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REGISTERING A TUITION STUDENT In Spackenkill Union Free School District

Welcome To Spackenkill Required Documents for Registering a Student

STEP 1: CALL CENTRAL REGISTRATION AT 845-463-7800 TO SCHEDULE AN APPOINTMENT. Hours are Mondays – Fridays, 9 a.m. to 11 a.m. and from 1:00 to 3:00 p.m.

STEP 2: COMPLETE TUITION REGISTRATION PACKET AVAILABLE ON WEBSITE.If unable to print from website, call 463-7800 and a packet can be mailed to you or you can pick one up.

STEP 3: PROVIDE REQUIRED DOCUMENTATION WITH REGISTRATION PACKET.

Welcome to the Spackenkill Union Free School District. Our school district is comprised of two elementary schools (one K-2, one 3-5), one middle school (6-8) and one high school (9-12) within a compact, six-square-mile area situated in the southern part of the Town of Poughkeepsie. Please visit the following link to learnmore about the Board tuition policy: https://tinyurl.com/SUFSD-tuition-policy.

Parents/guardians wishing to register their child/children in the Spackenkill Union Free School District should begin the process by calling Central Registration at 15 Croft Road (845-463-7800) and schedule anappointment. Hours of operation are Mondays – Fridays from 9:00 a.m. to 11 a.m. and 1:00 p.m. to 3:00 p.m., except school and federal holidays. Your child/children may accompany you, but this is not required.

In order to enroll a tuition student in Spackenkill schools, the school district must receive verification of the child’s date and place of birth, legal custody, appropriate immunizations and academic status. Parents/guardians may verify the information listed above by providing the following documents.

• DRIVER’S LICENSE OR PASSPORT PHOTO OR OTHER PICTURE ID

• AUTHENTIC BIRTH CERTIFICATE for each child being registered. No photo copies accepted. We mustbe able to see the raised seal or a copy that has been certified.

• Children must turn 5 by December 1 of the school year to start kindergarten.

• UP-TO-DATE IMMUNIZATIONS AND PHYSICAL from a physician’s office or Department of Health.There is a 14-day grace period during which the student can obtain the necessary documentation. Thephysical must be performed by a New York State licensed provider.

Spackenkill Tuition Student Registration Packet 1

https://tinyurl.com/SUFSD-tuition-policy

• A copy of the:

□ STUDENT'S TRANSCRIPT,□ MOST RECENT REPORT CARD (if applicable),□ IEP (if applicable),□ MOST RECENT PSYCHOLOGICAL EVALUATION (if applicable),□ MOST RECENT RE-EVALUATION (if applicable), and□ 504 ACCOMMODATION PLAN (if applicable).

• GUARDIANSHIP: If the student does not live with the Parent/Guardian, written proof of guardianship isrequired, such as a court document.

• CUSTODY: In the event of divorced or separated parent/guardians, written proof of custody is required.

____________________________

Parent/Guardian Signature & Date

_________________________

Signature of Witness (SUFSD)

Signature of parent/guardian will confirm that they have read and understand the residency requirements of the Spackenkill

Union Free School District and the consequence they might incur if false information is wrongfully provided.


SPACKENKILL UNION FREE SCHOOL DISTRICT REGISTRATION FORM

□Nassau (K-2) □Hagan (3-5) □ Todd Middle School (6-8) □Spackenkill High School (9-12) check one

CHILD’S NAME: _____________________________________________________ GENDER: ______ GRADE: _____ HS - DATE ENTERED Last Name First Name Middle Name 9TH GRADE ____________

HOME (9/year) STREET: ___________________________________________________________ PHONE: ( ) ________-_______________ □ UNLISTED

NAME OF APT COMPLEX______________________________________________ DATE OF BIRTH: _____________________________________

CITY/ZIP: __________________________________________________________ STATE/COUNTRY OF BIRTH: _______________________

LANGUAGE AT HOME? ___________________________ IS CHILD HOMELESS? _______ YEARS IN U.S. SCHOOLS: _________________________

LAST SCHOOL ATTENDED: ________________________________________________________________________ SCHOOL ADDRESS/PHONE: _______________________________________________________________________ IF NOT SPACKENKILL, PROVIDE DISTRICT OF RESIDENCE ____________________________________

THIS STUDENT HAS BEEN APPROVED FOR TUITION REGISTRATION EFFECTIVE DATE: _______________

By __________________________________________________________________ (Superintendent of Schools)

FAMILY INFORMATION___(Please list the parent/guardian to be contacted first)

Parent/Guardian with whom the child lives: _______________________________________________________________________________ (Full Name)

Relationship to Child: _______________________________________________ Cell Phone: ( ) _____________________ Place of Employment: _______________________________________________ Work Phone: ( ) __________________ EMail:_________________________________________________________________ *can receive correspondence including report cards Yes/No

