BLOOMINGDALE ELEMENTARY SCHOOLS Kindergarten Registration for 2016... · BLOOMINGDALE ELEMENTARY SCHOOLS ... EMERGENCY CONSENT If the parents or guardians cannot be contacted ...

BLOOMINGDALE ELEMENTARY SCHOOLS

Mr. Patrick R Haugens Principal

Mrs. Stacy Johnston Assistant Principal

Erickson Elementary School

277 Springfield Drive Bloomingdale, IL 60108 Phone: 630-529-2223

Fax: 630-893-9849 www.sd13.org

Developing Actively Involved Learners and Responsible Citizens

In Partnership with the Community

February 1, 2016

Dear Parents,

It is time to register your kindergarten student for the 2016-2017 school year. Eligible students must be 5

years of age on or before September 1, 2016.

Kindergarten Registration will take place from February 16th through February 19th in the Erickson

Elementary office. The Erickson office will be open until 6:00pm on Wednesday, February 17th to assist

with registration.

All parents must include a certified birth certificate for your child with registration material. The

school will make a copy of the birth certificate and return the original to you. In addition parents will

need to provide multiple documents to prove residency.

Completing these forms at home will reduce the amount of time it will take you to complete the

registration process. Please review the registration checklist to ensure all the necessary documents are

completed.

We are very excited to welcome your child to the Erickson family and look forward to seeing them soar

like an Eagle.

If you have any questions, please contact the building principal by phone 630-529-2223 or email

[email protected].

Sincerely,

Patrick Haugens

Principal

mailto:[email protected]

BLOOMINGDALE SCHOOL DISTRICT 13 2016-2017 KINDERGARTEN REGISTRATION CHECKLIST

*Please return this sheet with completed documents to the school office. Student’s Legal Name ________________________________________________________________

School _____________________________________________________________________________

Proof of Residency Three documents are required as shown on the “Proof of Residency” form. A child cannot start until the residency requirement is complete.

Certified Birth Certificate. Please have the parent contact the appropriate county office vital records department to obtain the official birth record for their child. Phone numbers for surrounding counties are: DuPage County – 630-682-7400; Cook County – 866.252.8974; Kane County – 630-232-5950; Lake County – 847-377-2400. The parent can also go to a local Currency Exchange to obtain a birth certificate.

Seven registration forms: Proof of Residency Sheet

Student Registration & Emergency Consent Form Ethnicity/Race Letter and Form Class Placement Background Information Sheet

Language Survey Medical Information/Release Form

Military Letter

Student fees. These fees are current fees that should be paid as part of registration. If fees are paid at a later date, they will be next year’s fees.

Student textbook fees ($50.00) – mandatory

Student technology Fee ($50.00) – mandatory Student milk fees ($22.00) – optional Student bus fees ($375.00) – when applicable

Optional Forms.

Affidavit Fee Waiver

BLOOMINGDALE SCHOOL DISTRICT 13 2016‐2017 PROOF OF RESIDENCY FORM

(Students must be District residents as of August 17, 2016)

ALL DOCUMENTS ACCEPTED FOR PROOF OF RESIDENCY MUST HAVE THE SAME ADDRESS:

Category I: Provide one of the following documents:

� Illinois Driver’s License � Illinois State ID � Other Photo ID

Category II: Provide one of the following documents:

� Current mortgage statement or closing statement from bank or lender � Real estate tax bill from current school year � Current lease showing the name, address and phone number of landlord � Notarized Affidavit of Residency Form including names of students living in the residence

Category III: Provide one of the following documents:

� Current electric, water, gas or cable/internet bill in your name � Valid Illinois vehicle registration � Current pay stub from your employer � Current public aid card or document from DHS or DCFS that includes your name ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ This proof of residency form is to attest that the child is not enrolling in the District solely for school purposes and is living on a permanent basis with the person having complete custody and control. Registration of a student who is not a resident is a fraudulent act. Any student found to have been fraudulently registered will be dropped from the attendance rolls immediately. Parents or guardians making a fraudulent registration will be subject to the payment of retroactive tuition charged for non‐resident students, not to exceed 110% of the per capita cost. A person who knowingly or willfully presents the District with any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in the District shall have committed a Class C misdemeanor and shall be prosecuted by the District. National Investigations, Inc. will be conducting a home visit if fraud is suspected.

