MEDWAY PUBLIC SCHOOLS

HIGH SCHOOL PACKET

In this packet you will find:

● Cover letter with Registration Checklist ● Registration Form ● Emergency Contact and Health History Form ● Home Language Survey ● Records Release Form ● School Calendar ● School Hours and Addresses ● Free and Reduced Lunch Application ● Communication from School Nurse

To be returned to the school:

● Digital Learning and Technology Acceptable Use Policy Agreement ● Nutrikids Form ● Vaccination Exemption Form

https://mhs.medwayschools.org/ Twitter: @MedwayHighInfo

MEDWAY PUBLIC SCHOOLS NEW STUDENT REGISTRATION CHECKLIST

Welcome to Medway Public Schools! Please complete New Student Registration Packet which includes:

● Registration Form ● Emergency Information Form ● Health History Form ● Home Language Survey

In addition to the forms above, the following documents are required:

● Proof of residency: ○ Utility bill ○ Signed Purchase and Sale (occupancy must take place within sixty (60) days) ○ Current Tax Bill

● Birth Certificate ● Copy of most recent physical exam - must be within the last year ● An immunization record from the physician. ● Previous school records release form (last report card if available) ● A copy of current 504/IEP plan (if applicable) ● Legal court documentation of guardianship (if applicable)- If divorced or separated, you

will need to show legal or official court documentation indicating that you are the custodial parent and have physical custody of your child.

● Free and Reduced Price School Meals Application (if applicable) Please note that all of the above must be presented to complete the registration process:

NO child will be able to register without all documentation.

All completed documents should be delivered to: Superintendent’s Office

45 Holliston Street Medway, MA 02058

Ph: (508)533-3222 x 3156

Medway Public Schools Medway, MA 

NEW STUDENT REGISTRATION Please print: 

Date: _______________________ School Year: _________________ Grade Entering: _________________ 

 

PART A 

Student’s Full Name: _______________________________________________________________________________ 

(Last name) (First name) (Middle name as it appears 

on Birth Certificate) 

Home Address: ___________________________________________________________________________________ 

(Street) (City/town) (Zip) 

Home Phone: ___________________________________ Sex:  Male Female 

Date of Birth: ______________________________ Birth City/State: _______________________________________ 

Previous School Information  

Last School Attended: _______________________________________ Grade: _______________________ 

City/Town: ________________________________________________ State: ________________________ 

Please check any additional services the student was receiving: 

Student has an Individual Education Plan 

Student has a 504 Plan 

Student was receiving LEP Services  

Student was receiving Title I Services  

 

Part B 

Parent/Guardian #1: _______________________________________________________________________________ 

 

Address if different: ________________________________________________________________________________ 

(Street) (City/town) (Zip) 

Please Provide all of the below information and check box to indicate primary contact number during school 

hours  

Home Phone _______________________ Work Phone ____________________  

Cell Phone ________________________ Email _________________________  

Parent/Guardian #2: _______________________________________________________________________________ 

Address if different: ________________________________________________________________________________ 

(Street) (City/town) (Zip) 

Please Provide all of the below information and check box to indicate primary contact number during school 

hours  

Home Phone _______________________ Work Phone ____________________ 

Cell Phone ________________________ Email _________________________  

 

Part C 

With whom does student reside? Both Parents Mother Father Guardian Other  

Who has legal custody of this student? Both Parents Mother Father Guardian Other 

Is there any other legal information that the school should be aware of? Yes No 

If yes, documentation is required. 

Is anyone restricted from contacting this child?   Yes  No 

If yes, documentation is required. 

Has this student ever attended Medway Public Schools?  Yes No 

Other Massachusetts Schools?  Yes No (OVER) 

Is student a state ward/foster child?  Yes No 

Is student a School Choice Student approved by the Superintendent?  Yes No   

Part D – In case of accident, illness, emergency or early dismissal and parent/guardian cannot be reached: 

 

Name: __________________________________ Relationship: ___________________________________ 

 

Phone: _________________________________ 

 

Name: __________________________________ Relationship: ___________________________________ 

 

Phone: _________________________________ 

If applicable: 

If both parents work, who is responsible for student after school? 

Name: __________________________________ Relationship: ___________________________________ 

 

Address: _________________________________ Phone: _________________________________________ 

 

Please list siblings who attend Medway Public Schools: 

Name: ___________________________________ Grade: _________________ 

Name: ___________________________________ Grade: _________________ 

 

Part E – Military Family Status – Required information 

Is the student a child of: 

● An active duty member of the uniformed services, National Guard,  

Or Reserve on active duty?    Yes No  

● Members or veterans who are medically discharged or retired within 

the last year? Yes No  

Member(s) who have died on active duty?  Yes No  

Part F – REQUIRED Information: 

The district is required to provide this information to the state and federal agencies for statistical purpose to 

demonstrate compliance with the 1964 Civil Rights Act. 

 

Please select from each of the categories: 

Ethnicity (select only one) Race (select one or more) 

Hispanic or Latino American Indian or Alaskan Native 

Not Hispanic or Latino Asian 

Black or African American 

Native Hawaiian or Other Pacific Islander 

White 

 

I hereby certify the information to be true and correct. 

