REGISTRATION FORMS CHECKOFF SHEET – Elementary

ALL REGISTRATION FORMS MAY BE ACCESSED ON THE T: DRIVE – FORMS – REGISTRATION FORMS

NEW STUDENTS

Registration Card

Health Record Questionnaire

Dental Sealant Permission Form

Parent Custody Notification

Residency Questionnaire

Transportation (Regular/Emergency Release)

Local Field Trip Permission Slip

Flouride Program Form

Network Agreement (Kinder/2nd/4th graders)

Dental Screening (Liberty Students only)

Permission to Release Records

Confidential Prior Services

Recent Arrivers

Home Language Survey (from school, as needed)

RETURNING STUDENTS

Student Profile Page (from school office)

Health Record Questionnaire

Dental Sealant Permission Form

Parent Custody Notification

Residency Questionnaire

Transportation (Regular/Emergency Release)

Local Field Trip Permission Slip

Flouride Program Form

Network Agreement (Kinder/2nd/4th graders)

Dental Screening (Liberty Students only)

Last School Attended:_____________________________________________________City:________________________________________State:_______________ Sibling Name:_______________________________________Grade___________ Sibling Name:_______________________________________Grade:___________

- Please answer both #1 and #2: 1. □Hispanic/Latino □Not Hispanic/Latino 2. □American Indian/Alaska Native □Asian □Black/African American □Native Hawaiian/Pacific Islander □White

I certify that the information above is, to my knowledge, true and accurate:

Parent Signature:______________________________________________________________Date:___________________________________________

Home Language Survey English Spanish Other

1. Which language did your child learn when he/she first began to talk?

2. Which language is most often spoken by the adults at home?

3. In what language do you prefer verbal and written communication from the school?

Does your student have any health or medical problems? □ Yes □ No Health questionnaire required for all students.

Does your child require medication at school? □ Yes □ No If yes, medication form required. See school office personnel

Please read and initial the following statements: I give my consent for my child to be released to me or my spouse or to the friend/relative I have designated and/or to be taken by ambulance to the nearest hospital in case of emergency. I understand that Tillamook School District does not provide

accident medical/dental coverage for students for injuries/illnesses occurring at school. I understand that I may voluntarily purchase a student accident insurance plan. I further acknowledge that I am financially responsible for medical, dental, ambulance, or other health care expenses or transportation of my child home, which might occur as a result of such illness or injury.

Please see Student/Parent Handbook, Annual Notifications. The school must be notified within 15 days of this notice if you do not want your student's directory information published.

Do you have Health Insurance? □ Yes □ No

Insurance Co:______________________________ Policy #:_____________________________

Tillamook School Dist. # 9

Liberty Elementary School 1700 Ninth Street Tillamook, OR 97141 2017-2018

Phone: (503) 842-7501 Fax: (503) 842-1314

Please print clearly, and return to the main office as soon as possible

Office Use Only

Student I.D. No.:_______________________

Enrollment Date:_______________________

Graduation Year:______________________

Teacher:______________________________

Status:_________________ Fees Paid

Student/Parent Handbook Given

Student’s Grade Level □ K □ 1

Student’s LEGAL Name:________________________________________________________________________________ Last Name First Name Middle Name

Student’s PREFERRED Name:___________________________________________________________________________ Birthplace:_______________________________ Birthdate:______________________Age:________ □Male □Female

Proof of birth date must be provided (new students only) Office use only: Vital Record/Birth Certificate _________ Hospital Record _________ Hospital Certificate _________ Other_________ Student Lives With: Name:___________________________ Relationship:______________ Name:___________________________ Relationship:_____________

SECONDARY ~ PARENT/GUARDIAN Same address/phone as student unless noted

1. Name:_________________________________________ Relationship:_____________________________________ Phone Number:_____________________________________ Work Phone:_______________________________________ Cell Phone:_______________________________________ Email:_______________________________________ □Required if address/phone is different from student: Address: ________________________________________ Mailing Address:_____________________________________ City, State, Zip:_________________________________________

□ Check if copy of correspondence is needed

If Parent/Guardian cannot be reached, Student may also be released to:

2. Full Name:____________________________ Phone/Cell:_____________________________ Relationship:_____________________________

3. Full Name:____________________________ Phone/Cell:_____________________________Relationship:_____________________________

4. Full Name:____________________________ Phone/Cell:_____________________________Relationship:_____________________________

5. Full Name:____________________________ Phone/Cell:_____________________________Relationship:_____________________________ .

