Welcome to

Marion Central School District

Registration Information: In order to help expedite your registration at MCS, please bring the following information with you: _______ Evidence of age:(birth certificate, record of baptism giving date of birth or passport) _______ Proof of residency: official driver’s license or learner’s permit, pay

stub, income tax form, voter registration document, state or government issued identification, documents issued by federal, state or local agencies (e.g., local social service agency, federal office of Refugee Resettlement) ( P.O. Box is not valid)

_______ Immunizations & copy of your last Dr.’s physical _______ Report card (most recent) _______ I.E.P. (Individual Education Plan), Psychological Reports (for Students receiving special education by a CSE or has remedial Needs) _______ Transcript of past grades/scores along with address and telephone Number of last school attended _______ Custody Papers and/or Court Documents / Orders DSS 2999 form ******* Please be advised that if any of the above material is not provided at the time of registration, the entrance of your child may be delayed by a few days until such information is forwarded from the last school attended.

MARION CENTRAL SCHOOL DISTRICT 4034 Warner Rd.

Marion, NY 14505 District office: (315) 926-2300 Fax: (315) 926-5797

RECORDS RELEASE REQUEST

Name of previous school: ________________________________ Previous school’s address: ________________________________ Previous school’s phone: ________________________________ Name of student: ________________________________ Last grade enrolled: ________________________________ Date of birth: ________________________________ This student is now registered in our school district. Please send us the following information as soon as possible so that we may be able to develop an appropriate program. _____ Educational Data (including academic transcript, past report cards and current Grades at the time of leaving your district) _____ Standardized test data _____ Medical records(including health records, Dr.’s physical & immunization dates) _____ Attendance records _____ IEP, Psychological reports, and special needs documentation _____ Free/reduced lunch paperwork

PARENTAL PERMISSION I hereby authorize school records to be sent to: MCS – District Office Att: Carol Brown 4034 Warner Rd. Marion, NY 14505 Phone: (315) 926-2300 X-1205 Fax: (315) 926-5797 __________________________________ ________________ (Signature of Parent/Guardian) (Date)

Marion Central School Student Enrollment Form

Office Use Only-Building & Enrollment Data Enrollment Date_________ Student is being enrolled in Jr-Sr High School ______ Elementary _________ Student number __________ Teacher Name _________________ Room Number _________ Bus #_________ Locker # ____________

Today’s Date _________________________ Section I

1.) To enroll your child, you must provide proof of age & immunization record. 2.) Are you a legal resident of Marion Central School District? ___Yes ___ No Examples of proof of residency on first page. 3.) Has your child attend M.C.S. schools previously? ___Yes ___ No 4.) Was your child ever registered at M.C.S. under a different name? ___Yes ___ No If yes, what name? _______________________________ 5.) List other schools your child has attended include name, address & dates:

_______________________________________________________________ _______________________________________ _______________________________________ _______________________________________ Section II

1.) Student’s Last Name______________________ First Name___________________ Middle Name __________________________ Nickname____________________

2.) Student’s Address____________________________________________________ 3.) Current Grade ________

4.) Gender ___M ___F

5.) Student’s Date of Birth ______________ (MM/DD/YEAR)

6.) Student’s Place of Birth (City & State) ____________________________________

7.) Is student currently eligible for free or reduced lunch? ___ Yes ___ No

8.) Has student ever been identified as having a disability (CSE or CPSE)? ___Yes ___No

If yes, please describe:________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Section III

1.) Father’s Name______________________________Last grd. completed _________ 2.) Address______________________________________________________________

3.) City/State______________________________________ Zip __________________

4.) Home Phone____________________________Cell Phone______________________

5.) Parents marital status: ___Married ___Divorced ___ Separated ___Single ____

6.) Student lives with: ___Mother ___Father ___Both ___Other____________________

7.) Employer’s Name & address_______________________________________________

8.) Work phone #_____________________________________________

9.) Email address______________________________________________

10.) Mother’s Name_________________________________Last grd. Completed_____

11.) ____Married ____Separated ____ Divorced ____ Single

12.) Home address____________________________Phone__________Cell #__________

13.) Employer Name & address_________________________________Wk PH#________

14.) Email address_______________________________________________

15.) Guardian’s Name ___________________________________________________

16.) Home Address_____________________________Phone_________Cell#__________

17.) Employer’s name & address___________________________Wk. PH#____________

18.) Email address_____________________________________________

Section IV – All other adults and children who reside in the same household as the student: Name Relationship to

student Date of Birth

Grade Level

Disability Yes or No

The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKenney-Vento Act may also be entitled to free transportation and other services.

