Not able to attend Beye Night? - Oak Park Elementary School

Transcripción

Not able to attend Beye Night?
Limited spots are still available for the
following parties:
Parties for Kids
K/1 Movie Night – April 8 ($15*)
K-2 Code Play Learn Party – April 10 ($20)
3-5 Code Play Learn Party – April 10 ($20)
2/3 Indoor Block Party – April 23 ($15*)
4/5 Scavenger Hunt – May 20 ($15*)
3-5 Beye Baseball – May 22 ($20)
Parties for Adults
Rock 101 – March 20 ($30)
Ladies’ Craft and Chat– April 14 ($20)
Men’s Poker Night – April 22 ($35)
Murder Mystery Party – April 23 ($50)
Block Progressive Party – May 7 ($50)
Ladies’ Night Out – May 12 ($35)
Ladies’ Derby Lite – May 25 ($40)
Beye/Whittier Beer Olympics – June 4 ($30)
Parties for Families
Family Geocaching/Scavenger Hunt – May 14
($50/family)
Family Grill and Swim – September 11 ($15)
To request a space, email [email protected]
*Scholarships are available for grade-level parties.
2016 Beye-In Parties
Parties for Kids
K/1 Movie Night – April 8
K-2 Code Play Learn Party – April 10
3-5 Code Play Learn Party – April 10
2/3 Indoor Block Party – April 23
4/5 Scavenger Hunt – May 20
3-5 Beye Baseball – May 22
Parties for Adults
Rock 101 – March 20
Ladies’ Craft and Chat at Alley Cat – April 14
Men’s Poker Night – April 22
Murder Mystery Party – April 23
Block Progressive Party – May 7
Ladies’ Night Out – May 12
Ladies’ Derby Lite – May 25
Beye/Whittier Beer Olympics – June 4
Co-ed Beer Tasting – June 9
Parties for Families
Family Geocaching/Scavenger Hunt – May 14
Family Grill and Swim – September 11
Please note:
ALL parties MUST be paid for when purchasing,
by check or credit card.
PARTIES FOR KIDS
K/1 Movie Night
April 8, 6-8pm
Let your Kindergarteners and 1st graders go to the show the Beye School way! Your
student will enjoy Inside Out complete with popcorn and a drink in the Beye
Auditorium. Co-hosted by Beye’s 3rd grade Brownie troop. Scholarships available!
Cost: $15
Location: Beye School Auditorium
Number of attendees: 30
Hosts: Monica Saydah, Lisa Kozinski, Lori Browder, Alisa Najera
2/3 Indoor Block Party
April 23, 2-4pm
Two hours of high energy block party-inspired fun and games await your 2nd/3rd
grader in the Beye School gymnasium! Relay races, hula hoop contest, face painting,
craft projects, healthy snacks and drinks included.
Scholarships available!
Cost: $15
Location: Beye School Gym
Hosts: Stephanie Kloster-De la Rosa, Christine Bonomo, Amy Moriarta, Kynyada
Pipkin
4/5 Scavenger Hunt
May 20, 3-5pm
Let your child show off his or her Beye knowledge in the annual school scavenger
hunt! Teams of students will hunt high and low to find clues and be the first to
decipher the hidden code. We will then gather in the commons for dinner.
Scholarships available!
Cost: $15
Location: Beye School Commons
Hosts: Troy Koch and Kelly Simkowski, Beye PTO Co-presidents
K-2 Code Play Learn
3-5 Code Play Learn
April 10, 12:30-2:30pm
April 10, 3-5pm
Code Play Learn is excited to offer two Beye-In parties for K-2nd graders and 3rd-5th
graders. Participants will construct their own Lego robots and then using the WEDO
programming platform, we make their creations come alive.
Parents of kindergarteners should plan to stay to assist. 1st and 2nd parents are
welcome and encouraged to stay.
Cost: $20
Location: Code Play Learn, 30 Chicago Ave.
Number of attendees: 15 per session
Host: Wil Greenwald
3-5 Beye Baseball
May 22, 4-6pm
Come spend a day on the diamond with Beye School’s own Mr. Manus and Mr.
