Does the student use a language other than English? Yes. No. Language: Is a language other than English used in the home? Yes. No ... Email Address ...
If I have any questions, I will discuss them with a counselor or a school .... Race and Ethnicity/Residence History/Home Language Survey. South Adams School ...
Sep 23, 2010 - NAME AND ADDRESS OF LAST SCHOOL ATTENDED: ... Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
A person having origins in any of the original peoples of North and South. America (including Central America), and who maintains tribal affiliation or community ...
Subsection (e). (See Registration Documents section below + Foreign Exchange. Documents). 6. The student resides within the school district and is 18 years of ...
Feb 22, 2017 - Active Duty. National Guard/Reserve Military person relation to child ... Household Parent Information .... Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine ... Gifted record
This is a records release form authorizing the release of all school records ... for a student who has made application for enrollment in the Platte County R-3 ..... Please return this letter to the school office in person. .... We will update our Tw
JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ. Is this student currently under suspension / expulsion from ...
Page 1 ... my son or daughter who is in college? When a student turns 18 years old or ..... __________Add another student to my existing Parent Portal account.
Copy of student's current 504 Plan for any student with a Plan (from prior school). 8. WITHDRAWAL FORM (Pertains to transfer students who have been enrolled ..... Over-the-counter medications may be administered up to one hour before ... as specified
New Student Enrollment Form Student’s Legal Name (Last)______________________________(First)_____________________(Middle)______________________ Grade Entering _____
Date of Birth _____/_____/_________
Gender: ___M ___ F
Social Security # __ __ __-__ __-__ __ __
Home phone __ __ __-__ __ __-__ __ __ __ Guardian email address __________________________________________________ Student cell phone __ __ __-__ __ __-__ __ __ __ Is the student Hispanic or Latino? ___ Yes ___ No Ethnicity ___ African American ___ American Indian ____ Asian/Pac Islander ___ White ___ Hispanic ___ Multiracial Home Address _______________________________________ __City ___________________ State _____ Zip Code _____________ Mailing Address (i.e. post office box) _____________________________ City ______________ State ___ Zip Code __________ Student lives with _______________________________________ Father’s Name (Last) ____________________________ (First) _________________________ Father’s Home Phone __ __ __-__ __ __-__ __ __ __ Work Phone __ __ __-__ __ __-__ __ __ __ Cell __ __ __-__ __ __-__ __ __ __ Father’s Mailing Address (if different than student) __________________________________________________________________ Mother’s Name (Last) ____________________________ (First) _________________________ Mother’s Home Phone __ __ __-__ __ __-__ __ __ __ Work Phone __ __ __-__ __ __-__ __ __ __ Cell __ __ __-__ __ __-__ __ __ _ Mother’s Mailing Address (if different than student) _________________________________________________________________ Guardian’s Name (Last) ____________________________ (First) _________________________ Guardian’s Home Phone __ __ __-__ __ __-__ __ __ __ Work Phone __ __ __-__ __ __-__ __ __ __ Cell __ __ __-__ __ __-__ __ __ Guardian’s Mailing Address (if different than student) _______________________________________________________________ Please list in order the contact names for student in case of an emergency Name #1 __________________________________ Relationship: _________________ Contact Phone __ __ __-__ __ __-__ __ __ __ Name #2 __________________________________ Relationship: _________________ Contact Phone __ __ __-__ __ __-__ __ __ __ Name #3 __________________________________ Relationship: _________________ Contact Phone __ __ __-__ __ __-__ __ __ __ Doctor’s Name ____________________________________ Doctor’s Phone ______________________________ Is anyone legally barred from seeing this student? ____ Yes ____ No If so, who? ______________________________________ Relationship to student ___________________________ (Court documentation and physical description must be provides to the school office) Is the student’s parent/guardian an active duty member of the Unites States Armed Forces? ____ Yes ____ No Please list siblings attending South Adams Schools (sibling name and grade level: ____________________________________________________________________________________________________________ Form Completed By: ____________________________________
Relation to Student: ____________________________________
Release and Authorizations Parent/guardian initials by each statement and signature below is permission for all requests listed. A separate form is available in the school office to deny permission. Student Name (Please Print): ______________________________________________
Permission to Photograph/Video Tape _____ I give permission for South Adams to release appropriate pictures, video and information about my child to the media press, school website or school social media. Medical Information for CHIRP and PowerSchool _____ I give permission for South Adams to release information concerning my child to the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (CHIRP) and South Adams student management system (PowerSchool). Food Services _____ Yes. I DO want school officials to share my lunch status information with institutions of higher education (SAT/ACT Fee Waivers) and community institutions offering assistance (i.e. LOVE, INC.) _____ No. I DO NOT want information of my lunch status shared with any institution and/or program. Field Trip Permission _____ I grant permission for my child to attend school approved functions/field trips. PowerSchool Parent Access _____ I agree that I will only access my student’s educational records for which I have a legitimate educational interest as defined by the Family Educational Rights and Privacy Act of 1974 (FERPA). I