MISCELLANEOUS
INFORMATION
REQUESTS/ORDERS
REPORTS,
ETC.
35
TABLE OF CONTENTS
Fax Sheet
38
Sign-in Sheet
39
Handbook/Policy Signature Sheet
40
Internet Use Agreement
41
Employee Information Sheet
42
PLC I Committee Minutes
43
Requisition For Supplies
44
Referral for Counseling
45
School Social Work Referral Report
46
PSRC administration of Medication
47
Spanish Version
48
Request for Medication Administration
49
Parent Permission Form for Medication
50
Required Annual Health Status
51-52
Student Health Referral Form
53
Accident Report
54
Incident Report
55
Request for Use of VCR, DVD, (Outside Resource Person)
56-57
St. Pauls Elementary Field Trip Check list
58-59
Field Trip Information-
60
PSRC Charter Bus List
61
Morning Check Off List for AM
62
Field Trip Form for Student
63
36
Extended Trip
64
Transportation Consent Form (Parent)
65
Use of Yellow School Buses
66
PSRC Activity Bus Request
67
Tutoring/Extra Bus Use Mileage Form
68
PSRC Internet Use Agreement
69-70
Student Information Sheet
72
PSRC Release of Student and Directory Information
73
Child Custody Issues
74-76
Cumulative Folder Verification Sheet
77
Cumulative Record Check off sheet
78
Award Ceremony Invitation
79
Grade Placement for the Next School Year-
82
PBIS Referral Forms
83
Referral Form for Office
84
Low Level Referral form
85
Student Parent Teacher Agreement
86
SPE Grading Policy
87
SPE Substitute Folder
Purchase Order Checklist
Prior Approval Checklist
Immunization/Health Assessment for Parents
Retention Notice One
Retention Notice Two
Retention Notice 3
88
89
90
91
92
93
94
37
ST. PAULS ELEMENTARY SCHOOL
222 Martin Luther King Jr. Dr.
St. Pauls, N.C 28384
Phone: 910-865-4103
Fax: 910-865-3730
Dr. Jill Hathaway, Principal
Date: __________________
To: ______________________
Fax: ___________________________
Re: __________________________________________________________
Pages (Including Cover) _________
Comments: __________________________________________________
_____________________________________________________________
_____________________________________________________________
Thank You And Have A Nice Day!
38
St. Pauls School Elementary School
Event: __________________________
Date: __________________________
Students
Parents
39
Public Schools of Robeson County
Handbook/Policy Manual
My signature indicates that I have read the Public Schools of Robeson County
Policy Manual on-line or hard copy and have had an opportunity to discuss its
contents.
Employee Signature _________________________Date _________________
St. Pauls Elementary School Staff Handbook
My signature indicates that I have read the St. Pauls Elementary Staff
Handbook on-line or hard copy and have had an opportunity to discuss its
contents.
Employee Signature _______________________Date ____________________
St. Pauls Elementary School Student Handbook
My signature indicates that I have read the St. Pauls Elementary School Student
Handbook on-line or hard copy and have had an opportunity to discuss its
contents.
Employee Signature ______________________ Date ____________________
40
ST. PAULS ELEMENTARY SCHOOL
PUBLIC SCHOOLS OF ROBESON COUNTY
INTERNET USE AGREEMENT
I understand and will abide by the Internet Use Agreement. I further
understand that any violation of the regulations above is unethical and
may constitute a criminal offense. Should I commit any violation, my
access privileges may be revoked, school disciplinary action may be taken
and or appropriate legal action.
___________________________________________________________
St. Pauls Elementary School Staff Member Signature
Date
41
ST. PAULS ELEMENTARY SCHOOL
EMPLOYEE INFORMATION
SHEET
2015-2016
Name: __________________________________________________________________
Last Name
First Name
Middle Name
Address: ____________________________________________
____________________________________________
Phone Number: ______________/Cell Number: ______________
 Number of years for which you are paid (Experience)
 Number of years of service in PSRC (Do not include this year)
__________
 (Teachers Only) Are you tenured? ____Yes ____No
 (Teachers Only) Certification: _____A _____G
 Birthdate: ________________
 Social Security Number: (Last four digitals) __________
……………………………………………………………………...........
Emergency Contacts:
Name: _____________________ Relationship
Phone Number: ______________/Cell Number ____________/
Work Number: _____________________
Name: _____________________ Relationship
Phone Number: ______________/Cell Number ____________/
Work Number: _____________________
Name: _____________________ Relationship
Phone Number: ______________/Cell Number ____________/
Work Number: _____________________
42
ST. PAULS ELEMENTARY SCHOOL
222 Martin Luther King Jr Dr
Telephone- 910 865-4103
St. Pauls, NC 28384
Fax – 910-865-3730
Dr. Jill Hathaway, Principal
COMMITTEE MINUTES
Date: ____________________________
Time: _________________________
Name of COMMITTEE: ________________________________________________
Members Present
Chairperson: _______________________________________________________
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
Purpose of MEETING
________________________________________________________________________
Instructional Items Discussed:
________________________________________________________________________
Plans for Follow-up:
Targeted Students Making Progress
Chairpersons should submit this completed form to the principal following the committee
meeting.
43
REQUISITION FOR SUPPLIES
NAME
DATE OF REQUEST
_
,
MATERIALS NEEDED:
Description
Quantity
Color/Size
44
Dr. Jill 0. Hathaway, Principal
222 Martin Luther King Jr.
ST. PAULS ELEMENTARY
SCHOOL
St. Pauls, NC 28384
Referral for Counseling
Wendell Acosta
School Counselor
Yolanda McArthur
School Counselor
Teacher Name: ___________________
Date of Referral: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Student Age:
Student Name:
Grade:
Parent/Guardian(s): ___________________
Student Address: __________________________________________________________________
Telephone: ____________________________________________________________________________
Reason(s) for referral: Circle the one(s) that apply or write on the lines provided.
a. Peer Relationships
b. Disruptive Behavior c. Attendance d. Academic Concerns
e. Withdrawn Behavior
__________________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Strategies already implemented to remedy the situation:
1.
2.
3.
4.
Warning in Class: __________________________
Conference with student: _____________________
Parent/Guardian Contact: _____________________
Conference with Principal: _____________________
Date: __________________
Date: __________________
Date: __________________
Date: __________________
Counselor’s Consolations Notes
Interventions:
1.
2.
3.
4.
5.
Individual counseling sessions: _____________________
Parental/Guardian Conference: _____________________
Referral to other school resources: __________________
Recommend student to be referred by teacher to the SSMT
Referral to community resources: ___________________
Date: __________
Date: __________
Date: __________
Date: __________
Date: _________
45
Social Worker Referral Form
Student's Name: _________________________
Referral Date __________
School: ____________________________________________
NC Wise #
Parent/Legal Guardian:
_
DOB:________________
Address: __________________ Contact: _______
(*) HWC
Reason for referral:
(Please attach ALL supportive documentation)
___Attendance (# of days ____)
____Academics
_____ Medical Issues
___ Behavior Issues
____ Personal Needs _____ Abuse/Neglect
Brief description of presenting issue and schools efforts to resolve the issue:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Signature of person making referral: _______________________________________
To be completed by Social Worker
Action taken by social worker:
_____________________________________________________
_____________________________________________________
_____________________________________________________
Social Worker Signature: ______________________ Date: ______
46
Public Schools of Robeson County
Post Office Drawer 2909
Lumberton, North Carolina 28359
(910) 671-6000
Fax (910) 671-6024
Office of the Superintendent
Date
Dear Parent:
Our school has a written policy to assure the safe administration of medication to students during the
school day. If your child must have medication of any type given during school hours, including over-thecounter drugs, you have the following options:
(1) You may come to school and give the medication to your child at the appropriate time(s)
(
(2) You may obtain a copy of a medication form from the school nurse or school secretary. Take
the form to your child's doctor and have him/her complete the form by listing the
medication(s) needed, dosage, and number of times per day the medication is to be
administered. This form must be completed by the physician for both prescription and overthe-counter drugs. The form must be signed by the doctor and by you, the parent or guardian.
Medication(s) must be brought to school by the parent/guardian in a pharmacy-labeled bottle
which contains instructions on how and when the medication is to be given. The medication
must be "signed in" at school by the parent/guardian. Over-the-counter drugs must be received
in the original container and will be administered according to the doctor's written instructions.
(3) You may discuss with your doctor an alternative schedule for administering medication (i.e.,
outside of school hours.)
(4) Self-medication: In accordance with NCGS §115C-375.2 and G.S. 115C-375.3, students
requiring medication for asthma, anaphylactic reactions, or both, and diabetes, may selfmedicate with physician authorization, parent permission, and a student agreement for selfcarried medication.
School personnel will not administer any medication to students un less they have received a medication
form properly completed and signed by both doctor and parent/guardian, and the medication has been
received in an appropriately labeled container. In fairness to those giving the medication and to protect the
safety of your child, there will be no exceptions to this policy.
If you have questions about the policy, or other issues related to the administration of medication in the
schools, please contact the school nurse.