Parent/Guardian with whom the child lives: _______________________________________________________________________________ (Full Name)


Parent/Guardian Living Outside of the Home _______________________________________________________________________________ (Full Name)


Parent/Guardian Living Outside of the Home _______________________________________________________________________________ (Full Name)


Has your child attended Spackenkill previously? ___ Yes ___ No


EMERGENCY CONTACT INFORMATION -- If parents or guardians above cannot be reached, please contact:

Primary Emergency Contact: ________________________________________ Secondary Emergency Contact: _______________________________

Relationship: __________________________________________________________ Relationship: ___________________________________________________

Address: _______________________________________________________________ Address: _________________________________________________________

Home Phone: ________________________ Cell:___________________________ Home Phone: _________________________ Cell:____________________

Doctor’s Name & Number: __________________________________________________________________________________________________________________

Drug or Insect Allergy: ______________________________________________________________________________________________________________________

Do you own or rent? _______________________ Effective Date: ____________________ Expiration Date: _______________ Live with: ___________________________________________

Are parents now separated? Yes ___ No ___ Divorced? Yes ___ No ___ If yes, who has custody? ______________________________ (Please provide copy of agreement.)

Please list below all children in your family ranging from birth to age 21 years. NOTE: If more space is needed, please attach.

Last Name, First Name Age

Date of Birth

Gender M/F Grade

Of Hispanic

Origin (Y/N)

Race Code(s)

Disability Y/N

Name of School Child will be

attending

CHILD’S NAME:______________________________________________ GRADE: _____________________

1. Has your child ever attended school in other districts? If yes, please list with dates:__________________________ _______________________________________________________________________________________________

2. Is your child presently under suspension from another school district? Yes ___ No ___ Explain:

_______________________________________________________________________________________________

3. Has your child repeated a grade? Yes ___ No ___ Explain: ____________________________________________

4. Is your child receiving special education services (IEP)? Yes ___ No ___ Explain: __________________________

_______________________________________________________________________________________________


5. Does your child have a 504 plan? Yes ___ No ___

6. Has your child ever received remedial math? Yes ___ No ___

7. Has your child ever received remedial reading and/or writing services? Yes ___ No ___

8. Has your child ever received speech or language services? Yes ___ No ___ Explain: ___________________

________________________________________________________________________________________

9. What is your child’s first language? _____________________

10. Is your child an English language learner? Yes ___ No ___ Or fluent in English language? Yes ___ No___

11. Has your child ever received English as a New Language (ENL) services? Yes ___ No ___ Explain: _____

________________________________________________________________________________________

12. Has your child participated in a Gifted and Talented Program? Yes __ No __ If yes, in what district?______

13. Has your child ever had difficulties in school (attendance, behavior, academic, etc.)? If yes, please explain:

________________________________________________________________________________________

14. Is the student listed as a deduction on anyone’s state or federal income tax return? Yes ___ No ___

If so, on whose return? ____________________________________________________________________

15. Is your child covered under any health insurance? Yes ___ No ___

If yes, please indicate the name of the individual(s) that the student is insured under.

Name:_________________________________________ Relationship: ___________________________

Address: _______________________________________________________ Phone: __________________

Name of Insurance Company: ________________________________________________________________

Policy Number: ___________________________________________________________________________

16. Are there circumstances or experiences in your child’s life that may impact your child’s performance in school? Yes

___ No ___ Please explain: ____________________________________________________

________________________________________________________________________________________

17. In an effort to better know your child, please use the area below & back to offer additional information that you

wish to share with us.


STUDENT RACIAL AND ETHNIC IDENTIFICATION: All students between 5 and 21 years of age have the right to a free public education. Children may not be refused admission because of race, color, creed or national origin, sex, citizenship, handicapping condition, or immigration status.

Directions to parent/guardian: Please answer questions (1) and (2). Please read them before you respond. For question

(1) check box that best describes your child. Check only ONE box.

1. Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of

Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture, regardless of race.

Yes, Hispanic □ No, not Hispanic

2. Select one or more races from the following five racial groups (For question (2) check all groups that apply to

your child; check at least one box):

American Indian or Alaska Native: A person having origins in any of the original peoples of North America

and who maintains cultural identification through tribal affiliation of community recognition, e.g.

Cherokee, Mohawk, Inuit.

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.

Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii,

Guam, Samoa, or other Pacific Islands.

Black: A person having origins in any of the black racial groups of Africa.

White: A person having origins in any of the original peoples of Europe, North America, or the Middle East.

A screening of new entrants designed to obtain information regarding your child’s progress in physical development,

cognitive development, receptive and expressive language, articulation skills and motor development will be done in

the spring prior to entry or within 30 days of entrance as required by State Law. You will be notified of the results. A

new entrant shall mean a pupil entering a New York State public school for the first time, or re-entering a New York

State public school with no available record of prior screening.

