Purple and Gold Early
Childhood Program
Registration Checklist
Student’s Name (Please print)
Session Preference:
8:00-11:00 AM
12:00-3:00 PM
Your child must be 4 years old on or before September 15 of the year to register
for preschool. 5-year-olds are ineligible for the Purple and Gold Early Childhood
Program.
Student Registration Information form
Child Health Form–completed by parent
Child Health Form–completed by physician
Authorization Form
Sunscreen Permission Form
Ethnicity/Race form
Home Language Survey form
Student Directory Information
Dated
The following documents are legal requirements. It is the parent’s
responsibility to provide all of these documents before your child will be
enrolled in school.
Proof of Birth; i.e., Birth Certificate
Proof of Immunization Records
For Office Use:
Date Submitted
Return this form on top of your registration packet with checked-off
items included.
Please submit the following documents:
o
o
o
Completed Registration Packet
1. Student Registration Information
2. Child Health Exam Form
Pages 1 and 2—completed by parent
Pages 3 and 4—completed by a physician or a copy of recent physical
3. Authorization Form
4. Sunscreen Permission Form
5. Home Language Survey
6. Ethnicity Form
Child’s Immunization Records or Appropriate Waiver (legal requirement)
Child’s proof of birth; i.e., Birth Certificate (legal requirement)
Return all documents to your neighborhood elementary until the end of the 2016-17 school year.
Documents returned during the months of June, July and August can be dropped off at Wilder
Elementary or to Julie Ormsby at the Administration Office (1304 East Second Avenue).
If you are registering your child for Kindergarten, please complete a
Kindergarten Registration Packet.
Questions
Please direct questions to:
Ed Johnson, 515.961.9570; Ext 7130, or [email protected]
Kim Post, 515.961.9565, Option 5, or [email protected].
Office Use Only
Local ID #
State ID #
Today’s Date
Start Date
Immunization: Y N
Proof of Birth:
Y N
BC #
Start Code
Desired Session for 2017-18:
8:00-11:00 AM
12:00-3:00 PM
Important Notice: Iowa Code § 282.3 unequivocally states your child must be 4 years old on or before
September 15 of the year to enter preschool and 5 years old to enter kindergarten.
Signature of Parent/Guardian
Date
Student’s Legal Name
Gender
Last Name
Birth Date
First Name
M
F
Middle
Nickname
Birthplace
Date Entered US
City
State
Country (IF NOT USA)
(If not born in US)
Month
Day
Year
State
Zip
Primary Student Address and Phone
Address
Apt/Lot #
Home Phone (
City
)
Residency Verification: The residency information provided on this form is true and accurate as of this date. I understand
that falsification of an address or the use of any other fraudulent means to achieve an enrollment or assignment shall be cause
for revocation of the student’s enrollment and assignment to the school serving the home attendance area.
Signature of Parent/Guardian
Date
Parent/Guardian Residing with Student
Parent
Step-Parent
Name (first, middle, last)
Foster Parent
Other
Work Phone (
)
Cell Phone (
)
Email Address
ICSD (01.12.17)
H:/Registration/Student Registration PS
_____
1
Parent
Spouse of Parent/Guardian Residing with Student
Name (first, middle, last)
Work Phone (
Step-Parent
Relationship
to Student
)
Cell Phone (
Fiancé(eé) of Parent
Other
)
Email Address
Is there a Parent/Guardian Not Residing with Student (Non-Custodial Parent, etc.)? If yes,
Name
Relationship to Student
Home Phone (
)
Cell Phone (
Work Phone (
)
Spouse Name
)
Address
Email Address
Should school mailings be sent to this household also?
Yes
No
Yes
No
Former School Information
Did this student attend Indianola Community Schools last year?
Please list the last school attended (other than Indianola):
School Name
(
Address
City/State/Zip
County
Has this student ever attended Indianola schools before?
)
Phone Number
Yes
No
Year
Child Care Provider or Afterschool Program
Name
Home Phone (
Work Phone (
)
Cell Phone (
)
)
Household Information
School-Age Siblings
Grade/Age
Does this student qualify for special services;
i.e., Gifted and Talented, 504 Plan, ELL, Title I?
