CUSTODY STATEMENT

ID #________________ Grade _____________ Grid Code _________ Entry Date _________ Entry Code ________ Teacher/Counselor_________ REGISTRATION FORM Mesa County Valley School District 51 2115 Grand Avenue Entered in SASI __ Copy to ESL ___ Grand Junction, CO 81501 School ___________________________ Please print and fill in all the information below. Student Information Section 1 Last Name First Name Date ________________ Middle Name Grade Gender M__ F__ Has student attended a U.S. school for more than 3 full academic years? Yes___ No____ Temporary Housing Yes__ No__ Resident Address Mailing Address (If different) Date of Birth Birth State Social Security # Birth Country City State Zip Phone Ethnic Code (Please check only one) ___1=Am. Indian/Alaskan Native ___ 2=Asian/Pacific Islander ___ 3=Black ___ 4=Hispanic ___ 5=White Health Insurance (Please check one) ___ Private ___ CHP+ ___ Uninsured ___ Medicaid Consent to bill Medicaid ____ Yes ____ No ____ N/A Birth Name (Please Print) Parent /Guardian Information Section 2 Is this student subject to a court order regarding school attendance, custody or a major decision making agreement? Yes_____ No _____ Please complete the attached custody statement. If student does not live with parent/guardian, student lives with: Name _________________________________ Phone Address Relationship Who makes major educational decisions for student? Both Parents____ Mother____ Father____ Guardian____ 1. Parent/Guardian Name Address Relationship Other____(Specify) Relationship Phone Other Work Phone 2. Parent/Guardian Name Phone Address Other Employer Work Phone Employer List names of brothers, sisters and other school age children living in this home: Emergency Information Section 3 1. Last Name 2. Last Name First Name First Name If a parent/guardian cannot be reached, please contact the following: Phone Phone Home Work Home Work Relationship to Student Relationship to Student Medical Emergency Information: Section 4 Phone # Hospital Physician name Takes medications: No____ Yes____ List: Medical information (allergies, chronic illness, disabilities) Please fill out Health History sheet. Previous School Information Section 5 Has student ever attended any District 51 school? No___ Yes___ Last school attended? City/State Has student ever been retained? No___ Yes ___ Has this student ever received special education services? What grade?________ What school?__________________ Yes____ No____ Has student been involved in any early childhood experience? No____ Yes ____ ____Private Preschool 1. 2. 3. 4. 5. 6. ____Childcare Center ____Head Start ____District #51 Preschool ____Home Child Care ____Other Home Language Survey Section 6 Mark only those that apply to your family (Please don’t include languages you’ve learned in school) What was the first language spoken by the student? English ____ Spanish ____ Other Identify all languages spoken in the home English ____ Spanish ____ Other List all languages understood by student English ____ Spanish ____ Other Language spoken in the home by student English ____ Spanish ____ Other Has your child ever been enrolled in an English as a Second Language Program? No _______ Yes _____ Do you require district information translated in a language other than English? No ____ Yes____ If yes, what language? I request the school to notify me in case of an emergency or serious illness. If I am unable to be reached, I grant permission for the school to contact appropriate emergency agency/facility. Parent / Guardian Signature: (White –Cum Folder Yellow-Building Copy) ______ ___________________________________Date______________ Revised 3/2007 Form WH008093 Pink-ESL Department CUSTODY STATEMENT Name student goes by: ________________________ Last Name ______________________ First Name __________ Grade __________ Middle ______________________________________________________ Student’s name as shown on Birth Certificate Please complete the following: 1. Who has legal custody or major decision making responsibility? _______Mother ________Father ________Both __________Other Please Specify. 2. Please complete Parent(s) or Legal Guardian(s) name and address: Father/Guardian Address City, State, Zip Home Phone Work Phone Mother/Guardian Address City, State, Zip Home Phone Work Phone 3. Is any one else allowed to pick up your child in case of an emergency that is not listed on Registration form? Name Address City, State, Zip Phone Name Address City, State, Zip Phone 4. Does a current legal custody agreement exist?__________ If yes, please attach a copy of the agreement. Attendance, grades, etc., may be released to the following if requested by them: Name Name Relationship to the child Relationship to the child If both parents share joint decision making regarding educational decisions and are unable to reach an agreement for the child, or in the absence of parent authorization, the school will make a decision based on the best interest of the child. Under the Privacy Act of 1974, parents are entitled to copies of their child’s records, unless their rights have been terminated by the courts or the district has received a Colorado Court Restraining Order specifically requesting we not release student records to the requesting parent. PLEASE NOTE: If possible, both parents must sign this statement indicating they agree with the above information. If there is only one signature, District 51 requires an explanation as to why there is only one signature. __________________________________ Parent/Guardian Signature Date ______________________________ Parent/Guardian Signature Date If only one signature, please explain why:_________________________________________________________________________________ Revised 03/26/09 pg 2009-2010 PRESCHOOL IMMUNIZATION REQUIREMENTS Please provide the school with your child's current immunization records. Colorado State Board of Health requires the following immunizations for compliance with the school entry Immunization Law: 1. DTaP 2. Polio 3. Hib - 4 doses 3 doses The age a child begins the Hib series will determine the number of doses required. There is a current Hib shortage, please check with your child’s provider regarding the need for Hib. 1 dose given on or after the first birthday 3 doses 1 dose given on or after the first birthday OR Documented disease history from an approved health care provider 4. MMR 5. Hepatitis B 6. Varicella – Contact school personnel if you would like to obtain a personal, religious or medical exemption. You may have your child immunized at his/her doctor’s office or at the Mesa County Health Department (248-6900). Please note: Colorado School Entrance Immunization Law requires all students to provide proof of immunizations to attend school. FAILURE TO SUPPLY THE NECESSARY INFORMATION MAY RESULT IN YOUR STUDENT BEING SUSPENDED FROM SCHOOL. Thank you for your cooperation, Nursing Services Mesa County Valley School District 51 NURSING SERVICES-PRESCHOOL HEALTH SCREENING Hawthorne Building, 410 Hill Ave, Grand Junction, CO 81501 This form must be turned into the school office before child can attend preschool PRESCHOOL HEALTH HISTORY TO BE COMPLETED BY PARENT / GUARDIAN UPON REGISTRATION STUDENT: PHYSICIAN: BIRTHDATE: PHONE: GENDER: SCHOOL: GRADE: HEALTH HISTORY AND MEDICAL CARE: Please fill in the information below if your child has been diagnosed and treated for any of the following conditions: DIAGNOSIS / TREATMENT DATE of PRESCRIPTION Describe (write details) in the area provided DIAGNOSIS or MEDICATIONS or use the back of the sheet LAST EPISODE Allergy (Severe) or Allergic Reaction Symptoms: Asthma: Diabetes: Seizure Disorder: ADD/ADHD: Pregnancy/Delivery/Congenital problems: Acquired Traumatic Brain Injury: Other injuries or illnesses (please specify-use back of the sheet as needed): If you would like the Registered Nurse to call you about the health condition(s) you have checked above, please provide your name _________________________________and phone number ___________. The above information is considered confidential and is shared on a “need to know” basis between the Registered Nurse (District/School Nurse) and School Staff who will be in contact with and responsible for your child during the school day. The Health Offices in Mesa County schools are staffed by Health Assistants under the supervision of a Registered Nurse. Medications given at school must be accompanied by a signed physician order, signed parental permission (forms are available in the school Health Office), and must be in the original labeled container. Parents/Guardians are responsible for informing the school of any health issues that have changed for their student throughout the school year. Health Care Professional Signature:___________________________________________ Date______________ Parent/Guardian Signature:___________________________________________________________ Date_______________ Attention Parents: Do you find yourself in one of the following temporary or transitional living situations? Living in a hotel or motel Living in a shelter or “safe house” Living doubled up with friends or relatives Living in a park or campground Living in a camper, camp trailer or vehicle Living in sub standard housing as outlined by HUD definitions An unaccompanied or runaway youth If so, Mesa County Valley School District 51’s REACH program has some ways to support you with your school- related needs, as well as access to other community resources and supports. Contact your child’s school or call our offices at 254-5350 and ask for the REACH department. There is an advocate assigned to each school that will assist you. Atención Padres: ¿Se encuentra Ud. en una de las siguientes viviendas temporales o transitorias? Vive en un hotel o motel Vive en una casa de refugio Vive con parientes o amigos Vive en un parque o en un campamento Vive en un camper, en una tráiler o en su vehículo Vive en una casa inadecuada según el departamento de HUD Es Ud. un joven abandonado o un joven que anda huyendo Si es así, el programa de REACH del Distrito Escolar 51 del Condado de Mesa tiene algunas maneras para apoyarlo a Ud. con sus necesidades escolares, y también para darle acceso a los recursos de la comunidad. Comuníquese con la escuela de su criatura o llame a nuestra oficina al número 254-5350 y pregunte por el departamento de REACH. Hay una persona asignada a cada escuela que le puede ayudar. CONSENT TO PHOTOGRAPH AND RELEASE NAME I, (PRINT NAME) _______________________________________________________,parent/guardian of (PRINT CHILD'S NAME)___________________________________________________________________, consent to the use of photographs, video/audio tape (television or radio), and use of my child’s name for school or district communication purposes, including media interviews, district publications and website. In giving this consent I release (NAME OF SCHOOL) _____________________________________School and Mesa County Valley School District 51 from any liability for any violation of any personal or proprietary rights I may have in connection with the use of the photographs, video/audio tape (television or radio) and use of my child’s name. I (the parent/guardian) am more than 21 years of age. __________________________________________________________________ SIGNATURE OF PARENT/GUARDIAN ______________________________________________________________________________________ PRINT NAME ___________________________________________________________________ DATE CYBERSCHOOL (ONLINE COURSE) INFORMATION Student Name ______________________________________________________ SASI # ________________________ Last First Middle School ______________________________________________________________ Grade ______________ Is student currently registered and using online courses with a Cyberschool in Colorado?  