I hereby attest that all registration information provided to the Spackenkill Union Free School District for the child

named on this form is accurate. I understand that providing any false information will prohibit this child from

attending Spackenkill schools and may result in other penalties.

Signature of Parent/Guardian:____________________________________________ Date: _____________

Notarized Signature

Sworn to before me this ______ Day Of _______________, 20 _____

_________________________________________________ (Notary)


Spackenkill Union Free School District Student Registration

CUSTODIAL AFFIDAVIT Note: This form is to be used only when it applies, e.g. divorce.

______________________________________________ STUDENT’S NAME (Print last name first)

1.______________________________(Name of Custodian), being duly sworn, deposes and says:

2. I live at_________________________________________________________________________.

__________________________________________________________(full name of child) is my

_______________________(child’s relationship to custodian) and he/she has been living with me

since____________________(date).

3. ____________________________(name of child) intends to reside with me for _________________________(length

of time).

4. This arrangement is : ___ Permanent ___ Temporary

If temporary, the arrangement will be terminated on ________________________

Please explain: _______________________________________________________________________

____________________________________________________________________________________

5. Describe the reason(s) and purpose for surrendering the care, custody and control of the child to you.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

__________________________________________________________

6. Former address(es) where child lived:

Street City State Dates With Whom

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_____________________________________________


7. __________________________(name of child) does not live at any other address.

8. Food, clothing, and all other necessities are provided to ________________________ (name of child) by

____________________________

9. Will the child be spending overnight, weekends, holidays or vacation elsewhere? ___ Yes___ No

If so, please explain: _______________________________________________________________

_________________________________________________________________________________

10. Does each parent intend to remain at his/her present address? ___ Yes___ No

Please explain: _______________________________________________________________________

11. Where is each parent registered to vote? Parent_______________ Parent_________________

12. What court orders have been made with respect to the child’s guardianship or custody? (Attach a copy of all such

orders)

_________________________________________________________________________________________________

_____________________________________________________________________________________

13. If the guardian has any other children, supply the following information:

Name Age Address Relationship to Guardian School

____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________________________________________

14. I___________________________________(Name of custodian) assume full responsibility for all matters relating to

________________________(Name of child) education and medical care.

15. Statement of other relevant facts:

____________________________________________________________________________________


QUESTIONS “A” THROUGH “E” MUST BE ANSWERED WHEN APPLICATION FOR ADMISSION IS FILED BY PERSONS OTHER THAN A NATURAL PARENT (GUARDIAN).

A) Why is the child not living with his/her natural or adoptive parents?

_________________________________________________________________________________

_________________________________________________________________________________

B) Does the student live in your home exclusively? _____________________________________

C) How often will the parents see the child? ____________________________________________

D) What percentage of financial support will be made by the natural parents?

_________________________________________________________________________________

E) What percentage of financial support will be made by you?

_________________________________________________________________________________

________________________ ___________________________ Parent’s Signature Custodian’s Signature

______________________ __________________________ Date Date

Sworn to before me this Sworn to before me this

_______day of ______, 20__ _______day of _______, 20__

__________________________ ____________________________ Notary Public Notary Public



Dear Parents/Guardians:

New York State Education Law requires new entrants to a school to have a physical examination by a provider licensed in New York State. A copy of the completed physical along with up-to-date immunizations must be provided to the school health office within 14 days of entrance to school. Dental certificates, if available, may also be provided. The required immunizations for school attendance are:

DTaP/DTP: for Gr. K-5, 5 doses unless 4th dose was given at 4 yrs or older or 3 doses if 7 years or older andseries was started at 1 year or older / for Gr. 4 & 5, 5 doses unless 4th dose was received at 4 yrs or older /Gr 6-12, 3 doses

Tdap: Gr 6-12, 1 dose Polio: for Gr K-3 and 6-9 / 4 doses (3 if 3rd does was given at age 4 or older)/ for Gr 4-5 and 10-12, 3 doses Varicella: Gr. K-3, 6-9, 2 doses; Gr 4-5, Gr. 10-12, 1 dose MMR: 2 doses for all students Hepatitis B: 3 doses for all students (or 2 doses of adult hepatitis B vaccine (Recombivax) received between

ages 11 and 15 at least 4 months apart Meningococcal: by Grade 6, 1 dose / 12th Grade , 2 doses or 1 dose if received at age 16 or older

Please make arrangements for your child to have a physical examination as soon as possible. A copy of a physical exam completed no more than twelve months prior to the commencement of the school year is acceptable. If documentation is not received, the school physician will examine your child.

Please contact the school nurse with any questions: Hagan 463-8398 Nassau 463-6390 Todd 463-6527 High School 463-2043

Very truly yours, Spackenkill School Nurses *******************************************************************************

Student Name_________________________________________ Grade_________

______ My child has been examined by his/her personal physician. Certificate to be provided within 14 days of registration.

