telephone

BLOOMINGDALE SCHOOL DISTRICT 13 2016-2017 REGISTRATION FEE WAIVER APPLICATION

The Board of Education of Bloomingdale School District 13 waives school fees for children whose parents are experiencing

economic hardships. If you believe your child(ren) may qualify for a fee waiver due to current financial or emergency

conditions, please complete this form and return it with the registration materials. If you have any questions, please contact

the Director of Finance, Adam Parisi, at 630.671.5035. You will be notified of acceptance or denial within 14 days.

----------------------------------------------------------------------------------------------------------------------------------

Name of Student: ______________________________________________ School _________________

Name of parent or guardian: _____________________________________ Grade _________

I hereby request school fees are waived for the above listed student for the following reason:

Household Income Section:____________________________________________________________

[ ] The student’s household gross income meets the Federal income requirement for waiver approval. Documentation must be

attached that supports household size and gross income level. The following documents must be enclosed: Recent W-2

form(s); recent pay stub; Front page of most current Federal 1040 tax form.

Household

Size

Annual Household

Income (Gross)

Monthly Household

Income (Gross)

Weekly Household

Income (Gross)

[ ] I have attached a copy of my most current pay stub

[ ] I have attached a copy of my most current W-2 form (s)

[ ] I have attached a copy of my most current Federal 1040 tax form showing dependents

OR

Public Aid Section: ___________________________________________________________________

[ ] The household is receiving public aid (i.e. Aid to Families with Dependent Children (AFDC), Temporary Assistance for Needy

Families (FANF), or Department of Human Services Food Stamps). Evidence of participation in AFDC, TANF, or Food Stamp

Program must be attached. LINK card and Illinois Department of Public Aid MediPlan cards will not be accepted as

verification of pubic aid.

[ ] I have attached a copy of my card indicating participation in AFDC, TANF or Food Stamp Program.

Case ID Number: ______________________________________________________________

I have reviewed the District’s policy and I am aware supplying false information is a class 4 Felony (720 ILCS S/17-6). I attest

that the statements made here are true and correct.

_________________________________________________________________ _____________________ Parent Signature Date

*********************************************************************************************

Office Use Only:

____ Approved ____ Disapproved

Director of Finance’s Signature: __________________________________________________ Date: _________________

BLOOMINGDALE SCHOOL DISTRICT 13

MEDICAL REQUIREMENTS CHECKLIST FOR KINDERGARTEN The Illinois school code requires all children entering kindergarten to have a physical exam and certain immunizations prior to entering school in the fall. A dental exam and eye exam are also required. Please use this checklist to help answer questions and complete the necessary requirements for kindergarten. COMPLETED PHYSICAL EXAM REQUIREMENTS _______________ “Certificate of Child Health Examination” form must be completed and returned to

school no later than 2 weeks before the start of school. _______________ Complete all information on top of the Physical form (name, address, birth date, and

grade). Please put name on both sides of form. _______________ Parent/Guardian completes and signs the “Health History” portion of the form (top

of back side of form). _______________ Immunizations (front side of form). Include all immunizations child has had. The

month, day, and year in which the immunizations were given must be noted. Doctor or Health Care Professional needs to sign and date immunization portion of the form.

_______________ DIABETES SCREENING is required. The doctor should identify if your child is at

risk. _______________ LEAD SCREEN RISK QUESTIONNAIRE All children 6 months through 6 years

of age should be assessed for lead poisoning. A lead assessment is a required part of the physical exam for kindergarten entry.

_______________ PHYSICAL EXAMINATION (Bottom portion of back side of form) Physical must

include: Height, Weight, Blood Pressure, BMI and a review of systems. Lab work is not required but strongly recommended.

_______________ Physical must be dated within 1 year of entering kindergarten and must be signed

by the Physician. The Illinois School Code also allows advanced practice nurses and physician assistants who have a collaborative agreement with a physician to conduct and sign a health examination.

IMMUNIZATION REQUIREMENTS _______________ DPT (Diphtheria, Pertussis, Tetanus) Need a total of 4 doses, given at least 4 weeks

apart, with the last dose given after 4 years of age. _______________ OPV/IPV (Polio) 4 or more doses, the first three doses in the series are no less than 4

weeks apart, with the last or 4th dose given on or after 4 years of age and the last dose shall be administered at least 6 months after the previous dose.

_______________ MEASLES 2 doses of Measles Vaccine, the first dose must have been received on or

after the first birthday and the second dose no less than 4 weeks later. _______________ RUBELLA 2 doses of Rubella Vaccine, the first dose must have been received on or after the first birthday and the second dose no less than 4 weeks later.

_______________ MUMPS 2 doses of Mumps Vaccine, the first dose must have been received on or after the first birthday and the second dose no less than 4 weeks later.

