PLEASE COMPLETE, SIGN, AND RETURN THIS FORM TO THE PRINCIPAL’S OFFICE

Student Handbook belongs to:

Name______________________________________________ Grade____________

According to ACT 104 of 1983, parents or legal guardians and students must by law receive a

copy of the student discipline policies. Your signature means that you have read, understand,

and agree to abide by the policies in this handbook.

Please initial the items below to indicate that you “accept” or “deny” to each item listed and sign

below.

“ACCEPT” “DENY”

Verify receipt of Student Discipline Policy,

Homework Policy, Attendance Policy, and

Parental/Community Involvement Plan.

(Only stating “I Received the Student Handbook.”)

To allow publication of directory information to all

public sources. (This would permit the release of

directory information to the Military, postsecondary

institutions, potential employers and all other sources

such as newspapers.)

To allow publication of directory information to all

school sources. (This would permit the student’s

directory information to be included in the school’s

yearbook and other school publications.)

Display student information, photo or video on web

site or media.

Student Internet Use Agreement.

Student will be assigned an email/login account to

meet the Common Core State Standards technology

projects due to Cedar Ridge being a Google Apps for

Education School.

____________________________________________ _______________ SIGNATURE OF PARENT/GUARDIAN DATE

____________________________________________ _______________ SIGNATURE OF STUDENT DATE

Cedar Ridge School District

PLEASE COMPLETE, SIGN, AND RETURN THIS FORM TO THE PRINCIPAL’S OFFICE

Parental Consent to Release Personal Identifiable Information

Hearing and Vision Screenings/Personal Care Services

Student Name__________________________________________________________________

Address_______________________________________________________________________

Date of Birth________________________ Social Security No.___________________________

School________________________________________________ Grade_________________

Physician’s Name_______________________________________________________________

Medicaid/AR Kids 1st Information:

Is your child covered by Medicaid/AR Kids 1st? Yes No

If yes, please list the corresponding number __________________________________________

When the child was enrolled in the Medicaid/AR Kids 1st program, parental consent to bill for

services was received from the parent/guardian.

Parental Permission Information for the Release of Personal Identifiable Information:

Under the Family Education Rights and Privacy Act (FERPA), parental permission is required in

order to release a student’s personal identifiable information to agencies not identified in the Act.

This permission grants the Cedar Ridge School District the ability to release these records for the

purpose of billing Medicaid. The information that MAY be released includes: student’s name,

date of birth, social security number, and dates of service. The parent has the right to revoke this

permission at any time.

By signing below, I give Cedar Ridge School District permission to access Medicaid to receive

reimbursement for hearing and vision screenings and/or personal care services delivered to my

child in school. The Cedar Ridge School District can release the above stated information each

time that access to Medicaid is made for the purpose of determining eligibility, billing for

services, and/or completing audit/review requests is needed.

___________________________________ _____________________ Parent/Guardian Signature Date

NAME OF SCHOOL

CEDAR RIDGE SCHOOL DISTRICT

HOME LANGUAGE SURVEY

Student’s Name: __________________________________________________________ Nombre del Estudiante

Sex: Male Female Date of Birth: ______/______/______ Age: _______ Sexo: Masculino Feminino Fecha de nacimiento Edad

School:_______________________________________ Grade: ____________ Escuela Grado

What language did your child learn when he/she began to talk? __________________

¿Qué idioma aprendió su hijo cuando empezó a hablar?

What language is most frequently used by adults in the home? ___________________

¿ Qué idioma hablan más frecuentamente los adultos en casa?

What language is most frequently used by the student with siblings?_______________

¿ Qué idioma habla más frecuentamente el estudiante con sus hermanos?

What language is spoken in your home most of the time? _______________________

¿ Qué idioma se habla en su casa la mayoría del tiempo?

What language does the student speak most of the time? ________________________

¿ Qué idioma habla el estudiante la mayoría del tiempo?