Where is the student currently living? (Please check one box) � In a shelter � With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as “doubled up”) � In a hotel / motel � In a car, park, bus, train, or campsite � Other temporary living situation (please describe)___________________________________ � In Permanent housing

STUDENT NAME__________________________

SIGNING OUT Marion Central School District

New York State Education Law (Chapter 549, Section 1, Subdivision of Section 3210) requires us to request a list of names of people to whom your child may be released from school with your authorization. When a person requests the release of your child, we are required to check to see if this person’s name is on the list. Please sign your name and PRINT the names of others who have permission to come to our schools to sign out your child in case of emergency or for other legal reasons. (“Signing out” will be required anytime after a child has arrived at school.) All people signing students out should have picture identification with them. At the time of release, the person must present a signed note from you. In cases of emergency, you must call the main office and verify who is being authorized to pick up your child. If you have not notified the office and the person you send is not listed as an authorized “sign-out” person, we will not release your child to him/her. If this information changes throughout the school year, it is the parent’s / guardian’s responsibility to notify the school. It is very important that this information remains current. Teacher:_____________________________________________ Grade______________ In the event that a person requests the release of my child, (print your child’s name)_______________________________________, only the people whose names are listed below are authorized to remove my child from the Marion Central Schools during the 2007-2008 school year. NAME(Print) RELATIONSHIP ADDRESS PHONE Parent/Guardian___________________________________________________________ Parent/Guardian___________________________________________________________ Others:

1. ________________________________________________________________

2. _________________________________________________________________

3. _________________________________________________________________

4. _________________________________________________________________

5. _________________________________________________________________ Parent/Guardian Signature____________________________________ Date ____________

For Marion Elementary School only.

CHILD CARE PROVIDER FORM*

DATE:_______________

Student Name: _____________________, ______________________, _________ (last) (first) (M.I.) Child Care Provider’s Name:_____________________________________________ (sitter / Daycare) Address & Phone Number of Care Provider:_________________________________ ___________________________________ ___________________________________ Days at Child Care: A.M. M T W TH F P.M. M T W TH F Not Applicable

• This information is used for transportation purposes.

Marion Central School District Elementary School (K – 6)

FIELD TRIP PERMISSION FORM

For the 2014-2015 School Year In order that my child,_______________________________________, may receive the educational benefits derived from the attendance on all field trips, I hereby consent to his/her attendance under such conditions as may be prescribed by the school. Some of the tentatively planned field trips are on the school grounds within walking distance (e.g. visits to the bank, post office, town park, etc.) I understand that if the place to be visited is beyond walking distance, students will ride in a School bus driven by an approved bus driver. Further, I understand that field trip descriptions, which will include location, time, and other Specific information will be sent home prior to each trip. My signature below authorizes my child to participate in all walking and bused field trips. Signature:_________________________________________________ Date: _______________________

All students between 5 and 21 years of age have the right to a free public education. Children maynot be refused admission because of race, color, creed or national origin, sex, citizenship,handicapping condition, or immigration status.Name of School:

School District Student Identification Number: Date of Birth (MonthlDaylYear):

LStudent Name: Last, First, Middle: Grade Level:

DIRECTIONS TO PARENT/GUARDIANPLEASE ANSWER QUESTIONS (1) and (2). PLEASE READ THEM BEFORE YOU RESPOND. [For question (1) Check ( 1 thebox that best describes your child.1 Check ( ) only ONE box.

Sianature of Parent/Guardian/Other

Relationship to Student (please check one box below):

Date

Mother J Father Guardian Other (Specify):

See reverse for important message toParents/Guardians and Confidentiality Procedures andRegulations.

