GRIFFITH PUBLIC SCHOOLS
www.griffith.k12.in.us
RETURNING STUDENT REGISTRATION
Elementary School
Application Packet
2012-2013 School Year
REQUIRED DOCUMENTS AT REGISTRATION: (Parent or legal guardian must be present)
1. PROOF OF RESIDENCY:
HOMEOWNERS:
1. Mortgage statement
2. Two utility bills in homeowner’s name (NIPSCO, phone, water bill, etc.) 3. Valid Indiana driver’s license or State I.D. (Griffith resident address)
4. Valid Indiana vehicle registration (Griffith resident address)
RENTERS: 2, 3, 4 above, plus lease agreement listing custodial parent and student name
2. IMMUNIZATIONS – required medical documentation for Kindergarten, First Grade, and Sixth Grade students
REQUIRED FORMS (attached):
1. RESIDENCY VERIFICATION – required, review, complete information, sign 2. EARLY DISMISSAL PLAN - required, review, complete information, and sign 3. ONECALL NOW INFORMATION – required, complete
4. ADULT PARTICIPATION – optional, must be completed before any school volunteer activity 5. FREE AND REDUCED MEALS and TEXTBOOK ASSISTANCE – optional, application provided 6. HEALTH SERVICES INFORMATION SHEET – required, review, complete information, and sign
GRIFFITH PUBLIC SCHOOLS
RESIDENCY VERIFICATION
Student Name Address____________________________________________________________________________I, _______________________, the parent and legal guardian of named student do hereby attest that we are residents within the boundaries of the Griffith Public Schools and currently reside at the address given on this form.
I fully understand that should the information contained herein not be true and correct, or should the conditions change, and should it be determined that my child is /children are not living as a legal Griffith resident, the school corporation will initiate student exclusion proceedings against my child/children and charge for any legal, collection, or other costs the school may have incurred.
I hereby furnish proof of residency within the boundaries of the Griffith Public Schools: a. ___ Current lease (if renter), Mortgage statement (if owner.)
b. ___ Affidavit supporting residency (notarized) if living with another party c. ___ Indiana Driver’s License (or state I.D. with Griffith address)
d. ___ Valid Indiana vehicle registration (with Griffith address)
e. ___ 2 copies of homeowner’s business mail (ex. Nipsco, Phone, or Water bill)
______________________________ _____________________________
Parent Signature Date
Notice: READ CAREFULLY: Knowingly falsifying this document is a violation of the I.C. 35-44-2 which is a class D Felony. Further the affidavit will be billed (and prosecuted in court, if necessary) to collect all back tuition which may be due.
Inaccurate and/or false information will result in immediate withdrawal of your child(ren) from the Griffith Public School Corporation.
GRIFFITH PUBLIC SCHOOLS
EARLY DISMISSAL PLAN
Student Name _____________________________
EARLY DISMISSAL PLAN
Parents and school personnel share a common concern – Where do children go if school is dismissed early? There are a few situations, which may arise that could lead to an early dismissal. Some of these include weather, plumbing/heating problems, and electrical outages. School personnel will inform parents as soon as possible through the OneCall system. In addition, emergency closure information will be posted on the Griffith Public Schools website. However, we will NOT be able to allow students to call out from the school office and we will not be able to handle messages or calls from parents because our telephone lines would be needed for emergency calls. For this reason, we are asking each of you to complete and return the form below for your children. Teach your child the plan and “quiz” him/her from time-to-time to be certain he/she knows what to do.
We want to stress that it is your responsibility to develop a plan for your family. This plan should include the procedures for your child to follow. Please completely fill out the form below and turn it in at the office. Your child’s teacher will keep it on file to be certain your child knows what to do in case of an early dismissal. YOU MUST BE CERTAIN TO CONTACT YOUR CHILD'S TEACHER IF THIS PLAN CHANGES FOR ANY REASON.
Please check the appropriate line(s).
1. My child should go home in the following manner on early dismissal days:
a. _____ Ride the bus home (only if your child rides the bus on a daily basis) b. _____ Walk home
c. _____ My special instructions for my child on early dismissal are:
______________________________________________________________________
______________________________________________________________________
___________________________ ___________________ _________________
GRIFFITH PUBLIC SCHOOLS
ONECALL NOW SYSTEM
Student Name: ___________________________________ Grade Level: _____________________
The OneCall Now System, is an automated calling system used by Griffith Public Schools for the purpose of contacting the parents or guardians of students with building announcements, or any school emergency.