No Continue to asterisk, read statement, sign and date – no other information is necessary.  Yes Full-time  Part-time  Continue filling in form. CYBERSCHOOL INFORMATION: Name of Cyberschool ________________________________________________________________________________ Cyberschool’s sponsoring School District ________________________________________________________________ Name of Cyberschool contact _________________________________________ Position _________________________ Telephone __________________________________________ E-mail ________________________________________ Street _____________________________________________ City ____________________________ Zip ___________ List your online courses ______________________________________________________________________________ *If at any time during the school year you enroll your child in a Colorado Cyberschool (online courses) you must immediately notify this school/district. Enrollment in online courses is enrollment in another district. Students may not be served in two districts without agreement between districts. Parent/guardian name __________________________________________________ Last First MI Parent/guardian signature _____________________________________________ Date ___________________________ INFORMACIÓN DE CYBERSCHOOL (CURSO EN LÍNEA INTERNET) Nombre del Estudiante ______________________________________________________ SASI # _________________ Apellido Primer Nombre Segundo Nombre Escuela ______________________________________________________________ Grado ______________ ¿Esta el estudiante actualmente registrado y utilizando los cursos en línea de una cyberschool en Colorado?  No Continúe al asterisco, lea la declaración, firme y fecha - ninguna otra información es necesaria.  Sí Tiempo Completo  Parte del Tiempo Continúe llenando la forma completamente. INFORMACION CYBERSCHOOL: Nombre de la Cyberschool ____________________________________________________________________________ El Distrito Escolar que Patrocina la Cyberschool___________________________________________________________ Nombre de contacto de la Cyberschool___________________________________ Puesto _________________________ Teléfono __________________________________________ Correo Electrónico________________________________ Domicilio _________________________________________ Ciudad _______________________ Código ___________ Lista de cursos en línea ______________________________________________________________________________ * Si durante el año escolar Ud. inscribe a su niño/a en una Cyberschool de Colorado (cursos en línea) Ud. debe notificar a esta escuela/distrito escolar inmediatamente. Matriculación en los cursos en línea es matriculación en otro distrito. No podemos servir a los estudiantes en dos distritos sin entre los distritos. Nombre del Padre/guardián ________________________________________________________ Apellido Nombre Segundo Nombre Firma del Padre/guardián _____________________________________________ Fecha___________________________ John P. Pomaski Director – ELA/ Migrant 930 Ute Avenue Grand Junction, CO 81501 (970) 254-5336 ~ Office (970) 254-5391 ~ Fax jpomaski@mesa.k12.co.us Student Name (Nombre del Estudiante): ____________________________________ School (Escuela): ______________________ Telephone (Teléfono) ______________ Does your Family qualify as Migrant? If the answers to the following four questions are YES, your child qualifies for the Migrant Education Program. 1. Did the child move (alone, with, or to join a parent, spouse, or guardian) within the last 36 months? _________ 2. Was the move from one school district to another? ________ 3. Was the purpose of the move to obtain work that is (1) temporary or seasonal AND (2) agricultural, fishing, or dairy? ________ 4. Was the work an important part of providing a living for the worker and his or her family? ________ Please return the following sheet to the Migrant Office on 930 Ute Avenue or to your child’s school if you have answered yes to all questions. If you have questions about immunizations please call 254-5338. Thank you John Pomaski/ ESL/Migrant Director ¿ Califica su Familia como Migrante? Si las respuestas a las siguiente cuatro preguntas son Sí, su niño califica para el Programa de Educación Migrante. 1. ¿Dentro de los últimos 36 meses, el niño se mudó (solo, con, o para reunirse con su padre(s), esposo, o guardián)? ______ 2. ¿La movida fue de un distrito escolar a otro? ________ 3. ¿El propósito de la movida era para obtener trabajo que es (1) temporal o estacional Y (2) agrícola, pesca, o lechería? ______ 4. ¿El trabajo fue una parte importante en proporcionar una vivienda para el obrero y su familia? _________ Si usted ha contestado sí a todas las preguntas, por favor devuelva la hoja a la Oficina Migrante en 930 Avenida Ute o a la escuela de su niño. Si usted tiene preguntas sobre inmunizaciones favor de llamar al 254-5338. Gracias, John Pomaski/Director ESL/Migrant MARILLAC CLINIC AND MESA COUNTY VALLEY SCHOOL DISTRICT 51 PRESCHOOL - DENTAL SCREENING PROGRAM Date: ________________________________ I give my permission for (child’s name)_____________________________________________ to receive a limited FREE dental screening (no x-rays) from Marillac Dental Clinic. The screening is held at my child’s preschool. This releases any liability of Marillac Dental