Chicago Public Schools School Enrollment Form

Chicago Public Schools School Enrollment Form

Rev. 01/20141
Chicago Public Schools
School Enrollment Form
School Name
Student Information
Student's siblings' names if
currently enrolled in CPS:
School Use Only:
Prevent duplicate student records. Search in SIM for an existing Student ID before
creating a new one.
Student ID#
Last Name
Gender
Personal and Immigrant
Information
Birth date
YIN
Birth Certificate on File
(when first entering CPS)
Birth Verification Type
_ .
Birth State
* Birth Country
*
Registration Grade Level
(nm/ddlyyyy)
Note to Parent/Guardian:
Your student may be eligible for
additional resources and services
if identified as born outside the
United States (US) and/or has
refugee status. Please complete
this information.
Generation (Jr., etc)
Middle Name
First Name
Birth City
Complete if student was not born in the United States (US) or one of its Territories:
Date of first enrollment in any US School:
Full Years completed school in US:
Date first entered US:
Student has refugee status:
Country of refugee:
Y/N
School Use Only Note that "Dale offirst enrollment in any US School" becomes a required field in SIM if "Birth
Country" is not the ITS or one of its Territories.
Student Address/Phone
Physical (Home) Address
Street Number and Name
Apt.
City
State
Zip Code
Street Number and Name
Apt.
City
State
Zip Code
Mailing Address
(if different than Home)
Home Phone Number
Demographic,
Home Language,
Parent/Guardian Contacts,
Emergency/Health Information
Federa l Ethnic and Race Categories:
Home Language Survey:
(Enter information into SIM from the Race and Ethnicity Survey form)
(Enter information into SIM from the Home Language Survey form)
Parent/Guardian Contacts:
(Enter information into SIM from the Request for Emergency and Health Information form)
Emergency/Health Information:
(Enter information into SIM from the Request for Emer2encv and Health Information form)
Enrollment
Enrollment Status Codes:
01 - No Former School
02 Chicago Public School
(to incl. Charter/Contract)
03 - Chicago Private School
04 - IL Public Schl, not Chicago
05 - IL Private Schl, not Chicago
06 -- US Public Schl, not Illinois
07 -- US Private Schl, not Illinois
08 - Not in USA
—
*School Transferring From
((if not a Chicago Public, Charter or Contract School)
*Is the student in good standing?
City and State
Y/N
(Instructions to school: for out-of-state public school or any private school students, a certification of "good standing" should be received
from the Parent/Guardian. Refer to CPS Policy 10-0623-P01 for more information.)
Last Chicago Public, Charter, or Contract School Attended
Is the student receiving any type of Special Education services?
Y/N
(Instructions to school: ifyes, please notify the Case Manager.)
Student Enrolled by
(Print Name and Relationship)
Date of Enrollment
Signature of Parent/Guardian
School Use Only
Enrollment Status Code (Insert a # from the left)
Grade Level
Homeroom/Division #
Rev. 01/2014
Escuelas Pliblicas de Chicago
Formulario para el Registro en Escuelas
Nombre de la escuela
School Use Only:
Informed& del estudiante
Nombres de los hermanos del
estudiante si estan matriculados
actualmente en CPS:
Prevent duplicate student records. Search in SIM for an existing Student ID before
creating a new one
ID# Estudiante
Genero
Personal and Immigrant
Information
Nota para el Padre/Tutor:
Su estudiante puede ser elegible
para recursos y servicios
adicionales si es identificado
como nacido fuera de los Estados
Unidos (EE.Utf.) y/o tiene estatus
de refugiados. Por favor Ilene
esta information.
Fecha nacimiento
Nivel de grado registrado
(mes/dta/abo)
S/N
Certificado de nacimiento archivado
GeneraciOn (Jr., etc)
Segundo nombre
Primer nombre
Apellido
(cuando ingresa a CPS por pnmera vez)
Tipo de verificacion de nacimiento
Ciudad donde naci6
Estado donde naciet
* Pais donde naci6
* Llenar si el estudiante no naciO en los Estados Unidos (EE.UU.) o alguno de sus territorios:
Fecha del primer registro en cualquier escuela de los EE.UU.:
Altos completos en escuelas de los EE.UU.:
Fecha de ingreso a los EE.UU.:
El estudiante tiene estatus de refugiado:
Pais del refugiado:
S/N
School Use Only Note that `•Dale of lint enrollment In any US School" becomes a required field in SIM if "Birth
Country' is iiqt the US or one of its Territories.
Direccidn/telefono del estudiante
DirecciOn fisica (domicilio)
Mimeo) y nombre de la calle
Apto.
Ciudad
Estado
C6digo postal
Direccilm para correspondencia
NUmero y nombre de la calle
Apto.
Ciudad
Estado
Um:lig° postal
(si es diferente al domicilio)
Telefono del domicilio
Demografla,
Idioma del hogar,
Contactos Padre/Tutor,
Informacitln de
Emergencia/Salud
Categorias federales de Etnias y Razas: (Enter information into SIM from the Race and Ethnicity Survey form)
Encuesta de Idioma del Hogar: (Enter information into SIM from the Home Language Survey form)
Contactos Padre/Tutor: (Enter information into SIM from the Request far Emergency and Health Informationform)
InformaciOn de Emergencia/Salud: (Enter information into 5154 from the Reauest for Emergency and Health Information form)
InscripclOn
C6digos de Estatus de
Inscripcien:
01 No Former School
—
02 — Chicago Public School
(to incl. Charter/Contract)
03 Chicago Private School
04 — IL Public Schl. not Chicago
05 — IL Private Schl, not Chicago
06 — US Public Schl, not Illinois
07 — US Private Schl, not Illinois
08 — Not in USA
-
*Escuela de la que es transferido
((si no es escuela palica de Chicago, Charter o por Contrato)
*i,Se encuentra el estudiante en regla?
Ciudad y Estado
S/N
(Instructions to school: for out-of-state public school or any private school students, a certification of "good standing" should be received
from the Parent/Guardian. Refer to CPS Policy 10-0623-P01 for more information.)
Ultima escuela publica de Chicago, Charter o escuela por Contrato a la que asistiO
i,Recibe el estudiante cualquier tipo de servicio de education especial?
S/N
(Instructions to school: )dyes, please notify the Case Manager.)
Estudiante registrado por
(Escriba el nombre y la relation)
Fecha de la inscripciOn
Firma del Padre/Tutor
School Use Only
Enrollment Status Code (insert a it front thC left)
Grade Level
Homeroom/Division #
Complete this Home Language Survey at the student's initial enrollment in a Chicago Public School.
Chicago
Pubic
Schools
This form must be kept in the students folder.
Area:
Unit
Room:
School:
Student ID No.:
Student Name:
English
IMPACT REGISTRATION PROCESS
(Far oaks
a#1)
1. Is a language other than English spoken in your home?
• The Non- English language identified on either
(Language)
Yes
No
If
question is the Home Language.
2. Does the student speak a language other than English?
M
Ili t ib tt kko%
H
Yes
No
. If two different non-English languages are identified,
enter the language identified in question 2 as the
(Language)
Home Language.
• Enter ENGLISH as a Home Language ONLY when
If the answer to either question is yes, the law requires the school to
both questions are answered no.
assess your child's English language profidency.
Polish
Spanish
1. i,Se habla algiln otro lenguaje que no sea
angles en su
hoilar?
No
(Lenguaje)
Sf
2. ,Habla at estudiante un league* que no sea el Incites?