Please list two phone numbers that you would like the OneCall Now System to call to receive information.
Phone Number 1: ___________________________________ Area Code Number
Phone Number 2: ___________________________________
Area Code Number
Email ___________________________________
*Race: I = American/Pacific Islander
A=Asian W=White B=Black M=Multi Racial U=Unknown
GRIFFITH PUBLIC SCHOOLS
SCHOOL ACTIVITY
ADULT PARTICIPATION FORM
Student Name
Individuals named below would like to participate in school activities during the 2012-2013 school year, and understand that a criminal history background check is REQUIRED, per Board policy (examples: PTC, Grandparents’ Day, Field Day, field trips, Daddy-Daughter Dance, Market Day, choir events, Reality Store, dances, etc.). Please list below all family members who will be participating in any school function
throughout the school year.
I/We agree to abide by all relevant School Board policies and administrative guidelines while on duty volunteering for the District or attending a District function, and understand that, although covered under the District's liability insurance policy, I/we are not covered by its health insurance policy or eligible for workers' compensation. Should I/we become ill or suffer an accident while doing volunteer work for the Corporation or attending an activity as a guest, it is agreed that the District shall not be responsible for any hospital or medical charges that may accrue.
I/We understand further that, as a volunteer or District guest, I/we are in no manner considered an employee or entitled to any benefits provided to employees. I/we further release the Board from any and all liability for any damages, whatever their nature, which may result as a consequence of my/our volunteer services or status as a guest. For the protection of the children in the schools, the District inquires of its volunteers and guests whether or not they have ever been convicted of a crime related to children. We would appreciate your cooperation by indicating that no one listed below has ever been convicted of any of the following offenses: aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, aggravated menacing, abuse or neglect of a child, kidnapping, abduction, child stealing, criminal child enticement, rape, sexual battery, corruption of a minor, gross sexual imposition, importuning, voyeurism, public indecency, felonious sexual penetration, compelling prostitution, promoting prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually-oriented matter involving a minor, illegal use of a minor in nudity-oriented material or performance, endangering children, contributing to the delinquency of children, carrying concealed weapons, improperly discharging a firearm at or into a school or house, corrupting another with drugs, placing harmful objects in or adulterating food or confection. Your signature below confirms no one listed has ever been so convicted.
_________________________________ Signature/Date
Indiana State Police
Criminal History Information/Limited Criminal History, 317-233-5424 www.IN.gov/ISP
First Name Last Name 2012-13 Activities (list all anticipated activities for each person)
Date of Birth mo/date/yr
Gender Race*
_______________________________ Administrator(Principal or Athletic Director)
GRIFFITH PUBLIC SCHOOLS
FREE AND REDUCED MEALS
AND TEXTBOOK ASSISTANCE APPLICATION
- Only one application is required per family, regardless of which school
your child attends
- Application for the free and reduced meal / textbook assistance program is optional - All applications remain confidential
- Because of the school district’s computerized cafeteria cash register system, students on assistance are not identified as ‘free or reduced’ in the school lunch line
- Families who have received ‘pre-certification’ letters in the mail over the summer do not need to complete these forms
2013 Parent Letter/Instructions Page 1 of 4
Dear Parent/Guardian:
Children need healthy meals to learn. Griffith Public Schools offer healthy meals every school day. The Elementary breakfast regular price is $1.25; lunch is $1.90. The Middle and High school breakfast regular price is $1.50; lunch is $2.15. Your children may qualify for free meals or for reduced price meals. Reduced price is $0.30 for breakfast and $0.40 for lunch.
1. Who can get free or reduced price meals? All children in households receiving Food Stamps or TANF can get free
meals regardless of your income. Also, if your household income is within the limits on the Federal Income Chart, your children can get free or reduced price meals.
2. Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price
meals. Use one application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to your child’s school.
3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or
court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income.
4. My child’s application was approved last year. Do I need to fill out another one? Yes. Your child’s application is
only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year.
5. Should I fill out an application if I received a letter this school year saying my children are approved for free meals? Please read the letter you got carefully and follow the instructions. Call the school if you have questions.