Thank you for your cooperation.
(Revised 7-10)
47
Public Schools of Robeson County
Post Office Drawer 2909
Lumberton, North Carolina 28359
(910) 671-6000
Office of the Superintendent
Fecha
Estimado padre:
Nuestra escuela tiene politicas establecidas para asegurar Ia administraci6n, sin riesgo alguno, de
medicamentos a estudiantes durante el dia escolar. Si su hijo(a) debe tomar medicamentos de cualquier
tipo durante las horas escolares, incluyendo medicinas compradas sin receta medica, usted tiene las
siguientes opciones:
(1) Usted puede venir a Ia escuela y darle el medicamento a su hijo(a) a Ia hora apropiada.
(
(2) Usted puede solicitarle a Ia enfermera o secretaria de Ia escuela una copia de Ia solicitud de
medicamento. Lleve Ia solicitud al doctor de su hijo(a) y pidale que complete Ia solicitud
especificando por escrito los medicamentos que se necesitan, Ia dosis y el numero de veces al
dia que se debe suministrar el/los medicamento(s). Esta solic.itud debera ser completada por el
doctor para medicamentos con o sin receta medica. Los medicamentos con receta medica
deberan ser traidos a Ia escuela en el frasco etiquetado por Ia farmacia que contiene las
instrucciones sobre c6mo y cuando se debe administrar el medicamento. Los medicamentos
comprados sin receta medica deben ser recibidos en el empaque original y seran administrados
de acuerdo a las instrucciones escritas por el medico.
(3) Usted puede hablar con su doctor sobre un horario altemati vo para Ia administraci6n de los
medicamentos (por ejemplo, fuera de horario escolar)
(4) Automedicaci6n: De acuerdo con Ia ley de Carolina del Norte G.S. §115C-375.2 y G.S. 115C375.3, los estudiantes que requieren medicamentos contra el asma, reacciones alergicas graves
(termino medico, Anafilaxis) y diabetes pueden automedicarse con autorizaci6n del medico,
pem1iso del padre y con un contrato de tenencia de medicamentos entre Ia escuela y el
estudiante.
El personal de Ia escuela no administrara ningun medicamento a estudiantes a menos que hayan
recibido Ia solicitud medica debidamente completada y firmada por el doctor y el padre o encargado
(tutor) y el medicamento haya sido recibido en el empaque debidamente etiquetado. Haciendo justicia
con aquellos que administran el medicamento y para proteger Ia seguridad de su hijo(a), no se
concederan excepciones a esta polftica.
Si tiene preguntas sobre esta polftica o sobre otros asuntos relacionados con Ia administraci6n de
medicamentos en las escuelas, por favor contacte a Ia enfermera de Ia escuela.
Gracias por su cooperaci6n.
(Revised 7/10)
48
Public Schools of Robeson County
Post Office Drawer 2909
Lumberton, North Carolina 28359
(910) 671-6000
Office of the Superintendent
School Name: ____________________
School Fax:__________________________________
Request for Medication Administration in School
To Be Completed By Physician (One medication per form)
Student ____________________________ DOB __________ School ____________________
Medication ____________________
Dosage _______________________________________
Purpose of Medication _____________________________________________________________
Time(s) Medication is to be given _____________________________________________________
Administration Dates: Begin: _____________________ Stop: ___________________________
Significant information (include side effects, toxic reactions, omission reactions, contraindications):
_______________________________________________________________________________
_______________________________________________________________________________
If an emergency situation occurs during the school day or if the student becomes ill, school officials
are to:
a. ______Contact me at my office _____________Telephone ______________________
b. ______Take child immediately to the emergency room at ________________________
c. ______ Other ____________________________________________________________
FOR SELF-ADMINISTRATION- Please complete this section:
YES ___NO ____ Student has demonstrated understanding of and ability to self-administer
asthma medication, diabetes medication, or medicine for anaphylactic reactions and may carry
_____MDI (*Metered Dose Inhaler)
____*MDI with spacer ___Epi-pen _____Insulin
*Parent/guardian must provide an extra inhaler to be kept at school in case of emergency.
A written statement, treatment plan and written emergency protocol developed by the student's health
care provider must accompany this authorization form in accordance with requirements stated in G.S.
115C-375.2
Student must have a self-medication treatment contract (to be completed at school).
All medication for use at school will be furnished by parent or guardian in a container properly
labeled by a pharmacist with identifying information, (e.g., name of child, medication dispensed,
dosage prescribed, and the time it is to be given or taken).
___________________________
Physician’s Signature
_________________
Date
___________________________________
Telephone
_____________________________________________________________________________________
Physician’s Address
49
PARENT'S PERMISSION
I hereby give my permission for my child (named above) to receive medication during school
hours. This medication has been prescribed by a licensed physician. I hereby release the School Board and
their agents and employees from all liability that may result from my child taking the prescribed medication.
This consent is good for the school year, unless revoked.
______________________________________
Parent/Guardian Signature
________________
Phone Number (s)
Approved: ________________________________
Principal’s Signature
Reviewed by: _________________________________
School Nurse’s Signature
_______________________________
Date
Date: ________________________
Date: _______________________
50
Public Schools of Robeson County
Required Annual Health Status Update Form
School Year
Dear Parent/Guardian:
In order to plan for your child's health care needs during school hours we need current health information. Please complete
and return to your child's teacher as soon as possible. Your child's health information may be shared with school staff as needed.
Student:
Birth Date:
School:
Age:
Grade/Teacher:
Gender: Male_____ Female ______
Parent/Guardian/Emergency Contacts
Relationship
Phone
st
Call 1
Home:
Cell:
Work:
nd
Call 2
Home:
Cell:
Work:
Student's doctor/healthcare provider: ________________________________Phone:_________________
Student's dentist: ___________________________________ Phone: _______________________
Does your child have any type of healthcare insurance (Medicaid, Health Choice, Private, etc)? __Yes ___No
If answered no to previous question, would you like more information on free/reduced health insurance? __Yes __No
INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH ANY OF THE FOLLOWING :
Health Condition
Severe Allergies (that require
emergency medical intervention)
Asthma
Diabetes
Seizure Disorder
Heart Condition
Hemophilia/Bleeding Disorder
Sickle Cell Anemia
Bowel/Bladder Issues
Migraine Headaches
Bone/Muscle Problems
ADD/ADHD
Mental Health
Behavioral Issues
Wears Glasses/Contacts
Hearing Loss
Other Serious Illness or Injury
Medication (Prescription or OTC)
Taken on a regular basis
Yes
No
Explanation if "Yes"
Check type of allergy(s) that apply:
Medication
Food
Bees/Insects
Other
Identify specific allergy(s):
Does your child require an Epipen? Yes
No
Date of last asthma attack:
Medication for asthma:
Does your child need this medicine at school? Yes
No
Type 2 (Oral medication) or
Type 1 (Insulin Dependent)
Prediabetes
Medication for diabetes:
Does your child need this medicine at school? Yes
No
Date of last seizure:
Medication for seizures:
Does your child need this medicine at school? Yes
No
Specify:
Treatment:
Specify:
Treatment:
Treatment:
Specify:
Triggers:
Treatment:
Activity Restrictions:
Specify:
Medication for ADD/ADHD:
Specify:
Treatment/Medication:
Glasses
Contacts ---For Distance
For Reading
Hearing Loss Left Ear
Hearing Loss Right Ear
Does your child wear a hearing aid(s)? Yes
No
Specify:
Date of Onset:
List (if not already listed above):
Please contact the school nurse of any change(s) in medication and/or health status of your child. If your child needs medication at
school, a medication form must be completed and signed by the parent and child's doctor. Please request a medication form
from your child's school office.
Parent/Guardian Signature
51
Rev. 05/2012
Procedure: Required Annual Health Status Update
Collection
Objective: Health information will be obtained
annually in order to meet students' health
care needs during school hours.
Methods:
 Each school will distribute the Required Annual Health Status
Update forms to students at the beginning of each school year
 Teachers will collect and review each form returned. Forms that
indicate health problems should be photocopied and the copies
forwarded to the school nurse for case management of the
student's health care needs.
 Within the first 30 days of school, teachers will file all original
forms in student's cumulative folders and discard forms from the
previous year.
 A Health Status Update form should be completed during
enrollment for students who enroll throughout the school year and a
copy should be forwarded to the school nurse if health problems are
indicated
52
STUDENT HEALTH REFERRAL FORM
Date,
_
School
To The: Nurse;
This student _______________________ of grade ______ needs professional medical
attention in respect to ___________________________________________________
(state observation finding above)
according to my observation.
