Carol Barone-Martin - Pittsburgh Public Schools Page Street, Pittsburgh, PA 15233 Phone...

1398 Page Street, Pittsburgh, PA 15233 Phone 412-529-4291/Fax 412-325-0702 Carol Barone-Martin Executive Director, Early Childhood Education

Dear Parents/Guardians:

Thank you for your interest in the Pittsburgh Public Schools Early Childhood Program. In this packet you will find information about our program as well as the application.

Early Childhood Program Entrance Requirements Children must be City of Pittsburgh residents. Children must be 3 by September 30, 2016 (Children may stay in the program until

they are age eligible to enter kindergarten). Program Details

Each Early Childhood location is open 5 days per week, Monday through Friday, for six hours per day, September through June. (Certain locations have before and after-school programs available). Our program follows the standard K-12 school calendar and observes all district holidays

The Early Childhood Program is available in over 31 locations throughout the City of Pittsburgh. Families may select any location depending on availability. If there is greater interest in one location than spaces available, a lottery will be held for those locations.

Breakfast and lunch is served at all locations The fee for the Early Childhood Program is $6,500.00 per academic school year.

Depending on your family income you may qualify for a Head Start or State funded scholarship. In most cases these scholarships cover all of the costs. You can determine whether you qualify for a scholarship by calling Ruth Hendler at 412-529-4291.

Families are responsible for providing transportation to and from the Early Childhood Center.

How to Apply for the Pittsburgh Public Schools Early Childhood Program: 1. Complete the enclosed application and copy the required documents. 2. Send the completed application packet to Pittsburgh Public Schools, Early Childhood

Education Program, 1398 Page Street, Room A226, Pittsburgh, PA 15233. Applications will be accepted from 8:30 a.m. on Friday, February 5, 2016 through 3:00 p.m. on Friday, March 18, 2016. Any applications received after March 18 will automatically be placed on the waiting list after the last name drawn from the lottery.

Note: Twins or other multiple births are treated as one when considered for the lottery. If one child is accepted, the other is accepted as well.

o Families whose children are currently on the waiting list for the 2015-2016 school year will need to reapply for the 2016-2017 school year.

3. The following documentation is required with your application. o Provide income verification (1 month copy of pay stubs, W2, etc.) o Provide a copy of your child’s immunization records. o Provide a copy of your child’s birth certificate or passport o Provide 2 current proofs of residency (i.e. driver’s license, utility bill, etc.)

The lottery will be held on April 15, 2016. Families will be notified of their child’s acceptance into the program by mail no later than April 29, 2016.

Children not accepted in the lottery will be placed on a waiting list and will be contacted by the Early Childhood Program as space becomes available.

If your child is accepted in the lottery, you must provide the following documents by June 21, 2016. If documentation is not provided, you will forfeit your child’s space and your child’s name will be placed on the waiting list.

A copy of a current physical including lead and hemoglobin test results A copy of dental record

If you have any questions about applying for the PPS Early Childhood Program, please contact Ruth Hendler, Early Childhood Intake Manager, at 412-529-4291. Sincerely,

Carol Barone-Martin

Carol Barone-Martin, Executive Director Early Childhood Education Program CBM:rfh

