Lancaster Central School District 149 Central Avenue Debi Mascia Lancaster, NY 14086 District Registrar Phone (716) 686-3218 Fax (716) 686-3219 [email protected]dm, rev 9/1/2019 Documents you will need to bring to the registration appointment… 2 forms proof of residency ex. homeowner - non-contingent binding contract, deed, mortgage statement, tax bill, utility bill if renting - lease agreement & utility bill Proof of Age – ex. Certified birth certificate, baptismal certificate Updated immunization record Health appraisal form (physical within a year) Custody agreement - (if both parents are not in the home) Recent report card IEP (if receiving special ed services) *Student Registrations are by appointment only* When you have everything together, please call 716-686-3218 to make an appointment. If you need to have anything faxed in, the fax number is 716-686-3219, or you can email to [email protected]
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*Student Registrations are by appointment only* · 2020-01-31 · *Student Registrations are by appointment only* When you have everything together, please call 716-686-3218 to make
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Lancaster Central School District
149 Central Avenue Debi Mascia
Lancaster, NY 14086 District Registrar Phone (716) 686-3218
IT’S EASIER THAN EVER TO APPLY FOR HEALTH INSURANCE
Free or low-cost health insurance is now available for all children and teens in New York through Child Health Plus.
Please complete this form if you would like to receive more information. We will be offering a seminar to assist in the enrollment process each fall, and at various times throughout the school year. Enrollment assistance is also available on an individual basis. If you have any questions please contact Anne Monin, Lancaster Family Support Center Coordinator, at 686-3806.
Best Time to Reach You: Daytime: _____ Evenings: _____ Weekends: _____
Please Read and Sign
“I agree to having the information on this referral form shared with facilitated enrollment organizations providing application assistance for Child Health Plus, Medicaid and Family Health Plus. I understand this information is being shared with facilitated enrollment organizations so that they may contact me or members of my family about applying for Child Health Plus, Medicaid or Family Health Plus.”
Please return to the School Nurse; or the Lancaster Family Support Center at Lancaster Middle School
Lancaster Central School District Registration Form Page 1/4
LANCASTER CENTRAL SCHOOL DISTRICT STUDENT REGISTRATION FORM (Please print in ink and complete all areas)
NOTICE
Please be advised that the provision of false information on this registration form could constitute a crime. In addition, the District reserves its right to recover from parents, legal guardians or other responsible parties the entire actual cost of educating a student, plus related costs, for the entire period that any non-resident student is enrolled in the District's schools with authorization and/or under false pretenses. The cost of educating a student for the schoolyear ranges from approximately $9,500 elementary to $10,000 secondary.
I HAVE READ AND UNDERSTAND THIS NOTICE.
Signature FOR OFFICE USE ONLY:
ID: SCH: GR: START:
STUDENT INFORMATION
Student’s Last Name:_________________________________ First Name: ____________________________ Middle: ______________
Street Address: ___________________________________________________________________________________________________
City: ________________________ State: ______ Zip Code: _________ Primary Household Phone:____________________________
Gender: Male Female Date of Birth:_______________ City/State of Birth: ____________________________
mm/dd/yyyy
Military Connected Youth: Yes No (Parent/Guardian is on Active Duty, a Member of National Guard/Reserves, or is a
Veteran of United States Military)
RESIDENCE INFORMATION
Residence Type: Own Rent Lease Foster Care Agency Unknown
________________________If rent/lease, name of property owner: ____________________________________________Telephone:
Proof of Residency:
Property Tax Bill House Deed Utility Bill Lease/Rental Agreement Mortgage Statement
Purchase Contract Other than above: _____________________________________________________________________
Previous Address: _____________________________________________________________________________Number of years:
Street Apt. No. City/Town Zip Code
Please list all other properties owned by either parent/guardian:
Street Apt. No. City/Town Zip Code
Street Apt. No. City/Town Zip Code
Please list all other properties rented by either parent/guardian:
Street Apt. No. City/Town Zip Code
Street Apt. No. City/Town Zip Code
Lancaster Central School District Registration Form Page 2/4
SCHOOL HISTORY
Attended LCSD Before? Yes No If YES, previous Enrollment Date: Previous Grade:
If NO, what was the last school attended by this student?
