Fairview Park City School District
Brion Deitsch, Superintendent Ryan Ghizzoni, Treasurer 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
Welcome to the Fairview Park City Schools!
We are pleased you have chosen the Fairview Park City School District to educate your child. To make the registration process flow smoothly, please carefully read the information below. Upon completion of your registration packet, please call Patty Yager in the registration office for an appointment. Registration is done by appointment ONLY during the hours of 8:00 a.m. to 3:30 p.m., Monday through Thursday. Patty Yager (440) 356-3541 You will need to bring the following information with you to your registration appointment: • Two (2) Proofs of Residency • Birth Certificate • Immunization Records • Custody Papers (if applicable) • IEP/MFE (if student is a special education student) Copies will be made of all the above documentation. If you are registering a middle school or high school student, an additional appointment will be made for you to meet with a guidance counselor during this time. If registering a high school student: It is very important that you obtain an OFFICIAL transcript from your previous school. If registering a middle school student: Please have the most recent report card or class schedule with you. Again, thank you for choosing the Fairview Park City Schools.
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
Fairview Park City School District
Brion Deitsch, Superintendent Ryan Ghizzoni, Treasurer 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
REGISTRATION REQUIREMENTS FOR THE FAIRVIEW PARK SCHOOLS
1. Certified Birth Certificate, Baptismal Record, U.S. Passport, or Visa (will not enroll without one) EXCEPTION: The Fairview Park Schools do not accept students with I-20 Student Only Visa 2. Two (2) Proofs of Residency – (Name and Fairview Park address need to be on all proofs) (will not enroll without proof) *The first Proof of Residency MUST be: Signed Lease Purchase Agreement Mortgage Statement Deed *The second Proof of Residency may be one of the following: Current Utility Bill Homeowner or Tenant Insurance Policy Municipal Income Tax Bill (RITA) Driver’s License not acceptable PLUS - If living with relatives – In addition to the above stated documents, a notarized letter from relative stating that the custodial parent and child(ren) are living with them is required. The relative and custodial parent must also bring in a proof of residency to that address. 3. Guardianship Papers (will not enroll without papers) 4. Custodial Papers, if divorced, or Pending Court Case Number (will not enroll without papers) 5. Complete Immunization Record 6. Driver’s License/Picture I.D.
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
Fairview Park City School District
Brion Deitsch, Superintendent Ryan Ghizzoni, Treasurer 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
SCHOOL HEALTH QUESTIONNAIRE
Name:
_____
Grade______________________________ Phone#________________________________ Sex: M_____________ F ___________ Birthdate_______________________________
Address:____________________________________________ Name of Physician____________________________________ School_________________ Previous School_______________
Parents/Guardian: Father ______________________________ Mother ______________________________________
Health History Allergies – List and describe reactions: Insect Stings _______________________________________________________________________ Food/Plants/Animals _________________________________________________________________ Medications _______________________________________________________________________ Recommended Treatment_____________________________________________________________ Asthma____________ Treatment Required: ____________________________________________________ Blood Disorders __________________________________________________________________________ Bone/Joint Disorder _______________________________________________________________________ Cancer_________ Explain __________________________________________________________________ Chicken Pox Disease _________ Date______________ Convulsions/Seizures ________ Frequency ____________________Medication_______________________ Diabetes____________ Age of onset_________________ Treatment________________________________ Ear Infection____________________________ Hearing Difficulty____________________________________ Hearing Problems _____________________________________ Hearing Aids: Yes________ No __________ Heart Disease __________ Describe__________________________________________________________
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
(Please complete back of form)
Kidney Disease_____________ Describe ______________________________________________________ Nervous System Disorder ___________________________________________________________________ Scarlet Fever/Strep Infection ________________________________________________________________ Skin Disorder____________________________ Describe_________________________________________ Stomach/Intestinal Disorder________________ Describe__________________________________________ Vision Problems________ Describe___________________________________________________________ Glasses: No_________________ Yes________________ Near/Far Other Health Problems Hospitalizations, serious illnesses, injuries and surgeries (explain and give dates) _____________________________ __________________________________________________________________________________ Family history – Indicate if any member of immediate family has or has had any serious illnesses or diseases (such as a history of color deficiency (color blindness) ___________ __________________________________________________________________________________ Immunization Information
Please list day, month and year: DPT/DTaP: 1___________ Polio: HIB: Hepatitis B: MMR: 1.___________ 1. __________ 1.___________ 1.___________ 2.____________ 2.____________ 2.____________ 2.____________ 2.____________ 2.____________ 3._______________ 4._____________ 3._______________ 4._____________ 3._______________ 4._____________ 3._______________ Hepatitis A 1._____________ 2._______________ 5._______________ 5._______________
Varicella 1.___________ Chicken Pox
Other:____________________ _________________________
I certify that this child has had the above immunizations and give permission for the above information to be shared with the Fairview Park Schools Staff involved with my child’s educational program.
