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Transcript of MES Step 2
Meadowlark Elementary School
On-‐Line Enrollment Step 2 Document 2011/2012
WELCOME BACK TO
MEADOWLARK ELEMENTARY
New Students Enroll
Monday, August 8 (8 a.m. to 12 p.m. & 1 p.m. to 4 p.m.) (in the Meadowlark Office)
Returning Students Enroll Tuesday, August 9 (12:30 p.m. to 7 p.m.)
(in the Meadowlark Office)
Meet Your Teacher Night Tuesday, August 16 (5:30 p.m. to 6:30 p.m.)
First Day - Grades 1st thru 5th
Thursday, August 18 (8:35 a.m.)
First Day - Kindergarten (Monday, August 22) All Day 8:35a.m. to 3:35 p.m.
Half Day 11:35 p.m. to 3:35 p.m.
Kindergarten Screening Thursday, August 18
Friday, August 19
Office Use: Amount $_______________Check#_____________Cash__________Online__________
2011-2012 Meadowlark Elementary
Student Name:
Grade:
Required Fees $65.00 - Half Day Kindergarten Textbook Fee
$75.00 - All Day Kindergarten, 1st thru 5
th Grade
$25.00 - All Day Kindergarten, 1st thru 5
th Grade
$12.50 - Half Day Kindergarten Technology Fee
Elective Fees $100.00/1 student - Transportation Fee (for all students who live less than 2.5 miles from their school and choose to ride
the bus)
$150.00/family - Transportation Fee (for all students in one family who live at the same address)
$275.00 – Monthly Fee for All Day Kindergarten
Food Service Fees $1.50 – Breakfast
$2.05 – Lunch
$0.40 – Snack Milk (kindergarten only)
Required Fee Payment Options • Check or money order payable to Meadowlark Elementary School• Pay online at www.usd385.org
Elective Fee Payment Options • Check or money order payable to USD• Pay online at www.usd385.org
Food Service Payment Options • Check or money order payable to USD #385 Food Service• Pay online at www.usd385.org
Applications for free and reduced fee assistance are
The following forms will need to be printed off and returned to the school off
complete. Please check off that you are returning the following forms:
_____ Request for Transcript (new students
_____ Placement Information (new students only)
_____ Proof of Residence (new students only)
_____ School Directory Form (optional)
_____ PTO Committees (optional)
_____ Request for Paper Copy of Newsletter (optional)
_____ Free & Reduced Application (if applicable)
_____ Student Requiring Special Meals (if applicable
_____ Birth Certificate (new students only)
Amount $_______________Check#_____________Cash__________Online__________
Elementary Fees
Half Day Kindergarten Textbook Fee
Grade Textbook Fee
Grade Technology Fee
Half Day Kindergarten Technology Fee
for all students who live less than 2.5 miles from their school and choose to ride
(for all students in one family who live at the same address)
or All Day Kindergarten
payable to Meadowlark Elementary School
payable to USD #385
payable to USD #385 Food Service
Applications for free and reduced fee assistance are available online.
The following forms will need to be printed off and returned to the school office
Please check off that you are returning the following forms:
new students only)
(new students only)
(new students only)
opy of Newsletter (optional)
applicable)
if applicable)
Amount $_______________Check#_____________Cash__________Online__________
for all students who live less than 2.5 miles from their school and choose to ride
(for all students in one family who live at the same address)
ice before enrollment is
Volunteer Sign-up Sheet
All Meadowlark parents and staff are members of the school’s Parent-Teacher Organization (PTO). The PTO coordinates more than 30
different school activities and services which cannot happen without our wonderful Meadowlark parent volunteers! Please consider being
involved. Mark the box next to the committees you could help with. Thank you!
Name:_______________________________________Primary/Secondary Phone Numbers: _____________________________________
E-mail address:________________________________Name of Child/Children & grade(s)_______________________________________
General Volunteer Receive e-mails when help is needed for any PTO activity. Help when you can.