L

Marion Central School DistrictSTUDENT RACIAL AND ETHNIC IDENTIFICATION

1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican,Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.YES, Hispanic

NO, not Hispanic

2. Select one or more races from the following five racial groups [For question (2) Check ( J ) all groups that apply to your child; check(J ) at least ONE box.]:

AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North and SouthAmerica (including Central America), and who maintains tribal affiliation or community attachment.ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinentincluding for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam,Samoa, or other Pacific Islands.

LI BLACK OR AFRICAN AMERICAN: A person having origins in any of the Black racial groups of Africa.

LI WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Marion Central School DistrictSTUDENT RACIAL AND ETHNIC IDENTIFICATION

To the Parent/Guardian: Marion Central School District has adopted a policy which requires the collection andrecording of the ethnic identity of students in the Marion Central School Dstrict n accordance with the federal categoriesand definitions. The information will be used to:

- Report information to the State and federal Education Departments.- Plan educational programs and make sure that they are readily available to all students.- Analyze differences in academic performance, attendance and completion of school.

We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions on the back of thispage. Put a check ( ) in the box for the category or categories which best describe your child. The SAMPLESCHOOL DISTRICT understands the sensitive nature of this information and wishes to assure you that it will be keptsecure and confidential in accordance with all State and federal student privacy laws and regulations. If theinformation requested is not provided on this form on behalf of your child, a student records officer from the school ordistrict will be required to identify the group to which the student appears to belong, identifies with, or is regarded inthe community as belonging. Thank you for your cooperation.

CONFIDENTIALITY PROCEDURES AND REGULATIONS ITo School Staff: This form will be filed in the student’s permanent record as confidential information

To the Parent/Guardian: The information which you have provided on this form is confidential. It isprotected by the Confidentiality Regulations cited below.

The Family Educational Rights and Privacy Act (1974) prohibits unauthorized access to student records andunauthorized release of any student record information identifiable by either student name or studentidentification number

Ii Please complete the form on the reverse side of this page

The University of the State of New York • The State Education Department • Office of Bilingual EducationAlbany, New York 12234

Home Language Questionnaire (HLQ)

I

______________________

Ii

________

j

____________

(i/ boxes that apply)

Understands English

Writes English

specify

________________

U Does Not Writespecify

Dear Parent or Guardian:

In order to provide your child with the

best possible education, we need to

determine how well he or she under

stands, speaks, reads and writes

English. Your assistance in answering

these questions is greatly appreciated.

Thank You

TO BE COMPLETED BV SCHOOL PERSONNEL

DISTRICT Plense print Sr type clearly

SCHOOL GRADE

STUDENT NAME

DATE OF BIRTH

Month: Day: Year:

STUDENT IDENTIHCATION NUMBER

COUNTRY OF BIRTH / ANCESTRY

NUMBER OF YEARS ENROLLED IN SCHOOL OUTSIDE THE U.S

NAME/POSITION OF SCHOOL PERSONNEL COMPLETING THIS SECTION

DETERMINATION: U Possible LEP

U English Proficient

speczfy1. What language(s) is spoken in the student’s U English U Other

_______

home or residence?

2. What language(s) are spoken most of the time U English U Other

_______

to the student, in the home or residence?

3. What language(s) does the student understand? U English U Other

_______

4. What language(s) does the student speak? U English U Other

_______

5. What language(s) does the student read? U English U Other

6. What language(s) does the student write? U English U Other

7. In youi opinion, how well does the student understand, speak, read and write English?

Very well Only a little Not at all

specify

specify

specify

U Does Not Read

Speaks English

Reads English D

D D U

Month: Day: Year:

Signature of Parent/Guardian/Other Date HLQ(2/50) 99-337CM

The University of the State of New York • The State Education Department • Office of Bilingual EducationAlbany, New York 12234

CUESTIONARIO SOBRE EL IDIOMA QUE SE HABLA EN EL HOGAR

(“Home Language Questionnaire, HLQ”) — Spanish

1. Que idioma(s) se habla en el hogar U Ingles U Espaflol U Ot-ro

o residencia del estudiante? (Especifique cud()

2. En qué idioma(s) se le habla al estudiante U Ingles U Espaflol U Otto

la mayor parte del tiempo (Especifiqtte couP)

en el hogar o residencia?

