Grades 4-82016-17

Back-to-SchoolForms

Please complete all included forms and submit to the front desk. Scheduled paperwork turn in times are as follows:

Tuesday, July 12, 19, or 26 between 7-9amWednesday, July 13, 20, or 27 between 11am-1pm

Thursday, July 14, 21, or 28 between 4-6pmOR when dropping off or picking up from camp

POLICY ACKNOWLEDGEMENT FORMMy child and I have received a copy of the Merryhill Handbook including the Technology Usage Agreement. I understand that the handbook contains information that my child and I will need during the school year.

Printed Name of Student: ______________________________________________________Signature of Student: _________________________________________________________Signature of Parent: __________________________________________________________Date: _________________________

PHOTO RELEASE FORMGENERAL RELEASE:This is a general release made on July _____, 2016 between Nobel Learning Communities, Inc., hereinafter referred to as “I,” and ______________________________________________________(Parent/Guardian name).

IT IS HEREBY AGREED AS FOLLOWS:That I, the undersigned, for good and valuable consideration, the receipt of which is hereby acknowledged, do for myself and on behalf of my child or legal ward, hereby grant to Nobel Learning Communities, Inc. and its parent corporations, subsidiaries, affiliates and other related companies (collectively, “NLCI”), and all of its or their respective officers, directors, agents, employees, partners, licensees, shareholders, predecessors, successors and assigns, solely for NLCI promotional purposes (the “Permitted Use”), the right to use and publish the picture, portrait, likeness and/or testimonial of _________________________________(Child’s Name).

I acknowledge that the Permitted Use includes any medium now or hereafter known, without restriction as to manner, frequency or duration of usage, and shall be without compensation of any kind. I further agree that my child’s picture, portrait, likeness and/or testimonial may be used with whatever visuals, copy or other elements NLCI may determine, subject to the terms of this general release, and I agree that all such materials produced hereunder are and will remain the sole and exclusive property of NLCI and will not have to be reviewed with me prior to their use, and that NLCI will have no liability to me resulting from the Permitted Use.

I acknowledge that if in the future I submit a written withdrawal of the foregoing permission to the school’s principal, such withdrawal of permission will pertain only to future or new materials, and will not terminate the Permitted Use with respect to any material previously produced or used.

IN WITNESS WHEREOF, I have caused this general release to be duly executed as of the day and year first above written.

________________________________________________ _______________________Parent Signature Date

STUDENT EMERGENCY/MEDICAL INFORMATION CARD(Must be completed each school year and submitted prior to the first day or school)

STUDENT INFORMATION:Student Name: _______________________________________________________________Grade: _________ Age: ________ Birthdate: ________________________________Home Address:_______________________________________________________________Home Phone: _______________________ Student Cell Phone: ________________________Ethnicity: ________________________ Resides with: _____________________________

PARENT/GUARDIAN INFORMATION:Parent/Guardian Name: ________________________________________________________Employer: ___________________________________ Position: ________________________Work Address: _______________________________________________________________Cell Phone: ____________________________ Other Phone: _________________________Email Address: _______________________________________________________________

Parent/Guardian Name: ________________________________________________________Employer: ___________________________________ Position: ________________________Work Address: _______________________________________________________________Cell Phone: ____________________________ Other Phone: _________________________Email Address: _______________________________________________________________

EMERGENCY CONTACTS & PICK UP AUTHORIZATION:In case child listed above needs to be picked up by someone other than myself, becomes ill, or is injured at school and I cannot be contacted, the school authorities have my permission to grant and release my child to the custody of one of the following:

Emergency Contact #1 Name: ___________________________________________________Relationship: _________________________ Contact Number: ____________________Emergency Contact #2 Name: ___________________________________________________Relationship: _________________________ Contact Number: ____________________

MEDICAL INFORMATION:Insurance Name & Member Number: _____________________________________________Health Care Provider Phone Number: _____________________________________________

My child has:____No known medical conditions____Major medical issues*: __________________________________________________________Medications taken regularly: _____________________________________________________Allergies/Allergic* to: _____________________________Treatment: _________________*For severe allergic reactions or other more severe medical issues, an accommodation plan is required along with required forms outlining instructions for emergency situations (i.e.: administering an epi-pen injection). See below.

ALLERGY PRECAUTIONS (if applicable):The allergy can be prevented by: _________________________________________________Peanut allergies: _____ My child has an airborne peanut allergy and cannot be near,

touch, or ingest peanuts._____ My child can be in a facility with peanuts but cannot ingest

them.

