Registering a Student
in the
Mexico Academy and Central School District
Welcome to the Mexico Academy and Central School District. There are three elementary
schools (Pre-K – Grade 4), a junior high school (Grades 5 -8) and a high school (Grades 9 – 12).
Registration forms can be downloaded from Mexico Academy & Central School District website
for parent to complete prior to registering their child(ren) in person.
Listed below are items that are necessary to register your child in the Mexico School District.
Please note there may be additional forms necessary to fill out once you arrive in person to
register your child. All student registrations are completed through the District Office.
Please bring originals to be copied:
1. Birth Certificate
2. Immunization Record (Shot Record including Lead Levels)
3. Dental Screenings – Grades Pre-K, K, 2nd, 4th,7th, 10th
4. Physical
5. 3 Proof of Residency (Please see accompanied letter for appropriate forms)
6. Custody Paper (If Applicable)
7. Proof of Guardianship (Court Ordered)
8. Child’s IEP (If child is receiving Special Education Services)
9. Child’s 504 Plan (If child is receiving 504 Accommodations)
10. Middle School/High School Students – copy of previous schedule and report card
11. Foster Students (social worker name/number and paperwork from County DSS included
with registration packet)
Student photos will be taken at time of registration for SchoolTool. Please bring student to
registration.
1/2016
Mexico Academy & Central School
16 Fravor Road, Suite A
Mexico, NY 13114
Phone 315-963-8400
Fax 315-963-5801
Jeremy Belfield
Director of Personnel
Ext. 5407
Lorie Gates
Personnel Assistant
Ext. 5409
Donna Devore
Senior Typist
Ext. 5409
Dear Families:
Welcome to Mexico Academy and Central School District! We are excited to be serving your child and we look forward to
fostering a strong home and school connection to support the educational needs and interests of your child.
Students in New York State are entitled to a free and appropriate public education in the district in which they reside. In the
event that you elect to enroll your child in a school district other than your child’s district of residence, Education Law requires
school districts to collect non-resident tuition. Exceptions to this may be considered under the provisions of the McKinney-Vento
Act. We are asking all families to provide proof of residency when they register their students and/or complete the residency
questionnaire to determine your residency status.
Mexico CSD requires any new, permanently housed, registrants to provide proof of residency. The following items required at
time of registration:
One of the following:
- Deed or Mortgage
If you are not the owner of the house, but live with the owner - such as a grandparent of the child - please call 315-963-8400 x
5407 for further instructions. You will need to provide additional documentation.
- Lease
If you rent an apartment or house, your child's name must appear on the lease or lease application. If the child's name is not
listed, then, in addition to the lease, you must also bring a letter from the landlord stating that the child lives at that address. The
letter must include the landlord's name and phone number.
- Contract to Build/Buy a Home (for September entrance only).
In addition to the above, two (2) more proofs of residency are required. Any two of the following are acceptable:

Bank account and/or credit union statement

Paycheck

Automobile and/or homeowners/renters insurance policy

Automobile registration (NOTE: A driver's license is not acceptable)

Telephone, cable and/or utility bills
Documents must be current and original - they will be copied and returned to you immediately. Print-outs from online
accounts will be accepted if they show the name and address of the resident and have a current date.
In the event that you are not able to provide proof of residency, Mexico CSD will require that you pay non-resident tuition or
enroll your children in their district of residence.
Tuition amounts for non-resident are established by the Commissioner of Education and are affirmed by local school district
boards of education. Non-resident tuition for the 2013-14 school year for students in grades K-6 has been established as $7,030
and tuition for students in grades 7-12 has been established as $7,927.
If you have any questions regarding residency, please feel free to contact Jeremy Belfield at extension 5407. If you have
questions regarding the McKinney-Vento Act, please feel free to contact Carolyn Maloney at extension 3410.
Sincerely,
Jeremy Belfield
Director of Personnel
Mexico Academy and Central School
16 Fravor Rd Suite A
Mexico, New York 13114
(315) 963-8400 ext. 5400
(315) 963-5810 (fax)
Mexico Elementary School
26 Academy St.
963-8400 x 2310
Robert Briggs, Principal
New Haven Elementary School
4320 State Route 104
963-8400 x3500
Richard Chapman, Principal
Palermo Elementary School
1638 County Route 45
963-8400 x1000
Peggy Scorzelli, Principal
Dear Parent/Guardian,
The Mexico Academy & Central School District is pleased to welcome your child to our Kindergarten program. We
have Kindergarten classes in each of our three Mexico School District Elementary Schools. Students will be placed
in the elementary building where you reside. Students who are eligible for kindergarten are to be five years old by
December 1st.
The Kindergarten program is full day, five days a week. Completed applications must be submitted to the District
Office by April 18th. Elementary Schools will be calling during late April to secure an appointment for your
student. Screening for Kindergarten will be completed during the month of May. Therefore, you are encouraged
to submit your registration as early as possible. Verification of the application information may be required at a
later date.
Enclosed you will find a registration forms and immunization form to register your child for the Kindergarten
program. The required immunizations for acceptance into the Kindergarten program are as follows: 4-5 Doses of
DTap/DTP/Tdap; 3-5 Doses of Polio, 1 Dose of MMR, 3 Doses of Hep B, and 2 Doses of Varicella. If your child is
missing any of these immunizations in the required number of doses, he/she will not be accepted into the school.
*Your child cannot be registered without a completed immunization form. A dental form is enclosed to be
completed by your child’s dentist. The completed application, along with all the required documentation should
be sent to Terri Herrington, Central Registrar at the District Office. Applications may also be returned to your local
elementary school and they will forward to Mrs. Herrington.