__________________________________ _______________________________________ 

Date Parent/Guardian Signature 

 

_______________________________________ 

Parent/Guardian PRINT NAME  

 

For office use only LASID # _________________________ SASID # _____________________________________

New student Registration FORMS Rev 12/15/17 

Medway Public Schools

EMERGENCY CONTACT AND HEALTH INFORMATION FORM Please Print

Grade: __________Homeroom Teacher _____________________________ Bus #_____________________________________

Student Name: _____________________________________________Date of Birth: ___________________ Address: __________________________________________________ Sex: ___________________________ Student lives with: _________________________________________________________________________ Guardian/Parent 1: __________________________________________ Relationship_____________________ Address: ______________________________________________________________________ Email Address: ________________________________________________________________ Check primary # ☐ Home Phone: _________________________________________________

☐ Work Phone: _________________________________________________ ☐ Cell Phone: __________________________________________________

Guardian/Parent 2: ___________________________________________Relationship_____________________ Address:_______________________________________________________________________ Email Address: _________________________________________________________________ Check primary # ☐ Home Phone: _______________________________________________

☐ Work Phone: ________________________________________________ ☐ Cell Phone: _________________________________________________

Siblings:___________________________________________________________________________________________________

Name/DOB/Grade Name/DOB/Grade Name/DOB/Grade Name/DOB/Grade List two neighbors or nearby relatives who are available during the day to pick up your child and will assume temporary care if you cannot be reached.

Name: ______________________________Relationship: _____________________Cell:_______________

Name ______________________________Relationship: _____________________Cell:_______________ A physical exam is required of all students newly entering Medway Public Schools as well as upon entering Kindergarten, Grades 4, 7, and 10. Please ask your healthcare provider to supply you with a signed copy of the physical exam form with immunizations. I give permission to the school nurse to share my child’s relevant health information with appropriate school personnel. I give permission to exchange information with my child’s primary care physician for the purpose of referral, diagnosis, and treatment. YES______ NO______ The following over the counter medications are ordered by the school physician for student use on an as needed basis:Tylenol, Ibuprofen, Tums, Caladryl, Hydrocortisone Cream 1%, antibiotic ointment (bacitracin), cough drops with menthol, petroleum jelly, contact lens solution, & aloe vera burn gel. My child may have any of the medications above on a limited basis if needed. Yes_____ NO_____ If NO, list the medications your child cannot receive____________________________________________________________ _____________________________________________________________________________________________________ Please Note: If your child will require Tylenol or Ibuprofen on a more routine basis, an order from your child’s doctor must be obtained. In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow his/her instructions. If it is impossible to contact this physician, the school may make whatever arrangements seem necessary. Physician: _________________________________________ Office#: ______________________________ Dentist: ___________________________________________ Office#: _____________________________ Health Insurance: ________________________________________________________________________

Company ID # Signature of parent or guardian: _______________________________________ Date: _____________

**Please inform your school nurse of any changes in contact &/or health information during the school year**

Rev. 7/26/17, 3/18cb Page 1(2)

HEALTH HISTORY: Student Name__________________________ Grade___________

Please indicate if your child has experienced any of the following health concerns. Note the year it was last an issue. I wish to speak to the Nurse personally Yes_____ No______ Please check if your child has an existing plan: IEP___ 504____ IHP____ YES NO EXPLAIN YEAR

1. Autoimmune disorders

2. Allergies- please circle - food, insects, latex, medication, environmental

3. Asthma/breathing difficulties

4. Cancer

5. Cardiac

6. Diabetes

8. Dietary restrictions

5. Eczema or other skin issues

6. Frequent cold, sore throats, earaches

7. GI, stomach, bowel or urinary issues

10. Headaches or Migraines (frequent and/or severe)

11. Hearing impairments

12. Hospitalizations

13. Menstrual / Gyn

14. Mental Health Anxiety Depression PTSD, OCD, Bipolar, Other

17. Neurological

ADD/ADHD

Concussion

Seizures

18. Orthopedic concerns musculoskeletal issues, scoliosis

19.Special equipment needed at school

20. Speech

21. Vision Impairments, color blindness, glasses, contacts

List all Current Medications/Supplements. Please place an * next to the medications that will be needed at school and/or on a field trip.

Medication Name Dosage Time(s) given Reason for Medication

1

2

3

4

Parent/Guardian Signature_____________________________________________________________Date_________________________________

Home Language Survey 

Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s

home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a

language other than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important

requirement by answering the following questions. Thank you for your assistance.

Student Information 

 

    F M 

First Name Middle Name Last Name Gender 

/ / / /  

Country of Birth   Date of Birth (mm/dd/yyyy)   Date first enrolled in ANY U.S. school (mm/dd/yyyy) 

School Information 

 

/ /20 ______  

Start Date in New School (mm/dd/yyyy) Name of Former School and Town Current Grade  

Questions for Parents/Guardians   

What is the primary language used in the home, regardless of the 

language spoken by the student? 

