Kindergarten and New Student Registration Required ...€¦ · NIS REGISTRATION FORM - Lombard...

Our Mission: The mission of Lombard School District 44, working in partnership with students, families, and community members, is to educate the “whole child” in order to achieve personal excellence.

Address: 150 West Madison Street, Lombard, Illinois 60148-3317 Telephone: 630.827.4400 FAX: 630.620.3798

Kindergarten and New Student Registration Required Document Check List 2016-2017

Please use the check list below to confirm you’ve completed and returned documents necessary for the enrollment of your student(s).

Welcome to Lombard District 44.

Student Registration Form ............................................................................................ pages 2-3 Registration Fee Form .................................................................................................. page 4 Health Questionnaire .................................................................................................... page 5 Home Language Survey ............................................................................................... pages 6-7 Authorization for Student Electronic Network Access ................................................... pages 8-13 Permission for Photo/Video in D44 Communications ................................................... page 14 Pesticide Use Notification ............................................................................................. page 15 Student Records Release Authorization Request Form ............................................... page 16-17 Waiver for Written Communications ............................................................................. page 18 Original, certified birth certificate

NIS REGISTRATION FORM - Lombard Elementary School District 44 OFFICE USE

Student # School LEGAL Student Last Name

LEGAL First LEGAL Middle Grade Teacher Court Order Room (code) Emergency Card Street Address City Zip Code Date Entered Residency Aff’t Child resides with: Parents/Guardians Parent/Guardian 1 Parent/Guardian

2 Grandparent Aunt/Uncle Bus No. Health Records

M F Sister Brother Other (specify) Resident Dist Fees Pd Birth date: Place of birth: Network Use Form Birth Cert

Is the student’s ethnicity Hispanic/Latino? Yes No Records Requested Records Rec’d

What is the student’s race? (check all that apply) American Indian or Alaska Native Black or African American White Asian Native Hawaiian or other Pacific Islander Please circle primary number below Name of: M F

✓ if Deceased Home Address, if Different from Above Home Phone Business Phone Cell Phone

Parent/Guardian 1: Maiden name (if applicable): Parent/Guardian 1 Email:

Stepparent/Guardian: Parent/Guardian 2: Maiden name (if applicable): Parent/Guardian 2 Email: Stepparent/Guardian:

Pre-kindergarten experience: Yes No Name of preschool: Dates attended: Has student previously attended District 44: Yes No Dates/Schools attended: Has student been in a special program? Yes No If yes, please specify:

Emergency Contact Information School Transferred From Grade List two individuals who live nearby and are permitted to pick up your child(ren) and will assume temporary care of

your child(ren) if you cannot be reached. Be sure to notify these people that you have used their names on this form.

Address

Name: Relationship: City State Zip Address: Ph: Ph:

Name: Relationship: List names of brothers and sisters, beginning with the oldest: Address: Ph: Ph: Name (First and Last) Birth Date M / F

In case my child becomes ill at school or is injured, I request the school call me. If unable to reach me,

I authorize school authorities to take whatever action is deemed necessary.

Date Signature

** INDIVIDUALS WITH A COURT ORDER PERTAINING TO SCHOOL AGE CHILDREN MUST COMPLETE OTHER SIDE ** Rev. 6/04/14, 1/15, 2/16, 3/16 F-662 NotInSystem (Y)

mmerkle

Typewritten Text

2

TO BE COMPLETED BY THE PARENT OR GUARDIAN WITH A COURT ORDER RELATED TO SCHOOL

List name(s) of child/children affected by court order and the school they are attending.

Name School

Name School

Name School

Name School

1. 1. Is there any court order dealing with the above child’s/children’s custody or visitation that impacts the school or the school day?

YES (If yes, a copy of the court order must be attached specifying this.) NO

2. 2. Does the current court order affect the rights of the visitational parent to be kept advised of the

child’s/children’s school progress?