Please note: Due to NYS regulations, we must receive a report of a physical examination, signed by a licensed
health provider and a completed dental certification. The state also required that we receive proof of a blood lead
level test.
If you have any questions, please do not hesitate to contact Terri Herrington, District Office, 963-8400 ext. 5400.
Vision Statement
Every student at Mexico Academy & Central School District will acquire and sustain a passion for learning that ensures success.
MEXICO ACADEMY AND CENTRAL SCHOOL
MEXICO, NEW YORK 13114
STUDENT REGISTRATION FORM
______________________________________________________________________________________________________________________________
Please Print Legibly, Press Firmly
Student’s Name ________________________________________________________________________________________________________________
Last
First
Middle
Male _____
Female _____
Student’s Date of Birth ______________________
Month Day Year
Mailing Address _____________________________________________________ Residential Address __________________________________________
Home Phone # ______________________________________
Email Address __________________________________________________________
Cell Phone # ________________________________________
Emergency Contact#_____________________________________________________
Name of Emergency Contact Person: _______________________________________________ Relationship to Student: ___________________________
Address of Emergency Contact Person: ______________________________________________________________________________________________
Phone # of Emergency Contact Person: _______________________________________
Student Lives With: (circle all that apply) Both Parents
Mother Only
Father Only
Step-Parent
Grandparent(s)
Other
Name of Parent/Guardian Student Resides With, and Relationship to Student:
(i.e. mother, father, step-mother, step-father, grandparent, aunt, uncle, foster parent, brother, sister, unrelated male/female, etc.)
1.) _____________________________________________________________________ Relationship: _____________________________________
Place of Employment: __________________________________________________ Work #: __________________________________________
2.) _____________________________________________________________________ Relationship: _____________________________________
Place of Employment: ___________________________________________________ Work #:__________________________________________
Have Court Ordered Custody Papers Been Issued For This Student: ( ) Yes ( ) No
Are Court Papers Attached for Student File: ( ) Yes ( ) No
Other Parent Name and Address __________________________________________________________________________________________________
Other Parent Home Phone # _________________________________
Cell # ______________________________________________
List All Person(s) to Receive Correspondence _______________________________________________________________________________________
_______________________________________________________________________________________
Names and Birth Date of Other Children In Student’s Home:
1.) _____________________________________________________________________________________________________________________
Last
First
Middle
Sex
Birth Date
2.) _____________________________________________________________________________________________________________________
Last
First
Middle
Sex
Birth Date
3.) _____________________________________________________________________________________________________________________
Last
First
Middle
Sex
Birth Date
4.) _____________________________________________________________________________________________________________________
Last
First
Middle
Sex
Birth Date
5.) _____________________________________________________________________________________________________________________
Last
First
Middle
Sex
Birth Date
If there are additional children in the home, please attach a sheet and list their names, sex, and birth date.
Has the Student Previously Attended Mexico School District ( ) Yes ( ) No If Yes, What Grade(s)? __________________________________________
Does the Student Have an IEP (Individual Educational Plan) or a Section 504 Accommodation Plan: ( ) Yes, Copies Attached ( ) No
Does Your Child Currently Receive: (circle all that apply) AIS (Academic Intervention Services) Math, AIS (Academic Intervention Services) Reading
Counseling
Speech
Physical Therapy
Other
School Transferring From: _______________________________________________________________________________________________________
Address of Previous School District: _______________________________________________________________________________________________
*****Please Note:
At time of registration the following paperwork is necessary: Birth Certificate, Immunization Records, Physical, Dental Certificate, Custodial Papers, Report
Card, Proof of Residency (3 forms)
2/2/2016
MEXICO ACADEMY AND CENTRAL SCHOOL BUS INFORMATION
Check One: ( ) New Student
( ) Returning Student
( ) Current Student Changing Schools Within the District
Student’s Name: _______________________________________________________________
Home Phone: ____________________ ( )Male ( )Female Date of Birth: ______________
Residence Address: _____________________________________________________________
Mailing Address: ______________________________________________________________
Looking at Your Home
-Who is your neighbor or what landmark is on your left?
_____________________________________________________________________________
-Who is your neighbor or what landmark is on your right?
_____________________________________________________________________________
Name of Adults in the Home
#1 ________________________________________Relationship ________________________
#2 _________________________________________Relationship ________________________
Name of Emergency Contact _____________________________ Phone# _________________
Relationship_____________________________
Will Your Child be Bused to a Daycare Provider? ( )Yes ( )No
Name of Provider: ______________________________________________________________
Address of Provider: ____________________________________________________________
Phone of Provider: _________________________ ( )AM Only ( )PM Only ( )Both AM & PM
FOR SCHOOL USE ONLY
Date Entered: _________
Student ID Number: ______________________________
Grade: _____
Teacher: _______________________________________
Pick-up Bus Number: ________
Dismissal Bus Number: ________
( )Mexico Elementary ( )Palermo Elementary ( )New Haven Elementary
( )Mexico Middle School ( )Mexico High School
10/2014
MEXICO CENTRAL SCHOOL – EMERGENCY INFORMATION
Complete the Following Information and Return to the School Office Immediately.