understand that my access will be terminated if it is determined that I intentionally attempt to access records for any student other than the one(s) listed under parental/guardian care. Internet and School Technology _____ I understand that access to the Internet, network, and use of school devices is a privilege and not a right. I understand that any breech of the Code of Conduct can result in the immediate and permanent termination of my child’s use, along with possible suspension from school or other appropriate action. South Adams administrators and technology department will monitor my child’s Internet and technology activity and will make every attempt to safeguard access. I understand, however, inappropriate material may get through the filtering system and I will not hold South Adams Schools liable for this occurrence. I understand that if South Adams finds that inappropriate conduct has occurred, technology use can be terminated and legal action may be taken. I have read all the information for Acceptable Use Policy located in the student handbook and hereby give my son/daughter permission to use technology. Google Drive (parent permission required for students under 13) _____ I give permission for South Adams to create a Google Drive account for my child for the purpose of storing documents online, and sharing files with their teacher and SA students only. Gmail and Google social media apps are not open for student use. For more information on Google Drive terms and conditions, please visit the South Adams website.
Parent/Guardian Signature: _________________________________ Printed Name: _____________________________________ Relation to Student: _______________________________________ Date: ____________________________ FOR GRADES 9 – 12 ONLY No Child Left Behind of 2001 states that schools must comply with a request by a military recruiter or an institute of higher education for secondary students’ names, addresses, and phone numbers, unless the parent denies this request in writing. Non-compliance from the school will result in loss of federal funds. I grant permission to release information to Armed Forces and Military Recruiters, or Military Schools. _____ Yes _____ No I grant permission to release information to colleges, universities, or companies seeking employees. _____ Yes _____ No I grant permission to release my student’s transcript to institutions of higher education for purposes of dual credit enrollment. _____ Yes _____ No
Receipt of Student Handbook TO THE PARENT/GUARDIAN: In accordance with the Elementary and Secondary Education Act, Section 1111(h)(6) PARENTS' RIGHT TO KNOW, this is a notification from the South Adams School District to every parent of a student in a Title I school that you have the right to request and receive information in a timely manner regarding the professional qualifications of your student's classroom teachers. This information regarding the professional qualifications of your student's classroom teachers shall include the following: If the teacher has met state qualification and licensing criteria for the grade level and subject areas taught; If the teacher is teaching under emergency or temporary status in which Indiana qualifications and licensing criteria are waived; The teachers baccalaureate degree major, graduate certification, and field of discipline Whether the student is provided services by paraprofessionals, and if so, their qualifications If at any time your student has been taught for four (4) or more consecutive weeks by a teacher that is not highly qualified, you will be notified by the school of this information. This information is also available on the parent tab of the school website at www.southadams.k12.in.us/parents.cfm Please sign this form indicating receipt of the student handbook and return it to South Adams Schools; in person, with the student, or by mail. ____________________ Date _________________________________________________________ Printed Name of Parent/Legal Guardian
_________________________________________________________ Signature of Parent/Legal Guardian
TO THE STUDENT: My signature verifies that I have received a South Adams Schools Student Handbook. I am aware that I am expected to read this handbook and will be held accountable for its contents and any new additions. If I have any questions, I will discuss them with my teacher, a counselor or a school administrator. ______________________ Date _________________________________________________________ Printed Name of Student _________________________________________________________ Signature of Student (parent/guardian may sign for a minor child)
Student Legal Reporting Waiver & Code of Conduct
LEGAL REPORTING WAIVER Authorization for Release of Information I authorize the sharing of information with State and County Agencies including but limited to: Adams County Probation Department, Adams County Law Enforcement Agencies, Adams County Child Protective Services, Adams County Prosecuting Attorney and the Courts of Adams County with South Adams Schools regarding: Student’s Name (as printed above):
Date of Birth __ / __ /20___
1. This information is for the purpose of continuity of goals between the Student, Parents, South Adams Schools and the above listed Adams County Agencies. 2. I authorize the above parties to exchange information verbally or in writing concerning probation or supervision rules or activities that may be in violation of the South Adams Schools Code of Conduct. 3. I hold harmless: South Adams Schools, the above listed Adams County Agencies and other designees in regard to the use of Information authorized for release of exchange. 4. I understand this form may be revoked by me at any time except to the extent that action has already been taken. 5. I further understand revocation of this form will result in the termination of participation in extra-curricular activities at South Adams Schools. In the absence of revocation, this consent will expire upon the student’s withdrawal from or graduation from South Adams Schools. 6. A photocopy of this authorization is as authentic as the original Authorization of Release.