Home Room Parent Become the home room parent in your child’s class; plan the fall and spring parties with other parents’ help.
Helping Hands
Greet and direct students to their class and to/from the bus on the first few days of school. Help in the
lunchroom during the first week of school.
Welcome Wagon
Help plan the September Welcome Wagon Coffee to welcome all families back to Meadowlark for another
great year. Greet new families during the year at PTO meetings.
Spring Fund Raiser Help organize and work the fundraiser in April.
GAD Parade Help design and build the float for the Greater Andover Days Parade on October 1, 2011.
Parent/Teacher Conferences Provide food and other items for teacher meals during conferences in October and February.
Box Tops/Tyson
Help to collect, count and forward box tops to General Mills and Tyson labels to Tyson. This is a great
fundraiser for the school. All money received from Boxtops goes to the Staff Grant Program.
Family Fun Night Help plan and work at a fun school social in September.
Bulletin Board Help decorate the PTO bulletin board in the front lobby monthly or as needed.
Book Fair Help to set up and sell books at one or more shifts during the 2011 Scholastic Book Fair in October.
Picture Day Help photographer and school staff take pictures of students in the fall and spring.
Librarian Helper
Assist librarians throughout the year, shelving books and other duties as needed. Commitment could be once or
twice per month, once per week or other schedules.
Sunshine Committee Help recognize staff members on their birthdays throughout the year.
Holiday Staff Meal Provide items (drinks, food, paper products) to create a nice meal for the staff in December.
Staff Appreciation Week Help organize and provide food, decorations and gifts the first week in May.
All Star Reading
With a staff member, watch students on the playground at the extra 15 minute recesses at the end of each
quarter. Help with the All Star Reading T-shirt design contest in the spring.
Holiday Caring & Sharing
Help organize the collection of toys and money for the under-privileged in Andover starting after Thanksgiving
and finishing before Christmas break.
Office Helper Help office staff with getting Friday folders out and other duties as necessary. Serve once per month or more.
Art Helper Help Art Teacher hang artwork in the school hallways throughout the year.
Music Helper Help decorate for school music programs (all grades) and make signs and create costumes as needed.
Year Book
Help take and gather pictures for the school yearbook throughout the year. At least one picture chairperson per
grade level is needed.
T-Shirts Design, order and sell Meadowlark T-shirts, especially during August and September.
Nurse Helper Help nurses check in students for dental check up day, height/weight day and other duties as needed.
Counselor Helper
Help as needed with Drug Free Red Ribbon week in the fall, Careers on Wheels day in the spring and
Counselor Appreciation Day in February.
Reading Lab Helper Help Reading Specialist plan and work during Read Across America activities in early March.
PE Helper Help PE teacher with Fun in the Sun Field Day in May and sometimes other PE events throughout the year.
Outdoor Habitat Help maintain our beautiful outdoor habitat by volunteering to weed and plant as needed.
Future All-Stars Playgroup Be notified of upcoming playgroups for future Meadowlark students.
Recycling Help with the recycling program at Meadowlark throughout the year.
Staff Grant Program
Serve once per year or more on the monthly rotating committee to vote on staff applications for PTO-funded
classroom projects.
MEADOWLARK ELEMENTARY DIRECTORY PERMISSION
Dear Parents,
A 2011-12 school directory will be published for parents containing Meadowlark student contact
information. Please fill out this permission form and return it to the school office with your
enrollment packet. Students who do not have a permission form turned in will not be in the
school directory. Ordering information will go home with students at a later date. Even if you
will not be ordering a directory, we still need this form from you. If you have a child who has
more than one household, please fill out two forms and indicate the difference between the
addresses. If you have any questions, please contact Chris Steward, PTO President, at
Thank you for your help!