[] No
[---1
,._„_1 sr
1. Czykrzyklern innym nit angielsid mowl sic w domu?
1 -1
2. Czyt uczeri mows Innym jezyldem nit angielsid?
Nie
(Lenguaje)
Si Is respuesta a cualqulera de las preguntas as
-sr, la ley requiem
questa escuela (welds la ftuidez de su Me en el Idioms 'ogles.
___
I
Talc
t
Nie
Talc
pytati, przepisywymagajs, sby szkola sprawdzila poziom znajornoici jozyka
anglelskiego waszsgo Medal.
Arabic
Chinese
1., (1*E13 )W-'*4ttlat:L41-419 —tili -'7": r
U
H
(WOO
Jeall uctzlelli Penske° twierdzirei odposiedzi na ktorelcolwiskz powytszych
I A:
2. grcEPA -ILA4ri*gr.,?,A-#) ---11,7a: A
r r T'''
r
t 741.:Skril ;Ilk 144 4.$,Pli
to g 'a )
r rX
-----"' '.:`..---
eia (
;4'74 0 ,,si AS21 ,34 )
Y (
1
)
t 2.4. :itiasii .I.41 xi_ LI ica :.„;,1 ' ,..,,...et .,-;%:, 3, ,.
r
.i.i2I
6;i3-,A ;70
f—if
04-1 (
'Y (
}
If
H
ItlAfFRIBIRME412.-11—mem---c%
-a-, 9,1110#5/Z
45M
u.lc. :'•.1,.2. aptrill cjil cAp...11 cj.• 4) via .s.; :41+*>/1 ‘:441..S 1,1i
,;43.14N1 4.i.111 fd..tile..1 ,si ilf.L15.11 .5.-1,1,1 e.tar.1 A.
RAbtltP-.119XE3AMIlif.
Bosnian/Croatian/Serbian
Urdu
1i ,t-4, ,s4,44.3.ul ts-44,Ne-Jait.rl.e..AgtAl
1. Da li se u kuti pearl na stranum jezikti
(razlititom od engleskog)?
[ } NE I WA
tjerik)
2. Da li ikenik govori neki strani jezik (razlidit od
engleskog)?
[ j NE [ 3 DA
' (jezik)
Ukoliko ste na bilo koje od ovih pitanja odgovorili so "Da", gkola
ee biti zakonski dukna da procijeni vivo znanja engleskog jezika
kod vaSeg djeteta
Moe of
Language
and
Cultural
Educalkm
Signature of School Official
(A(
)
t.14(
) 04:(
ot--;(
)
( 1-,..))
)
(ul.6)
dfr91-14/h/S.C'
44
oaite4k
Date
44.‘t,ii,e1.4.11,-,1c..4Adirt.iito
...4.4ptua„eifiji
Signature of Parent/Guardian
If the parent/guardian does not speak English and the school does not have staff who speaks the parent/guardian's language,
identify the language spoken by the parent/guardian through any assistance available in the school.
• If exact name of the language cannot be determined, enter "Other" as a temporary entry. The exact language must be
Revised:
Mar. 2009
Date
Notes:
•
ult
—j -
determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available.
• Questions or concerns, contact your Area Compliance Facilitator.
:CAC:0
SCHOOL'?
CPS
ENGLISH
Race and Ethnicity Survey
Student's Name:
Gender:
Birth Date:
School Name:
School ID:
•
INSTRUCTIONS: Plesse answer the questions below. Both cuestions must be
answered. Part A asks about the student's ethnicity and Part. B asks about the
student's race. If you decline to respond to either question, the school district is required
to provide the missing information by observer identification.
Part A. Is this student Hispanic/Latino? (A person of Cubar, Mexican, puerto Rican,
South or Central American, or other Spanish culture or origin, regardless oil race.)
Choose only one.
❑ No, not Hispanic/Latino
❑ Yes, Hispanic/Latino
The question abova is about ethnicity, not race. No matter which answer 3Dil selected, continue
and respond to the question below by marking one cr more boxes to ind.'cote what you consider
this student's race: be.
`(:)
Part B. What is the student's race? Choose one or more.
❑ American Indian or Alaska Native (A person having o,igiN in any of the
original peoples of North and South America, including Centre; ✓ , merica, and who
maintains tribal affiliation or community attachment.)
❑ Asian (A person having origins in any of the original peoples 1:11 the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.)
❑ Black or African American (A person having origins in any of the black
racial groups of Africa.)
❑ Native Hawaiian or Other Pacific Islander (A person havirg origins in any
of the original peoples of Hawaii, Guam, Samoa, or other Pacific: Islands.)
White (A per>on having origins in any of the original peoples of Europe, the
Middle East, or North Africa.)
Kiel C.
scHoot.,
CPS
SPANISH
Encuesta sobre Reza y Etnicidacl
Nombre estucFante:
Genero:
Fecha nacimiento:
Nombre escuela:
ID Escuela:
INSTRUCCIONES: Por favor responda las preguntas de la parte inferior. Ambas
orequntas deben ser respondidas. La Parte A se refiere al origen etnico d 31 estudiante,
y la Parte B a la raza. Si usted no responde, at distrito escolar debe,r6 pro'feer esa
InformaciOn basandose en la identificaciOn realizada por un observador.
Parte A. ,?,Es este estudiante Hispano/Latino? (Una persona de origen
mexicano, puertorriquerio, suciamericano o centroamericano, o de ot -a cultura Li origen
espanol sin irnportar la raza).
Escoia solarnente una.
❑ No, no HispanolLatino
E.] SI, HispanolLatinc
La pregunta anterior as sobre origen °Ink°, no raze. Sin importer la respue:iti seleccionada,
continue y responda las preguntas que siguen ahora marcando una o mas ca..iiias pare indicar
Is raze clue usted considara correspond° a/ estudiante.
Parte B. t,Cual es la raza del estudiante? Escaja una
El
0
ma's.
Indio Americana o Nativo de Alaska (Una persona cuyos origenes pertenecen
a cualquiera de los habitantes originates de Norteamerica. Sudarnerica a
Centroarnerica, y cue mantiene afiliacion tribal o vinculo comunitario),
❑ Asiatic° (Una persona cuyos origenes pertenecen a cualquiera de los
habitantes originales del lejano oriente, sudeste asiatico o subcontinente
incluyendo por ejernpio Camboya, China, India, Japan, Corea,
Pakistan, Filipinas, Tailandia y Vietnam).
❑ Negro o Afroarnericano (Una persona cuyos origenes pertenecer a
cualquiera de los g -upos negros de Africa).
❑ Nativo de Hawaii o de otras Islas del Pacifico (Una persona cuyos
origenes pertenecen a cualquiera de los habitantes originales de Hawaii, Guam,
Samoa u otras isla:; del Pacifico).
❑ Blanco (Una persona cuyos origenes pertenecen a cualquiera ce Ics habitantes
originales de Europa, Medic) Oriente o Norte de Africa).
•
Homerooin
Alpha #
(for teachers)
Chicago Public Schools
Ed. 120-(Rev. SZ2)
COMM No. 201
REQUEST FOR EMERGENCY INFORMATION
STUDENT NUMBER
PLEASE PRINT
DATE
SCHOOL
Cleveland Elementary
PARENTS/GUARDIANS: Occasionally children become ill while they are in school or they may have an accident (usually not serious). The school must have on
file information that can be used to contact you. Please give the following Information for emergency use only. if there is a char:2e in this information, please
notify the school quickly in writing.