3. Does the current court order affect the release from school of the child/children to the visitational parent?


3. 4. If the answer is “yes” to any of the above questions, please name the other parent involved in the court 4. order affecting the above child/children:

Name (Area Code) Telephone Number

Street Address City State Zip Code

5. Are you, as the enrolling parent or guardian:

The Custodial Parent/Guardian; OR Joint Custodial Parent/Guardian and Residential Parent/Guardian

Signature Date Enrolling Parent/Guardian

F-662 Court Order Rev 2/14

LOMBARD ELEMENTARY DISTRICT 44 – K-5 REGISTRATION FEE FORM 2016-2017

K-5 registration fee $127.00 5th grade band fee $64.00 (returning students only) 5th grade orchestra fee $64.00 (returning students only)

Children in Band & Orchestra will not be allowed to participate in these programs until fees are paid in full.

Note: No refunds after completion of a student’s second band or orchestra lesson

1. Please list name, school of attendance, grade and fees for each child.

STUDENT NAME(S) SCHOOL GRADE REG. FEES

BAND FEES

ORCH FEES

A.

B.

C.

D. 2. Total fees to be paid by August 5, 2016 $

3. NEW and CURRENT student payments may be made by:

1) Check or money order made payable to Board of Education, District 44

2) Discover, Visa or MasterCard. Complete the information below if you would like to charge these fees.

Name: Acct. #:

Circle one: DISCOVER VISA MASTERCARD Expiration date:

Total Amount Charged: Signature: 4. ONLY CURRENT District 44 students

may pay online using www.myschoolbucks.com beginning July 6, 2016.

5. NEW students are to finalize their registration at their school of attendance.

Work Phone Parent/Guardian 1 Home Phone

Cell Phone

Work Phone Parent/Guardian 2 Home Phone

Cell Phone

F-660, Rev. 6/14, 1/15, 2/16, 5/16

Registration materials & fees

due by August 5, 2016

Health Questionnaire for 2016-2017 Lombard School District 44

Student Name School Name Grade Date of Birth

The parent(s) of the student on a yearly basis should complete the following questionnaire. It is designed to keep your child’s health record complete and up to date. This health information is shared with designated school personnel on a confidential, as-needed basis in order to ensure student safety.

1. YES NO

Has your child ever had any serious illness or injuries? If yes, please specify.

2. Does your child have any known allergies or asthma? (i.e. foods, medicine, etc.)

If yes, please specify.

3. Does your child currently take any medication? If yes, please specify.

If your child needs to take medication during school hours, please complete the necessary forms. These forms are available at your school’s health office.

4. Does your child have any speech, vision, or hearing difficulties? If yes, please specify. Does your child wear glasses?

5. Is there anything about your child’s health, physical, or emotional background that you would like the nurse to know?

If yes, please specify.

6. Due to the HIPAA privacy act, I give permission for the Health Office to share my child’s care plan/medical condition with staff as needed and/or in case of emergency.

7. In case my child becomes ill at school or is injured, I request the school call me. If unable to reach me, I authorize the school authorities to take whatever action is deemed necessary.

The health information I have provided above is, to my knowledge, current and accurate.

Parent/Guardian Signature Date

If anything changes during the school year, please contact your school nurse. Please feel free to contact your school nurse if there are any health concerns you would like to discuss.

Revised 2/14, 1/15

Signature of Parent/Guardian_______________________________________Date_________________

Office: Send copy to EL Teacher F-663 Revised 12/04, 3/09, 1/14, 2/15

Home Language Survey

The state requires the district to collect a Home Language Survey for every new student. This information is used to count the students whose families speak a language other than English at home. It also helps to identify the need for bilingual and English as a second language education services in the schools.

Go to http://www.isbe.net/bilingual/htmls/forms-and-notifications.htm

to download this form in other languages.

Please answer the questions below and return this survey to your child’s school.