Street City/Town Zip Code Address of school:
Telephone: Grade Last Attended: Present Grade:
Name and address of all schools previously attended: (Including any Lancaster schools ever attended)
*For UPK or K grade registration list pre-schools or daycares previously attended
Name of School Address Dates Attended Grades
Name of School Address Dates Attended Grades
Name of School Address Dates Attended Grades
Was the student suspended or removed from a school the student attended? Yes
If yes, explain:
Proof of Age: Birth Certificate Baptismal Certificate Passport OR Other, specify
Is your child currently receiving Special Education Services? ____ YES ____ NO
If YES, what is your child's classification:
List Services/Programs:
Is your child currently receiving Section 504 accommodations? ____YES ____NO
Is your child currently receiving other Academic Support Services (Title 1 Reading or Math?) ____YES ____ NO
If YES, please list services:
HEALTH INFORMATION
Physician’s Name: Telephone:
Please describe any conditions or requirements of which the District should be aware? (Food allergies, asthma, medications, etc.)
N O
Lancaster Central School District Registration Form Page 3/4
PARENT / GUARDIAN INFORMATION
PARENT/GUARDIAN # 1 (Note: Parent/Guardian #1 must reside at the same address as that indicated for the student.)
NAME: ___________________________________________________________________________________ Last First MI
YES NO Awaiting foster care (through the Department of Children and Family or Social Services) placement?
Living in a car, park, bus or train station? YES NO
Living in an abandoned building or similar substandard housing? YES NO
CERTIFICATION AND AUTHORIZATION
I hereby certify that the student listed on this registration form actually resides at the address specified on Page 1 within the Lancaster School District boundaries. I further certify that all the information I provided on this registration form is true and correct. I understand that I must immediately notify the District if the residency of the student changes from the address listed on this registration form.
I authorize the request of student records from previous schools and give permission to the Lancaster Central School District to verify telephone numbers and addresses. I understand that if the district believes that the information on this form is no longer correct or that the child being registered no longer lives at the address provided, the Lancaster Central School District has the right under New York State Law to investigate and to withdraw the child from the Lancaster Central School District.
HEALTH HISTORY HAS ANYTHING MEDICALLY CHANGED WITH YOUR CHILD? IF YES, PLEASE EXPLAIN AND PROVIDE MEDICAL
DOCUMENTATION FROM YOUR PHYSICIAN: ___________________________________________________________ ______________________________________________________________________________________________________________
Please note if any of the following conditions pertain to your child:
NAME OF PEDIATRICIAN: ______________________________________ PHONE: _______________________
I understand that this information may be shared with personnel involved with my child.: ____________________________________
(Parent’s signature)) 1/19jw
Dental Health Certificate Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 1,3,5,7,9,11. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Child’s Name: Last First Middle
Birth Date: / / Month Day Year
Sex: Male
Female Will this be your child’s first visit to a dentist? Yes No
School: Name Grade:
Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? Yes No
I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health.
I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below.
The Dental Health condition of __________________________________ on _________________ (date of exam) The date of the exam needs to be within 12 months of the start of the school year in which it is requested.
Check one:
Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.
No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.
NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.
Dentist’s name and address (please print or stamp) Dentist’s Signature
Optional Sections - If you agree to release this information to your child’s school, please initial here.:________
II. Oral Health Status (check all that apply).
Yes No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].
Yes No Untreated Caries – Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].
Yes No Dental Sealants Present
Other problems (Specify): ______________________________________________________________________________
III. Treatment Needs (check all that apply)
No obvious problem. Routine dental care is recommended. Visit your dentist regularly.