Student may not be released to: (if applicable)

Full Name:______________________________ Relationship:_____________________________

Full Name:______________________________ Relationship:_____________________________

PRIMARY ~ PARENT/GUARDIAN Same address/phone as student

1. Name:_________________________________________ Relationship:_____________________________________ Address: ________________________________________ Mailing Address:_____________________________________ City, State, Zip:_________________________________________ Phone Number:_____________________________________ Work Phone:_______________________________________ Cell Phone:_______________________________________ Email:_______________________________________ □ Check if parent/guardian is a member of the

Armed Forces on active duty or full-time National Guard.

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TILLAMOOK School District #9 Teacher: Grade:

HEALTH QUESTIONAIRE

STUDENT’S NAME: _________________________________ BIRTHDATE: ______________ COUNTRY OF BIRTH: ______________ STUDENT’S ADDRESS: __________________________________ PHONE: _____________________ CELL: _____________________

MY CHILD HAS A MEDICAL CONDITION WHICH MAY REQUIRE ATTENTION AT SCHOOL (MEDIC ALERT)

DOES YOUR CHILD HAVE ANY OF THE FOLLOWING? CIRCLE ONE

Hearing Problem NO YES

Speech Problem NO YES

Dental Problem NO YES

Has your child been seen by a dentist or dental hygienist in the past 12 months? NO YES____

Vision Problem NO YES

Has your child been prescribed Glasses or contact lens? NO YES

Allergies Environmental (dust, etc.) Insect Allergy NO YES

Food Allergy Medicine Allergy

Severe allergic reaction, that a doctor/nurse practitioner NO YES

has prescribed an Epipen or Epipen Jr?

Diabetes (if yes, please circle) Type 1 Type 2 Other NO YES

Digestive Problems (Ulcer, Colitis, Vomiting, etc.) NO YES

Heart Condition NO YES

If yes, what is the medical diagnosis?

Asthma or Other type of breathing problem NO YES

Epilepsy or Seizure Disorder NO YES

If yes, what kind of seizures?

Cancer – has your child ever been diagnosed with cancer? NO YES

If yes, what type of cancer? Is your child still being treated for cancer? YES NO

Headaches which are frequent or severe? NO YES

If yes, what helps your child when a headache occurs?

Has your child had one or more previous head injuries or concussions? NO YES

If yes, when did this occur?

Blood Disorder (Anemia, Hemophilia, Bleeding Disorder) NO YES

Cerebral Palsy NO YES

Orthopedic (Bone) Problem NO YES

Bowel or Bladder Problem NO YES

Kidney Problem NO YES

Skin Problem (eczema, hives, etc.) NO YES

If yes what type of skin problem?

Special Diet NO YES

If yes, type of diet: _____________________ Only students with the appropriate medical documentation on file at

school can have food substitutions in the school breakfast/lunch program.

Learning Difficulties NO YES

If yes, please describe:

Attention Deficit Disorder or ADHD NO YES

Does your child have any other health concerns not listed above? NO YES

If yes, please describe:

**A medication form must be filled out for all medication taken during school.

**To protect your child, this information will be shared with school staff working with your child.

If you would like to speak to the health nurse regarding any special health needs your child may have, please leave

a message at the school office or call the Tillamook Health Department at 503-842-3900.

Parent/Guardian Signature Date:

NO MEDICAL CONCERNS

DO YOU WANT YOUR CHILD TO

GET FREE DENTAL SEALANTS?Permission Form

I DO NOT want my child to be screened and get sealants.