MEADOWLARK ELEMENTARY SCHOOL DIRECTORY FORM
Name(s) of
Child: _____________________________________
Grade: _____
Child: _____________________________________
Grade: _____
Child: _____________________________________
Grade: _____
Child: _____________________________________
Grade: _____
Parents Name(s):
______________________________________________________________________
Address: ______________________________________________________________
City, State, Zip: _________________________________________________________
Home or Primary Phone #: (____)____________________________
Check one of the following:
_____I give permission for my address and family names to be published in the
Meadowlark Elementary School Directory.
_____I do not wish to have my address or family names published in the Meadowlark
Elementary School Directory.
__________________________________________ _________________
Signature Date
WE ARE ON THE WEB!
In an effort to reduce the time and expense involved in distributing
paper copies of school notes and newsletters, we will be posting links
to each classroom or department. Teachers have been asked to post
their class information, such as schedules, newsletters, and
handbooks. The Elementary Family Handbook will be available on our
school website as well. The monthly parent newsletter will be posted
on the school website along with a lunch menu.
Our school website can be accessed by going to www.usd385.org. By
going to the district website, you will have access to all our
Meadowlark links, lunch menu, district calendar, Powerschool and
much, much more!
If you do not have access to the internet, please return the completed
form below to the school office. A paper copy of any information you
may need will be sent home with your child.
I do not have access to the internet and will need a paper copy
of the newsletters, handbooks, and school notes.
Parent Name__________________________________________________
(Please print)
Name of Children
_________________________ Teacher__________________ Grade____
_________________________ Teacher__________________ Grade____
_________________________ Teacher__________________ Grade____
_________________________ Teacher__________________ Grade____
Kindergarten #2 Pencil (6)
Crayola crayons – 24 ct. (2) Crayola Classic thick washable markers - 8 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (4) Fiskar sharp scissors – 5” (1) Pocket only folder – any color (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (1) Black Sharpie (Fine pt.-Art) (1) Pop-up wipes (1) Backpack
1st Grade #2 Dixon Ticonderoga pencils -24ct. Pink bevel eraser (2) Crayola crayons – 24 ct. (2) Crayola Classic thick washable markers 8 ct. (1) Crayola 8 color washable watercolors (1) Chisel tip dry erase marker – black (4) Glue stick (4) Fiskar sharp scissors – 5” (1) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – yellow (1) Pocket only folder – green (1) Pocket only folder – blue (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (2) 12 ct. colored pencils (Art) 1 disinfecting wipes backpack
2nd Grade #2 Dixon Ticonderoga pencil (12)
Pink bevel eraser (1) Highlighter – fluorescent yellow (1) Chisel tip dry erase marker – black (3) Crayola crayons – 24 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (3) Fiskar sharp scissors – 5” (1) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – green (1) Pocket & brad folder – blue (1) Pocket & brad folder – yellow (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (2) Clorox Wipes Sharpie Extra Fine – black 1 (Art) Crayola Markers Classic Colors (10 ct) Backpack
3rd Grade #2 Pencil (24) Pink bevel eraser (1) Bic medium stick pen – red (2) Pen style highlighter – yellow (1) Chisel tip dry erase marker – black (4) Crayola crayons – 24 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Ross glue stick – 1.23 oz. (2) Fiskar sharp scissors – 7” (1) Filler paper wide rule – 200 ct. (2) Spiral comp. book wide rule – 70 ct. (2) Pocket & brad folder – red (1) Pocket & brad folder – green (1) Pocket & brad folder – blue (1) Pocket & brad folder-orange (1) Pocket & brad folder --yellow (1) Kleenex – approx. 120 ct. (2) 8 ct. Crayola Markers (Art) Glue Bottle Backpack