   

Which language(s) are spoken with your child? 

(include relatives -grandparents, uncles, aunts,etc. - and caregivers)

seldom / sometimes / often / always

seldom / sometimes / often / always

What language did your child first understand and speak? 

 

___________________________________ 

Which language do you use most with your child? 

 

________________________________

How many years has the student been in U.S. Schools? (not including 

pre-kindergarten)

Which languages does your child use? (circle one) 

seldom / sometimes / often / always

seldom / sometimes / often / always

Will you require written information from school in your native 

language? Y N 

 

If yes, what language? ________________________________ 

Will you require an interpreter/translator at Parent-Teacher meetings? 

Y N 

 

If yes, what language? ________________________________ 

 

Parent/Guardian Signature: 

X 

/ /20  

Today’s Date: (mm/dd/yyyy) 

MEDWAY PUBLIC SCHOOLS

RELEASE FOR STUDENT RECORDS

Student Name:

Date of Birth:

From School Name:

School Address:

School Phone: Fax:

Medway Public Schools requests the following information regarding the above student in order to provide proper placement and programs.

● Mass Transfer Card - including SASID (if applicable) ● Academic Record - including Attendance ● Grades on Withdrawal - required if transfer does not occur at the end of a term or school year ● Psychological Records ● Standardized Tests ● Discipline Record ● Chapter 766 Reports - Individual Education Plan and most recent testing (if applicable) ● Health Records ● EL documentation including ACCESS for ELLs, WIDA Screener, WIDA MODEL, Reclassification

form, progress reports, FELs monitoring ● Any other pertinent information concerning the child

**I hereby grant release of this information regarding the above student to Medway Public

Schools.** __________________________________________________________________________________

Signature of Parent/Guardian

Please send records to appropriate school: _______ McGovern School, 9 Lovering Street, Medway, MA 02053

Phone (508)533-3243 Fax (508) 533- 3263 _______ Burke Memorial School, 16 Cassidy Lane, Medway, MA 02053

Phone (508) 533-3266 Fax (508) 533-3274 _______ Medway Middle School, 45 Holliston Street, Medway, MA 02053

Phone (508) 533-3230 Fax (508) 533-3257 _______ Medway High School, 88 Summer Street, Medway, MA 02053

Phone (508) 533-3227 Fax (508) 533-3246

August (0 days) [0 to date]

M T W T F

26 27 PD PD X

August 28 and 29 = Professional Development Days – NO SCHOOL

---------------------------------------------------------------------------------------------------------

September (19 days) [19 to date]

M T W T F

LD 3 4 5 6

9 10 11 12 13

16 17 18 19 20

23 24 25 26 27

RH

September 2 = Labor Day – NO SCHOOL School Opens September 3

September 30 Rosh Hashanah – NO SCHOOL ---------------------------------------------------------------------------------------------------------

October (21 days) [40 to date]

M T W T F

1 2 3 4

7 8 YK 10 11

CD 15 16 17 18

21 22 23 24 25

28 29 30 31

October 9 = Yom Kippur – NO SCHOOL October 14 = Columbus Day – NO SCHOOL

---------------------------------------------------------------------------------------------------------

November (18 days) [58 to date]

M T W T F

1

4 5 6 7 8

VD 12 13 14 15

18 19 20 21 22

25 26 HD X X

November 11 = Veterans Day (Observed) – NO SCHOOL November 27 = Half Day – Gr. K-12

November 28-29 = Thanksgiving Recess – NO SCHOOL ---------------------------------------------------------------------------------------------------------

December (15 days) [73 to date]

M T W T F

2 3 4 EER 6

9 EER 11 12 13

16 17 18 19 20

X X X X X

X X

December 5 = Elementary Early Release – Grades K-4 ONLY December 10 = Elementary Early Release – Grades K-4 ONLY December 23 - January 1 = Holiday Vacation – NO SCHOOL

---------------------------------------------------------------------------------------------------------

January (20 days) [93 to date]

M T W T F

X 2 3

6 7 8 9 10

13 14 15 16 17

MLK PD 22 23 24

27 28 29 30 31

January 1 = New Year’s Day – NO SCHOOL January 2 – SCHOOL REOPENS

January 20 = Martin Luther King, Jr. Day – NO SCHOOL January 21 = Professional Development Day – NO SCHOOL

February (15 days) [108 to date]

M T W T F

3 4 5 6 7

10 11 12 13 14

X X X X X

24 25 26 27 28

February 17-21 = Winter Vacation – NO SCHOOL ---------------------------------------------------------------------------------------------------------

March (22 days) [130 to date]

M T W T F

2 3 4 5 6

9 10 11 12 ER

16 17 18 19 20

23 24 25 26 27

30 31

March 13 = Early Release Day Grades K-12

---------------------------------------------------------------------------------------------------------

April (16 days) [146 to date]

M T W T F

1 2 3

6 7 8 9 GF

13 14 15 16 17

X X X X X

27 28 29 30

April 10 =Good Friday – NO SCHOOL April 20-24 = Spring Vacation – NO SCHOOL

---------------------------------------------------------------------------------------------------------

