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Plainfield Community School Corporation

985 Longfellow Lane Plainfield, IN 46168

www.plainfield.k12.in.us

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Welcome to

Plainfield Community

School Corporation

Enrollment Packet




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REQUIRED ENROLLMENT DOCUMENTS

Plainfield Community School Corporation requires the following documents for enrollment of all students:

Birth Certificate

Health Records

Proof of Custody (if applicable)

IEP is required for all Special Education students (if applicable)

Proof of Residency:

o copy of purchase agreement or rental agreement AND

o copy of current gas or electric utility bill

Copy of parent driver's license or state ID

Please bring all documentation with you to enroll your student(s).




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Top section for office use only

2 Proofs of Residency Required Teacher Assignment_____________________________________

It is necessary to provide option A along with B and/or C. _____________________________________

A._____Current lease/rental agreement, purchase agreement or property tax statement

B._____Active and current utility bill

C._____Valid IN Driver’s License/State ID with current address

State Student #___________________ Student Login__________________________________ Student Password_________________________

PowerSchool#____________________ Guardian PowerSchool Login______________________ Guardian Password________________________

Plainfield Schools Student Enrollment Form

Student’s Legal Name:

(LAST) _____________________________ (FIRST) __________________________ (MIDDLE) _______________

Student’s Start Date _______________________ School __________________________________ Grade ______

Gender - Circle one: Male Female Date of Birth __________________ Age ___________

Bus Rider? Circle one: Yes No

Address _________________________________ City _______________________ State ______ Zip ________

Name of House Addition or Subdivision ______________________________________________________________

Is the student currently living at the address above? Yes No Please explain:_________________________

________________________________________________________________________________________________

Number of school age brothers and sisters attending other Plainfield Schools _______

1. _________________________________ Age _________ Grade _________ School __________________

2. _________________________________ Age _________ Grade _________ School __________________

3. _________________________________ Age _________ Grade _________ School __________________

Academic Information and History

School district of legal settlement ___________________________________________________________________

Name of last school attended ________________________ Phone# _______________ Fax# _______________

Address _________________________________ City ____________________ State _______ Zip ________

Has your child attended Plainfield Schools before? Circle one: Yes No Grade Level _____ Year __________

Has your child been in an English Language Learning (ELL) program? Circle one: Yes No

At your child’s previous school, was he/she in special education classes? Circle one: Yes No

If yes, what special education class? (504, LD, EH, etc.) ___________________________________________

At the previous school, did your child receive TITLE I reading/math services? Circle one: Yes No

At the previous school, did your child received SPEECH services? Circle one: Yes No

HS Students only: Are you a part of the 21st Century Scholars Program? Circle one: Yes No




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Parent/Guardian Information

Parents are: _____ Together _____ Separated _____ Divorced _____ Widowed

_____ Mother & Father _____ Mother & Stepfather _____ Guardian

_____ Mother Only _____ Father & Stepmother _____ Other (explain)

_____ Father Only _____ Grandparent(s) _____________________

Does this person have legal custody? Circle one: Yes No If no, who does have legal custody? _______________

Does a court order exist restricting contact with anyone? Circle one: Yes No

***If so, please attach a copy of the actual court document for our school records.

Custodial Parent/Guardian: (Match with the above choice)

First _________________________ Last _______________________________ Relationship _______________

Address ____________________________________ City ___________________ State ______ Zip _________

Home __________________________ Cell _________________________ Work __________________________

Email: __________________________________________________________________________________________

Place of Employment ______________________________________________________________________________

Step-Parent/Other Guardian Name: _______ N/A

First _____________________ Last ______________________________ Relationship ________________

Home __________________________ Cell _______________________ Work _______________________

Email ______________________________________________________________________________________

Custodial/Shared-Custodial/Non-Custodial Parent/Guardian #2:

First _________________________ Last _______________________________ Relationship _______________

Address ____________________________________ City ___________________ State ______ Zip _________

Home __________________________ Cell _________________________ Work __________________________

Email: __________________________________________________________________________________________

Place of Employment ______________________________________________________________________________

Step-Parent/Other Guardian Name: _______ N/A

First _____________________ Last ______________________________ Relationship ________________

Home __________________________ Cell _______________________ Work _______________________

Email ______________________________________________________________________________________

*All information will be entered into our PowerSchool data management system unless school is notified of desired alternative.