3. Qué idioma(s) entiende el estudiante? U Inglés U Español U Otro

(Especifique cud))

4. Qué idioma(s) habla el estudiante? U Ingles U Español U Otto

(Especifique cud!)

5. En qué idioma(s) lee el estudiante? U Ingles U Español U Otto U No lee

(Qué idioana)

6. En qué idioma(s) escribe el estudiante? U Ingles U Español U Otto U No escribe

(Qud idioms)

7. En su opinion, qué tan bien el estudiante entiende, habla, lee y escribe inglés?

Muy bien Un poco Nada

Entiende Ingles U U U

Habla Ingles U U U

Lee Ingles U U U

Escribelngles U U U

Mrs Dio Atio(Month) (Day) (Year)

Fecho(Dote)

Es tirnado Padre/Madre o Guardian:

Para poder ofrecer a su hijo(a) la mejor

educación posible, necesitcimos

determinar cua’n efectivamente él o ella

entiende, habla, lee y escribe el idioma

ingles. Sn ayuda será apreciada Si

contesta estas preguntas.

Gracias.

PARA SER COMPLETADO POR EL PERSONAL ESCOLAR(TO BE COMPLETED BY SCHOOL PERSONNEL)

DISTRITO IMPRIMA 0 ESCRIBA CLARAMENTE(District) (Please print or type Clearly)

ESCUELA GR°oO(School) (Grade)

NOMBRE DEL ESTUDIANTE(Student Name)

FEcHA DE NAcIMIENTO(Date Of Birth) Mes Dia Atio

(Month) (Day) (Year)

NUMERO DE IDENTEFICACION DEL ESTUDIANTE(Student Identification Number)

PATS NATAL 0 ASCENDENCIA(Country of Birth/Ancestry)

NUMERD DC A5J0S MATRICULADO EN ESCUELA)S) FUERA DE LOS EU.(Number of years enrolled in school outside the U.S.)

NOMBRE/POSICION DEL PERSONAL ESCOLAR LLENANDO ESTA SECCION(Name/Position School Personnel Completing This Section)

DETERMINAcION U Posiblemente LEP (Possibly LEP))Determiarotion)

U Dorninante en Tngles (English Proficient)

(v’ Marque las casillas que aplican)

Finna del Podre/Madre/Gttardidtt/Otro(Signature ofParenf/Gttardia;t/Other)

Ftt_Q 12/001 99-237 PM

HEALTH OFFICE — MARION ELEMENTARY SCHOOLLinda DePoint, School Nurse

315-926-2431 FAX (315-926-5048)

Dear Parents:

Before entering school, children must be satisfactorily protected against Diphtheria, Polio, Measles,Rubella (German measles), Mumps, Hepatitis B and Varicella (chicken pox). A copy of the immunizationrequirements is enclosed. Please bring a copy of your child’s immunization record. If you do not have arecord of your child’s immunizations, please contact your health care provider before registration andbring this to registration with you. Your child may not have all the immunizations needed to enterKindergarten, but we do need to have a certified record of your child’s immunizations at the time ofregistration. This information is required to register your child.

For your information the Public Health Nurses hold Immunization Clinics on the third Wednesday ofevery month from 3:00 PM at the Public Health Nurses Office on Nye Rd. Nye Rd. is the first right pastthe Wayne County Nursing Home on Route 31. (between Newark & Lyons) An appointment is necessaryand the child must be accompanied by a parent or guardian and have their immunization record withthem. Their phone number is 315-946-5749 or 1-800-724-1170.

The Health History/Emergency Information form should be completed and brought to school atregistration. (colored sheet) The information on this form is very important; to assure proper care foryour child we need to have your workplace and home/cell telephone number. Also the names,telephone numbers and relationships (grandparents, friends, sitters, etc.) of other people we may call ifyou are not available when your child is ill and needs to be taken home from school.