4th Grade # 2 pencil (12) Pink bevel eraser (1) Pen style highlighter – pink (1) Pen style highlighter – yellow (1) Sharpie Fine marker – black (1) Sharpie Extra Fine marker – black (1) Chisel tip dry erase markers – 4 pk (black or assorted color) 1 Crayola Classic thick washable markers – 8 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (2) Fiskar sharp scissors – 7” (1) Ruler – 12” clear plastic (1) 3 x 5 ruled index cards – 100 ct. (1) Filler paper wide rule – 100 ct. (2) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – yellow (1) Pocket & brad folder – green (1) Clip board – standard letter size (1) Kleenex – approx. 120 ct. (1) Crayola crayons – 24 ct. 1 (Art) 13 pocket expandable folder Backpack
5th Grade #2 pencil (24)
Bic medium stick pen – blue (3) Sharpie Fine marker – black (1) Pen style highlighter – yellow 2 Chisel tip dry erase marker – black (4) Crayola Classic thick washable markers – 8 ct. (1) Crayola 7” colored pencils – 24 ct. (1) Ross glue stick – 1.23 oz. (1) Fiskar sharp scissors – 8” (1) Ruler – 12” clear plastic (1) 3 x 5 plain index cards – 100 ct. (1) Filler paper wide rule – 200 ct. (2) Spiral comp. book wide rule – 70 ct. (2) Pocket & brad folder – assort. colors (6) Pencil bag – 8 x 10 see- thru plastic (1) Kleenex – approx 120 ct. (2) Glue bottle-4oz. (2) Clorox wipes Sandwich sized baggies zip close hand sanitizer paper towels Backpack
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 24 25 26 27 28 29
February 2012
The policies of the Board of Education of USD 385 prohibit discrimination on the basis of race, color, national origin, disability, religion and sex in all programs and activities of the district. Additionally, discrimination on the basis of age is prohibited in employment.. Equal Opportunity Employer. Approved 3/14/11
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18 19 20 21 22
30 31 23 24 25 26 27 28 29
October 2011 August
8 New Students Enroll (8 am to 12 pm & 1-4 pm) 9 Returning Students Enroll (12:30 pm to 7 pm) 10-11 New Teachers Report 12 .1.0 Flex Work Day (Outside of Contract time) 15-17 All Teachers Report—Building/District Inservice 18 First Day-Grades 1st-5th, 6th, & 9th 19 First Day For Grades 7th, 8th, 10th, 11th & 12th 22 First Day for Early Childhood and Kindergarten
September 5 All Schools Closed-Labor Day 26 Building/District Inservice
October 14 End of 1st Quarter (40 days) 17 No School - Morning Building Inservice/ Afternoon Flex Work Day 31 All Schools Closed - Conference Credit Day
November 23-25 All Schools Closed-Thanksgiving Break
December 21 End of 2nd Quarter (43 Days) Dismiss 2 hrs. early (meet teacher credit time) 22 .5 Flex Work Day 22-Jan 2 All Schools Closed-Holiday Break
January 3 School Resumes 16 Inservice All Day/MLK Day
February 20 All Schools Closed-President’s Day
March 8 End of 3rd Quarter (46 Days) 9 No School - Morning Building Inservice/ Afternoon Flex Work Day 19-23 All Schools Closed-Spring Break April 6 No School—Conference Credit Day 8 Easter May 20 Commencement ACHS & AHS 23 Dismiss 2 Hrs. Early for building Inservice Last Day for Students End of 4th Quarter (47days) 24 Morning Flex Work Day Last Day For Teachers
Legend Yellow-School in Session Red-All Schools Closed, Teachers Inservice White-All Schools Closed, Teachers off Duty Blue-All Schools Closed, Teachers Flex Day Brown-All Schools Closed, Conference Credit Day
District Office Mark A. Evans, Superintendent Dr. Andrew Koenigs, Associate Superintendent Tom Ostrander, Assistant Superintendent. Jim Freeman, Business Manager/Treasurer Keturah Austin, Communications (316) 218-4660
Andover High Robert Baier, Principal Gary Merritt, Asst. Principal Amanda Grier, Asst. Principal (316) 218-4600
Andover Central High Cheryl Hochhalter, Principal Doug Carr, Asst. Principal Brian Gregoire, Asst. Principal (316) 218-4700
Andover Middle Brett White, Principal Brent Jones, Asst. Principal (316) 218-4610
Andover Central Middle Tim Hayden, Principal Debra Regier, Asst. Principal (316) 218-4710
Cottonwood Elementary Shari Rooks, Principal (316) 218-4620
Robert M. Martin Elementary Dr. Crystal Hummel, Principal (316) 218-4720
Meadowlark Elementary Jody Baker, Principal (316) 218-4630
Prairie Creek Elementary Shelley Jonas, Principal (316) 218-4830
Sunflower Elementary Rita Decker, Principal (316) 218-4730
Wheatland Elementary Elton Armbrister, Principal (316) 218-4820
Food Service Ann Katt, Director (316) 218-4603
Transportation Julie Clopton, Director (316) 218-4621
Operations Bruce Sanderson/Exec Dir. of Operations (316) 218-4604
Technology Rob Dickson, Director (316) 733-3686
2011-2012 USD 385 PROFESSIONAL CALENDAR
Visit us online at www.usd385.org!