(Please Print Legibly)
Student’s Name ________________________________________________________________________________
Last Name
First Name
Teacher’s Name ____________________________________________ Grade _________ Room # ____________
Residential Address_____________________________________________________________________________
Mailing Address (if different) ______________________________________________________________________
Email Address ________________________________________________
Bus # ________ AM ______PM
1st Parent/Guardian _____________________________________________________________________________
Home Phone # ________________________Cell # _______________________Work #_______________________
Employer’s Name/Address _______________________________________________________________________
2nd Parent/Guardian ____________________________________________________________________________
Home Phone # ________________________Cell # _______________________Work #_______________________
Employer’s Name/Address _______________________________________________________________________
Does Your Child Go To A Daycare Provider
AM ( ) Yes ( ) No
PM
( ) Yes ( ) No
Providers Name ________________________________________________________________________________
Providers Address______________________________________________________________________________
Providers Phone # ______________________________________________________________________________
The following people have my permission to pick up my child at any time (Photo ID may be required). We will release your
child ONLY to the following adults.
1.
2.
3.
_______________________________________Relationship________________________________Phone _____________
_______________________________________Relationship________________________________Phone______________
_______________________________________Relationship________________________________Phone______________
The following information will be used if school closes early for any reason. We are NOT ABLE TO NOTIFY you when school closes
early. Listen to your TV and radio for closing information. Please remember that the alternate destination must be in the area that is
served by the elementary buses.
CHOOSE ONE (1) A OR B
When school dismisses early for any reason, please send my child to the following destination:
A. _____ Home on Bus # ______
B. _____ Alternate destination on Bus # _____
To ______________________________________________________________________________________________
St/Rd/Town________________________________________________Phone #_________________________________
Parent’s Signature
Date
9/2014
AUTHORIZATION FOR
RELEASE/EXCHANGE OF INFORMATION
MEXICO ACADEMY AND CENTRAL SCHOOL DISTRICT
16 Fravor Rd. Suite A
Mexico, NY 13114
(315)963-8400 ext. 5400
(315)963-5801 Fax
According to the Final Regulations – Family Education Rights and Privacy Act (Buckley Amendment) dated June 17,
1976, it is no longer necessary to obtain written consent to release records between schools. It states that school
officials, including teachers within the educational institution and officials of other schools in the school system
which the student may intend to enroll, may receive a student’s records without a written consent for such a
release.
Student Name: ______________________________________________________________ has enrolled in
Grade: ________________
At the Following School: ________________________________________________
Date of Birth: ____________________________
Parent Signature: ______________________________________________________________________________
Please forward the following information:
Transcript of grades including Regents, RCT’s, and Proficiency Grades Standardized Test Scores
Psychological Evaluations
Special Education Records
Discipline Records
Medical Records
Custody/Visitations Papers
Birth Certificate
Social Security Number
Regents Science Labs Completed for Year
Attendance Records
This authorization forms allows the exchange of Special Education records, not limited to, but including: IEP, 504,
Functional Behavioral Assessments, Speech, OT, PT, etc.
Transferring From: _____________________________________________________________________________
(School)
__________________________________________________________________________________________
(School Address)
__________________________________________________________________________________________
(School Phone Number)
9/2014
INSTRUCTIONS FOR COMPLETING THE ENROLLMENT FORM - RESIDENCY
QUESTIONNAIRE
Purpose of the Enrollment Form - Residency Questionnaire
All LEAs are required to identify students experiencing homelessness. Additionally, all LEAs that receive Title I funds
must ask enrolling students about their housing status. SED encourages all LEAs regardless of whether they receive Title I
funds to do the same. To collect this information, LEAs may:
1.
Use the Model Enrollment Form - Residency Questionnaire attached here,
2.
Update/modify the Model Enrollment Form - Residency Questionnaire to address the needs of the LEA,
or
3.
Incorporate the housing status question from the Model Enrollment Form - Residency Questionnaire into
the LEA’s Enrollment Form or other documents already used by the LEA during the enrollment process.
If an LEA elects the third option and incorporates the housing status question into the LEA’s Enrollment Form, the LEA
should take steps to ensure that a student’s housing status does not become a part of the student’s permanent record,
because of the sensitive nature of this information. Please see the section titled “Confidentiality” (below) for information
about how and when housing information may be shared within the LEA.
Who should fill out the Enrollment Form - Residency Questionnaire?
A Enrollment Form - Residency Questionnaire should be filled out for all students enrolling in school and for all students
who have a change of address in grades preschool-12. Preschool includes any LEA program for 3-5 year olds, such as
pre-k, Head Start, or Even Start. The Form - Questionnaire should be completed by the student’s parent, person in
parental relation, or in the case of an unaccompanied youth, by the student directly.
Confidentiality
Student housing information should be kept confidential to the maximum extent possible. This information should
only be shared with LEA/school staff members who need information about housing status to ensure that the
student’s educational needs are met. To this end, LEAs may share a student’s completed Enrollment Form Residency Questionnaire with LEA personnel such as:
1.
the LEA liaison,
2.
the registrar,
3.
the student’s teachers, and/or guidance counselor, and
4.
the LEA staff member responsible for reporting data to SED
However, this information should only be shared with the above staff members to the extent that it will enable
them to better meet the educational needs of the student in question and to fulfill reporting requirements
mandated by SED.
Other than the above uses, housing information should be kept confidential and generally should not be shared with
other LEA/school personnel due to its sensitive nature and the stigma attached to being labeled homeless. LEAs are also
encouraged to seek out ways of preventing Enrollment Form - Residency Questionnaires and housing information from
becoming a part of a student’s permanent record.
Discussing the Enrollment Form - Residency Questionnaire with Students and Families
In reviewing the Enrollment Form - Residency Questionnaire with parents, persons in parental relation, and
unaccompanied youth, LEAs should emphasize that the purpose of gathering the information is to ensure that students in
temporary housing arrangements are provided with the rights and services to which they are entitled under the McKinneyVento Act. These rights and services include:
1.