Parents: _______________________________
Address_______________________________
Phone________________________________
Teacher ___________________
PLEASE SEND HEALTH CARD WITH ALL STUDENT REFERRALS
RESPONSE TO TEACHER
To Teacher:
Date _______________
My observations and findings are:
l. No evidence of ailment
( )
2. Evidence mentioned present
3. Other
( )
( )
Referred to:
1. Physician
()
2. Dentist
()
3. Orthopedic Clinic ( )
4. Other
( )
Nurse _______________________
53
PUBLIC SCHOOLS OF ROBESON COUNTY REPORT OF ACCIDENT OR INJURY
School: _______________________________ Date: _____________________________
Student's Name: ____________________________________________
Teacher: ___________________________________________________
Location of accident: _______________________________________
Nature of accident/injury: _____________________________________
Time of accident: ___________________________________________________
What was the injured child/student doing at the time of the accident? (Person completing report
should provide as much detail as possible. Attach additional documents if necessary)
Accident Reported By: ___________________________
Witnesses: _____________________________________
Describe the supervision present at the time of the accident:___________________
Was the parent/guardian contacted about this accident/injury?
Yes____No____Time______
Name of Parent / Guardian: __________________________
Address:_______________________________________________
Teacher's Signature: ________________________ Date: ______
Principal's Signature ______________________ Date: _______
A copy must be kept on file in the principal's office for future reference
54
INCIDENT REPORT
Directions: Complete the following with as much information that is available and forward
to the Central Office as per direction in memo.
School:__
Date of Report:______________
Date of Incident: ____________
Original report: Yes ________No
If "No" this is a follow-up- to original report of _________________________
Date
Description of Incident: __________________________________________________________
Descriptions of Person(s) involved: _________________________________________________
______________________________________________________________________________
Were Law Enforcement Officials notified? Yes_____ No_____ if yes,
What agency? ______________________
Were parents or guardians of student(s) notified? Yes ________ No ____
Description of Disciplinary Action taken as of this date: _________________________________
Additional pertinent information: ______________________________________________________
Completed by: _________________________________ Title: ________________________
A copy of the report must be kept in the Principal's Office for future reference.
55
PUBLIC SCHOOLS OF ROBESON COUNTY
PROCEDURES
CLASSROOM SUPPLEMENTAL VISUAL MATERIAL
USAGE
Movies, videos, clips, internet downloads, and etc. can be used only to enhance the teaching of
the North Carolina Standard goals/objectives for the grade/subject that they are to be used.
When using these resources, the following guidelines shall be followed strictly (no exceptions):
1. The supplemental visual material usage form must be completed, attached to the classroom
teacher's lesson plans, and approved by the principal before it can be used in the teaching of any
standards to students.
2. Movies, videos, internet downloads, etc. shall not be used with substitute teachers. Only
teachers may use these resources when prior approved in their lesson plans!
3. All visual resources must be appropriate for students (absolutely no R rated, PG-13, no
sexual content, no profanity, no racial slurs, etc.) The propriety of family values shall be used
part of the basis for selecting any resources to enhance the teaching and learning process in the
classrooms
4. All movies, videos, clips, etc. shall be previewed by the teacher to ascertain the
appropriateness of the content of the visual resource to be used.
5. Introductory discussion (alignment with the standards to be included), guided questions, and
post activities shall be implemented in correlation with any movie or video shown to students.
56
REQUEST FOR USE OF VIDEOS/DVDs
OR OUTSIDE RESOURCE PERSON
Teacher: ______________________________________________________
Date: ______________ Grade: ________ Subject Area: ________
Title of Video/DVD: __________________________________________
Purpose:
Educational______________ Pleasure: _____________
Objective: _________________________________________________
_________________________________________________
__________________________________________________
Evaluation: __________________________________________________
___________________________________________________
____________________________________________________
Outside Resource Person:
Name: _____________________________ Topic: _____________________________
Please list any safety concerns (allergies, questionable topics, conflicts of interest, etc.)
_______________________________________________________________________
_______________________________________________________________________
_________________________________________________________
Approved: __________ Denied: ________
Reason for Denial: ____________________________
Principal Signature: ___________________________
57
ST. PAULS ELEMENTARY SCHOOL FIELD TRIP
CHECKLIST
1.___ Field
Trip Request form has been given to the principal for approval.
2.___Activity bus/chartered bus arrangements have been made.
3.___Transportation Department has been contacted one week in advance to inspect chartered
buses. (739-4743 or 737-5266)
4. ___Transportation Consent Forms have been filled out within a 48 period prior to the school
sponsored event for any parent wishing to take an alternative mode of transportation for their
child. Completed forms have been given to Ms. Hathaway.
5. ___Bus drivers have been contacted to drive activity buses- (Chairperson Responsibility).
6. ___The cafeteria manager has been notified at least three weeks in advance so food preparation
can be started for the field trip.
7.___A roster including lunch numbers has been turned in on the the morning of the field trip to
cafeteria manager. The cafeteria manager can provide you with a roster if you do not have one.
Indicate on the roster who will need bag lunches. If a student is bringing his/her own lunch, please
indicate so a lunch will not be prepared for that student.
8.___Permission slips have been obtained from all students who are going on the trip. Please keep
all permission slip copies on file to the end of the school year. Anytime a student leaves off
campus, a permission slip is required.
9.___Chaperones have been contacted to help assist with the field trip. (1: 1 0 ratio)
10. ___All money has been receipted and turned in to the office. Deadlines for collecting trip
money must be established at least a week in advance. A grade level letter must be provided to the
parents notifying them of the deadline to pay for the trip. Chairpersons must make sure that the
selected deadline will allow cancellations of buses and reservations to be made without penalty.
11. ___All checks (for buses, tours, etc ...) have been signed by the principal prior to the day of the
field trip (Very Important). Please keep the check in a safe location. Receipts must be brought back
to the school for auditing purposes.
12.___A copy of all students going on the field trip has been submitted to the principal.
13. ___Arrangements have been made with other teachers to keep the students who are not going
on the trip. Please provide a list of these students and where they will be located to the office.
58
14.___A cellular phone has been secured (if possible) for emergency purposes on the field trip.
Leave cell number in the main office.
15.___ All lunch bags and milk have been counted to ensure that everyone receives a proper lunch
during the field trip. (No shortages please!)
16.___A cooler has been obtained for milk during the field trip. (Obtaining a cooler is the
responsibility of the teacher.)
17.___Student Emergency Information must accompany each teacher during the field trip in case
of accidents.
18.___If for any reason a field trip has been canceled, please notify the administration and cafeteria
manager as soon as possible. Reminder: If one- fourth of the students in the grade level are
unable to attend a field trip, then the trip must be canceled.
19. ___ If a trip is non-re-refundable, then the following words must be written at the top and the
parent has to sign in order for this rule to apply. “No Refunds/No Exceptions”
Teachers cannot keep a discipline problem student from participating in a field trip unless the
parent has been notified in writing prior to the event. You must give several weeks notice and
monitor behavior for improvement. Communicating with the parent and giving the parent a chance
to improve the situation is very important. If the behavior does not improve after contact has been
made, then the child will not be allowed to attend. Always keep a copy of the letters sent. Require
the parents to sign and return. Please make sure you are taking any required medications a student
may need during the field trip (inhalers, epi-pens, etc.) Students cannot miss their medications due
to a field trip.
59
THE PUBLIC SCHOOLS OF ROBESON COUNTY
FIELD TRIP INFORMATION
THE PUBLIC SCHOOLS OF ROBESON COUNTY FELD TRIP INFORMATION
SCHOOL:
DATE:
INFORMATION FOR ALL FIELD TRIPS
1.
Organization and sponsor(s) planning trip:
2.
Date{s) of trip:
3.
Destination(s):
4.
Educational value(s):
5.
6.
-.
Name(s) of teacher(s) accompanying students:
Name{s) of other chaperones) accompanying students:
7.
Number of students going:
B.
Grade level{s) of students:
9.
Arrangements for meal{s):
Boys
Gins
students will:
_Provide bag lunch
__ Eat at cafeteria/restaurant
Eat at “Fast Food Place”
$
Approximate cost per meal
- .
10.
Arrangements for transportation:
Private vehicle(s) driven by
School-owned vehicle(s) driven by licensed chauffeur(s):
Commercial carrier:_____ Bus:____
Other: _____
Cost of transportation per students: ____________
Time of departure_____
from:____________
Approximate time of return___
to:_______________
return_____-ret
return:_____return
60
Public Schools of Robeson County
Transportation Department
621 Kenric Road
Lumberton, NC 28360
Phone: 910-739-4743
Fax: 910-671-6009
To: Principals and Assistant Principals
From: Raymond Cummings, Transportation Director
Re: Approved Charter Bus List for SY 2010-2011
Date: May 5, 2011
Baker Charter &
Tours
Pembroke, NC
910-521-8717
910-827-2891
910-827-2788
910-827-2891
Fax-910-521-4900
Blue Star Tours
Cardinal Coach
Carolina American
Tours
Cross Country Coach
Holiday Tours
McKenzie L&W Bus
Lines
Miles Charter
Prestuge Charters &
Tours, Inc.