Ellwanger! Parents will make up the cheering section while kids take a swing at the
bat. Team Manus will face off against Team Ellwanger then all will enjoy a delicious
hot dog cook out. Play ball!
Cost: $20
Location: Beye School baseball diamond
Hosts: The Simkowski and Beecroft families
PARTIES FOR ADULTS
Men’s Poker Night
April 22, 7pm
Guys, in a room, playing poker and drinking beer—enough said. Beer, pizza, and
snacks included. Bring extra money for the kitty, and you could be a winner!
Cost: $35
Location: The Delano house, 162 N Elmwood
Hosts: Tom Delano, Brian Bonomo, Scott Bellner, Matt Cotter
Block Progressive Party
May 7, 6:30pm
Calling all James Deans, Audrey Hepburns, Farah Fawcetts, and Don Johnsons:
Don’t be a square! Let’s have a gas and drink and nosh though 4 decadent
decades. Can you dig it!? Totally! Like, for sure!
Enjoy inspired cuisine, signature cocktails, music and ambiance characteristic of the
best of the 50's, 60's, 70's and 80's. Buckle up, there may be Jell-o salad but also
Seagrams.
Come as you are, or pull out your poodle skirt, fringe, bell bottoms or neon to take
the experience to another level of nostalgia.
Cost: $50
Location: South Scoville and South Elmwood
Hosts: Amanda and Chris Miller, Eva and Bill Pearson, Magda and Jeffery Piper,
Carrie and Matt Cotter, Jaime and Jared Lewis
Co-ed Kinslahger Beer Tasting and Brewery Tour
June 9, 7pm
Experience a tour and tasting at Oak Park's newest brewery, Kinslahger Brewing
Company. This event will include tastings of Kinslahger's flagship beers: Prohibition
Pilsner, Dunkel, Alt, Chicago Common, and Baltic Porter. Then choose your favorite
beer and stick around to socialize with fellow Beye parents. Light snacks and a
souvenir glass will be included.
Cost: $35
Location: Kinslahger Brewery, 6806 Roosevelt Rd.
Hosts: Pablo and Sarah Rodriguez, Ben and Monica Saydah
Ladies’ Night Out
May 12, 7-10pm
It is so hard to say goodbye...maybe Exit Strategy will help ease the pain! Join moms
who are exiting Beye School as they host a farewell party at the hottest brewery
around. Whether you have just begun or are graduating, all ladies of Beye are
invited. Beer, wine, food and maybe even some tears. Sorry guys, ladies only.
Cost: $35
Location: Exit Strategy, 7700 W Madison St, Forest Park
Hosts: A group of “Exiting” Beye moms
Derby Lite
May 25, 6:30-9:30pm
It’s time for girl time! REAL grrrrl-time! Join Beye ladies for a fun, sweaty, rocking
evening rolling macaroni led by Queen Bee (former Beye mom and Derby Lite
founder Barbara Dolan)! You’ll be equipped to skate, trained to go and fall, and
shown all the thrills and spills of roller skating a la roller derby – without the hitting
or impact! Have fun while enjoying the company of crazy women like yourself!
Bring a helmet and water bottle: all other equipment will be provided.
Dress like a derby girl if you’d like, and come and have a blast with us! T-shirt
provided. NO EXPERIENCE NECESSARY!
Cost: $40
Location: Beye School gym
Hosts: Lali Puig, Melissa Narum, Alisa Najera, Liz Kelley, Gina Ulrich
Ladies’ Craft and Chat
April 14, 7-9:30pm
Check out the offerings at Alley Cat, Oak Park’s new home décor shop. Staff will be
on hand to demonstrate their products, and attendees will have the chance to enjoy
the space and soak up design inspiration. Bring an old frame or mirror and give it a
new life with chalk paint. There’s something for everyone here!
Drinks and snacks provided.
Cost: $20
Location: Alley Cat Décor, 716 Lake Street
Hosts: Laura Derks, Andrea Lofgren
Rock 101
March 20, 1-3pm
Sign your inner rockstar up for Rock 101! Join fellow Beye parents in learning a rock
song or two, taught by School of Rock instructors. Guitar, drums, keyboards, vocals-the perfect band! Destroying guitars not allowed but skinny jeans and bad attitude
are. No music experience necessary. Instruments provided, or bring your own!