Clinic and Mesa County Valley School District 51 Preschool Program during this activity. Marillac Clinic may call me regarding further urgent dental needs for my child. Parent Name (Please Print): ________________________________________________________ Phone Number: ____________________________ Convenient time to call: ______________ Address: ____________________________________________________________________________ City: ___________________________________ Zip: ___________________ Parent /Guardian Signature: ______________________________Relationship to Child: _____________ Does your child have dental insurance? __Yes __ No Insurance Information: _ Medicaid __ CHP+ ___ Private Insurance __ None If Medicaid, child’s number is: __________________________ (If your child needs further dental care, Marillac Dental Clinic will need your most recent Medicaid card or number.) Does your child have a dentist? __ Yes __ No Dentist Name: __________________________________ **Please return this form to your child’s preschool teacher so your child can participate. If you have more than one child attending preschool, please fill out a form for EACH child. Consent for Fluoride Varnish At the time of the screening we recommend brushing a fluoride varnish on your child’s teeth. Below is a brief explanation of what a fluoride varnish is: Fluoride varnish is a non-harmful liquid coating that helps prevent tooth decay and stop the progression of early decay. It is applied to the teeth with a brush, takes 30 seconds to 2 minutes to apply and it dries instantly. To maintain continued effectiveness, it can be reapplied every 3-6 months. I give permission for my child to receive the fluoride varnish by the dentist or hygienist at the time of the screening. __________________________________ Parent/Guardian Signature ______________________ Date Revised 032009 pg FREE Vision Screening For children ages three through five The local Lions Club in your community, in conjunction with the Rocky Mountain Lions Eye Institute, will offer free vision screening to your child at his/her daycare or school. The screening uses state-of-the-art technology and is 85-90% effective in detecting the vision problems that could lead to lazy eye. No physical contact is made with your child and no eye drops or medications are used. NOTE: Do not complete this form if your child wears glasses and/or is under the care of an eye doctor. WHY VISION SCREENING? 1 in 20 children has an undetected vision problem that could turn into lazy eye if left untreated. Early detection and treatment is essential to prevent lazy eye. Parent/Guardian: Please fill out the following. All information is kept confidential and is not sold to third parties. PLEASE PRINT and ANSWER ALL QUESTIONS Child’s Full Name _________________________________________________________________ First Middle Day Year Last Male___ Female___ Child’s Date of Birth ____________________ Month Child’s Age _____ School Attending __________________________________ Parent or Guardian __________________________________________ Email __________________________________________ Address _______________________________________________City ______________________________ Zip Code _________ Phone INCLUDING area code _______________________________ 2nd Phone ________________________________________ Is your child currently under the care of an eye doctor? Yes CONSENT: I hereby give permission for my child to participate in the screening event. I have read and understand the following information regarding this program: The information obtained from this vision screening is preliminary only and does not constitute a diagnosis of vision problems. Not all vision problems are detected by the vision screening process. The results of my child’s screening will be sent back to my child’s daycare or school and then distributed to me. I may be communicated by telephone if my child does not pass the eye screening. I understand that if my child does not pass the eye screening, I am responsible for arranging for an eye exam with an eye doctor of my choice. I understand that I am responsible for all costs of any eye exams. I will not hold the Lions Clubs organization, the Rocky Mountain Lions Eye Institute, their employees, agents, officers, and representatives liable for any injury which may accrue as a result of the vision screening, including but not limited to errors of commission, errors of omission or other misdiagnosis. VOLUNTEER: Please staple Child's Vision Screening Photo or Readout here and label with child's initials and date of birth _______________________________________________ Signature of Parent or Guardian __________ Date RESULTS: _____Pass _____Borderline To Be Completed by KidSight Staff We are unable to detect a vision problem at this time. This screening is not a substitute for a complete pediatric eye exam. Consult an eye care professional if you suspect a vision problem. Your child may be developing a mild refractive error that does not need to be formally evaluated at this time. We recommend the child be re-screened by an eye care professional in one year or sooner, if you suspect a problem. We were unable to get reliable vision screening results for your child. This can happen occasionally if the child looks away from the blinking light during the screening. Consult an eye care professional if you suspect a vision problem. Your child should be examined because he/she may have the following condition: _____ Strabismus _____ Anisometropia _____ Astigmatism _____ High Hyperopia _____ High Myopia _____ Other: ___________________________________ Revised 10-08 The interpretation of your child's vision screening is as follows: _____Unreadable _____Refer