The New York State Education law requires that every child have a physical examination before enteringschool and at specific grade levels throughout the school years. Parents of kindergarten children shouldtake their children to their family doctor/health care provider for this examination. The family healthcare provider knows your child’s history and is able to do the most thorough and meaningfulexamination. This is an opportunity for the parents to be with their children during the examination; thefamily health care provider is able to examine your child when healthy and parents have an opportunityto discuss concerns at this time. The physical examination should be completed and the form returnedto school before September 1, along with an updated immunization record (if your student still neededimmunizations). Physicals will be accepted if they have been done not more than twelve months priorto the start of the school year (not accepted if done before 9/8/current school year. It is also suggestedthat your child see their dentist before entering school because dental health plays an important roll inkeeping your child healthy. A dental health certificate is enclosed and again if your child has seen thedentist not more than twelve months prior to school, you may have the dentist fill out the form fromthat appointment or plan to schedule an appointment. Please call if you need information aboutobtaining a dentist for your child. I would be glad to assist you.

Please do not hesitate to call me with any concerns or questions; I am usually in the Health Office duringthe school week from 7:30 AM until 4 PM.

Sincerely,

CERTIFICATE OF IMMUNIZATION FOR ENTRY INTO SCHOOLMARION ELEMENTARY SCHOOL

CHILD’S NAME DATE OF BIRTH____________

IMMUNIZATION HISTORY

*DPT (OR OTHER COMBINATIONS WITH Diptheria toxoid — please state type)

*TOPV

*IPV

*MMR (Measels, Mumps, Rubella)

*Hepatjtjs B

HIB

VARIVAX

Tuberculin Test

Others

SIGNATURE OF PHYSICIAN DATE

Physician’s name, address, telephone (please print)

New York State Education Law requires all children attending school to be immunized against Diptheria,Polio, Measles, Rubella (German Measles) Mumps and Hepatitis B. To be immunized for “legal entry” achild must have:

V 3 doses of diphtheria toxoid (usually administered as either DPT/TD or other combinations)V 3 doses of polio virus vaccine (TOPV or IPV — recommended a combination of 2 IPV/2TOPV)V 2 doses of live measles vaccine administered after the age of 12 months (usually administered as

MMR)V 3 doses of Hepatitis B if child is born after 1/1/93; also 3 doses of Hepatitis B before entering 7t1 gradeV I dose of live mumps vaccine administered after the age of 12 months (usually administered as MMR)V 1 dose of live rubella (German measles vaccine administered after the age of 12 months (usually

administered as MMR)V 1 dose of varicella vaccine if born on or after 1/1/98 and is entering Kindergarten after September

2003 or documentation of disease

Dear Parent or Guardian:

As a part of your child’s requirements for school, a physical examination hasbeen required for new students entering the district and for students inPrekindergarten or Kindergarten and in Grades 2,4, 7 and 10. A law was recentlyenacted that expands health screenings to include the dental health of students inNew York State.

After September 1, 2008, when we require that your child have a physical— examination, we will be requesting a dental certificate as well. There is a sample

certificate available for you to take to your child’s dentist and once it iscompleted, it should be returned to the School Nurse as it will be filed in yourchild’s Cumulative Health Record.

Thank you for your cooperation in this new health endeavor. Our studentsbenefit when we work together to promote the health and achievement of allstudents.

Please call the school’s Health Office if you have any questions or concerns.

Linda DePoint RN

Trena Fisher RN

Marion Central School Health Offices

Elementary School 315-926-2431

Junior-Senior High School 315-926-2406

Dental Health Certificate

PareritlGuardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry,K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess hislher fitness to attend school. Please completeSection 1 and take the form to your dentist for an assessment. If your child had a dental check-up before-tie/she started the school, ask yourdentist to fill out Section 2. Return the completed form to the school’s medical director or school nurse as soon as possible.

Section 1. To be completed by Parent or Guardian (Please Print)Child’s Name: ‘‘ Ik&1I

Birth Date 1 “ Sex: C MaleWill this be your child’s first visit to a dentist? C Yes C No

Mo,dh Dy Y,C Female

School: N

Grade

Marion Elementary School

Have you noticed any problem in the mouth that interferes with your child’s ability to chew, speak or focus on school activities? C Yes C No

I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand thisassessment is only a limited means of evaluation to assess the student’s dental health, and I would need to secure the services of a dentist in order formy child to receive a complete dental examination with x-rays if necessary to maintain good oral health.

I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship.Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow therecommendations listed below.