Remove the pink copy of the RIGHTS OF HOMELESS STUDENTS and keep for your records.
ROOM
STUDENTS NAME
(Last Name)
(Middle Initial)
(First Name)
CONFIDENTIAL INFORMATION BOX 1
COMPLETE THIS BOX ONLY IF (I) IT REFLECTS YOUR CHILD'S CURRENT LIVING SITUATION; OR (2) YOUR LIVING SITUATION IF YOU ARE A YOUTH
NOT LIVING WITH A PARENT OR GUARDIAN. (Your answer Will help sceaol staff with school enrollment and may enable the student to receive additional
services.) Check one box It you eta Wing:
Dina shelter Owen relatives or others due to lack of housing D at a train or bus station. park, or in a car Din a motel/hotel, camping ground, or other
similar situation due to the lack of alternative, adequate housing Din an abandoned apartment/building CI temporarily housed In a shelter awaiting a DCFS
permanent foster care placement
School Principal: If any box Is checked, see the Homeless Education Fragrant Policy and Other Important Documents.
STUDENT
STUDENT HOME
ADDRESS
PARENT/GUAR
TELEPHONE NUMBER (
PARENT/GUARDIAN EMERGENCY INFORMATION
INFORMATION
NAME
HOME
TELEPHONE
NUMBER (
NAME
HOME
TELEPHONE
UCellular NUMBER (
Li:Pager
ADDRESS*
NAME OF
EMPLOYER
WORK PHONE
NUMBER (
)
ADDRESS OF
EMPLOYER
'Please complete, if different
D2a9er
ADDRESS'
NAME OF
EMPLOYER
WORK PHONE
NUMBER (
ADDRESS OF
EMPLOYER
student's home telephone number andror address
.
CONFIDENTIAL INFORMATION BOX
Is there a current Order of Protection or No Contact order which concerns this student: Yes
OCOular
)
No
School PrIticIpet: If "Yes" Is chocked, follow the School Boirni Policy 704.4.
Please give the name of a relative or neighbor who could he notified in case of illness or accident:
NAME
ADDRESS
TELEPHONE
RELATIONSHIP
NAME
RELATIONSHIP
ADDRESS
TELEPHONE
If we cannot reach you and feel that your family doCtor is needed, please supply this information:
FAMILY DOCTOR
DOCTOR'S TELEPHONE
DOCTORS ADDRESS
I authorize you to call my doctor, if necessary
PARENT/GUARDIAN SIGNATURE
Teacher: Give this form to each student elle beginning of each school semester and when you learn that the student's emergency information has changed.
When the form is complete, check the Information on the form with that in the preprinted Attendance Book. If necessary, make changes In the Attendance Book
and give the White Copy to the School Office. Keep the Yellow Copy for your records.
School Clerk: Give this form to each erroltIng student. Enter information in the Student information (SI) system. Use STATUF to update student's status
information. Use EIUP to enter and/or apdate student's emergency information. If one of the boxes in the Confidential Information Box 1 section is checked,
give a copy of the form to your school's Homeless Education Liaison,
Email
Email
*** Please fill in all information. As information changes please update in main office. '**
Homeroom
Alpha #
for teachers)
Ed. tilfiRev. 8-0,2)
C.•,'rorrf No. -2:c1
Eeauelas P-,ublitat de Chicago
. „SOL CITUD.DE INFORMACioN DE116117:11GE..CLA
Par favor Ilene a rnaqu;ollfa a (sane Rote de Troide
(lCuriem de, iderfllfleacian
FECHA
ESCLE.LA
PADRES./ ENCARDADOS: De. vet en tuancla foe astathentes se artfennen en fa es -ousts o puede quo sufran etgin emir:tants (sue par lo general no es serial;
Pot tat razon ea' muy Importente qua is escuela tinge esta Inforroatitn de entarponla disponible pars rItAe oedemas la=lizerfolaa usted cuanto arias. Pot favor,
facneros este informeat5o.:Ltaleilig sake -florae erf.m_Lo
i, Si surglesa fuego un cambia so la informatian provista, por favor, nonflauenas
•
!rut ediatafmnVe pot eatta.
Desprenda to oopio color fO$D can loos DEREcRoa DE LOS ESTUD/ANTES SIN ROGAR. Pal0 y archtvala o gutrdele en tan Yager acsure,
SAL
NOMSRE DEL ES'l7JD1ANTE
•
(Apellicia
Onitla4
(Nombre)
Eir...0,51U,ADD I INFORMAL:ACM CONFlOtticiAL
OMPLETS eSTA INFORIIACK5N SOLO (1), St REFLEJA LAS CONDICIONES DE VIDAACTUALES DE SU 111.1Cht4 0 ph. SUS PROMS CDNOttIONES
E VIDA, SI ES LISTED LIMAJOVEN QUE NO ESTA.ACOMPARADO/A POR UNO OE EMS PADRES. (Su .respuestele ayuciarein at personal eimsfer can fa
reetricuid y puede nue eyude a que of o fa setudienfe oxide reObir ser&its edlolonalos.) Marque una casltia a cuadrita si viva en:
❑ un refuc• O cast de familiars& a ofrw personas por felts de un luger &Ada vivIr Ca ur, 4-an a estoolort de auttbuaas, paTaus a autcannvII t un
hotel, lager per acarriOar 0 n) stunk:lea o lugares shntlates debido s la eusatela de afro lugar altamo adacuedo pare vIvir Cl un apariernerrio u adifioct
ebandaf.-,do ❑ 'Mira lunar, enlaced° tennparalrnente, en eepera de sir aeignado par 'OOPS° (Dopertarnenta de Sentlaloe pare Milos FaMiDaS. per ells
Stglas en tr41683, si Una fra. milia qua is wide.
I r_, Ireator Sscoter: 8! algune de tes oaailias toe se.taactouada cot quite el Menus! da Rec,,Iss pare la Edutecfon do leo Esti:dist-nes Sin Regal' Fijq y °teas
1 d atumentaa in-toortantee.
DIPECCION 0
DOMIC11.10 DEL
ESTUD1ANTE
Infornealan de Ernerg arch) del Padre, Madre, Encerc-ade i1 Tutor Lena!
ti6roa-Fto CE
• _TELa7OND DE LA
CASA DEL ESTUD1ANTE
information de Entergenaa del Padre, Midis, Enctugade rr if sde Lege;
NOMBRE.
NCIWERD DE
TE‘tFONO
DE LA CAEV
1:1011/18Re
. DE
NOMERD
TELEFONO
DE LA CASA*
123 Le1:7211Zedor
(NW)
ID Locailzarjor
iD Tei::fetto
Ceuta(
C1 Telefone
(pawl
°Outer
--- 3
DIRECOON*
6iReccieArk
IRE DEL
NOMBRE DE.1
ENTLEADOR
EMPLEADOR
TFONO DEL
TEL EFOND
).____
EP.1131..EADDR.L
EMPLEADOR L . )
DIRECCiON DEL.
•DIRE.CCION DEL
MIKE/AMR
EMPLEAfXsa
'Co Ittefa, par favor,. Si e$: diferentO el rxwmera de tefifend a direcc1an domtifierfe dal eetudiente.
Eli/CASS:LADD 144FORMACioWcONROFAtiAL.