ALLERGIC REACTIONS (if applicable):Reaction symptoms: ___________________________________________________________Date of last reaction: _________________ Action taken: __________________________________ Requires epinephrine

*ALLERGIC REACTION RESPONSES:If your child has a severe food allergy*, click here to access the required action plan form. This must be submitted with medication prior to the start of school. Please refer to the Handbook section on medication.

OTHER CONDITIONS - If your child has a medical condition* requiring specific administration of medication or emergency action plans, procedures must be in writing from the doctor and provided to the school prior to the first day of school.

*These circumstances require accommodations on the part of the school. An accommodation action plan will be created by the school and requires parent signature.

CONSENT:I give my consent for the school to follow the procedures outlined above. If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for the school to take appropriate action for the safety and welfare of my child.

________________________________________________________ _________________Parent/Guardian Signature (Required) Date

SHOT RECORDS

Please submit updated shot records to the school office as administered. Updates must come from a doctor’s office.

SEVENTH GRADE IMMUNIZATION REQUIREMENTS

Updated shot records must be submitted to the school prior to the start of the 7th grade school year. Seventh grade students submit proof of administration of the following: Tdap - dose of Tetanus, Diphtheria, Pertussis (usually given at ages 11 and up).

Seventh grade students should have 1 Tdap dose and 2 MMR doses.

Merryhill Midtown 1043

2600 V Street, Sacramento, CA 95818

Merryhill Midtown 1043

2600 V Street, Sacramento, CA 95818

Elaine Westphal, Head of School

FIELD TRIP PERMISSIONMy child, ______________________________________________, has permission to attend all field trips that occur during the 2016-17 school year, unless notification is given in writing by the parent/guardian. Please check line 1 or line 2 to indicate the action desired in the event of an accident or emergency.

1. ____ In the event of an accident or other emergency, when a parent/guardian is unavailable, I hereby authorize a representative of the school to make the arrangements as he/she considers necessary for my child to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event said physician is not available at any time, I authorize such care and treatment to be performed by any licensed physician or surgeon.

Physician Name: ______________________________________________________________Phone Number: ________________________________Insurance Carrier: _______________________________ ID Number: ___________________

2. ____ I do not choose the above statement and desire the following action:________________________________________________________________________________________________________________________________________________________

The undersigned hereby agrees to bear all costs as a result of the foregoing.

BUS POLICIES & TRANSPORTATION SAFETY PLAN AGREEMENTThe safety of all Merryhill students and parents is our main objective and we appreciate your help in achieving that goal and insuring we comply fully with California law.

I, the parent/ guardian of _______________________________________________________ have read and understand the Transportation Safety Plan for Merryhill Schools. I understand that failure to comply with the bus safety and behavior rules may result in disciplinary action up to and including the suspension/expulsion of bus riding privileges for field trips.

My child will be using (check all that apply):_____Field Trip Only Services _____Street Side Bus Stop _____Care Campus Bus Stop

My child’s stops are (mark one):_____Davis to Midtown _____Target to Midtown _____Harbour Point to Midtown_____Millcreek to Midtown _____Field Trips Only

Daily Bus Riders: I accept that the behavior and safety of my student(s) is my sole responsibility while waiting for and approaching the bus to load/unload for a street side bus stop. I acknowledge the appropriate time for my child to be at the bus stop or inside the care campus is 5 minutes prior to bus arrival.

Printed Parent/Guardian Name: __________________________________________________Parent/Guardian Signature: _____________________________________________________

MERRYHILL SCHOOL STUDENT PLEDGE FOR iPad® Use

• I will use my iPad® in responsible and ethical ways and follow all school policies and procedures.

• I will only use my iPad® in appropriate ways and will not communicate inappropriately, be discourteous or abusive to others, or engage in an activity that is harmful to other people.

• I understand that my iPad® can be inspected by school staff or my parent/guardian at anytime and that school staff may delete unauthorized Apps or programs.

• I understand that the iPad® is school property and usage is a privilege.• I will purchase a cover, stylus, Apple charger, and ear buds for my iPad® and keep it covered

at all times. I will purchase a Lifeproof, Otterbox Defender Series, or Giffin Survivor Series as recommended by the school.