May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.
Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.
LANCASTER CENTRAL SCHOOL DISTRICT
1/09 MMC
22
Michael J. Vallely www.lancasterschools.org
Superintendent 716-686-3200
School Request for Student Records
To: ___________________________________________________
REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR
Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or
Committee on Pre-School Special education (CPSE).
STUDENT INFORMATION
Name: Sex: M F DOB:
School: Grade: Exam Date:
HEALTH HISTORY
Allergies ☐ No
☐ Yes, indicate type
☐Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached
☐Medication/Treatment Order Attached ☐ Asthma Care Plan Attached
☐ Intermittent ☐ Persistent ☐ Other : ___________________________
Seizures ☐ No ☐Medication/Treatment Order Attached ☐ Seizure Care Plan Attached
☐ Yes, indicate type ☐ Type: __________________________ Date of last seizure: ______________
Diabetes ☐ No ☐Medication/Treatment Order Attached ☐ Diabetes Medical Mgmt. Plan Attached
☐ Yes, indicate type ☐Type 1 ☐ Type 2 ☐ HgbA1c results: ____________ Date Drawn: _____________
Risk Factors for Diabetes or Pre-Diabetes: Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.
☐ Additional Information Attached _________________________ _____________
5/1/2018 Page 2 of 2
Name: DOB:
SCREENINGS
Vision Right Left Referral Notes
Distance Acuity 20/ 20/ ☐ Yes ☐ No
Distance Acuity With Lenses 20/ 20/
Vision – Near Vision 20/ 20/
Vision – Color ☐ Pass ☐ Fail
Hearing Right dB Left dB Referral
Pure Tone Screening ☐ Yes ☐ No
Scoliosis Required for boys grade 9 Negative Positive Referral
And girls grades 5 & 7 ☐ ☐ ☐ Yes ☐ No
Deviation Degree: Trunk Rotation Angle:
Recommendations:
RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK
☐ Full Activity without restrictions including Physical Education and Athletics.
☐ Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications
☐ No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling
☐ No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, skiing, swimming and diving, tennis, and track & field
☐ Other Restrictions:
☐ Developmental Stage for Athletic Placement Process ONLY
Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports
Student is at Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V
☐ Accommodations: Use additional space below to explain
☐ Brace*/Orthotic ☐ Colostomy Appliance* ☐ Hearing Aids
☐ Protective Equipment ☐ Sport Safety Goggles ☐ Other:*Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.
☐Order Form for Medication(s) Needed at School attached
List medications taken at home:
IMMUNIZATIONS
☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No
HEALTH CARE PROVIDER
Medical Provider Signature: Date:
Provider Name: (please print) Stamp:
Provider Address:
Phone:
Fax:
Please Return This Form To Your Child’s School When Entirely Completed.
Lancaster Central School DistrictCommittee on Special Education
177 Central AvenueLancaster, NY 14086 ((716) 686-3215)
Medicaid Consent
This is to ask your permission (consent) to bill your or your child’s Medicaid Insurance Program for special education and related services that are on your child's individualized education program (IEP).
This consent allows the school district to bill for covered health-related services and to release information to the school district’s Medicaid Billing Agent for that purpose.
I, _________________________________as the parent/guardian of ___________________ , have received a written notification from the school district that explains my federal rights regarding the use of public benefits or insurance to pay for certain special education and related services.
I understand and agree that the School District may access Medicaid to pay for special education and related services provided to my child.
I understand that: Providing consent will not impact my child’s/my Medicaid coverage; Upon request, I may review copies of records disclosed pursuant to this authorization; Services listed in my child’s IEP must be provided at no cost to me whether or not I give consent to bill Medicaid; I have the right to withdraw consent at any time; and The school district must give me annual written notification of my rights regarding this consent.