6. I get WIC. Can my children get free meals? Children in households participating in WIC may be eligible for free or
reduced price meals. Please fill out an application.
7. Can migrant, homeless, or runaway children get free meals? Yes, children who meet the definition of homeless,
runaway, or migrant qualify for free meals. If you haven’t been told your children will get free meals, please call or e-mail, Mr. Aron Borowiak, Homeless Liaison; phone 219-924-4250, email [email protected], to see if they qualify.
8. May I apply if someone in my household is not a U. S. citizen? Yes. You or your children do not have to be a U.S.
citizen to qualify for free or reduced price meals.
9. Who should I include as members of my household? You must include all people living in your household, related or
not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with you. If you live with other people who are economically independent (for example, people who do not support, who do not share income with you or your children, and who pay a pro-rate share of expenses), do not include.
10. Will the information I give be checked? Yes, we may ask you to provide written proof.
11. What if my income is not always the same? List the amount that you normally receive. For example, if you normally
get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
12. We are in the military; do we include our housing allowance as income? If you get an off-base housing allowance, it
must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income.
13. My spouse is deployed to a combat zone. Is her/his combat pay counted as income? No, if the combat pay is
received in addition to her basic pay because of her deployment and it wasn’t received before she was deployed, combat pay is not counted as income. Contact your school for more information.
14. If I don’t qualify now, may I apply again later? Yes. You may apply at any time during the school year. For example,
children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.
15. My family needs more help. Are there other programs available? To find out how to apply for food stamps or
other assistance benefits, contact your local assistance office.
16. What if I disagree with the school’s decision about my application? You should talk to the school officials. You also
may ask for a hearing by calling or writing to:
We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to:
Kathy Carter Beiriger Elementary School 601 N. Lillian, Griffith IN 46319
219-924-4030 ext. 26
If you have other questions or need help, call: Kathy Carter @ 219-924-4030 ext 26 Si necesita ayuda, por favor llame at teléfono: 219-924-4030 ext 26
Si vous voudriez d’aide, contactez nous au numero: 219-924-4030 ext 26 Sincerely,
2013 Parent Letter/Instructions Page 2 of 4
INSTRUCTIONS for APPLYING
Households getting TANF or Food Stamps:
1. In Part 1, list each enrolled child, include the TANF or Food Stamp case number for any child, and the name of the school.
EBT and Hoosier Healthwise numbers DO NOT qualify you for benefits.
2. In Part 2, enter the name and case number of any other household member who has a valid TANF or Food Stamp case number. 3. In Part 3, check the appropriate box, if any.
4. In Part 5, an adult must sign the application. The last four digits of the Social Security number are not required. 5. Part 6 and Part 7 are optional for meal benefits.
Migrant, Homeless, or Runaway:
1. In Part 1, list each enrolled child which are homeless, migrant, or runaway and the name of the school. 2. In Part 3, check the appropriate box and contact the school’s homeless liaison or migrant coordinator.
3. In Part 5, an adult must sign the application. The last four digits of the Social Security number are not required. 4. Part 6 and Part 7 are optional for meal benefits.
Foster Child:
If all children in the household are foster children:
1. In Part 1, list each enrolled foster child and the school name for each child. Check the box indication the child is a foster child. 2. In Part 5, an adult must sign the application. The last four digits of the Social Security number are not required.
3. Part 6 and Part 7 are optional for meal benefits.
If some of the children in the household are foster children:
1. In Part 1, list each enrolled child, include the TANF or Food Stamp case number for any child with a case number, and the name of the school. Check the box if the child is a foster child.
2. In Part 2, enter the name and case number of any other household member who has a valid TANF or Food Stamp case number. 3. In Part 3, check the appropriate box and contact the school’s homeless liaison or migrant coordinator for any listed child which
are homeless, migrant, or runaway.
4. If no one in the household has a valid TANF or Food Stamp case number, in Part 4 list everyone related or unrelated living in your household. Include yourself, spouse, all children, grandparents, other relatives, and unrelated people. Use another sheet of paper if you need to.
a. For each household member, list each type of income received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income , list the amount each person got for the month from welfare, child support alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits, regular contributions, from people who do not live in your household, and any other income. Do not include income from SNAP, FDIR, WIC, Federal education benefits, and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings From Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. If you have no income, put a checkmark (√) in the box. 5. In Part 5, an adult household member must sign the form, and if income information was provided, the adult household member
must provide the last four digits of their Social Security Number (or mark the box if s/he doesn’t have one). 6. Part 6 and Part 7 are optional for meal benefits.