1398 Page Street | Pittsburgh, PA 15233 Phone: 412-325-4291 | Fax: 412-325-0702

Carol Barone-Martin Executive Director, Early Childhood Education

2016-2017

Early Childhood Centers and Classrooms

Pittsburgh Allegheny K-5 810 Arch Street 15212 Pittsburgh Arlington Pre-K -8 2429 Charcot Street 15210 Pittsburgh Arsenal Pre-K-5 (Elem. Bldg.) 215 39th. Street 15201 Pittsburgh Beechwood Pre-K-5 810 Rockland Avenue 15216 Pittsburgh Brookline Pre-K-5 500 Woodbourne Street 15226 Pittsburgh Carmalt Pre-K-8 1550 Breining Street 15226 Pittsburgh Chartier’s Early Childhood Center 3799 Chartiers Avenue 15204 Pittsburgh Children’s Museum 10 Childrens Way 15212 Pittsburgh Concord Pre-K -5 2350 Brownsville Road 15210 Pittsburgh Conroy Early Childhood Center 1398 Page Street 15233 Pittsburgh Crescent Early Childhood Center 8080 Bennett Street 15221 Pittsburgh Dilworth Pre-K-5 6200 Stanton Avenue 15206 Pittsburgh Fulton Pre-K-5 5799 Hampton Street 15206 Pittsburgh Grandview K-5 845 McLain Street 15210 Pittsburgh Greenfield Pre-K-8 1 Alger Street 15207 Pittsburgh King Pre-K-8 50 Montgomery Place 15212 Pittsburgh Lincoln Pre-K-5 328 Lincoln Avenue 15206 Pittsburgh Manchester Pre-K-8 1612 Manhattan Street 15233 Pittsburgh Mifflin Pre-K-8 1290 Mifflin Road 15207 Pittsburgh Miller Pre-K-8 2055 Bedford Avenue 15219 Pittsburgh Minadeo Pre-K-5 6502 Lilac Street 15217 Pittsburgh Morrow Pre-K-5 1611 Davis Avenue 15212 Pittsburgh Obama/Peabody 515 N. Highland Avenue 15206 Pittsburgh Classical Academy Pre-K 6-8 1463 Chartiers Avenue 15220 Pittsburgh Roosevelt 1 Primary 200 The Boulevard 15210 Pittsburgh Roosevelt 2 Intermediate 17 W. Cherryhill Street 15210 Pittsburgh Science & Technology Academy 107 Thackeray Street 15213 Pittsburgh Spring Garden Early Childhood Center 1501 Spring Garden Avenue 15212 Pittsburgh Sunnyside Pre-K-8 4801 Stanton Avenue 15201 Pittsburgh Weil Pre-K-8 2250 Centre Avenue 15219 Pittsburgh Westwood Pre K-5 508 Shadyhill Road 15205 Pittsburgh Woolslair Pre K-5 501 40th Street 15224

1398 Page Street, Pittsburgh, PA 15233 Phone 412-325-4291/Fax 412-325-0702 Carol Barone-Martin Executive Director, Early Childhood Education

2016-2017 School Year

Dear Parents/Guardians: The Pittsburgh Public Schools Early Childhood Education Program invites you to participate in your child’s educational experience by volunteering in our program. In order to volunteer in the classroom or accompany the class on field trips, you must first provide us with:

State Criminal Record report Child Abuse Clearance Certification FBI (Federal) Criminal History Report (or FBI waiver forms) A copy of your TB test results

Please contact Ms. Debra Brucha at our Peabody/Obama Early Childhood office, phone number 412-529-8702 if you are interested in volunteering and she will mail you a clearance packet to complete and return to her. The Early Childhood program will pay for your State Criminal Record and Child Abuse Clearance Certification. You are responsible for obtaining and paying for the FBI Criminal report (if you do not qualify for a waiver) and your TB test. When you are cleared to volunteer your Criminal Check, Child Abuse and FBI Clearance will be in effect for 3 years. It must be renewed every three years.

Below are two locations where you may obtain a TB test. You may also obtain a TB test from your private physician. Allegheny County Health Department 3901 Penn Avenue, Pittsburgh, PA 15224 412-578-8162

We appreciate your cooperation and understanding as we work jointly to assure your child’s safety in a positive learning environment. If you have any questions, please contact the Early Childhood office Ms. Debra Brucha at 412-529-8702. Thank you for your interest in the Pittsburgh Public Schools Early Childhood Program.

Sincerely,

Carol Barone-Martin

Carol Barone-Martin Executive Director Early Childhood Programs CBM/rfh

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Directions on how to obtain the FBI Criminal Report can be found by visiting this website:

https://www.compass.state.pa.us/CWIS. If you have been a resident of Pennsylvania for the

last 10 years you can choose to complete a waiver of the FBI report. Please contact our office to receive the 2 forms that you will need (The Verification for Waiver of the FBI report and The Volunteer request for waiver of the FBI criminal History record check. These forms may be obtained from the Early Childhood office. When these forms are completed and returned to the Early Childhood Office they will be sent along with your Criminal and Child Abuse Clearances to the Legal Department for evaluation.

The Pittsburgh Public Schools reserves the right to require an FBI report even if the volunteer

submits the waiver request forms.

