1 Van Buren School District Beginning of School Electronic Forms This packet is an alternative collection of forms and documents to help replace the original forms sent home with your child on the first week of school. If you need another copy of the take home documents you can print this packet out in its entirety or print just the forms that you are missing. If you have any question regarding any form in this packet, please contact your child s school.
2 VAN BUREN SCHOOL DISTRICT HEALTH SERVICES Return these forms only if you DO NOT want your child to participate in one or both of the screenings BMI SCREENING Act 1220 of 2003, is an act passed by the Arkansas General Assembly to coordinate statewide efforts to combat childhood obesity and related illnesses and to improve the health of the next generation of Arkansans. Sometime during the school year, the District nurses will conduct this BMI screening. This screening will be done at each individual school and every effort to protect your child s privacy will be taken. You will be notified when the results are available. If you want your child to participate, do nothing. If you do NOT want your child to participate in this screening process, fill out the form below and return to your child s school tomorrow. If you have any questions, contact your school nurse. I DO NOT want my child to participate in the BMI screening process. Parent Signature STAR/Homeroom Teacher Grade ************************************************************************************************************ SCOLIOSIS SCREENING Sometime during the school year, the Nursing Staff will be conducting a Scoliosis Screening. Scoliosis is a sideways curving of the spine, resembling an S-curve or C-curve. Eighty-five percent of the time, scoliosis has no known cause and tends to run in families. This type of scoliosis first develops between the ages of years of age and occurs more often in girls than boys. If scoliosis is detected early, treatment can be started and almost all of the curving prevented. The procedure for screening is a simple one in which the child s back is observed as he/she stands upright and as he/she bends forward. To observe this condition, each child will be asked to remove their shirt or blouse (girls may wear bra or bathing suit top). The screening will be conducted in private with only the student and nurse present. Any curvature or back hump that is noticed during the screening may indicate the need for further studies. If a problem is found, you will be notified. We will recommend that you take your child to a physician of your choice for an evaluation. We encourage all students to participate in this program. If you want your child to participate, do nothing. If you do NOT want your child screened due to philosophical/religious beliefs, please fill out the form below and return to teacher. Phone calls will not be accepted. If your child is currently under treatment for a back problem, please let us know in writing. I DO NOT want to have my child screened for scoliosis. STUDENTS S NAME: GRADE: STAR/Homeroom Teacher: PARENT SIGNATURE:
3 FORMULARIO MEDICO PARA EL AUTOBUS ESCOLAR ESTE FORMULARIO ES UNICAMENTE PARA LOS ALUMNOS QUE UTILIZAN EL AUTOBUS ESCOLAR! Estimado Padre de Familia: Si su hijo tiene algún problema médico del cual el conductor del autobús escolar deba saber, por favor llene el formulario que se encuentra a continuación y regréselo a la escuela de su hijo. El personal del departamento de servicios médicos procesara estos formularios y se los darán a los conductores designados de los autobuses escolares. NOTA: Nosotros compartiremos la información contenida en este formulario con el conductor del autobús que utiliza su hijo UNICAMENTE si usted marca SI en la parte del formulario que le pregunta si su hijo podría necesitar tratamiento médico de emergencia. Muchas Gracias por su cooperación, La enfermera escolar de la escuela de su hijo Nombre del estudiante: Autobús # Dirección: Escuela: Grado: Maestro Titular: Padre: Madre: (Problemas de Salud): Se podría dar el caso que los problemas de salud del estudiante requieran tratamiento de emergencia? SI NO (Si contesto que si, por favor explíquenos que acciones quisiera Usted que el conductor del autobús tomara): Firma del padre de Familia: Al firmar este formulario usted nos está dando permiso para que compartamos la información de salud de su hijo con el conductor del autobús escolar que su hijo utiliza; si se diera la ocasión en que sea necesario comunicarse con los padres de familia, el conductor del autobús escolar de su hijo notificara a la escuela y el personal de la escuela se comunicara con Usted. Translator: W. Fountain revised 3/3/2010
4 BUS MEDICAL FORM FOR BUS RIDERS ONLY! Dear Parent, If your child has a medical problem the bus driver should be aware of, please fill out the form below and return it to your child s school. Medical services will process the forms and get them to the designated bus driver. NOTE: This form is forwarded to your child s bus driver only if you mark that emergency medical treatment would be required. Thanks for your cooperation, Your School Nurse Student: Bus #: Address: School: Grade: 6 th 7 th 8 th Homeroom / TAG Teacher: Parent (1): Parent (2): Health Problem(s): Would student s health problem(s) ever require emergency treatment? Yes No If yes, Explain the appropriate action that you would like for the bus driver to take: Parent s Signature: *** By signing this form you are giving your permission for your child s health information to be shared with your child s bus driver, if an occasion arises that requires a parent to be contacted, the bus driver will notify your child s school and the school will notify you.