Cost: $30
Location: School of Rock Oak Park, 219 Lake Street
Hosts: Kandy Shapiro, Laura Derks
Murder Mystery Party
April 23, 7 ‘til the case is solved!
Come join us at a local neighborhood speakeasy for a night of mystery during the
height of the roaring 20s. Get ready for blackmail, deceit, debauchery, intertwining
relationships, murder and a special appearance from a well known guest. You’ll
enjoy live piano music, local bartenders, free flowing libations, light fare catered by
Blue Plate Chicago and prizes for the detective who solves the case.
Dress for the 20s if you wish, but we’ll have period props (think boas, headdresses
and fedoras) for anyone who’d rather come unadorned. Take a starring role or
simply be a bystander. It’ll be the cat’s pajamas!
Cost: $50
Location: The Cronacher/Moen House, 167 N Ridgeland
Hosts: Suzanne Cronacher and John Moen, Jennifer Alten and Basil Shepherd, Sara
and Jack Neuner, Debra and Ryan Woods, Kristi and Folkert Kosten, Beth and Mike
Hayes, Gina and Mark Bazer
Beye/Whittier Beer Olympics
June 4, 7pm
2016 is the year of the Olympics! What better way to show your support of the ol’
Red, White, and Blue than by joining us at Oak Park Beer Olympics 2016! For the
first time ever, Beye and Whittier will join forces for a Beye-In party: Two schools,
double the fun! Hosted by the Whittier and Beye parents the Sorgs, Ryans, and
Steketees on June 4th, this epic multi-school competition will appeal to all of your
competitive instincts.
Food from around the world. Olympic caliber selection of adult beverages, including
the first samples of the well-crafted beers coming to the new Lake Street and Austin
brewery. Currently being reviewed by the Olympic committee: Podium celebrations;
Gold, Silver, and Bronze stuff. DJs spinning dance-inspiring tunes ‘til the wee hours
of the morning—most certainly. Events for all!
Cost: $30
Location: The Sorg house, 516 Augusta
Hosts: The Ryan (Whittier), Steketee (Beye) and Sorg (former Beye and current
Whittier) families
PARTIES FOR ALL AGES
Family Geocaching/Scavenger Hunt
May 14, 1-6pm
Solve the riddle, get the clue, find the cache. Treasure awaits you! Join us for an
afternoon of outdoor, high tech treasure hunting fun using GPS coordinates and your
wits. Walk, run or scoot your way around Oak Park (be sure to wear your
helmet!). The party will begin and end at the Readling home where a
post-geocaching cookout will follow.
Cost: $15/person, $50/family
Location: The Readling House, 207 S Cuyler
Hosts: Cate and Chip Readling, Monica and Ben Saydah, Don and Jola Orban, Rupa
and Ravi Datta Nemana
Family Grill and Swim
September 11, 2-5pm
Nobody said summer fun ends when school starts! Join us for a fun afternoon of
splish and splash with cocktails and the kids. Wear a swimming suit, and bring your
sun glasses, towel, and sunscreen. That’s it! Munchies and drinks will be served.
Cost: $15/person
Location: The Cote House, 232 N Harvey
Hosts: Marta and Matt Cote
RAFFLES
A framed, autographed photo of Chicago Cubs outfielder Bobby Dernier
Four 2015 lower level regular-season Chicago Sky tickets plus bag and pen
Four 2016 Northwestern football non-conference game tickets (Western
Michigan 9/3, Illinois State 9/10, or Duke 9/17)
 Four 2016 upper reserve Chicago White Sox tickets (valid for all April and
May games except opening day and the Boston series)
Two tickets to any 2015-2016 regular-season Chicago Wolves game

An excursion on Lake Michigan for four on Captain Jack Neuner’s 30-foot sailboat.
Date TBD between Jack and winner. Food and drink provided. Ages 5 and up.
A tour and wine-tasting for ten at Lynfred Winery in Roselle
There will also be auctions of framed prints by New
Yorker illustrator and Beye dad Chris Ware
AND local artist and Beye dad Ted Gordon.
THANK YOU!!
Thank you to all our Beye-In party hosts for their generous and creative
contributions!
