SALEM PUBLIC SCHOOLS SCHOOL HEALTH SERVICES MEDICAL INFORMATION SHEET
Student’s Name:______________________________________ Date of birth:_______________ Parent/Guardian Name:__________________________________________________________ Address: _____________________________________________________________________ Phone:________________________________ Cell: ____________________________________ Parent/GuardianName:___________________________________________________________ Address: ______________________________________________________________________ Phone: __________________________________Cell: __________________________________ Pediatrician: ______________________________________ MD Phone: ___________________ Dentist: ___________________________________________DMD Phone: _________________ Prescribed Medications: ______________________________________________________ Health Insurance Name: _______________________________________________________ Does your child have any allergies? _________YES _______ NO
If yes, please specify:
Foods: _______________________________________ Insects/Bees: ____________________ Medicines: __________________________ Animals: ___________________________ Seasonal/environmental allergies: ______________ Other: ____________________________ Allergy medication used: _____________________________________________
Describe any reaction; include date(s) of reaction(s):
______________________________________________________________________________ ______________________________________________________________________________ What treatment was given to your child?
______________________________________________________________________________ Has your child ever been given an Epi-‐Pen? ________Does your child have an Epi-‐Pen?______ Has your child been seen by an allergist, if so when:____________________________________ Allergy doctor:_______________________________________Phone:_____________________
Does your child have any health conditions?
________YES ________ NO asthma Nebulizer ______ yes ______ no Inhaler ______ yes ______ no
________YES ________ NO headaches ________YES ________ NO constipation ________YES ________ NO heart condition ________YES ________ NO sickle cell ________YES ________ NO diabetes ________YES ________ NO ADHD
________YES ________ NO urinary tract infections ________YES ________ NO bedwetting
________YES ________ NO seizures ________YES ________ NO food intolerances ________YES ________ NO short attention span ________YES ________ NO temper tantrums ________YES ________ NO celiac disease
________YES ________ NO hearing difficulty hearing aid? ______yes ____no ________YES ________ NO difficulty seeing wear glasses? ______ yes ____ no ________ YES ________ NO speech problems
Has your child ever been hospitalized or had surgery? ______yes ______ no
If yes, please explain_____________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________
Is there anything else you think we should know about your child?
Salem Public Schools
City of Salem
Parent Information Center
__________________________________________________________________________________
29 Highland Avenue, Salem, Massachusetts 01970 (978) 740-1225 Fax (978)740-1176
Registration Document Checklist
In order to properly register your child for school, you must provide the Parent Information Center with the following documents:
Required Forms
Assignment Application Form (please complete & sign)
Home Language Survey
Household Information Survey, and Acknowledgement Form
Birth Certificate (one of the following documents)
§ Child’s birth certificate (original or certified copy) § Passport
§ I-94 Card
§ Resident Alien Card
Immunization Records (Please provide your child's most recent physical examination and
immunizations. If your child has an appointment during the summer, send a copy of the updated information to PIC attention Paula Dobrow, RN. By law, children cannot be admitted to school
until the documentation has been received).
Medical Information Sheet & Emergency form
Proof of Parent/Guardian’s Identity – provide one of the following:
§ Massachusetts Driver’s License, § Massachusetts Photo ID
§ Passport
Proof of Address in Salem (two of the following documents)
§ Lease or mortgage statement in parent’s/guardian’s name, current electric, gas, cable, water, or telephone bills in parent’s/guardian’s name
§ If you do not have any utilities under your name and you reside with a family member or
friend: please provide a notarized letter from the person you live with and two proofs of address under that person’s name.
Special Education Individualized Educational Plan (IEP), if applicable
504 Plan, if applicable
Proof of address
Residency fraud is a violation of Massachusetts state law and is subject to per diem fines for every day that a student attends school outside the district in which s/he legally resides.
Legal guardianship
Legal guardianship requires additional documentation from a court or agency.
Homeless families
The McKinney-Vento Act requires schools to enroll homeless children and youth immediately, in the absence of the normally required documents, please talk to a PIC staff member.