5 BUS STUDENT FORM Student s Name: I am riding the bus in the am pm. School: Grade: Bus # Address: Parent/Guardian: Phone : Please complete and return to driver. BUS STUDENT FORM Student s Name: I am riding the bus in the am pm. School: Grade: Bus # Address: Parent/Guardian: Phone : Please complete and return to driver.
6 EMERGENCY CALL FORM STUDENT NAME TEACHER/GRADE ADDRESS (Physical) CITY/STATE/ZIP ADDRESS BIRTHDATE: BUS PARENT 1 (In Household) **We will call this parent first** PARENT 2 (In Household) Name Address (mailing) Home Phone Cell Phone Business Name Business Phone # Name Address (mailing) Home Phone Cell Phone Business Name Business Phone # Who else has permission to pick up your child that we may call in case of emergency? **If someone is not listed on this form, please inform the office that they will be coming to check out your child** 1. Name/Relationship Phone # 2. Name/Relationship Phone # 3. Name/Relationship Phone # 4. Name/Relationship Phone # 5. Name/Relationship Phone # 6. Name/Relationship Phone # **************PLEASE CALL THE SCHOOL WITH ANY CHANGES*************** Please list below any health conditions such as heart problems, asthma, diabetes, severe allergies, eye or ear problems, or any chronic or other conditions that we should know about: (Note: if you list asthma, you must provide the school with an inhaler or indicate that you child must carry their inhaler with them. Also, if you note severe allergic reaction, you must provide your child s school with epinephrine. ) Please list any medications that the student is currently taking and specify if he/she will be taking it at school: Please name the doctor and hospital you prefer in case of an emergency. (Please note, every attempt will be made to reach a parent before transporting a child to an emergency facility.) DOCTOR HOSPITAL I hereby authorize emergency medical services for this student. I hereby authorize Van Buren School District Health Services to share my child s health issues to pertinent staff members. PARENT/GUARDIAN SIGNATURE Date:
7 FORMULARIO PARA LLAMADAS DE EMERGENCIA NOMBRE DEL ESTUDIANTE: MAESTRO/GRADO: DIRECCION (Física) CIUDAD/ESTADO/CP: DIRECCION DE CORREO ELECTRONICO: FECHA DE NACIMIENTO: BUS PADRE #1 (Que viva en la casa) **Nosotros llamaremos primero a esta persona** PADRE # 2 (Que viva en la casa) Nombre: Dirección (correo): Numero de Teléfono de la Casa: Número de teléfono del celular: Lugar en donde Trabaja: Nombre: Dirección (correo): Número de Teléfono de la Casa: Número de teléfono del celular: Lugar donde Trabaja: # De teléfono de su trabajo: # de teléfono de su trabajo: En caso de emergencia, a quien más podemos llamar para que venga a recoger a su hijo a la escuela? **Por favor llame al personal de la oficina de la escuela si usted va a enviar a otra persona a recoger a su hijo y esa persona no está en esta lista. ** 1. Nombre/Relación con el estudiante: # de teléfono: 2. Nombre/Relación con el estudiante: # de teléfono: 3. Nombre/Relación con el estudiante: # de teléfono: 4. Nombre/Relación con el estudiante: # de teléfono: 5. Nombre/Relación con el estudiante: # de teléfono: 6. Nombre/Relación con el estudiante: # de teléfono: **************POR FAVOR LLAMENOS PARA HACERNOS SABER CUALQUIER CAMBIO************** Por favor enumere cualquier condición médica tal como puede ser: problemas del corazón, asma, diabetes, alergias severas, problemas con los ojos o del oído, o alguna condición crónica o otras condiciones de las cuales debamos saber: (Nota: si usted anota asma, por favor tráiganos un inhalador o pídale a su hijo que siempre mantenga consigo el inhalador. También, si usted