Selective Charter &
Tours
Travel Tours
Unlimited
Tyler Tours
Fayetteville, NC
Warsaw, NC
Fayetteville, NC
910-323-5079
Fayetteville, NC
Randleman, NC
Bladenbora, NC
910-323-2765
910-827-4747
910-485-0188
336-498-9000
910-648-2799
Newton, NC
Raleigh, NC
828-461-2022
919-552-2210
Bladenboro, NC
910-648-4235
910-797-5901
910-582-5899
704-975-4863
910-848-1668
910-528-0647
910-822-3252
Your Tours
Fayetteville, NC
Hamlet, NC
Raeford, NC
Fax: 910-858-0660
336-498-7569
910-648-2329
919-552-3027
910-648-2322
Same
Same
910-822-9932
61
CHECK OFF LIST THE
MORNING OF THE TRIP
 Student Emergency Information must accompany each teacher during the field trip in
case of accidents.
 A copy of all students going on the field trip has been submitted to the principal.
 St. Pauls Elementary School and Students will not be responsible for paying for staff,
family members and friends to attend a field trip. Like students, family members and
friends will be responsible for paying.

A list of students, who have paid to go on the trip, must be given to the book-keeper.
The book-keeper will be responsible for verifying these names in the receipt book for
auditing purposes.
 Arrangements have been made with other teachers to keep students who are not
going on the trip. Please provide a list of these students and where they will be
located to the office.
 Remember to bring a cell phone for emergency purposes on the field trip. Leave cell
number in the main office.
 All lunch bags and milk have been counted to ensure that everyone receives a proper
lunch during the field trip. (No shortages please!)
 A cooler has been obtained for milk during the field trip. (Obtaining a cooler is the
responsibility of the teacher.)
 Take any required medications a student may need during the field trip (inhalers,
Epi-pens, etc.) Students cannot miss their medications during to a field trip.
 Always make sure there is an adult monitor at the emergency exit doors on the bus.
 In case of accidents of emergencies, please notify the office at once so information
may be communicated with parents in a timely manner.
 Always do headcounts during any transition or before leaving any area during a field
trip. Assign students to partners. Tell students they are responsible for keeping up
with their partners.
62
PUBLIC SCHOOLS OF ROBESON COUNTY
PROPOSED SCHOOL SPONSORED TRIP INFORMATION FROM HOME
Name of Proposed Trip:
Date (s) of Trip:
Destination:
Time of Departure:
Cost Per Student:
Time of Return:
Mode of Travel:
1. As parent/guardian, I submit the following special health
considerations and instructions are needed for my son/daughter on
this trip (such as needed medication, information on history of
seizures, motion sickness, etc.)
2. Personal safety information> As parent/guardian, I certify that my
son/daughter requesting this trip has health/accident/medical
insurance coverage as follows:
School: Yes _________
No __________
Other Medical Insurance Coverage? If yes, list the company name
below:
Insurance Company
Name____________________ Policy# _____________________
(The school system is not
responsible beyond the
limits of insurance coverage)
3. As parent/guardian, I give permission to the chaperon to request
usual and customary medical or legal services for my son/daughter
if needed on this trip with the understanding that I will be
responsible for all such emergency costs not covered by insurance.
In case of an emergency, please call me at
Phone# ______________________________
4. I understand and agree to the conditions of the field trip as
described in “Information form school” and “Information from
Home” and give permission slip for
________________________________ to make this trip.
(Name of Student)
Signed: _____________________________________
_____________
(Parent/Guardian)
(Date)
63
Extended Trips
1. Detailed itinerary (dates, times, places for various activities):
Attach copy of itinerary.
2. Describe type of supervision planned for student during “free time”.
3. Five mode(s) of transportation to be used while at destination (bus.
Private vehicles, taxi, subway, etc.)
4. Name places of lodging and location on specific dates. Include
information on security and quality of lodging arrangements:
5. Financial arrangements for proposed trip:
a. Total anticipated cost: $ _____________
b. Cost per student: $________________
c. Cost per parent/teacher/chaperon: $_____________
d. Describe funding process: (sales, donations, assessments, etc.):
e. Describe process for generating funds for students unable to pay:
6. Is a field trip form on file for each participant? _____Yes
7.
_______________________
Principal Approval
_____No
________________
Superintendent’s Approval
Teacher’s Name ______________________________________________
64
PUBLIC SCHOOLS FO ROBESON COUNTY
TRANSPORATION TO AND FROM SCHOOL SPONSORED OR
SUPERVISED EVENTS CONSENT FORMS
___________________ (Student) is hereby granted permission to travel to
and/or form a school sponsored or supervised with
_____________________________ (Parent/Guardian).
The school sponsored or supervised event is designated as follows:
a. All school sponsored or supervised events; or
b. Only the following event: ________________________
The _______ day of ______________________
Parent/Guardian Statement:
Before signing the consent form, I acknowledge that I have been advised that I
must travel directly to and from the school sponsored or supervised event in
order for my son or daughter to be covered by the Catastrophic Insurance
Program in effect with the Public Schools of Robeson County. If I failed to
travel in my private vehicle directly to and from the school sponsored or
supervised event, I understand that the Catastrophic Insurance Program is not in
effect. By signing below I hereby acknowledge that I understand the coverage
and assume all responsibility for making sure that my son or daughter is in my
safe keeping to and/or from the school sponsored or supervised event.
_______________________
Parent/Guardian
____________________
Principal/Designee
______________________
Date
____________________
Date
Form must be signed within a 48 period prior to the school sponsored or supervised event, but not less
than six hours before the means of travel used by the PUBLIC SCHOOLS OF ROBESON COUNTY to
travel to the school sponsored or supervised event departs the school site, by parent/guardian and school
principal/designee.
65
USE OF YELLOW SCHOOL BUSES
The following process will be used when requesting the use of a yellow school bus.
 Yellow school buses are only used as a last resort when an activity bus can’t be retrieved.
 Use of yellow school buses for anything other than transporting student to and from school
must be approved by the superintendent’s designee, as well as payment must be paid within 30
days.
 Yellow school buses can’t be used for trips outside Robeson County.
 If your school has an activity bus, it must be used first before making a request to use a yellow
school bus.
 Unless it is a dire emergency, please refrain from making a request the day of the trip.
 When requesting a yellow school bus, the information below must be completed in its entirety
and faxed.
 All requests must be signed by the principal only.
Name of school _________________________________
Date(s) yellow bus to be used _____________________________
Reason for request (Name of event and location of event)
_________________________________________________
Number of buses requested ______________________________________
Identify the bus number/numbers _________________________________
The following efforts were made to use activity buses prior to making this request. List all schools, dates
requested, including requests for central office buses.
_________________________________________________________________
_________________________________________________________________
Principal’s Signature __________________________________
Date ___________________________________
Please include your FAX Number ________________ Approve ___Yes _____ No
Signature of Assistant Superintendent for Operations ________________________
 Upon approval a copy must be faxed to the Transportation Department to the attention of Alex
Leggett/Shop Foreman @ 910-671-6009
FOR SCHOOL USE ONLY
Beginning Odometer Reading ______ Ending Odometer Reading_______
Total Miles ____________________ Multiply Total miles Xs $1.72 to figure
the Invoice Amount
Total Miles Driven
X $1.72
Total Due _____________________ INVOICE INVOICE INVOICE
 Upon return of trip, return completed from along with payment, for the amount due to the
PUBLIC SCHOOLS OF ROBESON COUNTY TRANSPORTATION DEPARTMENT. Please
make check payable to the Transportation Department to the attention of Elaine Carter Griffin/Cost
Clerk.
Revised July 2015
66
PUBLIC SCHOOLS OF ROBESON COUNTY
ACTIVITY BUS REQUEST
Instructions: Complete this application and forward to the Environmental Office a minimum
of five (5) working days prior to the requested date for use. Section B will be completed by
office Personnel, and a copy returned to you as your confirmation of availability or nonavailability of a bus. The school will be invoiced at the rate of $1.50 per mile plus any
driver’s salary paid by Board of Education.
Phone: 910-735-2286
Fax: 910735-2493
Section A: To Be Completed By Applicant:
Date Submitted: ____________
School: __________________________
Requested By: ______________
Purpose of Trip: ___________________
Destination: ________________
Date(s) To Be Used: Pickup ______________ Returned: _________________
Time To Be Used: Pickup _______________ Returned: __________________
Need Bus With Wheel Chair Accommodations: ______________ Number of Buses Needed:
________
Section B: Status of Request
(To Be Completed By Office Personnel)
_________Approved
__________Disapproved
Date: ____________
Bus Assigned: ___________________
Fax: _____________
Section C: This section is to be completed, by driver of the Activity Bus and returned (with
keys) to Dannie Chavis’ office upon return of the bus.