Parent’s Signature Date

Section 2. To be completed by the Dentist

I. The Dental Health condition of

_______________________________

on

_________________

(date of exam) The date of theexam needs to be within 12 months of the start of the school year In whIch It Is requested. Check one:

[1 Yes, The student listed above is in fit condition of dental health to permit himTher attendance at the public schools.

LI No, The student listed above is not in fit condition of dental health to permit him/her attendance at the public schools.

NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student’s ability to chew, speak or focuson school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fitcondition of dental health to permit attendance at the public school does not preclude the student from attending school.

Dentist’s name and address (please print or stamp) Dentist’s Signature

Optional Sections - if you agree to release this Information to school, parent please Initial here. III. Oral Health Status (check all that apply).

C Yes C No Caries Experience/Restoration History — Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR atooth that is missing because it was extracted as a result of caries OR an open cavity].

U Yes C No Untreated Caries — Does this child have an open cavity? [At least % mm of tooth structure loss at the enamel surface, Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces.If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, areconsidered sound unless a cavitated lesion is also present].

C Yes C No Dental Sealants Present

Other problems (Specify):

Ill. Treatment Needs (check all that apply)

No obvious problem. Routine dental care is recommended. Visit your dentist regularly.

May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.

Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

Recommended/Sample FormNYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and

triennially for the Committee on Special Education (CSE).

HEALTH CERTIFICATE I APPRAISAL FORM

School: Marion Central School Gender: U M U F Grade:

IMMUNIZATIONS I HEALTH HISTORYEl Immunization record attached Sickle Cell Screen: El Positive ElNegative El Not done Date:El No immunizations given today PPD: El Positive ElNegative El Not done Date:El Immunizations given since last Health Appraisal: Elevated Lead: El Yes El No El Not done Date:

Dental Referral El Yes El No El Not done Date:

Significant Medical/Surgical History: El See attached

Allergies: El LIFE THREATENING El Food: El Insect: El Other

El Seasonal El Medication:

PHYSICAL EXAM

Height: Weight: Blood Pressure: Date of Exam:

_____________________________________________________ Referral

Body Mass Index:Vision - without glasses/contact lenses

R L

Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L

U less than 5th 5th through 49U

50th through 84th Vision - Near Point R L

U 85’ through 941h U 951h through 98th U ggth and higher Hearing U Pass 20 db sc both ears or: R L

El EXAM ENTIRELY NORMAL Tanner: I. II. III. IV. V. Scoliosis: El Negative El Positive:

Specify any abnormality (use reverse of form if needed):

MEDICATIONS

Name: DosagelTime:

Name: DosagelTime:

If AM dose is missed at home:

I assess this student to be self-directed El Yes El No Student may self carry and self administer medication El Yes El NoNote: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency

sheltering is necessary at school or if the morning medication has not been given.

r PHYSICAL EDUCATION I SPORTS / PLAYGROUND I WORK QUALIFICATION / CSE CONSIDERATION

El Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:

— Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.

— Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.

El Specify medical accommodations needed for school:

____________________________________________

El None

El Known or suspected disability:

El Restrictions:

El Protective equipment required: El Athletic Cup El Sport goggles/impact resistant eyewear El Other:

OPTIONAL INFORMATION, if known

Specify current diseases: 0 Asthma Diabetes: 0 Type 1 0 Type 2 El Hyperlipidemia El Hypertension

I 0 Other:

Provider’s Signature:

______________________________________________________

Phone:

_________________________

(Stamp below)

Provider’s Name/Address:

______________________________________________

Fax:

__________________________

Parent Signature:

_________________________________________________________

Date:

___________________________

This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than fivedays that will require review by private healthcare provider and the school medical director. Rev. 2/08

Name:

_______________ ____________________

Date of Birth:

Medications (list all): El None El Additional medications listed on reverse of form

El Please monitor

El Please monitor

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Marion Elementary Schoolheafth Hfstory/Emergency Information

ALL SECTIONS MUST E COMPLETED

SexChild’s Name

First Middle LastGrade Entering

Date of Birth

List 2 persons with whom you have already made arrangements, who are willing to come to school to get yourchild in case of illness or accident and will care for them. These people should be persons who would be athome when you are away. (designate relationship, sitter, friend, grandparent, aunt, etc.)

1.

2.

