2019-2020 RETURNING STUDENT CHECKLIST - PC\|MACimages.pcmac.org/Uploads/ShontoPrepSchool... ·...
Transcript of 2019-2020 RETURNING STUDENT CHECKLIST - PC\|MACimages.pcmac.org/Uploads/ShontoPrepSchool... ·...
The following information is needed for each student at the time of re-enrollment. Students will not be permitted to start school until all the required documentations are received.
Completed Application packet. Do not sign if you are not the custodial parent or have legal or temporary guardianship documents attached.
Current 2019 or later Immunization Record (We will not be accepting handwritten records). According to Arizona Revised Statutes §15-871-874; and Arizona Administrative Code, R9-6-701–708, students must have proof of all required immunizations, or a valid exemption, in order to attend school.
[If applicable] Boundary Waiver, if you recently relocated outside the district area. Out of boundary students requires their local School Board Official’s approval for enrollment. Must be completed before student can start class.
[If applicable] Legal Documentation. If you are not the legal guardian or custodial parent of a student we require one of the following documents for enrollment:
o Court Custody Documents o Social Service Placement Letter o Power of Attorney Form signed & notarized.
[If applicable] Other copies of Court Documents, Restraining Orders, etc,
If enrolling in the dormitory, student must first be approved for re-enrollment with K-8 school.
10 years and older may participate in School Athletics. Physical Exam forms are available in the Elementary Office and available for download at our school’s website. All required Athletic Forms are due before first day of practice.
CHECKLIST
2 0 1 9 - 2 0 2 0
RETURNING STUDENT
If you should have any questions, please contact the K-8 Registrar at 928-672-3530. Thank you
SHONTO PREPARATORY SCHOOL
APPLICATION FOR BUREAU FUNDED SCHOOLS AND FERDERAL BOARDING SCHOOLS UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF INDIAN EDUCATION
Start Date
End Date GRADE
STUDENT INFORMATION
Last
Name First Middle
Mailing
Address City State Zip
Physical
Address
Primary Household Contact Number (This number will be used for our School Closure Notifications and Emergencies.)
Date Of Birth Gender Male Female Student
Status: Dorm Walk Bus Route:
Tribal
Affiliation/Agency
Enrollment
Number Degree
What is the language that the student first acquired? Navajo English Other:
What is the language most often spoken by the student? Navajo English Other:
What is the primary language used in the home regardless
of the language spoken by the student? Navajo English Other:
FAMILY & BACKGROUND INFORMATION If other than birth parents, court orders, legal issues, guardianship and/or Power Of Attorney forms must be on file.
Lives with Father Guardian
Lives with Mother Guardian
Same As Above Address
Same As Above Address
City, State, Zip City, State, Zip
Home Location Home Location
Contact Number Contact Number
Email Email
Tribal Affiliation/Agency Tribal Affiliation/Agency
Enrollment Number Enrollment Number
Chapter Chapter
Documents on
File? YES NO
Valid
Dates
Documents on
File? YES NO
Valid
Dates
EMERGENCY CONTACT (OTHER THAN PARENT)
Name Contact # Physical Address
Contact 1
Contact 2
THE FOLLOWING ADDITIONAL PEOPLE HAVE PERMISSION TO PICK UP MY CHILD FROM SCHOOL
Limit four (4). The person(s) on the list MUST BE OVER 21 YEARS OF AGE. Any release of a student requires proper check out
procedures in the office. The parents/guardians are to notify the office of any changes. This policy is written in the Student Parent Handbook.
1. Relationship 3. Relationship
2. Relationship 4. Relationship
|Page 1 of 2
OFFICE USE ONLY
PREVIOUS SCHOOL for new enrollment only.
School
Address
Phone Fax
Dates Attended Grade Completed
Reason for transferring:
Has your child been
suspended/expelled from
previous school? If yes, reason?
YES NO
Reason:
Retained?
(Grade/Year) YES NO
Has your child participated in
an Exceptional Education
Program or have an IEP?
YES NO
DISCLAIMER AND SIGNATURE to be signed by Parent/Legal Guardian.
I am legally responsible for this student and hereby apply for his/her admission to this school. Therefore I certify that the foregoing information is accurate and complete to the best of my knowledge. I also understand that additional information may be requested by the school from myself and other public agencies in accordance with the rules and regulations or the Family Privacy Act to complete the enrollment of my child.
________________________________________________ /______________________________________________ ____________________________
Print Name Signature Date
OFFICAL USE ONLY THIS STUDENT PROVIDED ALL NECESSARY DOCUMENTS AND BACKGROUND CLEARANCE TO ATTEND SHONTO PREPARATORY K-8 SCHOOL.