Bus Picked Up:
Date: ___________________ Time: ____________
Bus Returned:
Date: ___________________ Time: ____________
Cleanliness of bus upon return: Interior _____________ Exterior ______________
Gasoline Level (Circle One): Empty
¼ Full
½ Full
¾ Full
Full
Was gasoline charged to Central Office Account? YES _____ No _______ (Attached
Tickets)
Describe any mechanical or other concerns that were observed or encountered.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
______________Ending Odometer Reading Upon Return
______________ Beginning Odometer Reading At Pickup
______________ Total Miles Driven
Driver’s Signature: _______________
Section D: To be completed by Central Office Personnel
______________ Miles at $1.50 per mile
Invoice
Driver’s Salary (If Applicable)
____________
Total Due
____________
Please make checks payable to: The Public Schools of Robeson County
(Revised August 3, 2009)
67
TUTORING/EXTRA BUS USE MILEAGE FORM
School _____________________________________________
Driver’s Name _______________________________________
Budget Code: ______________________
Circle Appropriate Program for Payment
st
21 Century
Credit Recovery
After School Tutoring
Summer School Remediation
Occupation Prep
Saturday Academy Other _______________
TO BE TURNED IN AT THE END OF EACH MONTH
Day
Date
Starting
Time
Ending
Time
Beginning
Mileage
Ending
Mileage
Total
Miles
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Total Miles
PLEASE 1- CIRCLE APPROPRIATE FUNDING SOURCE. 2- TOTAL MILES 3-TURN IN AT
THE END OF EACH MONTH TO Elaine Carter Griffin @ Transportation
68
PUBLIC SCHOOLS OF ROBESON COUNTY
INTERNET USE AGREEMENT
Please read this document carefully before signing.
Internet access is now available to students and teachers in the Public Schools of Robeson County.
We are very please to bring this access to the Public Schools of Robeson County and believe that Internet offers vast, diverse,
and unique resources to both students and teachers. Our goal in providing this service to teachers and students is to promote
educational excellence in schools by facilitating resource sharing, innovation, and communication.
The Internet is an electronic highway connecting thousands of computers ail over the world and millions of individual
subscribers. Students and teachers have access to:
1) Electronic mail communication with people all over the world.
2) Information and news from NASA as well as the opportunity to correspond with the scientists at NASA and other
research institutions.
3) Public domain software and shareware of all types.
4) Discussion groups on a plethora of topics ranging from Chinese culture to the environment to music to politics.
5) Access to many University Library Catalogs, the Library of Congress and ERIC.
With access to computers and people all over the world also comes the availability of material that may not be considered to
be of educational value in the context of the school setting. The Public Schools of Robeson County has taken precautions to
restrict access to controversial materials. However, on a global network it is impossible to control all materials and an
industrious user may discover controversial information. We (Public Schools of Robeson County) firmly believe that the
valuable information and interaction available on this worldwide network far outweighs the possibility that users may
procure material that is not consistent with education goals of the District.
Internet access is coordinated through a complex association of government agencies, and regional and state networks. In
addition, the smooth operation of the network relies upon the proper conduct of the end users who must adhere to strict
guidelines. These guidelines are provided here so that you are aware of the responsibilities you are about to acquire. In general
this requires efficient, ethical, and legal utilization of the network resources. If a Public Schools of Robeson County user
violates these provisions, his or her account will be terminated and future access could possibly be denied. The signature(s) at
the end of this document is (are) legally binding and indicates the party (parties) who signed has (have) read the terms and
conditions carefully and understand(s) their significance.
INTERNET-TERMS AND CONDITIONS
1. Acceptable Use - The purpose of NSFNET, which is the backbone network to the Internet, is to support research and
education in and among academic institutions in the U.S. by providing access to unique resources and the opportunity
for collaborative work. The use of your account must be in support of education and research and consistent with the
educational objectives of the Public Schools of Robeson County. Use of other organization's network or computing
resources must comply with the rules appropriate for that network. Transmission of any material in violation of any
US or state regulation is prohibited. This is included, but is not limited to: copyrighted material, threatening or
obscene material, or material protected by trade secret. Use of commercial activities is generally not acceptable. Use
for product advertisement or political lobbying is also prohibited.
2. Privileges - The use of the Internet is a privilege, not a right, and inappropriate use will result in a cancellation of those
privileges. (Each student who receives an account will be part of discussion with a Public Schools of Robeson County
69
faculty member pertaining to the proper use of the network). The system administrators will deem what is appropriate use
and the decision if final. Also, the system administrators may close an account at any time as required. The administration,
faculty, and staff of Public Schools of Robeson County may request the system administrator to deny, revoke, or suspend
specific user accounts.
3. Network Etiquette - You are expected to abide by the generally accepted rules of network etiquette. These include (but
are not limited to) the following:
a) Be polite. Do not get abusive in your messages to others.
b) Use appropriate language. Do not swear, use vulgarities or any other inappropriate language. Illegal
activities are forbidden.
c) Do not reveal your personal address or phone numbers of students or colleagues.
d) Note that electronic mail (e-mail) is not guaranteed to be private. People who operate the system do have access
to all mail. Messages relating to or in support of illegal activities may be reported to the authorities.
e) Do not use the network in such a way that you would disrupt the use of the network by other users.
£) All communication and information accessible via the network should be assumed to be private property.
4. The Public Schools of Robeson County makes no warranties of any kind, whether expressed or implied, for the service it is
providing. The Public Schools of Robeson County will not be responsible for any damages you suffer. This includes loss of
data resulting from delays, non-deliveries, mis-deliveries, or service interruptions caused by its own errors or omissions.
Use of any information obtained via the Internet is at your own risk. The Public Schools of Robeson County specifically
denies any responsibility for the accuracy or quality of information obtained through its services.
5. Security - Security on any computer system is a high priority, especially when the system involves many users. If you feel
you can identify a security problem on the Internet, you must notify a system administrator or your District Internet
Coordinator. Do not demonstrate the problem to other users. Do not use another individual's account without written
permission from that individual. Attempts to logon to the Internet as a system administrator will result in cancellation of
user privileges. Any user identified as a security risk or having a history of problems with other computer systems may be
denied access to Internet.
6. Vandalism - Vandalism will result in cancellation of privileges. Vandalism is defined as any malicious attempt to harm or
destroy data of another user, Internet, or any of the above listed agencies or other networks that are connected to the
NSFNET Internet backbone. This included, but not limited to, the uploading or creation of computer viruses.
70
PUBLIC SCHOOLS OF ROBESON COUNTY EMPLOYEE LEAVE
FOR PARENT INVOLVEMENT IN SCHOOLS APPLICATION
Employee’s Name: __________________________Date: ________________
Worksite Name: _________________________________________________
Requested Participation Date: ______________________________________
Time Requested to be Away From Worksite: From: ___________ To:__________
Purpose for School Visit: __________________________________________
Employee’s Signature: ____________________________________________
Principal/Supervisor’s Signature: ____________________________________
Visiting Site Principal’s Signature: ___________________________________
NOTE: All employees should submit a leave form to their
Principal/Supervisor at least 48 hours before time
desired to be away from work. Leave request forms
should be kept on file by the Principal/Supervisor
at the employee’s worksite.
71
PINEY GROVE ELEMENTARY SCHOOL
STUDENT INFORMATION SHEET
2015-2016
Student’s complete name (Name on Birth Certificate)
__________________________________________ Student Race ____________
Student’s Teacher_____________________________ Student’s Grade_________
Student’s Birth Date: ___________________________
Student’s Social Security Number: ______________________________________
Student’s Complete Address ___________________________________________
Student’s 911 Address________________________________________________
Student’s Phone No. ____________________Parent’s No.__________________+
Parent’s Email Address_______________________________________________
Mother’s Full Name _________________________________________________
Work Place ______________ Work No. _____________
Father’s Full Name___________________________________________________
Work Place________________________ Work No.____________________
Name of Parent/Guardian with Whom Student is Residing:
____________________________________Relationship__________________
Does student have any siblings attending St. Pauls Elementary? ____________________
If yes, list names and grades_________________________________________
________________________________________________________________
________________________________________________________________
Persons to Contact in Case of Emergency:
Name___________________________ Phone No.____________________
Name___________________________ Phone No.____________________
(c) Name___________________________ Phone No.____________________
14. Doctor’s Name ______________________ Phone No._____________________
Dentist’s Name_______________________ Phone No._____________________
Please provide directions from St. Pauls Elementary School to student’s home address.
72
Public Schools of Robeson County
NOTICE
Release of Student and Directory Information
Stl1dent and Directory Information is specific identifying data about Ii student designated by a school system as that which
can be shared with others who have the need to know without parental consent. Student and Directory Information is not
considered critical to a student's privacy rights and may be disclosed under certain circumstances without obtaining written
consent as long as parents are informed through public notice of the type of information designated. Parents have the right to
refuse disclosure of Student and Directory Information but must do so in writing.
Schools release Student and Directory Information on a routine basis for honor rolls, graduation lists, athletic team lists,
school pictures, etc. Additionally, infom1atiol1 about your child may appear in various ways such as newspaper articles, 011
television broadcasts, in radio broadcasts, on displays, or in District and/or school brochures and newsletters. Agencies,
organizations and businesses that have a documented need to know information also receive Student and Directory
Information.
Student and Directory Information eligible for release includes: a student's name, address, telephone listing, date and place
of birth, major field of study, participation in activities and sports, weight and height of members of athletic teams, dates of
attendance, degrees and awards received, the most recent prior school attended, and similar information.