Thank you also to the volunteers who helped make this year’s Beye Night
a hit!
Thank you to all the raffle donors!
Finally, special thanks to the following businesses and vendors:
School of Rock, Oak Park
Lagunitas Brewery
Beye School
New Rose Catering
Code Play Learn
Derby Lite
!
Come create with us this June!
Summer Adventures Camp with Beye Discovery
Join us for a thrilling start to the summer as we venture into “Playful Art & The Art of Play”,
inspired by artists both past and present; the natural world; and our own experiences, interests
and dreams. Through painting, drawing, printmaking and sculpture, children will develop their skills
and imagination to create unique works of art. Weather permitting, some projects will be created
outdoors. Classes are facilitated by Jocelyne Adkins, MAAE, School of the Art Institute, Chicago
and a teaching assistant.
Beye Discovery Camp Schedule (For children grades K-5, half day & full day options):
Students may register for 1 week, 2 weeks, or 3 weeks. Each week will offer new adventures!
Location: Beye School, Room 302
Week 1: Monday, June 13th - Friday, June 17th
Week 2: Monday, June 20th - Friday, June 24th
Week 3: Monday, June 27th - Friday, July 1st
Summer Program Options:
Morning Sessions: 8:30am - 11:30am ($125 per week)
Afternoon Sessions: 12:30pm - 3:30pm ($125 per week)
Morning & Afternoon Sessions* (please pack a lunch): 8:30am - 3:30pm ($290 per week)
*Extended day option from 3:30-6pm: Session fee + $80 per week
Please note, minimum enrollment is 4 children. Should this minimum not be met, caregivers will be
notified by May 11th. Also, early drop off option at 8 am for an added fee of $25 per week.
Additional Information:
Beye Discovery is an enrichment program of the Beye PTO that offers children opportunities for exploration and
growth, through creative project-based learning in art and science (during the school year).
To register, please contact Jocelyne Adkins, Program Director at [email protected]
"Distribution of information by a community group in accordance with District 97 policy does not imply,
directly or indirectly, that the group's program(s), event(s) and/or service(s) is sanctioned, sponsored or
endorsed by the district, the Board of Education or the superintendent."
BEYE SCHOOL TALENT SHOW 2016
Auditions April 7 (K-3rd) and April 8 (4th-5th)
Attention Beye School students and parents…
Calling all singers, dancers, musicians, magicians, silly stunt
performers, crazy skits, stage crew members and MC’s who
can deliver a punch line!
It’s time to start thinking about your act because auditions are in two
short weeks—just after spring break, April 7 & 8! Please note: All
students who audition will be included in the Talent Show as long as they attend all rehearsals
and both shows. We will work with each act to fine-tune the performance so we showcase all
of our talented Beye School students! If the assigned audition date does not work for your
performer, feel free to attend the other day.
We had so much fun doing TWO shows last year that we’re going to do TWO again
this year! Your child MUST be available for both performances in order to participate. Our
performers who work so hard on their acts will get to perform twice for our enthusiastic Beye
crowds!
To use the online permission form, please copy and paste this link (paper copies in office):
https://d97pto.wufoo.com/forms/mju6a0m1vvfoas/
AUDITIONS:
Thursday, April 7, 3:00 – 4:30 PM – Auditions for K-3rd graders only*
*Parents please attend with your child if they are in K, 1st or 2nd grade.
Friday, April 8, 3:00 – 4:30 PM – Auditions for 4th and 5th graders
Again, all students who audition will be included in the Talent Show as long as they attend all rehearsals.
REHEARSAL AND SHOW SCHEDULE:
4 REGULAR REHEARSALS: April 12, 19, 26 (3:00 – 4:30) and May 3 (3:00 – 5:00)
DRESS REHEARSAL: May 10 (Tuesday) – 3PM- 5:30PM
OPTIONAL Extra Rehearsal: May 11 (Wednesday) – 2PM-4PM
TALENT SHOW Performances:
May 12 (THURSDAY) – 7PM (performers arrive at 6:30)
May 13 (FRIDAY) – 7PM (performers arrive at 6:30)
The next page includes the general rules for participation in the Talent Show.