______ My child may be examined by the school physician.

Medications___________________________________________________________________□ None

Health conditions_______________________________________________________________□ None

Allergies______________________________________________________________________□ None

Parent signature___________________________________ Date________________

Printed name_____________________________________


HEALTH INFORMATION – NEW REGISTRANTS

Student’s legal name (print)___________________________________________________ ___M ___F

Date of birth______________________ Place of birth:_________________________________________

Legal residence_________________________________________________________________________

Parent/Guardian name________________________________ Employer________________________

Phone (w)____________ (c)_____________ (h)_____________ Custodial parent? ___Yes ___ No

Parent/Guardian name_______________________________ Employer________________________

Phone (w)____________ (c)_____________ (h)_____________ Custodial parent? ___Yes ___ No

Physician’s name________________________________________ Phone____________________

Dentist’s name__________________________________________ Phone_____________________

Allergies_______________________________________________________________________________

Current medications_____________________________________________________________________

Any medications in school?________________________________________________________________

Medical conditions_______________________________________________________________________

Significant medical history:________________________________________________________________

_______________________________________________________________________________________

Does your child wear glasses or contacts? ___Yes ___No If yes, are they needed for near work?

___Yes ___No Distance? ___Yes ___No

Does your child receive any of the following special services? Please circle any that apply.

Resource Room Special Class Counseling Speech OT PT

Academic Intervention for ____________________________________________________


Rev. 5/4/2018 Page 1 of 2

REQUIRED NYS SCHOOL HEALTH EXAMINATION FORM TO BE COMPLETED IN ENTIRETY BY PRIVATE HEALTH CARE PROVIDER OR SCHOOL MEDICAL DIRECTOR

Note: NYSED requires a physical exam for new entrants and students in Grades Pre-K or K, 1, 3, 5, 7, 9 & 11; annually for interscholastic sports; and working papers as needed; or as required by the Committee on Special Education (CSE) or

Committee on Pre-School Special education (CPSE).

STUDENT INFORMATION

Name: Sex: M F DOB:

School: Grade: Exam Date:

HEALTH HISTORY

Allergies ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Anaphylaxis Care Plan Attached

☐ Food ☐ Insects ☐ Latex ☐ Medication ☐ Environmental

Asthma ☐ No

☐ Yes, indicate type

☐ Medication/Treatment Order Attached ☐ Asthma Care Plan Attached

☐ Intermittent ☐ Persistent ☐ Other : ___________________________

Seizures ☐ No ☐ Medication/Treatment Order Attached ☐ Seizure Care Plan Attached

☐ Yes, indicate type ☐ Type: __________________________ Date of last seizure: ______________

Diabetes ☐ No ☐ Medication/Treatment Order Attached ☐ Diabetes Medical Mgmt. Plan Attached

☐ Yes, indicate type ☐Type 1 ☐ Type 2 ☐ HbA1c results: ____________ Date Drawn: _____________Risk Factors for Diabetes or Pre-Diabetes:

Consider screening for T2DM if BMI% > 85% and has 2 or more risk factors: Family Hx T2DM, Ethnicity, Sx Insulin Resistance, Gestational Hx of Mother; and/or pre-diabetes.

Hyperlipidemia: ☐ No ☐ Yes Hypertension: ☐ No ☐ Yes

PHYSICAL EXAMINATION/ASSESSMENT

Height: Weight: BP: Pulse: Respirations:

TESTS Positive Negative Date Other Pertinent Medical Concerns

PPD/ PRN ☐ ☐ One Functioning: ☐ Eye ☐ Kidney ☐ Testicle

Sickle Cell Screen/PRN ☐ ☐ ☐ Concussion – Last Occurrence: __________________________

Lead Level Required Grades Pre- K & K Date ☐ Mental Health: ________________________________

☐ Other: ☐ Test Done ☐ Lead Elevated > 10 µg/dL

☐ System Review and Exam Entirely Normal

Check Any Assessment Boxes Outside Normal Limits And Note Below Under Abnormalities

☐ HEENT ☐ Lymph nodes ☐ Abdomen ☐ Extremities ☐ Speech

☐ Dental ☐ Cardiovascular ☐ Back/Spine ☐ Skin ☐ Social Emotional

☐ Neck ☐ Lungs ☐ Genitourinary ☐ Neurological ☐ Musculoskeletal

☐ Assessment/Abnormalities Noted/Recommendations: Diagnoses/Problems (list) ICD-10 Code

_________________________ _____________

_________________________ _____________

_________________________ _____________

☐ Additional Information Attached _________________________ _____________

Rev. 5/4/2018 Page 2 of 2

Name: DOB:

SCREENINGS

Vision Right Left Referral Notes

Distance Acuity 20/ 20/ ☐ Yes ☐ No

Distance Acuity With Lenses 20/ 20/

Vision – Near Vision 20/ 20/

Vision – Color ☐ Pass ☐ Fail

Hearing Right dB Left dB Referral

Pure Tone Screening ☐ Yes ☐ No

Scoliosis Required for boys grade 9 Negative Positive Referral

And girls grades 5 & 7 ☐ ☐ ☐ Yes ☐ No

Deviation Degree: Trunk Rotation Angle:

Recommendations:

RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS/PLAYGROUND/WORK

☐ Full Activity without restrictions including Physical Education and Athletics.