What language do parents use to speak to the student most of the time? ____________

¿ Qué idioma le hablan los padres al estudiante la mayoría del tiempo?

What written language would you prefer to receive school communications in?_____________

¿En que idioma prefiere recibir información por parte de escuela?

Signature of Parent/Guardian: __________________________________________

Date: ______/______/______

Office:

Keep the HLS in the student’s permanent file.

Give a copy to the ESL Teacher of students who indicate another language on at least one of these questions.

FAX a copy to the ESOL Center.

Cedar Ridge School District

ACT 514 MILITARY DEPENDENT FORM

Act 514 of 2013 requires the Arkansas Department of Education to report the

enrollment of students that are military dependents and reside in the household of a

person who is on active duty or serving in the reserve component of a branch of the

United States Armed Forces.

Name: ____________________________________________________________

Active _______________________ Reserve _______________________

Military Branch: ____________________________________________________

Name/Names of dependent children enrolled in the Cedar Ridge School District:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

MEDICATION SELF-ADMINISTRATION CONSENT FORM

(Only return if child has rescue inhaler or injection pens)

This form is good for school year 2016-2017. This consent form must be updated anytime the

student's medication order changes and renewed each year and/or anytime a student changes

schools.

Student’s Name (Please Print) ___________________________________________________

The following must be provided for the student to be eligible to self-administer rescue inhalers

and/or auto-injectable epinephrine. Eligibility is only valid for this school for the current

academic year.

a written statement from licensed a health-care provider who has prescriptive privileges

that he//she has prescribed the rescue inhaler and/or auto-injectable epinephrine for the

student and that the student needs to carry the medication on his/her person due to a

medical condition;

the specific medications prescribed for the student;

an individualized health care plan developed by the prescribing health-care provider

containing the treatment plan for managing asthma and/or anaphylaxis episodes of the

student and for medication use by the student during school hours; and

a statement from the prescribing health-care provider that the student possesses the skill

and responsibility necessary to use and administer the asthma inhaler and/or auto-

injectable epinephrine.

If the school nurse is available, the student shall demonstrate his/her skill level in using the

rescue inhalers and/or auto-injectable epinephrine to the nurse.

Rescue inhalers and/or auto-injectable epinephrine for a student's self-administration shall be

supplied by the student’s parent or guardian and be in the original container properly labeled

with the student’s name, the ordering provider’s name, the name of the medication, the dosage,

frequency, and instructions for the administration of the medication (including times). Additional

information accompanying the medication shall state the purpose for the medication, its possible

side effects, and any other pertinent instructions (such as special storage requirements) or

warnings. Students who self-carry a rescue inhaler or an epinephrine auto-injector shall also

provide the school nurse with a rescue inhaler or an epinephrine auto-injector to be used in

emergency situations.

My signature below is an acknowledgment that I understand that the Cedar Ridge School

District, its Board of Directors, and its employees shall be immune from civil liability for injury

resulting from the self-administration of medications by the student named above.

____________________________________________________

Parent /Legal Guardian Signature

_________________

Date

EPINEPHRINE EMERGENCY ADMINISTRATION CONSENT FORM (Only return if child has epinephrine pen)

This form is good for school year 2016-2017. This consent form must be updated anytime the

student's medication order changes and renewed each year and/or anytime a student changes

schools.

Student’s Name (Please Print) ____________________________________________________

My child has an IHP developed under Section 504 of the Rehabilitation Act of 1973 which

provides for the administration of epinephrine in emergency situations. I hereby authorize the

school nurse or other school employee certified to administer auto-injectable epinephrine in

emergency situations when he/she believes my child is having a life-threatening anaphylactic

reaction.

The medication must be in the original container and be properly labeled with the student’s

name, the ordering provider’s name, the name of the medication, the dosage, frequency, and

instructions for the administration of the medication (including times). Additional information

accompanying the medication shall state the purpose for the medication, its possible side effects,

and any other pertinent instructions (such as special storage requirements) or warnings.