anota reacción alérgica, usted deberá proveer epinefrina.) Por favor enumere todos los medicamentos que el estudiante está tomando actualmente, y especifique si, él o ella, va a tomar esos medicamentos aquí en la escuela: Por favor anote el nombre del doctor y el hospital al cual usted desearía que lleváramos a su hijo en caso de emergencia. (Nota: Nosotros haremos todos los intentos posibles por ponernos en comunicación con alguno de los padres del estudiante antes de llevar al estudiante a un lugar de asistencia médica.) DOCTOR HOSPITAL Por este medio autorizo los servicios de emergencia médicos para este estudiante. Yo también autorizo a los Servicios de Salud del Distrito Escolar de Van Buren para que comparta la información de salud de mi hijo con los miembros del personal que ellos estimen pertinente. FIRMA DEL PADRE DE FAMILIA O TUTOR: Fecha:
8 FORMULARIO PARA LLAMADAS EN CASO DE EMERGENCIA Estimados Padres de Familia: Nosotros queremos ayudarles de cualquier manera posible en el cuidado de la salud de su hijo. Para poder hacerlo, nosotros necesitamos saber si su hijo tiene necesidades especiales de salud, tales como: medicamentos y/o condiciones de salud. Por favor regrese este formulario a la escuela de su hijo lo más pronto posible. Este formulario debe ser llenado y firmado UNICAMENTE por un padre de Familia! NOMBRE DEL ESTUDIANTE: GRADO: FECHA DE NACIMIENTO: MAESTRO TAG: DIRECCION: CIUDAD, ESTADO, CODIGO POSTAL: Padre/TUTOR LEGAL 1 Padre/TUTOR LEGAL 2 (en casa) (en casa) Nombre: Nombre: # de teléfono de la casa o celular: # de teléfono de la casa o celular: Lugar donde trabaja y puesto: Lugar donde trabaja y puesto: # de teléfono del trabajo y extensión: # de teléfono del trabajo y extensión: Dirección de correo electrónico: Dirección de correo electrónico: Quien más tiene permiso para recoger a su hijo en caso de que hubiera una emergencia? (ESTOS NOMBRES Y ESTOS NUMEROS DE TELEFONO DEBEN SER DIFERENTES A LOS QUE ESTAN EN LA LISTA DE ARRIBA): 1. Nombre y relación: # de teléfono: 2. Nombre y relación: # de teléfono: 3. Nombre y relación: # de teléfono: POR FAVOR HAGANOS SABER CUALQUIER CAMBIO ***************************************************************************************************** Por favor haga una lista de las condiciones de salud que padezca su hijo, tales como: problemas del corazón, asma, diabetes, epilepsia, alergias severas, problemas con los ojos o los oídos, o alguna condición crónica o cualquier otra condición de la cual nosotros debamos saber: (NOTA: Si usted anota asma, usted deberá proveer un inhalador al personal de la escuela o indicarle a su hijo que lo ande siempre. Además, si usted escribe reacción alérgica, usted deberá proveer un epi pen al personal de la escuela): Por favor haga una lista de todos los medicamentos que el estudiante este tomando y especifique si él/ella deberá tomarlos aquí en la escuela: Por favor tome nota que haremos todos los intentos necesarios para comunicarnos con los padres de familia antes de llevar a este estudiante a un centro médico. LIBERACION DE INFORMACION POR ESTE MEDIO AUTORIZO CUALQUIER SERVICIO DE EMERGENCIA PARA ESTE ALUMNO. POR ESTE MEDIO AUTORIZO A LOS SERVICOS DE SALUD DEL DISTRITO ESCOLAR DE VAN BUREN A QUE COMPARTA LAS CUESTIONES DE SALUD DE MI HIJO CON CUALQUIER MIEMBRO DEL PERSONAL QUE ELLOS ESTIMEN PERTINENTE. FIRMA DEL PADRE: FECHA: RECUERDE: QUE ES RESPONSABILIDAD DEL PADRE DE FAMILIA EL NOTIFICAR, AL PERSONAL DE LA ESCUELA DE SU HIJO, LOS CAMBIOS DE NUMERO DE TELEFONO O DE DIRECCION! *** Si su hijo tiene una condición médica de la cual usted quiere hablar, personalmente, con la enfermera, por favor comuníquese con el personal de la oficina para que pida una cita para hablar con la enfermera. **** Translator: Revised W. Fountain 01/24/2012