1398 Page Street | Room A226 | Pittsburgh, PA 15233 Phone: 412-325-4291 | Fax: 412-325-0702


Page 1

Child’s Name: __________________________ Date of Birth: ___________ Preferred Location: ______________________________________________ The following completed forms and information are mandatory to enroll your child:

Application - completed by parent/guardian

Health Consent - completed by parent/guardian

Health History - completed by parent/guardian

Nutrition Questionnaire - completed by parent/guardian

Physical Examination - completed by physician

Lead & Hemoglobin Screening Results - completed by physician

Immunizations - completed by physician

Dental Form - completed by dentist

Copy of Child’s Birth Certificate

Proof of Income – 1 month copies of paystub, W2, DPA printout, etc..

Two Proofs of Residence (must live in the school district of City of

Pittsburgh)

Please return all completed forms to the address above. How did you hear about our Early Childhood Program: ____Green Sheet ____PPS Web Site ____Pennysaver ____School ____Fairs ____Called 800 Number ____Bus Sign ____Radio ____Community Agency ____PPS Employee

____Newspaper (name)_________________________________________

____Other (name)______________________________________________

Application Status ________________ Pending ______________________ Waitlisted __________________

Application Date__________________ Early Head Start Entry _____________________

Enroll Date ______________________ Re-enrollment Date_______________________

rev. 1/16page 2

3

Employment Status ____Student ____ Disabled

Employment Status ____Student ____ Disabled

_____Sharing the housing of other persons due to loss of housing, economic hardship, or similar reason

_____In a motel, hotel, campsites, or cars due to a lack of alternative adequate accommodations

_____ Other places not designed for, or ordinarily used as, a regular sleeping accommodations for human beings

Date of Birth

Phone: ( ) home / work / cell / other

Highest Grade Completed

Relationship to child


Gender Male

Female

Primary Parent/Guardian Name:

Race: (Check all that apply) ____ Asian ____ African American ____ White ____ Hispanic ____American Indian or Alaska Native ____Hawaiian/Pacific Islander ____Other:

____ Full Time ____Part Time

____Unemployed ____ Retired

Date of Birth

Does your child have a sibling(s) in the Pittsburgh Public School System? ____ Yes ____No

Preferred Site/Location:1

If Yes, Child's Name(s): School and Grade

Race: (Check all that apply ) ____ Asian ____ African American ____ White ____ Hispanic ____American Indian or Alaska Native ____Hawaiian/Pacific Islander ____Other: ______________________________________________________

(First)

Gender Male

Female

2

_____None of these choices

Primary Health Coverage (Health Insurance) Secondary Health Coverage (Health Insurance)

Child's/Applicant's Legal Name (Last)

In what type of setting is the child living now?

_____ In an emergency or transitional shelter

Primary Language:

Secondary Language:

_____In a car, park, public spaces, abandoned building, substandard housing, bus or train stations, or similar settings

CHILD'S MEDICAID ELIGIBILITY STATUS _____Eligible _____Not Eligible _____Potentially Eligible

Type of Health Insurance for applicant _____Medicaid _____CHIP _____Private _____Military _____Other _____None

Does your child have an IEP? ___Yes ____No

Race: (Check all that apply) ____ Asian ____ African American ____ White ____ Hispanic ____American Indian or Alaska Native ____Hawaiian/Pacific Islander ____Other:

Highest Grade Completed

EMail Address :

Secondary Parent/Guardian Name:Gender

Male Female

Date of Birth

____ Full Time ____Part Time

WIC _____YES _____NOComplete for Primary Care GiverTANF (cash) _____YES _____NO

TANF (food stamps/SNAP) ____YES ____NO

Lives with Family?

____YES ____NO


Living Address:

Zip Code ______________

Relationship to child Living Address: EMail Address :


Parental Status (circle): One Parent Two Parent Foster Parent Other_______________________________

# in Family ______ # of children ______ # Age 0-3______ # Age 4-5______ # in Household supported by you______

Parent(s)/Guardian(s) on active Military _____YES ______NO If yes Branch __________________________________

2016-2017 School Year

PPS Early Childhood Application

Referred for services by a child welfare agency ___YES ___NO

____Unemployed ____ Retired

Child's Name ___________________________________________________ Date of Birth _______________________

State Zip

State Zip

State Zip

State Zip

State Zip

DOB GENDER GRADE

$

$

$

$

Parent/Guardian Signature X___________________________________________________ Date ______________________________

$

Total yearly income of family $

$

$

$

I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information will be held in strict confidence within the agency and is accessible to me during normal business hours.