The right to stay in the same school the student had been attending before losing his/her housing or the
last school attended (both known as the school of origin),
2.
The right to immediate enrollment for students who decide to transfer schools, even if the student does
not have all of the documents normally for enrollment,
3.
Transportation services if the student continues to attend the school of origin,
4.
Categorical eligibility for Title I services if offered in the LEA,
5.
Categorical eligibility for free meals if offered in the LEA, and
6.
Access to services provided with McKinney-Vento funds if available in the LEA.
The LEA should also ensure that the parent, person in parental relation, unaccompanied youth is aware that the student’s
housing status will kept confidential and will only be shared with those LEA staff responsible for providing services to the
student and those responsible for keeping track of how many students are identified as living in temporary housing in the
LEA.
LEAs are advised to explain to parents that if a parent claims that her/her child is living in temporary housing, and the
LEA wishes to conduct an investigation to verify this information, the LEA may conduct a home visit. However LEAs
cannot contact a landlord or building superintendent to verify a student’s housing status. Contacting a landlord or
building superintendent may be a violation of FERPA, a federal law, and may put the family at risk of losing its housing.
If the student is living in a doubled up situation, it may also lead to loss of housing for the primary tenants.
If the Parent, Person in Parental Relation, or Unaccompanied Youth Declines to Fill Out the Enrollment Form Residency Questionnaire
If the parent, person in parental relation, or unaccompanied youth declines to complete the Enrollment Form - Residency
Questionnaire, the LEA should note on the form that the parent, person in parental relation, or unaccompanied youth
declined to provide the information requested.
Completing the Form
If a parent, person in parental relation, or unaccompanied youth enrolling in school indicates that a student is living in one
of the five temporary housing arrangements, the school may not require proof to verify where the student is living before
enrolling the student. The five temporary housing arrangements are listed below:
1. In a shelter,
2. With another family or other person (sometimes referred to as “doubled-up”),
3. In a hotel/motel,
4. In a car, park, bus, train, or campsite, or
5. Other temporary living situation.
After the student is enrolled and attending classes, the school or LEA is permitted to verify the student’s housing
arrangements. However, the student must first be enrolled in school. Again, LEAs cannot not contact a landlord or
building superintendent to verify a student’s housing status. (See above for more information.)
Definitions of Temporary Housing Arrangements
“With another family or other person” (also referred to as “doubled-up”)”
LEAs should be aware that students who are sharing the housing of others are eligible for services under the McKinneyVento Act and State law, if sharing housing is due to loss of housing, economic hardship, or a similar reason.
“Other temporary living situation”
In addition to the four examples of temporary housing, students who lack a “fixed, adequate, and regular” nighttime
residence are also covered as homeless under the McKinney-Vento Act and State law. This may include unaccompanied
youth who have fled their homes or were forced to leave their homes and who do not otherwise meet the definition of
“doubled-up.”
“In permanent housing”
Permanent housing means that the student’s living arrangements are “fixed, regular, and adequate.”
Next Steps for LEAs with Students Living in Temporary Housing Arrangements
If the parent, person in parental relation, or unaccompanied youth indicates that a student is living in temporary
housing, the LEA must complete a Designation Form. If the LEA believes additional information is needed before
reaching a final decision on the student’s eligibility under McKinney-Vento, enrollment should not be delayed and a
Designation Form should still be filled out. For more information about determining eligibility see the National Center on
Homeless Education’s Determining Eligibility Brief, available at: www.serve.org/nche/downloads/briefs/det_elig.pdf
If a student who is identified as homeless was last permanently housed in a different school district, the district of
attendance/local district will be eligible for tuition reimbursement from SED for the cost of educating the student. School
districts should complete a STAC-202 form if eligible for tuition reimbursement. For more information about STAC-202
forms contact the STAC Office at 518-474-7116 or NYS-TEACHS at 800-388-2014.
1/2014
MEXICO ACADEMY AND CENTRAL SCHOOLS
16 Fravor Rd. Suite A
Mexico, NY 13114
STUDENT RESIDENCY QUESTIONNAIRE
Name of School:
Name of Student:
Gender: � Male
� Female
Last
First
Date of Birth:
/
Month
Middle
/
Day
Grade:
Year
Address:
(preschool-12)
Phone:
The answer you give below will help the district determine what services you or your child may be able to
receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are
entitled to immediate enrollment in school even if they don’t have the documents normally needed, such
as proof of residency, school records, immunization records, or birth certificate. Students who are
protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please check one box.)
In a shelter
With another family or other person (sometimes referred to as “doubled-up”)
In a hotel/motel
In a car, park, bus, train, or campsite
Other temporary living situation (Please describe):
In permanent housing
Print name of Parent, Guardian, or Student
(for unaccompanied homeless youth)
Signature of Parent, Guardian, or Student
(for unaccompanied homeless youth)
Date
Forward to: Carolyn Maloney - Mexico High School
I certify the above named student qualifies for services under the provisions of the McKinney-Vento Act.
__________________________________________________
McKinney-Vento Liaison Signature
________________________
Date
ACADEMIA Y ESCUELA CENTRAL DE MEXICO
CUESTIONARIO DE IMPLANTACIÓN
Nombre de Escuela: _______________________________________________________________________
Nombre de Estudiante: _____________________________________________________________________
Apellido
Primer Nombre
Segundo Nombre
Género:
Hombre
Mujer
Fecha de Nacimiento: _____ / _____ / ______
Mes
Dia
Dirección: _______________________________________________
Grado:______
Año
(jardín de infantes – 12)
Teléfono: _____________________
La respuesta que usted de abajo ayudará al distrito a determinar cuales servicios su niño pueda
ser capaz de recibir conforme al Acto de McKinney-Vento. Los estudiantes que son protegidos
conforme al Acto de McKinney-Vento tienen derecho a la inscripción inmediata en la escuela
aun si ellos no tengan los documentos necesario, como la prueba de residencia, archivos
escolares, archivos de inmunización, o partida de nacimiento. Los estudiantes que son
protegidos conforme al Acto de McKinney-Vento también pueden tener derecho a el transporte
gratuito y otros servicios.