I /.Existe urns Orden de Proteac(45n pkfe Pralbial6n de Centeitiffac5 ,c4n o de Contact° qua wntierne a este eatudiante?: Si
Par favor, Prov&ima .con el mare da un F ■arlentis, an:go a yealou quo Nada sarnaMicada en caw de qua' gal No% se enferfne a Ionge urn etc:ideate.
RELACION
DIRECC1ON
NOMBRE
rae...:FoNo
TELEPONO
NOMBRE
RELACION
•
rzn tato de no /content a usted.y fuese necaserlo clue su tokilea familiar esta presents, tor favor, (soffit/los Is hformar ..161 alg ■ 4e-ntec
TELEFON° DEL DOCTOR
DIRECCION Da DOCTOR
NOMBRE' DEL DOCTOR pa LA FAMILIA
Autodza flamer ml medico fartillar ss fuas naasaadd
. FIRMA DEL PADRE, MADRE, EtfnARGADO 0 TUTOR LEO.Al.
astlota?v cuando apfx-itera ea qua Ia direcan danlicHiana de Ice ague:antes ha
qatle•seineere
principlade
a
estistOntes
Uaeatrticx C este s011aitUdtiOS
. tarablaria. Cuando is SontifUd, see ourrplefsda, revise Is intarnied6n liar:fend° ufwv...1 Libra a Registro de Asistanda prolrapre,,.o. Si fuesstleatserio, hags los
omblos pertinenine an el Lifer°, a Regleiro dr3 Metartoiay hate' la etv,Aa Bianca a la China da to £eauela. 0.14iiese cote Ia eople emerilia pain sup is asthve
Entre Is Inf°"13aart an et Sistes"a
.
cf guarde. Saaretarlafa Ev.miar: Li*eta soltottaci s redo astiglianta qua sea matrIVadohl par yea Primera W, +. 13auala
err/a • •
de Informeclon dot Estudlente ("Sr', par sue Ogles era ingft). Use 'SrFtruP, pert ectitelizar Inlormen166 eStudlente. Use 'i iL r! pare ant- o'n Canfiderialid sea neareada,
vatuaker Is irearrnnaii3r1 de ernergetaiw dal esiudiatite. S1 urns de les oa.litas o osolllis bajo, el EnteallIatto I de Infarrne41
ur.a copia de la solialtud a le Perwns Due sue calla Enlace con le ORaIna de Eduaacitn de Estvdiatitzi Sirs Roger Ffjo (i4ornWoe, Educate?: Lis/son).
rr eC) `ie etrOrrl
CV
/•
ei.)treD C./Ceti-0,n k.0
1
Flo
j!ar Esualar: SI se he merceda co sell:ix/Outdo "Sd" poi r;?.siluesta,. Mae La Regla dela Junta de Educeti&r. 7(.4.4
Filres
•
FOR USE IN DCFS LICENSED CHILD CARE FACEJTIES
CFS 600
Rev 2/2013
State of Illinois
Certificate of Child Health Examination
Birth Date
Student's Name
Las t
a•
First
Middle
,
■
DC1FSM
Race/Ethnicity
Sex
School /Grade Level/ID#
Month/Day./Year
Tole hone # Have
ParcetiGuardian
k
Work
IMMUNiZATiONS: To he completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot
determine if the vaccine was given after the minimum interval or age. if a specific vaccine is medically contraindicated, a separate written statement must be
∎ 1 - the medical reason fur the contraindication_
attached ex I
■
DTP or DTaP
Tdap; Td or Pediatric
DT (Check specific type)
Polio
(Check speci ti c
MO DA YR
MO DA YR
MO UA YR
MU DA YR
1110 U.4 YR
MO UA Y"R
❑ Tdap❑Td❑DT
❑ rdap ❑Td❑DT
❑ Ttlap❑Td0DT
❑ Tdap❑Td❑DT
0 Tdap0TdODT
❑ Tdap ❑Td ❑DT
❑ IPV ❑ OPV
❑ WV ❑ OPV
❑ IPV ❑ OPV
❑ IPV ❑ OPV
❑ IPV ❑ OPV
❑ IPV ❑ OPV
type)
nib Haemophilus
influenza type b
' '*--
Hepatitis B (HB)
-l
COMMENTS:
Varicella
(Chickenpox)
MMR Combined
Measles Mumps. Rubella
Measles
Single Antigen
Rubella
Mumps
Vaccines
Pneumococcal
Conjugate
Other/Specify
Meningococcal, „
Hepatitis A, HPV,
influenza
Health care provider (MD, DO, APN, PA, school health professional, health official verifying above
intmunization history must sign below. I adding dates
to the above immunization history section, put your initials by date(s) and sign here.)
Signature
Title
Date
Sim ature
ALTERNATIVE PROOF OF IMMUNITY
Title
Date
I. Clinical diagnosis is acceptable if verified by physician.
•(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)
Physician's Signature
VARICELLA mu DA YR
*MEASLES (Rubeola) Nto DA YR MUMPS MO DA YR
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.
Person signing below is verifying that the parent/guardian's description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.
Signature
Date of Disease
3. Laboratory
Lab Results
confirmation (check one) DMeasles
Date
Date
Title
0Mumps
MO
on
0Hepatitis B
DRubella
CiVaricella
(Attach copy of lab result)
YR
VISION AND HEARING SCREENING BY IDPII CERTIFIED SCREENING TECHNICIAN
Date
Code:
Age/
Grade
R
L
II
L.
R
L
Vision
Hearing
1L444-4737 (R-02-13)
(COMPLETE BOTH SIDES)
R
L
R
L
R
L
P = Pass
F = Fail
U= Unable to test
R = Referred
G/C =
Classes/Contacts
Printed by Authority of the State of illinois
Grade
Level/
'
ID
reboot
'Sex
!Birth Date
First
I Last
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
HEALTH HISTORY
ALLERGIES
Month/Day' Year
Wale
MEDICATION
(Food, drug, insect, other)
(List all prescribed or taken on a regular basis.
Diagnosis of asthma?
Child wakes during night coughing?
Yes
Yes
No
Loss of function of one of paired
No
organs? (eye/ear/kidney/testicle)
Birth defects?
Yes
No
Developmental delay?
Yes
No
Hospitalizations?
Blood disorders? Hemophilia,
Sickle Cell, Other? Explain.
Diabetes?
Yes
No
Yes
No
Surgery? (List all.)
When? What for?
Serious injury or illness?
Head injury/Concussion/Passed out?
Yes
No
TB skin test positive (past/present)?
Yes
No
Yes
No
Yes
No
. Yes
No
When? What for?
Yes*
No
Seizures? What are they like?
Ycs
No
TB disease (past or present)?
Yes*
No
Heart problem/Shormess of breath?
Yes
No
Tobacco use (type, frequency)?
Yes
No
Heart murmur/High blood pressure?
Yes
No
Alcohol/Drug use!
Yes
No
Family history of sudden death
before age 51)? (Cause?)
Yes
No
Yes
No
Dizziness or chest pain with
exercise?
Eye/Vision problems?
Glasses ❑ Contacts ❑ Last exam by eye doctor
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Yes
Ear/Hearing problems?
No_.I
Bone/Joint problem/injury/scoliosis?
[Yes
Dental
0 Braces
*If yes, refer to local health
department.