Degree of Indian Blood/CIB
Birth Certificate
Current Immunization
Approval of School Application:
Approved Approved with Contract
Denied Principal Initials:____________
_______________________________________________/_____________________ Signature of Registrar Date
__________________________________________/___________________ Signature of Education Program Administrator Date
2019-2020 SY
Notes:
|Page 2 of 2
Student Parent Handbook Page | 46
S H O N T O P R E P A R A T O R Y K-8 S C H O O L S PO Box 7900 • Shonto, AZ 86054-7900 • (928) 672-2652 • www.shontoprep.org
PHOTOGRAPHIC and MEDIA CONSENT AND RELEASE FORM
I hereby authorize the Shonto Preparatory Schools (SPS) and those acting pursuant to its authority to:
(a) Record my likeness and/or voice on a video, audio, photographic, digital, electronic or any other medium;
(b) Use my name in connection with these recordings;
(c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet/www) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts.
I release Shonto Preparatory Schools and those acting pursuant to its authority from liability for any violation of any
personal or proprietary right I may have in connection with such use. I understand that all such recordings, in
whatever medium, shall remain the property of SPS. I have read and fully understand the terms of this release.
Name: ___________________________________________________________
Signature: ____________________________________________ Date: ________
Parent/Guardian Signature: ______________________________ Date: ________
(If under 18 years of age)
Student Parent Handbook Page | 43
S H O N T O P R E P A R A T O R Y K8 S C H O O L S PO Box 7900 • Shonto, AZ 86054-7900 • (928) 672-3500 • www.shontoprep.org
ACCEPTABLE USE POLICY AGREEMENT FORM
Sign and return this page only. Do not return the entire policy.
I have read and will abide by the Shonto Preparatory Schools Acceptable Use
Policy. I understand that I am responsible for my actions while using the District’s
academic computer systems and the Internet. I understand that my Internet activities
will be monitored by the District, and any violation may result in the loss of computer
privileges, discipline as per the District Discipline Policy, and/or appropriate legal action.
Printed Name of Student:
STUDENTS (For students under the age of eighteen, a parent or guardian must also sign the agreement.)
I have read and understand that my child must abide by the Shonto Preparatory Schools
Acceptable Use Policy. I understand that some materials on the Internet may be
objectionable, but I release Shonto Preparatory Schools and its employees from any
liability resulting from my child’s activities on the Internet. I understand that my child’s
Internet activities will be monitored by the District, and any violation may result in the loss
of computer privileges, discipline as per the District Discipline Policy, and/or appropriate
legal action.
Signature of Student: Date:
Printed Name of Parent or Guardian:
Signature of Parent or Guardian:
Date:
Revised 5/22/19 (Revised)
NO YES NO YES NO YES
NO YES NO YES
NO YES NO YES NO YES
NO YES NO YES
NO YES NO YES NO YES
NO YES NO YES NO YES
NO YES NO YES NO YES
NO YES NO YES NO YES
NO YES NO YES NO YES
NO YES NO YES NO YES
GRADE: _________________
(HOME) (CELL PHONE) (MESSAGE)
"My child's prescription medication(s) will be provided in a labeled container with his/her name, the prescription name, specific instructions and
expiration date. If at any time the information must be changed, I will notify the school nurse or administrator in writing. I agree to and do
hereby hold SPS and its employees harmless from any and all claims, demands, causes of actions, liability of loss or any sort, because of or
arising out of act or omissions with respect to this/these medication(s)."
Special Instructions: _________________________________________________________________________________________________________
Parent Signature: _______________________________________________________Print Name: ____________________________________________Date: ______________________________
Parent(s): __________________________________________________________________
Pneumonia
Rheumatoid Arthritis
Scoliosis
Vision/Hearing Problems
Allergic to food(s);
*Submit a Dietary Restriction Form.
Allergic to Medicine(s);
________________________________
Allergic to insect bites
Allergic to pet dander
Thyroid problem
Tuberculosis
Under Physician's Care
Other:_________________
Hepatitis
High Blood Pressure
Kidney Disease
Meningitis
Migraine Headache
___ Ibuprofen (200 mg) ___ Throat Lozengers ___ Tribiotic Ointment ___ Children's Benadryl
___ Orajel Toothache ___ Children's Sudafed ___ Mouth Sore Gel (Administered only as a temporary relief)
If the school cannot contact either parent/guardian, please list a "Next of Kin" or a relative who would have authority to advise us regarding
your child and/or to locate you immediately.
DOB: _____________________________Gender: Male ( ) or Female ( )Student Name: __________________________________________________
ADD/ADHD
Anemia
Asthma (diagnosed)
Bleeding Disorder
Bronchitis
Chicken Pox
Diabetes
Dietary Restrictions
Epilepsy/Seizures
Eyeglasses/Contacts
"I, ________________________________________, (Parent or Legal Guardian), authorize the following non-prescription medication(s)
to be administered as needed for my child by the School Nurse or designated SPS personnel";
___ Children's Tylenol ___ Allergy Relief Eye Drop ___ Blistex Ointment ___ Children's Pepto Bismol Tablets
___ Tylenol (325 mg) ___ Eye Lubricant ___ Carmex Oinment ___ Hydrocortisone 1% Cream
___ Children's Ibuprofen ___ Cough Suppressant ___ Neosporin Ointment ___ Head Lice Shampoo
HEALTH HISTORY QUESTIONNAIRE
NON-PRESCRIPTION MEDICATION CONSENT
SHONTO PREPARATORY SCHOOL
STUDENT HEALTH QUESTIONNAIRE & CONSENT FORM
Has your child had any of the following health conditions listed below? Circle YES or NO.