School-Age Siblings
Yes
If yes, please explain
Grade/Age
No
Does this student receive Special Education services and have an Individualized Education Plan
(IEP)?
Yes
No
If yes, please explain:
ICSD (01.12.17)
H:/Registration/Student Registration PS
_____
2
Infant, Toddler, Preschool Age – Child Health Exam Form
PARENTS/GUARDIAN COMPLETE PAGES 1 and 2 – Child Information
Child’s name
Child’s birthdate
Name of center, provider, or preschool
Telephone #
Parent 2 name
Parent 1 name
Child home address #1
Telephone # 1
Child home address #2
Telephone #2
Where parent # 1 works
Home phone #
Work address
Work #
Pager #
Cellular #
Home email
Work email
Where parent # 2 works
Home phone #
Work address
Work #
Pager #
Cellular #
Home email
Work email
In the event of an emergency, the child care provider is authorized to obtain EMERGENCY MEDICAL or DENTAL CARE even if
the child care center is unable to immediately make contact with the parent/guardian.
YES
NO
During an emergency the child care provider is authorized to contact the following person when parent or guardian cannot be
reached.
Parent/Guardian Signature: ______________________________________________ Date _______________
Alternate emergency contact person’s name:___________________________ Phone number:
Relationship to child:
Cellular number:
Doctor telephone # 1
Hospital choice
Doctor’s address
After hours telephone #
Does child have health insurance?
Yes, Company ______________
ID #
Child’s dentist’s name
Dentist Telephone # 1
Does child have dental insurance?
Yes, Company ______________
ID#
Dentist’s Address
After hours telephone #
NO, we do not have health
insurance.
Child Name:
Child’s doctor’s name
NO, we do not have dental
insurance.
Other health care specialist name
Type of specialty
February 2011
Telephone #
Please help us find health or dental
insurance.
1
PARENTS COMPLETE THIS PAGE
Parents: Tell us about your child's health.
Place an X in the box
if the sentence applies to your child. Check all that apply to
your child. This will help your doctor plan
your child’s physical exam.
Growth
Child’s Name: ___________________________
Body Health - My child has problems with
Skin, birthmarks, Mongolian spots, hair, fingernails or toenails.
Map and describe color/shape of skin markings
birthmarks, scars, moles
I am concerned about my child's growth.
Appetite
I am concerned about my child's eating /
feeding habits or appetite.
Rest -
I am concerned about the amount of sleep
my child needs.
Illness/Surgery/Injury - My child
had a serious illness, injury, or surgery.
Please describe.
Physical Activity - My child
must restrict physical activity.
Please describe.
Development and Learning
I am concerned about my child’s
behavior, development, or learning.
Please describe:
Eyes \ vision, glasses
Ears \ hearing, hearing aides or device, earaches, tubes in ears
Nose problems, nosebleeds, runny nose
Mouth, teething, gums, tongue, sores in
mouth or on lips, mouth-breathing, snoring
Frequent sore throats or tonsillitis
Breathing problems, asthma, cough, croup
Heart, heart murmur
Stomach aches, upset stomach, colic, spitting
up
Using toilet, toilet training, urinating
Bones, muscles, movement, pain with moving
Mobility, uses assistive equipment
Nervous system, headaches, seizures, or
nervous habits (like twitches)
Needs special equipment. Please describe:
Medication - My child takes medication.
List the name, time medication taken, and the
reason medication prescribed.
Allergies-My child has allergies (medicine,
food, dust, mold, pollen, insects, animals, etc.).