❑ Plate Other
❑ Bridge
Tnformation may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
No
Date
Signature
Entire section below to be completed by MD/DO/APN/PA
BMI
HEIGHT
WEIGHT
PHYSICAL EXAMINATION REQUIREMENTS
HEAD CIRCUMFERENCE if < 2-3 years old
B/P
And any two of the following: Family History Yes ❑ No ❑
DIABETES SCREENING (NOT REQUIRED FOR 1MV CARE) BVII>85% age/sex Yes❑ No❑
Ethnic Minority Yes❑ No ❑ Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans)Yes0 No ❑ At Risk Yes ❑ No ❑
LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school
and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.)
Result
Blood Test Date
Questionnaire Administered ? Yes ❑ No ❑
Blood Test Indicated? Yes 0 No ❑
TB SKIN OR BLOOD TEST Recommended only tar children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent ravel to or bunt
Test performed ❑
in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines.
No test needed ❑
mm
Skin Test: Date Read
/ /
Result: Positive ❑ Negative ❑
Blood Test: Date Reported
/ /
Value
Result: Positive ❑ Negative ❑
4
.
LAB TESTS (Recommended)
Date
Hemoglobin
emoglobin or Hematocrit
Sickle Cell (when indicated)
Urinalysis
Developmental Screening Tool
SYSTEM REVIEW
Results
Date
Results
..-
Normal Comments/Follow-up/Needs
Normal Comments/Follow-up/Needs
Skin
Ears
Endocrine
Gastrointestinal
Eyes
Amblyopia Yes❑
LW'
Genito-Urinary
No❑
Nose
Neurological
Throat
Musculoskeletal
Spinal Exam
Mouth/Dental
Cardiovascular/HTN
Nutritional status
❑ Diagnosis of Asthma
Respiratory
Mental Health
Currently Prescribed Asthma Medication:
❑ Quick-relief medication (e.g. Short Acting Beta Agonist)
Other
❑ Controller medication (e.g. inhaled corticasteroid)
NEEDS/MODIFICATIONS required in the school setting
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup
MENTAL HEALTH/OTHER
Is there anything else the school should know about this student?
if you would like to discuss this student's health with school or school health personnel, check title:
❑ Nurse
❑ Teacher
❑ Counselor
❑ Principal
EMERGENCY ACTION needed while at school due to child's health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?
Yes ❑
No ❑
If yes, please describe.
On the basis of the examination on this day, I approve this child's participation in
PHYSICAL EDUCATION
Yes ❑
NO ❑
Print Name
Address
(if No or Modified please attach explanation.)
Modified ❑
INTERSCHOLASTIC SPORTS
(MD,DO, APN, PA)
.
Signature
Phone
(Complete Both Sides)
Yes 0
No ❑
Date
Limited ❑
Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student's Name:
Address:
First
Last
ZIP Code
City
Street
i1 Birth Date:
Middle
I Telephone:
Gender:
Grade Level:
Name of School:
(MonthiDayNear)
0 Male L0 Female
Address (of parent/guardian):
Parent or Guardian:
To be completed by dentist:
Oral Health Status (check all that apply)
El Yes
❑ No
Dental Sealants Present
11 Yes E No
Caries Experience f Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it was
extract e d as a result of caries OR missing permanent is' molars.
23 Yes E No
Untreated Caries — At least 1/2 mm of tooth structure toss at the enamel surface. Brown to dark-brown coloration of the
walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained
root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings. are considered sound unless a cavitated lesion is also oreserc.
Soft Tissue Pathology
2 Yes El No
-
Yes
Malocclusion
No
Treatment Needs (check all that apply)
❑
Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
Restorative Care — amalgams, composites, crowns, etc.
7: Preventive Care — sealants, fluoride treatment, prophylaxis
Ei
Other — periodontal, orthodontic:
Please note
Signature of Dentist
Date
ess
Telephone
Street
City
ZIP Code
Illinois Department of Public Health, Division of Oral Health, 535 W. Jefferson St., Springfield, IL 62761
217-785-4899 TTY (hearing impaired use only) 800-547-0466 • \Antvw.idph.state.il.us
:=rinted by Authority of the State of Illinois
P.0.4S413 0. 86
Departamento de Salud PUblica de Illinois
FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR
Para ser completado por el padre/madre (por favor impresion):
Nombre del Estudiante:
Apellido
!nide!
Nombre
Fecha de Nacimiento:
/
,,
(MasiDfalAno)
Direccion:
Calle
Cddigo Postal
Ciudad
Nombre de la Escuela:
Sexo:
Grado:
Nombre del padre/madre o encargado:
%mem de Telefono:
0 M a s c u lino
0 Femenino
jDireccion del padre/madre o encargado:
To be completed by dentist: (Para ser completado por el dentista:)
Oral Health Status (check all that apply)
Yes
❑
No
Dental Sealants Present
73 Yes
❑
No
Caries Experience I Restoration History —
❑
A filling (temporary/permanent) OR a tooth that is missing because it was
extracted as a result of caries OR missing permanent 1s' molars.
:11 Yes
Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the
walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained
root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-
No
ered sound unless a cavitated lesion is also oresen:.
❑ No
▪ Yes
Soft Tissue Pathology
Malocclusion
.0 Yes IL: No
Treatment Needs (check all that apply)
Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swellinc
73 Restorative Care —
amalgams, composites, crowns, etc.
11 Preventive Care — sealants, fluoride
El Other —
treatment, prophylaxis
periodontal, orthodontic
Please note
Date
Signature of Dentist
Telephone
Address
Street
City
ZIP Cove_
Departamento de Salud PUblica de Illinois, Division de la Salud Oral
217-7854899 • TTY (solo pars personas con impedimento auditivo) 800-547-0466 • www.idph.state.il.us
,:npreso con Autoridad del Estado de Illinois
Office of Student Health and Wellness
125 South Clark Street, 9th Floor • Chicago, Illinois 60603
Telephone: 773-553-1886 •Fax: 773-553-1883
Office Use Only
Reviewed by:
Follow up:
Documents received:
Student Medical Information 2014/2015 School Year
INFORMATION MUST BE UPDATED AND SUBMITTED ANNUALLY AT THE BEGINNING OF THE SCHOOL YEAR
PLEASE LRINT AiAA0L
INJALQ
and RETURN FORM TO SCHOOL
1
IN F ORMATION
SCHOOL NAME:
Student Name:
Homeroom:
Grade:
Date of Birth:
To ensure the safety of your child during the school day, extracurricular activities, on any field trip, and when being
transported by CPS it is important that the school is aware of any health conditions that may impact your child. We
are asking you to please complete this form. For confidentiality purposes, this information will only be shared with
relevant CPS staff. Thank you for your cooperation in this important matter.
Please indicate with a check below if applicable:
❑ Food Allergies: (Type)
❑ Other Allergies: (Type)
❑ Asthma
❑ Diabetes: Type 1 ❑
Type 2 ❑
❑ Seizures
❑ Other Medical Condition
❑ My child has NO allergies, medical conditions and/or does not take any
medications during school hours
❑ My child has a primary healthcare provider (e.g., Doctor, Nurse Practitioner,
Physician Assistant, etc.)
For any medical condition identified above which requires a prescribed medication be available and taken by your
child during school hours, please include an Action Plan (Emergency, Asthma, or Diabetes) and/or verification
of condition signed by a medical provider, which includes signs and symptoms of episode, what medication is to
be given during school hours, including medication frequency, and any emergency procedures to be taken. You can
request an Action Plan from your primary healthcare provider. Your child may qualify for a 504 Plan due to his/her
condition; make sure you follow up with your school nurse and/or case manager once you have submitted this form.