☐ Restrictions/Adaptations Use the Interscholastic Sports Categories (below) for Restrictions or modifications

☐ No Contact Sports Includes: baseball, basketball, competitive cheerleading, field hockey, football, ice hockey, lacrosse, soccer, softball, volleyball, and wrestling

☐ No Non-Contact Sports Includes: archery, badminton, bowling, cross-country, fencing, golf, gymnastics, rifle, Skiing, swimming and diving, tennis, and track & field

☐ Other Restrictions:

☐ Developmental Stage for Athletic Placement Process ONLY

Grades 7 & 8 to play at high school level OR Grades 9-12 to play middle school level sports

Student is at Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V

☐ Accommodations: Use additional space below to explain

☐ Brace*/Orthotic ☐ Colostomy Appliance* ☐ Hearing Aids

☐ Insulin Pump/Insulin Sensor* ☐ Medical/Prosthetic Device* ☐ Pacemaker/Defibrillator*

☐ Protective Equipment ☐ Sport Safety Goggles ☐ Other: *Check with athletic governing body if prior approval/form completion required for use of device at athletic competitions.

Explain: _____________________________________________________________________________

MEDICATIONS

☐ Order Form for Medication(s) Needed at School attached

List medications taken at home:

IMMUNIZATIONS

☐ Record Attached ☐ Reported in NYSIIS Received Today: ☐ Yes ☐ No

HEALTH CARE PROVIDER

Medical Provider Signature: Date:

Provider Name: (please print) Stamp:

Provider Address:

Phone:

Fax:

Please Return This Form To Your Child’s School When Entirely Completed.


RELEASE OF STUDENT INFORMATION for Spackenkill Union Free School District

I hereby authorize (Name and address __________________________________________________________ of former school)

__________________________________________________________

__________________________________________________________

Phone: Fax:

to release any and all school (including attendance and discipline records) and health records including: psychiatric

evaluations, psychology evaluations, neurological evaluations and any other pertinent information concerning my

child ________________________________________________ .

(please print student name above)

Please send to: __ Hagan Elementary School __ Nassau Elementary School 42 Hagan Drive 7 Nassau Road Poughkeepsie, NY 12603 Poughkeepsie, NY 12601 Phone: (845) 463-7840 Phone: (845) 463-7843 Fax: (845) 463-7881 Fax: (845) 463-7842

__ O.A. Todd Middle School __ Spackenkill High School 11 Croft Road 112 Spackenkill Road Poughkeepsie, NY 12603 Poughkeepsie, NY 12603 Phone: (845) 463-7825 Phone: (845) 463-7822 Fax: (845) 463-7832 Fax: (845) 463-7877

__ Spackenkill District Office 15 Croft Road Poughkeepsie, NY 12603 Phone: (845) 463-7800 Fax: (845) 463-7804

It is understood that the privileged and confidential nature of such records will be preserved.

__________________________________ _________ Parent/Guardian Signature Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -


Release Mail Date __________ Release Fax ___________


1 ENGLISH

Dear Parent or Guardian: In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.

STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12

Lissette Colón-Collins, Assistant CommissionerOffice of Bilingual Education and World Languages

55 Hanson Place, Room 594 89 Washington Avenue, Room 528EB Brooklyn, New York 11217 Albany, New York 12234 Tel: (718) 722-2445 / Fax: (718) 722-2459 (518) 474-8775 / Fax: (518) 474-7948

Home Language Questionnaire (HLQ)

H O M E L A N G U A G E C O D E

Language Background (Please check all that apply.)