Please describe:
Parent questions or comments for the health care provider:
2
Iowa Child Care Infant, Toddler, Preschool Age – Child Health Exam Form
HEALTH PROFESSIONAL COMPLETE THIS PAGE 1
Allergies
Child’s Name: _____________________________
Environmental:
Medication:
Food:
Insects:
Other:
Birthdate:
Age today:
Date of Exam:_____________
Height/Length:
Weight:
Immunization: May attach a copy of Iowa Department of
Head Circumference-for children age 2 yr and under:
Public Health Immunization Certificate
Blood Pressure-start @ age 3 yr:
DtaP/DTP/Td
MMR
Hgb or Hct-anytime between 6-9 mo:
Hepatitis B
Pneumococcal
HIB
Varicella
Polio
Other
Blood Lead Level-start @ 12 mo:
Sensory Screening:
Influenza
Vision: Right eye ________ Left eye _________
TB testing (only for high-risk child)
Hearing: Right ear ________ Left ear _________
Medication: Health professional authorizes the child may
Tympanometry (may attach results)
receive the following medications while at child care or preschool:
(include over-the-counter and prescribed)
Developmental Screening 2 :
Medication Name
Cough medication
Diaper crème:
Fever or Pain reliever:
Sunscreen:
Other
Developmental screening results:
Autism screening results:
Psychosocial/behavioral results
Developmental Referral Made Today: □Yes
□No
Exam Results: (n = normal limits) otherwise describe
HEENT
Oral/Teeth
Oral Health/Dental Referral Made Today:
Yes
No
Heart
Dosage
Other Medication should be listed with written instructions for use
in child care.
Referrals made:
Referred to hawk-i today 1-800-257-8563
Other: _________________________________
Lungs
Health Provider Assessment Statement:
Stomach/Abdomen
The child may participate in developmentally appropriate child care/preschool with NO health-related
restrictions.
Genitalia
Extremities, Joints, Muscles, Spine
Skin, Lymph Nodes
Neurological
The child may participate in developmentally appropriate child care/preschool with the following restrictions:
Space is available on back page for detailed
comments or instructions pertaining to enrollment at child
care or preschool.
May use stamp
1
Iowa Child Care Regulations require an admission physical exam report
within the previous year. Annually thereafter, a statement of health condition signed by an approved health care provider. The American Academy of Pediatrics has recommendations for frequency of childhood preventative pediatric health care (RE9939, March 2000) www.aap.org
2
Developmental screening procedures were expanded to include autism, developmental surveillance, and psychosocial/behavioral screening
July 2009 by the Iowa EPSDT Medicaid program. Toll-free 800-3833826.
Signature ____________________________________
Circle the Provider Credential Type: MD DO PA ARNP
Address:
Telephone:
3
Health Care Provider comments or instructions:
Child’s name: ______________________
Iowa Health Care Provider -- Guide to Iowa Recommendations for Preventive Pediatric Health Care 3
Health Provider’s Guide
History:
Physical Exam
Measurement:
Initial and Interval
Height/ Weight
Head Circumference
Blood Pressure
Assess/Educate
1
mo
z
z
z
z
2
mo
z
z
z
z
4
mo
z
z
z
z
Nutrition
5
Oral Health Assessment
Development and Behavioral Assessment
Developmental Screening
Autism Screening
Developmental Surveillance
Psychosocial/behavioral Assessment
Sensory Screen:
Vision
6
Hearing
7
Immunizations:
per Iowa schedule
z
z
z
z
z
z
z
z
z
z
z
S
S
z
z
z
S
S
z
z
z
S
S
z
Lab:
z
Family Guidance:
Key:
Hemaglobinopathy/Metabolic Screen
Hematocrit or Hemoglobin
Urinalysis
Lead Test
Cholesterol Screen
10
TB test
Injury Prevention
Child Car Seat Counseling
Tricycle Helmet Counseling
Sleep Position Counseling
Nutrition & Physical Activity Counseling
Violence Prevention
Child Development Guidance
AGE
6
9
12
mo
mo mo
z
z
z
z
z
z
z
z
z
z
z
z
Risk Assessment
z
z
z
z
z
z
z
z
z
z
z
z
S
S
z
z
z
S
S
z
z
S
S
z
4
15
mo
z
z
z
z
18
mo
z
z
z
z
2
yr
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
S
S
z
z
S
S
z
z
z
z
S
S
z
3
yr
z
z
z
4
yr
z
z
z
5
yr
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
O
S
z
z
z
O
O
z
z
O
O
z
z
8
z
‹
z
‹
z
‹
‹
‹
z
‹
9
z
z
z
z
z
z
z
z
z
z
‹
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
z
1
mo
z
z
z
z
2
mo
z
z
z
z
4
mo
z
z
z
z
6
mo
z
z
z
z
9
mo
z
z
z
z
12
mo
z
z
z
15
mo
z
z
z
18
mo
z
z
z
2
yr
z
z
z
3
yr
z
z
z
4
yr
z
z
z
5
yr
z = to be performed
‹ = to be performed for high-risk children
Æ = Range in which the task may be completed
S = Subjective, by history
O = Objective, by standard testing
3
The periodicity schedule was revised July 2009 by the Iowa Medicaid EPSDT program. http://www.idph.state.ia.us/hpcdp/epsdt_care_for_kids.asp
If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule
should be brought up to date at the earliest possible time.