Date of physician's order ___________________________________________

Circumstances under which Epinephrine may be administered

_____________________________________________________________________________

_____________________________________________________________________________

Other instructions ______________________________________________________________

_____________________________________________________________________________

I acknowledge that the Cedar Ridge School District, its Board of Directors, and its employees

shall be immune from civil liability for damages resulting from the administration of auto-

injector epinephrine in accordance with this consent form, District policy, and Arkansas law.

____________________________________________________

Parent /Legal Guardian Signature

_________________

Date

GLUCAGON AND/OR INSULIN ADMINISTRATION CONSENT FORM (Only return if child has glucagon injection pen)

This form is good for school year 2016-2017. This consent form must be updated anytime the

student's medication order changes and renewed each year and/or anytime a student changes

schools.

Student’s Name (Please Print) ____________________________________________________

The school has developed an individual health plan (IHP) acknowledging that my child has been

diagnosed as suffering from diabetes. The IHP authorizes the school nurse to administer

Glucagon or insulin to my child in an emergency situation.

In the absence of the nurse, trained volunteer district personnel may administer to my child in an

emergency situation:

Glucagon

Insulin

I hereby authorize the school nurse to administer Glucagon or insulin to my child or, in the

absence of the nurse, trained volunteer district personnel designated as care providers, to

administer the medication(s) I selected above to my child in an emergency situation. I will

supply the medication(s) I selected above to the school nurse in the original container properly

labeled with the student’s name, the ordering provider’s name, the name of the medication, the

dosage, frequency, and instructions for the administration of the medication (including times).

Additional information accompanying the medication shall state the purpose for the medication,

its possible side effects, and any other pertinent instructions (such as special storage

requirements) or warnings.

I acknowledge that the District, its Board of Directors, its employees, or an agent of the District,

including a healthcare professional who trained volunteer school personnel designated as care

providers shall not be liable for any damages resulting from his/her actions or inactions in the

administration of Glucagon or insulin in accordance with this consent form and the IHP.

____________________________________________________

Parent /Legal Guardian Signature

_________________

Date

McKinney-Vento Eligibility Form

Cedar Ridge School District

Is the student living in any of the following situations? (Please complete one form per family.)

____ sharing housing with relatives or others due to a lack of housing

____ in a shelter or transitional living program

____ in a model, hotel, park, or campground due to lack of adequate housing

____ in a car or RV in a public place (such as a bus station)

____ in sub-standard housing

____ without a parent or guardian, or a teen (up to 21) living independently

____ awaiting foster care placement

____ parents are migrant workers (must be approved through state migrant program)

____ in other situations that are not fixed, regular, or adequate for nighttime residence

____ none of the above (form is complete and may be discarded)

If a student is living in one of the situations listed above, information will be provided to

the accompanying adult about services required under federal law.

Please list ALL children living with you up to age 21. Please include children of all ages and if

they are attending an educational program.

Name Date of Birth School attending Grade

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

I certify that the information provided here is true and correct. I understand the rights that have

been given to students eligible under the McKinney-Vento Act and that a school representative

has the responsibility to determine who is eligible. Parents and guardians may refuse services.

Name: __________________________________________________ Date _________________

Signature: ________________________________ Relationship to student _________________

Date received and verified by homeless liaison ________________________________________

AGRICULTURAL SURVEY Title I, Part C

YOUR CHILD/CHILDREN MAY QUALIFY FOR EDUCATIONAL SUPPORT SERVICES WHICH MAY INCLUDE TUTORING, BOOKS, SCHOOL SUPPLIES, PRESCHOOL INFORMATION, HIGH SCHOOL CREDIT THRU CORRESPONDENCE COURSES, COLLEGE SCHOLARSHIPS, AND LIMITED HEALTH SERVICES.