Student’s Name: _________________________________________ Birth Date: ________________

English Spanish

1. Is a language other than English spoken at home?

1. ¿Se habla en su casa otro idioma que no es el inglés?

Yes No Sí No

Language ¿Cuál?

2. Does the student speak a language other than English?

2. ¿Habla su niño(a) un idioma que no es el inglés?

Yes No Sí No

Language ¿Cuál?

If the answer to either question is yes, the law requires the school to assess your child’s English language proficiency.

Si la respuesta a cualquiera de las preguntas es “Sí”, la ley requiere que la escuela evalúe la fluidez de su niño en el idioma inglés.

Signature of Parent/Guardian_______________________________________Date_________________

Office: Send copy to EL Teacher

F-663 Revised 12/04, 3/09, 1/14, 2/15

Urdu Arabic

Polish Albanian

1. Czy w domu posługują się Państwo innym językiem niż angielski?

1. A flisni ndonjë gjuhë të ndryshme nga anglishtja në shtëpi?

Tak Nie Po Jo

Jakim językiem?

Çfarë gjuhe?

2. Czy Państwa dziecko posługuje się innym językiem niż angielski?

2. A flet fëmija juaj një gjuhë të ndryshme nga anglishtja?

Tak Nie Po Jo

Jakim językiem?

Çfarë gjuhe?

Jeśli udzielili Państwo twierdzącej odpowiedzi na którekolwiek z powyższych pytań, przepisy wymagają, aby szkoła sprawdziła znajomość języka angielskiego Państwa dziecka.

Nëse përgjigja e çdonjërës pyetje është po, ligji kërkon që shkolla të vlerësojë njohurinë e anglishtes së fëmijës suaj.


Lombard District 44 Authorization for Student Electronic Network Access

Dear Parents/Guardians: Our District has the ability to enhance your child’s education through the use of the District’s electronic network, including its computers, local and/or wide area networks, and the Internet. Our goal in providing this service is to promote educational excellence by facilitating resource sharing, innovation, and communication. Students and their parents/guardians must sign this Authorization for Student Electronic Network Access annually. The District filters access on its electronic network to materials that may be defamatory, inaccurate, offensive, or otherwise inappropriate in the school setting. However, it is impossible to guarantee the filtering of all such material, and it is possible that a user may gain access to inappropriate material. Ultimately, parents/guardians are responsible for setting and conveying the standards that their children should follow, and the District respects each family’s right to decide whether or not to authorize their student’s access to the District’s electronic network, including the Internet. With this educational opportunity also comes responsibility. The inappropriate use of the District’s electronic network, as defined in the Board’s Electronic Networks Policy and the attached Expectations for Acceptable Use, may result in the loss of the privilege to use this resource. Remember that you are legally responsible for your child’s actions. If you agree to allow your child to have access to the District’s electronic network, including Internet access, sign the Authorization form below and return it to your school.

I have read and accept the Board’s Electronic Networks Policy and parameters for acceptable use. I understand that access is designed for educational purposes and that the District has taken precautions to eliminate controversial material. However, I also recognize and agree that it is impossible for the District to restrict access to all controversial and inappropriate materials and that my child might access objectionable material through the electronic network. I understand that any unacceptable use of the electronic network is grounds for suspending or revoking network privileges and may result in discipline, up to and including expulsion from school, as well as criminal or civil penalties. In addition, I agree to indemnify the District for any losses, costs, damages, charges, or fees caused or incurred by my child relating to or arising out of my child’s use of the electronic network or any violation of the Policy, procedures, rules, or other terms or conditions of electronic network access. In consideration for my child’s access to the electronic network, I hereby release the District and its individual Board members, officers, employees, agents, successors, and assigns from any claims and damages arising out of or related to my child’s use of, or inability to use, the electronic network.

Continued……

Parent Authorization



Continued from page one….. I have discussed the terms of the Electronic Networks Policy and procedures with my child. By providing an electronic or written signature below, I swear that I am the parent/guardian of the student, I have the authority to complete and execute this document, and the information contained in this document is accurate to the best of my knowledge.