Donde está el estudiante viviendo actualmente? (Por favor marque una caja.)
En un refugio
Con otra familia o otra persona (a veces referido como "doblado")
En un hotel/motel
En un carro, parque, autobús, tren, o camping
Otra vivienda temporal (Por favor describa):
__________________________________________________________________________
 En un hogar permanente





________________________________________
Nombre de Padre, Guardian, o Estudiante
(para jovenes desamparado)
_______________________________________
Firma de Padre, Guardian, o Estudiante
(para jovenes desamparado)
____________________________
Fecha
Mandalo a: Carolyn Maloney – Escuela Secundaria de Mexico
I certifico que el estudiante nombrado arriba califica por servicios de bajo del provisiones del Acto McKinneyVento.
__________________________________________________
Firma de Oficial de enlace McKinney-Vento
________________________
Fecha
Potassium Iodide (KI)
Questions & Answers For Parents
1. What is potassium iodide (KI)?
Potassium iodide is a U.S. Food and Drug Administration (FDA) approved over the counter drug that can be used to protect the thyroid gland from
immediate and future radiation injury caused by radioactive iodine released during a nuclear accident.
2. How does KI work?
KI saturates the thyroid gland with stable (non-radioactive) iodine, thus preventing or reducing the amount of radioactive iodine that will be taken up by
the thyroid. Radiological emergencies may release radioactive iodine in the environment. Since iodine concentrated in the thyroid gland, inhalation of
air or ingestion of food contaminated with radioactive iodine can lead to injury to the thyroid – including an increased risk of thyroid cancer.
3. Does KI protect individuals from all types of radiation?
No. KI is only effective against exposure to radioactive iodine. KI does not protect against other types of radiation.
4. Does KI protect organs other than the thyroid?
No. KI does not protect body organs or tissues other than the thyroid.
5. Is a prescription necessary?
No. KI is a FDA approved over the counter drug.
6. Should some people avoid KI?
Yes. According to the FDA, people with known iodine sensitivity, thyroid diseases, clusters of itchy skin blisters (dermatitis, herpetiformis), and/or an
inflammation in blood vessels involving the skin or multiple organs of the body (hypocomplementemic vasculitis) should avoid the use of KI. A
physician should be consulted before an event occurs with individual concerns on whether to take KI in an emergency.
7. What are the possible side effects to KI?
According to the FDA, the benefits of taking KI far exceed the risks. The possible side effects may include stomach upset and minor rash.
8. When is KI most effective?
To be most effective, KI should be taken shortly before or shortly after exposure to radioactive iodine. Even if taken three to four hours after exposure,
it would still reduce radioactive iodine from being absorbed by the thyroid and still have a substantial effect.
9. How long is KI effective in the body?
The protective effects of KI last approximately 24 hours.
10. Is KI an alternative to evacuation?
No. Evacuation remains the primary protective action in a radiological emergency.
11. What happens if the ten-mile EPZ cuts through the school district?
Only school building located within the ten-mile EPZ will receive KI from the NYS Emergency Management Office (SEMO).
12. Who may administer the KI to children?
Designated individuals in the school may administer the KI to children once recommended by the NYS and/or County Department of Health in an
emergency situation.
13. What if a child can’t swallow pills?
The pill may be safely crushed and given with juice, applesauce, etc. in the event that an individual cannot swallow it. It may also be easily dissolved
in water.
14. How will schools be notified that events warrant the administration of the KI to children?
The State Department of Health and/or County Department of Health are charged with issuing the recommendation to administer KI in the event
radioactive is released into the environment.
15. Will the adults in the school building also e provided with KI?
Yes, KI will be provided to all adults in school buildings located within the 10-mile EPZ. However, according to the FDA, it is not necessary for persons
over 40 years of age to take KI in a radiological emergency.
16. Is a physician’s order necessary for KI administration in a radiological emergency?
No. KI administration in a school is part of an emergency protocol to deal with a radioactive iodine release into the environment.
9/2014
Mexico Academy & Central School
16 Fravor Road Suite A
Mexico, NY 13114
Potassium Iodide (KI)
I understand that potassium iodide (KI) may be given to my child if recommended by the
County and/or State Department of Health in a radiological emergency.
I have read and understand the Parent/Guardian letter, potassium iodide (KI) Parent Q&A’s and
Department of Health KI information sheet. I also understand that this permission is granted
until I revoke it in writing.
I DO want my child to be given potassium iodide (KI) in the event of a
radiological emergency.
I DO NOT want my child given potassium iodide (KI) in the event of a
radiological emergency.
Child’s Name _________________________________________________________________
Teacher/Homeroom ____________________________________________________
Grade ________
School _____________________________________________________
Parent/Guardian Signature _______________________________________________________
Date ____________ Telephone Number ___________________________________________
IF YOU DO NOT RETURN THIS FORM AND KI USE IS RECOMMENDED BY HEALTH OFFICIALS,
YOUR CHILD WILL RECEIVE POTASSIUM IODIDE (KI).