I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.

Parent/Guardian Signature ___________________________________ Date ___________________

Parent/Guardian Address _________________________________ Telephone ______________

Name of Student _______________________________________ School __________________




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E 05/01/08

CLASS PLACEMENT BACKGROUND INFORMATION SHEET

Student's Name Date of Birth________________ Date School _____________ Last Grade Completed ___________

Yes No

Was the student last enrolled in a regular education classroom? If no, please list type of classroom:

Was the student ever enrolled in a special education program? If yes,

Was it a full day class?

Was it a partial day class?

Was it for Learning Disabilities?

Was it for Speech?

Was it another type of class?

Does the student have special needs in:

Learning?

Communication?

Physical?

Health?

Social?

Has the student been in a gifted and/or talent program?

Has the student been in a Title I Program?

Has the student been in a Bilingual Education Program?

3/2010

STUDENT LANGUAGE SURVEY Indicate the best answer to each question: 1. Was English the first language the student learned? Yes No 2. If no is the answer to question # 1. What was the first language learned by

the child? ______________________________ 3. Can the student speak a language other than English? Yes No 4. Code number of language spoken in the home, if other than English. ______ 5. What language is spoken in the home? ________________________________ 6. What language do you most often use to speak to your child?

_________________________________ 7. What language does the student use most often when speaking to parents?

(Specific language spoken) ___________________________________________

8. What language does the child use most often with friends outside the home? _____________________________________

9. Please circle the number that corresponds with your appropriate race.

1. American Indian or Alaska Native 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Island 5. White

10. Can an adult family member or extended family member speak English?

______________________ If yes, who can speak English? _______________ Can they read English? ___________________

Prior Schooling: 11. When did your child first enter school in the USA? In what state?

_____________________________________

12. Was the student enrolled in a bi-lingual or ESL program? Yes No (over)

13. If #11 is yes, give the name and location of the school where the student

received the bi-lingual instruction. 14. Did the student exit the program? ____________ Exit Date: ______________ 15. What country was the student born in? 16. What is the student’s native country? 17. How many years has the student been in the United States? 18. What is the father’s native country? 19. What is the mother’s native country? Parent/Guardian Signature

3/2010

MEDICAL INFORMATION/RELEASE FORM Return to Health Office

*** THIS FORM MUST BE SIGNED and DATED ***

THIS FORM IS IMPORTANT IN THE CARE OF YOUR STUDENT WHILE AT SCHOOL, and IF YOUR CHILD SHOULD NEED IMMEDIATE EMERGENCY CARE, IT WOULD BE NECESSARY FOR THE HEALTH OFFICE TO HAVE THIS INFORMATION AVAILABLE IMMEDIATELY. PLEASE REMEMBER TO PROVIDE UPDATED INFORMATION TO THE NURSE WHEN HEALTH CHANGES OCCUR AND UPDATED INFORMATION TO THE SCHOOL OFFICE WHEN CONTACT INFORMATION CHANGES.

STUDENT NAME: DOB: GENDER: SCHOOL: GRADE: HEALTH/MEDICAL INFORMATION: Any known health conditions (please be specific): Current treatment: Any illnesses, injuries, or surgery within this last year: YES NO (If yes, please explain.)

Does your child need an asthma inhaler during the school day or for sports? YES NO

(If yes, please note any restrictions, include a copy of the emergency plan, and complete the medication authorization form. This form must be completed by both physician and parent. )

Does your child have any vision or hearing difficulties? If yes, please specify:

Please circle corrective devices your child may need at school: Glasses Contacts Hearing aid Orthopedic aides Other:

Is there anything about your child’s health (physical or emotional) that you would like the teacher or nurse to know? If yes, please specify:

ALLERGIES: Insects/Bees: Localized: YES NO Severe: YES NO Epi-Pen required? YES NO Benadryl required? YES NO Foods (please list): Epi-Pen required? YES NO Benadryl required? YES NO

(If yes, please note any restrictions, include a copy of the emergency plan, and complete the medication authorization form. This form must be completed by both physician and parent. )

Medication allergies (please list): MEDICATIONS: Medication taken at HOME on a regular basis:

Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason:

Medication needed at SCHOOL on a regular basis: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason: Medication name: Dose: Frequency: Reason:

