kindergarten round-up - home - anacortes school district · h:\roundup parent mtg notice.doc...

$: Kindergarten Round-Up - Home - Anacortes School District · H:\Roundup Parent Mtg Notice.doc ANACORTES SCHOOL DISTRICT #103 An informational meeting is scheduled for ALL PARENTS OF$
H:\Roundup Parent Mtg Notice.doc

ANACORTES SCHOOL DISTRICT #103

An informational meeting is scheduled for

ALL PARENTS OF 2016-2017 KINDERGARTEN STUDENTS

Regarding the Anacortes School District Kindergarten Program

TUESDAY, APRIL 26, 2016 - 7:00 p.m.

ANACORTES MIDDLE SCHOOL CAFETERIA

Administrators will be present to address your questions and concerns. We hope to see you there!

ANACORTES SCHOOL DISTRICT #103

An informational meeting is scheduled for

ALL PARENTS OF 2016-2017 KINDERGARTEN STUDENTS

Regarding the Anacortes School District Kindergarten Program

TUESDAY, APRIL 26, 2016 - 7:00 p.m.

ANACORTES MIDDLE SCHOOL CAFETERIA

Administrators will be present to address your questions and concerns. We hope to see you there!

Kindergarten Round-Up

Kindergarten Round-Up

ANACORTES SCHOOL DISTRICT 2200 M Avenue Anacortes WA 98221 Phone: (360) 293-1200 Fax: (360) 293-1222

http://www.asd103.org

A Lighthouse for Public Education in Our Community: Ensuring No Child Is Lost Creating Lifelong Learners Inspiring High Achievement Nurturing Responsible Citizenship

C:\Users\vwellington\Downloads\Roundup Letter on Letterhead (2).doc

KINDERGARTEN ROUND UP INFORMATION - 2016 Dear Parents, We would like to take this opportunity to inform you that Anacortes School District kindergarten registration, also known as “Kindergarten Round Up”, for the 2016 - 2017 school year will take place on Thursday, April 28rd and Friday, April 29th. It will be held at the Anacortes Christian Church, 12th and M Avenue, with parking in the lot off N Avenue. All parents are requested to register their pre-kindergarten children at this time. The purpose of Kindergarten Round Up along with the registration data is to assure that your child is healthy and ready to begin school. Vision, hearing, and speech screenings will be provided. Please try to update your child’s immunizations prior to this registration activity. PLEASE BRING YOUR CHILD WITH YOU AND PLAN FOR APPROXIMATELY ONE HOUR. You may want to bring a snack for your child. Please bring immunization records and official birth certificates or other legally accepted documents for proof of birth with you at the time of registration. Do not bring copies or unofficial certificates from hospitals. The certificate must be issued by the state of birth. Please note that district policy and State law prescribes that a child must be five years old on or before August 31, 2016 in order to enter Kindergarten. In order to have registration take a minimum amount of time and to make it a pleasant experience for your child, we are requesting that you follow the schedule given below -- if at all possible. Please do not bring younger siblings to Kindergarten Roundup. This activity will take a minimum of one hour after the registration forms are filled out. Registration packets will be available at the District Administration Office, 2200 M Avenue (back entrance of Anacortes Middle School – 2nd floor) beginning Monday April 11th for those who want to complete the forms in advance. A copy of the registration packet will also be available online at www.asd103.org. On Thursday, April 28, if your child’s last name begins with:

A to E register between 9:00 am to 11:00am F to L register between 11:00 am to 1:00pm

On Friday, April 29, if your child’s last name begins with: M to R register between 9:00 am to 11:00 am S to Z register between 11:00am to 1:00 pm If you have a child who will be eligible for kindergarten, we urge you to register at this time. Also, if you know anyone who has an eligible child, it would be helpful if you would contact those parents about registration. Parent concerns about possible developmental delays in children Birth – 4 years old may discuss their concerns with staff.

The New Kindergarten Parents meeting will be held on April 26st at 7:00 pm in the Anacortes Middle School Cafeteria, 22nd and M Avenue. Questions regarding the kindergarten program, transportation, etc will be answered at this time. Sincerely, Anacortes School District Health Team

New Student Enrollment Form Students Last Updated: 2/1/10 3121 F1

STU

DEN

T IN

FO

STUDENT NAME: Legal LAST Name Legal FIRST Name

Legal MIDDLE Name

BIRTHDATE (Month/Day/Year) / /

Has student’s name ever been legally changed? If yes, what was previous name?