5
Oral Health Assessment consists of dental history; recent concerns, pain or injury; visual inspection of hard and soft tissues of oral cavity; and dental
referral based on risk assessment. http://www.idph.state.ia.us/hpcdp/oral_health.asp or toll-free: 866-528-4020.
6
Infants born in Iowa should have record of results from newborn hearing screening. http://www.idph.state.ia.us/iaehdi/default.asp or toll-free 800-3833826.
7
Iowa Immunization program 1-800-831-6293.
8
All newborns should receive metabolic screening during neonatal period. www.idph.state.ia.us/genetics
9
Lead testing should be done at 12 & 24 months. Testing may be done at additional times for children determined at risk.
Lead program 1-800-972-2026.
10
TB testing for only at-risk children, Iowa TB program 1-800-383-3826.
4
4
Student Name
For your child’s safety and protection, please fill out the name of authorized persons to bring, or
take your child from the school, other than yourself. Please inform the authorized persons to be
prepared to identify themselves to our staff with photo identification. Please list another parent
other than one who signed this, if authorized to pick up.
Name
Relationship to Child
Phone
Father
Mother
Name of person(s) restricted from picking up the child by court order. A copy of the court order
must be on file in the school office:
Any other information we should be aware of?
This information is to be kept current and updated by the parent/guardian. Please notify us if
anything regarding this authorization should change.
Signature of Parent/Guardian
01.12.17
PK Authorization Form
Date
PARENT/GUARDIAN’S PERMISSION TO APPLY
SUNSCREEN TO HIS/HER CHILD
Name of Child: _________________________________________________
(last, first)
As the parent/guardian of the above child, I recognize that too much exposure to UV rays may increase my child’s
risk of getting skin cancer someday. Therefore, I give permission for the staff at:
(name of child care program)
to apply a sunscreen product that is broad spectrum with SPF 15 or higher to my child, as specified below, when
he/she will be playing outside, especially during the months of March through October and between the daily time of
10 a.m. and 4 p.m. I understand that sunscreen may be applied to exposed skin, including but not limited to the face
(except eyelids), tops of ears, nose, bare shoulders, arms and legs.
I have checked and initialed below all applicable information regarding the child care program’s choice in brand/type
and use of sunscreen for my child:
o ___
I do not know of any allergies my child has to sunscreen.
o ___
My child is allergic to some sunscreens. Please use ONLY the following brand(s)/type(s) of sunscreen:
o ___
Staff may use the sunscreen of the program’s choice following the directions and recommendations
printed on the product container.
o ___
I have provided the following brand/type of sunscreen for use for my child:
o ___
For medical or other reasons, please do NOT apply sunscreen to the following areas of my child’s
body:
Parent/Guardian’s Name:
Date:
Parent/Guardian’s Signature:
Health Care Provider’s Signature (optional):
NOTE: DO NOT RELY ON SUNSCREEN ALONE TO
PROTECT CHILDREN FROM SKIN CANCER!
Adapted from the California Early Childhood Sun Protection Curriculum (1998-Revised) from the
Skin Cancer Protection Program, Cancer Prevention and Nutrition Section, California Department of Health Services. • http://www.dhs.ca.gov/cpns/skin/skin_resources.html
California Childcare Health Program (CCHP) 07/03 www.ucsfchildcarehealth.org
SUN-SMART POLICY FOR CHILD CARE PROGRAMS
Our Sun-Smart policy has been developed to ensure that all children and staff participating in this program are
protected from skin damage caused by the harmful UVB and UVA rays of the sun. This policy will be implemented
throughout the year, but with particular emphasis from March through October.
