Warsaw Elementary School 220 Underwood St.

Warsaw, IL 62379

217-256-4614

Dear Parents/Guardian:

Illinois law requires a health examination for students entering Pre K, Kindergarten,

& 6th

grades and all students entering or transferring into an Illinois school. A dental

exam is required for students entering Kindergarten, 2nd

, and 6th

grades. A new state

health requirement is an eye exam. All children enrolling in kindergarten or upon first

entry into an Illinois school beyond kindergarten (i.e., grades 1-12) are required to have

an eye examination. Examinations must be performed by a licensed optometrist or

medical doctor who performs eye exams He/she shall complete and sign the Eye

Examination Report form. These examinations should be completed before school

registration in August. A “Live Birth Certificate” copy must also be submitted for all Pre

K and Kindergarten students as well as any student new to the district.

Immunizations required are:

DPT (Diphtheria/Pertussis/Tetanus) – Four or more doses of DPT with the last

booster received after age 4. Any child entering 6th

grade shall show proof of receiving

one dose of Tdap (tetanus, diphtheria, acellular pertussis) vaccine regardless of the

interval since the last Tdap, DT or Td dose.

POLIO (TOPV or IPV) – Three or more doses with the last dose being a booster

given after 4 years of age.

MMR (Measles, Mumps, Rubella) – Two doses, first dose at 12-15 months,

second dose 4-6 years before start of school.

Hepatitis B – Three dose series, the 2nd

dose should be given 1 month after the 1st

dose, and the 3rd

dose at least 4 to 6 months after the 2nd

dose.

Chicken Pox Vaccine- Beginning with school year 2014-2015, any child entering

kindergarten, sixth grade, or ninth grade for the first time shall show proof of having

received two doses of varicella vaccine, the first dose on or after the first birthday and the

second dose no less than four weeks (28 days) after the first dose, or proof of prior

varicella disease or laboratory evidence of varicella immunity.

A lead-screening test/questionnaire must be submitted for each pre k and

kindergarten student prior to admission. If the test/questionnaire was completed in pre-

school, and the results were normal, it does not need to be repeated in kindergarten.

However a copy of the lead screening test/questionnaire results must be on file in school.

Thank you for your cooperation and we hope your students’ experiences with Warsaw

Elementary School will be happy and successful ones.

Sincerely,

Brad Froman, Principal

Warsaw Elementary School

Community Unity School District #316

340 South 11th

Street

Warsaw, IL 62379

(217) 256-4282

2014-2015

STUDENT FEES

(Required)

Pre-K No Fee

Grades K – 6 $35.00

Grades 7 – 8 Nauvoo

Grades 9 – 12 $70.00 (Includes $10 technology fee)

Driver’s Education $100.00

High School PE Uniforms $15.00

STUDENT REGISTRATION 2014 – 2015

Please fill out the information below.

Parent or Guardian Name: _______________________________________________________

Address: _____________________________________________________________________

City: ______________________ Zip: _______________ Phone #: _____________________

Student Name Date of

Birth

Grade Student

Fees

PE

Uniform

Drivers Ed (if applicable)

Lunch

(Optional)

TOTALS

TOTAL ENCLOSED: ______________________

Make checks payable to : Community Unit School District #316

COMPLETED FORMS ARE DUE NO LATER THAN AUGUST 8th

, 2014. PLEASE

MAIL OR BRING COMPLETED FORMS WITH PAYMENT TO THE ELEMENTARY

OR HIGH SCHOOL OFFICE.

EMERGENCY CONTACT AND MEDICAL INFORMATION FORM

WARSAW ELEMENTARY SCHOOL STUDENT EMERGENCY FORM

Student’s Last Name _____________________ Middle ___________ First _________________

Grade _____ Date of Birth _______ City of Birth ________________State ______ Male Female

Mother/Guardian

Name ______________________________________ Relationship _______________________

Address _____________________________________ City ______________ Zip Code ________

Home Phone # ________________Work #________________Cell #_______________________

E-mail _______________________________________________________________________

Father/Guardian

Other Parent/Guardian:__________________________________________________________

Address_____________________________________City________________Zip Code________

Home Phone #_________________Work #________________Cell #______________________

E-mail _______________________________________________________________________

Persons (OTHER THAN YOURSELF)) to be notified in case of emergency if you can not be reached.

CALL FIRST:Name________________________________Relationship_____________________

Home Phone #__________________Cell #_________________Work #____________________

CALL SECOND:Name______________________________Relationship_____________________

Home Phone #__________________Cell #__________________Work #___________________

MEDICAL INFORMATION

Hospital/Clinic Preference_________________________________________________________

Physician’s Name_______________________________________Phone #__________________

Dentist’s Name_________________________________________Phone #__________________

Allergies/Special Health Considerations______________________________________________

If you and the physician of choice as indicated above cannot be reached in an emergency and, if in the judgment of the school

authorities, immediate medical and/or hospital attention is indicated, do you authorize responsible school authorities to send

your child (properly accompanied) to an available hospital or physician? YES N0

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Parent/Guardian Signature Date

Warsaw C.U.S.D. #316 7:270-E Page 1 of 2

7:270-E-Students

School Medication Authorization Form

To be completed by the child’s parent{s}/guardian{s}. A new form must be completed every school year. Keep in the

school nurse’s office or, in the absence of a school nurse, the Building Principal’s office.

