Thornton Creek • A Seattle Public School • 7711 43rd Avenue NE • Seattle, Washington 98115 • (206) 252-5300
Medical & Other Forms
Student Survey Form to Identify Disabled Students (504-2)
Authorization for Medications to be Taken at School
Form for Parents who are Away on Vacation and their Children are at School
Native American Identification Title VII Student Eligibility Certification
Privacy Rights
Notification of Rights Under the Family Educational Rights and Privacy Act (FERPA) and Opt-Out Form
This form is mentioned in the Consolidated Release Form in the Mandatory Forms packet. Please refer to that as needed.
Questions? Please contact the school office.
Internet Opt Out Form
Other Forms from Seattle Public School District
School nurse schedule
We will have nursing services at school every Thursday and every other Monday. You can reach nurse Judy Underhill at 252-5307.
For any medication to be given at school
A school must have a completed Authorization For Medications To Be Taken At School Form. Parents and the Health Care Provider need to complete the form before any prescription or over-the-counter medication can be given to a student. Completed forms may be faxed to school. The medication must be in its original bottle.
For any student with an emergency health condition:
o an allergy that requires administering an epi pen o a seizure disorder
o diabetes o other
The school nurse or the school office must have a completed care plan before the start of school.
Please call the school office to set up an appointment with the school nurse to create the care plan.
Information for Parents about Student Health Issues
SEATTLE
PUBLIC
SCHOOLS
FORM 504-2 Page 1 September 2013
SEATTLE SCHOOL DISTRICT
SURVEY TO IDENTIFY DISABLED STUDENTS (FORM 504-2)
The Seattle School District (“District”), as a recipient of Federal funds, is required by the U.S.
Department of Education to comply with the Rehabilitation Act of 1973, commonly referred to as
“Section 504.” This Act's regulations provide that any student with an identified disability who needs help to benefit from their school experience must receive services, modifications, and/or
accommodations in order to enjoy non-discriminatory access to programs and services and receive a free appropriate education (“FAPE”).
This survey should be filled out if you think your child has a disability or if you have documentation that your child is disabled (and is not currently eligible for Special Education services) and needs assistance to benefit from his or her educational experience. A "disability" for the purposes of Section 504 is having a mental or physical impairment that substantially limits one or more major life activity. Please fill out separate surveys for each child suspected of having a disability and return to the student's school. If you do not believe your child is disabled, you do not have to return this survey.
Student Name: ____________________________________ Birth Date: ______________________
School: ___________________________________________ Student ID #: ____________________
1. What mental or physical impairment(s) do you believe your child has? Please describe the condition or list information confirming the condition.
2. Please describe how you think this mental or physical impairment is impacting your child?
3. What things do you think are needed to assist your child in being able to benefit from his or her educational experience because of mental or physical impairment?
Signature of Parent/Guardian: _______________________________ Date: ____________________
The Seattle School District provides equal educational opportunity without regard to race, creed, color, national origin, sex, handicap/
disability, marital status, or sexual orientation. The District also complies with all applicable state and Federal laws and regulations to include, but not limited to, Title VI of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, RCW 49.60 (the law against discrimination), RCW 28A.640 (sex equality), and American with Disabilities Act (“ADA”), all of which prohibit discrimination in all District programs, courses, activities (including extra-curricular activities), services, and access to facilities, etc.
The Section 504 Program Coordinator with the overall responsibility for monitoring, auditing, and ensuring compliance with these policies is Carole Rusimovic, MS 32-151, P.O. Box 34165, Seattle, Washington 98124-1165; (206) 252-0118.
Seattle Public Schools
AUTHORIZATION FOR MEDICATIONS TO BE TAKEN AT SCHOOL
The following section is to be completed by the PARENT/GUARDIAN: (please print)
The following section is to be completed by the HEALTH CARE PROVIDER: (please print)
(Updated 8/14/2014)
School_______________________________________ Fax#_____________________ Grade________
Student’s Name _______________________________ _________________________ Initial________
Birth Date_______________________ ID#______________________ Gender____________________
_______________________________ _________________________ __________________________
(Health Care Provider’s Name) (Address) (Phone & Fax) Please check only one box:
□ I request that authorized persons at school assist my child in taking the medicine(s) described below. I also give my permission for exchange of information between the school district staff and the health care provider.