Information of Non-Custodial Parent

Student also resides with non-custodial parent? Yes No

Have you provided the school with a copy of custody papers? Yes No

Restraining Order on file? Yes No

Note: Copies of legal documents

MUST be on file in the guidance office

to support special custody limitations.




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Race & Ethnicity (Required for state and federal ethnicity reports)

Ethnicity (Check One)

Is this individual Hispanic or Latino? _____ No, Not Hispanic/Latino

_____ Yes, Hispanic/Latino (Cuba, Mexico, Puerto Rico, South or

Central America or other Spanish culture or origin.)

Race (Choose one or more)

_____American Indian or Alaskan Native

_____Asian (includes India, Malaysia or Pakistan, Japan, Korea, Philippines, Thailand, Vietnam)

_____Black or African American

_____Caucasian-White (includes Middle East except Pakistan)

_____Native Hawaiian or other Pacific Islander (including Guam, Hawaii, Samoa, other Pacific Islands)

Emergency Contact (other than parents) – used if parents cannot be reached

Name ____________________________________________ Relationship to child ___________________________

Phone ___________________________________ Please circle applicable option: Home Cell Work

I have reviewed and understand the information above and find it to be accurate. I realize any false information can

negate this enrollment.

I hereby give permission for the cumulative academic record, all testing, discipline and attendance records of the

above named student to be released to Plainfield Community School Corporation.

____________________________________________ _______________________________________

Parent/Guardian Printed Relationship

____________________________________________ _______________________________________

Parent/Guardian Signature Date

*****OFFICE USE ONLY*****

Entry Date into Plainfield Schools ____________________ Locker# ___________ Combo# ___________ Bus# _______ Date Records Requested __________




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KINDERGARTEN QUESTIONNAIRE

Child’s full name _____________________________________________________________________________

(First) (Middle) (Last)

Name child prefers to be called _________________________________________________________________

Child’s birthdate _______________________________ Language _____________________________________

Did child attend daycare ___________ How Long _______ Where ____________________________________

Did child attend preschool __________ How Long _______ Where ____________________________________

Circle the most appropriate answers:

Self-Concept Strong self-concept Good self-concept Insecure

Separation from parent With ease Easily most times With difficulty

Interaction with peers Outgoing Follower Shy

Can recite the ABC’s Yes Most of it Not Yet

Can count to 10 Yes Somewhat Not Yet

Can print first name by themselves Yes Somewhat Not Yet

Can cut with scissors Easily With help Not Yet

How often do you read to your child? 5-7 times a week 3-4 times a week 1-2 times or not at all

Activity Level Quiet Moderately active Very active

Temperament Pleasant Easily upset Angry

Attention span Focused Sometimes distracted Easily distracted

Impulsiveness Timid Watches first, then tries Adventurous

Cooperative Behavior Most times Sometimes Not often

Please list special things you would like us to know about your child: (example: strengths, limitations, special needs,

fears, health and/or behavior concerns) ________________________________________________________________

__________________________________________________________________________________________________

Parent Name (Printed) ___________________________________ Signature ___________________________________

Address _______________________________________________ Telephone Number(s) _________________________




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Home Language Survey (HLS)

The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and

charter schools to determine the language(s) spoken in each student’s home in order to identify their language

needs. This information is essential in order for schools to provide meaningful instruction for all students as outline

Plyer v. Doe, 457 U.S. 202 (1982)

The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to

all students enrolled in the school district/charter school. The HLS is administered one time, upon initial enrollment,

and remains in the student’s cumulative file.

Please note the answers to the survey below are student specific. If a language other than English is recorded for

ANY of the survey questions below, the WIDA Assessment test will be administered to determine whether or not the

student will qualify for additional English language development support.