• I will keep my iPad® in a safe and secure place at all times and will not leave it unattended.• I will not let friends, siblings, or others use my iPad®.• I will not eat or drink when using my iPad® and will keep these items away from the device. I

will not use during lunch or recess unless permission has been granted.• I will not disassemble any part or attempt any repairs and will immediately turn in my iPad® to

the Media Center if it is not working properly. • I will not remove or add anything to the outside of the device. I am allowed to decorate the

outside cover that I purchase.• I will make sure my iPad® is FULLY CHARGED and at school every day.• I will not put a security code on the iPad.• I will file a police report in case of theft, vandalism, or loss.• I will not utilize unauthorized photos, video, and/or audio recordings of myself or any other

person in an inappropriate manner.• I will be responsible for all damage or loss caused by neglect or abuse. I will not handle any

repairs or take the device to a shop for repairs. All repairs are done through the school.• I agree to return the device in good working condition.

I agree to the stipulations set forth in the above documents including the iPad® Policy, Procedures, and Information; the Acceptable Use Policy; iPad® Protection Plan and the Student Pledge for iPad® Use. I agree to immediately return the iPad® in good working condition upon request or withdrawal from Merryhill School. I assume full responsibility of my assigned iPad®. I acknowledge that this handbook is to be used as a guide to both acceptable and prohibited behavior of this technology.

Student Printed Name: _________________________________________________________

Student Signature: __________________________________________ Date: _____________Parent Signature: ___________________________________________ Date: _____________

Merryhill School iPad® Policies & Procedures Parent-Student Agreement

We have read, understand, and will comply with all policies and procedures within this document. We understand that we are responsible for purchasing a case for the device as well as an approved Apple charger and are also responsible for the replacement cost of an intentionally damaged or lost iPad®. I will be responsible for monitoring my child at all times while the iPad® is at home or in my presence.

As the parent, I agree to immediately return the iPad® and peripherals in good working condition upon withdrawal from Merryhill School. I acknowledge that this handbook and policy is to be used as a guide and does not attempt to address every required or prohibited behavior by its users.

Parent/Guardian Printed Name: __________________________________________________

Parent/Guardian Signature: ____________________________________ Date: ____________

Student Printed Name: _________________________________________________________

Student Signature: ___________________________________________ Date: ____________

Student Grade: ______

TO BE COMPLETED BY STAFF:Check out Date: _________________________

Device ID Number: _______________________Check in Date: __________________________

DEVICE QUALITY AT CHECK-IN:

_____Excellent - no wear and tear, all systems working properly_____Good – some normal wear and tear, all systems working properly

_____Fair – excessive wear and tear and/or some system malfunctions (approximately $75-100 + shipping & handling, if applicable)

_____Poor – device is broken such as a cracked screen, damaged systems, or locked out accounts, some fines may be assessed to the student (approximately $100 per issue +

shipping & handling, if applicable)_____Lost – device not turned in, replacement fee assessed to the student (approximately

$600 for iPad plus shipping & handling, if applicable)

MERRYHILL SCHOOLS ROUTE BUS RIDER POLICY & PROCEDURE ACKNOWLEDGEMENT FORM (route riders only)

I, the parent/guardian of ___________________________________, have read the Merryhill School Transportation Safety Plan and understand the policies regarding pick-up and drop-off procedures outlined within. I understand that failure to comply with this policy may result in disciplinary action up to and including the suspension of bus riding privileges.

Additionally (please acknowledge each point with a check mark):

For all route riders:_____I have read and understand the policies and procedures governing the “Street Side Bus Stop” and “Care Campus Bus Stop” locations.

_____I understand that no child will be allowed to cross the parking lot unescorted by me, the parent, for any reason.

_____I understand that circumstances may occur that are outside the control of the Merryhill Transportation department, which may result in a late bus, or suspension of bus service in part or completely.

For Street Side Bus Stop riders:_____I understand that it is my responsibility to escort my child TO THE BUS DOOR for pickup, and escort my child FROM THE BUS DOOR upon arrival.

_____I understand that the transfer of care for my child, and the transfer of responsibility for my child, will occur at the bus door ONLY AFTER the bus driver checks in or checks out my student.

_____I understand that I must be waiting and ready to deliver my child AND retrieve my child when the bus arrives.

_____I understand that the bus will not wait for me, the parent, if I am late. In such an instance, my child will be sent to the B/A Care campus for pickup.

_____I understand that if my child is sent into a B/A Care campus, I may be subject to disciplinary action, including a fees and/or suspension of bus riding privileges.

Parent/Guardian Name: ___________________________________________________

Parent/Guardian Signature:_________________________________________________

Date: ____________________

Optional form: Complete if your child will be riding a bus route to and/or from school.

Optional form: Complete if prefer to pay with credit card.

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Optional form: Complete to set up automatic payment for tuition.