□ I request that my child be allowed to self-administer medication. I also give my permission for exchange of information between the school district staff and the health care provider. I shall hold harmless and indemnify the school and Seattle Public School District’s officer, employees and agenda against all claims, judgments, or liability arising out of the self0adminsitariond and carrying of
medication of my child.
□ I am 18yo or older & am signing this form on my own behalf (RCW 26.28.015 or RCW 70.02.130). I also give my permission for the exchange of information between the school district staff and the health care provider.
______________ __________________________________ _________________ _________________
(Date) (Parent/Guardian/Student Signature) (Home Phone) (Emergency Phone)
I have determined that the medication named below is advisable during the school day.
Diagnosis for which medication is given: ________________________________________________________
Name of medicine:_________________________________ Dose:_________________________________
Route:___________________________________________________________________________________
If medicine is to be given DAILY, at what time:____________________________________________________
If medicine is to be given WHEN NEEDED, describe indications: _____________________________________
________________________________________________________________________________________
How soon can it be repeated:_________________________________________________________________
Is child authorized to medicate herself/himself? (circle) YES NO
If “Yes”, student has been trained by health care provider and is safe to self-administer? (circle) YES NO Length of time this treatment is recommended:___________________________________________________
Possible side effects: _______________________________________________________________________
Emergency procedure in case of serious side effects:______________________________________________
Date:_________________ Health Care Provider’s Signature:____________________________________
Whenever possible we encourage medication doses to be scheduled during non-school hours. For those students who need medication during school hours, the following is required by Washington State Law and must be completed and on file before any medication may be given at school:
1. ALL MEDICATIONS (INCLUDING OVER THE COUNTER) TO BE ADMINISTRATED AT
SCHOOL REQUIRE AN AUTHORIZED SIGNATURE OF BOTH THE PARENT/GUARDIAN AND A LICENSED HEALTH PROFESSIONAL
2. MEDICATION MUST BE IN A PROPERLY LABELED (see list) ORIGINAL PHARMACY CONTAINER
- Student’s Name
- Name and Strength of Medication/Including Dosage to be Given - Time and Method of Administration
- Length of Time/Days to be Given
3. MEDICATIONS OTHER THEN ORAL, EYE, EAR, OR TOPICAL MAY NEED TO BE ADMINISTERED BY A LICENSED NURSE: EPINEPHRINE AUTO INJECTORS (Epi-Pen, Auvi-Q) ARE AN EXCEPTION. PLEASE CONTACT YOUR SCHOOL NURSE FOR MORE INFORMATION.
Thank you for your cooperation.
Student Health Services P.O. Box 34165, MS 31-650 2445 Third Avenue South
Seattle, Washington 98124-1165 (206) 252-0750 (206) 252-0751 - fax
AUTHORIZATION FOR MEDICATIONS
TO BE TAKEN AT SCHOOL cont.
Thornton Creek • A Seattle Public School • 7711 43rd Avenue NE • Seattle, Washington 98115 • (206) 252-5300
Form for Parents who are Away on Vacation and their Children are at School
Please fill out all of the requested information. If your child has any medical conditions, please describe them in detail and tell us what we need to do to address each condition. Also, we must have at least one emergency phone number to call if we are unable to reach you. If any of the questions do not apply to your child answer that question with a “does not apply.”
CHILD’S NAME PARENT’S NAME
HOME ADDRESS HOME PHONE NO.
CELL PHONE NO.
TRIP DETAILS
VACATION DESTINATION: DATES OF TRIP
NAME OF HOTEL DATES OF STAY
CITY STATE COUNTRY HOTEL PHONE NO.
NAME OF HOTEL DATES OF STAY
CITY STATE COUNTRY HOTEL PHONE NO.
NAME OF HOTEL DATES OF STAY
CITY STATE COUNTRY HOTEL PHONE NO.
EMERGENCY CONTACTS
EMERGENCY CONTACT BACKUP EMERGENCY
CONTACT
HOME PHONE NO. HOME PHONE NO.
WORK PHONE NO. WORK PHONE NO.
CELL PHONE NO. CELL PHONE NO.
MEDICAL PROVIDERS
PRIMARY DOCTOR’S NAME DENTIST’S NAME
OFFICE PHONE NO. OFFICE PHONE NO.