PRIMARY LANGUAGE SPOKEN AT HOME English Spanish

Other _________________

GRADE LEVEL:

GENDER Male

Female

District Resident? Yes No

Student Social Security Number (Optional):

Birthplace: City: State: County: Country:

Original Birth Certificate REQUIRED RECEIVED BY DISTRICT

Proof of Immunization REQUIRED RECEIVED BY DISTRICT

PR

IMA

RY

HO

USE

HO

LD

PRIMARY PARENT/GUARDIAN INFORMATION (Household information where student resides)

Legal Parent/Guardian #1 Last Name

First Name

Primary Phone ( ) Please check if confidential (will not be published)

Second Phone ( ) Home Work Cell

Third Phone ( ) Home Work Cell

Email Employer: Active Military YES NO

Relation to Student: Father Mother Guardian Other: Student Lives with: Both Parents Father only Mother only Grandparents Father/Stepmother Mother/Stepfather Guardian Agency Self Other

Parent/Guardian #2 Last Name

First Name

Email Second Phone ( ) Home Work Cell


Relation to Student: Father Mother Guardian Other:

Employer:

Resident Address

Street Apt # City State Zip

Mailing Address (If different From above)

Street Apt # PO Box City State Zip

SEC

ON

D H

OU

SEH

OLD

SECOND HOUSEHOLD INFORMATION (Student does not primarily reside at this residence) Parent/Guardian #1 Last Name

First Name

Primary Phone ( ) Please check if confidential (will not be published)



Email


Employer:

Parent/Guardian #2 Last Name

First Name

Email:




Employer:

Resident Address

Street Apt City State Zip

Mailing Address (If different from above)

Street Apt # PO Box City State Zip

SIB

LIN

GS

Sibling Name

Sibling Age School Attending

Sibling Name

Sibling Age School Attending

Sibling Name Sibling Age School Attending

STUDENT ENROLLMENT FORM

Date: _________________________


EM

ERG

ENC

Y M

EDIC

AL

INFO

RM

ATI

ON

/ A

UTH

OR

IZA

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N

EMERGENCY MEDICAL INFORMATION

Please list any medications your child will be taking during school hours:____________________________________________ If the student needs medications/treatment while at school, a Medication at School Authorization Form must be completed for each medication/treatment.

Please list any known allergens:____________________________________________________________________________ Required treatment for allergies:______________________________________________________________________________________________ Other life threatening conditions (please provide information in writing to school):______________________________________________________________________________________________ EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of an accident or illness, every effort will be made to contact the parent/guardian immediately. If the parent/guardian cannot be reached, I authorize school authorities to obtain emergency medical care for my child.

X Legal Parent/Guardian SIGNATURE __________________________________________________________________________Date:_____________________

EMER

GEN

CY

CO

NTA

CT

AU

THO

RIZ

ATI

ON

EMERGENCY CONTACT INFORMATION When illness, injury or other non-emergency situations occur involving your child, we want to be able to quickly reach family members or other responsible adults. Our first contact is always a parent or guardian, but in the event that a parent/guardian cannot be reached, please list the persons you trust who are available during the day to provide care for your child

STUDENT RELEASE AUTHORIZATION: In the event that the school in unable to contact the parent/guardian, I authorize that my child may be released to the person(s) below:

X Legal Parent/Guardian SIGNATURE __________________________________________________________________________Date:_____________________

EMER

GEN

CY

CO

NTA

CTS

PRIMARY EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

SECOND EMERGENCY CONTACT LAST NAME FIRST NAME



Address:

THIRD EMERGENCY CONTACT LAST NAME FIRST NAME



Address:

FOURTH EMERGENCY CONTACT LAST NAME FIRST NAME



Address:

FIFTH EMERGENCY CONTACT LAST NAME FIRST NAME



Address:


C

HIL

D C

AR

E

DOES STUDENT ATTEND CHILD CARE? BEFORE SCHOOL AFTER SCHOOL BEFORE AND AFTER SCHOOL

BEFORE SCHOOL CHILD CARE PROVIDER NAME:_______________________________________________________________________

PHONE:__________________________________ _____ CELL PHONE :_____________________________

ADDRESS:___________________________________________________________________________________________________________

AFTER SCHOOL CHILD CARE PROVIDER NAME:_________________________________________________________________________

PHONE:__________________________________ _____ CELL PHONE :_____________________________

ADDRESS:____________________________________________________________________________________________________________

Additional Child Care Arrangements: Please provide additional information to school in writing.