Date
Signature of Parent or Guardian
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
02/08
Fairview Park City School District 21620 Mastick Road #A ● Fairview Park, Ohio ● 44126 440-331-5500
STUDENT REGISTRATION FORM (PLEASE PRINT)
Incoming Grade: Date Entered: Student ID #
YOG:
Last Name __________________________ First _______________________ Middle
M ____ F ____
Birthdate: Month ______/______/_______ ) ______________ Unlisted
Address:________________________________________ City: ______________________ State: _____ Zip: _______ Phone (
□
Birthplace: City ________________________________ State/County _________________________ Prior School __________________________ Address _______________________ City/State ____________________ Grade ____ Dates Attended _________ Prior Home Address Did student previously attend the Fairview Park Public Schools? Emergency Contact(s) 1.
(Two contacts needed other than parent)
Prior Phone Number
Residency Dates
□ No □ Yes
Phone # ( Phone # ( ) )
If yes, school attended /( /( ) ) Relationship Relationship Ethnic Origin □White, Non-Hispanic □ Black/African American □ Hispanic □ Asian/Pacific Islander □ Native American/Alaskan □ Multiracial
2. Legal Custody □ Mother □ Father □ Grandparents □ Guardian □ Other □ Restrictions/Date _____________ ______________________________
Student Lives With □ Parents □ Mother □ Father □ Guardian □ Step-parent □ Foster-parent □ Other __________________________
Citizenship □ U.S. Citizen □ Immigrant □ Refugee Student's Language □ English □ Other ________________________
List all other children under the age of 22 who live at this student's address: Child(ren) Birthdate Relationship School Attending
Family Information Father: Last Name First
Family Information Mother: Last Name First
□ Living □ Married
Address City Occupation Employer Birthplace
□ Deceased □ Single □ Divorced □ Separated
) )
□ Living □ Married
Address City Occupation Phone ( Language Employer Birthplace
□ Deceased □ Single □ Divorced □ Separated
) ______________ )
State ______Zip _______ Phone (
State _______Zip ______Phone ( Phone ( Language
□ Step-parent □ Other
Last Name Occupation Employer Language
□ Foster Parent
□ Guardian
First Phone (
□ Spouse
□ Step-parent □ Other
Last Name Occupation
□ Foster Parent
□ Guardian
First Phone (
□ Spouse
)
Employer Language
)
Additional Comments: I swear this student and his/her custodial parent or legal guardian resides within the boundaries of the City of Fairview Park.