_______________ MMR (Measles, Mumps, Rubella) If all 3 are given together, the shot must have been given after 12 months of age. _______________ VARICELLA (Chickenpox vaccine) 2 doses of Varicella Vaccine, the first dose must have been received on or after the first birthday and the second dose no less than 4 weeks later, or verification of disease by physician or health care provider with date and signature placed in the section labeled “Alternate Proof of Immunity.”

_______________ TB A Tuberculin Test is strongly recommended as a part of the physical exam.

OTHER MANDATED EXAMINATIONS _______________ DENTAL EXAMINATION is required. Included in your packet is a dental form which the dentist should sign and date, after completion. _______________ EYE EXAMINATION is required. Included in your packet is an eye examination form which the doctor should sign and date, after completion.

IF YOU REQUEST RELIGIOUS EXEMPTION A parent-signed letter detailing specific religious beliefs which conflict with a specific

immunization and/or exam must also now be signed by a health care provider (physician, advanced practice nurse, or physician assistant) and submitted to the school at which your child is registered. Please refer to the Joint Committee on Administrative Rules, Administrative Code, Title 77 and PA 099-0249 for further information.

MAKE APPOINTMENTS EARLY. Doctors/Dentists offices get very busy during the summer months. Don’t wait until August. Immunizations may also be obtained through the DuPage County Health Department. Call 630-682-7560. If the physical/immunization form is completed before the end of the 2015-2016 school year, you may return it to the Health Office at the school where you registered. There will be drop boxes at all the schools in which to place your completed health forms. PLEASE DO NOT PUT THEM WITH SCHOOL REGISTRATION FOR MS.

If you have any questions, please call the Health Office at the school where you registered. Thank you for your cooperation in fulfilling these health requirements.

DISTRICT 13 NURSES

Erickson Elementary School 630.529.2233 DuJardin Elementary School 630.894.9200

11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

State of Illinois Certificate of Child Health Examination

Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.

Student’s Name Last First Middle

Birth Date Month/Day/Year

Sex Race/Ethnicity School /Grade Level/ID#

Address Street City Zip Code

Parent/Guardian Telephone # Home Work

IMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication. REQUIRED Vaccine / Dose

DOSE 1

MO DA YR

DOSE 2

MO DA YR

DOSE 3

MO DA YR

DOSE 4

MO DA YR

DOSE 5

MO DA YR

DOSE 6

MO DA YR

DTP or DTaP

Tdap; Td or Pediatric DT (Check specific type)

TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT

Polio (Check specific type)

IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV

Hib Haemophilus influenza type b

Pneumococcal Conjugate

Hepatitis B

MMR Measles Mumps. Rubella

Comments: Varicella

(Chickenpox)

Meningococcal conjugate (MCV4)

RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose Hepatitis A

HPV

Influenza

Other: Specify Immunization Administered/Dates

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here. Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result. *MEASLES (Rubeola) MO DA YR **MUMPS MO DA YR HEPATITIS B MO DA YR VARICELLA MO DA YR 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title 3. Laboratory Evidence of Immunity (check one) Measles* Mumps** Rubella Varicella Attach copy of lab result. *All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence. **All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.

Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________ Physician Statements of Immunity MUST be submitted to IDPH for review.

Student’s Name

Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year

HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER ALLERGIES (Food, drug, insect, other)

Yes No

List: MEDICATION (Prescribed or taken on a regular basis.)

Yes No

List:

Diagnosis of asthma? Child wakes during night coughing?

Yes No Yes No

Loss of function of one of paired organs? (eye/ear/kidney/testicle)

Yes No Birth defects? Yes No Hospitalizations?

When? What for? Yes No

Developmental delay? Yes No

Blood disorders? Hemophilia, Sickle Cell, Other? Explain.

Yes No Surgery? (List all.) When? What for?

Yes No

Diabetes? Yes No Serious injury or illness? Yes No

Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No

Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No

Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No

Dizziness or chest pain with exercise?

Yes No Family history of sudden death before age 50? (Cause?)

Yes No

Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)

Dental Braces Bridge Plate Other

Ear/Hearing problems?

Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Signature Date Bone/Joint problem/injury/scoliosis? Yes No

PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P

DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE: Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm__________ Blood Test: Date Reported / / Result: Positive Negative Value LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Sickle Cell (when indicated) Urinalysis Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs

Skin Endocrine

Ears Screening Result: Gastrointestinal

Eyes Screening Result: Genito-Urinary LMP

Nose Neurological

Throat Musculoskeletal

Mouth/Dental Spinal Exam

Cardiovascular/HTN Nutritional status

Respiratory Diagnosis of Asthma Mental Health

Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid)

Other

NEEDS/MODIFICATIONS required in the school setting

DIETARY Needs/Restrictions

SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal

EMERGENCY ACTION needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Modified

Print Name (MD,DO, APN, PA) Signature Date

Address Phone

State of IllinoisEye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eyeexaminations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school forother children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinoisschool system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

Student Name ________________________________________________________________________________________________(Last) (First) (Middle Initial)