SCH

OO

L H

ISTO

RY

School previously attended (most recent)

Entry Date Withdrawal Date Previous School Address (Street, City, State and Zip)

Has student ever attended a school in the Anacortes School District?

Yes No

If yes, name of school attended:

School Year:

PR

ESC

HO

OL/

EA

RLY

CH

ILD

C

AR

E

Did student attend preschool/early childhood care center? Yes No

If yes, name of preschool/early childhood care center:

STU

DEN

T H

ISTO

RY

Has your child ever received services in any of the following programs? Check all applicable programs

Special Education 504 Accommodations Highly Capable ELL Title 1 Services LAP Services Speech

Migrant Services Other

Name of school where services were received ___________________________________________________

Does your child have any past, current, or pending disciplinary actions or any history of violent behavior? Yes No Date ________

Is your child presently on suspension from another school? Yes No If yes, reason _________________________________________

Is your child a military dependent? Yes No Is there a joint-custody or parenting plan in effect? Yes No (If yes, a certified copy of the most recent plan must be on file with the school for enforcement.)

Is there a restraining order against anyone pertaining to your student? Yes No (If yes, most recent certified legal papers must be on file with the school for enforcement.) Restraining order is against Mother Father Other _______________________________________________________

Special instructions regarding religious beliefs (please provide information to the school in writing):_______________________________________________________________________________________________________________


ET

HN

ICIT

Y A

ND

RA

CE

Ethnicity and Race School districts in Washington State are required to report student data by ethnicity and race categories to the state’s Office of Superintendent of Public Instruction. Ethnicity and race categories used in our district are the same as used in all Washington school districts. They are set by the federal government, the Washington State Legislature, and the state Superintendent of Public Instruction. Please complete the following: 1. Is your child of Hispanic or Latino origin?

No, my child is not Hispanic or Latino Yes, my Child is Hispanic or Latino - (Check all that apply): Cuban Puerto Rican South American Dominican Mexican/Mexican American/Chicano Latin American Spaniard Central American Other Hispanic/Latino

2. What race do you consider your child? (Check all that apply)

African American or Black White or Caucasian Asian Asian Indian Cambodian Chinese Filipino Hmong Indonesian Japanese Korean Laotian Malaysian Pakistani Singaporean Taiwanese Thai Vietnamese Other Asian

Native Hawaiian/Other Pacific Islander Native Hawaiian Fijian Guamanian or Chamorro Mariana Islander Melanesian Micronesian Samoan Tongan Other Pacific Islander

Native American Alaskan Native Chehalis Colville Cowlitz Hoh Jamestown S’Klallam Kalispel Lower Elwa Klallam Lummi Makah Muckleshoot Nisqually Nooksack Port Gamble S’Klallam Puyallup Quileute

Quinault Samish Sauk-Suiattle Shoalwater Bay Skokomish Snoqualmie Spokane Squaix Island Stillaguamish Suquamish Swinomish Tulalip Yakima Other Washington Indian

Tribe Other American Indian

Tribe/Alaska Native

PA

REN

T SI

GN

ATU

RE

“I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Anacortes Public Schools. I agree to notify the Anacortes School District in writing within five (5) school days following any change of my/our residency.”

X Legal Parent/Guardian SIGNATURE _________________________________________________________Date:_____________________

DIS

TRIC

T U

SE O

NLY

DISTRICT USE ONLY Birth Certificate Immunizations District Staff SIGNATURE ______________________________________________________________Date:__________________________

English

May 2014

Office of Superintendent of Public Instruction (OSPI)

Home Language Survey

Student Name:

Date:

Birth Date: Gender: Grade:

Form Completed by:

Parent/Guardian Name Relationship to Student

Parent/Guardian Signature

If available, in what language would you prefer to receive communication from the school?

Did your child receive English language development support through the Transitional

Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__

1. In what country was your child born?

____________________

2. What language did your child first learn to speak?*

__________________

3. What language does YOUR CHILD use the most at home?* ____________________

4. What language(s) do parent/guardians use the most when you speak

to your child?

_____________________

_____________________

5. Has your child ever received formal education* outside of the United

States? (Kindergarten – 12th grade)

_____Yes _____No

”Formal education” does not include refugee camps or other unaccredited

programs for children.

If yes, in what language(s)

was instruction given?