Questions? Contact DiAne Boese (708-595-8748, [email protected])
General Information and Guidelines/Rules for the Beye School Talent Show
1. ALL GRADE LEVELS are welcomed and encouraged to participate!
2. All acts MUST audition. If you are ill and planned to audition, please contact the director to re-schedule.
3. All acts MUST NOT be more than 2 minutes in length and performers can only be in ONE act.
4. All acts should be put together enough for the directors to understand the performance by the auditions.
Rehearsals are for staging, fine-tuning and the flow of the show!
5. All material, including lyrics, dance moves, etc., must be appropriate for elementary school. We HIGHLY
recommend Kidz Bop versions of pop songs. It uses appropriate language and the recorded music is readily
available. Show tunes are also a wonderful resource for material.
6. We recommend that dancers dance and singers sing, but that acts not include both singing and dancing. It is
impossible to successfully mic a dancer so that they can sing. Please choose singing OR dancing!
7. Lip-Synching is not allowed for singing acts.
8. Masters-of-Ceremony (MC’s) are restricted to 4th or 5th graders. Interested students should bring 2 minutes worth
of material (i.e. jokes, pretend introductions, etc.) to the audition; director(s) will help compose your final act.
There may be some additional rehearsals for the MCs, but will coordinate as needed.
9. Stage Crew is restricted to 4th or 5th graders. STAGE CREW ONLY will not have to attend the first two rehearsals.
Students interested in Stage Crew should attend the audition to introduce themselves and then may leave.
10. ALL K – 2 GRADE STUDENTS MUST BE SUPERVISED BY AN ACCOMPANYING ADULT during the audition
and ALL rehearsals. Your K-2nd grade child may leave with the accompanying adult following the rehearsal of
their act. We encourage parents/caregivers to trade off these duties with other parents/caregivers in the same
position. If you have any particular issues with this, please contact DiAne Boese to discuss. We will do our best to
assist you with this requirement.
11. ALL STUDENTS must follow the Beye Laws by demonstrating appropriate behavior during auditions and all
rehearsals. Students may be asked to leave the rehearsal and will forfeit their spot in the show if disruptive
behavior persists.
12. The director(s) ask for parents’ patience and understanding if rehearsals run late. We will do our best to begin and
end on time.
13. Students who wish to borrow and/or use school materials for their acts (e.g. gym mats) must secure the teacher’s
or other appropriate adult’s permission BEFORE auditions and have this in writing at auditions.
14. Parents and students please do not ask for special accommodations for Dr.’s appointments, piano lessons, team
practices, etc. In the interest of fairness, we are unable to honor such requests.
15. Parents please do not ask the director(s) for your child’s placement in Act I vs. Act II. Directors’ decision on act
placement is based on the needs of the overall show, and in the interest of fairness we are unable to honor such
requests.
16. Parents please send a snack with your child on audition and rehearsal days, as well as a quiet activity.
17. Acts WILL be allowed to audition on a walk-in basis, without a signed permission slip or completed online
permission slip. However, Director(s) will need to have a signed permission slip or completed online permission
slip from each student in an act on or before the 2nd rehearsal, April 19, 2016.
18. Singers and dancers should plan to leave a copy of their music, on CD, with the Sound Technician for
development of a master CD for the show. Yours will be returned to you. Remember to bring your music, any
props, etc., necessary for your act!
19. Have fun coming up with you act, encourage your friends to participate and practice, practice, practice!
Dental Screening and Sealant Program
Free Dental
Exams
and
Sealant
Placement
We are again offering dental screening and sealants in partnership with the IWS
Children’s Clinic. Beye Elementary School was chosen to take part in this
project, which provides free dental exams and sealant placement.
You will receive a copy of your child’s dental exam after he/she is seen.
If you wish for your child to participate please take a few minutes to read this
letter, complete the consent form on the back of this sheet and return it to your
child’s teacher by Wednesday March 23rd 2016
Screening will take place on: April 7th and 8th 2016
Q&A
Q: What are dental sealants?
A: Dental sealants are thin plastic coatings that are put onto the chewing
surfaces of the back teeth. Sealants are painted on the top of the back teeth
and harden to form a protective shield over the tooth.