Escuelas Públicas de Salem
Ciudad de Salem
Centro de Información para Padres
__________________________________________________________________________________
29 Highland Avenue, Salem, Massachusetts 01970 (978) 740-1225 Fax (978)740-1176
Lista de Verificación para Inscripción
Para matricular a su niño/a en la escuela, debe proveer al Centro de Información para Padres los siguientes documentos:
Documentos Requeridos
Aplicación de Asignación(completada y firmada)
Encuesta del Idioma Hablado en el Hogar
Encuesta de Información Familiar y Forma de Reconocimiento
Acta de Nacimiento(uno de los siguientes documentos)
§ Certificado de nacimiento (original o copia certificada)
§ Pasaporte
§ Tarjeta I-94
§ Tarjeta de residencia
Vacunas (incluya el examen físico y las vacunas más recientes de su hijo. Si su hijo tiene una cita durante el verano,
envíe una copia de la información actualizada a Paula Dobrow, RN. Por ley, los niños no pueden ser admitidos a la escuela hasta que la documentación haya sido recibida).
Hoja de Información Médica & Formulario de Emergencia
Prueba de Identidad del Padre/Tutor (uno de los siguientes documentos)
§ Licencia de conducir de Massachusetts
§ Identificación con foto de Massachusetts
§ Pasaporte
Prueba de Dirección en la Ciudad de Salem(dos de los siguientes documentos)
§ Arrendamiento o estado de hipoteca en nombre de los padres/tutor, factura de electricidad, gas, cable, agua, o teléfono a nombre de los padres/tutor
§ Si usted no tiene ninguna prueba de dirección bajo su nombrey vive con un familiar o
amigo/a: Necesitamos una carta de la persona con quien vive, certificada por un notario, acompañada de dos pruebas de dirección con el nombre de esa persona.
Plan Educacional Individualizado (PEI),si aplica
Plan 504, si aplica
Comprobante de domicilio
El fraude de residencia es una violación a las leyes estatales de Massachusetts y está sujeto a multas diarias por cada día que un estudiante asista a una escuela fuera del distrito en el cual él/ella reside legalmente.
La tutela legal
La custodia legal requiere documentación adicional de un tribunal o agencia. Familias sin hogar
La Ley McKinney-Vento ordena que las escuelas matriculen a niños y jóvenes sin hogar de inmediato, aún si no posee los documentos normalmente requeridos, por favor hable con un miembro del personal del Centro de Información para Padres.
Salem Public Schools School Health Services
Dear Parent / Guardian,
Massachusetts State Law, Chapter 76, s. 15 requires that all children receive these immunizations before the first day of Kindergarten.
Your child’s health records for Kindergarten entry must contain:
_____ Physical Examination (must be within 6 months of entering school) All immunizations _____ DTP #1 #2 #3 #4 #5 _____ Polio #1 #2 #3 #4 _____ MMR #1 #2 _____ Hepatitis B #1 #2 #3 _____ Varicella #1 #2
_____ or physician’s documentation of having had chicken pox disease _____ Lead Test
____ Health Questionnaire
______Vision Screening including stereopsis screening
Please contact your health care provider to schedule the required physical and/or
immunization visit(s). Vaccines are available, free of charge, at the Lydia Pinkham Clinic, 250 Derby Street, Salem, MA on Tuesday and Thursday afternoons from 1 PM until 4 PM.
Allhealth forms must be reviewed by the school nurse beforethe start of Kindergarten.
Children will not be allowed to be in school until the documentation has been received. If you have any questions, please contact your school nurse.
Please submit any health information completed during the summer to the Parent Information Center at Collins Middle School, 29 Highland Ave, attention Paula Dobrow, RN. Thank you for your prompt attention.
Paula J. Dobrow, RN, MSN
Director of Nursing and Health Services 978-825-5500
Salem Public Schools - Assignment Application
Date of Application:__________________ School Year: 2015-2016 Date of Enrollment: September 2015 Student Information
Child’s Full Name: ________________________________________________________________ Grade Entering: Kindergarten First Full Middle Last
Address: _________________________________________________________________ Age_________ Male Female
Place of Birth:______________________________________________________________Date of Birth: _____________________ City Country
If born in another country, date of arrival in USA: ________________________Is your child repeating Kindergarten? No Yes Name of last school /daycare of attendance:____________________City/State: ________________Last day attended: ____________
Parent/Guardian Information
I am the child’s Parent Legal Guardian E-mail: _________________________ Home Phone: _______________________ Mother’s Name: ____________________________________ child lives with Yes No Mobile Phone: ______________________ Father’s Name: _____________________________________ child lives with Yes No Mobile Phone: ______________________ Mother’s Work #:________________________________________ Father’s Work #: __________________________________ Guardian’s Name: _____________________________________________ Relationship: _________________________________ Parent’s address, if different from student’s:_____________________________________ Home Phone: ______________________ Contact’s Name: ____________________________________ child lives with Yes No Phone #: __________________________ (if parents are not available)
Ethnic/Racial Group: Primary Home Language
Hispanic or Latino: Yes No AND check all that apply: English Spanish Vietnamese Asian American Indian or Alaskan Native Russian Portuguese Albanian
Black White Other________________
Hawaiian/Pacific Islander In which language would you prefer your school notification sent? ______________________
Is student receiving special services? Yes No If Yes IEP 504 Plan Is student receiving the following services? Title 1 LEP (English Lang. Learner)
Medical Concerns/Daily Medications Yes No _________________________________________________________________________ (If not in violation of confidentiality)
Special Circumstances: Homeless Other: _________________________________________________________________________ Siblings: Name Date of Birth School Attending Grade ________________________________ ______________________________ _______________________ ________________ ________________________________ ______________________________ _______________________ ________________ ________________________________ ______________________________ _______________________ ________________
My Household qualifies for Free/Reduced Meals Yes No Staff Initials ________
Opt IN to the Bentley Academy Charter school lottery Yes No
Parent’s School Choices 1.___________________________ 2.___________________________ 3.__________________________
Would you like information about the Parent-Child Home Program for 2 and 3 year olds? Yes No
Parent’s signature:_________________________________________________ Date: ______________________________________________
Office Use Only
School Assignment: Prog.: Reg. ____ ESL___ Dual ___ NCP___ SEI ____SPED_________
Sibling Preference: Yes ___ No ___ If YES school: SASID # :
Sibling Attending SPS: Yes ___ No ___ If YES school: School Closest to Home:
Language Eval: Yes ___ No ___ If YES level: Free Transportation: Yes ___ No ___ Proximity:_______________
Salem Public Schools City of Salem
Parent Information Center
_______________________________________________________________________________________ 29 Highland Avenue, Salem, Massachusetts 01970 (978) 740-1225 Fax (978)740-1176
HOUSEHOLD INFORMATION SURVEY
Please complete, sign and return this application to the address above.
INSTRUCTIONS: Complete this survey and return to your child’s school or mail to the address listed above.
These selections must be completed by the Head of Household or Designee 1. SIZE OF FAMILY - Indicate the total number of individuals living in your household, including all adults and children:_______ 2. STUDENT INFORMATION - Complete for each student Pre-K through 12th grade
Last Name First Name Birth Date MM-DD-YY School Identify H if Homeless M if Migrant R if Runaway F if Foster 1. 2. 3. 4. 5. 6. 7. 8.
If you need additional lines, attach a second sheet to this survey or attach a copy of this survey clearly marked as Page 2
3. TOTAL MONTHLY HOUSEHOLD INCOME – Report Income for all members of household excluding foster children. If you have reported a case number above, you do not need to complete this section; proceed to section 4.
Type of Income Income No Income Circle if 1. Gross Monthly Earnings: Wages, Salary, Commissions $ None 2. Monthly Welfare Payments, Child Support, Alimony $ None 3. Monthly Payments from Pensions, Retirement, Social Security $ None 4. Monthly Dividends or Interest on Savings $ None 5. Monthly Worker’s Compensation, Unemployment, Strike Benefit $ None 6. Other Monthly Income (SSI, VA, Disability, Farm, other) $ None
Total Monthly Household Income (Add lines 1-6) $ 4. SIGNATURE
I certify (promise) that all information on this application is true and that all income is reported. I understand the school will be eligible for certain federal and/or state funds based on the information I give.
Sign Here: X________________________________________________ Print Name:______________________________________ Date____________________
Address City Zip Code
Home Phone Work Phone Email Address:
By providing your email address, you may be contact via email by the district
For Office Use Only:
Circle One QUALIFIES DOES NOT QUALIFY PROCESSED BY:
IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES M AS N AP or M A TA FD C be ne f its , PROVIDE THE AGENCY IDENTIFICATION NUMBER* LOCATED ON THE DEPARTMENT OF TRANSITIONAL ASSISTANCE (DTA) BENEFIT LETTER. Then proceed to Section 4. If no one receives these benefits, start with Section 1. Name:___________________________________________________ 10-Digit Case Number:________________________________
Home Language Survey
Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the following questions. Thank you for your assistance.
Student Information
F M
First Name Middle Name Last Name Gender
/ / / /
Country of Birth Date of Birth (mm/dd/yyyy) Date first enrolled in ANY U.S. school (mm/dd/yyyy) School Information
/ /20 ______
Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade
Questions for Parents/Guardians
What is the native language(s) of each parent/guardian? (circle one)
(mother / father / guardian)
(mother / father / guardian)
Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
seldom / sometimes / often / always seldom / sometimes / often / always
What language did your child first understand and speak? Which language do you use most with your child? Which other languages does your child know? (circle all that apply)
speak / read / write speak / read / write
Which languages does your child use? (circle one)
seldom / sometimes / often / always seldom / sometimes / often / always
Will you require written information from school in your native
language? Y N Will you require an interpreter/translator at Parent-Teacher meetings? Y N Parent/Guardian Signature:
Salem Public Schools
City of Salem
______________________________________________________________________________________________________________"
29"Highland"Avenue,"Salem,"Massachusetts"01970" """"""""""""""""""""(978)"740?1225""""""""Fax"(978)740?1176"
Acknowledgement
Eligibility for Free/Reduced Price Meals: How Information Will Be Used
Parent Name:____________________________ Student Name: _____________________________
I acknowledge and agree to release to the Salem Public Schools’ Parent Information Center and further acknowledge and agree that the Salem Public Schools’ free and reduced price meals officials may give to the Salem Public Schools’ Parent Information Center information concerning my child’s eligibility or non-eligibility for price meal benefits.
I acknowledge and agree that the Salem Public Schools’ Parent Information Center may use this information to help determine the placement of my child. I understand that both the Salem Public Schools’ and I free and reduced price meals officials will be releasing eligibility information to the Salem Public Schools’ Parent Information Center from the Price Meal Benefit Form for my child. I give up my rights to confidentiality for this purpose only.
I understand that I am not required to release this information and that my declining to sign this form will not affect my child’s eligibility and participation for price meal benefits or non-eligibility for price meal benefits.
I understand that if I elect not to release this information, the Salem Public Schools’ Parent Information Center will consider my child non-eligible for free and reduced price meals only for purpose of determining school placement for my child.
! I am choosing to release my eligibility for free or reduced price meal benefits and am attaching a copy of our meals application.
! I am electing not to release this information and/or my family is not eligible for this benefit.
I have read this release and understand its terms and sign it voluntarily. ___________________________________ Parent/Guardian Signature ___________________________________ Date
Please Note: This voluntary disclosure is used in the registration process only. When your child begins school, you must submit your formal application for the federal free and reduced price lunch program and be determined to be eligible to receive free or reduced price meals.