_____________________

For how many months? ____

6. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________

Month Day Year

7. Do grandparent(s) or parent(s) have a Native American tribal

affiliation?

_____Yes _____No

*WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by

parents, guardians, or others) for communication in the student's place of residence.

Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing

English

May 2014

The Purpose of the Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools. The following

information should help answer some of the questions you may have about this form.

What is the purpose of the Home Language Survey?

The primary purpose of the Home Language Survey is to help identify students who may qualify for

support to help them develop the English language skills necessary for success in the classroom and who

may qualify for other services. It is important that this information be correctly recorded since it can

affect the eligibility of students for services they need to be successful in school. Testing may be

necessary to determine whether or not additional language and academic supports are needed. No

student will be placed in an English language development program based solely on responses to this

form.

Why do you ask about the student’s first language and language(s) used in the home?

The two questions about the student’s language help us to determine:

if your student may be eligible for assistance with learning English, and

whether staff at the school should be aware of other languages being used by the student at home.

The language your child first learned may be different from the language your child uses for

communication at home now. The responses to both of these questions will assist the school in providing

instruction appropriate to the individual student’s needs as well as help with communication needs that

may arise. Students who first learned a language other than English may qualify for additional supports.

Even students who speak English well may still need support in developing the language skills needed to

be successful in school.

Why do you ask where the student was born?

This information helps the school district and the state determine if the student meets the definition of

immigrant for the purposes of federal funding. This applies even when the student’s parents are both US

citizens, but the student was born outside of the United States. This form is not used to identify students

who may be undocumented.

Why do you ask about my student’s previous education?

Information about a student’s education will help ensure that the student’s education both within and

outside of the United States is considered in any recommendations made for participation in programs and

district services. The student’s educational background is also important information to help determine if

the student is making adequate progress toward state standards based on their prior educational

background.

Thank you for providing the information needed on the Home Language Survey. Contact your school

district if you have further questions about this form or about services available at your child’s school.

Spanish (Español)

May 2014

Oficina de la Superintendente Estatal de Enseñanza Pública (OSPI) Encuesta sobre el idioma que se habla en el hogar

Nombre del alumno:

Fecha:

Fecha de nacimiento: Sexo: Grado:

Este formulario fue completado por:

Nombre del padre/madre/tutor: Relación con el alumno:

Firma del padre/madre/tutor:

Si está disponible, ¿en qué idioma desea recibir información de la escuela?

¿Su hijo recibió apoyo para el aprendizaje del idioma inglés a través del Programa Estatal de

Educación Bilingüe de Transición en la última escuela a la que asistió? Sí__ No__ No sé__

1. ¿En qué país nació su hijo?

_____________________

2. ¿Qué idioma aprendió su hijo primero?*

___________________

3. ¿Qué idioma usa más SU HIJO en casa?* _____________________

4. ¿Qué idioma(s) usan más los padres/tutores cuando hablan con su

hijo?

_____________________

_____________________

5. ¿Ha recibido su hijo educación formal* fuera de los Estados Unidos? (Kinder a 12.º grado)

_____Sí _____No

"Educación formal" no incluye programas en campos de refugiados ni otros

programas no acreditados para niños.

En caso afirmativo, ¿en qué

idioma se le dio la

instrucción? _____________

¿Por cuántos meses? ______

6. ¿Cuándo asistió su hijo a la escuela en los Estados Unidos por

primera vez? (Kínder a 12.º grado)

_______________________

Día Mes Año

*WAC 392-160-005: "Idioma principal" significa el idioma que el alumno usa con más frecuencia (no

necesariamente el idioma que usan los padres, tutores u otros) para comunicarse en el lugar donde vive el alumno.

Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing.

Spanish (Español)

May 2014

Propósito de la Encuesta sobre el idioma que se habla en el hogar

La Encuesta sobre el idioma que se habla en el hogar se proporciona a todos los estudiantes que se

inscriben en escuelas de Washington. La siguiente información debería contribuir a responder a algunas de

las preguntas que podría tener sobre este formulario.

¿Cuál es el propósito de la Encuesta sobre el idioma que se habla en el hogar?