*Source: PEN-Pension SSI-SSI SS-Social Security TAN-Tanf E-Employed F=Foster CS=Child Support U=Unemployment

**Twice a month x 24 = Annual income Monthly x 12 = Annual Income Weekly x 52 = Annual Income Every 2 weeks x 26 = Annual Income

Certification:

INCOME INFORMATION WORKSHEET FOR PARENT/GUARDIAN - MUST INCLUDE SUPPORTING DOCUMENTATION

FAMILY MEMBER *SOURCE AMOUNT **x ANNUAL INCOME

Practice Name City

Name

Phone

Address

Address

Phone ___Home /___Cell /___Work ( )

Name

Release To? _____YES _____NO

Phone ___Home / ___Cell / ___Work ( )

City

CHILD'S PHYSICIAN INFORMATION

Relationship to Child

Relationship to Child

City

City Phone ___Home / ___Cell / ___Work ( )

Address

LAST NAME FIRST NAME

Practice Name Address City

Phone

Address

Physician Name:

CHILD'S DENTIST INFORMATION

Dentist Name:

ADDITIONAL PEOPLE RESIDING IN HOUSEHOLD THIS INCLUDES ALL CHILDREN AND ADULTS


Name Relationship to ChildEMERGENCY INFORMATION


RELATIONSHIP to CHILD



Page 4

Child’s Name: _____________________________________ Date of Birth: ______________ Center: ___________________________________________

Health Consent Form I, ___________________________, give permission for ________________________ to receive the (parent/guardian) (child’s name) following health services:

Please initial next to each service for which you are giving consent. These services will not be conducted without this authorization form. IF YOU ARE REFUSING ANY OF THESE

SERVICES, PLEASE INDICATE BY WRITING REFUSE NEXT TO SERVICE ____ Emergency Medical/Dental Treatment and transportation of your child to and from the source of emergency treatment. ____ Behavioral Observation ____ Height & Weight Measurements ____ Development Screening ____ Hemoglobin Screening ____ Hearing Screening ____ Speech/Language Screening _____ Vision Screening ____ Lead Screening I understand that these screenings are a requirement of the Early Childhood Performance Standards and that I will be informed of any results which indicate the need for further professional evaluation. Otherwise, a health summary will be provided within the program year. I understand that I have the right to be present during any screening or examination. I understand that I have the right to refuse to participate in any screening or examination. If I refuse these services, I must obtain the above screening or examination and give to the Early Childhood Program within 30 days of the date of refusal. Otherwise, my child could be placed on the waiting list until proof of these services is obtained. _________________________________ __________________________ Parent/Guardian Signature Date _________________________________ ___________________________ Verifying Staff Signature Date

12/2013

page 5DOB:__________________

Yes No

1.

2.

3.

4.

5.

6.

Yes No

7.

8.

9.

10.

____ ____ ________ ____ ________ ____ ________ ____ ________ ____ ________ ____ ________ ____ ________

11.

Yes No

12.

13.

14.

15.Rolled over __________ Sat alone __________ Crawled _________Few words __________ Sentences _________ Talked __________Walked _____________ Toilet Trained __________

16.

Health Speech/Language Behavior Hearing Vision Other:_____________________________

Other:

*could require a medical plan before entering program

Child's Health Record(To be completed by Parent)

HEALTH HISTORY

Explain "Yes" AnswersDid mother have any problems during pregnancy or delivery?

Pregnancy/Birth

What was child's birth weight? Please write in "yes" column.Was anything wrong with the child at birth or in the nursery?

Is the mother pregnant now?

MeaslesMeningitisPolio

AccidentsAllergies

Has your child ever had accidents? (broken bones head injuries burns, poisoning)?

Has child ever had a serious illness?

AsthmaChicken PoxEar Infection

Elevated Lead LevelsSickle Cell Disease

SeizuresEczema

Heart Problems

Pneumonia

Was child born more than 3 weeks early or late?