Birth Date ____________________ Gender ______ Grade _____(Month/Day/Year)

Parent or Guardian ____________________________________________________________________________________________(Last) (First)

Phone ______________________________(Area Code)

Address _____________________________________________________________________________________________________(Number) (Street) (City) (ZIP Code)

County ____________________________________________

To Be Completed By Examining Doctor

Case HistoryDate of exam ________________

Ocular history: � Normal or Positive for ___________________________________________________________________

Medical history: � Normal or Positive for ___________________________________________________________________

Drug allergies: � NKDA or Allergic to ____________________________________________________________________

Other information _____________________________________________________________________________________________

ExaminationDistance NearRight Left Both Both

Uncorrected visual acuity 20/ 20/ 20/ 20/Best corrected visual acuity 20/ 20/ 20/ 20/

Was refraction performed with dilation? �Yes � No

Normal Abnormal Not Able to Assess CommentsExternal exam (lids, lashes, cornea, etc.) � � � __________Internal exam (vitreous, lens, fundus, etc.) � � � __________Pupillary reflex (pupils) � � � __________Binocular function (stereopsis) � � � __________Accommodation and vergence � � � __________Color vision � � � __________Glaucoma evaluation � � � __________Oculomotor assessment � � � __________Other _________________________ � � � __________NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis� Normal � Myopia � Hyperopia �Astigmatism � Strabismus �Amblyopia

Other _______________________________________________________________________________________________________

Continued on backPage 1

State of IllinoisEye Examination Report

Recommendations1. Corrective lenses: � No �Yes, glasses or contacts should be worn for:

� Constant wear � Near vision � Far vision� May be removed for physical education

2. Preferential seating recommended: � No �Yes

Comments ________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Recommend re-examination: � 3 months � 6 months � 12 months

� Other ____________________________________

4. _________________________________________________________________________________________________________

5. _________________________________________________________________________________________________________

Print name____________________________________________ License Number_____________________________________Optometrist or physician (such as an ophthalmologist)

who provided the eye examination � MD � OD � DO

Address ____________________________________________

____________________________________________

Phone ____________________________________________

Signature ____________________________________________ Date ___________________

(Source: Amended at 32 Ill. Reg. _________, effective ___________)

Consent of Parent or GuardianI agree to release the above information on my childor ward to appropriate school or health authorities.

(Parent or Guardian’s Signature)

(Date)

Page 2Printed by Authority of the State of Illinois

6/09IOCI1271-09

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

State of IllinoisIllinois Department of Public Health

To be completed by dentist:

Oral Health Status (check all that apply)

� Yes � No Dental Sealants Present

� Yes � No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it wasextracted as a result of caries OR missing permanent 1st molars.

� Yes � No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of thewalls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retainedroot, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-ered sound unless a cavitated lesion is also present.

� Yes � No Soft Tissue Pathology

� Yes � No Malocclusion

Treatment Needs (check all that apply)

� Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

� Restorative Care — amalgams, composites, crowns, etc.

� Preventive Care — sealants, fluoride treatment, prophylaxis

� Other — periodontal, orthodontic

Please note____________________________________________________________________________________

Signature of Dentist _________________________________________ Date of Exam ____________________

Address ___________________________________________________ Telephone _______________________Street City ZIP Code

Illinois Department of Public Health, Division of Oral Health217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us

Printed by Authority of the State of Illinois

Student’s Name: Last First Middle Birth Date:/ /

Address: Street City ZIP Code Telephone:

Name of School: Grade Level: Gender:� Male � Female

Parent or Guardian: Address (of parent/guardian):

(Month/Day/Year)

IOCI 0600-10

Dear Parents,

Welcome to the 2016-2017 school year! As a parent of a student at DuJardin School, you are already a member of the PTO.

The Membership Dues for PTO are $15.00 per family. This fee includes (but not limited to) the following benefits throughout the year:

• 3 Parties (Halloween, Winter Holiday, & Valentine’s Day) that allow the students to enjoy crafts,

games, and treats

• Field Day fun and lunch

• Teacher Appreciation Week (breakfast with students, lunches for teachers, & gifts)

• District 13 scholarships

• Back to school ice cream social

• School events (Bingo Night, 5th Grade Party, Jamba Juice)

Please return your PTO Dues in the envelope marked PTO to the DuJardin office.

PTO Family Dues maybe turned in at the time of

kindergarten registration or no later than September 15, 2016.

Please include check or cash for $15.00 made payable to the DuJardin PTO.

Thank you in advance for your prompt attention and support. If you have any questions please contact Elizabeth Threadgill at 630-607-2901.

PLEASE PRINT!

Child’s Name ___________________________________________Grade _____

Child’s Name ___________________________________________Grade _____

Child’s Name ___________________________________________Grade _____

Family Name ___________________________________________

Sincerely,

Your DuJardin PTO Team