STUDENT’S NAME________________________________________________GRADE_________BIRTHDATE_______________

PARENT’S NAME (S)_____________________________________________________________________________

PHONE #_______________________________ MESSAGE/CELL PHONE #__________________________________

STREET NAME___________________________________________HOUSE/APT. #___________________________

CITY_____________________________________STATE______________ZIP CODE _________________________

Within the past 3 years (including summer) have you or your family moved across school

district lines (permanently or temporarily ) to LOOK FOR or to DO any type of seasonal or

temporary agriculture work.

YES_____Please complete form.

NO_____You do not have to complete the rest of this form. Thank you.

If you checked “YES” please mark the job/jobs you worked at or looked for:

____Working at chicken/meat processing plants ____Working at a granary (Riceland Foods, Rice Mill, etc.) ____Farming (planting, harvesting crops, cutting & baling hay, etc.) _____Seed companies ____Cotton gin ____Working on a farm with fertilizer and chemicals (agri) ____Timber work (clearing land, skidding logs, harvesting trees, etc.) _____Working at plant/tree nurseries ____Fruit harvesting (watermelon work, picking strawberries, etc.) _____Caring for livestock ____Working on a fish farm ____Growing or picking vegetables ____Chicken houses ____Other agriculture job_________________________ If you checked “YES“ to the above question, when is the best time to contact you to determine if your

child/children may qualify for these services?__________________________________________________

Please list all children in your household:

NAME GRADE SCHOOL BIRTHDAY

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

For more information contact: Jamie Cunningham, Migrant Recruiter, Phone: 870-376-6100 Fax: 870-276-5333

Northeast Arkansas Migrant Education Cooperative

103 West Park, Bald Knob, AR 72010

501-724-6227

Supplemental Services We Can Provide

Free School Meals: All migrant students are eligible for free school meals (Public Law 108-

265). The Cooperative provides certification of eligibility to the school.

Family Assistance and Support: The Migrant Education Program provides a support system

to assist families in receiving basic needs and meeting emergency situations through

collaboration and referrals with other agencies.

Health Services: Limited services are available for students in school including

vision/hearing screening, wellness checkups, and blood pressure check by our nurse. Other

limited services include dental ($125 limit), eyeglasses ($144 limit), doctor’s visit ($75 limit),

and prescription ($40 limit).

Migrant Tutor: With sufficient enrollment, the Cooperative will reimburse the cost of a

tutor (full or half time) to provide supplemental instructional activities for migrant students.

Preschool Packets: Packets contain age-appropriate books and educational materials for

preschoolers.

Educational and Personal Care Packets: Packets of school supplies, dictionaries,

educational materials, hygiene products, etc. are provided for youth as needed.

PASS Courses: Free independent study courses designed specifically for mobile migrant

students in grades 9-12 allow students to stay on track for graduation. Grading and record

keeping is completed by Northeast Cooperative personnel.

Moving Up Arkansas - Summer School: Allows migrant qualified high school students in

grades 9 – 12 the opportunity to work on credit accrual leading toward graduation. This is a

three-week residential school operated by the Migrant Education Program and housed on a

college campus.

Extended Day & Summer School at the local level as funds are available

MSAC (Migrant Student Advisory Council): This is a dropout prevention program for

students in grades 9 – 12. Students meet two times per year to learn and practice leadership

skills. Career information is provided by cooperating agencies.

Arkansas Migrant Education Leadership Academy : A weekend ExCel Challenge

program for high school students to develop their leadership and teamwork skills.

CAMP (College Assistance Migrant Program): The college assistance program for eligible

students provides grant money for first year college expenses along with an academic tutoring

program.

On Track to Success: An organizational/tracking plan to help all migrant students graduate

from high school and successfully apply for scholarships and financial aid for their post-

secondary education.

LEP/ESL Materials: Packets contain translation booklets of common phrases, bilingual

flash cards, and other resources to help teachers communicate with English Learners. 1/1/14