Parental and Student Acknowledgements: 1. I have read and understand the above and affirm it was properly completed prior to my signature. 2. I have received, read and understand the South Adams Code of Conduct.
Parent/Guardian printed name: This Waiver, Authorization and Acknowledgement must be signed and on file in the school office prior to the student’s participation in all school activities; and it remains in effect throughout the student’s career at South Adams Schools unless revoked by parents or replaced by a subsequent signed and dated document. Activities include all regular school day activities and procedures, participation in any sport, club, or other affiliations to South Adams Schools.
Medical Information and Release Student Name: ___________________________________ Birth Date: ______________________ Grade Level: ________ Existing Medical Conditions (if any): ______________________________________________________________________________ ____________________________________________________________________________________________________________ Previous Medical Conditions (if any): ______________________________________________________________________________ ____________________________________________________________________________________________________________ Current Medications & Scheduled Dosage Times: ____________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Allergies (medications, insects, food): _____________________________________________________________________________ ____________________________________________________________________________________________________________ Describe Allergy Reaction: ______________________________________________________________________________________ Please list any treatment necessary for above allergy: ________________________________________________________________ (Please supply clinic with the necessary medication or device needed for treatment.) Note: The cafeteria director will need a doctor’s note in regards to any food allergies/dietary restrictions! Student’s Physician: __________________________________ Physician’s Telephone: _____________________________________ SPECIAL NEEDS: Glasses: ___ Yes ___ No
Contacts: ___ Yes ___ No
Hearing Aids: ___ Yes ___ No
Adaptive equipment needed: ____________________________________________________________________________________ Restrictions: _________________________________________________________________________________________________ By signing below, I give permission for South Adams School Corporation personnel:
To dispense simple, over-the-counter medicines (please check all that apply). Parent will need to supply medication. To treat and/or obtain the service of a physician, ambulance or hospital for the above names student in case of illness or accident and the parent/guardian cannot be contacted; and to take whatever action they consider is in the best interest of my child.
___ Other over-the-count (please name) ___________________
IF YOUR STUDENT HAS RECEIVED ANY ADDITIONAL IMMUNIZATIONS, PLEASE NOTIFY THE SCHOOL NURSE SO WE CAN ADD THE DATES AND COMPLETE THEIR RECORD.
Random Drug Testing Consent Form Extra-Curricular Activities Co-Curricular Activities Student Driver I have received a copy of the “South Adams Schools Extra-Curricular, Co-Curricular and Student Driver Random Drug Testing Program. A separate form is available in the school office to deny permission. I, (student name) _____________________________________, desire to participate in this program of South Adams Schools, and hereby, voluntarily agree to be subject to its terms for the entire school year. I accept the method of specimens, testing, and analysis of such specimen, and all other aspects of the program. I agree to cooperate in furnishing specimens that may be required from time to time. I further agree and consent to the disclosure of the sampling, testing, and results provided for this program. The consent is given pursuant to all State and Federal Privacy Statutes, and is a waiver of right on nondisclosure of such tests and results on to the extent of the disclosure in the program. Date: ___________________________
Race and Ethnicity (Note: Both Part 1 and Part 2 of the question must be answered) Part 1: Ethnicity Is the student Hispanic/Latino? (choose only one) _____ No, not Hispanic/Latino _____ Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race). Part 2: Race What is the student’s race? (choose one or more): _____ American Indian or Alaska Native: A person having origins in any of the original peoples of North America and maintaining cultural identification through tribal affiliation or community recognition. _____ Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. _____ Black of African American: A person having origins of any of the black racial groups of Africa. _____ White: A person having origins in any of the original peoples of North America and maintaining cultural identification through tribal affiliation or community recognition.
Residence History Has the student moved (alone, with or to join a parent, spouse or guardian within the last 36 months? _____Yes _____ No Was the move from one school district to another? _____ Yes _____ No (If Yes, Name of District) ______________________________ Was the purpose of the move to seek or obtain work? Yes___ No___ If YES, was the work agricultural AND was it temporary /seasonal? Yes___ No___
Home Language Survey (HLS) The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each students’ home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 467 U.S. 202 (1982). The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district/charter school. The HLS is administered one time, upon initial enrollment, and remains in the student’s cumulative file. Please note that the answers to the survey below are student specific. If a language other than English is recorded for ANY of the survey questions below, the WIDAACCESS Placement Test will be administered to determine whether or not the student will qualify for additional English language development support.