As the legal parent/guardian, I hereby consent to the release and exchange of information, including any personal health information, between the dental sealant staff; school staff; insurance carriers; the child’s dentist; community resources, such as Seaside Providence Hospital’s Dental Health Program; applicable Coordinated Care Organization; and/or the Dental Care Organization of record for the purpose of finding further treatment options or improving healthcare operations. If you have a Medicaid provider, they may be notified regarding services received. I have received a copy of “Notices of Privacy Practices.”You can get this document in other languages, large print, braille, or a format you prefer. Contact the Oral Health Program at 971-673-0348 or email oral.health@state.or.us. We accept all relay calls or you can dial 711. For more information, visit www.healthoregon.org/schooloralhealth.

OHA 8758 A (5/17)

Name of Child: ______________________________________________________________ (Last) (First) (Middle Initial)

My Child’s School: ______________________________________________________________________

YES!

Date of Birth: / / Grade: Gender: q Male q FemaleTeacher:

Parent/Guardian Name:

My child is taking (list medications):

My child is allergic to:

My child has: q Heart murmur or has had surgery

q Epilepsy q Asthma

q High blood pressure

q Diabetes q Other (describe):

q Behavioral Considerations (please describe): _________________ _____________________________________________________ _____________________________________________________

Best phone number to reach you during the day:

State law requires a basic medical history for each child receiving service. Please fill out this form and sign at the bottom.

NOIf no, please check the following to help us improve the program.

q My child already has sealants.

q My child regularly sees a dentist.

q My child’s dentist will provide sealants.

q Other (please describe): ________________ ____________________________________

Parent/Guardian Signature: Date:

I WANT my child to be screened and get sealants, if needed.

PLEASE CHECK YES OR NO

SIGN BELOW & RETURN BY:

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~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~

TILLAMOOK SCHOOL DISTRICT NO. 9 2510 – 1st Street

Tillamook, Oregon 97141

By law, if parents are legally separated or divorced, each parent has

equal rights to the custody of the child/children UNLESS a parent has a

court order that indicates which parent has custody of the child/children.

The school MUST HAVE A COPY OF THE COURT ORDER on file, otherwise,

either parent may check the child out of the school with proper

identification.

If a parent comes in with a court order stating current custody over the

enrolling parent, they may take the child/children after documents are

verified, as needed, and after every effort has been made to reach the

enrolling parent by phone.

I have read the above statement of the law.

Student’s Name Grade

Signature of Parent/Guardian Date

PARENT CUSTODY NOTIFICATION

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TILLAMOOK SCHOOL DISTRICT 9

Student Residency Questionnaire

Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, and/or Federal McKinney-Vento Education Act.

Eligibility can be determined by completing this questionnaire.

1. Are you and/or your family in any of the following situations? Check if true

A. Student staying with friends or couch surfing and not living with parent/guardian

B. Staying in a shelter or transitional housing

C. Sharing housing with others due to loss of housing, money difficulties or similar reason

D. Living in a car, park, campground, RV, public space, abandoned building, or housing not appropriate for your family

E. Temporarily living in a motel or hotel

2. Have you moved across school districts in the past 3 years with the intent to work in any type of fishing,

agriculture, forestry (logging/mill work), dairy, or other related seasonal or temporary jobs?

Yes

STOP

If you did not check any boxes, stop and do not continue. Turn the form in with the rest of your registration packet. If you did check any of the boxes in section 1 or 2 above, please continue filling out the form.

3. Student Name

First Middle Last

M/F

D.O.B.

Grade

School Name

4. Are there other children in the home?

(Check one) ____Yes ____ No How many?_________

Print Parent/Guardian Name Signature Date

____________________________________________ Phone number where you can be reached

Please submit this form with your registration packet.

************************************************************************************************************************************ For District Use Only: If parent has checked boxes in #1 or #2, make copy for school counselor.

Return original form to Cassie Thiemens at the District Office.