Parent/Guardian Name (please print)

Parent/Guardian Signature Date

I have read, or have had explained to me, the Policy and procedures regarding the use of the District’s electronic network. I will follow these rules when I use the electronic network, and I understand that I can be disciplined if I don’t. Discipline may include loss of electronic network use privileges, detention, suspension, expulsion, or other consequences. I understand that any information or documents I create or place on the network, including e-mail, belong to the District and may be looked at by District employees or others at any time, and that such information or documents will not be private in any way. I understand that if I misuse the electronic network or cause harm to the network or anyone else or their information or documents, my parents/guardians and I will be responsible for paying for the misuse or damage.

Student Name (please print)

Student Signature Date

Student Authorization (Required for students in 4th grade or higher)

F-617 Authorization for Student Electronic Network Access 2016-17.doc Approved 5/15


Lombard District 44 Expectations for Acceptable Use of Electronic Network

Privileges - The use of the District’s electronic network is a privilege, not a right, and inappropriate use will result in a cancellation of those privileges, disciplinary action, and/or appropriate legal action. The system administrator or building principal will make all decisions regarding whether or not a user has violated these procedures and may deny, revoke, or suspend access at any time. Unacceptable Use - The user is responsible for his or her actions and activities involving the network. Any use that is not for the purpose of education, research, or legitimate school business, or that is otherwise inconsistent with the District’s educational mission, is an unacceptable use. Some examples of unacceptable uses are:

• Using the network for any illegal activity, including violation of copyright or other intellectual property rights, or transmitting any material in violation of any state or federal law;

• Cyberbullying or taking any steps that threaten, or that may reasonably be interpreted to threaten, any person, group of persons, building, or property with harm, regardless of whether the user intends to carry out such threat;

• Unauthorized downloading of files, images or software, regardless of whether it is copyrighted or de-virused;

• Using the electronic network for private financial or commercial gain, including advertising; • Wastefully using resources, such as file space or printer resources; • Creating or forwarding chain letters, “spam,” or other unsolicited or unwanted messages; • Creating or sending e-mail or other communications which purport to come from another

individual (commonly known as “spoofing”), or otherwise assuming an anonymous or false identity in communicating with other individuals, businesses, or organizations;

• Modifying, disabling, compromising, or otherwise circumventing any anti-virus, user authentication, content filter, or other security feature maintained on the electronic network or on any external computer, computer system, or computer account;

• Hacking or gaining unauthorized access to files, resources, or entities; • Creating or deliberately downloading, uploading, or forwarding any computer virus, or

otherwise attempting to modify, destroy, or corrupt computer files maintained by any individual on any computer;

• Compromising the privacy or safety of individuals, including the unauthorized disclosure, dissemination, or use of personal identifying information such as personal addresses, telephone numbers, photographs, or other information of a personal nature; Using another user’s account or password;

• Disclosing any computer network password (including your own) to any other individual; • Posting material authored or created by another without his/her consent; • Posting anonymous messages; • Accessing, submitting, posting, publishing, or displaying any defamatory, inaccurate, abusive,

obscene, profane, sexually oriented, threatening, racially offensive, harassing, or illegal material;

• Using the network while access privileges are suspended or revoked; • Disrupting the educational process, including use that is reasonably foreseeable to result in a

disruption or interference with the rights of others at any time, either during the school day or after school hours;

• Disrupting or interfering with the District’s electronic network; • Sending mass electronic mail to multiple users without prior authorization by the

Superintendent or his/her designee; • Misrepresenting one’s identity in electronic communications;


• Using the District’s electronic network to participate in acts constituting “prohibited political activities” under the State Officials and Employees Ethics Act or “election interference” under the Election Code or to participate in any political activities that create an appearance of impropriety under those laws or under any ethics policy of the District relating to political activities of the District’s employees or Board members;

• Engaging in any activity that does not meet the intended purposes of the network, as set forth in the Electronic Networks Policy, these administrative procedures, and any other rules promulgated by the Superintendent of his or her designee;

• Communicating or socializing with students through private e-mail accounts, Internet accounts, texting, or other means of private electronic communication, including, but not limited to, social networking sites, without the prior authorization of the Superintendent or his/her designee;

• Sexting or otherwise electronically sending, receiving, or possessing sexual imagery or language about the user or others;

• Attempting to commit any action which would constitute an unacceptable use if accomplished successfully.