1. What language(s) is(are) spoken in the student’s homeor residence?

English Other

specify

2. What was the first language your child learned? English Other

_________________________________________ specify

3. What is the Home Language of each parent/guardian? Mother Fatherspecify specify

Guardian(s)specify

4. What language(s) does your child understand? English Other

specify

5. What language(s) does your child speak? English Other Does not speak

specify

6. What language(s) does your child read? English Other Does not read

specify

7. What language(s) does your child write? English Other Does not write

specify

TTHHIISS SSEECCTTIIOONN TTOO BBEE CCOOMMPPLLEETTEEDD BBYY DDIISSTTRRIICCTT IINN WWHHIICCHH SSTTUUDDEENNTT IISS RREEGGIISSTTEERREEDD::

Please write clearly when completing this section. S T U D E N T N A M E :

First Middle Last

D A T E O F B I R T H : G E N D E R :

Male Female Month Day Year

P A R E N T / P E R S O N I N P A R E N T A L R E L A T I O N I N F O :

Last Name First Name Relation to Student

S C H O O L D I S T R I C T I N F O R M A T I O N : S T U D E N T I D N U M B E R I N N Y S S T U D E N T

I N F O R M A T I O N S Y S T E M :

District Name (Number) & School Address


2 ENGLISH

Home Language Questionnaire (HLQ)—Page Two

Relationship to student: Mother Father Other:

Educational History

8. Indicate the total number of years that your child has been enrolled in school _____________

9. Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write inEnglish or any other language? If yes, please describe them.

Yes* No Not sure *If yes, please explain:____________________________________________________________________________

How severe do you think these difficulties are? Minor Somewhat severe Very severe

10a. Has your child ever been referred for a special education evaluation in the past? No Yes* *Please complete 10b below

10b. *If referred for an evaluation, has your child ever received any special education services in the past? No Yes – Type of services received: .

Age at which services received (Please check all that apply):

Birth to 3 years (Early Intervention) 3 to 5 years (Special Education) 6 years or older (Special Education)

10c. Does your child have an Individualized Education Program (IEP)? No Yes

11. Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)

12. In what language(s) would you like to receive information from the school? _________________________________________________

Month: Day: Year:

Signature of Parent or of Person in Parental Relation Date

OFFICIAL ENTRY ONLY - NAME/POSITION OF PERSONNEL ADMINISTERING HLQ

NAME: POSITION:

IF AN INTERPRETER IS PROVIDED, LIST NAME, POSITION AND CREDENTIALS:

NAME/POSITION OF QUALIFIED PERSONNEL REVIEWING HLQ AND CONDUCTING INDIVIDUAL INTERVIEW

NAME: POSITION:

ORAL INTERVIEW NECESSARY: NO YES

**DATE OF INDIVIDUAL INTERVIEW:

OUTCOME OF

INDIVIDUAL

INTERVIEW:

ADMINISTER NYSITELL

ENGLISH PROFICIENT

REFER TO LANGUAGE PROFICIENCY TEAMMO DAY YR.

NAME/POSITION OF QUALIFIED PERSONNEL ADMINISTERING NYSITELL

NAME: POSITION:

DATE OF NYSITELLADMINISTRATION:

PROFICIENCY LEVEL

ACHIEVED ON

NYSITELL: ENTERING EMERGING TRANSITIONING EXPANDING COMMANDING

MO. DAY YR.

FOR STUDENTS WITH DISABILITIES, LIST ACCOMMODATIONS, IF ANY, ADMINISTERED IN ACCORDANCE WITH IEP PURSUANT TO CSE RECOMMENDATION:


SPACKENKILL UNION FREE SCHOOL DISTRICT ATTENDANCE POLICY 5132

OVERVIEW

It is the goal of the Spackenkill Union Free School District to ensure that each student attend school the maximum number of days possible, and to afford each student the opportunity to meet his/her potential. We, therefore, institute this policy.

PURPOSE

Good attendance and class participation are essential ingredients for academic success. Classroom lessons foster and require social interaction, development of effective communication skills, and critical thinking in addition to subject mastery.

In order to achieve educational goals and to maintain a true academic environment, students must attend their classes.

ATTENDANCE REQUIREMENTS

I. Applicability

All students of compulsory education age who reside legally within the District must attend school. Legal school age and legal residence are determined by the Board of Education in accordance with state requirements as set forth in New York State Education Law §§3202, 3205 to 3208, 3209 to 3210 and 8 NYCRR §100.2.

II. Notification Regarding Attendance Policy

A.) Student Notification

1. School Handbooks shall include the District’s attendance policy and be distributed to all students.

2. If a student misses a class period or school day without an excuse, a designated staff person may reviewattendance requirements with the student and/or parent upon student's return to school.

3. School newsletters and publications may include periodic reminders of attendance requirements.

B.) Parental/Guardian Notification

1. All parents/guardians will be provided with a plain language summary of this policy at the beginning of eachschool year. Parents/guardians can discuss the policy at any time.

2. At registration, the District will provide each new student’s parent or guardian with a copy of the attendancepolicy.

3. If a student misses successive class periods or school days without an excuse, a designated staff person willnotify the parent/guardian regarding the absences.

C.) Faculty/Staff Notification


Each member of the faculty/staff will be given a copy of this policy, including any subsequent amendments. This policy will be distributed to new teachers upon commencement of employment. In addition, the building administrator may meet with faculty at the beginning of the school year to review policy and individual roles in its implementation.