˛ Sun-Smart strategies:
1. Encourage staff and children to wear hats with wide brims that protect their face, neck and ears
whenever they are outside.
2. Encourage staff and children to wear sun-protective clothing (i.e., tightly woven, loose-fitting, full length,
light-colored and light-weight) when temperatures are reasonable.
3. Encourage staff to wear sunglasses that block 100 percent of UVA and UVB rays (broad spectrum)
whenever they are outside.
4. Provide sufficient areas of shelter and/or trees providing shade on the play yard.
5. Encourage children to seek and use available areas of shade for outdoor play activities.
6. Schedule excursions and all outdoor activities before 10 a.m. and after 4 p.m. (10 a.m. to 3 p.m. during the
winter months) whenever possible. The availability of shade will be considered when planning excursions
and outdoor activities during these times.
7. Children will be hydrated and encouraged to drink water before and during prolonged physical outdoor
activities in warm weather.
8. Staff and parents/guardians will model sun safety behaviors by:
• Wearing appropriate hats and clothing when outdoors.
• Using broad spectrum SPF 15 or higher sunscreen for skin protection.
• Seeking shade whenever possible.
9. Provide broad spectrum SPF 15 or higher (and paba and alcohol free, if possible) sunscreen for staff and
children to use on exposed skin, except eyelids, 30 minutes before exposure to the sun and every two
hours while in the sun, unless parent/guardian provides their own sunscreen for their child.
10. Parents/guardians will complete and sign the Parent/Guardian’s Permission to Apply Sunscreen to His/Her
Child (see reverse) and it shall remain on file at the program.
11. Include learning about the skin and ways to protect the skin from the UV rays of the sun into the
program’s curriculum and daily routines.
12. The Sun-Smart Policy will be reinforced in positive ways through parent newsletters, staff memos, bulletin
boards and meetings. Signage shall be posted that reminds staff, parents and children to practice sun
safety.
13. Staff and parents will be provided with educational materials and resources on sun safety and protection.
˛ When enrolling their child, parents/guardians will be:
1. Informed of the program’s Sun-Smart Policy.
2. Asked to provide a suitable hat for their child’s use when outdoors in the care setting.
3. Required to provide permission for staff to apply sunscreen (and optional: health care provider’s signature
included on consent form).
4. Asked to provide a broad spectrum SPF 15 or higher sunscreen if their child is allergic to the program’s
offered brand/type.
5. Encouraged to practice Sun-Smart behaviors themselves.
RECOMMENDED STANDARD/OPTIONAL: Every child should have on file a standing order from their health care provider for the use of
sunscreen (nonprescription medication) in the care setting, in addition to the parental consent to have sunscreen applied1.
California Childcare Health Program (CCHP)
1
www.ucsfchildcarehealth.org
07/03
American Academy of Pediatrics and American Public Health Association, (2002). Caring for our children: National health and safety standards: Guidelines for out-of-home child care
programs, Second Edition. Elk Grove Village, IL.
Indianola Community School District
HOME LANGUAGE SURVEY
Student Name: ____________________________________________ Birth Date: ___________________ Sex: ❏ Male
❏ Female
Parent/Guardian Name: ________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Home Telephone: __________________________________________ Work Telephone: ____________________________________
School: __________________________________________________ Grade: ______________________ Date: ________________
1.
2.
❏
Was your child born in the United States?
Yes
❏ No
If yes, in which state?
___________________________________
If no, in what other country?
___________________________________
Has your child attended any school in the United States
for any three years during their lifetime?
❏
If yes, please provide school name(s), state, and dates attended:
Name of School ____________________________________________
Name of School ____________________________________________
Name of School ____________________________________________
Yes
❏ No
State ________ Dates Attended________________
State ________ Dates Attended________________
State ________ Dates Attended________________
3.
What language is spoken by you and your family most of the time at home?
___________________________________
4.
If available, in what language would you prefer to receive
communication from the school?
___________________________________
5.
Is your child’s first-learned or home language anything other than English?
❏
Yes
❏ No
If you responded “Yes” to question number 5 above, please answer the following questions:
6.
What language did your child learn when he/she first began to talk?
___________________________________
7.