May (20 days) [166 to date]

M T W T F

1

4 5 6 7 8

11 12 13 14 ER

18 19 20 21 22

MD 26 27 28 29

May 15 = Early Release Day – Grades K-12 May 25 = Memorial Day – NO SCHOOL

---------------------------------------------------------------------------------------------------------

June (14 days) [180 total]

M T W T F

1 2 3 4 5

8 9 10 11 12

15 16 17 180th 19

22 23 24 25 26

29 30

June 18 = 180th Day = Tentative Closing – Half Day Gr. K-12 June 19-25 = Inclement Weather Makeup Days

First Reading: November 15, 2018

Approved: December 6, 2018

2011

Medway Public Schools – 2019-2020 School Year

School Hours and Addresses

McGovern Elementary School: 9 Lovering Street, Medway, MA 02053 Phone (508) 533-3243

Pre-School at McGovern Elementary School

8:50 a.m. to 11:10 a.m. or

12:10 p.m. to 2:30 p.m. Full Day 8:50 a.m. - 2:30 p.m.

Early Release at 11:10 a.m. (No P.M. session)

McGovern (Full day Kindergarten and 1st Grade) Student instructional day: 8:45 a.m. to 3:00 p.m.

Burke-Memorial Elementary School: Grades 2-4

16 Cassidy Lane, Medway, MA 02053 - Phone (508) 533-3266 Student instructional day: 8:15 a.m. to 2:30 p.m.

Medway Middle School: Grades 5-8

45 Holliston Street, Medway, MA 02053 - Phone (508) 533-3230 Student instructional day 7:25 a.m. to 1:58 p.m.

Medway High School: Grades 9-12

88 Summer Street, Medway, MA 02053 - Phone (508) 533-3227 Student instructional day 8:04 a.m. to 2:31 p.m.

Times for Early Release Days School Day: McGovern School: 8:45 a.m. to 12:00 noon Burke- Memorial School 8:15 a.m. to 11:30 a.m. Middle School 7:25 a.m. to 11:02 p.m. High School 8:04 a.m. to 11:34 a.m. MEDI:

GRADES K-4 * PHONE: 508-533-7395 * Burke Memorial Morning - 7:00 A.M -8:35/8:45 A.M.

Afternoon - 2:30/3:00 P.M- 6:00 P.M. GRADES 5-6 * PHONE: 508-321-4782 * Medway Middle

Morning - 7:00 A.M- 7:25 A.M. Afternoon - 1:58 P.M.- 6:00 P.M.

FREQUENTLY ASKED QUESTIONS ABOUT FREE AND

REDUCED PRICE SCHOOL MEALS

Dear Parent/Guardian:

Children need healthy meals to learn. Medway Public Schools offers healthy meals every school day. Lunch costs

$2.65 at the elementary schools and $2.90 at the middle and high schools. Your children may qualify for

free meals or for reduced price meals. Reduced price is $.40 for lunch. This packet includes an application for free

or reduced price meal benefits, and a set of detailed instructions. Below are some common questions and answers to

help you with the application process.

1. WHO CAN GET FREE OR REDUCED PRICE MEALS?

All children in households receiving benefits from MA SNAP, MA TANF, are eligible for free meals.

Foster children that are under the legal responsibility of a foster care agency or court are eligible for

free meals.

Children participating in their school’s Head Start program are eligible for free meals.

Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.

Children may receive free or reduced price meals if your household’s income is within the limits on

the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced price meals

if your household income falls at or below the limits on this chart.

2. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members

of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary

housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who

have chosen to leave their prior family or household? If you believe children in your household meet these

descriptions and haven’t been told your children will get free meals, please call or e-mail Kathleen Bernklow

at 508-533-3229 or email kbernklow@medwayschools.org

3. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School

Meals Application for all students in your household. We cannot approve an application that is not complete, so

be sure to fill out all required information. Return the completed application to: Medway Public Schools

Business Office, 45 Holliston Street, Medway, MA 02053

4. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN

ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you got carefully and follow the

instructions. If any children in your household were missing from your eligibility notification, contact Medway

Public Schools Business Office, 45 Holliston Street, Medway, MA 02053 or call 508-533-3222 x3157

immediately.

FEDERAL ELIGIBILITY INCOME CHART For School Year 2018-2019

Household size Yearly Monthly Weekly

1 22,459 1,872 432

2 30,451 2,538 586

3 38,443 3,204 740

4 46,435 3,870 893

5 54,427 4,536 1,047

6 62,419 5,202 1,201

7 70,411 5,868 1,355

8 78,403 6,534 1,508

Each additional person: 7,992 666 154

5. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your

child’s application is only good for that school year and for the first few days of this school year. You must send

in a new application unless the school told you that your child is eligible for the new school year. If you do not

send in a new application that is approved by the school or you have not been notified that your child is eligible

for free meals, your child will be charged the full price for meals.

6. I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be

eligible for free or reduced price meals. Please send in an application.

7. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the

household income you report.

8. IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For

example, children with a parent or guardian who becomes unemployed may become eligible for free and

reduced price meals if the household income drops below the income limit.

9. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school

officials. You also may ask for a hearing by calling or writing to Medway Public Schools Business Office,

45 Holliston Street, Medway, MA 02053 or call 508-533-3222 x3157.

10. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other

household members do not have to be U.S. citizens to apply for free or reduced price meals.

11. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if

you normally make $1000 each month, but you missed some work last month and only made $900, put down

that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work

overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

12. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive

some types of income we ask you to report on the application, or may not receive income at all. Whenever this

happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be

counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.

13. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses

must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, it must

also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do

not include your housing allowance as income. Any additional combat pay resulting from deployment is also

excluded from income.

14. WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household

members on a separate piece of paper, and attach it to your application. Contact the Medway Public Schools

Business Office, 45 Holliston Street, Medway, MA 02053 or call 508-533-3222 x3157 to receive a

second application.

15. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how

to apply for MA SNAP or other assistance benefits, contact your local assistance office or call MA hotline 866-

950-3663

If you have other questions or need help, call 508-533-3222 x 3157.

Sincerely,

Armand Pires, Ph.D.

Superintendent of Schools

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS

Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to

submit one application per household, even if your children attend more than one school in Medway. The application

must be filled out completely to certify your children for free or reduced price school meals. Please follow these

instructions in order! Each step of the instructions is the same as the steps on your application. If at any time you are not

sure what to do next, please contact the business office, 508-533-3222 x3157.

PLEASE USE A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.

STEP 2: DO ANY HOUSEHOLD MEMBERS CURRENTLY PARTICIPATE IN SNAP, TANF, OR FDPIR?

If anyone in your household (including you) currently participates in one or more of the assistance programs listed below, your children are eligible for free school meals:

The Supplemental Nutrition Assistance Program (SNAP) or [MA SNAP].

Temporary Assistance for Needy Families (TANF) or [MA TANF].

The Food Distribution Program on Indian Reservations (FDPIR).

A) If no one in your household participates in any of the above listed programs:

Leave STEP 2 blank and go to STEP 3.

B) If anyone in your household participates in any of the above listed programs:

Write a case number for SNAP, TANF, or FDPIR. You only need to provide one case number. If you participate in one of these programs and do not know your case number, contact: [MA SNAP].

Go to STEP 4.

STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

How do I report my income? Use the charts titled “Sources of Income for Adults” and “Sources of Income for Children,” printed on the back side of the

application form to determine if your household has income to report.

Report all amounts in GROSS INCOME ONLY. Report all income in whole dollars. Do not include cents. o Gross income is the total income received before taxes. o Many people think of income as the amount they “take home” and not the total, “gross” amount. Make sure that the income

you report on this application has NOT been reduced to pay for taxes, insurance premiums, or any other amounts taken from your pay.

Write a “0” in any fields where there is no income to report. Any income fields left empty or blank will also be counted as a zero. If you write ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report. If local officials suspect that your household income was reported incorrectly, your application will be investigated.

Mark how often each type of income is received using the check boxes to the right of each field.

STEP 1: LIST ALL HOUSEHOLD MEMBERS WHO ARE INFANTS, CHILDREN, AND STUDENTS UP TO AND INCLUDING GRADE 12 Tell us how many infants, children, and school students live in your household. They do NOT have to be related to you to be a part of your household.

Who should I list here? When filling out this section, please include ALL members in your household who are:

Children age 18 or under AND are supported with the household’s income;

In your care under a foster arrangement, or qualify as homeless, migrant, or runaway youth;

Students attending Medway Public Schools, regardless of age. A) List each child’s name. Print each child’s name. Use one line of the application for each child. When printing names, write one letter in each box. Stop if you run out of space. If there are more children present than lines on the application, attach a second piece of paper with all required information for the additional children.

B) Is the child a student at [Medway Public Schools]? Mark ‘Yes’ or ‘No’ under the column titled “Student” to tell us which children attend [Medway Public Schools]. If you marked ‘Yes,’ write the grade level of the student in the ‘Grade’ column to the right.

C) Do you have any foster children? If any children listed are foster children, mark the “Foster Child” box next to the child’s name. If you are ONLY applying for foster children, after finishing STEP 1, go to STEP 4. Foster children who live with you may count as members of your household and should be listed on your application. If you are applying for both foster and non-foster children, go to step 3.

D) Are any children homeless, migrant, or runaway? If you believe any child listed in this section meets this description, mark the “Homeless, Migrant, Runaway” box next to the child’s name and complete all steps of the application.

STEP 3: REPORT INCOME FOR ALL HOUSEHOLD MEMBERS

3.A. REPORT INCOME EARNED BY CHILDREN A) Report all income earned or received by children. Report the combined gross income for ALL children listed in STEP 1 in your household in the box marked “Child Income.” Only count foster children’s income if you are applying for them together with the rest of your household. What is Child Income? Child income is money received from outside your household that is paid DIRECTLY to your children. Many households do not have any child income.

3.B REPORT INCOME EARNED BY ADULTS Who should I list here?