D.) Community Notification

Copies of this policy will also be available to any other member of the community upon request.

III. Guidelines

The District recognizes an important relationship between class participation and class performance. Consequently, each teacher may consider classroom participation as well as the student’s performance in homework, tests, papers and projects, etc. When a student is absent, with or without an excuse, he/she misses the opportunity for class participation. Any absence from a class, that is not made up, may result in a loss of points from the student’s class participation grade.

A.) Absences

1. Absences counted under the attendance/grading policy include:

a. All absences (whether excused or unexcused) not excluded below;

2. The following should NOT be counted as absences under the attendance policy:

a. In-School Suspension (“ISS”);b. Any period of OSS where student accepts alternative instruction;c. Attendance at a special education program or service offered by a public school or an approvedprivate school or facility when a student is homeless, disabled or incarcerated. (See §175.6 of theregulations of the NYS Commissioner of Education.)

B.) Makeup Policy

1. When a student misses a class or school day, he/she is expected upon his/her return to provide awritten explanation from his/her parent or guardian. Moreover, the student and/or parent must consultwith his/her teachers regarding missed work. If the absence is excused, the student may make up anywork missed by arranging an assignment with the teacher.

2. Make-up assignments must be completed by the date specified by the student’s teacher for theparticular class. Upon satisfactory and timely completion of the make-up assignment, any earnedpoints will be included when calculating the student’s final grade.

3. Reasonable make-up opportunities will be given to students with excused absences due to:

a) personal illness;b) illness or death in the family;c) disability;


d) impassable roads or weather;e) religious observance;f) quarantine;g) required court appearances;h) attendance at health clinics;i) approved college visits;j) approved cooperative work programs;k) military obligations; orl) such other reasons as may be approved by the Commissioner of Education.

4. Students who are unable to attend class period/day due to their participation in a school-sponsoredactivity (e.g., field trip, music lessons, etc.) and who arrange with their teachers to make-up missedwork, shall be given credit for class participation the class day/period missed.

C.) Consequences for Exceeding Absences Without Making Up Classwork

1. If a student loses credit in a course, he/she may request a meeting with his/her guidance counselor todiscuss all remaining options.

D.) Summer School Courses

Students may complete a course in summer school only if they have attended the regular school-year course for all quarters of the course.

IV. Attendance Taking Procedures [Effective July 1, 2003]

A.) Kindergarten – Grade 5

Attendance shall be recorded after being taken once per school day.

B.) Grades 6-12

Attendance shall be recorded during each class period of scheduled instruction [including instructional or supervised study activities.]

V. Maintenance of the Attendance Register

A.) For each student, the register of attendance must include:

1. Name;2. Date of birth;3. Date of enrollment;4. Parent/Guardian’s full name;5. Address where student resides;6. Phone number(s) where Parent/Guardian may be contacted;7. ALL absences, tardiness or early departures during any school day, in whole or in part, excused orunexcused;


8. Appropriate coding to identify the nature of the absence (full day, class cut);9. Dates of school closings for all or part of the day of schedule instruction due to extraordinarycircumstances, including: adverse weather conditions, heating problems, lack of water or fuel ordestruction or damage to a school building; and10. Date a student withdraws from, or is dropped from enrollment.

B.) A teacher or district employee designated by the Board of Education will make entries on the Attendance Register. All entries must be verified by the oath or affirmation of the person taking attendance.

C.) When additional information is received from a student during a student/staff conference that requires corrections to be made to a student’s attendance records, such corrections will be made immediately. Notice of the change will be sent to appropriate school personnel (e.g., homeroom teachers, attendance officer, etc.)

VI. Attendance Incentives

The District will design and implement incentives to acknowledge students’ efforts to maintain or improve school attendance.

VII. Incremental Interventions

The District will design and implement a system of specific incremental intervention strategies to identify and alleviate attendance problems in their early stages.

Any discipline imposed as a result of unexcused absences, shall be consistent with the District-wide Code of Conduct.

VIII. Appeals

A.) All appeals will be made directly to the principal or other designated administrator who will make the final decision regarding grading impacted by attendance.

B.) Appeals may be made to challenge the number of absences on record.

C.) If parent is successful on appeal, the Attendance Register will be changed to reflect outcome of Appeal process.

IX. Returns to District

Students, who leave the District and subsequently return, must still honor the attendance policy. All previous class absences will still count for that academic year.

RESPONSIBILITIES

Successful implementation of any attendance policy requires cooperation among all members of the educational


community including parents, students, teachers, administration and support staff.

I. Students’ Responsibilities

A.) Students must attend school daily and on time.

B.) Students must attend all classes.

II. Teachers’ Responsibilities

A.) Provide make-up assignments when requested by a student with an excused absence.

B.) Notify Parent/Guardian of attendance problems via comments on progress reports and on report cards.

