UPPER MERION AREA SCHOOL DISTRICT...REVISED 1/2020 6 FORM #12151 UPPER MERION AREA SCHOOL DISTRICT...

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UPPER MERION AREA SCHOOL DISTRICT STUDENT SERVICES DEPARTMENT 450 Keebler Road, King of Prussia, PA 19406

STUDENT REGISTRATION INFORMATION

The Upper Merion Area School District requires children entering Kindergarten to be five (5) years of age before September 1st and children entering 1st Grade to be six (6) years of age before September 1st.

REQUIRED INFORMATION TO COMPLETE A STUDENT REGISTRATION (ITEMS 1-7):

1. PROOF OF STUDENT’S AGE (one of the following)a. State Certified Birth Certificateb. Certified Baptismal Certificatec. Duly-Attested Transcript of Birth Certificate

2. STUDENT’S IMMUNIZATION RECORDS - Written and signed documentation from ahospital, clinic or physician must verify that the child has received or is in the process of receivingimmunizations for:

a. Diphtheria and tetanus - 4 or more properly spaced doses of DTP, Dtap, Td, or DT, or anycombination of the three with one dose administered on or after the fourth birthday

b. Polio - 3 or more properly spaced doses of polio vaccine (IPV or OPV) one dose administeredon or after the fourth birthday

c. Measles (Rubeola), German Measles (Rubella), and Mumps – one dose of each, preferablygiven as MMR, on or after the first birthday

d. Measles (Rubeola) – a second properly spaced dose, preferably given as MMRe. Hepatitis B - 3 properly spaced doses of Hepatitis B vaccinef. 2 doses of Varivax vaccine or history of diseaseg. One dose of tetanus, diphtheria, acellular pertussis (Tdap) (if 5 years has elapsed since last

tetanus immunization) (7th grade only)h. One dose of meningococcal conjugate vaccine (MCV) (7th grade only)

Please note: Once immunizations are reviewed by the Certified School Nurse, parents will be notified if immunizations are not complete. The student cannot attend school unless immunization requirements are met.

A Physical Examination is required for students upon entry into school. Any exam performed one year prior to the start of school is acceptable for the following school year. If your child has received this exam please bring documentation with you at the time of registration. If not, this requirement must be completed and returned to the school nurse by August 15th.

A Dental Examination is required upon original entry into school (kindergarten or first grade), in third grade and in seventh grade. A dental examination performed within the year prior to your child entering the required grade will be accepted.

During registration you will be given a tuberculosis assessment and health history form to complete. This will be reviewed by the school nurse. Parents will then be notified (by the school nurse) if the student will require tuberculin skin testing for entry into school.

3. PARENT/GUARDIAN IDENTIFICATION (one of the following)a. Valid PA driver’s licenseb. Valid temporary PA driver’s licensec. Valid Out-of-state driver’s licensed. Other type of photo identification

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4. PROOF OF RESIDENCY (one of the following)a. Homeowner’s (one of the following)

i. Tax Billii. Settlement Papersiii. Mortgage Bill/Statement

b. Lease (the parent/guardian has a lease in their name)i. Notarized Lessee Affidavit.

ii. Copy of your current dated Lease (or) a letter from your landlord listing all theindividuals who reside at your address, the expiration date of your lease agreementand the landlords contact information.

iii. Copy of the Parent(s) Driver’s License.c. Multiple Occupancy (the parent/guardian and student lives with a friend or family member)

i. Notarized Multiple Occupancy Affidavit.ii. Copy of the homeowner’s deed, tax bill, property settlement papers, current dated

Lease (or) a letter from the landlord listing all the individuals who reside at youraddress, the expiration date of your lease agreement and the landlord’s contactinformation.

iii. Copy of the Parent(s) Driver’s License.iv. Copy of the homeowner or lessee holders Driver’s License.

d. Guardianship (the parent(s) listed on the student’s birth certificate have given up parentalrights on a permanent basis)

i. Notarized Guardianship Affidavit.ii. Release of Claim to Exemption of Childiii. Copy of the guardian’s deed, tax bill, property settlement papers, current dated

Lease (or) a letter from the landlord stating the individuals who reside at youraddress, the expiration date of your lease agreement and the landlord’s contactinformation.

iv. Copy of the Parent(s) Driver’s License.v. Copy of the Guardian’s Driver’s License.

5. SCHOOL RECORDS (one of the following if transferring from a private or other public school)a. School Transfer/Withdrawal Formb. Report cardc. Transcriptd. Individual Education Plan (IEP) (must provide if the student has one)

6. CUSTODY ARRANGEMENT (for divorced, separated or single parents)If a written custody agreement exists, a copy should be filed with the school district. Furthermore,if there is a change in status regarding the custodianship/guardianship of the student, it is theresponsibility of the parents/guardians to notify the school district of any special accommodationsto be made concerning emergency contact and the report of pertinent academic information. Pleasenote that if no legal custody agreement is in place, then a written letter from the non-registeringparent will be accepted.

7. STUDENT REGISTRATION DATA FORMSDistrict Forms that can be obtained on the school district website at www.umasd.org or at any ofour school locations.