Student’s Name: __________________________________________Birth Date: ___________________________________

Address: _____________________________________________________________________________________________

Home Phone: ________________________Emergency Phone: ________________________________________________

School: _____________________________Grade: ______Teacher: ____________________________________________

To be completed by the student’s physician, physician assistant, or advanced practice RN:

Physician’s Printed Name: _______________________________________________________________________________

Office Address: ________________________________________________________________________________________

Office Phone: ______________________________________Emergency Phone: __________________________________

Medication Name: ______________________________________________________________________________________

Purpose: _____________________________________________________________________________________________

Dosage: ______________________________________________Frequency: _____________________________________

Time medication is to be administered or under what circumstances:___________________________________________

Prescription date: _________________Order date: _________________Discontinuation date: ______________________

Diagnosis requiring medication: __________________________________________________________________________

Is it necessary for this medication to be administered during the school day: Yes _____________No ________________

Expected side effects, if any: ____________________________________________________________________________

Time interval for re-evaluation: ___________________________________________________________________________

Other medications student is receiving: ___________________________________________________________________

____________________________________________________________________

Physician’s signature Date

Asthma Inhalers Parent{s}/Guardian{s}: Please attach prescription label here:

Warsaw C.U.S.D. #316 7:270-E Page 2 0f 2 Student Name: ______________________________________________________

For only parents/guardians of students who need to carry asthma medication or an EplPen®:

I authorize the School District and its employees and agents, to allow my child or ward to possess and use his/her asthma medication and/or epinephrine auto-injector: (1) while in school, (2) while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after normal school activities, such as while in before-school or after-school care on school-operated property. Illinois law requires the School District to inform parent(s)/guardian(s) that it, and its employees and agents, incur no liability, except for willful and wanton conduct, as a result of any injury arising from a student’s self-administration of medication or epinephrine auto-injector (105 ILCS 5/22-30). If you agree please initial: _________________________________ Parent(s)/Guardian(s) For all parent(s)/Guardian(s): By signing below, I agree that I am primarily responsible for administering medication to my child. However, in the event that I am unable to do so or on the event of a medical emergency, I hereby authorize the School District and its employees and agents, in my behalf, to administer or to attempt to administer to my child (or to allow my child to self-administer, pursuant to State law, while under the supervision of the employees and agents of the School District), lawfully prescribed medication in the manner described above. I acknowledge that it may be necessary for the administration of medications to my child to be performed by an individual other than a school nurse and specifically consent to such practices, and I agree to indemnify and hold harmless the School District and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the administration or the child’s self-administration of medication. __________________________________________ _______________________________________ Parent/Guardian printed name Parent/Guardian printed name Address: (if different from Student’s) _________________________________________________ Phone: ______________________________Emergency Phone: _______________________________ _______________________________________ ______________________________________ Parent/Guardian signature* Parent/Guardian signature* *Both parents and/or guardians, if available, should sign. Approved January 24, 2001

Warsaw Elementary School Pre-K

220 Underwood

Warsaw, IL. 62379

Transportation Information

Child’s Name____________________________________________

Child’s Home Address_____________________________________

Parent /Guardian_________________________________________

Home Phone ________________Work Phone_________________

Message /alternate contact name and phone number

Name__________________________________________________

Phone number___________________________________________

____My Child will come to school by bus and will be picked up at

____ I, or another adult will bring my child to school

____When my child leaves school, I will pick him/her up

____ After school, my child will ride the bus to

My child has a sibling at Warsaw Elementary who he/she will ride the bus home with

____My child is in AM Pre-K ____ My Child is in PM Pre-K

Start date______________

Parent /Guardian

Signature_____________________________________________________________________________

SCHOOL REACH Instant Parent Contact

To whom it may concern:

In our effort to improve communication between parents and school, we are instituting a telephone broadcast

system that will enable school personnel to notify all households and parents by phone within minutes of an

emergency or unplanned event that causes an early dismissal, school cancellations or late start. The service

may also be used from time to time to communicate general announcements or reminders. School Reach, a

company specializing in school-to-parent communications, provides this service. We will report school

closings due to snow or weather on the usual radio and TV stations and will use this system as an overlay to the

public.

When used, this service will simultaneously call all listed phone numbers in our contact list and will deliver a

recorded message from school personnel. The service will deliver the message to both live answer and

answering machines. No-answers and busy signal calls will be retried two times in 15-minute intervals after the

initial call.