El propósito principal de la Encuesta sobre el idioma que se habla en el hogar es contribuir a identificar a

los estudiantes que podrían calificar para obtener ayuda con el fin de desarrollar las habilidades del idioma

inglés necesarias para tener éxito en la clase y de recibir otros servicios. Es importante que esta

información se registre correctamente, ya que puede afectar la elegibilidad de los estudiantes para recibir

los servicios que necesitan para tener éxito en la escuela. Es posible que sea necesario evaluarlos a fin de

determinar si precisan servicios de apoyo adicionales en relación con el idioma y académicos. Ningún

estudiante será asignado al programa de desarrollo del idioma inglés solo en función de las respuestas a

este formulario.

¿Por qué preguntan acerca de la primera lengua del estudiante y del (de los) idioma(s) que se

habla(n) en el hogar?

Las dos preguntas sobre el idioma del estudiante nos ayudan a determinar:

si el estudiante puede ser elegible para obtener ayuda con el aprendizaje del inglés, y

si el personal de la escuela debería conocer otros idiomas utilizados por el estudiante en su hogar.

El idioma que su hijo aprendió primero puede ser distinto del idioma que su hijo utiliza para comunicarse

en el hogar ahora. Las respuestas a estas dos preguntas ayudarán a la escuela a proporcionarle

instrucción adecuada según las necesidades individuales del estudiante, y también contribuirán con las

necesidades de comunicación que puedan surgir. Los estudiantes que primero aprendieron un idioma que

no sea inglés pueden calificar para obtener servicios de apoyo adicionales. Incluso los estudiantes que

hablan bien inglés podrían precisar apoyo para desarrollar habilidades del idioma necesarias para tener

éxito en la escuela.

¿Por qué preguntan dónde nació el estudiante?

Esta información ayuda al distrito escolar y al estado a determinar si al estudiante le corresponde la

definición de inmigrante a los fines del financiamiento federal. Esto se aplica incluso cuando ambos padres

del estudiante son ciudadanos estadounidenses, pero el estudiante nació fuera de los Estados Unidos. Este

formulario no se utiliza para identificar a estudiantes que quizás sean indocumentados.

¿Por qué preguntan sobre la educación anterior del estudiante?

La información sobre la educación de un estudiante contribuirá a garantizar que la educación del

estudiante tanto dentro como fuera de los Estados Unidos sea tenida en cuenta en las recomendaciones

para la participación en programas y servicios del distrito. Los antecedentes educativos del estudiante

también constituyen información importante para ayudar a determinar si el estudiante está avanzando lo

suficiente hacia los estándares estatales en función de sus antecedentes educativos anteriores.

Gracias por proporcionar la información necesaria en la Encuesta sobre el idioma que se habla en el hogar.

Comuníquese con su distrito escolar si tiene otras preguntas sobre este formulario o sobre los servicios

disponibles en la escuela de su hijo.

C:\Users\vwellington\Downloads\Kindergarten Roundup Developmental Background.docC:\Users\vwellington\Downloads\Kindergarten Roundup Developmental Background.doc

H:\Kindergarten Roundup 2007\Developmental Background

ANACORTES SCHOOL DISTRICT 2200 M Avenue Anacortes WA 98221 Phone: (360) 293-1200 Fax: (360) 293-1222

http://www.asd103.org

A Lighthouse for Public Education in Our Community:

Ensuring No Child Is Lost Creating Lifelong Learners Inspiring High Achievement Nurturing Responsible Citizenship

H:\Roundup Immunizations Required letterhead.doc

Dear Parent/Guardian As a condition for school attendance, Washington State law requires that all students be immunized against certain preventable diseases or provide school personnel with written notification of exemption, with a signature from your child’s health care provider. A copy of the Washington State Department of Health document showing Vaccines Required for School Attendance, Grades K-12 for the 2016-2017 school year is included in this registration packet for your information. An official Washington State Certificate of Immunization Status (CIS) form has been included with this Kindergarten Round Up package. Completely fill in the month, day and year, for each dose of vaccine received. Parent/Guardian signature is required on this form. Documentation of disease immunity by blood test (titer) must be recorded on a CIS form and signed by a licensed health care provider. Verification of varicella disease by provider must also be documented on this form. A parent cannot document or verify either of these disease verifications. If you are claiming a personal, medical or religious exemption, please sign and complete part one of a Certificate of Exemption form. Your child’s provider will need to sign and complete part two of this

form and clearly identify which vaccines you are requesting exemption from. The general objective of this immunization law is to help prevent disease and protect both your child and the community.

Again, please understand that compliance with the law is required for school attendance.