Network Etiquette - The user is expected to abide by the generally accepted rules of network etiquette. These include, but are not limited to, the following:

• Be polite. Do not become abusive in messages to others. • Use appropriate language. Do not swear, or use vulgarities or any other inappropriate

language. • Do not reveal personal information, including the addresses or telephone numbers, of students

or colleagues. • Recognize that e-mail is not private and may be subject to public disclosure in certain cases.

People who operate the system have access to all e-mail on the electronic network. Evidence of inappropriate or illegal behavior will be reported and turned over to appropriate authorities.

• Do not use the network in any way that would disrupt its use by other users. Keeping Your Kids Safe On Social Networks

For students: • Put everything behind password-protected walls, where only trusted friends can see. • Protect your password and make sure you really know who someone is before you allow them onto

your friends list. • Do not post anything your parents, principal, or a predator couldn’t or shouldn’t see. • What you post online stays online - forever!!!! So ThinkB4UClick! • Do not do or say anything online you wouldn’t say offline. • Protect your privacy and your friends’ privacy too...get their okay before posting something about

them or their pictures online. • Check what your friends are posting/saying about you. Even if you are careful, they may not be and

may be putting you at risk. • Stop, Block and Tell! (Do not respond to any cyber-bullying message, block the person sending it to

you, and tell a trusted adult/teacher.) • R-E-S-P-E-C-T! (Use good netiquette and respect the feelings and bandwidth of others.) • Keep personal information private (The more information someone has about you, the more easily

they can bully you.)


Lombard Elementary School District 44 6:235

Instruction

Access to Electronic Networks

This policy and its implementing administrative procedures are intended to serve as a guide to the scope of the District's authority and the safe and acceptable use of the District's computers, computer network, and Internet access. This policy governs all use of computers, local and/or wide area networks, and Internet access operated or maintained by the District, which will be collectively referred to in this policy and its implementing procedures as the District's "electronic network." For purposes of this policy and implementation plan or administrative procedures, use of the District's electronic network also includes any use of computers outside the District's electronic network where those computers are used to access the District's electronic network. Additionally, use of the District's "electronic network" includes use of other electronic communication devices owned and/or issued by the District or used to access the District's electronic network, including, but not limited to cellular or mobile phones, smart phones, and text messaging devices. The District's electronic network, including the Internet, is a part of the District's instructional program and serves to promote educational excellence by facilitating resource sharing, innovation, and communication. The Superintendent shall develop an implementation plan for this policy and appoint system administrator(s).The Superintendent or his or her designee(s) may also promulgate additional administrative procedures, rules, and other terms and conditions of electronic network use as may be necessary to ensure the safe, proper, and efficient use and operation of the District's electronic network. The School District is not responsible for any information that may be lost or damaged, or become unavailable when using the electronic network, or for any information that is retrieved or transmitted via the Internet. Furthermore, the District will not be responsible for any unauthorized charges or fees resulting from access to the Internet.