Parent Name (Please Print):
Date:
Parent Signature:
Phone number:
E-mail:
Revised: June 1, 2013
Educate • Inspire • Transform
Office of Student Health and Wellness
125 South Clark Street, 9th Floor • Chicago, Illinois 60603
Telephone: 773-553-1886 • Fax: 773-553-1883
Office Use Only
Reviewed by:
Follow up:
Documents received:
InformaciOn medica del estudiante Aiio escolar 2014/2015
LA INFORMACION DEBE SER ACTUALIZADA Y PRESENTADA ANUALMENTE AL COMIENZO DEL ARO ESCOLAR
ESC
•i•
EN LET
E IMP NTA DEVUELVA EL O •
ARIO A A E UE A
NOMBRE DELA ESCUELA:
Nombre del estudiante:
Fecha nacimiento:
Grado:
Salon:
Para asegurar la seguridad de su nino durante el dia escolar, actividades extracurriculares, viajes de estudio y
cuando es transportado por CPS, es importante que la escuela este informada de cualquier condiciOn de salud que
pueda afectar al MAO. Le pedimos que complete este formulario. Por razones de confidencialidad, esta information
solamente sera compartida con el personal relevante de CPS. Gracias por su cooperaciOn en este importante asunto.
Por favor, sefiale abajo si es aplicable:
❑
❑
❑
❑
❑
❑
Alergias alimenticias: (Tipo)
Otras alergias: (Tipo)
Asma
Diabetes: Tipo 1 ❑
Tipo 2 ❑
Convulsiones
Otra condicion medica
❑ Mi nifio 1 Q tiene alergias, o condicion medica y no toma ninguna medicina
durante las horas de escuela
• Mi nifio tiene un proveedor medico primario (ej., medico, enfermero practicante,
asistente medico, etc.)
Por cualquier condiciOn medica identificada arriba que requiera una medicina de receta disponible y administrada
a su nitio durante las horas de escuela, por favor incluya un Plan de Accion (Einergencia, Asma o Diabetes) y/
o una verification de condicion firmado por un proveedor medico, que incluya sefiales y sintomas del episodic).
que medication debe recibir durante las horas de escuela, incluyendo la frecuencia, y cualquier procedimiento de
emergencia a ser tornado. Usted puede solicitar un Plan de Accion a su proveedor primario de salud. Su nifio puede
calificar para un Plan 504 debido a su condicion; asegOrese de hacer el seguimiento con la enfermeria de su escuela
y/o la persona encargada de casos una vez que haya presentado este formulario.
Fecha:
Nombre del padre (Letra imprenta):
Firma del padre:
Numero de telefono:
Correo eleetronico:
Revisado: 1 de junio, 2013
Educate • Inspire • Ti ansfOrm
CLEVELAND SCHOOL
Debora Ward, Principal
Robert Staszczak, Asst.Prindpal
__tz Cleveland Elementary School
Chicago Public Schools
3121 W. Byron Street
Chicago, Illinois 60518
CHICAGO PU LTC CHOOLS
Dear Parents,
Please mark with an X the language in which you prefer to receive your child's
report card, Please sigp the form.
Room
Name of child
English
Spanish
Other
Report cards will be provided in those native languages
where translations are available.
Signature of parent or guar
Estimados padres de familia,
Favor de marcar con una X el idicdna en el cual quisieran recihir las califacaciones
de su hijo/a. Favor de firmar esta forma.
Salon
Nombre del nifiola
Ingles
Espanol
Firma del padre o tutor legal
773-534-5130
office Number
773-534-5266
Fax Number
www.clevelandschool.org
WebsIte
Chicago Public Schools
Media Consent Form and Release
Consent/Release
I hereby consent to have my student photographed, video taped, audio taped and/or interviewed by the Board or the news
media when school is in session or when my child is under the supervision of the Board. I understand that during the
school year, the Board might like to celebrate my child's accomplishments and work. Therefore, I further consent to
allow the Board to release my student's name, academic/non-academic awards, and information concerning my child's
participation in school-sponsored activities, organizations and athletics.
I also consent to the Board's use of my student's name, photograph or likeness, voice or creative work(s) on the Internet
or on a CD or any other electronic/digital media or print media.
As the child's parent or legal guardian, I agree to release and hold harmless the Board, its members, trustees, agents,
officers, contractors, volunteers and employees from and against any and all claims, demands, actions, complaints, suits or
other forms of liability that shall arise out of or by reason of, or be caused by the use of my child's name, photograph or
likeness, voice or creative work(s), on television, radio or motion pictures, or on the Internet, or on a CD, or any other
electronic/digital media or print media.
It is further understood and I do agree that no monies or other consideration in any form, including reimbursement for any
expenses incurred by me or my child, will become due to me, my child, our heirs, agents, or assigns at any time because
of my child's participation in any of the above activities or the above-described use of my child's name, photograph or
likeness, voice or creative work(s).
I understand that T may cancel this release by providing written notice to the principal. I also understand that this release
is valid for one school year, including the following summer.
Instructions: Check Box #1 or Box #2
1.
❑
I consent as outlined in the above consent/release section.
2.
❑
I DO NOT consent to my child being photographed, video taped, audio taped and/or interviewed by the Board
or the news media when school is in session or when my child is under the supervision of the Board.
Furthermore. I do not consent for the Board to release my student's name, academic/non-academic awards,
and information concerning my child's participation in school-sponsored activities, organizations and
athletics. I do not consent for the Board to use my student's name, photograph or likeness, voice or creative
work(s) on the Internet or on a CD or any other electronic/digital media or print media.
Signature of Parent/Guardian/Student if age 18 or older Printed Name of Parent/Guardian/Student if age 18 or older
Student's Name
Student ID t
Date
School
I understand that I have the right to inspect and copy my student's records, challenge the contents of such records; and
limit my consent to the designated records or designated portions of information within the records.
Department of Policy and Procedures
July 2012
CHCCAC 0
PUBLIC
- SCHOOLS
Escuelas Ptiblicas de Chicago
Consentimiento de prensa y dispensa de responsabilidad
Consentimiento/Dispensa
Pot- la presente autorizo a que tni estudiante sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta de
Education de Chicago o por medios de prensa cuando Ia escuela este funcionando o cuando el nitio se encuentre bajo Ia supervision de
la Junta. Entiendo que en el curso del atio escolar la Junta quiera celebrar los logros y el trabajo de mi nino. Por to tanto, tarnbien
autorizo a la Junta la divulgaeion del nombre de mi nitio, de sus premios academicos y no academicos y de information relacionada
con su participation en actividades auspiciadas por la escuela, organizaciones y deportes.
Tambien autorizo a Ia Junta el uso de fotografias o retratos de mi nino, o de su voz o trabajo creativo, en Internet o en un CD
educativo, o en cualquier otro medio electronico/digital o impreso.
Como padre o tutor legal del nifto, libero de toda responsabilidad a Ia Junta, a sus tniembros, sindicos, agentes, oficiales, contratistas,
voluntarios y empleados ante cualquiera y todos los reclamos, demandas, acciones, quejas, juicios u otras formas de responsabilidad
que puedan surgir por cualquier razOn, o puedan ser causadas por el uso del trabajo creativo, fotografia, retrato o voz en television,
radio o peliculas, o en medios impresos, Internet o cualquier otro medio electrOnico/digital.