Here is some specific information you should know:

Caller ID: The caller ID will display a school phone number

(217) 256-4614 – Elementary School

(217) 256-4281 – High School

(217) 256-4282 – District Office

Live Answers: There is a short pause at the beginning of the message. Answer your phone as

you normally would and wait for the message to begin. Multiple “hellos” will

delay the message.

Answering Machines: The system will detect that your machine has answered and will play the

recording. Maximum number of rings is 5, before the system will hang up.

Attendance: We will use the system to notify you when your child is absent, unless you

call the school before 9:00 a.m.

Cell Phones: We need to know your carrier (US Cellular, Sprint, etc) to allow the service to

go directly to your voice mail. Otherwise, it may “time out” and you may only

get part of the message.

Please fill out the information below so that we can get all the information we need into our system. This

service will allow up to 3 numbers per student to be called. This form needs to be filled out and returned even if

there are no changes from the last year.

STUDENT NAME: ______________________________________________ GRADE: _____________

1st Number to Call (with area code): ___________________________________ Carrier: ______________

2nd

Number to Call (with area code): __________________________________ Carrier: _______________

3rd

Number to Call (with area code): ___________________________________ Carrier: _______________

Note: Carriers are only needed for cell phone numbers.

Illinois Department of Public Health Childhood Lead Risk Assessment Questionnaire

ALL CHILDREN 6 MONTHS THROUGH 6 YEARS OF AGE MUST BE ASSESSED FOR LEAD POISONING

(410 ILCS 45/6.2)

Name ___________________________ Today’s Date_________________________________ Age _____________ Birthdate ________________ ZIP Code _________________ Respond to the following questions by circling the appropriate answer. R E S P O N S E 1. Is this child eligible for or enrolled in Medicaid, Head Start, All Kids

or WIC? Yes No Don’t Know 2. Does this child have a sibling with a blood lead level of10 mcg/dL or higher? Yes No Don’t Know 3. Does this child live in or regularly visit a home built before 1978? Yes No Don’t Know 4. In the past year, has this child been exposed to repairs, repainting or renovation of a home built before 1978? Yes No Don’t Know 5, Is this child a refugee or an adoptee from any foreign country? Yes No Don’t Know 6. Has this child ever been to Mexico, Central or South America, Asian

countries (i.e., China or India), or any country where exposure to lead from certain items could have occurred (for example, cosmetics, home

remedies, folk medicines or glazed pottery)? Yes No Don’t Know

7. Does this child live with someone who has a job or a hobby that may involve lead (for example, jewelry making, building renovation or repair, bridge construction, plumbing, furniture refinishing, or work with automobile batteries or radiators, lead solder, leaded glass, lead shots, bullets or lead fishing sinkers)? Yes No Don’t Know

8. At any time, has this child lived near a factory where lead is used (for example, a lead smelter or a paint factory)? Yes No Don’t Know

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If there is any “Yes” or “Don’t Know” response; and • there has been no change in the child’s living conditions; and • the child has proof of two consecutive blood lead test results (documented below) that are

each less than 10 mcg/dL (with one test at age 2 or older), a blood lead test is not needed at this time.

Test 1: Blood Lead Result_____mcg/dL Date _____ Test 2: Blood Lead Result_____mcg/dL Date _____

Please discuss any questions or concerns with your child’s health care provider. For more information, call:

Illinois Department of Public Health Childhood Lead Poisoning Prevention Program

800-545-2200 or 217-782-0403 TTY (hearing impaired use only) 800-547-0466

________________________________________ Signature of Doctor/Nurse Date

Childhood Lead Poisoning 1. What is lead? Lead is a naturally-occurring metal that is unsafe at any level in the body. 2. What is lead poisoning? Lead poisoning is the presence of too much lead in the body. 3. What are the symptoms of lead poisoning?

Children with lead poisoning usually have no obvious signs or abnormal symptoms.

4. How does lead poisoning affect children? Lead decreases children’s ability to learn and may lead to behavior problems. 5. Who gets lead poisoning?

People of any age, race or economic level, but children are at the greatest risk because of oral behaviors and hand contamination.

6. What are sources of present lead exposure?

• Dust and paint chips from deteriorating lead-based paint in homes built before 1978

• Soil contaminated with lead • Imported glazed pottery or other products made outside the United States

that contain lead • Food, medicines or folk remedies from foreign countries that contain lead • Family members who have occupations or hobbies involving lead • Drinking water from plumbing containing lead

7. How can I tell if my child has lead poisoning?

The only way to diagnose lead poisoning is through a blood test. The blood sample is sent to a laboratory to find out how much lead it contains.

8. When should I have my child assessed or tested?

• A child should be assessed for lead exposure at every well child visit between 6 months and 6 years of age.

• Blood lead tests are recommended at 12 and 24 months of age. • When a high risk of lead exposure exists. • All children eligible for or enrolled in Medicaid, Head Start, All Kids or WIC

are required to have blood lead testing.

Printed by Authority of the State of Illinois P.O. # 507345 2M 5/07