ALL INFORMATION LISTED ABOVE IS REQUIRED TO COMPLETE A STUDENT REGISTRATION!

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HELPFUL RESOURCES IMMUNIZATIONS MAY BE COMPLETED BY YOUR FAMILY PHYSICIAN OR BY VISITING ANY OF THE FOLLOWING… Montgomery County Health Department 55 East Marshall Street Norristown, PA 19401 (610) 278-5145

Walgreens Pharmacy Health Care Clinic 699 West Germantown Pike Norristown, PA 19403 (610) 630-5819

CVS Pharmacy Minute Clinic 3125 Henderson Road King of Prussia, PA 19406 (610) 205-1264

Norristown Regional Health Center (Sliding fee scale available) 1401 DeKalb Street Norristown, PA 19401 (610) 278-7787

TO OBTAIN A BIRTH CERTIFICATE FOR CHILDREN BORN IN PENNSYLVANIA… Bureau of Vital Statistics PA Department of Health P.O. Box 1528 New Castle, PA 16103 (412) 656-3100http://www.health.pa.gov/MyRecords/Certificates/

TO OBTAIN NOTARY SERVICES…CALL BEFORE ARRIVAL Rep. Tim Briggs 149th Legislative District Montgomery County 554 Shoemaker Road, Suite 149 King of Prussia, PA 19406 (610) 768-3135(610) 768-3112

UPPER MERION AREA SCHOOLS… Upper Merion Area High School – (grades 9-12) –610-205-3800 Upper Merion Area Middle School – (grades 5-8) – 610-205-8800 Bridgeport Elementary – (grades PK-4) – 610-205-3600 Caley Elementary – (grades K-4) – 610-205-3650 Candlebrook Elementary – (grades K-4) – 610-205-3700 Gulph Elementary – (grades K-4) – 610-592-2020 Roberts Elementary – (grades K-4) – (610) 205-3750

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P T C

Your child’s Parent Teacher Committee (PTC) would like to include you and your child in all forms of their communications. If you would like to be contacted by a PTC representative, please complete this form and submit it at the time of a new student registration or to your child’s building secretary in an envelope marked “PTC”.

Student’s Full Name ___________________________________________________________________

School ______________________________________________________________________________

Grade ______________________________

Parent(s) and/or Guardian Name _________________________________________________________

Address _____________________________________________________________________________

City____________________________________________ State _____________ Zip Code __________

Home Phone Number _______________________Cell Phone Number ____________________________

Parent Email Address ___________________________________________________________________

Parent/Guardian Signature: _____________________________________________ Date: ___________

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HEALTH EXAMINATIONS / SCREENINGS SCHOOL HEALTH SERVICES

The School Health Act of the Commonwealth of Pennsylvania mandates that all children have a health examination upon entry to a Pennsylvania School as well as in grades six (6) and eleven (11).

Parent(s) and/or Guardian are encouraged to use their family physician for these examinations to provide continuity of care for the student. Family doctors are better able to detect physical changes, begin treatment if indicated, follow through with needed care and give immunization boosters. A physical performed within one year prior to September of the school year in which the physical is required is acceptable.

The regional Health Center in Norristown, 610-278-7787 also provides primary care and immunization services with a sliding fee-scale for people without health insurance or without a family physician.

Private Physical Examination forms and Immunizations should be submitted at the time of a new student registration or to your child’s School Health Suite by August 15th.

Bridgeport Elementary Health Suite - Fax: 610-205-3947 900 Bush Street, Bridgeport, PA 19405

Caley Elementary Health Suite - Fax: 610-205-3790 725 Caley Road, King of Prussia, PA 19406

Candlebrook Elementary Health Suite - Fax: 610-205-3798 310 Prince Frederick Street, King of Prussia, PA 19406

Gulph Elementary Health Suite - Fax: 610-205-2099 650 S Henderson Road, King of Prussia, PA 19406

Roberts Elementary Health Suite - Fax: 610-205-3799 889 Croton Road, King of Prussia, PA 19406

Upper Merion Area Middle School Health Suite - Fax: 610-205-8849 450 Keebler Road, King of Prussia, PA 19406

Upper Merion Area High School Health Suite - Fax: 610-205-3994 440 Crossfield Road, King of Prussia, PA 19406

Any questions can be directed to your child’s school nurse.

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ORAL HEALTH EXAMINATION

The Commonwealth of PA requires dental examinations for all students in Kindergarten, 3rd grade, 7th grade and any student that is newly enrolled.

If your child HAS been evaluated at a dental office within the past year, after September 1st, kindly ask the dentist to complete the enclosed PA Dentist Examination of Pupil form and return to your child’s school health suite by August 15th. This form is also available on the district website.

If your child HAS NOT been evaluated in a dental office within the past year, you will be required, at your own expense, to obtain a report from a licensed dentist. The report of examination is due by November 1st or 60 days after enrolling in the school district. If a PA Dentist Examination of Pupil report is NOT submitted to your child’s school health suite by November 1st, a dental screening will be performed by a licensed, certified school dental hygienist using universal precautions.