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10 11 12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
August 2011 Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
September 2011 Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
November 2011
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24 25 26 27 28 29 30 31
December 2011 Sun Mon Tue Wed Thur Fri Sat
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
January 2012
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
March 2012
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30
April 2012 Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
May 2012
Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23
24 25 26 27 28 29 30
June 2012 Sun Mon Tue Wed Thu Fri Sat
1 2 3 4 5 6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
July 2012
The following pages
only apply to
students new to
Andover Public Schools.
ANDOVER USD #385 PROOF OF RESIDENCE
This form must be accompanied by a verification of residency. Acceptable forms of
verification are: Utility Bills, Lease Agreement or Homeowner Contract
Date: _______________________ School: ________________ Student(s) Name(s): Grade: ______________________________________ ______________ ______________________________________ ______________ ______________________________________ ______________ ______________________________________ ______________ I, ___________________________________, the parent/guardian declare that the above students reside with me at the following address:
Street Address: ______________________________________________________________
City, Zip: ____________________________________________________________________
I understand that the accuracy of the above information is important to the continued enrollment of my child(ren).
Parent/Guardian Signature: _________________________________________________
Meadowlark Elementary USD # 385
1411 N. Main – Andover, KS 67002
Ms. Jody Baker – Principal Phone: 316-218-4630
Mrs. Tammy Clarkson – Counselor Fax: 316-218-1000
Request for Transcript
Date: _________
Student: ___________________________________ Grade: ________
Registrar:
Please send us at your earliest convenience, all official records, transcript of grades,
cumulative records, birth certificate, test results, health records, athletic eligibility,
psychological test results and any other data directly related to this student.
Thank you for your time.
Former School: _____________________________________
_____________________________________
_____________________________________
Parent/Guardian Signature: ___________________________________
Send Records To:
Meadowlark Elementary school
1411 N. Main
Andover, KS 67002
Parental permission is no longer required when records are requested by authorized school personnel.
Family Education Rights and Privacy Act, Final Rule on Education Records, Federal Register
June 17, 1976, Vol. 41, No. 118, page 24673
MEADOWLARK ELEMENTARY New Student Placement Information Form
2011-2012 School Year
Student Name: ___________________________________________ Male or Female
(Please circle)
To better help us place your student, please provide the following information:
1. Was your child ever retained? If so, which grade(s)?
2. How was your child performing academically at his/her previous school?
3. Was your child involved in any special programs and what were they?
(Example: Title I reading, and math programs, speech, language, learning
disabilities, special classroom placement, gifted, enrichment, etc.)
4. Please describe your child’s personality. (Is he/she excitable, creative, very
active, quiet, etc.)
5. Would you say your child would benefit from (please circle):
A. A structured classroom
B. A flexible classroom
C. Either type of classroom
Please use the back of this form to add any additional information about your child that
would help with your child’s placement. Thank you.