Signature Relationship Date
Fairview Park City School District
Brion Deitsch, Superintendent Patricia Flynn, Director of Pupil Services 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
FAIRVIEW PARK CITY SCHOOLS HOME LANGUAGE SURVEY As required by Federal Law, this form must be completed for all students at the time of enrollment Name of School Student Name Address Place of Birth 1. What Language did your child speak when first learning to talk? 2. List all languages spoken in the home. Circle the language used most frequently when speaking to your child. 3. Circle the people in your home who speak a language other than English. Father Mother Grandmother Grandfather Aunt Uncle Cousins Caregiver None 4. List language(s) the child speaks in the home. 5. List language(s) the child responds to in the home. Grade Date SEX Phone Student Number Date of Birth / /
(If English is the only language in the home – go to question 10.) 6. What is the parent’s native language? 7. Which parent speaks English? 8. Which parent reads English? 9. Is an interpreter needed? 10. Circle your child’s dietary needs: List Food Allergies Mother Mother YES No Restrictions Vegetarian Mother Father Father NO No Pork Products Father Both Both
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
PRINT THE FOLLOWING: 11. Father’s Name List Brothers including (Step) Name Birth Date School Name Mother’s Name List Sisters including (Step) Birth Date School
12. List all schools student attended in U.S. Name of School Year Grade Location City & State Days Enrolled
For Office use Only – Date Enrolled This completed form is to be placed in the student’s permanent folder and remain there until graduation. If language(s) other than American English is/are listed, please send a copy of the completed form, plus registration form, passport/birth certificate, names and addresses of all schools attended in U.S. to Pupil Services Attention ESL. Revised 07/28/2008
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
Fairview Park City School District
Brion Deitsch, Superintendent Ryan Ghizzoni, Treasurer 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
SCHOOL ENTRANCE MEDICAL RECORD FOR KINDERGARTEN
(TAKE THIS TO YOUR PHYSICIAN)
School: Name of Child: Address:
Grade: Birthdate:
Month Day Year
EXAMINATION Height: Vision: R. 20/ Hearing Test: Type: Referred to ear/eye specialist? Yes______ No_______ Nose: Throat: Mouth: Teeth: Is dental work indicated? Yes_____ No_____ If so, are plans being Posture: General Condition: Skin: Orthopedic: Neck: Nervous System: Heart: Lungs: Abdomen: Hernia: Genitalia: Urinalysis: Remarks and Recommendations: Date: Eyes: Ears:
Weight: L. 20/ R____
L_____
made? Yes____ No_____
IMMUNIZATIONS – (Please give exact dates)
DPT (Diphtheria, Tetanus, Whooping Cough): 5 DOSES REQUIRED (unless 4th after 4th birthday, then 4 required) 1.____________ 2._______________ 3._______________ 4.______________ 5.______________ Polio: 4 DOSES REQUIRED (unless an all IPV or all OPV sequence was used and 3rd was after 4th birthday, then 3 required)
1.____________2._____________ ___3._______________ 4._____________ 5._______________
MMR (Measles, Mumps, Rubella): 2 DOSES REQUIRED
st
Varivax(Chicken Pox)
1 ____________ (must be given after 1 birthday) 1.______________ 2 ____________ (must be given at least 1 month after 1st dose)
Hepatitis B: 3 DOSES REQUIRED
th
(2 dose at least 1 month after 1 , 3 at least 2 months after 2 and not before age 6 months, or a 4 dose is needed)
nd
st
rd
nd
and follow 1 by at least 4 months
st
1._________________ 2._______________ 3._______________4.______________________ Hib: (haemophilus b)__________________ ______ ____ Other______________ Latest Tuberculin Test: Type___________ Date__________ Positive______ Negative________ I CERTIFY THAT THIS CHILD HAS HAD THE ABOVE IMMUNIZATIONS ________________________ Date
02/08
____________________________________________ Signature of Physician
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
Fairview Park City School District
Brion Deitsch, Superintendent Ryan Ghizzoni, Treasurer 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
Dear Parents/Guardians of Children Entering Kindergarten: According to the Ohio Department of Health, by state legislative action effective January 15, 1999 [Sections 3701.13, 3313.671 and 5104.011 A (5)], your child must meet the following immunization requirements to attend school in the fall.* FIVE (5) DOSES OF DTP (Diphtheria, Tetanus, Whooping Cough) – Unless the 4th dose was given after 4th birthday, then 4 doses required. b) FOUR (4) DOSES OF POLIO (Poliomyelitis) – Unless an all IPV or OPV sequence was used and 3rd dose was after 4th birthday, then 3 doses required. c) TWO (2) DOSES OF MMR (Measles, Mumps, Rubella) 1) One dose must be given after first birthday. 2) Second dose must be given at least one month after 1st dose. d) THREE (3) DOSES OF HEPATITIS B (Viral Hepatitis B) 1) 2nd dose must be one month after the 1st dose 2) 3rd dose must be at least two months after 2nd and follow 1st by four months and not before six months of age (or 4th dose is needed) e) ONE (1) DOSE OF VARICELLA VACCINE OR CHICKENPOX DISEASE
a)
*Note: Exceptions are provided for under the law. This can be discussed with the school nurse.