Private Dental Report forms should be submitted at the time of a new student registration or to the School Health Suite by August 15th.

Bridgeport Elementary Health Suite - Fax: 610-205-3947 900 Bush Street, Bridgeport, PA 19405

Caley Elementary Health Suite - Fax: 610-205-3790 725 Caley Road, King of Prussia, PA 19406

Candlebrook Elementary Health Suite - Fax: 610-205-3798 310 Prince Frederick Street, King of Prussia, PA 19406

Gulph Elementary Health Suite - Fax: 610-205-2099 650 S Henderson Road, King of Prussia, PA 19406

Roberts Elementary Health Suite - Fax: 610-205-3799 889 Croton Road, King of Prussia, PA 19406

Upper Merion Area Middle School Health Suite - Fax: 610-205-8849 450 Keebler Road, King of Prussia, PA 19406

Upper Merion Area High School Health Suite - Fax: 610-205-3994 440 Crossfield Road, King of Prussia, PA 19406

Any questions can be directed to the UMASD Dental Hygienist, Nancy Cuttic at [email protected] or 610-205-8816.

Adapted in part from the Pre-participation Physical Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

H511.336 (Rev. 9/2012) Page 1 of 4: STUDENT HISTORY

Private or SchoolPHYSICAL EXAMINATION

OF SCHOOL AGE STUDENT

Student’s name __________________________________________________________________________ Today’s date___________________________

Date of birth ________________________ Age at time of exam___________ Gender: � Male � Female

Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to. GENERAL HEALTH: Has the student… YES NO 1. Any ongoing medical conditions? If so, please identify:� Asthma � Anemia � Diabetes � InfectionOther_________________________________________________

2. Ever stayed more than one night in the hospital?3. Ever had surgery?4. Ever had a seizure?5. Had a history of being born without or is missing a kidney, an eye, a

testicle (males), spleen, or any other organ?6. Ever become ill while exercising in the heat?7. Had frequent muscle cramps when exercising?

HEAD/NECK/SPINE: Has the student… YES NO 8. Had headaches with exercise?9. Ever had a head injury or concussion?10. Ever had a hit or blow to the head that caused confusion, prolonged

headache, or memory problems?11. Ever had numbness, tingling, or weakness in his/her arms or legs

after being hit or falling?12. Ever been unable to move arms or legs after being hit or falling?13. Noticed or been told he/she has a curved spine or scoliosis?14. Had any problem with his/her eyes (vision) or had a history of an

eye injury?15. Been prescribed glasses or contact lenses?

HEART/LUNGS: Has the student... YES NO 16. Ever used an inhaler or taken asthma medicine?17. Ever had the doctor say he/she has a heart problem? If so, check

all that apply: � Heart murmur or heart infection� High blood pressure � Kawasaki disease� High cholesterol � Other:_____________________

18. Been told by the doctor to have a heart test? (For example, ECG/EKG, echocardiogram)?

19. Had a cough, wheeze, difficulty breathing, shortness of breath orfelt lightheaded DURING or AFTER exercise?

20. Had discomfort, pain, tightness or chest pressure during exercise?21. Felt his/her heart race or skip beats during exercise?

BONE/JOINT: Has the student... YES NO 22. Had a broken or fractured bone, stress fracture, or dislocated joint?23. Had an injury to a muscle, ligament, or tendon?24. Had an injury that required a brace, cast, crutches, or orthotics?25. Needed an x-ray, MRI, CT scan, injection, or physical therapy

following an injury?26. Had joints that become painful, swollen, feel warm, or look red?

SKIN: Has the student… YES NO 27. Had any rashes, pressure sores, or other skin problems?28. Ever had herpes or a MRSA skin infection?

GENITOURINARY: Has the student… YES NO 29. Had groin pain or a painful bulge or hernia in the groin area?30. Had a history of urinary tract infections or bedwetting?

31. FEMALES ONLY: Had a menstrual period? � Yes � NoIf yes: At what age was her first menstrual period? ______

How many periods has she had in the last 12 months? ______ Date of last period: ___________

DENTAL: YES NO 32. Has the student had any pain or problems with his/her gums or teeth?33. Name of student’s dentist: ________________________________

Last dental visit: � less than 1 year � 1-2 years � greater than 2 years

SOCIAL/LEARNING: Has the student… YES NO 34. Been told he/she has a learning disability, intellectual or

developmental disability, cognitive delay, ADD/ADHD, etc.?35. Been bullied or experienced bullying behavior?36. Experienced major grief, trauma, or other significant life event?37. Exhibited significant changes in behavior, social relationships,

grades, eating or sleeping habits; withdrawn from family or friends?38. Been worried, sad, upset, or angry much of the time?39. Shown a general loss of energy, motivation, interest or enthusiasm?40. Had concerns about weight; been trying to gain or lose weight or

received a recommendation to gain or lose weight?41. Used (or currently uses) tobacco, alcohol, or drugs?FAMILY HEALTH: YES NO 42. Is there a family history of the following? If so, check all that apply:

� Anemia/blood disorders � Inherited disease/syndrome�� Asthma/lung problems � Kidney problems� Behavioral health issue � Seizure disorder� Diabetes � Sickle cell trait or disease

� Other________________________________________________43. Is there a family history of any of the following heart-related

problems? If so, check all that apply:� � Brugada syndrome � QT syndrome� Cardiomyopathy � Marfan syndrome � High blood pressure � Ventricular tachycardia � High cholesterol � Other________________�

44. Has any family member had unexplained fainting, unexplained seizures, or experienced a near drowning?

45. Has any family member / relative died of heart problems before age 50 or had an unexpected / unexplained sudden death before age 50 (includes drowning, unexplained car accidents, sudden infantdeath syndrome)?