___________________________________________ _________________
Parent/Guardian Signature Date
USD 385 DEPARTMENT OF HEALTH SERVICES
ANDOVER, KANSAS
IMMUNIZATION STATEMENT Please sign and return with enrollment forms.
Name of Student: _________________________________________ Date of Birth: _____________________________________________
I have been notified that Kansas Law (K.S.A. 72-5208, 72-5209, 72-5210, 72-5211 and 72-5211a) requires every pupil enrolling in any school for the first time, prior to admission, to present proof from a physician or local health department that the pupil has received such tests and inoculations as are deemed necessary.
In USD 385, proof of each inoculation received must be presented prior to admission. Also, mandatory booster inoculations in all required series must be received (within 30 days for students admitted after September 1). If transferring into USD #385, it is the parents obligation to make sure proof of inoculations are received within 30 days. Required inoculations include the following:
DTP, DTaP and/or DT/Td Additions for Early Childhood OPV or IPV Hib MMR PCV7 (pneumococcal) Hepatitis B Hepatitis A Varicella
Parents will be notified of any additional requirements.
Parent/Guardian Signature Indicating Receipt of Notice:
_______________________________________Date:_________________ Student is transferring from: _____________________________________ Name of School City St.
Date Student Entered USD #385: _______________________________
KANSAS CERTIFICATE OF IMMUNIZATIONS (KCI)This record is part of the student's permanent record and shall be transferred from one school to another as defined in Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.)
Student Name:
Parent or Guardian Name:
Address:
Birthdate (MM/DD/YYYY): SEX: [ ] MALE [ ] FEMALE
Phone:
CountyRace: Ethnicity:
RECORD THE MONTH, DAY, AND YEAR THAT EACH DOSE OF VACCINE WAS RECEIVEDVACCINE
7th6th5th4th3rd2nd1st
If additional doses are added,
please initial the dose and sign
below:
Polio Required for school entry.
HEP B (Hepatitis B) Required for school entry through Grade 10 for 2010-
2011 school year. Recommended for all children.
Varicella (Chickenpox) Required for school entry through Grade 10 for
2010-2011 school year. Recommended for all children.
MMR (Measles, Mumps, and Rubella combined) Required for school entry.
HIB (Haemophilus Influenzae Type B) Required < 5 years of age for preschool
or child care operated by a school.
PCV7 (Pneumococcal Conjugate) Required < 5 years of age for preschool or
child care operated by a school.
HEP A (Hepatitis A) Required < 5 years of age for preschool or child care
operated by a school.
Physician Signature:
MCV4 (Meningococcal) Recommended at 11 years of age. Not required for
school entry.
DTaP/DT/Td/Tdap (Diphtheria, Tetanus, Pertussis) Required for
school entry.
HPV (Human Papillomavirus) Recommended for females and provisionally
recommended for males at 11 years of age. Not required for school entry.
Rotavirus Recommended < 8 mo. Not required for school entry.
Hx of Disease:
State Type
Influenza (Flu) Recommended annually for ages 6mo - 18 yrs. Not required
for school entry.
I certify I reviewed this student's vaccination record and transcribed it accurately.
Agency Name:
1. "Annual written statement signed by a licensed physician (Medical Doctor/M.D. or Doctor of Osteopathy/D.O.) stating the physical
condition of the child to be such that the tests or inoculations would seriously endanger the life or health of the child." Medical exemption
shall be validated annually by physician completion of KCI Form B and attachment to the KCI.
KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf
2. "Written statement signed by one parent or guardian that the child is an adherent of a religious denomination whose religious
teachings are opposed to such tests or inoculations."
DateParent/Legal Guardian's Signature
I give my consent for information contained on this form to be released to the Kansas Immunization
Program for the purpose of assessment and reporting.