Sitter or Daycare Provider

Place ofBirth

Name of AddressParent(s)/Guardian

living in homeTelephone Cell Phone

Name of Parent AddressGuardian Out of

horn eTelephone TCell Phone

Name:

_____________

Relation Phone

I/Doctor

____

Famyjentist

Ph one

Phone

[He]!th ns nc Tcontrct Numb’r Insunnc Carried h:

LZZZZZ 1JL1ZZZ

_

• __._ —— _. --

___________

— -

_____________________

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Medic3l Hstory

Question Circle One or fIH inDoes ,our child have any diagnosed disabilities or diacnosed clircnic disease? YES NO

‘I le. Acthrno D htes

_____

Does your child have alkrius?____

_______

IYES NOIf yes please explain what he/she is allergic to, how’h!she is treated and by whom Doctor Name

Dons you child have frequent earaches or has he/she_had frequente iaches in th p9si f YES NO ]Doesjmir oh ye agy problems with heanp J YES NODoes your child havean1problems with vision?

____

-

- YES NODoesjcur child wear correcti;e lenses? . ‘(ES NC

- —------— -.- —----- — ---- ------ ---- ---

Has your child had any communicable disease lex:impie. Crckcn Pox) or ‘c ‘i ES NuLSri0lL_ -

-

___

— _iIf yes, obese desiqnate illness, date and Doctor who treated YOLII child. Doctor Name

Hoes your chld have any problems with his/her kidneys, bladder or bo’iels? Such as YES NOI frequent i bey!blodder infections, frequent chnrrhea or constib it rrbedwottin? , - - -

If yes please eqbein

Hasjnur child had ay venous accidents or injunes2— YES NO -

if yes please explain

Has your child ever Peen hospitalized? !e. surgeries YES NOIf yes, ploese state reason for hospitalization, date and doctor who treated your child. Doctor Name

Does your oh ild have ssizures or has he/she had seizures in thast?

________

YES NO

_______

yes, please desciibe seizures, frequency, treatment, and doctor who is treating your

oh Id

0.

lstherea family history_of seizures’?

_____ __________

. 1_YES_..NODoes your child take any medication leg uiay? - -_ .s ‘ -

- YES NO -

If yes, whet medications, amount and what time of day.

If your child needs to take medication during the school hour, please contact the School Nurse for a form to becompleted by your doctor Parents must also sign this medication request. The medication will then bedispensed in the health Office accnrcHcg to the doctor’s ord’r

V/lien was your child’s iast !:hyscal yarnination?

_______________________

_ — -

PLEASE ADD ANY INFORMATION THAT WILL HELP US TO MAKE YOUR CHILD’S SCHOOLDAY COMFORTABLE AND SUCCESSFUL:

____________

____

-

:*-‘ .O’o4• ;.

____

Pr-rit/C3uardLio iiqi iaturo

Dear Parent/Guardian:

Our school buildings are located within or near the ten-mile emergency planning zone(EPZ) of the Ginna nuclear power plant. In another step to safeguard public health, thefederal Nuclear Regulatory Commission amended its policy on the availability and usageof the over-the-counter drug potassium iodide (KI) during a radiological emergency. Asa result, New York State also revised its policy regarding the administration of KI.

KI is an over-the-counter drug that protects the thyroid from exposure to radioactiveiodine. KI only protects this one organ against radioactive substance. It is not analternative to evacuation or sheltering. In fact, evacuation and sheltering remain NewYork’s primary public protective actions in the event of an accident at any nuclear powersite. Attached is an information sheet regarding 1<1.

Should the County andJor State Department of Health recommend the use of KI during anemergency while students are at school, the Marion Central School District will have Uavailable on-site for your child. Evacuation from the ten-mile EPZ remains our primaryprotective radiological action. In the event that evacuation is not immediately possibleand/or KI use is recommended by the County and/or State health officials, an appropriatedose of U will be provided to your child.

If you do NOT want the school to provide your child with i<i in a radiologicalemergency, you MUST sign and return the enclosed form (on the reverse side of thisletter) and return it to Kathryn Wegman, Superintendent. This form will remain in effectas long as your child attends this school district, unless you notif’ us in writing that younow wish your child to be provided with KI. Please note that if you do not return theenclosed form and KI use is recommended by health officials, your child will receiveKI.If you have any concerns regarding the emergency use of KI or questions on yourchild’s health and the use of 1(1, please discuss this with your child’s health careprovider.If you have any lIirther questions about the school’s program please contact me (926-23 00), Trena Fisher, lr.-Sr. High school nurse (926-2406), Linda DePoint, Elementaryschool nurse (926-243 1).