Transportation/Emergency Form 2017-2018 - Liberty and South Prairie

Tillamook School District #9(All information is strictly confidential)

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Circle Grade (School) : K 1 (Liberty) 2 3 (South Prairie)

Father/Guardian's Name:

Father's/Gaurdian's Phone:

Father's/Gaurdian's Work Phone:

Monday [ ] Picked Up by Name :

[ ] Bus Rt # ______Address: ______________________________________________________________

Tuesday [ ] Picked Up by Name :

[ ] Bus Rt # ______Address: ______________________________________________________________

Wednesday [ ] Picked Up by Name :

[ ] Bus Rt # ______Address: ______________________________________________________________

Thursday [ ] Picked Up by Name:

[ ] Bus Rt # ______Address: ______________________________________________________________

Friday [ ] Picked Up by Name:

[ ] Bus Rt # ______ Address:______________________________________________________________

Bus Rt # Name Address

PhoneDate

Emergency Pick Up Names & Phone Numbers

#1______________________________________________________________________________________________

#2 ______________________________________________________________________________________________

#3 _____________________________________________________________________________________________

Parent / Guardian Signature__________________________________________ Date ___________________________

Mother's/Guardian's Phone:

Mother's/Guardian's Work Phone:

Emergency

or Early

Release

Teacher:

Student's Name:

END OF THE DAY - Regular Transportation Schedule

ONLY AUTOMATED CALLS FROM THE DISTRICT WILL BE MADE.

IF YOUR CHILD IS NOT PICKED UP 10 MINUTES PRIOR TO THE BUSSES LOADING,

THEY WILL BE TRANSPORTED TO THE ADDRESS GIVEN BELOW.

EMERGENCY RELEASE

Home Phone:Home Street Address:

Mother/Guardian's Name:

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Student Name: _____________________________ Teacher: _____________________________

TILLAMOOK SCHOOL DISTRICT #9

Field Trip Permission Slip

2017-2018

Dear Parent,

This permission slip will allow your child to attend local activities without

having to get a new permission slip signed by you each and every time.

You will be notified of all off campus activities via the school newsletter

and/or teacher information flyers. Any out-of-town field trips will require a

specific permission slip to be signed by you prior to your child attending.

Local field trips include but are not limited to such activities as:

Performances at the High School

Bowling

Farm Festival

Field Trips to local businesses

Activities at other schools

Library

______________________________________________________

Parent Name (Please Print)

_____________________________________ ____________

Parent Signature Date

□ Liberty

□ SPrairie

□ East

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King Fluoride Tablet Program

2017-2018

The King Fluoride Program is given in your child’s school through the Oral Health Section of the

Department of Human Services, Office of Family Health. The program has two ways for the

teachers/nurses to give fluoride. The American Dental Association and The American Academy

of Pediatrics recommend both programs. The programs are for areas that do not have the right

amount of fluoride in their drinking water to help fight cavities. The programs are the Daily

Tablet Program and the Weekly Rinse Program. Both programs can help fight cavities.

Your teacher/nurse has chosen to use the Daily Tablet Program. Every school day, school

children who take part in the Daily Tablet Program will be given a fluoride tablet. Each child

chews this tablet for 30 seconds, swishes the mixture for 30 seconds, and then swallows.

If your child is already taking daily fluoride tablets or home fluoride given by your dentist, do not

enroll them in this program. Home use is a better way to take fluoride because your child can

take it on weekends, holidays and vacations. Tablets should be taken every day. If your child is

not taking fluoride tablets at home, the school program is a good way to get started.

Do not enroll your child in the Tablet Program if the drinking water source for your home has

fluoride in it. You can find this out by calling the number on your water bill. If your drinking water

comes from a private well, you can have your well water tested for fluoride.

There is no cost for this voluntary program. Your child must be at least 3 years old and must

return this signed permission slip.

For any questions please contact: Laurie Johnson, Prevention Specialist at 971-673-0339.

King Fluoride Tablet Program Permission Slip

Child’s Name _____________________________________________________(Please print)

Teacher’s Name __________________________________________room _____ Grade ___

Yes. My child is age three or older and I want my child to take part in the daily Fluoride

Tablet Program.

No. I do not want my child to take part in the Fluoride Tablet Program.

___________________________________________ ___________________

Parent/Guardian Signature Date

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Telecommunications Network Signature Page

Tillamook School District 9

2510 First Street

Tillamook, OR 97141

The immediate section below is to be completed and signed by all USERS of the Tillamook School District

Telecommunications Network.

I have read the terms of the Tillamook School District Telecommunications Network Guideline/Agreement. I

have understood these terms. I understand that this is a legally binding contract and that my privileges as a user

on the Tillamook School District Telecommunications Network can be revoked by the Network Manager at any

time if I fail to abide by the provisions of the agreement.