KANSAS IMMUNIZATION PROGRAM
1000 SW Jackson, Suite 210, Topeka, KS 66612-1274
PHONE 785-296-5591 FAX 785-296-6510
WEB SITE www.kdheks.gov/immunizeRev. 02/01/2010
Date:
q
Authorized Representative:
Address:
The record presented was:
Kansas Immunization Record
Other Immunization Record (Specify)
DOCUMENTATIONKCI MAY ONLY BE SIGNED BY A PHYSICIAN (MD/DO), HEALTH DEPT, OR SCHOOL.
LEGAL ALTERNATIVES TO VACCINATION REQUIREMENTS "KSA 72-5209"
KANSAS IMMUNIZATION REQUIREMENTS: Based on age of child as of September 1 of current school year.
As per Kansas Statute 72-5209, all children upon entry to school must be appropriately vaccinated. In each column below, vaccines are required for all ages listed in that column.
Ages 0-4
Recommended Schedule
Birth
2 Months
4 Months
6 Months
12-15 Months
HEP B
DTaP/DT
POLIO
HIB
PCV7
ROTAVIRUS
DTaP/DT
POLIO
HEP B
HIB
PCV7
ROTAVIRUS
DTaP/DT
MMR
VAR
HIB
PCV7
HEP A
DTaP/DT
POLIO
HEP B
HIB
PCV7
ROTAVIRUS
Ages 5-6 Ages 7 and Older
DTaP/*DT: 5 doses
4 week minimum interval between doses, with at least 6 months between dose 3
and dose 4.
4 doses acceptable if dose 4 given on or after the 4th birthday.
If dose 4 is administered before the 4th birthday, a 5th dose must be given at 4-6
years of age.
If 1st DT dose given at <12 months of age, 4 doses recommended; acceptable
only when Pertussis component is contraindicated by the physician.
If 1st DT dose given at 12 months or older, 3 doses complete primary series;
acceptable only when Pertussis component is contraindicated by the physician.
a)
b)
c)
*
*
POLIO:
4 doses of POLIO are acceptable IF:
3 doses of POLIO (all IPV) are acceptable IF:
4 week minimum interval between doses, regardless of age given.
† - The ACIP Schedules may be accessed at: http://www.cdc.gov/vaccines/recs/schedules
Vaccine doses given up to 4 days before the minimum interval or age may be considered valid.
With the exception of Hepatitis B vaccine, immunizations given before 6 weeks of age are not considered valid.
Half doses or reduced doses of vaccine are not considered valid.
PARENTS AND/OR GUARDIANS ARE NOT AUTHORIZED TO COMPLETE KCI FORMS.
A ROSTER WITH THE NAMES OF ALL EXEMPT STUDENTS SHOULD BE MAINTAINED. PARENTS OR GUARDIANS OF EXEMPT CHILDREN SHOULD BE INFORMED THAT
THEIR CHILDREN SHALL BE EXCLUDED FROM SCHOOL IN THE EVENT OF AN OUTBREAK OR SUSPECTED CASE OF A VACCINE-PREVENTABLE DISEASE.
KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf
BLANK VERSION OF KCI FORM is available at http://www.kdheks.gov/immunize/download/KCI_Form.pdf
Recommendations are based
on the ACIP recommended
schedule.†
The limit for DTaP vaccine is 6 doses, regardless of schedule.
a)
4 week minimum interval between each dose, with 1 dose given on or after the
4th birthday.
a)
The limit for POLIO vaccine is 5 doses, regardless of schedule.
Single antigen measles vaccine will not meet requirements without the addition of
mumps and rubella vaccine.
First dose must be on or after the 1st birthday.
4 week minimum interval between doses.
a)
b)
MMR: 2 doses
a)
b)
c)
First dose must be on or after the 1st birthday.
None required if prior varicella disease verified.
Two doses are recommended for all children.
VARICELLA: 2 doses required for Kindergarten and Grade 1 for 2010-11 school
year; 1 dose required for Grades 2-10 for 2010-11 school year
a)
b)
c)
d)
4 week minimum interval between dose 1 and dose 2.