6/2016
Pamela J. Buddendeck
Director of Pupil Services
Mexico Academy and Central School
26 Academy Street
Mexico, New York 13114
(315) 963-8400 ext. 5404
(315) 963-5804 (fax)
[email protected]
Medicaid Consent
This is to ask your permission (consent) to bill your or your child's Medicaid Insurance Program for special
education and related services that are on your child's Individualized Education Plan (IEP). This consent
allows the School District to bill for covered health-related services and to release information to the school
district's Medicaid Billing Agent for that purpose.
(Student's name)
Have received a written notification from the School District that explains my federal rights regarding the use of
public benefits or insurance to pay for certain special education and related services.
I understand and agree that the School District may access Medicaid to pay for special education and related
services provided to my child, and that this consent extends to any eligible services provided in prior school
years.
I understand that: providing consent wilt not impact my child's/my Medicaid coverage; upon request, I may
review copies of records disclosed pursuant to this authorization; services listed in my child's IEP must be
provided at no cost to me whether or not I give consent to bill Medicaid; I have the right to withdraw consent at
any time; and the School District must give me annual written notification of my rights regarding this consent.
I also give my consent for the School District to release the following records/information about my child to the
State's Medicaid Agency for the purpose of billing for special education and related services that are in my
child's IEP. The following records will be shared.
Records to be shared (such as records or information about services your child receives)
IEP
Written Order/Referral
Evaluation Reports
Session Notes
e
l
v
e
s
)
Medication Administration Report
Special Transportation Log
Other Personally Identifiable Information
Any Other Specific Records Pertaining to the Student's Services or Program
I give my consent voluntarily and understand that I may withdraw my consent at any time. I also understand
that my child's right to receive special education and related services is in no way dependent on my granting
consent and that, regardless of my decision to provide this consent, all the required services in my child's IEP
will be provided to my child at no cost to me.
Parent/Guardian Signature:
Print Name:
_
Date:
MEXICO ACADEMY AND CENTRAL SCHOOL DISTRICT
16 Fravor Rd. Suite A
Mexico, NY 13114
(315)963-8400 ext. 5400
(315) 963-5801 (Fax)
STUDENT RACIAL AND ETHNIC IDENTIFICATION
To the Parent/Guardian:
The Mexico School District is required to collect and record the ethnic identity of students, in accordance with the
federal categories and definitions. The information will be used to:
-
Report information to the State and Federal Education Departments, as required.
-
Plan educational programs and make sure that they are readily available to all students.
-
Study the movement of students in different ethnic groups as they move from school to school.
-
Analyze the difference in academic performance, attendance and completion of school.
We need your help in order to accomplish this task. Please review the Racial/Ethnic definitions on the back of this
page. Put a check (√) in the box for the category or categories which best describe your child. The Mexico
School District understands the sensitive nature of this information and wishes to assure you that it will be kept
secure and confidential in accordance with all State and Federal student privacy laws and regulations. The Family
Educational Rights and Privacy Act (1974) prohibits unauthorized access to student records and unauthorized
release of any student record information identifiable by either student name or student identification number. If
the information requested is not provided on this form on behalf of your child, a student records officer from the
school or district will be required to identify the group to which the student appears to belong, identifies with, or is
regarded in the community as belonging. Thank you for your cooperation.
9/2014
MEXICO ACADEMY AND CENTRAL SCHOOL DISTRICT
16 Fravor Rd. Suite A
Mexico, NY 13114
(315)963-8400 ext. 5400
(315) 963-5801 (Fax)
STUDENT RACIAL AND ETHNIC IDENTIFICATION
All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of
race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.
Name of School: ______________________________________________________________________
School District Student Identification Number: ___________________ Date of Birth: _______________
Student Name: Last, First, Middle: _________________________________________________________
Grade Level: ___________
DIRECTIONS TO PARENTS/GUARDIANS:
PLEASE ANSWER QUESTIONS 1 AND 2. PLEASE READ THEM BEFORE YOU RESPOND. (For question #1, check (√ ) the line
that best describes your child.) Check only ONE line.
1.
Is the student Hispanic, Latino, or of Spanish origin? (Hispanic, Latino, or of Spanish origin means a person of Cuban,
Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
_____ YES, Hispanic
_____ NO, not Hispanic
2.
Select one or more races from the following five racial groups (For question #2, Check (√) all groups that apply to your
child. Check (√) at least ONE line.)
_____ American Indian or Alaska Native: a person having origins in any of the original peoples of North America and
who maintains cultural identification through tribal affiliation or community recognition. e.g. Cherokee, Mohawk, Inuit.
_____ Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent including for example, Cambodia, China, India, Japan, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.
_____ Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
_____ Black: A person having origins in any of the black racial groups of Africa.
_____ White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
____________________________________________
Signature of Parent/Guardian/Other
____________________________
Date
Relationship to Student (please check one below)
_____ Mother
_____ Father
_____ Guardian _____Other (Specify): _________________
9/2014
Mexico Central Schools
Health History
Name: _________________________________________________ Date of Birth: _________________
Sex: ( ) Male (
) Female
School: ( ) Mexico Elementary ( ) Palermo Elementary ( ) New Haven
( ) Mexico Middle School ( ) Mexico High School
Birth and Developmental History:
Birth Weight: ___________
Place of Birth: _____________________________
Complications of pregnancy or delivery?
Developmental Milestones: ____________ Sat up ___________ Walked
__________ First Word
Medical History
Does your child have any serious medical problems? (Ex: Asthma, Diabetes, Heart or Kidney Problems,
Seizures, Broken Bones, Head Injuries, Migraines, etc.)