Please answer the following questions regarding the language spoken by the student:

1. What is the native language of the student? ________________________________

2. What language(s) is spoken most often by the student? ________________________________

3. What language(s) is spoken by the student in the home? ________________________________

4. What is the student’s country of origin? ________________________________

5. Length of time student has been in the United States? ________________________________

Student Name: _____________________________________________________________ Grade: ________________

Parent/Guardian Name: _____________________________________________________________________________

Parent/Guardian Signature: ____________________________________________________ Date: ________________

By signing here, you certify that responses to the three questions above are specific to your student. You

understand that if a language other than English has been identified, your student will be tested to determine if they

qualify for English language development services, to help them become fluent in English. If entered into the

English language development program, your student will be entitled to services as an English learner and will be

tested annually to determine their English language proficiency.

For School Use Only:

School personnel who administered and explained the HLS and the placement of a student into an English

language development program if a language other than English was indicated:

Name:_________________________________________________________________ Date: ____________________

Revised 9/3/2013

The Migrant Education Program (MEP) provides supplemental education and support services to eligible

children through national funding. The purpose of the program is to ensure that all migrant students reach

the academic standards and graduate with a high school diploma (or complete a GED).

WORK SURVEY

Thank you for answering the following questions. If your child is eligible for the Migrant Education

Program, they may receive additional educational support. This information is strictly confidential.

Parents’ Names: _____________________________________________________________________________________

Address: _________________________________________City:______________________ Telephone: (___) _________

1. How long have you lived in this city/school district? _____________________________

2. Within the last 3 years, has your child(ren) moved from one school district to another within the

United States, with a parent, relative or guardian so that person could look for seasonal or

temporary work in agriculture? YES ___ NO _____ If you answered NO, please stop.

If you answered YES, please continue.

3. When was the last time you or anyone in your household has moved to look for, or work in an

agricultural activity within the United States? Month________________ Year_________________

4. Please check any of the agricultural activities listed below that you have looked for or worked in:

_____ Plant or harvest vegetables or fruits _____ Canning vegetables or fruits

_____ Detassel corn _____ Sod farm

_____ Tobacco farm _____ Planting, pruning or cutting trees

_____ Poultry and/or egg farm _____ Dairy farm

_____ Duck, turkey, chicken, pork or beef processing plant _____ Flora culture/gladiola farm

_____ Aquaculture/fish hatcheries _____ Green house or plant nursery

Please list the names of all of the children in the household under 22 years of age.

Child’s Name Date of Birth (D.O.B.)

1.

2.

3.

4.

5.

Revised 9/3/2013

El Programa de Educación Migrante (MEP) provee educación y servicios suplementarios a niños que

califican a través de fondos nacionales. El propósito de MEP es asegurar que todos los estudiantes

migrantes tengan éxito académico y que se gradúen con su diploma (o que completen el GED)

ENCUESTA DE TRABAJO

Gracias por contestar las siguientes preguntas. Si su hijo(a) resulta elegible para el Programa de

Educación Migrante, podría recibir apoyo educativo adicional. La información es totalmente

confidencial.

Nombres de los Padres: ______________________________________________________________________________

Dirección: ___________________________________ Ciudad: _______________________ Teléfono: (___)_________

1. ¿Cuanto tiempo han vivido en esta ciudad/distrito escolar? ___________________________________

2. Durante los últimos tres años, ¿Se han mudado sus hijos o han cambiado de distrito escolar

dentro de los Estados Unidos, solos, con un padre o pariente, para que esa persona pudiera

buscar trabajo temporal o de temporada en algo relacionado con la agricultura?

SI_____ NO_____ Sí contestó NO, favor de parar aquí.

Sí contestó SI, favor de continuar.

3. ¿Cuando fue la última vez que usted o un miembro de su familia se mudó para trabajar en

la agricultura? Mes _______________________________ Año _________________________________

4. Por favor marque en la parte abajo la actividad agrícola en la cual usted buscó trabajo o

trabajó.