Q: Does it hurt to have sealants put on teeth?
A: No, getting sealants is painless. Right after placement, normal activities are
fine.
Q: How long will sealants last?
A: Sealants can last five to ten years if they are done right and teeth are
properly cared for after placement.
Q: How do sealants prevent cavities?
A: Dental sealants fill the pits and grooves of the teeth. The teeth are easier to
keep clean because the food is easier to brush off with your toothbrush.
Q: Is brushing still important when teeth have sealants on them?
A: Yes, brush and floss every day!
Please contact Dr. Betsy Samore (708-848-0528) if you have more questions.
Prizes
Call Us
The classroom that returns the most consent forms will receive a prize!
This program does not replace the advice or care from your regular dental
professional.
If your child does not have a dentist please contact the IWS Children’s Clinic at
(708) 848-0528 to schedule an appointment.
Thank you.
320 Lake Street - Oak Park Illinois 60302 telephone 708.848.0528 fax 708.848.5855
email [email protected] web www.childrenscliniciws.org
Detección Dental y Programa de Selladores
Gratis
exámenes
dentales
y
selladores
Estamos ofreciendo el programa de detección dental y selladores dental en
asociación con the IWS Children’s Clinic patrocinado por el Oak Park River Forest
Infant Welfare Society.
Beye Elementary School fue elegida para participar en este proyecto que
proporciona revisiones dentales gratis y colocación de selladores en las muelas
para los estudiantes de Beye. Usted recibirá una copia del examen dental
después de nuestra visita.
Si desea que su niño/a participe en este programa por favor llena el formulario
de consentimiento detrás de esta página y devuélvela al maestro de su hijo/a
antes del miércoles 23 de marzo 2016.
La revisión va ocurrir: el 7 y 8 de abril 2016
P&R
P: ¿Que son los selladores?
R: Los selladores o sellantes dentales son unas capas plásticas, delgadas, que se
aplican sobre las superficies de las muelas. Los selladores se aplican “pintando” el
diente con una capa liquida que se endurece rápidamente y forma un
recubrimiento protector.
P: ¿Causa dolor cuando se aplican los selladores?
R: La aplicación de los selladores es sencilla y no causa dolor. Inmediatamente
después de que se sequen, puede regresar a sus actividades normales.
P: ¿Por cuánto tiempo duran los selladores?
R: Selladores pueden durar hasta cinco años.
P: ¿Cómo trabajan los selladores para prevenir la caries?
R: Los selladores dentales rellenan las pequeñas grietas y ranuras de las muelas.
Es más fácil mantener las muelas limpias con los selladores puestos porque los
alimentos de comida se sacan más fáciles con usar el cepillo de dientes.
P: ¿Todavía es importante cepillarse los dientes aunque tengan selladores
puestos?
R: ¡Si, cepillase los dientes y usar el hilo dental todos los días!
Si tiene alguna otra pregunta o preocupación relacionada con los selladores
dentales, por favor llame a la Dra. Betsy Samore al (708) 848-0528.
Premios
Llámanos
La clase que devuelva más formularios de consentimiento firmadas ganara un
premio!
Este programa no sustituye los consejos ni el cuidado de su profesional dental
regular. Si su hijo/a no tiene una dentista, por favor llame the IWS Children’s Clinic
al (708) 848-0528 para hacer una cita.
Gracias.
IWS Children’s Clinic
Formulario de consentimiento del Padre/Guardián para liberación
de responsabilidad y consentimiento de tratamiento dental
Primer Nombre De Niño/A
Apellido De Niño/A
Raza
Fecha De Nacimiento
Edad
SEXO
Nombre De Padre O Guardián
Masculino
Número De Teléfono
Profesor/A
Dirección
Escuela
Ciudad, Estado, Código Postal
¿Mi Hijo/A Es Elegible Para Almuerzos
Reducidos?
SÍ NO
¿Tiene Su Hijo Tarjeta Médica? o ALL KIDS?
SÍ NO
número de identificación Será Cobrado
___ ___ ___ ___ ___ ___ ___ ___ ___
Grado
Femenino
¿Tiene Su Hijo a Seguro Dental?