Print Name :____________________________________________ Student’s ID#: ______________________

Student’s Grade: ____________Student’s Graduation Year: ______________

The signature area below is to be completed and signed by the parent or guardian of the student

requesting access to the Tillamook School District Telecommunications Network.

As the parent or guardian of the student named above, I take responsibility for the conduct of this student on the

Tillamook School District Telecommunications Network and will see to it that she or he understands and abides

by the provisions in the Tillamook School District Telecommunications Network Guideline/Agreement. I have

understood these terms. I understand that this is a legally binding contract and that the privileges as a user on

the Tillamook School District Telecommunications Network can be revoked by the Network Manager at any

time if I fail to abide by the provisions of the agreement.

Print Name: ______________________________________________________________________________

Parent: ________________ Guardian: ________________ (check one)

Address: ___________________________________________________

City: _____________________________________ State: ___________________ Zip: _________________

Signature: __________________________________________________________ Date: _________________

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Network Access Guideline Agreement

The Tillamook School District Electronic Information Network System has been created for the purpose of supporting

educational activities for students and staff. It is not intended as a means of creating a first amendment forum for free

expression of speech. The district dedicates the property comprising the Tillamook School District Electronic Information

Network System and grants access to it by users only for the educational activities authorized under this agreement and

guideline and the specific limitations contained therein. The Tillamook School District Electronic Information Network

System encompasses all electronic information access mediums, including and not limited to Bulletin Board System

(BBS’s), Internet access through the Tillamook School District “Internet Service Provider” (ISP) or other

private/commercial ISPs, modem usage for dial-in, dial-out, download or upload purposes.

Access to the Tillamook School District Electronic Information Network System from school sites is limited to officially

enrolled students and employees of Tillamook School District, as approved by the Technology Committee and the

Network Manager. It is understood that offering access to anyone else constitutes a gift of public monies and puts the

district in conflict with the commercial providers, direct violations of state law. Dial-in access (using modems from non-

district sites) to the Tillamook School District Electronic Information Network System will initially be limited to staff as

directly related to their jobs.

During this age of information, it is fundamental that students and employees develop electronic research skills. The

board expects that staff will blend thoughtful use of such information throughout the curriculum and that the staff will

provide guidance and instruction to students in the appropriate use of such resources. Staff will use the guidelines cited

by the Curriculum and Technology Committee for the selection of instructional materials to guide use of electronic and

telecommunication resources with students.

Students are responsible for good behavior when using electronic resources and networks just as they are in a classroom

or school hallway. Communications on networks are often public in nature. School rules for behavior and

communications also apply to these networks to conduct research and communicate with others. Access to Tillamook

School District Electronic Information Network services will be provided to students and staff who agree to act in an

appropriate and responsible manner.

Independent student use of the Tillamook School District Electronic Information Network System will be permitted upon

submission of permission and agreement forms submitted by students, with parental consent forms.

Access to telecommunications will enable students and staff to explore thousands of libraries, databases, and bulletin

boards while exchanging messages with people throughout the world. The board believes that the benefits to students and

staff from access to electronic information resources and opportunities for network, collaboration exceed the potential

disadvantages. Ultimately, parents and guardians of minors are responsible for setting and conveying standards for their

children to follow when using media and information resources. To that end, Tillamook School District support and

respect each family’s right to decide whether or not to apply for student access.

In addition, use of the Tillamook School District Electronic Information Network System by students and staff is subject

to the Tillamook School District Internet Acceptable Use Guideline as outlined in the procedures section of this guideline.

Internet Acceptable Use Procedures/Guideline

General:

1. Use of the Tillamook School District Electronic Information Network System must be in support of education

and research and be consistent with the mission of the district. The district reserves the right to prioritize the use

and access to the network system.

2. The Tillamook School District Electronic Information Network System must conform to state and federal laws,

network provider policies and licenses, and district policies. Use of the Tillamook School District Electronic

Information Network System for commercial solicitation or personal financial gain is prohibited. Use of the

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Tillamook School District Electronic Information System for charitable purposes must be approved in advance by

the District Office.