____ Matadero de patos, pavos, pollos, cerdos o vacas ____ Enlatar o congelar verduras o frutas en la bodega

____ La espiga (maíz) ____ Trabajar en la siembra o cosecha de césped

____ Cultivar tabaco ____ Plantar, emparejar o cortar árboles

____ Pollería o granja de huevos ____ Granja de vacas lecheras

____Plantar o cosechar verduras o frutas ____ Cultivar y cosechar flores

____ Trabajar en un criadero de peces ____ Trabajar en la cría de plantas

Por favor escribe los nombres de todos los niños, menos de 22 años de edad, que viven con usted.

Nombre del niño(a) Fecha de nacimiento

1.

2.

3.

4.

5.




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PCSC PARTICIPATES IN C.H.I.R.P.

Children and Hoosiers Immunization Registry Program (C.H.I.R.P.) is the free and innovative online system that

stores and updates immunizations records of both children and adults in Indiana. It is confidential and free.

BENEFITS OF C.H.I.R.P.

Providers can determine when a patient is due or overdue for vaccinations based on up-to-date

guidelines.

Providers reduce under and over immunization by viewing immunization records from multiple

providers.

Providers can print Official Immunization Cards for day care, school, camp, or employment.

I give the Plainfield Community School Corporation Nurses permission to register my child’s immunization records

onto the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (C.H.I.R.P.).

The information that may be needed is student’s name, date of birth, address, phone number, and parent’s name.

I understand that my child’s information will be available to the immunization registry of another state, a healthcare

provider, a local health department, an elementary or secondary school that is attended by the individual, a child

care center and the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and

planning. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3.

I understand that the information in the registry may be used to verify that my child has received proper

immunizations. I understand that it can also be used to inform me of my child of my child’s immunization status or

that an immunization is due according to recommended immunization schedules.

I hereby consent to the release of such information.

______________________________________________________________ ________________________________

Parent/Guardian Signature Date

__________________________________________________________________________________________________

Printed Name of Parent/Guardian

______________________________________________________________ ________________________________

Child’s Name Child’s Date of Birth

2016 – 2017 School Year IN State Department of Health

School Immunization Requirements Updated November 2015

3 to 5 years old

3 Hep B (Hepatitis B) 4 DTaP (Diphtheria, Tetanus & Pertussis) 3 Polio (Inactivated Polio) 1 MMR (Measles, Mumps, Rubella) 1 Varicella

K – 2nd Grade

3 Hep B 5 DTaP

4 Polio 2 MMR

2 Varicella 2 Hep A (Hepatitis A)

Grades 3 to 5

3 Hep B 5 DTaP 4 Polio 2 MMR

2 Varicella

Grades 6 to 11 3 Hep B 5 DTaP 4 Polio 2 MMR

2 Varicella 1 Tdap (Tetanus & Pertussis) 1 MCV4 (Meningococcal conjugate)

Grade 12 3 Hep B 5 DTaP 4 Polio 2 MMR

2 Varicella 1 Tdap 2 MCV4

Hep B The minimum age for the 3rd dose of Hepatitis B is 24 weeks of age.

DTaP Four doses of DTaP/DTP/DT are acceptable if 4th dose was administered on or after child’s 4th birthday.

Polio Three doses of Polio are acceptable for all grade levels if the third dose was given on or after the 4th birthday and at least 6 months after the previous dose with only one type of vaccine used (all OPV or all IPV). For students in grades kindergarten through 6th grade the final dose must be administered on or after the 4th birthday, and be administered at least 6 months after the previous dose.

Live Vaccines (MMR, Varicella & LAIV) Live vaccines that are not administered on the same day must be administered a minimum of 28 days apart. The second dose should be repeated if the doses are separated by less than 28 days.

Varicella Physician documentation of disease history, including month and year, is proof of immunity for children entering preschool through 8th grade. Parental report of disease history is acceptable for grades 9-12.

Tdap There is no minimum interval from the last Td dose.

MCV4 Individuals who receive dose 1 on or after their 16th birthday only need 1 dose of MCV4.