Es entendido ademas, y estoy de acuerdo, en que no se me debe a mi, a mi Milo, a nuestros herederos, agentes o designados ningim
dinero o consideration de ninguna especie, incluyendo el reembolso de cualquier gasto realizado por mi o por mi nirio durante la
participation en cualquiera de las actividades mencionadas, o por el uso de su trabajo creativo, fotografias, retrato o voz.
Entiendo que puedo cancelar este consentimiento mediante una comunicacion por escrito al director escolar. Tambien entiendo que
esta dispensa es valida por un afio escolar, incluyendo el verano siguiente.
Instrucciones: marque la caja #1 o caja #2
1.
❑ Autorizo lo sefialado arriba en la section consentirniento/dispensa.
2.
0 NO autorizo que mi nifio sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta o por medios
de prensa cuando la escuela este funcionando o cuando el nifio se encuentre bajo La supervision de Ia Junta Tampoco autorizo
que la Junta divulgue el nombre de mi nifio, sus premios academicos y no academicos e informaciOn relacionada con su
participaciOn en actividades auspiciadas por la escuela, organizaciones y deportes. No autorizo a la Junta el uso del nombre
de mi estudiante, fotografias o retratos, de su voz o trabajo creativo en Internet o en un CD educativo, o en cualquier otro
medio electrOnico/digital o impreso.
Firma padre o tutor, o del estudiante si tiene 18 afios o mas
Nombre en imprenta del padre o tutor, o del estudiante si
tiene 18 afios o mas
Nombre del estudiante
NOmero de ID del estudiante
Fecha
Escuela
Entiendo que tengo el derecho de inspeceionar y copiar los registros de mi estudiante, de disputar el contenido de dichos registros; y
limito mi consentimiento a los registros designados o porciones designadas de information contenida en los registros.
Departamento de Politica y Procedimientos
Julio 2012
Chicago Public Schools
Grover Cleveland School (2800)
NCLB Title I School- Parent Compact
School Year
As a student I promise to attend school
regularly and arrive on time.
As a parent/ Legal Guardian I promise to
have high expectations for my child.
As a teacher I promise to look at each child
as an individual
As an administrator I promise to show that
I care about all students.
2014/2015
Como Estudiante yo prometo asistir a
clases regularmente.
Como Padre/Tutor yo prometo tener una
expectative alta.
Como Maestra/Maestro yo prometetratar a
cada estudiante individualmente.
Como Administrador yo prometo
demonstrar mi interes a cada estudiante.
Signature/ Firma Student
Date/Fecha:
Signature/Firma:
Parent
Date/Fecha:
Signature/Firma:
Teacher
Date/Fecha:
Signature/ Firma
Administrator
Date/Fecha:
tic
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UN
E OBLIGATORIO PARA LOS ES - Mb
rt
DE LA ESCUELA CLE 'ELAND
rf•
\--1
Camisas o franelas blancas con mangos,
1
SI .
Pantalones, faldas, jumpers, o
pantalones para hocer ejercicios de
color and marina a negro.
Camisas tipo polo, blusas, sucteres o
Cuello de tortuga blancos.
PARA EL SIMNASSO: PaWalone$ con el logo de la escueia Cleveland, pantalanes carton,
parlalones pa m. hacer ejercicim: de color azul merino a negrv, y camisa o framela blancc..
ZAPATe_75 DEPORTI-VO:5.
No vestimenta o cUadros, con mos,
con fiores, con eslogan, con logos,
o con munequitos.
FECHA:
FIRMA:
0\11 0
pt,
:4.
No pantclones blue jeans (mexclilla), a
pantalones muy cortos, faldas muy cortos,
camisas sabre ombligo a camisetas sin
mangos.
Student Fee
$25.00
June 2, 2014
Dear Parent's and Guardians,
I think that you have heard by now that there is a serious crisis with funding education for
the State of Illinois. Currently, the State of Illinois has not paid their bills for the last
quarter. This crisis has begun to affect us at the school level. We will have significantly
less money to operate the school than we usually do. The Local School Council and I are
truly concerned about the lack of resources that will be available to our students. In order
to offset some of these losses and for the best interest of our students we have decided to
charge a $25.00 mandatory student fee for each student.. The student fee will cover the
cost of a student agenda book, a math workbook and a reading workbook. Cleveland is a
wonderful school with dedicated staff and wonderful parents. Thank You for your
understanding in this matter. As always, please feel free to contact us with any questions
or concerns.
Sincerely,
2
Debora Ward
Principal
Cleveland School
Enclosed is $25.00 to cover the cost of the student fee.
Student's name
Room Number
Junio 2, 2014
Estimados Padres y/o Tutor Legal,
Pienso que ya han escuchado que existes una crisis severa con los fondos destinados para
la educacion en el Estado de Illinois. El Estado de Illinois actualmente no ha pagado las
deudas del ultimo cuadro. Esta crisis ya ha comenzado a afectarnos a nivel escolar. Ya
nos dijeron que para el proximo alio los salones de clase tendran 35 estudiantes cada uno.
El Kindergarten tambien cambiara a un programa de medio dia. Todos los programas
despues de la escuela de las Escuelas Publicas de Chicago, inciuyendo los de deportes
han sido eliminados. La mayoria de los programas de las artes no se ofreceran.
Tendrernos una cantidad significativa menos de la regular para operar la escuela. El
Concilio Local de la Escuela y yo realmente estamos preocupados por la falta de recursos
disponibles para nuestros estudiantes. Para poder compensar estas perdidas con el mejor
de los intereses de nuestros estudiantes en mente hemos decidido cobrar una cuota
obligatoria de $25.00 por cada estudiante para el proximo afio escolar. Esta cantidad
cubrird el costo de la agenda y el libro de trabajo de matematicas o el de lectura de cada
estudiante. Cleveland es una escuela maravillosa con un personal docente dedicado y
unos padres maravillosos. Gracias por su comprension en este asunto. Y como siempre,
favor de sentirse con toda la confianza para comunicarse con nosotros para cualquier
pregunta o inquietud. Que tengan un gran verano!
Sinceramente,
Debora Ward,
Directora de la
Escuela Cleveland
RIGHTS OF HOMELESS STUDENTS
The Chicago Public Schools shall provide an educational environment that treats all students with dignity and respect. Every CPS
homeless student shall have equal access to the same free and appropriate educational opportunities as students who are not
homeless. This commitment to the educational rights of homeless children, youth, and youth not living with a parent or guardian,
applies to all services, programs, and activities provided or made available by the CPS.
A student is considered "homeless" if he or she is presently living:
* in a shelter * sharing housing with relatives or others due to lack of housing
* in a motel/hotel, camping ground, or similar situation due to lack of alternative, adequate housing
* at a train or bus station, park, or in a car * in an abandoned building
* temporarily housed while awaiting DCFS foster care placement
All Homeless Students Have Rights To:
•
Immediate school enrollment. A school must immediately enroll students even ilthey lack health, immunization or school
records, proof of guardianship, or proof of residency.
•
Enroll in:
*the school he/she attended when permanently housed (school of origin)
*the school in which he/she was last enrolled (school of origin)
*any school that non-homeless students living in the same attendance area in which the homeless
child or youth is actually living are eligible to attend.
•
Remain enrolled in his/her selected school for as long as he/she remains homeless or, if the student becomes permanently
housed, until the end of the academic year. Academic success is helped when the student remains in the same school.
•
Priority in certain preschool programs. Parents or guardians are encouraged to seek enrollment in these programs.
•
Participate in a tutorial-instructional support program, school-related activities, and/or receive other support services.