When filling out this section, please include ALL adult members in your household who are living with you and share income and expenses, even if they are not related and even if they do not receive income of their own.

Do NOT include: o People who live with you but are not supported by your household’s income AND do not contribute income to your

household. o Infants, Children and students already listed in STEP 1.

B) List adult household members’ names. Print the name of each household member in the boxes marked “Names of Adult Household Members (First and Last).” Do not list any household members you listed in STEP 1. If a child listed in STEP 1 has income, follow the instructions in STEP 3, part A.

C) Report earnings from work. Report all income from work in the “Earnings from Work” field on the application. This is usually the money received from working at jobs. If you are a self-employed business or farm owner, you will report your net income.

What if I am self-employed? Report income from that work as a net amount. This is calculated by subtracting the total operating expenses of your business from its gross receipts or revenue.

D) Report income from public assistance/child support/alimony. Report all income that applies in the “Public Assistance/Child Support/Alimony” field on the application. Do not report the cash value of any public assistance benefits NOT listed on the chart. If income is received from child support or alimony, only report court-ordered payments. Informal but regular payments should be reported as “other” income in the next part.

E) Report income from pensions/retirement/all other income. Report all income that applies in the “Pensions/Retirement/ All Other Income” field on the application.

F) Report total household size. Enter the total number of household members in the field “Total Household Members (Children and Adults).” This number MUST be equal to the number of household members listed in STEP 1 and STEP 3. If there are any members of your household that you have not listed on the application, go back and add them. It is very important to list all household members, as the size of your household affects your eligibility for free and reduced price meals.

G) Provide the last four digits of your Social Security Number. An adult household member must enter the last four digits of their Social Security Number in the space provided. You are eligible to apply for benefits even if you do not have a Social Security Number. If no adult household members have a Social Security Number, leave this space blank and mark the box to the right labeled “Check if no SSN.”

STEP 4: CONTACT INFORMATION AND ADULT SIGNATURE All applications must be signed by an adult member of the household. By signing the application, that household member is promising that all information has been truthfully and completely reported. Before completing this section, please also make sure you have read the privacy and civil rights statements on the back of the application.

A) Provide your contact information. Write your current address in the fields provided if this information is available. If you have no permanent address, this does not make your children ineligible for free or reduced price school meals. Sharing a phone number, email address, or both is optional, but helps us reach you quickly if we need to contact you.

B) Print and sign your name and write today’s date. Print the name of the adult signing the application and that person signs in the box “Signature of adult.”

C) Mail Completed Form to: Medway Public Schools Business Office, 45 Holliston St, Medway, MA 02053

D) Share children’s racial and ethnic identities (optional). On the back of the application, we ask you to share information about your children’s race and ethnicity. This field is optional and does not affect your children’s eligibility for free or reduced price school meals.

X X X X X

2017-2018 Prototype Household Application for Free and Reduced Price School Meals Apply online:Complete one application per household. Please use a pen (not a pencil).

STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)

Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.”

Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School

Meals for more information.

Child’s First Name MI Child’s Last Name Grade Student?

Che

ck a

ll th

at a

pply

Yes No Foster Child

Homeless, Migrant, Runaway

STEP 2 Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

NO If YES > Write a case number here then go to STEP 4 (Do not complete STEP 3) Case Number:

Write only one case number in this space.

STEP 3 Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2) Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

Are you unsure what income to include here?

Flip the page and review the charts titled “Sources of Income” for more information.

The “Sources of Income for Children” chart will help you with the Child Income section.

The “Sources of Income for Adults” chart will help you with the All Adult Household Members section.

A. Child IncomeSometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here.

B. All Adult Household Members (including yourself)List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Child income

$

How often?

Weekly Bi-Weekly 2x Month Monthly

Name of Adult Household Members (First and Last) Earnings from Work How often? Public Assistance/

Child Support/Alimony

How often? Pensions/Retirement/ All Other Income

How often?

Weekly Bi-Weekly 2x Month Monthly Weekly Bi-Weekly 2x Month Monthly Weekly Bi-Weekly 2x Month Monthly

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Total Household Members (Children and Adults)

Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member

Check if no SSN

STEP 4 Contact information and adult signature. MAIL COMPLETED FORM TO YOUR SCHOOL AT:

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional)

Printed name of adult signing the form Signature of adult Today’s date

> Go to STEP 3

INSTRUCTIONS Sources of Income

Sources of Income for Children Sources of Child Income Example(s)

- Earnings from work - A child has a regular full or part-time jobwhere they earn a salary or wages

- Social Security- Disability Payments- Survivor’s Benefits

- A child is blind or disabled and receives SocialSecurity benefits- A parent is disabled, retired, or deceased, and their child receives Social Security benefits

-Income from person outside the household - A friend or extended family memberregularly gives a child spending money

-Income from any other source - A child receives regular income from aprivate pension fund, annuity, or trust

Sources of Income for Adults Earnings from Work

- Salary, wages, cashbonuses - Net income from self-employment (farm orbusiness)If you are in the U.S. Military:

- Basic pay and cash bonuses(doNOT include combat pay,FSSA or privatized housingallowances)- Allowances for off-base housing, food and clothing

Public Assistance / Alimony / Child Support

- Unemployment benefits- Worker’s compensation- Supplemental SecurityIncome (SSI)- Cash assistance fromState or localgovernment- Alimony payments- Child support payments- Veteran’s benefits- Strike benefits

Pensions / Retirement / All Other Income

- Social Security(including railroadretirement and black lungbenefits)- Private pensions ordisability benefits- Regular income fromtrusts or estates- Annuities- Investment income- Earned interest- Rental income- Regular cash paymentsfrom outside household

OPTIONAL Children's Racial and Ethnic Identities

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.