Hep A The minimum interval between 1st and 2nd dose of Hepatitis A is 6 calendar months

For children who have delayed immunizations, please refer to the 2016 CDC “Catch-up Immunization Schedule” to determine adequately immunizing doses. All minimum intervals and ages for each vaccination as specified per 2016 CDC guidelines must be met for a dose to be valid. A copy of these guidelines can be found at http://www.cdc.gov/vaccines/schedules/

http://www.cdc.gov/vaccines/schedules/

Año académico 2016 - 2017 Departamento de Salud del Estado de Indiana

Requisitos de Vacunación de la Escuela Actualizado en noviembre de 2015

De 3 a 5 años

3 Hep B (Hepatitis B) 4 DTaP (Difteria, tétanos y tos ferina) 3 Polio (Poliomelitis inactivada) 1 MMR (Sarampión, paperas, rubéola) 1 Varicela

Jardín de infantes y 2.º grado 3 Hep B 5 DTaP

4 Polio 2 MMR

2 Varicela 2 Hep A (Hepatitis A)

De 3.º a 5.º grado

3 Hep B 5 DTaP 4 Polio 2 MMR

2 Varicela

De 6.º a 11.º grado 3 Hep B 5 DTaP 4 Polio 2 MMR

2 Varicela 1 Tdap (Tétano y pertusis) 1 MCV4 (Meningocócica conjugada)

12.º grado 3 Hep B 5 DTaP 4 Polio 2 MMR

2 Varicela 1 Tdap 2 MCV4

Hep B La edad mínima para la 3.ª dosis de Hepatitis B es 24 semanas de edad.

DTaP Cuatro dosis de DTaP/DTP/DT son aceptables si la 4.ª dosis se administró en el 4.º cumpleaños del niño o después

de esa fecha.

Polio Tres dosis de polio son aceptables para todos los niveles de grados si la tercera dosis se administró en el 4.º

cumpleaños o después de esa fecha, o bien, al menos 6 meses después de la dosis anterior con un solo tipo de vacuna utilizada (todas OPV o todas IPV). Para los alumnos que estén en el jardín de infantes hasta 5.º grado, la dosis final se debe administrar en el 4.º cumpleaños o después de esa fecha, y debe administrarse al menos 6 meses después de la

dosis anterior. Para los alumnos que estén en el jardín de infantes hasta 5.º grado, la dosis final debe administrarse en el 4.º cumpleaños o después de esa fecha, y debe administrarse al menos 6 meses después de la dosis anterior.

Vacunas vivas (MMR, Varicela y LAIV) Las vacunas vivas que no se administran el mismo día se deben administrar con una

diferencia mínima de 28 días. La segunda dosis debe repetirse si las dosis se administraron con una diferencia de menos de 28 días.

Varicela La documentación médica de los antecedentes de enfermedades, incluidos el mes y el año, es la prueba de inmunidad para los niños que ingresan en preescolar hasta 7.º grado. El informe de los padres sobre antecedentes de enfermedades es aceptable para los grados 8.º a 12.º.

Tdap No hay ningún intervalo mínimo desde la última dosis de Td.

MCV4 Las personas que reciben la 1ª dosis en su 16º cumpleaños o después de esa fecha solo necesitan 1 dosis de

MCV4.

Hep A El intervalo mínimo entre la 1.ª y la 2.ª dosis de Hepatitis A es de 6 meses calendario.

Para los niños que se han retrasado con su vacunación, consulte el “Programa de Actualización de Vacunas” del Centro para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés) de 2015, a fin de determinar las dosis de vacunación de forma adecuada. Para que una dosis sea válida, deben cumplirse todas las edades e intervalos mínimos para cada vacuna especificados según la Guía del CDC de 2015. Una copia de estas guías puede encontrarse en http://www.cdc.gov/vaccines/schedules/.

http://www.cdc.gov/vaccines/schedules/


985 Longfellow Lane

Plainfield, IN 46168

317-839-2578

CONSENT FOR RELEASE OF INFORMATION

Attention: Guidance Office/Registrar/Student Records Date:

Previous School:

Phone Number:

Fax Number:

Student Name:

Date of Birth: Grade:

The student named above has applied to enroll in Plainfield Schools.