SÍ
NO
Favor de apuntar cuantas personas viven en
su hogar:
Liberación de Responsabilidad para el Programa Dental. Doy mi consentimiento a the IWS Children’s Clinic patrocinado por
el Oak Park River Forest Infant Welfare Society, para proveer atención dental a mi niño/a. Por la presente, autorizo y libero
cualquier responsabilidad a the IWS Children’s Clinic and Beye Elementary , sus empleados y personales por daños y
perjuicios, por cualquier reclamo o demanda hecha por daño o enfermedad resultado del procedimiento dental. Yo he
leído y entendido este contrato y voluntariamente estoy de acuerdo con todos los términos y condiciones.
Yo entiendo que The Children’s Clinic está proviniendo estos procedimientos como un servicio público. Esta autorización
expirá cinco años apartir de la fecha. Este Programa de Servicios de Salud Dental fue proveído por the IWS Children’s Clinic
con fondos de Illinois Department of Public Health. Dentistas, Higienistas y Asistentes vendrán a la escuela de su niño con un
equipo portable para proveer los servicios. Para que su niño participe, usted DEBE completar la forma y FIRMAR abajo. Los
niños que regresen con su forma completada serán elegibles para recibir tratamiento dental. No regrese esta forma si usted
no esta interesado en los servicios.
Firma Del Padre/Guardián
Fecha
Historia Médica
Marca si su hijo/a tiene o ha tenido alguno de
los siguientes:
 Cardíaco
 Diabetes
 Epilepsia

Problemas o enfermedades de la sangre



Asma
Alergia al Látex (Goma, Plástico)
Alergias
Cuáles Alergias
Fecha de la última visita dental
Nombre del dentista familiar
¿Su hijo/a está tomando medicamentos?
SÍ NO Cuales medicamentos:
¿Qué tipo de agua toma su hijo/a?
□ de la ciudad □ embotellada □ filtrada
¿Ha tenido su hijo/a lesiones en la boca, la
cabeza o los dientes?
SÍ NO
IWS Children’s Clinic
Dental Treatment Agreement and
Parent/Guardian Release of Liability Consent Form
Child’s First Name
Child’s Last Name
Child’s Race
Date of Birth
Child’s Age
Sex
Parent/Guardian’s Name
Female or
Telephone Number
Teacher’s Name
Address
School
City, State, Zip
Is your child eligible for the Free or
Reduced Lunch Program?
YES NO
Is your child enrolled in the All Kids Program?
(Public Aid/Medical Card)
YES NO
If yes, include your child’s recipient ID number
___ ___ ___ ___ ___ ___ ___ ___ ___
Grade
Male
Is your child covered by other dental
insurance?
YES NO
How many people live in your household?
Release of Liability for the Dental Program. I give my consent for the IWS Children’s Clinic sponsored by the Oak Park River
Forest Infant Welfare Society, to provide dental care to my child. I hereby release, waive and discharge the IWS Children’s
Clinic and Beye Elementary their employees and agents, from any liability to me, my personal representatives or next of kin
for any and all damages, and any claim or demands made on account of injury or dental disease resulting from the dental
procedures. I have read and understood this agreement and voluntarily agree to all of its terms and conditions.
I understand that the IWS Children’s Clinic is providing these procedures as a public service. This authorization expires five
years from this date. This Dental Health Services Program was provided by the IWS Children’s Clinic with funding from the
Illinois Department of Public Health. Dentists and dental hygienists will come to your child’s school with portable equipment to
perform these services. In order for your child to fully participate, you MUST complete the form and SIGN below. Any child
who returns a form will be eligible to receive dental treatment. Do not return this form if you are not interested in the services.
Signature of Parent/Guardian
Date
Health History
Circle if your child has had any of the following:
 Heart Disease
 Diabetes
 Epilepsy or Seizures
 Blood Diseases or Disorders
 Asthma
 Latex Allergy
 Allergies
If yes, List Allergies:
Date of Last Dental Exam
Name of Family Dentist
Is your child taking any medications? YES NO
If yes, List Medications:
What type of water does your child drink?
□city water □ bottled water □filtered water
Has your child had injuries to mouth, head or
teeth?
YES NO

Not able to attend Beye Night? - Oak Park Elementary School

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