Curriculum and Appropriate Online Behavior The use of the District's electronic networks shall: (1) be consistent with the curriculum adopted by the District as well as the varied instructional needs, learning styles, abilities, and developmental levels of the students, and (2) comply with the selection criteria for instructional materials and library resource center materials. As required by federal and state law and Board policy 6:60, Curriculum Content, students will be educated about appropriate online behavior, including but not limited to: (1) interacting with other individuals on social networking websites and in chat rooms, and (2) cyberbullying awareness and response. Staff members may, consistent with the Superintendent's implementation plan and any administrative procedures, rules, and other terms and conditions of electronic network use, use the Internet throughout the curriculum. The District's electronic network is part of the curriculum. It is not a public forum for general use and is not to be used in conflict with the basic educational mission of the District. Use of the electronic network may be restricted in light of the maturity level of students involved and the special characteristics of the school environment. Therefore, the District shall not permit use of the electronic network that: (a) disrupts the proper and orderly operation and discipline of schools, programs, and services operated or provided by the District; (b) threatens the integrity or efficient operation of the electronic network itself; (c) violates the rights of others; (d) is socially inappropriate or inappropriate for a student's age or maturity level; (e) is primarily intended as an immediate solicitation of funds; (f) is illegal or for illegal purposes of any kind; or (g) constitutes gross disobedience or misconduct. The District shall also implement technology protection measures consistent with the Children 's Internet Protection Act and its implementing regulations.

Acceptable Use All use of the District's electronic networks must be: (1) in support of education and/or research, and be in furtherance of the goals stated herein, or (2) for a legitimate school business purpose. Use is a privilege, not a right. Students and staff members have no expectation of privacy in any material that is stored, transmitted, or received via the District's electronic network. The District's rules for behavior and communications apply when using the electronic network. The Superintendent shall establish additional guidelines for the acceptable


use, etiquette, and terms of use of the District's electronic network. Electronic communications and downloaded material, including files deleted from a user's account but not erased, may be monitored or read by school officials.

Internet Safety Each District computer with Internet access will be used with technology protection measures, including a filtering system that protects against Internet access to visual depictions that are: (1) obscene, (2) pornographic, or (3) harmful or inappropriate for students, as defined by federal law and as determined by the Superintendent or designee. The Superintendent or designee shall enforce the use of such filtering devices. An administrator, supervisor, or other authorized person may disable the filtering device only for bona fide research or other lawful purpose, if the person receives prior permission from the Superintendent or system administrator. The Superintendent or designee shall include measures in this policy's implementation plan to address the following:

1. Ensure staff supervision of student access to online electronic networks, 2. Restrict student access to inappropriate matter as well as restricting access to harmful materials, 3. Ensure student and staff privacy, safety, and security when using electronic communications, 4. Restrict unauthorized access, including "hacking" and other unlawful activities, and 5. Restrict unauthorized disclosure, use, and dissemination of personal identification

information, such as, names and addresses. The District shall monitor the use of its electronic network to ensure compliance with this policy; its implementation plan or administrative procedures, and other rules, regulations, or other terms or conditions of electronic network access established by the Superintendent or his or her designee(s); and any other disciplinary policies and regulations necessary to further the educational, safety, and pedagogical concerns of the District.

Authorization for Electronic Network Access Each staff member, upon employment in the District, must sign the District's Authorization for Employee's Electronic Network Access as a condition for using the District's electronic network. Each student and his or her parent(s)/guardian(s), on an annual basis, must sign the Authorization for Student's Electronic Network Access before being granted use of the District's electronic network. All users of the District's electronic network shall maintain the confidentiality of student records. No confidential student information shall be loaded onto an electronic network unless sufficient measures are in place to prevent unauthorized access to confidential student information. The failure of any student or staff member or any other authorized user to follow the terms of this policy, its implementation plan or administrative procedures, or other rules, regulations, or other terms or conditions of electronic network access established by the Superintendent or his or her designee(s), will result in the loss of privileges, disciplinary action, and/or appropriate legal action.

LEGAL REF.: No Child Left Behind Act, 20 U.S.C. §6777.

Children's Internet Protection Act, 47 U.S.C. §254(h) and (1). Enhancing Education Through Technology Act, 20 U.S.C §6751 et · 47 C.P.R. Part 54, Subpart F, Universal Service Support for Schools and Libraries. 720 ILCS 135/0.01.