QUESTIONS OR CONCERNS YES NO 46. Are there any questions or concerns that the student, parent or

guardian would like to discuss with the health care provider? (If yes, write them on page 4 of this form.)

I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of health information between the school nurse and health care providers.

Signature of parent / guardian / emancipated student_____________________________________________________ Date_______________

Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the student have any allergies? � No � Yes (If yes, list specific allergy and reaction.)

� Medicines � Pollens � Food � Stinging Insects

Bureau of Community Health Systems Division of School Health

PARENT / GUARDIAN / STUDENT: Complete page one of this form before student’s exam. Take completed form to appointment.

of 4: PHYSICAL EXAM STUDENT NAME:

STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes � No �

Physical exam for grade:

K/1 � 6 � 11 � Other �

CHECK ONE

*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS

NO

RM

AL

*AB

NO

RM

AL

DEF

ER

Height: ( ) inches

Weight: ( ) pounds

BMI: ( )

BMI-for-Age Percentile: ( ) %

Pulse: ( )

Blood Pressure: ( / )

Hair/Scalp

Skin

Eyes/Vision Corrected �

Ears/Hearing

Nose and Throat

Teeth and Gingiva

Lymph Glands

Heart

Lungs

Abdomen

Genitourinary

Neuromuscular System

Extremities

Spine (Scoliosis)

Other

TUBERCULIN TEST DATE APPLIED DATE READ RESULT/FOLLOW-UP

MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION

(Additional space on page 4)

Parent/guardian present during exam: Yes � No �

Physical exam performed at: Personal Health Care Provider’s Office � School � Date of exam______________20______

Print name of examiner _______________________________________________________________________________________________________

Print examiner’s office address___________________________________________________________________ Phone_______________________

Signature of examiner______________________________________________________________________ MD ��DO ��PAC ��CRNP �

of 4: IMMUNIZATION HISTORY STUDENT NAME:

HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.

IMMUNIZATION EXEMPTION(S):

Medical Date Issued:___________ Reason: __________________________________________________ Date Rescinded:___________



NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.

VACCINE DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization

Diphtheria/Tetanus/Pertussis (child) Type: DTaP, DTP or DT

1 2 3 4 5

Diphtheria/Tetanus/Pertussis (adolescent/adult)

Type: Tdap or Td

1 2 3 4 5

Polio Type: OPV or IPV

1 2 3 4 5

Hepatitis B (HepB) 1 2 3 4 5

Measles/Mumps/Rubella (MMR) 1 2 3 4 5

Mumps disease diagnosed by physician Date:__________

Varicella: Vaccine Disease 1 2 3 4 5

Serology: (Identify Antigen/Date/POS or NEG) i.e. Hep B, Measles, Rubella, Varicella

1 2 3 4 5

Meningococcal Conjugate Vaccine (MCV4) 1 2 3 4 5

Human Papilloma Virus (HPV) Type: HPV2 or HPV4

1 2 3 4 5

Influenza Type: TIV (injected)

LAIV (nasal)

1 2 3 4 5

6 7 8 9 10

11 12 13 14 15

Haemophilus Influenzae Type b (Hib) 1 2 3 4 5

Pneumococcal Conjugate Vaccine (PCV) Type: 7 or 13

1 2 3 4 5

Hepatitis A (HepA) 1 2 3 4 5

Rotavirus 1 2 3 4 5

Other Vaccines: (Type and Date)

of 4: ADDITIONAL COMMENTS (PARENT / GUARDIAN / STUDENT / HEALTH CARE PROVIDER)STUDENT NAME:

H514.027 COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF HEALTH

PRIVATE DENTIST REPORT OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE

NAME OF SCHOOL________________________________________________ DATE ____________________ 20 ___

NAME OF CHILD

_____________________________________________________________Last First Middle

AGE SEX

! !

M F

GRADE SECTION/ROOM

ADDRESS

______________________________________________________________________________________________________________________ No. and Street City or Post Office Borough or Township County State Zip

REPORT OF EXAMINATION

TOOTH CHART

RIGHT LEFT

UPPER 1 2 3 4

A 5 B

6 C

7 D

8 E

9 F

10G

11H

12I

13 J

14 15 16 Upper

LOWER 32 31 30 29

T 28S

27R

26Q

25P

24O

23N

22M

21L

20 K

19 18 17 Lower

UPPER Upper

LOWER Lower

Is The Child Under Treatment Yes ! No !

Treatment Completed Yes ! No !

_________________________________________________Date of Dental Examination

_________________________________________________ _________________________________________________Signature of Dental Examiner Print Name of Dental Examiner

_________________________________________________Address

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STUDENT REGISTRATION DATA (PLEASE PRINT CLEARLY)

Today’s Date: ____________________ Enrollment Grade: _________________________

STUDENT INFORMATION: (Note: Student’s Full Name must match what appears on their birth certificate)

Last (Family) Name: _____________________________________ First (Given) Name: ____________________________________

Middle Name: ______________________ Suffix: _________ Nickname: _______________________ (name child prefers to be called)

Home Address: ______________________________________________________________________________________________

City: ___________________________________________________________ State: ____________________ Zip Code: ________

Male _____ Female _____ Date of Birth: ____/ ____/ 20___

ETHNICITY: (choose one)

White (Non‐Hispanic) Black/African‐American Asian Hispanic Multi‐Racial

Native American/Alaskan Native Native Hawaiian/Pacific Islander

PARENT/GUARDIAN INFORMATION: Parent 1: Full Name: _____________________________________________________Relationship to Student: _________________________

Lives with Student: YES ____ NO ____ Release To: YES ____ NO ____ (If NO, Court Order MUST be presented to school office)

Have you experienced a recent crisis in housing or living arrangements that requires assistance? ____ YES ___ NO

Home Address (if different from student address):_________________________________________________________________

City: ___________________________________________________________ State: ___________ Zip Code: _________________

Home Phone: ________________________ Cell Phone: _____________________ Work Phone: ____________________________

Email: ___________________________________ Occupation: _________________________ Employer: _____________________

FOR DISTRICT USE ONLY

Proof of Residency: YES _____ NO _____ Type: _________________________

Birth Certificate: YES ______ NO _______ Immunizations: YES _____ NO _____ Parent ID: YES _____ NO _____

Location Code of Residence: 01 _____ 02 _____ 03 _____ 04 _____ 05 _____ 06 ______ 07 _______

Location Code of Attendance: 01 _____ 02 _____ 03 _____ 04 _____ 05 _____ 06 ______ 07 _______

Custody Agreement: YES ____ NO _____ Guardianship: YES _____ NO _____ Grade Verified: YES ____ NO _____

PA Secure ID Number: _______________________________________ UMASD ID Number: _________________________

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Parent 2: Full Name: ______________________________________________________ Relationship to Student: _______________________

Lives with Student: YES ____ NO ____ Release To: YES ____ NO _____ (If NO, Court Order MUST be presented to school office)

Home Address (if different from student address):_________________________________________________________________

City: ___________________________________________________________ State: ___________ Zip Code: _________________

Home Phone: ________________________ Cell Phone: _____________________ Work Phone: ____________________________

Email: ___________________________________ Occupation: _________________________ Employer: _____________________

EMERGENCY CONTACT INFORMATION (Nearby responsible adults in case of emergency):

Full Name: ______________________________________________________Relationship to Student: _______________________

Home Phone: ___________________________ Cell Phone: ______________________ Work Phone: _________________________

Full Name: ______________________________________________________Relationship to Student: _______________________

Home Phone: ___________________________ Cell Phone: ______________________ Work Phone: _________________________

STUDENT’S EDUCATION HISTORY:

Has the student previously been enrolled in school?: YES _____ NO _____

Nursery School _______ Elementary School _______ Middle School _______ High School _______

Name of Previous School: ______________________________________________________________________________________

School’s Address: ____________________________________________________________________________________________


School’s Phone: ____________________________ School’s Fax: ____________________________

Completed Grade Level: ____________ Date Range Attended: ____________________________________ (mm/yyyy – mm/yyyy)

Student’s Previous Home Address: ______________________________________________________________________________


Date when first enrolled in PA Schools: _______________________________________ (mm/yyyy)

City of Birth: ___________________________ State of Birth: ___________________ Country of Birth: ______________________

Date of arrival in the US: __________________ (mm/yyyy) Date when first enrolled in US school: ___________________ (mm/yyyy)

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OTHER CHILDREN LIVING IN THE HOME:

Name Age Date of Birth School (if school age)

________________________________________________ _______ ________________ ________________________________

________________________________________________ _______ ________________ ________________________________

________________________________________________ _______ ________________ ________________________________

________________________________________________ _______ ________________ ________________________________

________________________________________________ _______ ________________ ________________________________

SPECIAL SERVICES:

IEP (Individual Education Plan): YES _____ NO _____ If Yes, Grades: _________, copy provided: YES _____ NO ____

GIEP (Gifted Individual Education Plan): YES _____ NO _____ If Yes, Grades: _________, copy provided: YES _____ NO _____

504 Plan: YES _____ NO _____ If Yes, Grades: ___________, copy provided: YES _____ NO _____

ELL (English Language Learner) Classes: YES _____ NO _____ If Yes, Grades: __________

Ever Retained? YES _____ NO _____ If Yes, Grades: ___________

I have completed the above student registration packet in its entirety to the best of my knowledge and the information provided is accurate.

Parent/Guardian Signature: ___________________________________________________________________ Date: _____________

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PARENTAL REGISTRATION STATEMENT

Pennsylvania School Code §13‐1304‐A states in part “Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration, provide a sworn statement or affirmation stating whether the pupil was previously suspended or expelled from any public or private school of the Commonwealth or any other state for an act of offense involving weapons, alcohol or drugs, or the willful infliction of injury to another person or for any act of violence committed on school property.”

I hereby swear or affirm that my child: _________________________________________ was ____ was not _____ previously suspended or expelled from any public or private school of the Commonwealth or any other state for an act of offense involving weapons, alcohol or drugs, or the willful infliction of injury to another person or for any act of violence committed on school property. I make this statement subject to the penalties of 24 P. S. §13‐1304‐A (b) and 18 Pa C.S.A. §4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information, and belief.

Name of the school which the student was suspended or expelled; the reason for the suspension / expulsion; and the dates of the suspension or expulsion (optional):

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Any willful false statement made above shall be a misdemeanor of the third degree. This form shall be maintained as part of the student’s disciplinary record.


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CHILD CUSTODY INFORMATION

□ Student resides with both Biological Parents


□Student DOES NOT reside with both Biological Parents

The following information is requested when the enrolled student does not reside with both natural parents due to separation or divorce. The parent with whom the child resides will be considered the custodial parent; however, the non‐custodial parent has access to the child’s records in the absence of a court order forbidding it. It is the responsibility of the custodial parent to provide the school with any limiting court order.

Student Name: _______________________________________________________________________________________________

Name of custodial parent with whom the child resides: _______________________________________________________________

Name of non‐custodial parent: __________________________________________________________________________________

Non‐custodial parent’s home address: _____________________________________________________________________________

City: _______________________________________________________________ State: ___________ Zip Code: ______________

1. Do you, as custodial parent, have legal custody through a court order?YES _____

NO _____

PENDING _____, Date finalization expected? __________

2. If there is a court order, does it limit the non‐custodial parent’s access to school records?YES _____, (If YES, a copy of the court order MUST be supplied to the school office to be kept on file)

NO _____

3. May the child be released from school to the non‐custodial parent?YES _____

NO _____, (If NO, a copy of the court order MUST be supplied to the school office to be kept on file)

4. Can we provide the non‐custodial parent progress information such as report cards and conference reports?YES _____

NO _____ (If NO, court order MUST be supplied stating parent relinquished educational rights)


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RESIDENCY VERIFICATION & TUITION PAYMENT RESPONSIBILITY

The Upper Merion Area School District is proud to offer a high quality public education to our residents. The district also has a very active residency verification program to protect our community resources. This program can include, but is not limited to, complete documentation verification, independent investigation by law enforcement officials, and surveillance.

It is the intent of the Upper Merion Area School District to prosecute, to the fullest extent of the law, any individual furnishing false information in the accompanying registration forms for the purpose of enrolling nonresident students.

If the student registered is found to be a non‐resident, the individual registering said student will be financially responsible for all tuition costs. Depending on the educational program of the student the tuition liability ranges from $10,000 to $21,000 annually. Parent or guardians will be responsible for this payment.

I grant the Upper Merion Area School District permission to investigate the information I have presented in this statement by discussing the presented information with all appropriate parties, including tax authorities and residency investigators, as necessary to confirm factual accuracy. To further its investigation, the District may request additional documentation from parents to substantiate residency; this may include but is not limited to: a copy of a driver’s license, motor vehicle registration with address, copy of state and federal program enrollment documents with address, paycheck stub indicating address.

I understand the district may contact any or all of the following agencies to verify a student’s residency within the Upper Merion Area School District.

● Social Security Administration● Internal Revenue Service● Public Welfare Department● Montgomery County Housing Authority● Montgomery County Children and Youth● Zoning Offices of West Conshohocken Borough, Bridgeport Borough and Upper Merion Township

I certify that I have read and understand the above notice. Additionally, I agree to pay the Upper Merion Area School District its full tuition cost if the student being enrolled is found to be a non‐resident.


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SCHOOL HEALTH SERVICES & STUDENT HEALTH HISTORY

Student’s Full Name: __________________________________________________________________________________________

Address_____________________________________________________________________________________________________

City ________________________________________________________________ State ___________ Zip Code _______________

Home Phone________________________________ Date of Birth ____________ (mm/dd/yyyy) Sex________ Grade__________

Mother _______________________________ Father ___________________________ Guardian _____________________________

Has child had chickenpox disease? YES _____ NO _____, if yes date of disease __________________________________ (mm/yyyy)

Describe any serious illnesses, accidents or operations your child has had: ________________________________________________

Check items that student has had or currently has:

Allergies: □ Food □ Medica on □ Bee S ng □ Insect Bite □ Other Comments____________________________________________________________________________________________

Respiratory: □ Asthma □ Bronchi s □ Chronic Cough □ Frequent Coughs □ Pneumonia □ Tuberculosis □ Other

Comments____________________________________________________________________________________________ Cardiac: □ Heart Murmur □ Congenital Defect □ Arrhythmias □ Other

Comments____________________________________________________________________________________________Eyes, Ears, Nose, Throat: □ Ear Aches □ Hearing Loss □ Sore Throat

□ Speech Difficul es □ Visual Impairment □ OtherComments____________________________________________________________________________________________

Gastrointestinal: □ Gastric Reflux □ Stomach Aches □ Toile ng Problems □ Other Comments____________________________________________________________________________________________

Genitourinary: □ Urinary Accidents □ Urinary Tract Infec ons □ Other Comments____________________________________________________________________________________________

Neurological: □ A.D.D./A.D.H.D. □ Congenital Condition □ Convulsions □ Other

□ Developmental Delays □ Headaches/Migraines □ Toure e’s syndromeComments____________________________________________________________________________________________

Skeletal: □ Fractures □ Orthopedic Condi on □ Scoliosis □ OtherComments____________________________________________________________________________________________

Emotional: □ Depression □ Suicide □ Family Stressors □ Other Comments____________________________________________________________________________________________

Chronic Conditions: □ HIV/AIDS □ Cancer □ Diabetes □ Epilepsy □ Gene c Condi ons □ Arthri s □ Blood Disorders □ Other

Comments____________________________________________________________________________________________ Family History: (has any family member had):

□ Cancer □ Diabetes □ HIV/AIDS □ Heart DiseaseComments____________________________________________________________________________________________

□ Child currently under medical treatment‐explain___________________________________________________________________

____________________________________________________________________________________________________________

□ Child currently taking daily medica on, explain areas of concern or informa on that would be helpful _______________________

____________________________________________________________________________________________________________


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SCHOOL HEALTH SERVICES & TUBERCULOSIS SCREENING ASSESSMENT

Student’s Full Name: __________________________________________________ Date of Birth: _________________ (mm/dd/yyyy)

Parent/Guardian Full Name: ______________________________________________________ Student’s Grade: _______________

HAS CHILD OR ANY FAMILY MEMBER…

Been in contact with someone known or suspected of having tuberculosis? YES _____ NO _____

Been exposed to someone with an undiagnosed chronic (prolonged) cough? YES _____ NO _____

Traveled to Asia, Middle East, Latin America or Africa or been in contact with someone who has? YES _____ NO _____

Regularly visit someone living in a major city? YES _____ NO _____

Been exposed to someone who is HIV infected? YES _____ NO _____

Been exposed to someone who has been in jail or an institution such as a hospital, nursing home, group home, etc.? YES ___ NO___

Do you know of any tuberculosis cases that have been discovered in your neighborhood? YES _____ NO _____

Have you moved here from a developing country or been in contact with someone who has? YES _____ NO _____

Name of Student’s Doctor: _____________________________________________________ Phone: _________________________

Preferred Hospital: ___________________________________________________________________________________________

Medication(s) to be dispensed at school: __________________________________________________________________________

____________________________________________________________________________________________________________

Permission for Medication: A doctor’s note is required for all prescription medication. A doctor’s note is required for all over the counter medication other than those listed below.

The school nurse may administer: Acetaminophen (generic Tylenol) YES _____ NO _____

Ibuprofen (generic Advil) YES _____ NO _____

Benadryl for allergic reaction YES _____ NO _____


FOR NURSING STAFF USE

Medical evaluation required? YES _____ NO _____

If yes, referred to __________________________________________________________________________________

Evaluation/Testing to be completed by ________________________________________________________________

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HOME LANGUAGE SURVEY AND QUESTIONNAIRE

The Office of Civil Rights (OCR) requires the school districts to identify limited English proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identification. Name of Student: __________________________________________________________________ Date: _____________________

Address: ___________________________________________________________________________________________________

City: _____________________________________________________________ State: ________ Zip Code: ___________________

Grade: ______________________ School: ________________________________________________________________________

1. What is/was the student’s first language? ______________________________________________________________________

2. Does the student speak a language(s) other than English: YES _____ NO _____, If yes, what language(s) ____________________

3. What language(s) is/are spoken in your home? ___________________________________________________________________

4. Has the student attended any United States school in any 3 years during his/her lifetime? YES _____ NO _____, if YES, completethe following:

Name of School State Dates Attended

____________________________________________________ _______________________ ____________________________

____________________________________________________ _______________________ ____________________________

Person completing this form (if other than parent/guardian): _________________________________________________________

Native Country: __________________________ Date arrived in the US: ________________ (mm/yyyy)

Has the student ever been in an ELL program in a US school? YES _____ NO _____, If yes was the student exited: YES _____ NO _____, if yes what was the exit date: ____________ (mm/yyyy)

What language(s) is the student most comfortable using with his/her siblings? _____________________, friends________________

Does the family need the use of a translator to communicate with the school? YES _____ NO _____ (If yes, choose one):

I have a translator. Name: ________________________________________________ Phone: ________________________

I do not have a translator, and please provide one if possible for the following language: _____________________________

STUDENT’S FATHER: What language(s) do you speak? ________________________ Is this the language you use to speak to your child? YES ___ NO ___

Do you read English? YES _____ NO _____What language is your child most comfortable using with you? ___________________

STUDENT’S MOTHER: What language(s) do you speak? ________________________ Is this the language you use to speak to your child? YES ___ NO ___

Do you read English? YES _____ NO _____What language is your child most comfortable using with you? ___________________

This school has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the school has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLS, the school district may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the school in the future.


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PARENTAL AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION FROM OR TO UPPER MERION AREA SCHOOL DISTRICT

Student’s Full Name ___________________________________ Date of Birth _______________ Grade_______

Address____________________________________________________________________________________

City__________________________________________________ State _____________ Zip Code ___________

Upper Merion Area High School435 Crossfield RoadKing of Prussia, PA 19406610-205-3821 610-205-3886 (fax)

Upper Merion Area Middle School 450 Keebler Road King of Prussia, PA 19406 610-205-8833 610-205-8856 (fax)

Bridgeport Elementary School900 Bush Street Bridgeport, PA 19405610-205-3600 610-205-3649 (fax)

Caley Elementary School 725 Caley RoadKing of Prussia, PA 19406 610-205-3650 610-205-3699 (fax)

Candlebrook Elementary School 310 Prince Frederick Street King of Prussia, PA 19406 610‐205‐3700 610‐205‐3749 (fax)

Gulph Elementary School 650 S Henderson Road King of Prussia, PA 19406 610‐592‐2020 610‐ 205‐2099 (fax)

Roberts Elementary School 889 Croton Road Wayne, PA 19087 610‐205‐3750 610‐205‐3799 (fax)

This will authorize the Upper Merion Area School District to release or obtain confidential records and/or information from/to the following school or agency: School or Agency Name________________________________________________________________________________________

Address ____________________________________________________________________________________________________

City_____________________________________________________________________ State _____________ Zip Code _________

Phone Number ______________________________________________ Fax Number ______________________________________

The specific information to be released is:

_____ ALL RECORDS _____ Teacher / School Reports / Grades to Date/Transcript _____ Discipline/Attendance Records _____ Signed Permission to Evaluate _____ Additional Testing/Evaluations/Assessments _____ Sign GIEP Invite/GIEP _____ Signed NOREP

_____ Medical / Immunization Records _____ State Test Results _____ Evaluation/Re‐Evaluation _____ Signed IEP Invite/IEP _____ Signed NORA _____ Other _______________________________________

Student Withdrawal Date from UMASD __________________________________ (mm/dd/yyyy) (if applicable)

Witness Signature: _________________________________________________________________________ Date: ______________

Parent/Guardian Signature: __________________________________________________________________ Date: ______________

REVISED 1/2020 17 FORM #12151

PARENT NOTIFICATION/PERMISSION FORM

Name of Student: __________________________ School: ___________________________ Date: ______________________________

During the school year, students can become involved in activities that go beyond the confines of the classroom or typical educational setting and/or the usual day to day instructional process. In most cases, these are routine events associated with a student’s learning and personal development.

Please review the activities/events listed below. It is important to note that this list may not include all activities that could arise during the school year. If the types of activities/events listed below pose no concerns for you and your child, simply check the first box below and sign the form at the bottom. If you have concerns with any particular activities/events, they should be specifically listed the second box below should be checked and the form should be signed at the bottom.

ACTIVITIES/EVENTS

1. Individual/Group photographs in yearbooks and other school publications. Names may be used in conjunction with such pictures.

2. School academic/activity photographs in news articles for newspapers. Names may be used in conjunction with such pictures.

3. Inclusion in general interest news media reports/interviews (i.e. television, radio, newspapers), including listings of studentsaccomplishments (e.g., honor rolls, spelling bees). Students may be identified in such reports/interviews/listings.

4. Events/Parties that relate to cultural observances such as Thanksgiving, holidays, cultural awareness months, etc.

5. The release of student directory information as per the Federal Family Educational Rights and Privacy Act (FERPA).

6. Participation in educational research studies (with student anonymity) as approved by student principals.

7. Academic group testing per state and location regulations/practices.

8. Individual/Group photographs/videos that include the student and/or oral or written comments by the student that appear on the schooldistrict website or other media. No student names will be included with such photos or videos.

9. Walking field trips within the vicinity of the school, but may be off school premises.

10. Visitation by U.S. military recruiters and/or providing them with access to directory information.

PLEASE CHECK THE APPROPRIATE BOX AND SIGN

I recognize the above events/activities as components of a comprehensive school program and give permission for my child to be involved.

I recognize the above events/activities and DO NOT give permission for my child to be involved.

Parent Signature: _________________________________________________ Date: _______________________________________

*Please be advised that the school district may require additional permission for specific other activities or programs.

Please Note: When a student is a member of a school sponsored extracurricular activity at which the public, including members of the news media are invited to attend, provided any entrance fees and/or other entrance requirements have been met, the parent(s)/guardian(s) may not prohibit the photographing and/or videotaping or any participant, including their own child. Parent(s)/Guardian(s) who have an objection to such photographing and/or videotaping are advised to withdraw their child from participation in such activities.

**Upon approval it is then the parent/guardian’s sole responsibility to notify the district of any change.

UPPER MERION AREA SCHOOL DISTRICT...REVISED 1/2020 6 FORM #12151 UPPER MERION AREA SCHOOL DISTRICT...

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