Please answer the following questions regarding the language spoken by the student: 1. What is the native language of the student: _____ English, _____ Spanish, _____ German (Amish) _____ Japanese _____ Other, please specify _______________________ 2. What language(s) is spoken most often by the student: _____ English, _____ Spanish, _____ German (Amish) _____ Japanese _____ Other, please specify _______________________ 3. What language(s) is spoken by the student in the home? : _____ English, _____ Spanish, _____ German (Amish) _____ Japanese _____ Other, please specify _______________________ By signing the below, you certify that responses to the above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.
Dear Parent/Guardian, McKinney-Vento Act Residency & Educational Rights Information questionnaire must be completed for each student. In Indiana over 29,000 children experience homelessness each year. The McKinney-Vento Homeless Assistance Act was created with the goal of ensuring the enrollment, attendance, and success of homeless children and youth in school. When families and students find themselves in transition due to their housing situation, it is important that they know their rights regarding education. If students meet the requirements as stated in the McKinneyVento Act (42 U.S.C. § 11432), their rights are as follows: 1) 2) 3) 4) 5) 6)
Students must be provided a statement of their rights when they enroll and at least one additional time per year. Students may attend their school of origin or the school where they are temporarily residing. Immediate enrollment in the school they last attended or the school in whose attendance area they are currently staying even if they do not have all of the documents normally required at the time of enrollment; Access to free meals, textbooks, Title I and other educational programs, and other comparable services including transportation and technology; To attend the same classes and activities that students in other living situations also participate in without fear of being separated or treated differently due to their housing situations. Educational services for which the homeless student meets eligibility criteria including services provided under Title 1 of the Elementary and Secondary Education Act or similar State or local programs, educational programs for students with limited English proficiency. Students must be provided a statement explaining why they are denied enrollment or any other services. Students must receive services, such as transportation, while disputes are being settled.
According to the U.S. Department of Education, people living in the following situations are considered homeless:
Doubled up with family or friends due to loss of housing or economic hardship Living in motels and hotels for lack of other suitable housing Runaway and displaced children and youth – Unaccompanied Youth Homes for unwed or expectant mothers for lack of a place to live Homeless and domestic violence shelters Transitional housing programs
The streets Abandoned buildings Public places not meant for housing Cars, trailers (does not include mobile homes intended for permanent housing), and campgrounds Migratory children staying in housing not fit for habitation
Please complete the form on the reverse side of this document and return to your school office. Questions may be directed to your Principal, School Counselor, or: School Corporation Liaison.
Updated on 5-22-18
SOUTH ADAMS SCHOOLS RESIDENCY INFORMATION FORM This questionnaire is in compliance with the McKinney-Vento Act, 42 U.S.C. § 11432. Your answers will help us determine residency to further assist student(s). South Adams sends this questionnaire to all parent(s)/guardian(s)/unattached youth August 31st AND January 31st in accordance with legal requirements. ****One form per family**** Parent/Guardian ___________________________________ Phone/Pager ________________________ Address ______________________________________________________________ City ____________ Child #1 ___________________________________________Grade _____ Child #2 ___________________________________________Grade _____ Child #3 ___________________________________________Grade _____ Child #4 ___________________________________________Grade _____ Please choose which of the following situations the students currently reside in (may choose more than one): □ Rent/own my own home or apartment. STOP: If you rent/own your own home, sign below and submit form to school personnel. Please indicate any of the following circumstances that your child/student may be facing related to housing: □ Currently does not have a fixed, regular, adequate nighttime residence □ Temporarily living with another family or friends because: □ cannot find affordable housing □ recent loss of housing/eviction □ economic hardship □ other similar reasons: ______________________ □ Temporarily living in a hotel or motel □ Currently staying at an emergency shelter □ Currently living in substandard housing (does not meet health and safety codes) □ Currently living in a vehicle, trailer park or campground without running water or electricity. □ Currently living in a public or private place not ordinarily used as regular sleeping accommodations. □ Displaced due to natural disaster (flood, hurricane, tornado, fire, etc.) □ Other: ___________________________________________________________ □ Since (date)_____________________________, I/we have not had a permanent home. If student is seeking enrollment without an accompanying adult (not in the physical custody of a parent or guardian), please check one of the following: □ Student is with an adult that is not a parent or legal guardian □ Student is alone without an adult McKinney-Vento Liaison: Sheila Graber 589-1102 x207 or the State Coordinator at (317) 233-3372. By signing below, I acknowledge that I have received and understand the stated rights. _____________________________________________________________________________________ Signature of Parent/Guardian/Unattached Youth Date