CROSS REF.: 5:100 (Staff Development Program), 5:170 (Copyright), 6:40 (Curriculum Development),

6:60 (Curriculum Content), 6:210 (Instructional Materials), 6:230 (Library Media Program), 6:260 (Complaints About Curriculum, Instructional Materials, and Programs), 7:130 (Student Rights and Responsibilities), 7:180 (Prevention of and Response to Bullying, Intimidation, and Harassment), 7:190 (Student Discipline), 7:310 (Restrictions on Publications)

ADOPTED: June 14, 2016



Permission for Inclusion of Photo/Video in District 44 Communications

I understand that my child's photo or video image may be utilized in school brochures, advertisements for the school, on the website, in social media, and in other school publications as they see fit. I further understand that the District 44 website contains a notice prohibiting the copying of any work or photograph without the expressed permission from the District 44 Website Team. (In the event anyone requests such permission, those requests will be forwarded to you, the parent or guardian.) No last names, home addresses, or home telephone numbers will appear on the site or press releases. I grant permission to District 44 for communications for the 2016-17 school year I do not grant permission to District 44 for communications for the 2016-17 school year

Parent/Guardian name (please print) Parent/Guardian Signature

Child’s name Grade level




Date

F-618 Permission Photo_Video in D44 Communications 4/16



Notice to Parents Regarding District Use of Pesticides

According to Lombard School District 44 Policy 4:160, we shall take reasonable measures to protect our students by maintaining a registry of families requesting notification before application of pesticides. The District tries to limit its use of such products. However, occasionally needs arise where their use cannot be avoided. In addition, the District does maintain a contract for professional pesticide service at the GWMS production kitchen area in compliance with County health ordinances. If you would like to be notified when these pesticide applications will occur, please sign and return the bottom portion of this notice and return to your child’s principal. If you have children in more than one building, please respond to all principals, as applications are not necessarily consistent from building to building since the applications are based on individual building need. Please note that this is an annual election and is only valid for the upcoming school year. Thank you for your interest in this matter. -----------------------------------------------------------------------------------------------------

USE OF PESTICIDE NOTICE RESPONSE SCHOOL YEAR 2016-2017

Yes, please notify me at the phone number or email listed below if it is the District’s

intention to spray a pesticide

No need to notify

Parent/Guardian name:

Parent/Guardian email:

Student name:

Daytime phone:

Today’s date:

F-653 Rev 9/03,9/04, 5/05, 5/06, 5/07 5/08, 5/10, 11/13, 5/15

F-‐676 Rev. 1/94,7/00,6/06,5/07,8/07,5/11,4/12,5/13,2/15

STUDENT RECORDS RELEASE AUTHORIZATION REQUEST SCHOOL TO SCHOOL

Student’s Name _________________________________________ Birth Date _____________ Student’s Current Address ________________________________________________________ Student’s New Address __________________________________________________________ School (Leaving) ______________________________________________ Grade Level ______ School Address _________________________________________________________________ Street City Zip Code Telephone Number __________________________ Fax Number ________________________ School (Entering) _____________________________________________ Grade Level ______ School Address _________________________________________________________________ Street City Zip Code Telephone Number __________________________ Fax Number ________________________

I hereby authorize Lombard Elementary District 44 to obtain pertinent information concerning the above named student, including academic records, health records, special education records (if applicable), and ISBE Transfer Form (33-‐78) or letter of good standing.

-‐OR-‐ I hereby authorize Lombard Elementary District 44 to release pertinent information concerning the above named student, including academic records, health records, special education records (if applicable), and ISBE Transfer Form (33-‐78) or letter of good standing.

I have received information regarding the maintenance and destruction of student records in District 44, according to Illinois School Code.