HISTORY OF ANY HEALTH CONDITIONS/ANY MEDICAL CONDITION THAT WE SHOULD KNOW ABOUT:
PAGE 1 OF 2
ALLERGIES:
MEDICATION:
PLEASE DESCRIBE YOUR CHILD’S ALLERGIC REACTION:
DOES YOUR CHILD’S ALLERGY CREATE AN EMERGENCY SITUATION?
FOOD ALLERGIES:
PLEASE DESCRIBE YOUR CHILD’S ALLERGIC REACTION:
DOES YOUR CHILD’S ALLERGY CREATE AN EMERGENCY SITUATION?
ASTHMA:
MEDICATION:
PLEASE DESCRIBE YOUR CHILD’S ALLERGIC REACTION:
DOES YOUR CHILD’S ALLERGY CREATE AN EMERGENCY SITUATION?
HAS YOUR CHILD EXPERIENCED SEIZURES?
DESCRIBE TYPE GENERAL COMMENTS:
MEDICAL INSURANCE MEDICAL INSURANCE COMPANY:
POLICY NUMBER:
VACCINATION HISTORY
DATE OF MOST RECENT TETANUS VACCINATION CONSENT FOR EMERGENCY CARE
I (PARENT’S NAME) AUTHORIZE (NAME OF PERSON CONSENT GIVEN TO) TO CONSENT TO EMERGENCY MEDICAL OR DENTAL CARE FOR MY CHILD.
NAME OF PERSON AUTHORIZED TO CONSENT TO CARE:
SIGNATURE OF PARENT NOTARY’S SEAL NOTARY’S NAME NOTARY’S ID NUMBER NOTARY’S SIGNATURE
****IF YOUR CHILD TAKES REGULAR MEDICATION (INCLUDING ASPIRIN, TYLENOL, ALLERGY MEDICATION, OR VITAMINS) YOU MUST COMPLETE THE ATTACHED MEDICATION AT SCHOOL AUTHORIZATION FORM, AND YOU MUST HAVE YOUR
CHILD’S PHYSICIAN SIGN THE FORM. MEDICATION WILL BE KEPT BY THE TEACHER FOR SAFETY. YOUR CHILD WILL BE RESPONSIBLE FOR TAKING HER/HIS MEDICATION UNDER THE SUPERVISION OF THORNTON CREEK STAFF.
PAGE 2 OF 2
PRINT CHILD’S NAME ROOM #
Pre-K to 8 FERPA FORM
Revised July 2012
SEATTLE PUBLIC SCHOOLS (SPS)
NOTIFICATION OFRIGHTS UNDER THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) and OPT-OUT FORM
Under the Family Educational Rights and Privacy Act (FERPA), parents/guardians of students under age 18, and students over 18 years of age (“eligible students”) have certain rights with respect to student “education records.” If the student is 18 years old, even if living with the parent/guardian, the student has all the rights under this Act. These rights are:
(1) The right to inspect and review their education records within 45 days of the day SPS receives a written request.
(2) The right to request the amendment of an education record for a student that the parent or eligible student believes is inaccurate, misleading, or is in violation of the student’s right to privacy. If SPS decides not to amend the record, SPS will notify the parent/guardian or eligible student of the decision and advise them of their right to a hearing regarding the request for amendment.
Additional information regarding the hearing procedures will be provided to the parent/guardian or eligible student when notified of the right to a hearing.
(3) The right to provide written consent before the school discloses personally identifiable information contained in the education records of a student, except to the extent that FERPA authorizes disclosure without consent. One exception that permits disclosure without consent is disclosure to school officials with legitimate educational interests. A “school official” is a person employed by SPS as an administrator, supervisor, instructor, or support staff member (including health or medical staff and law enforcement unit personnel).
A “school official” also may include a volunteer or contractor outside of the school who performs an institutional service or function for which the school would otherwise use its own employees and who is under the direct control of the school with respect to the use and maintenance of personally identifiable information from education records, such as an attorney, auditor, medical consultant, or therapist, a parent or student volunteering to serve on an official committee, such as a disciplinary or grievance committee; or a parent, student, or other volunteer assisting another school official in performing his or her tasks. A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility. Upon request, SPS discloses education records without consent to officials of another school where a student seeks to enroll.