Name, McKinney-Vento Liaison For school use only: YES NO
______________________________August 7, 2018_____________ Date initials______ Date__________ Notes:_______________________
Student/Parent/School Compact Families and schools must work together to help students achieve high academic standards. Through a process that include teachers, families, students and community representatives, the following are agreed upon roles and responsibilities that we as partners will carry out to support student success in school and in life. Student Name: _______________________________
Staff Pledge - I agree to carry out the following responsibilities to the best of my ability: Provide a safe and supportive learning environment. Motivate my students to learn with skills necessary to be successful by providing exciting and innovative lessons. Set high expectations and help every child be successful in meeting the Indiana academic achievement standards and to provide many different ways for your child to learn the skills necessary to be successful in his/her grade. Communicate frequently and meet annually with families about student progress and the school-parent compact. Provide opportunities for parents to volunteer, participate, and observe in South Adams’ classrooms. Participate in professional development opportunities that improve teaching and learning and support the formation of partnerships with families and the South Adams community. Active participate in collaborative decision making with parents and South Adams colleagues to make our school accessible and welcoming for families. Respect the school, students, staff, and families. To give assistance needed to parents so that they can help with the homework assignments. The assignment directions will be clear and understandable. Student Pledge – I agree to carry out the following responsibilities to the best of my ability:
Come to school ready to learn and work hard. Bring necessary materials, completed assignments and homework. Know and follow school and class rules as outlined in the South Adams student handbook, so everyone can learn. Ask questions and communicate with teachers and parents. Limit my TV watching, video game playing, and Internet usage. Read at home on a regular basis and to complete homework. Respect the school, classmates, staff and families including adherence to the South Adams anti-bullying policy.
Family/Parent Pledge – I agree to carry out the following responsibilities to the best of my ability:
Provide a quiet time and place for homework and monitor TV viewing. Encourage my child to read every day. Ensure that my child attends school every day and gets adequate sleep, regular medical attention and proper nutrition. Regularly monitor my child’s progress in school, including assisting with his/her homework on a regular basis. Participate, as appropriate, in decisions about my child’s education including constructive suggestions on how to improve South Adams Title I program. Attend parent-teacher conferences. Communicate the importance of education and learning to my child. Respect all South Adams staff, students, and families.
South Adams Elementary/Middle School 1012 Starfire Way Berne, IN 46711 Shellie Miller, Elementary Principal Jeff Rich, Middle School Principal REQUEST FOR RECORDS Date: ______________________ TO WHOM IT MAY CONCERN: According to the Final Regulations-Family Educational Rights and Privacy Act dated June 17, 1976, it is no longer necessary to obtain written parent/guardian consent to release records between schools. It states that school officials, including teachers within the educational institution and officials of other schools in school systems in which the student enrolls may receive a student’s record without written consent for such release. We would appreciate records including courses, grades, test scores, health records, attendance, and psychological testing information on the following student(s): Student:
Thank you very much for your cooperation. Please send information to:
South Adams Elementary/Middle School 1012 Starfire Way Berne, IN 46711
Consent Form for Formal Classroom Instruction on Human Sexuality South Adams Middle School in conjunction with Senate Enrolled Act 65 will offer parents the option to review and inspect all materials related to the instruction on human sexuality and for their child to opt-out of instruction on human sexuality in classes at the Middle school level. Below are the classes taught and topics discussed that fall under the heading of human sexuality:
Terry Hall “Good Touch/ Bad Touch” Program—Grades K-8 Indiana State Police Internet Safety Program—Grades 3-5 Health / Science Classes – Body Systems – Cell Reproduction Grades 6-8 Alive and Well (5 class periods) Helping Teens Make Healthy Choices – Creating Positive Relationships Program Grades 6-8
Our goal is to help our students understand the above mentioned topics in an attempt to positively impact their current and future health. Our purpose is to supplement the efforts of parents, and we encourage you to talk to your child about these issues. If you have any questions regarding the material taught or if you would like to review/inspect materials, please contact South Adams Middle School at (260)5891102. Student Name: ______________________________________ This form serves as the: __X___ First Notice _____ Second Notice
Date of Notice: ___8/7/2018_______ Date of Notice: _________________
Please return consent form to the main office of South Adams Middle School Please Check: _____ Consents to the Instruction
*If the school does not receive a response within ten days after the second notice, the student will receive the instruction on human sexuality unless the parent, or the adult or emancipated minor student, subsequently opts out of the instruction for the student.