3. The Tillamook School District Electronic Information Network System constitutes public facilities and must

conform to all rules of the Public Disclosure Commission regarding political candidates, political issues, or ballot

measures. Use of the Tillamook School District Electronic Information Network System for personal political

agendas is prohibited.

4. No use of the Tillamook School District Electronic Information Network System shall disrupt the operation of the

system; no part of the system components, including hardware or software, shall be destroyed, modified or abused

in any way.

5. Malicious use of the Tillamook School District Electronic Information Network System to develop programs that

harass other users, such as viruses, gain unauthorized access to any computer or computing system and/or damage

the components of a computer or computing system is prohibited.

6. Malicious use that disrupts the use of the Tillamook School District Electronic Information Network System, or

the productivity of any of its employees or students will result in disciplinary action.

7. Any attack on the Tillamook School District Electronic Information Network System, or any of its employees or

students, that originates from outside or within the Tillamook School District Electronic Information Network

System, will result in disciplinary action.

8. Users are responsible for the appropriateness and content of the material they transmit or publish on the

Tillamook School District Electronic Information Network System. Hate mail, chain mail, mail bombs,

harassment, discriminatory remarks, or other antisocial behaviors are expressly prohibited.

9. Use of the Tillamook School District Electronic Information Network System to access store, or distribute

obscene, vulgar, lewd, plainly offensive or pornographic materials is prohibited.

10. It is important to understand that the Internet contains resources and information that may be considered

offensive, obscene, inappropriate, and/or pornographic to some users. Tillamook School District staff will be

diligent about working with students to assure that the information and resources they use conform to district

policies and goals. However, students may at times access network services without the direct supervision of

teachers as in a school library. Students will be held personally responsible for any objectionable, obscene or

pornographic information which they might access and are expected to exercise the same judgment and

responsibilities as expressed by district goals and procedures.

11. The use of chat programs and subscriptions to mailing lists, chat groups and commercial on-line services and

other information services must be justified to the Curriculum and Technology Committee and pre-approved by

the Superintendent or designee.

12. Diligent effort must be made to conserve system resources. For example, use of the network during peak

afternoon hours should be limited to necessary tasks and dial-in access, if available, must be limited to the hours

between 4:00 p.m. and 7:00 a.m. Users should frequently delete their personal E-mail and their unused files. No

person shall have access to the Tillamook School District Electronic Information Network System without having

received training and signed Network Access Permission form. Students must have the approval of a

parent/guardian.

Supervision/Security

1. Tillamook School District Electronic Information Network System accounts are to be used only by the authorized

owner of the account or the authorized purposes. Users may not share their account number or password with

another person or leave an open file or session unattended or unsupervised. Account owners are ultimately

responsible for all activity under their account.

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2. Users shall not seek information, obtain copies, or modify files, data, or passwords belonging to other users;

misrepresent other users on the system; or attempt to gain unauthorized access to the system.

3. Nothing in these regulations is intended to preclude the supervision of the system while under the direction of the

teacher or other approved user acting in conformity with district agreement and procedures.

4. For security and administrative purposes, the district reserves the right for authorized personnel to review system

use and file content and edit or remove any material which they believe is unlawful, obscene, abusive, or

otherwise objectionable. In such events, the district’s Network Manager reserves the right to disconnect the user

account or hardware to prevent further unauthorized activity.

5. Communications may not be encrypted so as to avoid security review.

6. Users should change passwords regularly and avoid easily guessed passwords.

Personal Security

1. Personal information such as addresses and telephone numbers should remain confidential when communicating

on the system. Students should never reveal such information without permission from their teachers or other

school official.

2. Students should never make appointments to meet people in person that they have contacted on the system

without district and parent permission.

3. Students should notify their teacher or other school official whenever they come across information or messages

tat are dangerous, in appropriate or make them feel uncomfortable.

Copyright

1. The unauthorized installation, use, storage, or distribution of copyrighted software or materials on district

computers is prohibited.

Sanctions

1. Violations of any of district policies and/or procedures may result in immediate loss of access to the

Tillamook School District Electronic Information Network System.

2. Additional disciplinary action may be determined at the building level in accordance with exisiting practice

regarding inappropriate use, language and/or behavior.