Tuberculosis (TB)

If so, is she receiving prenatal care?

Hospitalization/Illnesses Explain "Yes" AnswersHas your child ever been hospitalized or operated on?

Scarlet FeverTonsillitis

Foods:

Medications:

Allergies (requires medical plan before entering program) Reactions

Kidney Problems

Developmental History (Please note actual ages or if child seemed normal compared to other children)

Concerns: Do you have any special concerns about your child's:(circle all that apply)

Child's Name___________________________________________

*Past/Present Illnesses: (Check all that apply and state how often)Strep Throat

Lead PoisoningHerniaHeart Murmur

Does your child have difficulty seeing? (squinting, cross eyes, looks too closely at books)Does your child have problems with his/her ears or hearing? (frequent earaches, discharge, favoring one ear over the other?)Is your child currently taking any medications? If yes, write name of medication in "Yes" column. Will it need to be taken during class time?

Explain "Yes" Answers


Carol Barone-Martin Executive Director, Early Childhood Education Page 6

Child’s Name: DOB: Center:

Nutrition (To be completed by parent)

Dietary Habits 1. What kind of foods does your child especially like?___________________________________________ 2. Are there any foods your child dislikes? ____________________________________________________ Yes No

3. Does your child have any food allergies? If yes, list them in “Comments” section

3

4.

Is your child on a special diet? If yes, is this diet prescribed by a doctor? If yes, describe it in the “Comments” section below?

*

4

* *

5. Is there any food your child should not eat for religious or personal reasons? If yes, list them in the “Comments” section below.

* 5

6.

Does your child take vitamins and mineral supplements? If yes, what kind? Do they contain Iron? Do they contain Fluoride? Were they prescribed by a doctor?

*

6

*

7. Has there been a big change in your child’s appetite in the last month? * 78. Does your child take a bottle? * 89. Does your child eat or chew things that aren’t food? * 910. Does your child have trouble chewing or swallowing? * 10

11. Does your child often have: Diarrhea? Constipation?

* 11*

12. Do you have any concerns about what your child eats? * 12 Comments

*Some Yes answers may require follow-up. Please explain or provide additional comments in this section.

CHILD HEALTH ASSESSMENT page 7

_____IN/CM _____LB/KG %ILE_____

DATE DATE DATE DATE

SIGNATURE OF PHYSICIAN OR CRNP:

LICENSE NUMBER DATE FORM SIGNED:

MEDICAL CARE PROVIDER:

ADDRESS:

PHONE:

HEALTH PROBLEMS OR SPECIAL NEEDS, RECOMMENDED TREATMENT/MEDICATIONS/SPECIAL CARE (ATTACH ADDITIONAL SHEETS IF NECESSARY)

NONE DATE OF THIS EXAM:

VISION

OTHER

LEADANEMIA (HGB/HCT)

URINALYSIS (UA) at age 5)HEARING

HIB

HEP B

MMR

VARICELLA

MENINGOCOCCAL

PNEUMOCOCCAL

SCREENING TESTS DATE TEST DONE NOTE HERE IF RESULTS ARE PENDING OR ABNORMAL

INFLUENZA

HEP A

ROTAVIRUS

IMMUNIZATIONS COMMENTS

DTaP/DTP/Td

POLIO

DATE

SKIN/LYMPH NODESNEUROLOGIC & DEVELOPMENTAL

EXTREMITIES/JOINTS/BACK/CHEST

PHYSICAL EXAMINATION √ = NORMAL IF ABNORMAL - COMMENTS

Health history and medical information pertinent to routine child care and emergencies (describe, if any):

NONE

Allergies to food or medicine (describe, if any):

NONE

FACILITY PHONE: COUNTY:

%ILE_____ _____IN/CM %ILE_____ _____/_____

Screening Test. Highlighted items are required by Head Start and recommended by the American Academy of Pediatrics for children 3-5. Enter dates if done previously. When recording results, enter at a minimum "N", "S", or "A" for NORMAL, SUSPECT OR ATYPICAL/ABNORMAL, respectively.