A tuberculin skin test for detection of exposure to tuberculosis is not required, but may be done upon physician recommendation. ACCORDING TO SECTION 3313.671 ON THE 15TH DAY AFTER SCHOOL ENTRANCE IT WILL BE NECESSARY TO EXCLUDE ALL PUPILS FROM SCHOOL WHO DO NOT MEET THE ABOVE REQUIREMENTS. Medical authorities and school educators urge that every child have a complete medical examination before entering school in order that abnormalities, if present, may be addressed and the child is physically ready to accept all the advantages which education has to offer. Since the school nurse is required to check the records of all new entrants for compliance with immunization requirements, please have your physician complete the attached School Entrance Medical Record and return it by August 1st or preferably as soon as possible. FPCS Early Education Learning Center 21620 Mastick Road #B Fairview Park, Ohio 44126 I am aware that my daughter/son will be excluded after 15 school days if required immunization history is not provided. Signed: Date:
02/08
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
Fairview Park City School District
Brion Deitsch, Superintendent Ryan Ghizzoni, Treasurer 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 f:440.356.3545 www.fairviewparkschools.org
PARENT RESIDENCY
I, following students: , certify that I am the custodial parent/legal guardian of the _____
I reside at _________________________in Fairview Park, Ohio. Address I further certify that the above-mentioned student(s) reside with me at this address and attach to this form a copy of my _____purchase agreement _____rental contract _____other.
(“Residence,” within the meaning of ORC 3313.64, must be in a place where important family activity takes place during significant parts of each day-a place where the family eats, sleeps, works, relaxes, plays. It must be a place, in short, which can be called “home.”)
I understand that I may not have my child or ward enrolled in the Fairview Park City School District at any time unless I am maintaining a bona fide residence within the City of Fairview Park. Any effort on my part to illegally have my child or ward enrolled in the Fairview Park City School District, in violation of the residency requirements, can result in criminal prosecution for the theft of service under Ohio revised code section 2913.02 and for a violation of any other criminal statutes that may apply. Any conviction carries a potential fine and jail sentence. I also understand that in addition to the aforementioned criminal sanctions, I am also responsible for repayment of tuition for any time that my child or ward is enrolled in the Fairview Park City School District when I am not a bona fide resident of Fairview Park. Tuition cost for the school year is in excess of $1000 per month (cost determined each year by the Ohio Department of Education per ORC 3317.08). I hereby waive my rights to confidentiality of information relative to my residence and understand that the Fairview Park City School District will use whatever legal means it has at its disposal to verify my residency. If I change my residence, it is my duty to immediately inform the school district of my new address. Date ___________________________ Signature
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.
Fairview Park City School District
Brion Deitsch, Superintendent Nancy Colby, Dir. Transportation 21620 Mastick Rd. #A Fairview Park, OH 44126 440.331.5500 ext 1126 f:440.356.3545 www.fairviewparkschools.org
TRANSPORTATION FORM
LAST NAME: ____________________________________________________GRADE:__________________________ FIRST NAME: ___________________________________________________PHONE:__________________________ HOME ADDRESS: _______________________________________________BIRTHDATE: _____________________ GENDER: M or F
FAMILY INFORMATION
MOTHER’S FIRST NAME: __________________________________LAST NAME: ____________________________ WORK/ CELL NUMBER: ___________________________________EXT: ___________________________________ FATHER’S FIRST NAME:___________________________________LAST NAME: ____________________________ WORK / CELL NUMBER:___________________________________ EXT: ___________________________________
EMERGENCY CONTACTS
NAME 1. _______________________ 2. _______________________ RELATIONSHIP __________________________ __________________________ PHONE NUMBER ______________________ ______________________
HEALTH CONCERNS: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
MISSION STATEMENT The Fairview Park City Schools are committed to provide superior services and academic programs that challenge the mind and instill the joy of lifelong learning and responsible citizenship.