All Other Household Types: Including WIC households
1. In Part 1, list each enrolled child.
2. In Part 2, check the appropriate box, if any. Skip Part 3.
3. In Part 4, list everyone related or unrelated living in your household. Include yourself, spouse, all children, grandparents, other relatives, and unrelated people. Use another sheet of paper if you need to.
a. For each household member, list each type of income received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You
2013 Parent Letter/Instructions Page 3 of 4
should be able to find it on your pay stub or your boss can tell you. Do not include income from SNAP, FDIR, WIC, Federal education benefits, and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings From Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. If you have no income, put a checkmark (√) in the box.
INCOME TO REPORT: Social Security Earnings from Work Before Deductions Veteran payments
Wages/salaries/tips Supplemental Social Security Income
Strike benefits All Other Income
Unemployment compensation Earnings from second job Workman’s compensation Disability benefits Net income from self-owned business or farm Interest/Dividends
Welfare/Child Support/Alimony Cash withdrawn from savings
Public assistance payments Income from Estates/Trusts/Investments Welfare payments Regular contributions from persons not living
Alimony payments in the household
Child support payments Royalties/Annuities/Rental Income
Pensions/Retirement/Social Security Any other monies that may be available to pay for
Pensions the child’s meals
Retirement income
4. Part 5. An adult must sign the application and list the last four digits his/her Social Security number, or put a checkmark (√) in the box if you have no social security number.
5. Part 6 and Part 7 are optional for meals benefits
OTHER BENEFITS: Put a checkmark where you want the information released. By signing this section you will allow the
school to release information that shows you have applied for free or reduced price benefits under the NSLP. The information will only be used for the programs you have marked on the application.
Textbook Assistance
–You must answer this question and sign, in order to receive textbook assistance. You are not required to answer this question to receive meal benefits.
PLEASE NOTE: For Textbook Assistance, these are specific things that you must complete in addition to
the required items for meal benefits.
1) Living with parent/caretaker relative,
(The definition of a caretaker relative is a relative, either by blood or by law, who lives with the child and exercises parental responsibility [care and control] in the absence of the child’s parent. Examples include, but are not limited to: Grandparents, Aunts, Uncles, Cousins, Step-Parents, and Adult Siblings.)
2) grade, and
3) check if you are applying for textbook assistance and sign under Other Benefits. Your application must contain 2 signatures for meals and textbooks.
Your children may qualify for free or reduced price meals if your household income falls within the limits on this chart.
FEDERAL INCOME CHART FOR SCHOOL YEAR 2012-2013 Household Size Yearly Monthly Twice Per
Month Every Two Weeks Weekly
1……… 20,665 1,723 862 795 398 2……… 27,991 2,333 1,167 1,077 539 3……… 35,317 2,944 1,472 1,359 680 4……… 42,643 3,554 1,777 1,641 821 5……… 49,969 4,165 2,083 1,922 961 6……… 57,295 4,775 2,388 2,204 1,102 7……… 64,621 5,386 2,693 2,486 1,243 8……… 71,947 5,996 2,998 2,768 1,384
2011 Parent Letter/Instructions Page 4 of 4
Hoosier Healthwise
– Your child(ren) may qualify for free or low-cost health insurance under Medicaid or Hoosier Healthwise. If you
DO WANT this information released for the purpose of Hoosier Healthwise, please sign. For more information
Page 1 of 2 Program Year 2013 Prescribed by State Board of Accounts School Form No. 521 / Revised 2011
GRIFFITH PUBLIC SCHOOLS
4700SCHOOL CORPORATION CORP. NUMBER
APPLICATION FOR FREE OR REDUCED PRICE MEALS AND OTHER BENEFITS
Effective July 1, 2005 - One Application per HouseholdPart 1. NAME OF CHILD (First Name, MI, Last Name)
LIVING WITH PARENT or CARETAKER RELATIVE BIRTH DATE SCHOOL GRADE CHECK IF A FOSTER CHILD
TANF or Food Stamps Case # (If you receive both benefits, list the TANF Case #) YES - NO / / / / / / / / / YES - NO / / / / / / / / / YES - NO
/ / / / / / / / / YES - NO / / / / / / / / / YES - NO / / / / / / / / / YES - NO / / / / / / / / / If ALL children listed above are foster children, skip to Part 5 and sign. If ANY of the children have a food stamp/TANF case number, skip to Part 5 and sign.