The National Defense Authorization for Fiscal Year 2002 requires access by military recruiters to students, under
certain conditions, and to secondary school students names, addresses, and telephone listings unless the parent chooses to opt
out and signs the request to not release Student and Directory Information.
You may choose not to have your child's Sl11dent and Directory Information released by the school by completing the
OPT OUT request form below.
Parental Opt Out Request
To Not Release Student & Directory Information
I choose not to have Student and Directory Information for my child (ren)
Student Name (s)
released by the school I understand by completing this request that my child=s Student and Directory Information will not be released.
Date ___________________________
Parent’s Signature __________________________
Student Signature ___________________________
(If I8 years of age or older)
Please return this form to your child’s school within ten (10) days.
73
Child Custody Issues:






Teachers, remember that the parent with primary custody will be the major person making
decisions concerning the child. The primary custodial parent has the right to determine who has
access to a child. Refer to custody sheets.
The person with secondary custody (weekend visits, etc) cannot determine whose name goes on
the student access sheets. Secondary custody only gives that parent access to school records and to
the teacher (scheduled visits). Parents with secondary custody cannot visit the child, eat lunch with the
child, etc., during the instructional day unless the court papers state otherwise. Parents with secondary
custody can attend PTOs, Parent Nights, etc.
If parents share custody of the child (joint custody), both parents have equal rights. Both parents
may add whom they want to the sheet (joint custody).
Do not provide written statements to parents who are involved in custody battles. Teachers must
remain impartial to both parents. The school will only get involved if you are subpoenaed by a
judge (not a lawyer). The social worker will also be utilized to handle situations such as these.
Only share information concerning the child to the people who have custody of the child. Do not
involve boyfriends, girlfriends, grandparents, etc. This way you know you have not violated any
FERPA laws.
If you have any questions, concerns, or uneasy feelings, do not release the child to leave school
grounds with questionable adults. Contact the legal parent/guardian instead. Remember to
practice safety first.
74
Teacher ____________________________
STUDENT
NAME
1.
WHO CAN HAVE
ACCESS TO
STUDENT
Grade _____________
WHO CANNOT HAVE
ACCESS TO
STUDENT
Parent (s) __________
2.
3.
4.
5.
ARE
CUSTODY
PAPERS ON
FILE?
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
2.
Parent (s) __________
2.
3.
4.
5.
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
3.
Parent (s) __________
2.
3.
4.
5.
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
4.
Parent (s) __________
2.
3.
4.
5.
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
5.
Parent (s) __________
2.
3.
4.
5.
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
6
Parent (s) __________
2.
3.
4.
5.
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
7.
Parent (s) __________
2.
3.
4.
5.
Yes ________
No ________
Is there a custody issue?
Yes ___ No ____
75
Students who have Custody Issues/Disputes
Teacher’s Name: ____________________________________________
Grade: ____________________ Year: ________________________
Student’s Names
Custodial Parent/Guardian
76
ST. PAULS ELEMENTARY SCHOOL
DIRECTIONS:
NAME
CUMULATIVE FOLDER VERIFICATION SHEET
Write student names in appropriate section. Place a check (√) if
information is in place. Place an (X) if information is missing.
Teacher must contact parents about missing information.
Birth
Certificate
Social
Security
Card
Immunization
Record
Standardized
Test Records
Permanent
Health Record
My signature verifies that I have closely inspected the following folders assigned to me. My signature also verifies the
following information is located in the folders.
Teacher Signature _________________________________ Date ________________
77
Cumulative Records
Check Off Sheet
















File Label (Outside
Folder)____
Custodial
Orders____________
Attendance Report & Report
Card___________
Inspection Log (Green
Form)_____________
SSMT Checklist (If
Applicable)______________
Student Information Sheet
(Recent)___________
Personal Data Sheet
_____________
Scholastic Record (White)
____________
Standardized Test Record
(Yellow) _____________
PSRC Reading Sheet
___________________
Student Language Survey
_________________
Health Status Card/Folder
(Salmon) _____________
Required Annual Health
Status ______________
K-Health Assessment (Blue)
_______________
Copy of Certified Birth Cert.
_____________
Immunization Record
__________________
Copy of Social Security Card
____________
Authorization for Release of
Student Health
Information_______________
Other Health Related Records
EAPs, PEPs
______________
K-2 Assessments (K-2 Only)
_______________
Teacher’s Initials
_________________
Counselor’s Initials
_____________________
Cumulative Records
Check Off Sheet
















File Label (Outside
Folder)____
Custodial
Orders____________
Attendance Report & Report
Card___________
Inspection Log (Green
Form)_____________
SSMT Checklist (If
Applicable)______________
Student Information Sheet
(Recent)___________
Personal Data Sheet
_____________
Scholastic Record (White)
____________
Standardized Test Record
(Yellow) _____________
PSRC Reading Sheet
___________________
Student Language Survey
_________________
Health Status Card/Folder
(Salmon) _____________
Required Annual Health
Status ______________
K-Health Assessment (Blue)
_______________
Copy of Certified Birth Cert.
_____________
Immunization Record
__________________
Copy of Social Security Card
____________
Authorization for Release of
Student Health
Information_______________
Other Health Related Records
EAPs, PEPs
______________
K-2 Assessments (K-2 Only)
_______________
Teacher’s Initials
_________________
Counselor’s Initials
_____________________
Cumulative Records
Check Off Sheet
















File Label (Outside
Folder)____
Custodial
Orders____________
Attendance Report & Report
Card___________
Inspection Log (Green
Form)_____________
SSMT Checklist (If
Applicable)______________
Student Information Sheet
(Recent)___________
Personal Data Sheet
_____________
Scholastic Record (White)
____________
Standardized Test Record
(Yellow) _____________
PSRC Reading Sheet
___________________
Student Language Survey
_________________
Health Status Card/Folder
(Salmon) _____________
Required Annual Health
Status ______________
K-Health Assessment (Blue)
_______________
Copy of Certified Birth Cert.
_____________
Immunization Record
__________________
Copy of Social Security Card
____________
Authorization for Release of
Student Health
Information_______________
Other Health Related
Records
EAPs, PEPs
______________
K-2 Assessments (K-2 Only)
_______________
Teacher’s Initials
_________________
Counselor’s Initials
_____________________
78
ST. PAULS ELEMENTARY SCHOOL
Awards Ceremony Invitation
________________________
Date
Dear Parent(s) / Guardian(s),
Your child, ___________________________________, will be receiving an award /
special recognition on _________________ at ______________. You are
Date
Time
cordially invited to attend this joyous occasion in the school gym.
Please join us.
____________________
Teacher
ST. PAULS ELEMENTARY SCHOOL
Awards Ceremony Invitation
________________________
Date
Dear Parent(s) / Guardian(s),
Your child, ___________________________________, will be receiving an award /
Special recognition on ___________________ at ______________. You are
Date
Time
cordially invited to attend this joyous occasion in the school gym.
Please join us.
______________________
Teacher
79
ST. PAULS ELEMENTARY SCHOOL
222 Martin Luther King Jr Dr
St. Pauls NC 28384
Telephone - 910 865-4103
Fax – 910-865-3730
Dr. Jill Hathaway
Principal
2016-2017
CORPORAL PUNISHMENT
At the present time, St. Pauls Elementary School discourages the use of corporal
punishment as a means of discipline. However, in order to become compliant with State
Board Policy, the following infractions may result in the use of corporal punishment
being administered to a student as a last resort only.
1. Fighting
2. Using inappropriate or vulgar language
3. Displaying blatant disrespect for teachers and other school personnel
4. Skipping School
5. Creating an unsafe situation at school
6. Creating an unsafe situation on the school bus
7. Other actions not mentioned above that have the potential to endanger the safety
and welfare of students and staff as deemed by the principal
A student will receive no more than three licks to the buttocks with a paddle
if corporal punishment is administered.
