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West Plains Middle School
PARENT CONSENT TO RELEASE OR OBTAIN RECORDS
Fax: 417-256-8907
Date______________
STUDENT’S LEGAL NAME
Last____________________ First____________________ Middle________________ Nickname_________________
Date of Birth: ____ /____ /____ Grade _______
Previous School’s Name/City, St. ____________________________________________________________________
My child has received special services (IEP/504) at his/her former school. Yes No
Please send the following information:
Transcript State Assessment Test Scores/NCLB requirement Withdrawal Grades Attendance Discipline Records Immunizations/Health Records Special Services Records/IEP/Psychological Records MOSIS Number ________________________
_________________________________________________________________________________________________ Print Name Parent/Guardian Signature of Parent/Guardian Relationship to Student
_________________________________________________________________________________________________ Address City, State, Zip Phone
Please fax, email, or send student records to: West Plains High School 730 East Olden West Plains, MO 65775 Attn: Stacy Kerley Phone: 417-256-7152 Ext. 4201 Fax: 417-256-8907 Email: stacy.kerley@zizzers.org This consent may be modified or revoked by me at anytime upon written request to the party releasing the information, except to the extent that action has already been taken in reliance on
this authorization. I understand that this information may not be forwarded to another individual, agency or organization without my written consent. I understand that I have the right to
inspect, copy and challenge the information contained in the records received. I certify that I am the parent or legal guardian of the above named student and have the authority to sign this
release. I understand that failure to consent to such release of information may have an impact on the quality of services to be provided, but will not be grounds for termination of services by
West Plains R-VII School District.
WEST PLAINS STUDENT INFORMATION
Public Schools 2017-2018 PLEASE PRINT Form Version 101217
STUDENT’S LEGAL NAME Enrollment Date__________________
Last____________________ First____________________ Middle________________ Nickname_________________
Gender: Female Male Date of Birth: ____ /____ /____ Grade _______ Student Cell Phone______________
Who has legal custody?: Both Parents Father Mother Other _____________________________
Are there legal documents concerning custody, educational decision making, etc. associated with this student? Yes No
If yes, please provide a copy of the legal document to the school. Legal Documents Provided: Yes No NA
High School ONLY – What school district do you live?
Fairview Glenwood Howell Valley Junction Hill Richards West Plains
RACE/ETHINICITY/HOME LANGUAGE Please check all that apply:
Is the student Hispanic/Latino? Yes No American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
PREVIOUS EDUCATIONAL INFORMATION
Last Date in School ______________ Last School Attended ___________________________________________
Has student ever attended West Plains School District before Yes No If yes, what grade?________
Has student ever attended a Missouri school before? Yes No
Has this student been retained? ……………………………………………………………... Yes No
If yes, what grade?__________
Have you been enrolled in a gifted program? ……………………………………………… .. Yes No
Have you been enrolled in Special Education classes (includes Speech) or have a 504 Plan?..... Yes No
Behavior/Discipline
Is this student currently under suspension, or expulsion, from another school district?............. Yes No
If yes, please answer the following:
1. Reason for suspension/expulsion ___________________________________
2. Date of suspension/expulsion ______________________________________
3. Name of School_________________________________________________
4. School’s Address: City ______________________State______ Zip_________
Has this student ever at any time been involved with juvenile/law enforcement authorities?.... Yes No
If yes, please explain ______________________________________________________
High School ONLY - Have you been enrolled in the Missouri A+ program?.......................... Yes No
By my signature below, I certify the information I provided on and in connection with this form is true, accurate and complete.