What language does your child most frequently speak at home?
___________________________________
8.
What language do you most frequently speak to your child?
(Father) ___________________________________
(Mother) ___________________________________
9.
Please describe the language understood by your child. (Check only one)
A. ❏
Understands only the home language and no English.
B. ❏
Understands mostly the home language and some English.
C. ❏
Understands the home language and English equally.
D. ❏
Understands mostly English and some of the home language.
E. ❏
Understands only English.
______________________________________________
Parent or Guardian's Signature
___________________________________
Date
OFFICE USE ONLY
Student ID #
Date Distributed
00NCLB-B1 (Rev. 04/13 - IA)
Date Received
© 2013 TransACT Communications, Inc.
253324
Indianola Community School District
Student Race and Ethnicity Reporting
Student Name: _____________________________________________ Date Form Completed: ___________________
Date of Birth: ______________________________________________ ❏ Male
Person Completing This Form:
❏
Parent/Guardian
❏
Student
❏
❏
Female
Other: __________________________
The U.S. Department of Education has implemented new standards for school districts to report student race and ethnicity.
Your answers to the following will be held strictly confidential and data will be used only in the aggregate.
1.
Is your child of Hispanic, Latino, or Spanish ethnicity:
❏ Yes
❏ No
Includes persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin.
If you answered “Yes” to question #1, you may also check one or more of the racial categories in question #2. If you
answered “No”, please check one or more of the following racial categories.
2. Racial Categories:
❏
American Indian or Alaska Native
Origins in any of the original peoples of North, Central, and South America who maintain a tribal
affiliation or community attachment.
❏
Asian
Origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent for
example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and
Vietnam.
❏
Black or African American
Origins in any of the black racial groups of Africa
❏
Native Hawaiian or Other Pacific Islander
Origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
❏
White
Origins in any of the original peoples of Europe, the Middle East, or North Africa.
Please complete the entire form and return it to:
Indianola Community Schools
515.961.9500
Name: __________________________________________________________
Phone Number: __________________
1304 East 2nd Avenue
Indianola
IA
50125
Address: ____________________________________
City: _______________
State: _____________
Zip: ________
00NCLB-B1 (04/13 - IA)
© 2013 TransACT Communications, Inc.
253324
School Board Policy 506.2—Student Directory Information
During the school year your child may make headlines as a hero of the big game, or he or she might win an academic
honor. Often, stories about what is happening at school will feature students. We also might want to use your child’s name
or may get a great photograph or videotape of your child that we’d like to use in a school district publication or
presentation.
Student directory information is designed to be used internally within the school district. Directory information is defined in
the annual notice and may include:
•
•
•
•
•
•
Student's name, address, telephone number
Date and place of birth
E-mail address, grade level, enrollment status
Major field of study
Dates of attendance
Participation in officially recognized activities and
sports
•
•
•
•
•
Weight and height of members of athletic teams
Degrees and awards received
The most recent previous educational agency or
institution attended by the student
Student artwork, student photos and other likeness
Other similar information
Prior to developing a student directory or to giving general information to the public, parents will be given notice
annually of the intent to develop a directory or to give out general information and have the opportunity to deny
the inclusion of their child's information in the directory or in the general information about the students.
If you do NOT want the district to release “Directory Information” and/or publish your child’s photo, and/or release
videotape of your child, please complete and return the form below by the first day of school. OTHERWISE, IT IS NOT
NECESSARY TO TAKE ANY ACTION. If you have any questions, please call 515.961.9500; Ext. 1506.
Indianola Community School District
Directory Information and Photographs
(Return one form for each child.)
Directory Information
Do not release any “Directory Information” on my child.
or
Do not release “Directory Information” on my child, but you can include my child’s name in the school newsletter
and school directory.
Photograph/Videotape
Do not release my child’s photograph/videotape to the news media or use my child’s photograph in any Districtwide printed publication (such as the calendar).
Class Photograph
Do not release my child’s individual class photo for use in the school annual or yearbook.
Child’s Name:
School/Grade:
Parent/Guardian Printed Name:
Phone #:
Signature:
Date:
ICSD (01.27.15)
H:/Registration/Student Directory Info