Sincerely,

Kathryn WegmanSuperintendent

Potassium Iodide (KT)Questions & Answers for Parents

1) What is potassium iodide (KI)?

Potassium iodide is a U.S. Food and Drug Mministration (FDA) approved over-the-counter drug that can be used to protect the thyroid gland from immediate and futureradiation injury caused by radioactive iodine released during a nuclear accident.

2) How does KI work?

KI saturates the thyroid gland with stable (non-radioactive) iodine, thus preventing orreducing the amount of radioactive iodine that will be taken up by the thyroid.Radiological emergencies may release radioactive iodine in the environment. Sinceiodine concentrates in the thyroid gland, inhalation of air or ingestion of foodcontaminated with radioactive iodine can lead to injury to the thyroid — including anincreased risk ofthyroid cancer.

3) Does XI protect individuals from all types of radiation?

No. KI is only effective against exposure to radioactive iodine. KI does not protectagainst other types of radiation.

4) Does XI protect organs other than the thyroid?

No. U does not protect body organs or tissues other than the thyroid.

5) Is a prescription necessary?

No. KI is a FDA approved over-the-counter drug.

6) Should some people avoid KI?

Yes. According to the FDA, people with known iodine sensitivity, thyroid diseases,clusters of itchy skin blisters (dermatitis herpetiformis), and/or an inflammation in bloodvessels involving the skin or multiple organs of the body (hypocomplementemicvasculitis) should avoid the use of Xl. A physician should be consulted before an eventoccurs with individual concerns on whether to take KI in an emergency.

7) What are the possible side effects to KI?

According to the FDA, the benefits of taking KI fr exceed the risks. The possible sideeffects may include stomach upset and minor rash.

8) When Is XI most effective?

To be most effective, KI should be taken shortly before or shortly after exposure toradioactive iodine. Even if taken three to four hours after exposure, it would still reduceradioactive iodine from being absorbed by the thyroid and still have a substantial effect.

9) How long is KI effective in the body?

The protective effects of KI last approximately 24-hours.

10) Is 1(1 an alternative to evacuation?

No. Evacuation remains the primary protective action in a radiological emergency.

11) What happens if the ten-mile EPZ cuts through the school district?

Only school buildings located within the ten-mile EPZ will receive KI from the NewYork State Emergency Management Office (SEMO).

12) Who may administer the KI to children?

Designated individuals in the school may administer the KI to children oncerecommended by the New York State and/or County Department ofHealth in anemergency situation.

13) Is a physician’s order necessary for Xl administration in a radiologicalemergency?

No. KI administration in a school is part of an emergency protocol to deal with aradioactive iodine release into the environment.

14) What if a child can’t swallow pills?

The pill may be safely crushed and given with juice, applesauce, etc. in the event that anindividual cannot swallow it. It may also be easily dissolved in water.

15) How will schools be notified that events warrant the administration of the KI tochildren?

The State Department of Health andlor County Department of Health are charged withissuing the recommendation to administer KI in the event radioactive iodine is releasedinto the environment.

16) Will the adults in the school building also be provided with KI?

Yes. KI will be provided to all adults in school buildings located within the 10-mile EPZ.However, according to the FDA, it is not necessary for persons over 4.0 years of age totake KI in a radiological emergency.

Potassium Iodide (Ki) Opt-Out Form

If you DO NOT want your child given potassium iodide (KI) in the event ofa radiological emergency, complete this form and return it to KathrynWegman, Assistant Superintendent at Marion Central School District Officeby

I understand that potassium iodide (KI) may be given to my child ifrecommended by the County and/or State Department of Health in aRadiological emergency.

I have read and understand the Parent/Guardian letter and the informationsheet

I DO NOT want my child to take potassium iodide (KI) in the event of aRadiological emergency.

Child/Children’s Name: Building:

Parent / Guardian Signature:___________

Date:________________ Telephone number: