TILLAMOOK School District #9 Teacher: Grade:

HEALTH QUESTIONAIRE

STUDENT’S NAME: _________________________________ BIRTHDATE: ______________ COUNTRY OF BIRTH: ______________ STUDENT’S ADDRESS: __________________________________ PHONE: _____________________ CELL: _____________________

MY CHILD HAS A MEDICAL CONDITION WHICH MAY REQUIRE ATTENTION AT SCHOOL (MEDIC ALERT)

DOES YOUR CHILD HAVE ANY OF THE FOLLOWING? CIRCLE ONE

Hearing Problem NO YES

Speech Problem NO YES

Vision Problem NO YES

Has your child been prescribed Glasses or contact lens? NO YES

Allergies Environmental (dust, etc.) Insect Allergy NO YES

Food Allergy Medicine Allergy

Severe allergic reaction, that a doctor/nurse practitioner NO YES

has prescribed an Epipen or Epipen Jr?

Diabetes (if yes, please circle) Type 1 Type 2 Other NO YES

Digestive Problems (Ulcer, Colitis, Vomiting, etc.) NO YES

Heart Condition NO YES

If yes, what is the medical diagnosis?

Asthma or Other type of breathing problem NO YES

Epilepsy or Seizure Disorder NO YES

If yes, what kind of seizures?

Cancer – has your child ever been diagnosed with cancer? NO YES

If yes, what type of cancer? Is your child still being treated for cancer? YES NO

Headaches which are frequent or severe? NO YES

If yes, what helps your child when a headache occurs?

Has your child had one or more previous head injuries or concussions? NO YES

If yes, when did this occur?

Blood Disorder (Anemia, Hemophilia, Bleeding Disorder) NO YES

Cerebral Palsy NO YES

Orthopedic (Bone) Problem NO YES

Bowel or Bladder Problem NO YES

Kidney Problem NO YES

Skin Problem (eczema, hives, etc.) NO YES

If yes what type of skin problem?

Special Diet NO YES

If yes, type of diet: _____________________ Only students with the appropriate medical documentation on file at

school can have food substitutions in the school breakfast/lunch program.

Learning Difficulties NO YES

If yes, please describe:

Attention Deficit Disorder or ADHD NO YES

Does your child have any other health concerns not listed above? NO YES

If yes, please describe:

**A medication form must be filled out for all medication taken during school.

**To protect your child, this information will be shared with school staff working with your child.

If you would like to speak to the health nurse regarding any special health needs your child may have, please leave

a message at the school office or call the Tillamook Health Department at 503-842-3900.

Parent/Guardian Signature Date:

NO MEDICAL CONCERNS

TILLAMOOK SCHOOL DISTRICT #9

PERMISSION TO RELEASE RECORDS

TO: (Student’s former school/agency)

(Address of former school/agency)

Phone: ____________________ Fax: _____________________

(Student Name) (Date of Birth) (Grade)

(Student Name) (Date of Birth) (Grade)

(Student Name) (Date of Birth) (Grade)

has entered Tillamook School District. I am requesting all records for the above named student(s) which

include:

Student Education Records which include full legal name of student, birth date and place of birth, name of parents/guardians,

date of entry, name of previous school, subject taken, marks received, credits earned, attendance, date of withdrawal, social

security number (if provided), tests related specifically to achievement or measurement of ability.

Health Records which include immunization records, sports physical examinations, health screening records, medication

administration records, and other related documents.

Behavioral Records which include psychological tests, personality evaluations, records of observations and any written

transcript of incident(s) relating specifically to student behavior. TAG identification and records. This should include information

relating to youth’s history of engaging in activity that is likely to place school staff or other student safety at risk, or that requires

appropriate counseling or education.

Special Education Records including, but not limited to, records of eligibility, correspondence with parent/guardian, and all

previous and current IEP’s.

Portfolio

OTHER (specify)

Signature Date

Parent or School Registrar

PLEASE SEND ALL RECORDS TO:

Liberty School South Prairie School East Elementary School

1700 Ninth St 6855 South Prairie Rd 3905 Alder Lane

Tillamook, OR 97141 Tillamook, OR 97141 Tillamook, OR 97141

Ph# (503) 842-7501 Ph# (503) 842-8401 Ph# (503) 842-7544

Fax# (503) 842-1314 Fax# (503) 842-1452 Fax# (503) 842-1246

**Office Use Only: Withdraw Date: ______________ Enrollment Date: ___________________

Subject to ORS 330.260, a district receiving this request shall transfer all education records no later than 10 days after receipt of request. Should

any of the requested records be on file in other departments, please forward this request to the appropriate office. If no records are on file, please

contact the school requesting the records.

Office Use Only:

Date Faxed: ___________________

Second Request: _______________

Student Name:

Current School: Current Grade:

YES NO

Parent Signature: Date:

An awareness of any special services is important in order to plan the most appropriate educational program for a child.

Has your child ever received or participated in the following services?

1. Special Education

a. Currently on an IEP?

i. Speech

ii. Academics (please specify, math/read/write/etc.)

3. Talented and Gifted (TAG)

iii. Other (e.g. vision, hearing)

b. Currently in testing or evaluation process?

c. Previously on an IEP or evaluated?

6. Medication If yes, what type:

4. Extra Academic Assistance If yes, what kind:

If yes, what specific services:

If yes, what special services:

7. Special health issues or concerns If yes, list:

5. Counseling If yes, what issue:

8. Does your child need any special services at this time?

(e.g. Title I, ELL)

9. Has your child received any special services in the past

two years? (Title I, ELL)

10. Would you like one of our administrators to contact you

at this time to discuss any issues or concerns?

Contact number:

2. 504 Plan

Tillamook School District # 9

Confidential Prior Services

~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~

TILLAMOOK SCHOOL DISTRICT NO. 9 2510 – 1st Street

Tillamook, Oregon 97141

By law, if parents are legally separated or divorced, each parent has

equal rights to the custody of the child/children UNLESS a parent has

a court order that indicates which parent has custody of the

child/children.

The school MUST HAVE A COPY OF THE COURT ORDER on file,

otherwise, either parent may check the child out of the school with

proper identification.

If a parent comes in with a court order stating current custody over

the enrolling parent, they may take the child/children after

documents are verified, as needed, and after every effort has been

made to reach the enrolling parent by phone.

I have read the above statement of the law.

Student’s Name Grade

Signature of Parent/Guardian Date

PARENT CUSTODY NOTIFICATION

~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~

TILLAMOOK SCHOOL DISTRICT NO. 9 2510 – 1st Street

Tillamook, Oregon 97141

Randy Schild, Superintendent 503/842-2558 • FAX 503/842-6854

schildr@tillamook.k12.or.us

IMPORTANT – “Recent Arrivers” Information

What – Beginning in 2012, the Oregon Department of Education requires that we collect information

to determine the number of “Recent Arrivers” in our school district.

Why – Title III is a Federal grant that provides funding for language instruction for Limited English

Proficient and Immigrant Students. Title III will use information about “Recent Arrivers” to help in distributing these funds. Therefore, the Oregon Department of Education is required to provide information about “Recent Arrivers” to the US Department of Education every year.

Who – All new to TSD9 students/families must respond to this questionnaire.

Any student born outside of the US or Puerto Rico, including foreign exchange students and

students born abroad to military members, must be included in the “Recent Arriver” count, if they meet all three criteria.

The Questions Student first and last name: __________________________________________________ Student school : ___________________________________________________________

1. Is the student 3 to 21 years of age? _____Yes _____No

Student date of birth: _________________________________________________

2. Was the student born outside of the United States or Puerto Rico? _____Yes _____No

(This includes foreign exchange students and students born abroad to military members.)

3. Has the student attended school in the United States for less than a total of three full school

years? _____Yes _____No

Date the student first attended school in the United States _____________________________

Has the student left US schools at any time since that date? _____Yes _____No

If Yes, please give dates that student was not in US schools. ___________________________

____________________________________________________________________________

Parent signature _________________________________ Date: ________________________

TILLAMOOK SCHOOL DISTRICT 9

Student Residency Questionnaire

Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, and/or Federal McKinney-Vento Education Act.

Eligibility can be determined by completing this questionnaire.

1. Are you and/or your family in any of the following situations? Check if true

A. Student staying with friends or couch surfing and not living with parent/guardian

B. Staying in a shelter or transitional housing

C. Sharing housing with others due to loss of housing, money difficulties or similar reason

D. Living in a car, park, campground, RV, public space, abandoned building, or housing not appropriate for your family

E. Temporarily living in a motel or hotel

2. Have you moved across school districts in the past 3 years to seek or obtain temporary or seasonal work

in any type of fishing, agriculture, forestry or dairy?

Yes

STOP

If you did not check any boxes, stop and do not continue. Turn the form in with the rest of your registration packet. If you did check any of the boxes in section 1 or 2 above, please continue filling out the form.

3. Student Name

First Middle Last

M/F

D.O.B.

Grade

School Name

4. Are there other children in the home?

(Check one) ____Yes ____ No How many?_________

Print Parent/Guardian Name Signature Date

____________________________________________ Phone number where you can be reached

Please submit this form with your registration packet.

************************************************************************************************************************************ For District Use Only: If parent has checked boxes in #1 or #2, make copy for school counselor.

Return original form to the District Office, Office of Student Success.

Transportation/Emergency Form 2015-2016 - Liberty and South Prairie

Tillamook School District #9(All information is strictly confidential)

Circle Grade (School) : K 1 (Liberty) 2 3 (South Prairie)

Father/Guardian's Name:

Father's/Gaurdian's Cell:

Father's/Guardian's Work Phone:

Monday [ ] Pick Up Name & Address:

[ ] Bus Rt # ______

Tuesday [ ] Pick Up Name & Address:

[ ] Bus Rt # ______

Wednesday [ ] Pick Up Name & Address:

[ ] Bus Rt # ______

Thursday [ ] Pick Up Name & Address:

[ ] Bus Rt # ______

Friday [ ] Pick Up Name & Address:

[ ] Bus Rt # ______

Bus Rt # Name Address

Phone

Parent/Guardian's Signature Date

Mother's/Guardian's Cell:

Mother's/Guardians Work Phone:

Emergency

or Early

Release

Teacher:

Student's Name:

Regular Transportation Schedule

ONLY AUTOMATED CALLS FROM THE DISTRICT WILL BE MADE.

IF YOUR CHILD IS NOT PICKED UP 10 MINUTES PRIOR TO THE BUSSES LOADING,

THEY WILL BE TRANSPORTED TO THE ADDRESS GIVEN BELOW.

EMERGENCY RELEASE

Home Phone:Home Street Address:

Mother/Guardian's Name:

Student Name: _____________________________ Teacher: _____________________________

TILLAMOOK SCHOOL DISTRICT #9

Field Trip Permission Slip

2015-2016

Dear Parent,

This permission slip will allow your child to attend local activities without

having to get a new permission slip signed by you each and every time.

You will be notified of all off campus activities via the school newsletter

and/or teacher information flyers. Any out-of-town field trips will require a

specific permission slip to be signed by you prior to your child attending.

Local field trips include but are not limited to such activities as:

Performances at the High School

Bowling

Farm Festival

Field Trips to local businesses

Activities at other schools

Library

______________________________________________________

Parent Name (Please Print)

_____________________________________ ____________

Parent Signature Date

□ Liberty

□ SPrairie

□ East

King Fluoride Tablet Program

2015-2016

The King Fluoride Program is given in your child’s school through the Oral Health Section of the

Department of Human Services, Office of Family Health. The program has two ways for the

teachers/nurses to give fluoride. The American Dental Association and The American Academy

of Pediatrics recommend both programs. The programs are for areas that do not have the right

amount of fluoride in their drinking water to help fight cavities. The programs are the Daily

Tablet Program and the Weekly Rinse Program. Both programs can help fight cavities.

Your teacher/nurse has chosen to use the Daily Tablet Program. Every school day, school

children who take part in the Daily Tablet Program will be given a fluoride tablet. Each child

chews this tablet for 30 seconds, swishes the mixture for 30 seconds, and then swallows.

If your child is already taking daily fluoride tablets or home fluoride given by your dentist, do not

enroll them in this program. Home use is a better way to take fluoride because your child can

take it on weekends, holidays and vacations. Tablets should be taken every day. If your child is

not taking fluoride tablets at home, the school program is a good way to get started.

Do not enroll your child in the Tablet Program if the drinking water source for your home has

fluoride in it. You can find this out by calling the number on your water bill. If your drinking water

comes from a private well, you can have your well water tested for fluoride.

There is no cost for this voluntary program. Your child must be at least 3 years old and must

return this signed permission slip.

For any questions please contact: Laurie Johnson, Prevention Specialist at 971-673-0339.

King Fluoride Tablet Program Permission Slip

Child’s Name _____________________________________________________(Please print)

Teacher’s Name __________________________________________room _____ Grade ___

Yes. My child is age three or older and I want my child to take part in the daily Fluoride

Tablet Program.

No. I do not want my child to take part in the Fluoride Tablet Program.

___________________________________________ ___________________

Parent/Guardian Signature Date

Tillamook School District 2015-2016

Title 1 Rights/Responsibilities 2015

Student Name: ___________________

Teacher: ________________________

My child is a student at Tillamook School District. I understand that Tillamook School District

has a Title I schoolwide program. Title I is a federally funded program and its purpose is to help

disadvantaged students meet the same high standards expected of all children.

As a parent of a student in a Title I schoolwide program, I have the following rights and

responsibilities:

1. I can ask questions of the classroom teacher, Title I staff, school principal and the district

Title I coordinator regarding my child’s academic progress and the academic program at

East.

2. I can participate in the review of policies and programs.

3. I can ask for information regarding what services my child is receiving, who is providing

those services and what qualifications this person holds (professional licenses, degrees,

state qualifications).

4. Parenting resources are available for me to check out at the Tillamook School District

library.

5. I am responsible for fulfilling my duties as a parent as outlined in the Tillamook School

District partnership agreement.

I also acknowledge receipt of the following materials which more specifically explain the Title I

program at Tillamook School District and my rights and responsibilities:

1. Tillamook School District Partnership Agreement for 2015-2016

2. Title I Brochure

3. Parent Handbook

Parent signature ____________________________________________

Date ________________________________________

□ Liberty

□ SPrairie

□ East

Title 1 Compact Form.2015

□ Liberty

□ SPrairie

□ East Tillamook School District Partnership Agreement 2015-2016

Tillamook School District 9 is committed to setting High Academic Standards and teaching students to be Safe, Healthy, Responsible Citizens who Respect Diversity and become Life Long Learners. As a Teacher I will do my personal best to:

Provide a safe, positive, and respectful learning environment. Promote life long learning and Life Skills. Consistently enforce classroom and school rules. Strive to meet student’s individual needs. Collaborate with students, staff and families.

Signature_________________________________________ Date___________________ As a Student I will do my personal best to:

Respect others. Follow classroom, school and bus rules. Complete and turn in assignments including homework. Practice Life Skills. Listen and follow directions.

Signature________________________________________ Date____________________ As a Parent I will do my personal best to:

Provide my child with nutritious food and plenty of rest. Ensure regular attendance. Supervise completion of homework. Provide time for my child to read or to be read to each day. Support school by being involved and informed of activities, assignments and policies.

Signature________________________________________ Date___________________

As a Principal I will do my personal best to:

Provide a safe and enriched learning environment Promote communication and collaborate between students, staff and families Provide leadership that will address staff, students and families’ needs and concerns. Promote life long learning and Life Skills.

Signature________________________________________ Date___________________