3. When applicable, law enforcement agencies may be involved.

Hold Harmless

1. The district will not be liable for any direct or indirect, incidental, or consequential damages, costs, expenses

or fees which may be suffered or incurred due to information gained and/or obtained as a result of the use of

the Tillamook School District Telecommunication Network.

2. The district does not guarantee that the network will be error free or that services will be uninterruptible. The

district will not be liable for any direct or indirect incidental or consequential damages, costs, expenses or fees

which may be suffered or incurred due to loss of data or inability to use the Tillamook School District

Informational Network System.

Form 1468-1

Dental Screening Certification Form State law now requires a child who is 7 years of age or younger to have a dental screening before entering school for the first time. (HB 2972 (2015)) ______________________________________________________________________________ IF YOUR CHILD HAS ALREADY RECEIVED A DENTAL SCREENING Parent/Guardian:

If you know your child has already had a dental screening, please check the box below, fill out this section, and sign it.

If you do not know if your child has had a dental screening, please have a dental provider fill out this section and sign it.

Please return this form to the school office.

My child ________________has received a dental screening. (First name) (Middle initial) (Last name)

Parent/Guardian or Dental Provider Print Name: ___________________________________

Signature ______________________________________________ Date ______________________________________________________________________________ TO OPT-OUT OF THE DENTAL SCREENING REQUIREMENT Parent/Guardian: You may choose to have your child opt-out of a dental screening due to a reason listed below. Please fill out this section and sign it. Then return this form to the school office. My child was not screened due to the following: (please check all that apply):

We already submitted a certification form at a previous school. The dental screening is contrary to student or families religious beliefs. The dental screening is a burden.

The dental screening is a burden for the student or the parent or guardian of the student when:

(A) The cost of obtaining the dental screening is too high; (B) The student does not have access to a screener or; (C) The student was unable to obtain an appointment with an screener

Parent/Guardian

Print Name : _____________________________________________

Signature ______________________________________________ Date

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TILLAMOOK SCHOOL DISTRICT #9 9

PERMISSION TO RELEASE RECORDS

TO: (Student’s former school/agency)

(Address of former school/agency)

Phone: ____________________ Fax: _____________________

(Student Name) (Date of Birth) (Grade)

(Student Name) (Date of Birth) (Grade)

(Student Name) (Date of Birth) (Grade)

has entered Tillamook School District. I am requesting all records for the above named student(s) which

include:

Student Education Records which include full legal name of student, birth date and place of birth, name of parents/guardians,

date of entry, name of previous school, subject taken, marks received, credits earned, attendance, date of withdrawal, social

security number (if provided), tests related specifically to achievement or measurement of ability.

Health Records which include immunization records, sports physical examinations, health screening records, medication

administration records, and other related documents.

Behavioral Records which include psychological tests, personality evaluations, records of observations and any written

transcript of incident(s) relating specifically to student behavior. TAG identification and records. This should include information

relating to youth’s history of engaging in activity that is likely to place school staff or other student safety at risk, or that requires

appropriate counseling or education.

Special Education Records including, but not limited to, records of eligibility, correspondence with parent/guardian, and all

previous and current IEP’s.

Portfolio

OTHER (specify)

Signature Date

Parent or School Registrar

PLEASE SEND ALL RECORDS TO:

Liberty School South Prairie School East Elementary School

1700 Ninth St 6855 South Prairie Rd 3905 Alder Lane

Tillamook, OR 97141 Tillamook, OR 97141 Tillamook, OR 97141

Ph# (503) 842-7501 Ph# (503) 842-8401 Ph# (503) 842-7544

Fax# (503) 842-1314 Fax# (503) 842-1452 Fax# (503) 842-1246

**Office Use Only: Withdraw Date: ______________ Enrollment Date: ___________________

Subject to ORS 330.260, a district receiving this request shall transfer all education records no later than 10 days after receipt of request. Should

any of the requested records be on file in other departments, please forward this request to the appropriate office. If no records are on file, please

contact the school requesting the records.