8 week minimum interval between dose 2 and dose 3.
16 week minimum interval between dose 1 and dose 3.
Dose 3 must be given after 24 wks of age.
HEPATITIS B: 3 doses required through Grade 10 for 2010-11 school year
4 week minimum interval between dose 1 and dose 2.
8 week minimum interval between dose 2 and dose 3.
16 week minimum interval between dose 1 and dose 3.
Dose 3 must be given after 24 wks of age.
a)
b)
c)
d)
HEPATITIS B: 3 doses required through Grade 10 for 2010-11 school year
a)
b)
c)
First dose must be on or after the 1st birthday.
None required if prior varicella disease verified.
Two doses are recommended for all children.
VARICELLA: 1 dose required through Grade 10 for 2010-11 school year
First dose must be on or after the 1st birthday.
4 week minimum interval between doses.
a)
b)
MMR: 2 doses
The limit for POLIO vaccine is 5 doses, regardless of schedule.
4 week minimum interval between each dose, with 1 dose given on or after the
4th birthday.
a)
3 doses of POLIO are acceptable IF:
4 week minimum interval between doses, regardless of age given.a)
4 doses of POLIO are acceptable IF:
POLIO - All IPV or OPV Schedule
Booster dose of Tdap is required at 7th grade if more than 2 yrs since previous dose
of Td. Tdap booster required 10 years after the completion of the primary series or
previous dose. Only one dose of Tdap is needed during adolescence. KCI Form B
Medical Exemption should be completed by a physician if pertussis is contraindicated.
4 week minimum interval between dose 1 and dose 2.
6 month interval between dose 2 and dose 3.
a)
b)
Tdap/Td: 3 doses if DTaP/DT series not completed previously†
One of the doses must be Tdap if student is without a Pertussis
medical exemption.
POLIO - IPV/OPV Combination Schedule
4 doses of POLIO are acceptable IF:
4 week minimum interval between each dose, regardless of age given. Three
doses of a combination schedule are NOT acceptable.
a)
ANDOVER PUBLIC SCHOOLS USD 385
HEALTH EXAMINATION REPORT
Pupil’s Name_____________________________________ SS#__________________ Birth Date_____________ Grade___________
Last First
To Parents: For maximum health your child should have a periodic health
examination. If your child is entering Kindergarten (or is new to Kansas
Schools and is under 9 years of age) please obtain an examination of
your child by your family doctor. Gender: M______F_______
Height_____ Weight_____ BP_____ T_____ P_____ R_____
Central Nervous System________________________________________
Epilepsy?__________ Emotional Disturbance?______________
Cardio-Vascular System________________________________________
Heart Disease?____________________ Limitation?__________
EENT (Eye, Ear, Nose & Throat)_________________________________
Myringotomy?____________________ Glasses?____________
Endocrine System_____________________________________________
Diabetes Mellitus?_____________________________________
Gastrointestinal System________________________________________
Nutritional Status______________________________________
Genitourinary System__________________________________________
Musculo-Skeletal System_______________________________________
Scoliosis?____________________ Arthritis?________________
Respiratory System____________________________________________
Asthma?_____________________ Allergies?_______________
Social Development (family, peer, school if appropriate)______________
Recommendations:____________________________________________
Physician’s Signature__________________________________________
Immunization – Please attach green Kansas
Certificate of Immunization (KCI) with all dates
for DPT, Polio, MMR, Varicella, and Hepatitis B
recorded - with Physician Signature and Date.
Optional other vaccines or tests:____________________
Are routine medications prescribed? Yes No
NOTE: If medication is to be given at school, please
provide written physician/parental request.
Physical Education:
Regular_______________________________________
Limited (explain)_______________________________
None (explain)_________________________________
Date__________________________________________
MAY USE BACK OF CARD FOR ADDITIONAL SPACE