_____ Yes, I agree for my child to receive corporal punishment.
______ No, I do not want my child to receive corporal punishment.
Child’s Name _______________________________________________
Teacher ________________________
Grade ___________________
Parent Signature _____________________________________________
Date ___________________ Home Phone # _______________________
Work Phone # _______________ Cell Phone # ____________________
Please Submit copy IMMEDIATELY to Central Office
School Name: _____________________________ School# ______________
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CORPORAL PUNISHMENT REPORT
Date: __________________________
Student Name: _______________________
Student’s Identification # (Power School) _____________________ SS#_________________
Sex: _____ Race: ________ Grade: ____________ Age: ___________
Program: ________________ Regular: _______________ Exceptional: ____________
(Specify) ____________________
Corporal punishment was administered to the above student for the following reasons:
INCIDENT CODE: ________________
ACTION CODE: __________________
Description of Punishment: ____________________________________________________
___________________________________________________________________
Previous Action Taken:
Held conference with student
Sent written report home
Consulted with counselor
SSMT
Held conference with parent
Detention/ISS
Corporal Punishment
Other:
Official administering punishment: ____________________________________
Official’s Job Title: _________________________________________________
_________________________________
Signature
_______________
Date
_________________________________
Witness’ Name
_______________
Date
________________________________
Witness’ Signature
_______________
Date
______________________
Principal’s Signature
Copies: Parent -White
Superintendent- Yellow
School- Pink
81
GRADE PLACEMENT FOR THE NEXT SCHOOL YEAR
Student Name
Grade Placement for the Next Year
Directions: Please circle the corresponding
information for your student. Meet as a grade
level to distribute students evenly based on the
following characteristics:
Student Name
Grade Placement for the Next Year
Directions: Please circle the corresponding
information for your student. Meet as a grade
level to distribute students evenly based on the
following characteristics:
RACE/ETHNICITY
RACE/ETHNICITY
African American
African American
American Indian
American Indian
Asian
Asian
Caucasian
Caucasian
Hispanic
Hispanic
GENDER
GENDER
Male
Male
Female
Female
ACADEMIC ACHIEVEMENT
LEVEL
High
AIG Medium
EC
ACADEMIC ACHIEVEMENT
LEVEL
High
AIG Medium
EC
Low
SPEECH
Low
MEDICATION
ADMINISTRATION
Yes
No
EAP
MEDICATION
ADMINISTRATION
Yes
No
EAP
CUSTODY ISSUE
Yes
SPEECH
No
Separate from the following
students:__________________________________
CUSTODY ISSUE
Yes
No
Separate from the following
students:__________________________________
82
PBIS Referral Forms
To provide each student the opportunity to make wise choices in their behavior, two new
referral forms have been created for St. Pauls Elementary School. The OFFICE REFERRAL
FORM will be implemented for administration discipline referral. Our new form, Low Level
Referral Form will give the teacher the tool for reflection on a student’s behavior. Three
offenses must be recorded on the Low Level Referral Form before a student is sent to the office.
Reflective questions a teacher can ask are: Is the negative behavior occurring mostly outside
the classroom, at a particular area, with a resource(s), or on a particular day. This form allows
the teacher to determine if specific variables are connected to the negative behavior and what
can be done to correct the behavior BEFORE referring the student to administration.
PGS’s administration hopes this will eliminate negative behavior so that a positive and
educational environment will be maintained.
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ST. PAULS ELEMENTARY SCHOOL OFFICE REFERRAL FORM
Student Name:
Grade:
Parent/Guardian Name:
NC Wise Number:
DOB:
Race:
Date Of Incident:
Time of Incident:
Address:
Number of Office Referrals:
Location of Incident:
Phone Number:
Level I (deal w/in classroom)
Number of Referrals: ____
Level II (deal w/in classroom)
Number of Referrals: ____
Comments: __________________________________________
____________________________________________________
____________________________________________________
Level I and Level 11 Offenses
__ Uncooperative Behavior
__ Failure to follow Classroom Rules
__ Running (inside building/classroom)
__ Failure to follow Playground Rules
__ Possession of non-school related items
__Talking
__ Put Downs
__ Cheating
Consequences for Level III Offenses:
_____Contact Parents/Guardian
_____Administrative Conference
with parent/guardian
_____Parent Escort at School
_____Suspension
_____Restitution
_____RTI Procedures
Level III (Send to the Office)
_____Chronic Level II Behaviors
_____Continued Disrespect to Adults
_____Directed Profanity
_____Fighting/Aggressive Behavior
_____Stealing
_____Vandalism
_____Bullying
_____Possession of or under the
Influence of drugs or
inappropriate items
_____Self-injurious threats & actions
_____Other
Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
__ Inappropriate Gestures
__ Unsafe Rough Play
__ Out of Assigned Area
__ Unacceptable Language
__ Talking
__ Put Downs
__ Littering/Chewing Gum
__ Other _________
Comments:
____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Action Taken by Administration/Comments:
How were you engaged at the time of the incident?
Circle to indicate student’s general academic performance:
Above
Average
Slightly
Average
Below
Well
Below
Teacher Signature:________________________ Parent Signature:______________________________
Principal Signature:_____________________ Reporter Signature:______________________________
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St. Pauls Elementary School Low Level Referral Form
Student: ______________________ Staff Member: ________________________ Date: ______________
4th
st
1 Incident
Location
o
o
o
o
o
o
o
Classroom
Hallway
Cafeteria
Bathroom
Playground
Bus
Other
Date:
Problem Behavior
o
o
o
o
o
o
o
2nd Incident
Location
o
o
o
o
o
o
o
Classroom
Hallway
Cafeteria
Bathroom
Playground
Bus
Other
Date:
Problem Behavior
o
o
o
o
o
o
o
3rd Incident
Location
o
o
o
o
o
o
o
Classroom
Hallway
Cafeteria
Bathroom
Playground
Bus
Other
Possession of non-school items
Out of assigned area
Inappropriate gestures
Failure to follow school rules
Uncooperative behavior
Non-directive profanity
Disrespect to adults
Possession of non-school items
Out of assigned area
Inappropriate gestures
Failure to follow school rules
Uncooperative behavior
Non-directive profanity
Disrespect to adults
Date:
Problem Behavior
o
o
o
o
o
o
o
Possession of non-school items
Out of assigned area
Inappropriate gestures
Failure to follow school rules
Uncooperative behavior
Non-directive profanity
Disrespect to adults
Time:
Staff Intervention Administered
o
o
o
o
o
o
o
o
Clarified how behavior did not meet expectations
Re-taught/practice the behavior skill: Class/group
Identified environmental predictors
Utilized pre-correction techniques
Established a behavioral cue/prompt
Provided a structured choice
Reviewed common assessment data
Contacted parent: ____/___ Phone call/Copy sent
Time:
Staff Intervention Administered
o
o
o
o
o
o
o
o
Clarified how behavior did not meet expectations
Re-taught/practice the behavior skill: Class/group
Identified environmental predictors
Utilized pre-correction techniques
Established a behavioral cue/prompt
Provided a structured choice
Reviewed common assessment data
Contacted parent: ____/___ Phone call/Copy sent
Time:
Staff Intervention Administered
o
o
o
o
o
o
o
o
Re-taught/practiced the behavior skill (one-on-one)
Modified environment based on identified predictors
Identified the possible function of the misbehavior
Provided a structure choice
Reviewed discipline data for patterns and trends
Met with team/student to identify additional supports
Collaborated with team/counselor/admin
Met with parent: ____/___ School/Home
Incident- See Attached Office Referral Form
85
PUBLIC SCHOOLS FO ROBESON COUNTY
STUDENT/PARENT/TEACHER AGREEMENT
The State Board of Education and the Public Schools of Robeson County Board of Education have
adopted policies requiring students to meet state and local standards for promotion and for graduation
from high school. Both boards believe that learning can take place best when there is effort, interest, and
motivation by students, parents, and staff. This agreement is intended to bring about a unified effort to
improve the education of all K-12 students.
We are committed to _________________________________ ‘s success in school and promise to work
together to promote his/her achievement.
As a student St. Pauls Elementary School, I will…
 Respect myself and the rights of others;
 Attend school regularly;
 Follow the Code of Student Conduct;
 Come to school dressed appropriately, with necessary materials, and prepared to work;
 Ask my teacher when I do not understand ; and
 Complete all of my assignments on time.
Signed: ___________________________________
Date: _________________________________
As the parent of _____________________________________, I will…
 Provide ample, quiet study time at home and encourage good study, habits;
 Make sure my child is well-rested and at school on time;
 Support the school staff in their efforts to promote appropriate behavior;
 Encourage my child to read more;
 Monitor my child’s homework;
 Read, sign and return my child’s progress reports; and
 Attend parent/teacher conferences as requested.
Signed: ____________________________________
Date: _________________________________
As a classroom teacher in St. Pauls Elementary School, I will …
 Explain my expectations, instructional goals, and grading system to the student and parent;
 Teach the standards and objectives set and developed by the State of North Carolina
 Provide a climate in my classroom that is conductive to learning;
 Communicate with parents through conferences, progress reports, and by telephone;
 Employ various teaching methods which work best for the student; and
 Provide enrichment and remediation opportunities for the student as needed.
Signed: __________________________________
Date: _______________________
The principal of your child’s school is committed to providing a sage and orderly environment that is
conductive to learning. As the instructional leader of the school, he/she will support the teachers in their
efforts to teach all students. Opportunities for the establishment and attainment of high expectations will
be made available to all students.
Parent involvement is essential as we work to give your child the best educational experiences possible!