In accordance with Illinois School Code (105 ILCS 10/8.1b), request shall be honored within 10 days after it is received. I understand that I/we have the right to inspect, copy and challenge the information contained in the above named school records:

I do not wish to exercise my rights and consent to the immediate transfer of the above named student records.

-‐OR-‐ I wish to inspect the above named student records prior to transfer.

_______________________________________________________ _____________________ Signature of parent/guardian/student Date

F-‐676 Rev. 1/94,7/00,6/06,5/07,8/07,5/11,4/12,5/13,2/15

Information Regarding the Maintenance and Destruction of Student Records

School District 44 retains student permanent records for 60 years after the student transfers, graduates or otherwise withdraws from District 44. The District will destroy each student’s permanent record in late June (between June 15 and June 30) immediately after the end of the 60-‐year period.

School District 44 retains student temporary records for 5 years after the student transfers, graduates or otherwise withdraws from District 44. The District will destroy each student’s temporary record in late June (between June 15 an June 30) immediately after the end of the 5-‐year period. At any time prior to the destruction of the records, parents/guardians have the right to request a copy of the records and/or the information contained therein.

The information contained in permanent and temporary records is as follows: Permanent Record Must include:

• Basic identifying information including the student’s name and address, birth date and place, gender and the names and addresses of the student’s parents

• Academic transcripts, including grades, class rank, graduation date, grade level achieved, and scores on college entrance exams

• Attendance records • Health records (defined as those medical documents necessary for enrollment) • Scores on state assessment test in grades 9 through 12 only

May include: • Honors and awards • Information concerning participation in school-‐sponsored activities and athletics, or offices held in

school-‐sponsored organizations No other information may be placed in the permanent record Temporary Record Must include:

• Information regarding discipline, a suspension or an expulsion for drugs, weapons or bodily harm to another

• Scores on state assessment tests in grades K through 8 only • A record release form • Reports of “indicated” physical or sexual abuse from DCFS • Health-‐related records (defined as medical records, other than those necessary for enrollment) • Accident reports • The completed home language survey • Any biometric information that is collected by the school

May include: • Family background information • Participation in school events • Intelligence scores • Teacher notes • Aptitude tests • Other disciplinary information • Reports of psychological evaluations • Special education files • Honors and awards • 504 plans and documents



Waiver for Written Communication

Dear Parents:

By checking this box you waive the requirement to receive district communications in your native language and agree to accept all district communications in English.

Al chequear esta caja usted renuncia el requisito de recibir comunicaciones del distrito en su idioma nativo y esta de acuerdo en que se manden tal comunicación en ingles. (Spanish)

Zaznaczajac kwadrat po levej stronie, odstepuja Panstwo od wymogu otrzymywania korespondencji z Okregu Szkolnego 62 w jezyku polskim i zgadzaja sie Panstwo na korespondencje tylko w jezyku angielskim. (Polish)

(Arabic)

본 학군에서 보내주는 모든 통신문들을 한글이 아니라 영어로 받고 싶으시면 옆에 상자에 체크해 주십시오. (Korean)

આ બૉકસ ને ચેક કરવાથી હુ઼ ંસવિકાર કરું છુ ંકે સકૂલ ડીસટરીકટ નો જે કંઈ પત્ર વહેવાર હૉય હું મારી દેશી ભાષા માં મેળવવાનો હક જતો કરું છુ ંઅન ેપત્ર વહેવાર અંગરેજી ભાષામા ંમળે એ મન ેમાનિય છ ે (Gujarati)

Чрез маркиране на това поле се отказватe от изискването за получаване на комуникации от Училищен Oкръг 62 в родния си език и се съгласявате да приемате всички комуникации от Училищен Oкръг 62 на английски език. (Bulgarian)

Duke kontrolluar këtë kuti ju heqë dorë nga kërkesa për të marrë komunikime të qarkut në gjuhën tuaj amtare

dhe të bien dakord për të pranuar të gjitha komunikimet e qarkut në anglisht .(Albanian)

(Urdu)

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