Ethnicity (check one): Hispanic or Latino Not Hispanic or Latino Race (check one or more): American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410

fax: (202) 690-7442; or email: program.intake@usda.gov.This institution is an equal opportunity provider.

Do not fill out For School Use Only

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24 Monthly x 12

Total IncomeHow often?

Weekly Bi-Weekly 2x Month Monthly Household Size

Categorical Eligibility

Eligibility:

Free Reduced Denied

Determining Official’s Signature Date Confirming Official’s Signature Date Verifying Official’s Signature Date

*Only use this address if youare filing a complaint ofdiscrimination

Medway Public School

School Nurse Health Services Dear Incoming Students and Families; As required by the Department of Public Health, we are providing you with information regarding meningococcal disease as well as information on the availability, effectiveness, and risks of the meningococcal vaccine. Please review the attached information. For more information please refer to the link below or call Massachusetts Department of Public Health, Division of Epidemiology and Immunization at 617-983-6800. Meningococcal Disease and Students: Commonly Asked Questions Mass.Gov Meningococcal Disease Information Sincerely, The School Nurses Penny McKay, MSN, RN John D. McGovern School 9 Lovering Street, Medway, MA 02053 508-533-6626 ext 5354 fax 508-533-3263 pmckay@medwayschools.org Cheryl F. Gay, BSN, RN, NCSN Memorial Elementary School 16 Cassidy Lane, Medway, MA 02053 508-533-3265 x5152 fax 508-533-3274 chgay@medwayschools.org Colleen Langille, BSN, RN, NCSN Medway Middle School 45 Holliston Street, Medway, MA 02053 508-533-7654 x4123 fax 508-321-4753 clangille@medwayschools.org Janice DiSalvio, BSN, RN Medway High School 88 Summer Street, Medway MA 02053 508-533-6643 x 5008 fax 508-533-3246 jajorgensen@medwayschools.org

Massachusetts Department of Public Health Division of Epidemiology and Immunization, 305 South Street, Jamaica Plain, MA 02130 October 2016 Provided by the Massachusetts Department of Public Health in accordance with M.G.L. c.111, s.219.

Meningococcal Disease and Students: Commonly Asked Questions

What is meningococcal disease? Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can infect the tissue (the “meninges”) that surrounds the brain and spinal cord and cause meningitis, or they may infect the blood or other organs of the body. In the US, about 1,000-1,200 people get meningococcal disease each year and 10-15% die despite receiving antibiotic treatment. Of those who survive, about 11-19% may lose limbs, become hard of hearing or deaf, have problems with their nervous system, including long term neurologic problems, or have seizures or strokes.

How is meningococcal disease spread? These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an infected person’s saliva in order for the bacteria to spread. Close contact includes activities such as kissing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is infected; or being within 3-6 feet of someone who is infected and is coughing or sneezing.

Who is most at risk for getting meningococcal disease? High-risk groups include anyone with a damaged spleen or whose spleen has been removed, those with persistent complement component deficiency (an inherited immune disorder), HIV infection, those traveling to countries where meningococcal disease is very common, microbiologists and people who may have been exposed to meningococcal disease during an outbreak. People who live in certain settings such as college freshmen living in dormitories and military recruits are also at greater risk of disease caused by some of the serotypes.

Are students at increased risk for meningococcal disease? The risk of meningococcal disease starts to increase in adolescence and young adulthood. In this age group, the highest rates of disease are in those 15-24 years of age.

Is there a vaccine against meningococcal disease? Yes, there are 3 different meningococcal vaccines. Quadrivalent meningococcal conjugate vaccine (Menactra and Menveo) protects against 4 serotypes (A, C, W and Y) of meningococcal disease. Meningococcal serogroup B vaccine (Bexsero and Trumenba) protects against serogroup B meningococcal disease, for age 10 and older. Quadrivalent meningococcal polysaccharide vaccine (Menomune) is recommended for people age 56 and older with certain high-risk conditions.

Should my child or adolescent receive meningococcal vaccine? Different meningococcal vaccines are recommended for a range of age and risk groups. Quadrivalent meningococcal conjugate vaccine is recommended routinely for children 11-12 years of age, with a second dose at age 16. MDPH strongly recommends two doses of quadrivalent meningococcal conjugate vaccine: a first dose at age 11-12 years, with a second dose at 16 years. College freshmen and other newly enrolled college students living in dormitories who are not yet vaccinated are also recommended to receive meningococcal conjugate vaccine. Meningococcal B vaccine is recommended for people over age 10 in certain relatively rare high risk groups. In addition, adolescents and young adults (16 through 23 years of age) may be vaccinated with a serogroup B meningococcal vaccine, preferably at 16 through 18 years of age, to provide short term protection for most strains of serogroup B meningococcal disease. Talk with your doctor about which vaccines your child should receive.