(4) The right to file a complaint with the U.S. Department of Education concerning alleged failures by SPS to comply with the requirements of FERPA. Written complaints should be directed to Family Policy Compliance Office, U.S. Department of Education, 400 Maryland Avenue S.W., Washington, DC 20202.
Directory Information: Under FERPA, SPS may release “directory” information to anyone, including but not limited to parent-teacher organizations, the media, colleges and universities, the military, youth groups, and scholarship grantors, unless you notify SPS in writing that you do not want the information released. The following information is considered directory information: parent/guardian and student name, home address, home telephone number, home email address, student photograph, student date of birth, dates of enrollment, grade level, enrollment status, degree or award received, major field of study, participation in officially recognized activities and sports teams, height and weight of athletes, most recent school or program attended, and other information that would not generally be considered harmful or an invasion of privacy if disclosed.
Release of Directory Information for Students in Grades Pre-Kindergarten to Eight (Pre-K to 8)
As a parent/guardian of a pre-kindergarten student, an elementary student, or a middle school student you have the right to choose between two (2) options on whether directory information concerning your student is released or not. Once this form is completed and returned to the school, your choice will be electronically recorded and it will not change until you complete and submit a new form. Please check one box below and return this form to the school your student attends no later than October 1st. If the parent/guardian does not check one of the boxes or does not return this form, SPS considers the lack of response as consent for box A.
Turn Over for Signature and Selection
Revised July 2013
preizler@gmail.com
Pre-K to 8 FERPA FORM
Revised July 2012
For students in grades Pre-Kindergarten through Eight (Pre-K to 8):
Please mark only one box:
A. I consent to the release of the above directory information about the student named below.
B. I do NOT consent to the release of the above directory information about the student named below, except as authorized by law.
Notice of Right to File a Public Records Request:
Pursuant to RCW 28A.320.160, school districts are required to notify parents/guardians that they have the right, under the Washington Public Records Act (RCW 42.56), to request the public records regarding school employee discipline. To file a public records request with SPS, send a written request, in writing, to: Office of the General Counsel: Attn: Public Records Request; SPS: MS 32-151; PO Box 34165: Seattle, WA 98124, or fax your request to (206) 252-0111.
__________________________________
PRINT Signer’s Full Name
__________________________________ _____________________ __________________________________
PRINT Student’s Full Name Date of Birth Student’s School ID number
____________________________________________ _________________________________
Parent/Guardian/Eligible Student’s Signature Date
PLEASE RETURN THIS FORM DIRECTLY TO THE STUDENT’S SCHOOL EITHER IN PERSON OR BY U.S. MAIL.
If you have more than one student, you must return a separate form for each student to each student’s school.
This form will be retained in your student’s folder at his or her school.
Revised July 2013
Internet Opt Out Form
Before gaining access to the District network, students are required to sign a Network Use Agreement which includes access to the District’s network and access to the Internet (Board Policy No. 2022 and Board Policy 3540). Board Policy No. 3540 gives Parents/Guardians the choice of “opting out” of Internet access.
Access to the District network will allow students to access their personal Internet email accounts. All access to the District network and personal email accounts is intended for academic and learning purposes only. If you do not want your child to access their personal Internet email account, you may opt out. However, please be advised that by opting out of email, you will also be opting out of access to Internet service, and your student will not have access to the Internet from school.
If you do not want your child to have access to the Internet at school, please check the box below, complete and sign the form and return it to the office at your child’s school.
NO, I do not want my child to access the Internet and personal Internet email from school.
Student Name
Parent/Guardian Name
Parent /Guardian Signature Date
For school use
Sysop/Analyst has moved the student into the school’s no Internet group Sysop/Analyst signature Date
(See the reverse side of this form for reference information on Internet safety.)
Seattle Public Schools believes that students need to be proficient users of information, media, and technology to succeed in a digital world. It is the District’s goal to provide students with rich and ample opportunities to use technology in schools for important purposes like collaborating on school projects, sharing and/or transferring files between school and home, and submitting assignments to instructors online.
However, along with technology and online resources comes the question of Internet safety. It is of utmost importance to the District that all students be educated on the appropriate use of technology and online behavior. In addition to providing appropriate instruction to students on Internet safety, SPS encourages parents and instructors to use the tools and tips found in Common Sense Media as they talk to students about technology and the Internet.
Please visit www.commonsensemedia.org for more information.