Sincerely Anacortes School District Nurses

Statement of Exemption to Immunization Law

Your child may be exempted (excused) from immunization for medical, personal or religious reasons. Your child’s health care provider must sign a Certificate of Exemption form. However, if there is an outbreak of a vaccine-preventable disease that your child has not been immunized against, your child may be excluded from school, preschool or childcare until the outbreak is over.

Parents - Are Your Kids Ready for School?

Required Immunizations for School Year 2016-2017

Hepatitis B DTaP/Td/Tdap* (Diphtheria, Tetanus,

Pertussis) Polio*

MMR (Measles, Mumps,

Rubella)

Varicella (Chickenpox)

Kindergarten – 5th Grade

3 doses 5 doses 4 doses 2 doses

2 doses OR

Healthcare provider verified child had

disease

6th – 12th Grade 3 doses

5 doses DTaP

AND

1 dose Tdap

4 doses 2 doses

2 doses OR

Healthcare provider verified child had

disease

*Vaccine doses required may be fewer than listed.

Students must meet minimum intervals and ages to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements.

Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/

If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). DOH 348-295 December 2015

Parent/Guardian Resource

Instructions: To see which vaccines are required for school, find your child’s grade and look only at that row going across to find the vaccines and number of doses required.

http://www.immunize.org/cdc/schedules/

Certificate of Immunization Status (CIS) DOH 348-013 January 2015

Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System. Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex:

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record.

Parent/Guardian Signature Required Date

Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only

■ Recommended, but not required

I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Date

Vaccine Dose Date

Month Day Year Hepatitis B (Hep B) 1 2 3 or Hep B - 2 dose alternate schedule for teens 1 2

■ Rotavirus (RV1, RV5) 1 2 3 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 1 2 3 4 5 Tetanus, Diphtheria, Pertussis (Tdap) 1

■ Tetanus, Diphtheria (Td) 1 2 Haemophilus influenzae type b (Hib) 1 2 3 4

■ Influenza (flu, most recent)

Vaccine Dose Date

Month Day Year Pneumococcal (PCV, PPSV) 1 2 3 4 5

Polio (IPV, OPV) 1 2 3 4

Measles, Mumps, Rubella (MMR) 1 2

Varicella (chickenpox) 1 2

■ Hepatitis A (Hep A) 1 2

■ Human Papillomavirus (HPV) – does not print from the IIS; write dates in by hand 1

2

3

■ Meningococcal (MCV, MPSV) 1 2

If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option 1, 2, OR 3 below (see # 5 on back) 1) Chickenpox disease verified by printout from the Immunization Information System (IIS) Must be marked by printout (not by hand) to be valid. 2) Chickenpox disease verified by healthcare provider (HCP) If you choose this box, mark 2A OR 2B below.

2A) Signed note from HCP attached OR 2B) HCP sign here and print name below:

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name: 3) Chickenpox disease verified by school staff from the Immunization Information System

If the child can show immunity by blood test (titer) and hasn’t had the vaccine, ask your HCP

to fill in this box. Documentation of Disease Immunity

I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached.

Diphtheria Hepatitis A Hepatitis B Hib Measles

Mumps Polio Rubella Tetanus Varicella

Other: _______________

_______________

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name:

Office Use Only: Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

EXAMPLE

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

#1 To print with information filled in: First, ask if your healthcare provider’s office puts vaccination history into the WA Immunization Information System (Washington’s statewide database). If they do, ask them to print the CIS from the IIS and your child’s information will fill in automatically. Be sure to review all the information, sign and date the CIS, and return it to school or child care. If your provider’s office does not use the IIS, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):

#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the

“Vaccine” column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here

#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#5 If your child had chickenpox (varicella) disease and not the vaccine, use only one of these three options to record this on the CIS: 1) If your child’s CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box 1 is automatically

marked. To be valid, this box must be marked by the IIS printout (not by hand). 2) If your healthcare provider can verify that your child had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your provider, or

2B if your provider signs and dates in the space provided. Be sure your provider’s full name is also printed. 3) If school staff access the IIS and see verification that your child had chickenpox, they will mark box 3.

#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your healthcare provider fill in this box. Ask your provider to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.

#7 Be sure to sign and date the CIS, and return to the school or child care.