Parent/Guardian Signature____________________________________________Date_________________
OFFICE USE ONLY
Did parents/guardians mark “yes” to any of the McKinney-Vento information on Household Form? Yes No If yes, please document when Dr. Ross was contacted: (date)_____________Initials_______ If “yes” was given on any of the questions above, please document who was notified and the date.:
Contacted _____________________about ____________________________ on (date)_____________Initials_____
Contacted _____________________about ____________________________ on (date)_____________Initials_____
Verified by counselor: Signature_______________________________________________ Date________________
WEST PLAINS R-7 SCHOOL MEDICATION FORM
Student Legal Name: Last____________________ First____________________ Nickname_________________
Gender: Female Male Date of Birth:____ /____ /____ Grade _______
Parent/Guardian_____________________________Home Phone________________Work Phone__________________
Emergency Contact_______________________________Home Phone________________Work Phone_____________ Additional Phone Numbers___________________________________________________________________________ Drug/Food Allergies (BE SPECIFIC) ___________________________________________________________________ Significant Health Problems__________________________________________________________________________ Medications Taken at Home__________________________________________________________________________ The West Plains R-7 School District has my permission to administer the following Over-the-Counter medications checked: _____ Acetaminophen for temperatures, general discomfort- (not to exceed one dose per day)- (80mg) Grades Pre-K-2 four tablets, (325mg) grades 5-8 one tablet, grades 9-12 two tablets _____ Antacid regular strength for upset stomach/heartburn (not to exceed one dose per day) _____ Chloroseptic spray for sore throat, Canker sores, minor irritations gums/mouth (3) Sprays for PK-8 (5) for 9-12 (may repeat every two hours) _____ Anbesol for toothache pain, cold sores (may repeat every two hours as needed) _____ Camphonpenique for insect bites/chapped lips (not to exceed twice daily) _____ Sting kill swabs for insect bites/bee stings _____ Calamine Lotion for irritated/itching skin (not to exceed twice daily) _____ Clean abrasions/wounds with soap and water/Hydrogen Peroxide- Apply Antibiotic Ointment _____ Benadryl 12.5 mg FOR ALLERGIC REACTIONS ONLY! _____ Cough Drop (one given per day) Parent/Guardian Signature___________________________________________ Date____________________ West Plains R-7 District has my permission to administer the following medication: Medication _________________________________________________ Amount to give __________________ Doctor Prescribing_________________________________________ Time to give_______________________ Reason taking medication____________________________________________________________________ Parent/Guardian Signature__________________________________________ Date_____________________ *For medications to be given you must follow the medication protocol outline in the Handbook and attached to this note, or they WILL NOT be given. * Leslie Murray, LPN Sara Edelen, RN Amy Green, RN Jennifer Tidwell, RN Kati McKee, LPN High School Middle School Elementary Elementary South Fork 256-6150 ext. 4317 256-6150 ext. 4209 256-6150 ext. 4115 256-6150 ext. 4115 256-2836
Student Legal Name: Last____________________ First____________________ Nickname_________________
School Medication Policy
Student’s medication should be given at home if at all possible. This decreases the chance of errors such as missed or forgotten doses. Medication will only be given during school hours by complying with these guidelines.
1. Medication consent form must be completed and signed. 2. Prescription medication must be in the original bottle for use. Medications given on a regular basis
(inhalers, Ritalin…etc.) must have the newest refill and send no more than a month’s supply at a time. Medication will only be given during school time if prescription states: at noon, every four hours or every six hours. Three times a day will not be given during school hours.
3. Over-the-counter medication (other than those listed on the Medication Consent Form) muse come in the original container and a medication consent form signed by parent or guardian turned into the school nurse.
4. All medications must be turned in at the School Nurse’s Office along with a dated note giving permission for the nurse to administer the medication. Medications are NOT to be sent on the bus. Incidents regarding the transportation of controlled substances on the bus will be referred to law enforcement officials.
5. Medication bottles will be sent home when medication course is completed or expired.
*Please send cough drops for your child to keep in the teacher’s classroom*
Questions concerning this policy may be directed to your School Nurse. For medications to be given you must follow protocol outlined herein and in the hand book.
Family Doctor: ____________________________________________________________________________ Insurance Provider: ________________________________________________________________________ Parent Signature: ______________________________________________Date: ______________________ Leslie Murray, LPN Sara Edelen, RN Amy Green, RN Jennifer Tidwell, RN Kati McKee, LPN High School Middle School Elementary Elementary South Fork 256-6150 ext. 4317 256-6150 ext. 4209 256-6150 ext. 4115 256-6150 ext. 4115 256-2836
Administrative Office
305 Valley View Drive
West Plains, MO 65775
417-256-6155
417-256-8616 (fax)
Zizzer Pride
A Tradition of Excellence
Dr. John Mulford, Superintendent
Dr. Julie Williams, Assistant Superintendent Dr. Luke Boyer, Assistant Superintendent Dr. Scott Smith, Assistant Superintendent Dr. Jack Randolph, Senior High Principal Mr. Kevin Hedden, Assistant. Senior High Principal Mr. Lenny Eagleman, Assistant Senior High Principal Mr. Ronnie Harper, Dean of Students Mr. Jim Laughary, Director, South Central Career Center Dr. Josh Cotter, Assistant Director, South Central Career Center Dr. Wesley Davis, Middle School Principal Mrs. Erica Walker, Assistant Middle School Principal Mr. Donnie Miller, Elementary Principal Mr. Matthew Orchard, Assistant Elementary Principal Dr. Seth Huddleston, South Fork Principal Mr. Greg Simpkins, Athletic Director Dr. Amy Ross, Special Services Coordinator Mrs. Lana Snodgras, Director, Communications and Community Relations
BOARD OF EDUCATION Mr. Jimmy E. Thompson, President Mrs. Cindy Tyree, Vice-President Mr. Sam Riggs, Member Mr. Lee Freeman, Member Mr. Brian Mitchell, Member Mrs. Christena Silvey-Coleman, Member Mrs. Courtney Beykirch, Member Ms. Linda Y. Collins, Secretary Dr. Luke Boyer, Treasurer
Student Language Survey
Student’s Name: ___________________________________________________
Person Completing Survey: ________________________________________________
Does anyone in your home speak a language other than English? IF YES, CONTINUE
IF NO, (STOP)
If yes, please circle the best answer to the following questions:
1. Was the first language the student learned English? Yes No
2. Can the student speak a language other than English? Yes No
If yes, what language? __________________________________
3. Is any language other than English used at home? Yes No
4. Which language does the student most often when you speak to friends?
English Other (specify) _____________________________________________
5. Which language does the student use when speaking to parents?
English Other (specify) _____________________________________________
6. Has the student attended school in a country other than the U.S.? Yes No
If so, how long and what grades? _________________________________________________
7. Has the student attended another school in the U.S.? Yes No
If so, where and how long? _____________________________________________________
8. Has the student attended another school in Missouri? Yes No
9. Please provide any other related information that would help the school (for example, referral to Gifted or Special
Education programs in prior schools, etc.):
___________________________________________________________________________
*If the student’s survey indicated that another language is spoken, then it may be necessary to give fluency tests to see if she/he is
limited in their English proficiency and in need of services to improve their proficiency in English.
Student’s Date of Birth: ________________________ Grade: ___________________________
Parent’s Name: ____________________________________________________________________
Address: ___________________________________________________________________________
Home Telephone: ____________________________________ Cell Phone: __________________________
Parent’s Place of Employment: _____________________________________________________________
Parent’s Signature: _______________________________________________________________________
Note to school staff: This form should be given to all new and enrolling students. Any student that indicates use of a language
other than English should be assessed as to English language proficiency.
Registration Questionnaire
STUDENT’S LEGAL NAME (Please Print)
Last____________________ First____________________ Nickname_________________ Grade ____________
1. Should child be enrolled in SPECIAL EDUCATION CLASSES (this includes Speech)? Yes No
If yes, please list the class and the number of class periods child should be SPED. If child is in LD (learning
disabilities) please list any specific disability. The district needs a diagnostic summary (testing data) and current
IEP.
___________________________________________________________________________________________
___________________________________________________________________________________________
2. 7th and 8th Grade: Which Math should child be enrolled in? (Check One)
7th Grade: Math Pre-Algebra
8th Grade: Pre-Algebra Alg I-Part I Algebra I
3. 7th and 8th Grade: Which ELA should your child be enrolled in? (Check One)
7th and 8th Grade: Regular Advanced ELA
4. 6th, 7th and 8th Grade: Has child taken Band previously? Yes No
If yes, should child be enrolled in Band this year? Yes No
If yes, what instrument? _________________________
Do you own your own instrument? Yes No
5. Should child’s physical activities be limited in any way? Yes No
If yes, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
*If child is to be excused from P.E., you are required to bring a written note from your doctor explaining the situation and the
length of time child is to be excused.
6. Does child have any special needs (physical, emotional, etc..) that the counselor and/or teachers need to be
aware of? Yes No
If yes, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
*If child is a Special Education student, the counselor may need to visit with you personally. If you have a copy of your
child’s IEP, we will need to make a copy. Please list the name of your child’s previous special education teacher and the
school phone number below if possible:
___________________________________________ ________________________ (Previous Special Education Teacher) (School Phone Number)
Bus Slip
Please fill out and return to the bus driver:
Transportation information
BUS #_________ (Bus number will be assigned by school personnel)
STUDENT NAME_________________________________________
PARENT NAME__________________________________________
GRADE_________ AGE_________
HOME PHONE_________________ WORK PHONE #_____________
CELL PHONE#_________________
HOME ADDRESS__________________________________________
DAYCARE OR OTHER
CHILDCARE PROVIDER_____________________________________
___________________________________________________________
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