LENGTH/HEIGHT HEAD CIRCUMFERENCE BLOOD PRESSUREWEIGHT

HEAD/EARS/EYES/NOSE/THROATTEETHCARDIO RESPIRATORYABDOMEN/GIGENITALIA/BREASTS

PARENT/GUARDIAN:

ADDRESS:

WORK PHONE:

CHILD'S LAST NAME: CHILD'S FIRST NAME:

DATE OF BIRTH: HOME PHONE:

CHILD CARE FACILITY NAME:

Yes No

1.

2.

3.

4.

4A

5.

6.

6A

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.Are you involved with any other community agencies that can provide assistance? If yes, what is the name of group?

Assistance to Families of Incarcerated

Child Abuse and Neglect Services

Domestic Violence Services

Child Support Assistance

Health Education (including Prenatal)

Parenting Education

21.

Marriage Education

Health problems or disabilities

Job Training

Substance Abuse Prevention/Treatment

Parent/Guardian Name: _____________________________________________________

Child's Name:______________________________________________________________

Explain "Yes" Answers

Emergency

Crisis Assistance

Transportation

Mental Health Services

Adult Education

EARLY CHILDHOOD EDUCATION PROGRAM

Do you need assistance in any of the following below? If yes, please explain

English as a Second Language

FAMILY SUPPORT FORM

Literacy or Education

Do you own a car?

Food

Housing

During the past six months, have you at any time been homeless or lived in emergency shelter?

Clothing

Pittsburgh Public School Early Childhood Programs Family Goal Assessment

1/5/16

Student’s Name: ________________________ Parent / Guardian Name ________________________

Early Childhood Programs provides ongoing learning opportunities for parents in individual and group settings. Review the list below and mark each subject as Strength, Making Progress or Needs Assistance. You will have the opportunity to receive more information or resources on these topics throughout the year that may be conducted at the center or within the local community. Feel free to name topics that are not on this list.

FAMILY WELL-BEING Strength Making

Progress Needs

Assistance Employment, Job Skills and Job Training Income Management, Financial Security and Budgeting Medical and Dental Care Safe and Efficient Housing Physical and Mental Wellness Affordable Access to Food, Meal Preparation, Healthy Living Transportation – access/affordable/reliable POSITIVE PARENT-CHILD RELATIONSHIPS Strength Making

Progress Needs

Assistance Managing my Child’s Behavior Spending Quality Time with my Child Actively Involved with my Child Developing Routines for my Child FAMILIES AS LIFELONG EDUCATORS Strength Making

Progress Needs

Assistance Knowledge and skills to teach my children Knowledge and Understanding of Child Development Reading with my Child and other Educational Activities Communicating with my Child’s Teachers Supporting Learning at Home Supporting Educational Plans for my Child FAMILIES AS LEARNERS Strength Making

Progress Needs

Assistance Basic life skills (i.e. cooking, budgeting, socialization, time management etc.)

Educational Level – Continuing or Furthering Education Reading and Writing Skills Communication Skills (Ability to express yourself positively and effectively)

FAMILY ENGAGEMENT IN TRANSITIONS Strength Making Progress

Needs Assistance

Understanding the Transitioning Process Comfortable with New Teachers and Program Preparation toward Elementary School Setting Goals for my Child

Page 10


1/5/16

FAMILY CONNECTIONS TO PEER AND COMMUNITY Strength Making

Progress Needs

Assistance Immediate and/or Extended Family Support System Connection/support with Local School Connected to Other Parents and Families with young children Connection/support from other Community Agencies and Services FAMILIES AS ADVOCATES AND LEADERS Strength Making

Progress Needs

Assistance Involvement in my Child’s Education Volunteering in my Child’s Classroom and School Volunteering in my Community Comfortable Making Decisions about my Child’s Health Confident in Speaking up for my Child and Family Awareness of State/Federal Issues that Impact Young Children & Families

Parent/Guardian Signature _____________________________________ Date _____________________

Staff Signature _______________________________________________ Date _____________________

Next Review Date: ______________________________________

Page 11


1/5/16

Family Partnership Goals:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family Partnership Objectives (steps the family will take to achieve goal): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Services (from Early Childhood Staff, referrals, info, workshops, etc.):

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Progress:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other: (legal services, child care, abuse resources, relationships, etc.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Parent/Guardian Signature _____________________________________ Date _____________________

Staff Signature _______________________________________________ Date _____________________

Page 12

Last Name: First Name: Middle Name:

Generation (Jr.): Nickname: Gender (Check One): Female Male

Date of Birth (Month/Day/Year): Hispanic/Latino: Yes No

Student Race: White Black Hispanic Asian(not Paci�c Islander) American Indian/ Native Hawaiian/ Multi-racial

Physical Street Address (House #, ½ , Street Name, Street Suf�x):

Apt# (#, Floor): City, State, Zip: Student Phone (if applicable):

Physical and Mailing Address are the same: Yes No (If yes, do not �ll out mailing address.)