Massachusetts law requires newly enrolled full-time students attending colleges and schools with grades 9-12, who will be living in a dormitory or other congregate housing, licensed or approved by the school or college, to receive a dose of quadrivalent meningococcal vaccine (A, C, W, Y) or sign a waiver declining vaccination. There is no requirement for meningococcal B vaccine for entry to school or college. More information about this requirement may be found in the MDPH document entitled “Information about Meningococcal Disease and Vaccination and Waiver for Students at Residential Schools and Colleges.”

How can I protect my child from getting meningococcal disease? The best protection against meningococcal disease and many other infectious diseases is thorough and frequent handwashing, respiratory hygiene and cough etiquette. Individuals should:

1. wash their hands often, especially after using the toilet and before eating or preparing food (hands should be washed with soap and water or an alcohol-based hand gel or rub may be used if hands are not visibly dirty);

2. cover their nose and mouth with a tissue when coughing or sneezing and discard the tissue in a trash can; or if they don’t have a tissue, cough or sneeze into their upper sleeve.

3. not share food, drinks or eating utensils with other people, especially if they are ill.

If your child is exposed to someone with meningococcal disease, antibiotics may be recommended to keep your child from getting sick. You can obtain more information about meningococcal disease or vaccination from your healthcare provider, your local board of health (listed in the phone book under government), or the MDPH Division of Epidemiology and Immunization at (617) 983-6800 or on the MDPH website at www.mass.gov/dph.

Acknowledgement of receipt of the 2019-2020 Medway High School Student-Parent Handbook:

______________________________________ ____________________________________ Print Student/Staff Name Print Parent/Guardian Name ______________________________________ ____________________________________ Sign Student/Staff Name Sign Parent/Guardian Name ______________________________________ ____________________________________ Date Date

Medway Public Schools Medway, MA

Digital Learning and Technology Acceptable Use Policy Agreement

Student or Staff member

I have read, understand and will abide by the Digital Learning and Technology Acceptable Use Policy . I further understand that any violation of the regulations is unethical and may constitute a financial expense and possible criminal offense. Should I commit any violation, my access privileges may be revoked, school disciplinary action and/or appropriate legal action may be taken.

If you are under the age of 18, a parent or guardian must also read and sign this agreemen

_______________________________________ Print Student’s Name or Staff member’s name

________________________________________ Student/Staff Member Signature

_________________________________________ Date

Parent or Guardian

As the parent or guardian of this student, I have read the Digital Learning and Technology Acceptable Use Policy. I understand that this access is designed for educational purposes. I recognize it is impossible for Medway Public Schools to restrict access to all controversial materials and I will not hold them responsible for materials acquired on the network. Further, I accept full responsibility for supervision if and when my child's use is not in a school setting. I hereby give permission to grant access to the Internet for my child and certify that the information contained on this form is correct.

_______________________________________ Print Parent/Guardian’s Name

________________________________________ Parent/Guardian’s Signature

_________________________________________ Date

FAILURE TO RETURN THIS FORM INDICATES THE STUDENT DOES NOT HAVE PERMISSION TO USE THE SCHOOL NETWORKNote: The full text of this policy may be found here on the MPS website: Policy #92

New Student NutriKids Form: Student ID (LASID) ___________________________________________ First Name ___________________________________________ Last Name ___________________________________________ School ___________________________________________ Grade ___________________________________________ Homeroom ___________________________________________ Guardian ___________________________________________ Address ___________________________________________

___________________________________________

Phone Number ___________________________________________ Email ___________________________________________

Medway Public Schools

Student Vaccine Exemption 2019

As a parent / guardian, having responsibility for _______________________________________________, a minor enrolled in Medway Public Schools, I request that said minor be exempt from the vaccination and immunization requirements on medical and/or religious grounds in accordance with the provisions of chapter 76, Section 15, General Laws of Massachusetts. https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXII/Chapter76/Section15 I request that my child be exempt from the following vaccination and immunization requirements (please list)_____________________________________________ _________________________________________________________________ This decision is based on: Please check off all that apply

❏ Religious Grounds, Receipt of vaccination and immunization would

conflict with my sincere religious beliefs. ❏ Medical Grounds

- Explain:_____________________________________________________________________________________________________

❏ I have attached a letter from a medical provider indicating the need

for a medical exemption from vaccination and immuniation, yearly rquirements of M.G.L. Ch. 76, Sec. 15.

I realize that according to the Massachusetts Department of Public Health, my child may be excluded from school and school functions should an outbreak of a communicable disease occur. __________

parent/guardian initials Parent/Guardian:_________________________________Date:___________________ Address:_______________________________________________________________ Principal:_______________________________________ Date:__________________ School Nurse:____________________________________Date:__________________