Office Use Only:

Date Faxed: ___________________

Second Request: _______________

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Student Name:

Current School: Current Grade:

YES NO

Parent Signature: Date:

2. 504 Plan

Tillamook School District # 9

Confidential Prior Services

5. Counseling If yes, what issue:

8. Does your child need any special services at this time?

(e.g. Title I, ELL)

9. Has your child received any special services in the past

two years? (Title I, ELL)

10. Would you like one of our administrators to contact you

at this time to discuss any issues or concerns?

Contact number:

If yes, what specific services:

If yes, what special services:

7. Special health issues or concerns If yes, list:

c. Previously on an IEP or evaluated?

6. Medication If yes, what type:

4. Extra Academic Assistance If yes, what kind:

i. Speech

ii. Academics (please specify, math/read/write/etc.)

3. Talented and Gifted (TAG)

iii. Other (e.g. vision, hearing)

b. Currently in testing or evaluation process?

An awareness of any special services is important in order to plan the most appropriate educational program for a child.

Has your child ever received or participated in the following services?

1. Special Education

a. Currently on an IEP?

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Tillamook School District 9 is an equal opportunity educator and employer.

TILLAMOOK SCHOOL DISTRICT 9

Recent Arrivers and Students with Interrupted Formal Education

What – Beginning in 2012, the Oregon Department of Education required that we collect information

to determine the number of “Recent Arrivers” in our school district. The Oregon Department of Education now requires that we also identify “Students with Interrupted Formal Education.” These are immigrant students, or those who come from a home where a language other than English is spoken, who enter a U.S. school after grade 2 and have at least two years less schooling than their peers, function two years below grade level in reading and math, and may be pre-literate in their native language.

Why – Title III is a Federal grant that provides funding for language instruction for Limited English

Proficient and Immigrant Students. Title III will use information about “Recent Arrivers” and “Students with Interrupted Formal Education” to help distribute these funds. Therefore, the Oregon Department of Education is required to provide information about “Recent Arrivers” and “Students with Interrupted Formal Education” to the US Department of Education every year.

Who – All new to TSD9 students/families must respond to this questionnaire. Any student born

outside of the US or Puerto Rico, including foreign exchange students and students born abroad to military members, must be included in the “Recent Arriver” count if they meet all three criteria.

The Questions Student first and last name: __________________________________________________ Student school: ___________________________________________________________ 1. Is the student 3 to 21 years of age? _____Yes _____No Date of birth: __________________

2. Was the student born outside of the United States or Puerto Rico? _____Yes _____No (This includes foreign exchange students and students born abroad to military members.)

3. Has the student attended a U.S. school for three full school years? _____Yes _____No

Date the student first attended school in the United States: _____________________________

Has the student attended schools outside of the United States? _____Yes _____No

If yes, please indicate: Country Grades Attended Less than Half Year Attended Half Year Attended Full Year

Parent signature: _________________________________ Date: ________________________

LIBERTY ELEMENTARY SCHOOL ~ BREAKFAST PERMISSION SLIP STUDENT___________________________________ TEACHER____________________ Breakfast is offered at Liberty Elementary School. Doors Open at 8:50 am on Mondays and 7:50 am Tuesday through Friday. Students on FREE or REDUCED meal plans may eat breakfast at no cost. Students who pay FULL PRICE for lunch will be charged $1.20 per breakfast. Permission for breakfast may be changed at any time during the school year by contacting the school office. Federal School Meal applications are available at the office anytime also. I would like my child to be able to eat breakfast at school. YES _____ NO _____ Parent /Guardian Signature _________________________________ date _______________ ESCUELA LIBERTY ~ PERMISO DE DESAYUNO Nombre de Estudiante_______________________________ Maestra _________________ El desayuno será servido en la escuela Liberty. Los lunes en 8:50 am - y los martes hasta los viernes en 7:50 am Los estudiantes con proyectos de comida libres o reducidos comerán el desayuno gratis. Los estudiantes que pagan el precio lleno para el almuerzo pagarán $1.20 para el desayuno. El permiso ser cambiado en cualquier momento. Las aplicaciones de comida están disponibles en la oficina. Me gustaría mi niño ser capaz de comer el desayuno en la escuela. Sí ______ No ______ Firma ________________________________________ Fecha ____________________________