Vaccine Trade Names in alphabetical order (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf)

Trade Name Vaccine Trade

Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB Hib FluLaval Flu Ipol IPV PedvaxHIB Hib Twinrix (Twnrx) Hep A + Hep B

Adacel Tdap FluMist Flu Infanrix DTaP Pentacel (Pntcl) DTaP + Hib + IPV Vaqta Hep A

Afluria Flu Fluvirin Flu Kinrix (Knrx) DTaP + IPV Pneumovax PPSV or PPV23 Varivax Varicella

Boostrix Tdap Fluzone Flu Menactra MCV or MCV4 Prevnar PCV or PCV7 or PCV13

Cervarix HPV2 Gardasil HPV4 MenHibrix (Mnhbrx)

Meningococcal C/Y- HIB-PRP

ProQuad (PrQd) MMR + Varicella

Daptacel DTaP Havrix Hep A Menomune MPSV or MPSV4 Recombivax HB Hep B

Engerix-B Hep B Hiberix Hib Menveo Meningococcal Rotarix Rotavirus (RV1)

Fluarix Flu HibTITER Hib Pediarix (Pdrx) DTaP + Hep B + IPV RotaTeq Rotavirus (RV5)

Vaccine Abbreviations in alphabetical order (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf) Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A (HAV) Hep B (HBV)

Hepatitis A Hepatitis B

MPSV or MPSV4 Meningococcal Polysaccharide Vaccine

Rota (RV1 or RV5)

Rotavirus

DTaP Diphtheria, Tetanus,

acellular Pertussis Hib

Haemophilus influenzae

type b MMR / MMRV

Measles, Mumps, Rubella /

with Varicella Td Tetanus, Diphtheria

DTP Diphtheria, Tetanus, Pertussis

HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Tetanus, Diphtheria, acellular Pertussis

Flu

(IIV or LAIV) Influenza IPV

Inactivated Poliovirus

Vaccine

PCV or PCV7 or

PCV13

Pneumococcal Conjugate

Vaccine TIG Tetanus immune globulin

HBIG Hepatitis B Immune Globulin

MCV or MCV4 Meningococcal Conjugate Vaccine

PPSV or PPV23 Pneumococcal Polysaccharide Vaccine

VAR or VZV Varicella

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 January 2015

Vaccine Dose Date Month Day Year

Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 1 01 12 2011 DTaP 2 03 20 2011 DTaP 3 06 01 2011

H:\Roundup Student Health Information Form (1).doc

ANACORTES SCHOOL DISTRICT

STUDENT HEALTH INFORMATION Student Name _______________________________ Birthdate __________ Grade_____ Please check any health concern you or your doctor have noticed: Are any of these conditions considered “Life Threatening”? Yes ____ No ____ If so, please notify the school nurse for further instruction to protect your child at school. MEDICAL HISTORY: PLEASE CHECK APPROPRIATE BOX. IF YES, COMMENT AND GIVE DATES.

NO YES

ADD/ADHD (hyperactivity) If yes, does student take medication?_____ If yes, what type?________________________________________________________________

ASTHMA

Allergies (bee sting / food / other)

DIABETES

SEIZURES (Epilepsy)

Loss of consciousness / serious blows to the head

Headaches

Meningitis / Encephalitis

Nose bleeding

Sinus trouble

Recurrent ear infections (more than 2 per year)

Ear tube placement

Hearing aids / problems

Stomach aches / indigestion

Diarrhea / vomiting

Heart trouble, blood disease

Kidney disease

Chest / lung problems

Bone / Joint problems

Hospitalizations / operations

Depression / emotional health issues

Receiving ongoing medical treatment

Daily medication: Type__________________________ Dosage___________ When_________ (including inhalers)

Does medication need to be administered at school?

Adult supervision required during school hours:________________________________________ Explain:________________________________________________________________________

Other medical information that would be helpful for the school to know:________________________________ ________________________________________________________________________________________ Family Physician: _____________________________ _________________________ _________________ Name Address Phone Family Dentist: _____________________________ _________________________ _________________ _________________________________________________________ ____________________________ Signature of Parent/Guardian Date SHI Rev. 04/07

H:\Roundup Birth Cert Reminder.doc

Anacortes School District

If you have not presented an official birth certificate (not a copy) at Kindergarten Round-Up, the certificate must be brought to the

Whitney School office by May 31st.

Classroom assignments will be made only for students with complete registration records.

Anacortes School District

If you have not presented an official birth certificate (not a copy) at Kindergarten Round-Up, the certificate must be brought to the

Whitney School office by May 31st.

Classroom assignments will be made only for students with complete registration records.

kindergarten round-up - home - anacortes school district · h:\roundup parent mtg notice.doc...

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