Surgical History
Has your child ever had any operations? (Ex. Tonsillectomy, Adenoids, Hernia, Ear Tubes, Dental,
Appendectomy, Broken Bones, etc.)
Family History
Is there any family history (siblings, parents, grandparents) of diabetes, high blood pressure, heart
disease, cancer, tuberculosis, asthma?
Does your child have any allergies? (food, medicine, bee stings, environmental)
Does your child take any prescription medications (daily or as needed)? Please list.
Will your child need any medication during school hours? ( ) Yes ( ) No
If yes, name of medication: ______________________________________________________________
Written permission from the parent/guardian and your child’s health care provider is required. The
medication must be delivered to school in the original container.
HEALTH HISTORY CONTINUED
Does your child wear glasses/contacts
( ) Yes ( ) No
Has your child seen an eye doctor?
( ) Yes ( ) No
Does your child have a hearing problem?
( ) Yes ( ) No
If yes, when? ___________________________________________________________________
Does your child have braces?
( ) Yes ( ) No
Has your child visited a dentist?
( ) Yes ( ) No
If yes, when? ___________________________________________________________________
Do you have any concerns about your child’s growth (height or weight)?
Social History:
Number of Adults at Home: __________
Number of children at home: __________
Any Smokers Living in the Home:
( ) Yes
( ) No
Did the Child Attend Pre-School?
( ) Yes
( ) No
Type of Dwelling: House _______
Apartment _____
Mobile Home _____
Type of Heat: Gas _______
Electric _______
Wood Stove _______ Pellet Stove _______
Flooring in Bedroom: Carpet ____ Wood _____ Tile _____
Linoleum _____ Laminate _____
Type of Pets
Number of Pets
Indoor Pet
Outdoor Pet
Emergency Information:
Child’s Health Care Provider: _____________________________________________________________
Phone Number: _______________________________________________________________________
In case your child is ill or injured at school or if there is an urgent situation, please list in order of priority,
the adult that should be contacted first:
Name: ______________________________________________ Phone: __________________________
Name: ______________________________________________ Phone: __________________________
Name: ______________________________________________ Phone: __________________________
9/2014
Mexico Academy and Central School District
Mexico, NY 13114
Authorization for Treatment
As a parent or legal guardian of __________________________________________, I give the
Mexico Central School District permission to care for my child at school in accordance with the
District’s established medical and first aid guidelines. I grant the school nurse permission to
exchange medical information about my child with my child’s physician and current teachers as
necessary.
This consent is valid indefinitely from this date unless revoked by the parent or guardian.
Parent/Guardian Signature _______________________________________________________
Date _________________________________________
9/2014
Mexico Academy and Central School District
School Physical Consent Form
Student Name: _______________________________________ School _______________________________
Dear Parents,
All students who transfer to the Mexico Central School District or students entering grades Pre-K, K, 2, 4, 7, and 10 are
required by New York State Law to have a physical exam by a NYS licensed health care provider. This health exam must
have taken place within 12 months prior to entering, and proof of this is required by the school within 30 days of
starting school.
If the health exam is more than 12 months old when your child starts school, you will need an updated physical exam.
This can be completed by your own physician or our School Physician. Please note that in the event that the
documentation of a current physical is not provided to the school within 30 days of starting school, then we are required
by law to have our School Physician conduct this physical exam. You would first receive notification of this and then it
would take place in the nurse’s office at your child’s school.
Please choose from the following:
(
)
I will have a physical completed by our family physician. I understand that I must provide this documentation
(Mexico Central School Health Appraisal Form) within 30 days of the start of school or the School Physician will
conduct this physical, upon written notification to me.
(
)
I give permission for the designated School Physician to complete a school physical examination as required by
NYS Education Law. I understand this will be performed at the school my child attends and that there is no
charge for the school physical. School physicals will begin in October and are conducted periodically throughout
the year.
This consent form is valid from the date noted below unless revoked by the parent or guardian. If custody or
guardianship changes in the future, it is your responsibility to notify the school district of such a change.
Signature: ____________________________________________
Parent or Legal Guardian
Date: ___________________
If you have any questions please call your school’s nurse at the extension below.
Mexico High School – Deborah Wallace – 963-8400 ext. 5052
Mexico Middle School – Carolee McCoy –963-8400 ext. 4205
Mexico Elementary – Shannon Main – 963-8400 ext. 2307
Palermo Elementary – Darlys Forbes – 963-8400 ext. 1019
New Haven Elementary – Jill LaRock – 963-8400 ext. 3502
3/2016
Mexico Academy and Central School District
Your healthcare provider will require the Release of Information Form below to share Protected Medical Information
with the school district. Please sign and give the form to your healthcare provider and/or to your school nurse to avoid
delays.
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I, ___________________________________________________________authorized my child’s healthcare provider(s)
listed below to release my child’s (name) ________________________________________ medical records to the
district’s medical officer, physical (PT), speech therapists (ST), school nurse, and/or school psychologist.
Name__________________________________________________ Phone_______________ Fax___________________
Name__________________________________________________ Phone_______________ Fax___________________
Name__________________________________________________ Phone_______________ Fax___________________
The healthcare provider may disclose the following protected health information: (check all that apply)
_____ Immunization
_____ Health Appraisals
_____ Past/current medical condition and its impact on attendance, school programming, and/or PT, OT, ST needs
_____ Other
The protected health information may be used, disclosed or received for the following purpose(s): (check all that apply)
_____ To develop care or therapy plans for routine and emergent school management.
_____ To design appropriate educational programs.
_____ To assess the impact of the medical conditions(s) on school programming and/or attendance.
_____ To share school observations/concerns surrounding behavior.
_____ To assess a medical basis for modification of transportation and/or home tutoring.
_____ Medication delivery and/or therapy prescriptions for PT, OT, ST.
_____ At patient’s request with no specified purpose.
_____ Other_______________________________________________________________________________________
Please select one:
( ) This authorization is valid for the entire academic school year 20___ - 20___.