Per parent request, please fax the student educational records to the school checked below:

Plainfield High School

1 Red Pride Drive, Plainfield, IN 46168 P: 317-838-3622 F: 317-838-3685

Plainfield Community Middle School

709 Stafford Road, Plainfield, IN 46168 P: 317 838-3672 F: 317-837-7225

Brentwood Elementary School

1630 East Oliver, Plainfield, IN 46168 P: 317-839-4802 F: 317-838-3991

Central Elementary School

110 Wabash Street, Plainfield, IN 46168 P: 317-839-7707 F: 317-838-3646

Clarks Creek Elementary School

401 Elm Drive, Plainfield, IN 46168 P: 317-839-0120 F: 317-838-7316

Van Buren Elementary School

225 Shaw Street, Plainfield, IN 46168 P: 317-839-2575 F: 317-838-3993

NOTE: Please include any special education, speech or 504 documentation/records.

Thank you for your prompt attention to this request.

PREMISSION TO RELEASE RECORDS

I hereby give permission for the records and test information of the above named student to be released to the above mentioned school.

Parent/Guardian Printed Name:

Parent/Guardian Signature:

Relationship: Date:




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VOLUNTEER AGREEMENT

BACKGROUND INFORMATION AUTHORIZATION AND RELEASE

Please check one of the options below that applies to you:

Parent/Guardian _____ Student Teacher_____ Other_____ Please explain: _______________________________

It is MANDATORY to have this background check on file for any volunteering in the classroom, to include field trips.

If you have filled this form out in the past with Plainfield Schools, it is not necessary to fill it out again.

STUDENT(S): SCHOOL(S): TEACHER(S):

___________________________________ _____________________________ __________________________

___________________________________ _____________________________ __________________________

___________________________________ _____________________________ __________________________

Dear Volunteer:

Volunteering with the Plainfield Community School Corporation involves contact with our student population.

Therefore, we request that you complete the questions below to assist us in evaluating your suitability to work with

students. All volunteers must provide us with background information; you are not being singled out from other

volunteers for closer inspection. Any misrepresentation or omission of facts may be grounds for disqualification

from further consideration.

Conviction of a crime or any affirmative answer provided by you on this form is not an automatic ban to volunteering.

Plainfield Community School Corporation will consider the nature of the conviction or alleged conduct underlying an

affirmative response, the date of the alleged conduct, and your intervening conduct.

_____Yes _____No A. If you are now working, is your conduct as an employee or the quality of your

work the focus of any investigation by your current employer?

_____Yes _____No B. Have you ever resigned from a job after being disciplined by your employer or

after being offered the opportunity to resign rather than be terminated?

_____Yes _____No C. Have you ever been investigated for, charged with, plead guilty, or “no contest”

to any crime involving the sexual abuse of any person or indecency with a minor?

_____Yes _____No D. Have you ever been charged with a crime, other than a minor traffic offense,

where the court has deferred further proceedings without entering a finding of guilt

and placed you on probation in public service, or an education program?

_____Yes _____No E. Have you ever been convicted of any crime?

__________________________________________ _____________________________ ___________________

SIGNATURE CONTACT PHONE # DATE

If you answered yes to any of the above questions, explain the circumstances of each on a separate sheet and

attach it to this volunteer application. (page 1 of 3)




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VOLUNTEER AGREEMENT BACKGROUND INFORMATION AUTHORIZATION AND RELEASE

AUTHORIZATION AND RELEASE

I understand that if I am a volunteer for the Plainfield Community School Corporation, I must obtain a Limited

Criminal History.

Therefore, I authorize local, state, and federal agencies to provide this information concerning the matters described

herein for inspection by the school corporation. I understand that I must provide the school corporation with my

legal name and date of birth so they may process my “Limited Criminal History” information.

I also understand that I may not volunteer with the school until a copy of the Limited Criminal History information

has been obtained.