School Year 2019 - 2020
Phone #'s: ________________________________________________________________________________________________________________________
Home Location: ____________________________________________________
Teacher: _________________
Name: __________________________________________________Relation to Child: __________________Phone #: _______________________________________
Explain "YES" answers here or "other"; ______________________________________________________________________________________________________________
Heart Murmur/Disease
FLUORIDE VARNISH AND DENTAL SEALANT CONSENT FORM
Dental sealants are one of the best ways we have to prevent tooth decay. They are hard plastic
coatings which protect the grooved surfaces of permanent teeth. They seal the deep pits and grooves of
teeth, keeping bacteria out and preventing decay. By having sealants placed now, your child may be
spared future, more extensive dental work. The application is painless and does not require numbing of
the mouth or drilling.
This preventative measure has very few risks. In rare cases, as with any dental procedure,
gagging or swallowing of dental materials may occur. In addition, your child may notice minor changes
in bite that should become less noticeable as excess material wears away over time. Please keep in mind
that sealants only protect the chewing (grooved) surfaces of teeth. Therefore, fluoride toothpaste and
mouth-rinse are also recommended to protect the smooth surfaces of the enamel.
Fluoride varnish can be painted on the teeth to prevent tooth decay delivering a safe and effective
dose of fluoride. The varnish sets up on contact with saliva so children usually cannot swallow the
varnish. The varnish will cause the teeth to look yellow for several hours and will gradually wear off.
Used at the right levels, it is safe and effective. Swallowing too much fluoride can cause stomach upset
or make white or brown spots on permanent teeth.
As a service to our patients, students are transported in with their teachers and classes to the
Inscription House Health Center IHS Dental Clinic for screening exams and, if indicated, the placement
of sealants.
Please answer ALL of the questions below, sigh, and return to the school.
MEDICAL HISTORY
Has your child EVER had:
Allergies Yes___ No___ Liver Disease/Hepatitis Yes___ No___
If Yes, to what?___________________ Heart Murmur Yes___ No___
Bleeding tendencies Yes___ No___
Seizures Yes___ No___ Heart/Vascular Disease Yes___ No___
Medication Usage Yes___ No___ Under MD’s care Yes___ No___
If yes, what ?_____________________ If yes, for what?_________________________
I ______DO ______DO NOT give consent for my child to receive fluoride varnish.
I ______DO ______DO NOT give consent for my child to participate in the dental sealant program.
Student’s name: _________________________________________________
Mailing Address: _________________________________________________
School: _________________________________________________
Grade & Teacher: _________________________________________________
Date of Birth: _________________________________________________
Chart Number: _________________________________________________
_____________________________________________________ __________________
Signature of Parent or Legal Guardian Date
SHONTO PREPARATORY SCHOOL (KDG – 8TH)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC & INDIAN HEALTH SERVICE CONSENT FORM CONSENT OF PARENT OR LEGAL GUARDIAN OR OTHER PERSON WITH PRIMARY RESPONSIBILITY FOR THE CARE OF THE CHILD
I (We), _________________________________, Parent(s) of _______________________________
(Parent/Legal Guardian) (Student)
have read the Consent Form for the Public and Indian Health Service to arrange for or to provide the following
health services for my child. (Please Check Mark)
1. ___Dental Care include dental examinations, preventive use of sealant & fluorides and necessary
emergency dental care.
2. ___Emergency health care for accident or illness.
3. ___Health care include medical examinations, sport physicals, annual health screenings, x-ray
procedure, skin tests and routine immunizations.
4. ___Mental Health services include evaluation and treatment as necessary.
5. ___Optometry care for eye examinations and eye glasses.
6. ___Psychiatric services to include assessment, treatment, and medication as necessary.
7. ___Transportation of child to and/or from a health facility for these services.
PLEASE CHECK THE APPROPRIATE BOX (ES):
- I hereby give consent for all of the above services.
- Exceptions or special instructions: ________________________________________________________
- I hereby give consent for reasonable cause and essential need to assure the health and safety of my child
to Shonto Preparatory School staff while my child is in attendance.
Parent/Guardian Signature: __________________________________________ Please Print Name: __________________________________________________ Address: _____________________________City: _____________ Zip: __________ Phone#: ______________________ Alternate Phone #: _____________________ Relationship: __________________________________
Date: ___________________________ *Valid Until: June 2020
Check the one that applies: ___-Enrolled in AHCCCS, ___-No Health Insurance,
___-Other Health Insurance, #___________
--------------------------------------------------------------------------------------------------------------------
Please be advised that Shonto Preparatory School staff will make every attempt to contact you before any of the above
services are rendered. *This consent is only valid for one year from the date it was signed.