I also give my consent for the school district to release the following records/information about my child to the State’s Medicaid Agency for the purpose of billing for special education and related services that are in my child’s IEP. The following records will be shared.
Records to be shared (such as records or information about services your child receives)IEP Medication Administration ReportWritten Order/Referral Special Transportation LogEvaluation Reports Other Personally Identifiable InformationSession Notes Any Other Specific Records Pertaining to the Student’s Services
or Program
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand that my child’s right to receive special education and related services is in no way dependent on my granting consent and that, regardless of my decision to provide this consent, all the required services in my child’s IEP will be provided to my child at no cost to me.
Student Name: ____________________________________Client Identification Number (CIN): ________________
In an effort to save you time, we ask that you fill out the
following forms prior to your appointment, so the school
district can collect them immediately after your child’s
registration is complete.
The following forms are not part of the registration process;
the school district will not ask for them prior to completing
the registration process. Please do not present them to the
school official until after your child is registered. Your
answers to the questions on these forms have no bearing on
your ability to register your child for school.
Thank you.
1 ENGLISH
Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.
STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12
Lissette Colon-Collins, Assistant Commissioner
Office of Bilingual Education and World Languages
55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB
Please write clearly when completing this section. S T U D E N T N A M E :
First Middle Last
D A T E O F B I R T H : G E N D E R :
Male Female Month Day Year
P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :
Last Name First Name Relation to Student
S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T
I N F O R M A T I O N S Y S T E M :
District Name (Number) & School Address
2 ENGLISH
Home Language Questionnaire (HLQ)—Page Two
Relationship to student: Mother Father Other:
Educational History
8. Indicate the total number of years that your child has been enrolled in school _____________
9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write in English or any other language? If yes, please describe them.
Yes* No Not sure *If yes, please explain:____________________________________________________________________________ How severe do you think these difficulties are? Minor Somewhat severe Very severe
10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below
10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .
Age at which services received (Please check all that apply):
Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)
10c. Does your child have an Individualized Education Program (IEP)? No Yes
11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)
12. In what language(s) would you like to receive information from the school? _________________________________________________
Month: Day: Year:
Signature of Parent or of Person in Parental Relation Date
OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ NAME: POSITION:
IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:
NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW
NAME: POSITION:
ORAL INTERVIEW NECESSARY: NO YES
**DATE OF INDIVIDUAL
INTERVIEW:
OUTCOME OF
INDIVIDUAL
INTERVIEW:
ADMINISTER NYSITELL
ENGLISH PROFICIENT
REFER TO LANGUAGE PROFICIENCY TEAM MO DAY YR.
NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL
FOR STUDENTS WITH DISABILITIES, LIST ACCOMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:
Revised January 2019
LANCASTER CENTRAL SCHOOL DISTRICT
STUDENT RACIAL-ETHNIC-LANGUAGE IDENTIFICATION
All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition or immigration status.
Name of School: __________________________________________ Grade: __________________
District Student ID Number: _________________________________ Date of Birth: ___________________ (month/day/year)
1. Is the student Hispanic, Latino, or of Spanish origin?(Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South
American, or other Spanish culture or origin, regardless of race.)
Please check ( ) the box that best describes your child. Check ( ) only ONE box.
YES, Hispanic
NO, not Hispanic
2. Select one or more races from the following five racial groups.
Please check ( ) all groups that apply to your child; check ( ) at least ONE box.
AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of
North America and who maintains cultural identification through tribal affiliation or community recognition.
e.g., Cherokee, Mohawk, Inuit.)
ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian
subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
BLACK: A person having origins in any of the black racial groups of Africa.
WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
3. What are the languages spoken at home? ____________________________________________ .
Does the student understand English? YES NO
What language does the student: read? ________________ write? ______________speak? ______________
X _____________________________________________________ ________________________ (Signature of Parent/Guardian/Other) (Date)
Relationship to Student (please check box below): Mother Father Guardian Other (specify): ______________________________