C.) Forward to Administration any required paperwork or notice indicating student absences.

III. Administration’s Responsibilities

A.) When a student cuts class or is otherwise absent without excuse, designated staff member(s) will notify the student’s parent(s)/guardian(s) and review the attendance policy.

B.) Notify the student and parent/guardian when the teacher of the course has provided notice of unexcused absence(s). Hold at least one meeting to explain the attendance policy to the student.

C.) Notify the student and parent/guardian when the student has exceeded a certain number of absences without making up course work.

D.) Review of Attendance Records

1. Each building must have a person(s) who is designated to review attendance records and initiateappropriate action to address unexcused absences, tardiness and early departures.

2. Attendance records must be reviewed by the designated attendance officer and principal to addressunexcused absences, tardiness and early departures.

IV. Guidance Counselors’ Responsibilities

A.) Counsel students individually when they first receive a notification of excessive absences in any subject area. One meeting with the counselor will be sufficient for all subject areas.


KINDERGARTEN ONLY Screening Inventory/Home Survey Spackenkill Union Free School District

Date: __________________ Child’s Name: ________________________________________ DOB: __________________

Child’s Address: ____________________________________________________________________

School: ___________________________________________________________________________

Person Completing Form: ___________________________________________________________

In order to help us better understand your child and meet his/her educational needs, please take a few minutes to answer the following questions:

Family History: (See Spackenkill Registration Form for further detail)

Parent’s Name _______________________________________ Age _________________

Parent’s Name: _______________________________________ Age ________________

Sibling’s Names: ______________________________________ Age ________________

______________________________________ Age ________________

______________________________________ Age ________________

Parents’ Marital Status: Married _______ Divorced _______ Separated ______

With whom does the child reside? ________________________________________

What language is spoken at home? ________________________________________

Does anyone in the family have a history of learning difficulties? _______________________________________________ ______________________________________________________________________________________________________

Medical History Was the pregnancy full term? _____________________________ If not, please explain. ___________________________________________________________________________________ ______________________________________________________________________________________________________ Were there any complications during pregnancy? ____________________________________________________________ If yes, please explain. ___________________________________________________________________________________ ________________________________________________________________________Baby’s birth weight? ____________ Was oxygen required for the baby? ___________________________ Did the baby cry immediately? ______________________________ Did the baby stay longer in the hospital than the mother? _______________________ If yes, please explain: ____________________________________________________________________________________ During the hospital stay did the baby have yellow jaundice, rash, blue spells? _____________________________________ If yes, please explain: ____________________________________________________________________________________


Child’s Health Has your child ever been hospitalized? _______________________________________ If yes, please explain: ____________________________________________________________________________________ ______________________________________________________________________________________________________ Has your child had surgery _________________________________________________ If yes, please explain: ____________________________________________________________________________________ Does your child have any allergies? __________________________________________ If yes, please explain: ____________________________________________________________________________________ Has your child ever had trouble seeing? _______________ Hearing? ______________ If yes, please explain:___________________________________________________________________________________ Has your child had frequent ear infections? ____________________________________ If yes, please explain: ___________________________________________________________________________________ Has your child ever had any seizures, fainting or black outs? ______________________ If yes, please explain: _____________________________________________________ Does your child have any current medical problems or is he/she on any medications? _____ If yes, please explain: ___________________________________________________________________________________ ______________________________________________________________________________________________________

Development When did your child sleep through the night? __________________________________ When did your child sit up? ________ Crawl? _________ Walk? _____ When did your child say his/her first words? _____________ Speak in sentences? _____ Does your child have any difficulty speaking? __________________________________ If yes, please explain: _____________________________________________________ Can strangers understand his speech? _________________________________________ When was your child completely toilet trained? _________________________________ Does your child eat with or without assistance? _________________________________ Does your child dress himself with or without assistance? ________________________ Can he/she button? _____________ Zip? __________________ Does your child have any difficulty sleeping? ________________ Eating? ___________ Can your child separate easily from you? ______________________________________ Does your child cry easily? _________________________________________________ How would you describe your child: Highly active? ____ Average?___ Very Quiet?____

SCHOOL HISTORY

Has your child attended nursery school or preschool? ______ If yes, where _________________________________________________ How long: ___________________________________________________

Has your child received any special services ( e.g., speech, occupational or physical therapy) or been identified as a Preschool Child with a disability? __________________ If yes, please explain: _____________________________________________________ ________________________________________________________________________ Does your child show a preference for the right or left hand? ______________________ Does your child have proper pencil grasp? _____________________________________ Can he/she ride a bicycle? ___________ Throw and catch a ball? _______________ Does your child get along well with other children? _____________________________ How do you discipline your child? What do you think works best and how does he/she respond to discipline? _____________________________________________________________________________________________________ Does your child like books? ___________ Puzzles? __________


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