( ) This authorization shall expire on ____/____/____ (MO/DD/YR) and/or Graduation Date.
I acknowledge that I have the right to revoke this authorization at any time by sending written notification to the Privacy
Officer at my healthcare provider’s office and to the District Administration Building.
I understand the revocation of this authorization is not effective if the Healthcare Provider or District has used the
authorization for disclosure of the Protected Health Information before receiving my written revocation notice.
I understand that any Protected Health Information disclosed as a result of this Authorization to anyone not covered by
the state and federal privacy laws may be subject to re-disclosure and may no longer be protected by the federal or
state law.
I understand that my child’s treatment is not dependent on my agreement to release or withhold information.
________________
Date
______________________________________________________
Signature of Parent/Guardian or Patient (Over 18)
___________________
Relationship
9/2014
Dental Health Certificate
Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K,
2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete
Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your
dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Lasl
Child's Name:
Birth Date:
I
Month
School:
I
Doy
Year
First
I
Sex: D Male
D Female
I
Middle
D Yes
Will this be your child's first visit to a dentist?
D No
Name
Grade
Have you noticed any problem in the mouth that interferes with your child's ability to chew, speak or focus on school activities? D Yes D No
I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this
assessment is only a limited means of evaluation to assess the student's dental health, and I would need to secure the services of a dentist in order for
my child to receive a complete dental examination with x-rays if necessary to maintain good oral health.
I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship.
Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the
recommendations listed below.
Parent's Signature
Date
Section 2. To be completed by the Dentist
I. The Dental Health condition of
on
(date of exam) The date of the
exam needs to be within 12 months of the start of the school year in which it is requested. Check one:
0 Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.
0
No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.
NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus
on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit
condition of dental health to permit attendance at the public school does not preclude the student from attending school.
Dentist's name and address {please_Qrint or stamp)
Dentist's Signature
Optional Sections- If you agree to release this information to your child's school, please initial here.
II. Oral Health Status (check all that apply).
I
I
DYes D No Caries Experience/Restoration History- Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a
tooth that is missing because it was extracted as a result of caries OR an open cavity].
[]Yes D No Untreated Caries- Does this child have an open cavity? [At least Y, mm of tooth structure loss at the enamel surface. Brown to darkbrown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces.
If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are
considered sound unless a cavitated lesion is also present].
DYes D No Dental Sealants Present
Other problems (Specify):
Ill. Treatment Needs (check all that apply)
D No obvious problem. Routine dental care is recommended. Visit your dentist regularly.
D May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation.
D Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.
NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and
triennially for the Committee on Special Education (CSE).
MEXICO CENTRAL SCHOOLS HEALTH APPRAISAL FORM
Name:
Date of Birth:
School: _________________________________________
Gender:  M  F
Grade: _____________________________________
IMMUNIZATIONS / HEALTH HISTORY
 Immunization record attached
Sickle Cell Screen:  Positive Negative  Not done
Date:
 No immunizations given today
PPD:
 Positive Negative  Not done Date:
 Immunizations given since last Health Appraisal:
Elevated Lead:
 Yes
 No
 Not done Date:
Dental Referral
 Yes
 No
 Not done Date:
Significant Medical/Surgical History:  See attached _____________________________________________________________________
______________________________________________________________________________________________________________________
Allergies:  LIFE THREATENING
 Food:
 Insect: ________  Seasonal ____
 Medication:
PHYSICAL EXAM
Height: ______
Weight: ______ Blood Pressure: _______
Body Mass Index:
____ ____ . ____
Vision - without glasses/contact lenses
Weight Status Category (BMI Percentile):
 less than 5th
 85 through 94
th
th
Referral
R
L
Vision - with glasses/contact lenses
R
L
 5th through 49th
 50th through 84th
Vision - Near Point
R
L
 95 through 98
 99 and higher
Hearing  Pass 20 db sc both ears or:
R
L
th
th
 EXAM ENTIRELY NORMAL
th
Tanner:
I.
II.
III.
IV.
V.
Scoliosis:
 Negative  Positive:
Specify any abnormality (use reverse of form if needed):
MEDICATIONS
Medications (list all):
 None
 Additional medications listed on reverse of form
Name: ____________________________________________________ Dosage/Time: _________________________________________________
Name: ____________________________________________________ Dosage/Time: _________________________________________________
If AM dose is missed at home: ________________________________________________________________________________________________
I assess this student to be self-directed  Yes  No
Student may self carry and self administer medication  Yes  No
Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency
sheltering is necessary at school or if the morning medication has not been given.
PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION
 Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:
___ Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball.
___ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump.
 Specify medical accommodations needed for school:
 None
 Known or suspected disability:
 Please monitor
 Restrictions:
 Please monitor
 Protective equipment required:  Athletic Cup
Specify current diseases:
 Other:
Provider’s Signature:
 Asthma
 Sport goggles/impact resistant eyewear  Other:
OPTIONAL INFORMATION, if known
Diabetes:  Type 1
 Type 2
 Hyperlipidemia
Phone:
Provider’s Name/Address:
Fax:
Parent Signature:
Date of Exam:
 Hypertension
(Stamp below)
This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five
days that will require review by private healthcare provider and the school medical director.
Rev. 2/2016