IF NEITHER PARENT/GUARDIAN CAN BE CONTACTED, I AUTHORIZE THE SCHOOL ADMINISTRATION TO TAKE SUCH EMERGENCY ACTION AS NEEDED. DATE: SIGNATURE OF PARENT/GUARDIAN: PRINTED NAME OF PARENT/GUARDIAN: PHONE:

BLOOMINGDALE SCHOOL DISTRICT 13 2016‐2017 AFFIDAVIT OF RESIDENCY FORM

(Students must be District residents as of August 17, 2016)

*The Bloomingdale School District 13 resident must also submit residency documents from Category I and Category III along with this form. These documents must come from the resident, not the person who will be living with the resident.

I, ________________________________________, the parent or legal guardian of (Printed Name of Parent/Legal Guardian) __________________________________________, being first duly sworn, state on oath that (Printed Name of Student or Students) the named student(s) above is/are under my custody, but we will be residing with _______________________________________ at ___________________________________

(Printed Name of Resident) (Address)

for the 2016‐2017 school year. The reason that the student must reside at this address is _________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ This affidavit of residency form is to attest that the above child is not enrolling in the District solely for school purposes and is living on a permanent basis with the person having complete custody and control. Registration of a student who is not a resident is a fraudulent act. Any student found to have been fraudulently registered will be dropped from the attendance rolls immediately. Parents or guardians making a fraudulent registration will be subject to the payment of retroactive tuition charged for non‐resident students, not to exceed 110% of the per capita cost. A person who knowingly or willfully presents the District with any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in the District shall have committed a Class C misdemeanor and shall be prosecuted by the District. National Investigations, Inc. will be conducting a home visit if fraud is suspected. I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.

SUBSCRIBED AND SWORN TO _________________________ before me this _________ day Parent Signature of _____________, 20______

_________________________ Telephone __________________________ Notary Public _________________________

Owner of Property Signature (Stamp)

_________________________ Telephone

BLOOMINGDALE SCHOOL DISTRICT 13 2016‐2017 REGISTRATION FEE WAIVER APPLICATION

The Board of Education of Bloomingdale School District 13 waives school fees for children whose parents are experiencing economic hardships. If you believe your child(ren) may qualify for a fee waiver due to current financial or emergency conditions, please complete this form and return it with the registration materials. If you have any questions, please contact the Director of Finance, Adam Parisi, at 630.671.5035. You will be notified of acceptance or denial within 14 days. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Name of Student: ______________________________________________ School _________________ Name of parent or guardian: _____________________________________ Grade _________ I hereby request school fees are waived for the above listed student for the following reason: Household Income Section:____________________________________________________________ [ ] The student’s household gross income meets the Federal income requirement for waiver approval. Documentation must be attached that supports household size and gross income level. The following documents must be enclosed: Recent W‐2 form(s); recent pay stub; Front page of most current Federal 1040 tax form.

Household Size

Annual Household Income (Gross)

Monthly Household Income (Gross)

Weekly Household Income (Gross)

[ ] I have attached a copy of my most current pay stub [ ] I have attached a copy of my most current W‐2 form (s) [ ] I have attached a copy of my most current Federal 1040 tax form showing dependents

OR

Public Aid Section: ___________________________________________________________________ [ ] The household is receiving public aid (i.e. Aid to Families with Dependent Children (AFDC), Temporary Assistance for Needy Families (FANF), or Department of Human Services Food Stamps). Evidence of participation in AFDC, TANF, or Food Stamp Program must be attached. LINK card and Illinois Department of Public Aid MediPlan cards will not be accepted as verification of pubic aid. [ ] I have attached a copy of my card indicating participation in AFDC, TANF or Food Stamp Program. Case ID Number: ______________________________________________________________ I have reviewed the District’s policy and I am aware supplying false information is a class 4 Felony (720 ILCS S/17‐6). I attest that the statements made here are true and correct.

_________________________________________________________________ _____________________ Parent Signature Date

********************************************************************************************* Office Use Only: ____ Approved ____ Disapproved Director of Finance’s Signature: __________________________________________________ Date: _________________

BLOOMINGDALE SCHOOL DISTRICT 13

MEDICAL REQUIREMENTS CHECKLIST FOR KINDERGARTEN

The Illinois school code requires all children entering kindergarten to have a physical exam and certain

immunizations prior to entering school in the fall. A dental exam and eye exam are also required. Please use

this checklist to help answer questions and complete the necessary requirements for kindergarten.