Part 3. If any child you are applying for is migrant, homeless, or a runaway, check the appropriate box and call Mr. Aron Borowiak at 219-924-4250. Migrant Homeless Runaway
Part 4. LIST ALL HOUSEHOLD MEMBERS
ALL OTHER HOUSEHOLD TYPES
GROSS (before deductions) HOUSEHOLD INCOME FROM ALL SOURCES
Examples: $100 / monthly or $100 / every 2 weeks or $100 / twice a month or $100 / weekly
NAME Earnings from Work Before Deductions W e e kly E ve ry 2 Wee ks T wi ce A M o n th M o n th ly Y e a rly Welfare Payment Child Support, Alimony W e e kly E ve ry 2 Wee ks T wi ce A M o n th M o n th ly Y e a rly Pension, Retire-ment, Social Security W e e kly E ve ry 2 Wee ks T wi ce A M o n th M o n th ly Y e a rly All Other Income W e e kly E ve ry 2 Wee ks T wi ce A M o n th M o n th ly Y e a rly Check if NO income Example: Jane Smith $ 200 $ 150 $ 100 $ 50
1. $ $ $ $ 2. $ $ $ $ 3. $ $ $ $ 4. $ $ $ $ 5. $ $ $ $ 6. $ $ $ $ 7. $ $ $ $
Part 5. SIGNATURE: An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four
digits of his or her Social Security Number or mark the “No Social Security Number” box. (See Privacy Act Statement on the back of this page.)
I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.
X__________________________________ *** - ** - __ __ __ __ No Social ______________________________
Signature Of Adult Household Member Social Security Number Security Number Home Telephone # / Work Telephone # ______________________________________ ____________________ _________________________________________________ Printed Name of Adult Household Member Date Signed Home Address/Apt # Zip Code
Part 6. OTHER BENEFITS – This section does not need to be completed to receive free or reduced price meal benefits.
Do you want to receive textbook assistance? YES If, YES, SIGN TO THE RIGHT NO
I certify that I am the parent/guardian of the child(ren) for whom application is being made. My signature below authorizes the release of information on this application for textbook assistance. I give up my right of confidentiality for this purpose only. This application information will be shared with the Indiana Family and Social Services Administration pursuant to I.C. 20-33-5-2 and I.C. 12-14-28-2, solely for purposes of complying with 45 C.F.R. PARTS 260 AND 265.
X__________________________________ _________
SIGNATURE OF PARENT/GUARDIAN DATE
SCHOOL USE ONLY: Approved Denied Not Applicable
SEE PAGE 2 IF YOU WANT THIS INFORMATION RELEASED FOR THE PURPOSE OF HOOSIER HEALTHWISE.
Part 2. If any member of your household (adult or non-student) has a valid Food Stamp or TANF case number, please provide the name and case number for the person who receives the benefit and then skip to Part 5.
Page 2 of 2 Program Year 2013 This application information may be shared with the Family and Social Services Administration for the purpose of identifying children who may qualify for free or low-cost health insurance under Medicaid or Hoosier Healthwise. If you want the application information shared for this purpose, please sign below. I certify I am the parent/guardian of the child(ren) for whom application is being made. I authorize the release of information for this purpose.
X__________________________________________ ________________ For information about Hoosier Healthwise Signature of Parent/Guardian Date health insurance, call 1-800-889-9949.
Part 7. RACE AND ETHNICITY:
Optional - You are not required to answer this question. No child will be discriminated against because of race, color, sex, national origin, age, or disability.
Mark one or more racial identities: Asian
Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander White
Mark one ethnic identity: Hispanic or Latino Not Hispanic or Latino
Privacy Act Statement: This explains how we will use the information you give us.
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for
administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly.