Mailing Address (House #, ½ , Street Name, Street Suf�x):

Apt# (#, Floor): City, State, Zip:

Student E-mail Address (if applicable):

Please list the names and dates of birth of siblings in your household, grades PreK–12 (attending either a public or non-public school):

1. Student Name (First, Last): Date of Birth (Month/Day/Year):



Enrollment* & Emergency Care Form2015–2016 School Year

PPS Personnel ONLY:

Date Received:

Date Processed:

Processed by:

Process Location:

Proof of Child’s Age (copy attached):B=Birth Certi�cate, S=School Record, R=Religious Record (i.e. baptismal certi�cate), H=Hospital Record, P=Passport, N=Notarized Statement from Parent/Guardian

2 Current Proofs of Residency (check all that apply/copies attached): Tax StatementMortgage StatementVehicle RegistrationOf�cial Public AssistanceLetter/Document

Utility BillLease (Signed and Notarized)Drivers Licensure/State IDSocial Security Letter/Document

Voter Registration CardBank Statement Credit Card StatementOther

Other submitted/received documentation (check all that apply): Current Immunizations Parent Registration Statement Student Records Photo ID

Student ID#: 2015–16 Grade:

School of Enrollment:

Alaskan Paci�c Islander

Please Print or Type. Answer ALL questions and return form and necessarydocumentation in person to either your Neighborhood School OR:

Pittsburgh Public Schools | Of�ce of Information & Technology | Student Information Management

Room #353 | 341 S. Belle�eld Avenue | Pittsburgh, PA 15213-3516

The Pittsburgh Public Schools (PPS) does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs,activities or employment and provides equal access to the Boy Scouts and other designated youth groups. Inquiries may be directed to the Title IX

Coordinator or the Section 504/ADA Title II Coordinator at 341 S. Bellefield Avenue, Pittsburgh, PA 15213 or 412.529.HELP (4357).

Page 1Revised 7.17.15

*An enrollment can include either a new enrollment, a re-enrollment or a transfer from other Pittsburgh Public Schools building.

Student Legal Student Legal Student Legal

Student resides primarily with (check one below):

Parents Mother(s) Father(s) Guardian(s) Foster Parent(s) Institution Self (Legally Emancipated/18 Years and Older)

Contact #1 Type: Parent Mother Father Guardian Foster Parent Institution Self

Parent/Guardian/Institution Name #1: Phone #1:

E-mail Address: Phone #2:

Contact #2 Type: Parent Mother Father Guardian Foster Parent Institution Self

Parent/Guardian/Institution Name #2: Phone #1:

E-mail Address: Phone #2:

Home Cell Work Other


Primary ContactsPlease PRINT name(s) and phone number(s) where individual(s) can be reached during the day.

(First Name, Last Name, Generation)



(First Name, Last Name, Generation)

1. School/Program: Pittsburgh Dates attended:



Previous PPS School InformationPrevious Pittsburgh Public School (PPS)/Program attended:



/ / to / /

/ / to / /

/ / to / /

1. School/Program: City, State:

Phone: Fax:

School District YOU resided in while attending:

Grade level(s) at the time of attendance: Dates attended:


Phone: Fax:




Phone: Fax:



Previous Non-PPS School InformationPrevious NON Pittsburgh Public School (Non-PPS)/Program attended:

/ / to / /

/ / to / /

/ / to / /


Home Language Survey*The Of�ce of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS identify limited English pro�cient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identi�cation.