Obtain information regarding how to get fee waivers, free uniforms, and low-cost or free medical referrals.
•
Transportation services: A homeless student attending his/her school of origin has a right to transportation to go to and
from the school of origin as long as (s)he is homeless or, if the student becomes permanently housed, until the end of the
academic year. CPS staff shall inform homeless parents/guardians or youth of transportation services to and from school and
school-related activities.
Types of transportation services:
* For homeless students:
CTA transit cards, transfer fares, and if a student is age 12 years or older a CTA riding permit
* For parents of homeless students:
- CTA transit cards for a parent/guardian of homeless Pre-K to Grade 6 students to accompany them to/from school
* For preschool through 6th grade, alternative transportation such as busing in parental "hardship" situations where
documentation is provided. Examples of "hardship" situations are:
- parent employment, job training, or educational program
- mental and/or physical disability
- children need to be transported to/from schools at different locations
- rules of shelter or similar facility will not permit parent/guardian to leave to transport children to/from school
- court order, DCFS, or DCFS contract agent requires activities that do not enable parent/guardian to transport children
to/from school
- other good cause why parent/guardian cannot use public transportation to transport children to/from school
Dispute Resolution: If you disagree with school officials about enrollment, transportation or fair treatment of a homeless child or
youth, you may file a complaint with the principal. The principal must respond and attempt to resolve it quickly. The principal must
refer you to free and low cost legal services to help you, if you wish. During the dispute, the student must be immediately enrolled in
the school and provided transportation until the matter in resolved. The Homeless Education Dispute Resolution Process Form is
available at all Chicago Public Schools and offices, including the Department of Educational Support for Students in Temporary
Living Situations (773) 553-2242.
Every Chicago Public School has a Students in Temporary Living Situations (STLS) Liaison who will assist you in making enrollment
and placement decisions, providing notice of any appeal process, and filling out dispute forms. If you have questions about
enrollment in school, or want more information about the rights of homeless students in the Chicago Public Schools, call the CPS
Department of Educational Support for Students in Temporary Living Situations at (773) 553-2242 or the Chicago Public Schools at
(773) 553-1000. If you want more information about the tights of homeless students in Illinois, call the Illinois State Board of
Education at (1-800) 215-6379.
DERECHOS DE LOS ESTUDIANTES
SIN HOGAR
Las Escuelas Pablicas de Chicago proveeran un ambiente educativo que trate a todos los estudiantes con dignidad
y re sp e to. Cada alumno sin hogar de CPS tendra acceso igualitario a las mismas oportunidades educativas gratuitas y
apropiadas que los demas. Este compromiso con los derechos educativos de los nifios y javenes sin hogar, y javenes que no viven con
un padre o tutor, se aplica a todos los servicios, programas y actividades ofrecidas o hechas disponibles por CPS.
Un estudiante es considerado "sin hogar" s i en la actual i da d vive:
* en un refugio * comparte alojamiento con familiares u otros debido a la falta de un techo fijo
* en un motel/hotel, campamento o situacion similar, debido a la falta de alojamiento alternativo, adecuado
* en una estacion de trenes o de autobuses, parque o automOvil * en un edificio abandonado
* alojado temporalmente mientras aguarda ubicacion por DCFS (Servicios a Nitios y Familiak) en un hogar temporario
Todos los estudiantes sin hogar tienen derecho a:
•
Matriculation inmediata en una escuela. La escuela deben inscribirlos inmediatamente aim cuando carezcan de registros
de salud o de vacunas, prueba de tutela o de domicilio.
•
Matricularse en:
*la escuela a la que asistian cuando tenian vivienda permanente (escuela de origen)
*la altima escuela en la que estuvieron inscriptos (escuela de origen)
*cualquier escuela en la que sewn elegibles los nifios o javenes de la misma area de asistencia.
•
Permanecer inscripto en la escuela elegida durante el tiempo que permanezca sin hogar, o si el estudiante consigue
vivienda permanente, hasta el fin del afio academic°. El exito academic° es ayudado cuando el estudiante permanece en la
misma escuela.
•
Prioridad en ciertos programas preescolares. Se alienta a padres y tutores a buscar inscription en esos programas.
• Participar en programas de tutorias-apoyo de instruction, actividades escolares relacionadas y/o a recibir otros servicios de
apoyo.
•
Obtener information relacionada a dispensas y unifomtes gratuitos, ademis de servicios medicos de bajo costo o gratuitos.
•
Servicios de transporte: Un estudiante sin hogar que asista a su escuela de origen tiene el derecho a recibir transporte hacia
y desde la escuela de origen durante el tiempo en que permanezca en esa situation, 0, si el estudiante consigue alojamiento
permartente, hasta el fin del ano academic°. Personal de CPS debe informar a los padres/tutores de los estudiantes sin
alojamiento sabre los servicios de transporte hacia y desde la escuela, y para las actividades escolares relacionadas.
Tipos de servicios de transporte:
* Para los estudiantes sin hogar:
- Tarjetas de transit° de CTA, transferencias, y si el estudiante tiene 12 alias a mas, el permiso para viajar en CTA
* Para los padres de estudiantes sin hogar:
Tarjetas de transit° de CTA para que los padres/tutores de estudiantes sin hogar acompaiien hacia y desde la escuela a
niiios desde preescolares al 6°. Grado
* Para preescolares al 6o. grade, transporte alternativo coma autobuses en los casos de padres en "dificultades"
documentadas. Ejemplos de situaciones dificiles son:
- empleo de los padres, capacitation laboral o programa educativo
- discapacidad mental y/o fisica
- nifios que necesiten ser transportados desde y hacia la escuela en lugares diferentes
- reglas del refugio o instalacion similar que no permitan salir al padre/tutor para transportar al nifia hacia a desde in escuela
- orden de la carte, de DCFS o contrato de un agente del DCFS que requiera actividades que no permitan al
padre/tutor transportar al niflo hacia y desde la escuela
- otra causa valida por la cual el padre/tutor no pueda usar el transporte public° para llevar y traer al nitio de la escuela
Solution de disputas: Si usted no esti de acuerdo con las autoridades escolares sobre la matricula, transporte o tratamiento justo de
un nino o joven sin domicilio, puede presentar una queja al director. Este debe responder e intentar resolverlo rapidamente. El
director debe referirlo a servicios legates gratuitos o de bajo costo para que to ayuden, si asi lo desea. Durante la disputa, el estudiante
debe ser matriculado inmediatamente en la escuela y recibir transporte hasta que el tema sea resuelto. El Formulario del Proceso para
Resolver Disputas esta disponible en todas las escuelas pablicas de Chicago y oficinas, incluyendo el Departamento de Apoyos
Educativos para Estudiantes en Situaciones Temporales de Vivienda (773) 553-2242.
Cada escuela pablica de Chicago tiene un enlace para los Estudiantes en Situaciones Temporales de Vivienda (STLS) que lo apadard
con las decisiones de matricula y ubicacion, le informard sobre el proceso de apelacion y con el Ilenado de los formularies de disputa.
Si tiene alguna pregunta sabre la matricula escolar, o quiere saber mas sabre los derechos de los estudiantes sin hogar en las Escuelas
Pablicas de Chicago, llame al Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda al (773)
553-2242, o al liftmen) de las oficinas centrales (773)553-1000. Si necesita mas information sabre los derechos de los estudiantes sin
hogar en Illinois, llame a la Junta de Education de Illinois por el (1-800) 215-6379.