I EXPRESSLY WAIVE IN CONNECTION WITH ANY REQUEST FOR, OR PROVISION OF SUCH INFORMATION, ANY CLAIMS,

CAUSES OR ACTIONS, INCLUDING WITHOUT LIMITATION, DEFAMATION, INFLECTION OF EMOTIONAL DISTRESS,

INVASION OF PRIVACY, OR INTERFERENCE WITH CONTRACTUAL RELATIONS THAT I MIGHT OTHERWISE HAVE

AGAINST THE SCHOOL CORPORATION, IT’S OFFICIALS, EMPLOYEES, TRUSTEES OR AGENTS, OR AGAINST ANY

PROVIDER OF SUCH INFORMATION.

I have read this authorization and release of all claims, and I expressly agree to the terms set out herein.

_______________________________________________ _____________________________________________

APPLICANT’S SIGNATURE APPLICANT’S LEGAL NAME PRINTED

___________________________________ _________ _________

APPLICANT’S DATE OF BIRTH FEMALE MALE

OPTIONAL:

_____ AMERICAN INDIAN

_____ ASIAN

_____ BLACK

_____ HISPANIC

_____ MULTI-RACIAL

_____ WHITE

(page 2 of 3)




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VOLUNTEER AGREEMENT BACKGROUND INFORMATION AUTHORIZATION AND RELEASE

PCSC Volunteer Confidentiality Agreement Thank you for your willingness to volunteer your talents to help our students and our school! We certainly appreciate

your time and know that our schools are better because of people like you! Please take a moment to read and sign

the following confidentiality agreement to help us protect all of our students.

Again, thank you for being a PCSC school volunteer.

I,__________________________________________ (printed name), understand and agree that any and all

information gained while assisting in a classroom or any other part of the school building in one or more of the PCSC

schools must be held in confidence. This confidence applies not only to specific students with whom I may be

involved, but to all other students who are part of the environment observed. Furthermore, any student names that

may be learned as part of my work or seen as part of classroom displays or activities shall not be conveyed to any

other individual at any time.

As part of volunteering with PCSC, I may be privy to certain sensitive and/or confidential information regarding the

students and/or families served by PCSC. This includes, but is not limited to, any of the following: a) educational

information related to students’ academic performance or behavior, b) medical information, or c) other types of

private or sensitive material. I understand the importance of confidentiality and respect the rights of the students,

teachers, schools, and families that PCSC services.

I agree to abide by all school rules and visitation policies, including those pertinent to building security (i.e. signing in

an out and wearing a name badge) so that building personnel are aware of my presence.

I agree to comply with all the requests of the classroom teacher or other school employee with whom I am working

and to perform my duties so that I do not disrupt the education process of the students in the class or the school

building. I understand that the classroom teacher’s priority will be the instruction of students an my duties may not

unduly disrupt that learning environment.

______________________________________________ __________________________

VOLUNTEER’S SIGNATURE DATE

______________________________________________ __________________________

VOLUNTEER’S PRINTED NAME DATE

______________________________________________ __________________________

SCHOOL PERSONNEL’S SIGNATURE DATE

(page 3 of 3)




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Transportation Data Form Please check applicable school below.

Brentwood _____ Central _____ Clarks Creek _____ Van Buren _____

This form must be completed and returned to the school for your child to receive bus service. In order to

establish bus routes, it is necessary to know if your child will be riding a bus and where your child will be

picked up and dropped off.

Please complete the following information:

Child’s Name _______________________________________ Grade ___________________

Home Address ____________________________________ Home Phone # _______________

Parent/Guardian Name ______________________________ Cell Phone # ________________

No, my child will not be riding the bus. I will provide my own transportation.

Yes, my child needs bus service.

Parents must choose ONE consistent Pick Up Point and One consistent Drop Off Point at home or

Daycare. Pickup point and drop off point may not vary daily and must be in your child’s Elementary

District.

Address of PICK UP Point ______________________________________________________

Address of DROP OFF Point ____________________________________________________

Daycare/Babysitter’s Name _____________________________ Phone # ______________

Emergency Contact Name _______________________________ Phone # _____________

A parent or designated individual must be at the Bus Stop when your Kindergarten child is delivered.

*Please notify your child’s school if your address changes. A new Transportation Form must be completed

before changes can be made to your child’s bus service.

__________________________________________ __________________________

Parent Signature Date Revised 3/6/14

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