What is/was the student’s �rst language?:

Does the student speak a language(s) other than English? (Does not include languages learned in school.) Yes No

If Yes, specify the language(s):

What language(s) is/are spoken in your home (home language)?:

Has the student attended any other school in the United States during his/her lifetime?: Yes No

What language would you prefer to have District Communications in (language of correspondence)?:

Person (if other than parent/guardian) completing this form:

Name of School State Dates Attended

*The school district/charter school/full day AVTS has the responsibility under the federal law to serve studentswho are limited English pro�cient and need English instructional services. Given this responsibility, the school district/charter school/full day AVTS has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school/full day AVTS may conduct screenings or ask for related information about students who are already enrolled in the school as well as from studentswho enroll in the school district/charter school/full day AVTS in the future.


State Required PhysicalThe Commonwealth of Pennsylvania mandates that all students have physical examinations in grades K–1, 6 and 9. Thesewill be provided to your child free of charge, or the examination may be done by your family physician or health care provider.If your child is in Grades K–1, 6 or 9, please answer both statements below:

1. I want my child’s physical examination to be completed by the School District. Yes No

2. I will have my child’s physical examination to be completed by our family physician or health care provider and sent to the school Nurse. Yes No

Note: Please send record of physical examination to the School Nurse by OCTOBER 31st of this school year.

Health InformationIf additional room is needed for responses to the items below, please use the space provided on the last page of this form.

Check any of the following health condition(s) that your child may have: Asthma Diabetes Epilepsy Allergies (Drugs/Food)

Other condition(s):

List allergies to drugs/food:

Please list ALL medications your child is presently taking:

Does your child have health care insurance (CHIP, Medicaid or Private) coverage?: Yes No

If yes, what is your health insurance company?:

Consent to Obtain Health RecordsI give consent for the school to obtain immunization information and/or a copy of the last physical from my child’s physician. Yes No

Physician’s Name: Phone Number:

Required VaccinesIt is required that all children in grades 7–12 get a Tdap vaccine and a Menactra (meningitis MCV4) vaccine. Has your childreceived these vaccines?: Yes NoIf no, to prevent your child from being excluded from school, please provide proof that your child has received these vaccines.

Consent for Treatment of ChildIn addition to First Aid, the School Nurse/School Nurse Practitioner may treat my child with the following. Check Yes or No for each:Tylenol: Yes No Antacid: Yes No Benadryl: Yes No Ibuprofen: Yes No(Acetaminophen) (Stomach Ache) (Allergy Medication) (Advil/Motrin)



By my printed and signed name, I give my consent to the school nurse to carry out ALL of those items indicated by “Yes”responses above. I also hereby verify that the information provided on this form is true and correct to the best of my knowledge,information and belief. I understand that false statements may be subject to penalties of 18 Pa. C.S.A. §4904. Also, by my signature,I authorize the release of information concerning the education of my child and/or education records of my child to the SchoolDistrict of Pittsburgh. This Release shall remain in effect for one year.

Parent/Guardian Print (Full Name):

Parent/Guardian Signature (Full Name): Date:


Attachment A:Parental RegistrationStatement



Student Name:

Date of Birth: Grade:

Parent or Guardian Name:

Address:

Telephone Number:

Signature of Parent or Guardian: Date:

Name of the school from which student was suspended or expelled:

Dates of suspension or expulsion:(Please provide additional schools and dates of expulsion or suspension on back of this sheet.)

Reason for suspension/expulsion (optional):

Pennsylvania School Code §13-1304-A states in part “Prior to admission to any school entity, the parent, guardian or other

person having control or charge of a student shall, upon registration provide a sworn statement or af�rmation stating whether the

pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other

state for an action of offense involving a weapon, alcohol or drugs, or for the willful in�iction of injury to another person or for

any act of violence committed on school property.”

Please complete the following:

I hereby swear or af�rm that my child was was not previously suspended or expelled, or is is not presently

suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving

weapons, alcohol or drugs, or for the willful in�iction of injury to another person or for any act of violence committed on school property.

I make this statement subject to the penalties of 24 P.S. §13-1304-A(b) and 18 Pa. C.S.A. §4904, relating to unsworn falsi�cation to

authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief.

If this student has been or is presently suspended orexpelled from another school, please complete:

Any willful false statement made above shall be a misdemeanor of the third degree.This form shall be maintained as part of the student’s disciplinary record.


Carol Barone-Martin - Pittsburgh Public Schools Page Street, Pittsburgh, PA 15233 Phone...

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