86
ST. PAULS ELEMENTARY SCHOOL’S
GRADING POLICY
To: Parents of St. Pauls Elementary School
From: The Curriculum Committee
Date: August 24, 2015
The school-wide grading policy will be in the form of letter and number grades. A variety of assessments will
be used to determine a grade. Kindergarten, first, and second grade students will be graded with the
following number grades:
4=Excels at Grade Level
S=Satisfactory
3= On Grade Level
N= Needs Improvement
2= Below Grade Level
/= Not assessed at this time
1= Not yet meeting expectations
Grades three through six will be graded with the following letter scale for English/Language Arts, Math,
Science, and Social Studies:
A= 4.0 (90-100)
D= 1.0 (60-69)
B= 3.0 (80-89)
F= 0.0 (59 and Below)
C= 2.0 (70-79)
*IP= In Progress
*The grade of IP (In Progress) will be assigned when a student has not completed the required work in the nineweek grading period. The student will have the next nine-week grading period in which to complete the work. If
the work is not completed during that time, the IP will become an F.
Conduct letter grades will be: S=Satisfactory N= Needs to Improve U= Unsatisfactory
Music, Art, & Physical Education will be graded with the following scale: S= Satisfactory
N= Needs to Improve
U= Unsatisfactory
Report Cards will be issued at the end of each nine-week grading period. Progress reports will be sent home
mid-point of each grading period. The Parent-Student Handbook contains a calendar of the dates for Progress
Report and Report Cards. Each grade level will send home a grading criteria.
Grading Criteria
1/3 (One Third) of the grade:
Tests and other assessments
2/3 (Two Thirds) of the grade:
Presentations, classwork, homework, and special class assignments.
ACADEMIC RECOGNITION
Students with meet the criteria set forth by the Incentive Committee will be recognized at the end of each
Nine-Week period. Honor Roll and perfect Attendance Certificates will be given to students at the end of
each nine week reporting period. Student names will also be submitted to the newspaper for special
recognition. Students who make the honor roll and who receive an “S” in conduct and work habits will
participate in Pioneer Incentive Day. An awards program will be held at the end of the school year to
recognize students for their academic achievement.
******************************************************************************************
_____ I have read and understand the grading policy of St. Pauls Elementary School.
________________
Student Name
___________
Grade
_______________________
Teacher
_________________________
Parent/Guardian Signature
87
ST. PAULS ELEMENTARY SCHOOL
Substitute Folder
Substitute Folders will be kept in the office. Substitute Folders need the following information.













Seating Chart
School daily schedule
Tardy bell and dismissal schedules
Lunch schedule
Procedures for emergency drills
Schedule for non-instructional duty
Emergency lesson plans
Medical information for designated students
Emergency Acton Plans (EAPs) for designated students
Legal custody of certain students
Bus schedule and list of bus students and bus numbers
List of how students depart: car, daycare, after school care, bus, etc.
List of students in special programs and scheduled times: speech, AIG, resource, Battle of
the Books, etc.,
 Procedures of attendance roster/Power School
 Copy of classroom rules
 Collecting student money- Substitutes are NOT ALLOW to handle money.
Chairpersons are to collect student money and write receipts. See
______________________ for handling money.
(Staff Member)
88
ST. PAULS SCHOOL
PURCHASE ORDER CHECKLIST
 Purchase orders are used when funds given by the Board of Education are utilized.
 All purchase orders must be typed. Please see Mrs. Usher for template.
 Tax, shipping/handling, and a budget code number company phone numbers and
faxes must be listed on every purchase order. (If company does not charge shipping,
asked secretary if the budget code still require 10% shipping).
 Make sure the items will be sent to YOUR ATTENTION at St. Pauls Elementary
School.
 Once type email to Mrs. Usher ([email protected]) .
 All purchase orders must be signed by the principal.
 Completed purchase orders (all pages in tack) are sent by Mrs. Usher to the correct
personnel at the BOE.
 Mrs. Usher holds the green sheet until the items arrive. Once the items arrive, YOU
must check to see if everything has arrived. If the order is complete. The green sheet
must be signed and dated by YOU. Mrs. Usher will then return the green sheet
back to the BOE. When the green sheet is returned, the BOE will know to quickly
pay the bill.
 If all items have not arrived, the procedure is for YOU to call the company to
inquire about the arrival date. The green sheet is held until all materials arrive. The
company cannot get paid until the green sheet is returned with YOUR signature to
the BOE.
 If the green sheet is held too long at the school (for no reason) then system can
receive bad credit.
89
ST. PAULS ELEMENTARY SCHOOL
PRIOR APPROVAL CHECKLIST
For Reimbursement Purposes
(Workshops, Conferences, Gas, Hotel. Food,
Substitutes, and Registration Cost
Directions: Follow these directions when assigned to attend any conference/workshop.
 Prior Approval Forms must be filled out two weeks prior to any conference/workshop
that you will be attending (See Ms. Hathaway for Prior Approval Forms.)
 Sub Information: Workshop must be documented on the blue card in the office.
Immediately inform the secretary that you will be out on specified days and will
need a sub.
 After completing Prior Approval form (front page only), give it to Ms. Hathaway for her
signature and to determine what funding will be used. (The office will be responsible for
submitting prior approval to BOE.)
 Conference participants are responsible for reserving hotel rooms and confirming
registration.
 After attending conference/workshop, participant must see Dr. Hathaway to complete the
back section of the prior approval. This must be done within 10 of returning from
conference/workshop. (Dr. Hathaway should not have to contact you.) Note: No one will
be reimbursed unless this section is completed. All receipts for registrations, hotel,
and parking must be attached to the back of prior approval form.
 If the school pays your registration fee, it is YOUR RESPONSIBILITY to reimburse
the school after the BOE reimburses you. Failure to reimburse the school will result in
your paycheck being withheld.
Dr. Hathaway will always keep a copy of prior approvals in a notebook in her office.
90
ST. PAULS ELEMENTARY SCHOOL
222 Martin Luther King Jr. Dr
St. Pauls, NC 28384
Telephone: 910-865-4103
Fax: 910-865-3730
To: ____________________________________
From: Dr. Jill Hathaway, Principal
Re: Immunization/Health Assessments/Certified Birth Certificate
Date: ___________________________________
The State of North Carolina requires all Kindergarten students to receive proper immunization and a physical
within 30 calendar days. Our records indicate that your child, _________________________,
(Child’s Name)
Needs _________________________________. This must be done by ________________. After this date
your child will be suspended and will not be allowed to return to school until all Kindergarten
requirements are fulfilled. Proper documents must be submitted to your child’s teacher showing that he/she
has received a physical, required short, or certified birth certificate. We cannot accept the mother’s copy for a
birth certificate. If you have any questions, feel free to contact your child’s teacher or Dr. Hathaway. Thank
you.
Sincerely,
Dr. Jill Hathaway
Principal
Number of days left until deadline: ________
Parent Signature: _______________________________________
91
St. Pauls Elementary School
222 Martin Luther King Jr. Dr.
St. Pauls, NC 28384
910-865-4103
Date ____________
Dear _________________:
The first half of the school year has passed. At the end of each nine weeks, we assess the
progress of our students. ______________________________ is not making expected
progress, and we feel a conference is necessary. You have been scheduled
for a conference on _________________ at _____________ in _______________.
Date
Time
Location
Hopefully, we can reach some tentative decisions on what is best for your child. Thank you for
your continued support and interest in your child’s education.
Sincerely,
_________________________________, Teacher
Dr. Jill Hathaway, Principal
92
ST. PAULS ELEMENTARY SCHOOL
222 Martin Luther King Jr. Dr
Lumberton, NC 28360
Telephone: 910-865-4103
Fax: 910-671-6010
Dr. Jill Hathaway
Principal
Date ____________
Dear _______________________
You received a letter in January concerning your child’s progress and the possibility of
retention. We are still in the process of assessing his/her progress.
At this time no determination has been made as to where __________________________
Will be best served next year. However, _________________________ is still not making
expected progress and we feel a conference is necessary.
You have been scheduled for a conference on ____________________ at ______________
Date
Time
in _________________________________.
Location
Please call if this time is not convenient for you. We must discuss what is best for your child.
Thank you for your continued support and interest in your child’s education.
Sincerely,
___________________________, Teacher
Dr. Jill Hathaway, Principal
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ST. PAULS ELEMENTARY SCHOOL
222 Martin Luther King Jr. Dr.
St. Pauls, NC 28384
(910) 865-4103
Dr. Jill Hathaway
Principal
Date ____________________
STUDENT: ___________________ GRADE: ________
TEACHER: ________________
Dear Parent/Guardian;
Your child is being recommended to be retained in his/her present grade level. My recommendation is that
_________________ repeat the _______________ grade during
the 2016-2017 school year in an effort to get him/her performing on grade level and create academic success..
This will offer your child the opportunity to make future school years happier and more productive. Please
complete the information below indicating whether you agree or disagree with this recommendation.
Sincerely,
______________________, Teacher
______ I accept the teacher’s recommendation that my child be retained during the 2016-2017
School year.
______________________________
Parent/Guardian
________________
Date
OR
______ I would like an appointment to discuss this recommendation as soon as possible. Please
contact me with a time and date for a meeting.
______________________________
Parent/Guardian
________________
Date
The principal of the school shall make the final recommendation based on the best interest of the individual
child.
94