COMPLETED PHYSICAL EXAM REQUIREMENTS

_______________ “Certificate of Child Health Examination” form must be completed and returned to

school no later than 2 weeks before the start of school.

_______________ Complete all information on top of the Physical form (name, address, birth date, and

grade). Please put name on both sides of form.

_______________ Parent/Guardian completes and signs the “Health History” portion of the form (top

of back side of form).

_______________ Immunizations (front side of form). Include all immunizations child has had. The

month, day, and year in which the immunizations were given must be noted. Doctor

or Health Care Professional needs to sign and date immunization portion of the

form.

_______________ DIABETES SCREENING is required. The doctor should identify if your child is at

risk.

_______________ LEAD SCREEN RISK QUESTIONNAIRE All children 6 months through 6 years

of age should be assessed for lead poisoning. A lead assessment is a required part of

the physical exam for kindergarten entry.

_______________ PHYSICAL EXAMINATION (Bottom portion of back side of form) Physical must

include: Height, Weight, Blood Pressure, BMI and a review of systems. Lab work is

not required but strongly recommended.

_______________ Physical must be dated within 1 year of entering kindergarten and must be signed

by the Physician. The Illinois School Code also allows advanced practice nurses and

physician assistants who have a collaborative agreement with a physician to conduct

and sign a health examination.

IMMUNIZATION REQUIREMENTS

_______________ DPT (Diphtheria, Pertussis, Tetanus) Need a total of 4 doses, given at least 4 weeks

apart, with the last dose given after 4 years of age.

_______________ OPV/IPV (Polio) 4 or more doses, the first three doses in the series are no less than 4

weeks apart, with the last or 4th dose given on or after 4 years of age and the last dose

shall be administered at least 6 months after the previous dose.

_______________ MEASLES 2 doses of Measles Vaccine, the first dose must have been received on or

after the first birthday and the second dose no less than 4 weeks later.

_______________ RUBELLA 2 doses of Rubella Vaccine, the first dose must have been received on or


_______________ MUMPS 2 doses of Mumps Vaccine, the first dose must have been received on or


_______________ MMR (Measles, Mumps, Rubella) If all 3 are given together, the shot must have been

given after 12 months of age.

_______________ VARICELLA (Chickenpox vaccine) 2 doses of Varicella Vaccine, the first dose must

have been received on or after the first birthday and the second dose no less than 4

weeks later, or verification of disease by physician or health care provider with date

and signature placed in the section labeled “Alternate Proof of Immunity.”

_______________ TB A Tuberculin Test is strongly recommended as a part of the physical exam.

OTHER MANDATED EXAMINATIONS

_______________ DENTAL EXAMINATION is required. Included in your packet is a dental form

which the dentist should sign and date, after completion.

_______________ EYE EXAMINATION is required. Included in your packet is an eye examination

form which the doctor should sign and date, after completion.

IF YOU REQUEST RELIGIOUS EXEMPTION

A parent-signed letter detailing specific religious beliefs which conflict with a specific

immunization and/or exam must also now be signed by a health care provider

(physician, advanced practice nurse, or physician assistant) and submitted to the school

at which your child is registered. Please refer to the Joint Committee on Administrative

Rules, Administrative Code, Title 77 and PA 099-0249 for further information.

MAKE APPOINTMENTS EARLY. Doctors/Dentists offices get very busy during the summer months. Don’t

wait until August. Immunizations may also be obtained through the DuPage County Health Department. Call

630-682-7560.

If the physical/immunization form is completed before the end of the 2015-2016 school year, you may return it to

the Health Office at the school where you registered. There will be drop boxes at all the schools in which to place

your completed health forms. PLEASE DO NOT PUT THEM WITH SCHOOL REGISTRATION FORMS.

If you have any questions, please call the Health Office at the school where you registered.

Thank you for your cooperation in fulfilling these health requirements.

DISTRICT 13 NURSES

Erickson Elementary School 630.529.2233

DuJardin Elementary School 630.894.9200

State of Illinois

Certificate of Child Health Examination

IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

Student’s Name Last First Middle

Birth Date Month/Day/Year

Sex Race/Ethnicity School /Grade Level/ID#

Address Street City Zip Code

Parent/Guardian Telephone # Home Work

IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication.

Vaccine / Dose 1 MO DA YR

2 MO DA YR

3 MO DA YR

4 MO DA YR

5 MO DA YR

6 MO DA YR

DTP or DTaP

Tdap; Td or Pediatric DT (Check specific type)

TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT

Polio (Check specific type)

IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV

Hib Haemophilus influenza type b

Hepatitis B (HB)

Varicella (Chickenpox)

COMMENTS:

MMR Combined Measles Mumps. Rubella

Single Antigen Vaccines

Measles Rubella Mumps

Pneumococcal Conjugate

Other/Specify Meningococcal, Hepatitis A, HPV, Influenza

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature Title Date

ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date MO DA YR (Attach copy of lab result)

VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN

Date Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts

Age/ Grade

R L R L R L R L R L R L R L R L R L

Vision Hearing

FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013

Birth Date Sex School Grade Level/ ID

# Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

ALLERGIES (Food, drug, insect, other) MEDICATION (List all prescribed or taken on a regular basis.)

Diagnosis of asthma? Child wakes during night coughing?

Yes No Yes No

Loss of function of one of paired organs? (eye/ear/kidney/testicle)

Yes No

Birth defects? Yes No Hospitalizations? When? What for?

Yes No

Developmental delay? Yes No

Blood disorders? Hemophilia, Sickle Cell, Other? Explain.

Yes No Surgery? (List all.) When? What for?

Yes No

Diabetes? Yes No Serious injury or illness? Yes No

Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department.

Seizures? What are they like? Yes No TB disease (past or present)? Yes* No

Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No

Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No

Dizziness or chest pain with exercise?

Yes No Family history of sudden death before age 50? (Cause?)

Yes No

Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)

Dental Braces Bridge Plate Other

Ear/Hearing problems?

Yes No Information may be shared with appropriate personnel for health and educational purposes.

Parent/Guardian Signature Date Bone/Joint problem/injury/scoliosis? Yes No

PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P

DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No

LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.)

Questionnaire Administered ? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born

in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm ______________ Blood Test: Date Reported / / Result: Positive Negative Value ______________

LAB TESTS (Recommended) Date Results Date Results

Hemoglobin or Hematocrit Sickle Cell (when indicated)

Urinalysis Developmental Screening Tool

SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs

Skin Endocrine

Ears Gastrointestinal

Eyes Amblyopia Yes No Genito-Urinary LMP

Nose Neurological

Throat Musculoskeletal

Mouth/Dental Spinal Exam

Cardiovascular/HTN Nutritional status

Respiratory Diagnosis of Asthma Mental Health

Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid)

Other

NEEDS/MODIFICATIONS required in the school setting

DIETARY Needs/Restrictions

SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal

EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe.

On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.)

PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited

Print Name (MD,DO, APN, PA) Signature Date

Address Phone

(Complete Both Sides)

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

State of IllinoisIllinois Department of Public Health

To be completed by dentist:

Oral Health Status (check all that apply)

� Yes � No Dental Sealants Present

� Yes � No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it wasextracted as a result of caries OR missing permanent 1st molars.

� Yes � No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of thewalls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retainedroot, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-ered sound unless a cavitated lesion is also present.

� Yes � No Soft Tissue Pathology

� Yes � No Malocclusion

Treatment Needs (check all that apply)

� Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

� Restorative Care — amalgams, composites, crowns, etc.

� Preventive Care — sealants, fluoride treatment, prophylaxis

� Other — periodontal, orthodontic

Please note____________________________________________________________________________________

Signature of Dentist _________________________________________ Date of Exam ____________________

Address ___________________________________________________ Telephone _______________________Street City ZIP Code

Illinois Department of Public Health, Division of Oral Health217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us

Printed by Authority of the State of Illinois

Student’s Name: Last First Middle Birth Date:/ /

Address: Street City ZIP Code Telephone:

Name of School: Grade Level: Gender:� Male � Female

Parent or Guardian: Address (of parent/guardian):

(Month/Day/Year)

IOCI 0600-10

State of IllinoisEye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eyeexaminations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school forother children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinoisschool system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

Student Name ________________________________________________________________________________________________(Last) (First) (Middle Initial)

Birth Date ____________________ Gender ______ Grade _____(Month/Day/Year)

Parent or Guardian ____________________________________________________________________________________________(Last) (First)

Phone ______________________________(Area Code)

Address _____________________________________________________________________________________________________(Number) (Street) (City) (ZIP Code)

County ____________________________________________

To Be Completed By Examining Doctor

Case HistoryDate of exam ________________

Ocular history: � Normal or Positive for ___________________________________________________________________

Medical history: � Normal or Positive for ___________________________________________________________________

Drug allergies: � NKDA or Allergic to ____________________________________________________________________

Other information _____________________________________________________________________________________________

ExaminationDistance NearRight Left Both Both

Uncorrected visual acuity 20/ 20/ 20/ 20/Best corrected visual acuity 20/ 20/ 20/ 20/

Was refraction performed with dilation? �Yes � No

Normal Abnormal Not Able to Assess CommentsExternal exam (lids, lashes, cornea, etc.) � � � __________Internal exam (vitreous, lens, fundus, etc.) � � � __________Pupillary reflex (pupils) � � � __________Binocular function (stereopsis) � � � __________Accommodation and vergence � � � __________Color vision � � � __________Glaucoma evaluation � � � __________Oculomotor assessment � � � __________Other _________________________ � � � __________NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis� Normal � Myopia � Hyperopia �Astigmatism � Strabismus �Amblyopia

Other _______________________________________________________________________________________________________

Continued on backPage 1

State of IllinoisEye Examination Report

Recommendations1. Corrective lenses: � No �Yes, glasses or contacts should be worn for:

� Constant wear � Near vision � Far vision� May be removed for physical education

2. Preferential seating recommended: � No �Yes

Comments ________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Recommend re-examination: � 3 months � 6 months � 12 months

� Other ____________________________________

4. _________________________________________________________________________________________________________

5. _________________________________________________________________________________________________________

Print name____________________________________________ License Number_____________________________________Optometrist or physician (such as an ophthalmologist)

who provided the eye examination � MD � OD � DO

Address ____________________________________________

____________________________________________

Phone ____________________________________________

Signature ____________________________________________ Date ___________________

(Source: Amended at 32 Ill. Reg. _________, effective ___________)

Consent of Parent or GuardianI agree to release the above information on my childor ward to appropriate school or health authorities.

(Parent or Guardian’s Signature)

(Date)

Page 2Printed by Authority of the State of Illinois

6/09IOCI1271-09

ERICKSON ELEMENTARY

PARENT TEACHER ORGANIZATION

277 Springfield Drive, Bloomingdale, Illinois 60108

Erickson Parents:

The 2016-2017 Erickson Elementary School Parent Teacher Organization (PTO) Membership Dues are

listed below.

The Membership Dues for PTO participation are $15.00 for one child and $25 for two or more children.

This fee includes: all classroom parties, PTO membership and inclusion and access to our new online

directory. The PTO sponsors such events as: Fall Carnival, Fundraisers, School Assemblies, AR Night Out,

Thanksgiving Feast, Teacher Wish Lists and many more. The directory information policy is contained in

the district calendar. We will publish the information provided to the district unless you notify the school

office in writing that you do not wish to have your information listed in the directory.

Complete the bottom portion of this form. Include a check payable to Erickson PTO. Please place the form

and payment in the envelope marked ERICKSON PTO. Do not combine these dues with other fees you may

be sending in.

Thank you in advance for your prompt attention and support.

Sincerely,

Gina Gattuso PTO President Erickson Elementary

______________________________________________________________

ERICKSON PTO MEMBERSHIP DUES 2016-2017

_______ $15 One Child _______ $25 for two or more children

CHILD’S NAME______________________________________ GRADE______



FAMILY NAME ___________________________________________________

TOTAL $______

_______________________________________________________________

DIRECTORY INFORMATION 2016-2017 (Student name, address, phone number)

______ Yes, I approve my directory information to be published in the directory

______ No, I do wish for my information to be published in the directory

Parent Signature ___________________________________________________

BLOOMINGDALE ELEMENTARY SCHOOLS Kindergarten Registration for 2016... · BLOOMINGDALE ELEMENTARY SCHOOLS ... EMERGENCY CONSENT If the parents or guardians cannot be contacted ...

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