“In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basisof race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of
Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who
are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”
FOR SCHOOL USE ONLY – DO NOT WRITE BELOW THIS LINE
INCOME CONVERSION to YEARLY: WEEKLY INCOME X 52
EVERY 2 WEEKS X 26 TWICE A MONTH X 24 MONTHLY INCOME X 12
ELIGIBILITY DETERMINATION
Income Eligibility: Total Household Size:______ Total Income:$___________ per: Weekly Every 2 Weeks Monthly Twice a Month Yearly
OR Categorical Eligibility: Food Stamps TANF Migrant Homeless Runaway Foster Eligibility Determination: Approved Free Approved Reduced price Denied
Reason for Denial: Income Too High Incomplete Application Other(Reason)_______________________ Temporary: Free Reduced Time Period:__________________ (expires after _____ days)
Signature of Determining Official:________________________________________ Date:____________ Date Withdrawn: ______________
VERIFICATION
Confirmation Review Official: ___________________________ Date Verification Notice
Sent:________________ Date Response Due from Households:__________ Date Second Notice Sent (or N/A): _____________
Approval Based On:
Food Stamps / TANF Case Number
Household Size and Income Other _________ Verification Results: No Change Free to Reduced Free to Paid Reduced to Free Reduced to Paid
Reason for Change:
Income:________________
Household Size: _________
Change in Food Stamps /TANF
Did not respond
Other: _________________ Date Notice of Change Sent:__________ Date Change Made:_________
Date Hearing Requested:_________________ Hearing Decision: _______________________
Verifying Official's Signature:________________________ Date:__________________________________
GRIFFITH PUBLIC SCHOOLS
HEALTH SERVICES INFORMATION
Student Name _____________________________
To Parent or Guardian:
In order to provide the best educational experience, the school must understand your child’s health needs. Please complete this form and sign in the appropriate areas so that we can provide the best possible care for your student.
* Please check any conditions that apply to your student:
Yes Year Yes Year
Asthma Frequent Headaches
Allergies Migraines
Food Gastro-Intestinal Problems
Medication Kidney/Bladder Problems
Insects Heart Problems/Irregularities
Other Ulcer
ADHD/ADD Seizures
Anxiety Sickle Cell
Blood Disease Other
Depression Vision Problems
Diabetes Glasses
Fainting High Blood Pressure Contacts
Skin Problems Hearing Problems
History of Cancer Tubes
Orthopedic Problems Hearing Aids
If any of the above condition are checked Yes please explain:
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Please list any physical restrictions the student may have:
Y or N Has your child had any hospitalizations, operations, or major illnesses? Y or N Has your child had any significant injury or accident?
Y or N Has your child had any dental work we should be aware of (braces or tooth replacement)?
Y or N Does your child take any medication daily? (If so please list below the name of the medications & dosages) If Yes is circled in any of the above please explain:
_____________________________________________________________________________________________ _____________________________________________________________________________________________
It is State Law, IC 20-8.-7-10.1 that a school corporation shall require the parents of a child who has enrolled in a school corporation to furnish, no later than the first day of school, a documented statement of the child’s immunization record. The parent/guardian must assume responsibility for obtaining these records. IF at the end of 20 days the record or a schedule for the immunizations established by a physician or the Board of Health is not received, the child will be excluded from school until said records are presented to the school. Please Note: Transfer from another school corporation is not an adequate reason for lack of proper immunization records. It is the parent’s/guardian’s responsibility to obtain such records before enrolling the student for school.
IMMUNIZATION HISTORY/CONSENT TO RELEASE INFORMATION
I give Griffith Public School Corporation permission to release the following information concerning the student being registered to the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP). This includes information such as name, immunization data and other information such as date of birth or other identifying information as applicable. I understand that the information may be used to verify that my child has received proper immunizations and to inform me or my child of my child’s immunization status or that an immunization is due according to recommended immunizations schedules. I understand that my child’s information will be available to the immunization data 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, the office of Medicaid policy and planning, or a contractor of the Medicaid policy and planning. I also understand that other entities may be added to this list through amendment to IC 16-38-5-3. I hereby consent to release of such information. History of Varicella (Chicken Pox) Disease:
Please state date (month/day/year) when child had Chicken Pox ________/_________/________ Parent/Guardian Signature _____________________________ Required by IC 20-34-4-2
All information that you provide is CONFIDENTIAL and is for the exclusive use of Griffith Public Schools. It will not be released to non-school personnel without the parent’s written consent.
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Parent/Guardian Signature Printed Name of Parent/Guardian
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GRIFFITH PUBLIC SCHOOLS