9 Student s Name: Teacher s Name: FIELD TRIP PERMISSION SLIP TO ATTEND ANY FIELD TRIP FOR THE SCHOOL YEAR Dear Parent/Guardian: This permission slip will enable your child to attend any Field Trip sponsored by Northridge Middle School for the entire school year. You will receive information regarding specific field trips, but you will not have to complete an additional permission slip. If at any point you do not want your child to attend a field trip, simply make the teacher aware of this fact. I give my child,, permission to attend any Field Trips with my child s school for the school year. Parent/Guardian Signature Date
10 This packet contains: FREE AND REDUCED PRICE SCHOOL MEALS APPLICATION AND VERIFICATION FORMS SCHOOL YEAR INSTRUCTIONS FOR SCHOOL DISTRICTS Required information that must be provided to households: Letter to Households Free and Reduced Price School Meals Application Notice of Approval / Denial* Direct Certification Notice of Approval Migrant / Homeless / Runaway / Foster / Head Start / Even Start Notice of Approval Verification of eligibility information materials: Notification of Selection for Verification of Eligibility Letter of Verification Results Verification Tracker Verification Timelines Optional application-related materials that may be provided to households: Sharing Information With Other Programs The pages are designed to be printed on 8½ by 11 paper. Some pages may be printed front and back. You will need to identify the benefits that are offered in your school, such as Afterschool Snacks. The [Bold bracketed fields] indicate where you need to insert school district specific information. For example, you must include your district s no-charge telephone number for verification assistance on the verification materials. If you make additional changes, you must submit your application package to Arkansas Department of Education, Child Nutrition Unit (ADE, CNU) for approval prior to public distribution. This prototype application package includes information regarding the exclusion of housing allowance for those in the Military Housing Privatization Initiative. If this is not pertinent to your school district, please modify as appropriate. If you have questions, contact: Child Nutrition Unit Arkansas Department of Education 2020 West Third, Suite 404 Little Rock, AR * All households must be notified of their eligibility status. Households with children who are denied benefits must be given written notification of the denial. The notification must advise the household of the reason for the denial of benefits, the right to appeal, instruction on how to appeal and a statement that the family may re-apply for free and reduced price meal benefits at any time during the school year. Households with children who are approved for free or reduced price benefits may be notified in writing or verbally. Instructions to School Districts School Year Page 1 of 1
11 Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your children may qualify for free meals or for reduced price meals. 1. Do I need to fill out an application for each child? No. You can use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to your children s school. 2. Who can get free meals? All children in households receiving benefits from the Supplemental Nutrition Assistance Program (SNAP) benefits (formerly the Food Stamp Program) can get free meals regardless of your income. Also, your children can get free meals if your household gross income is within the free limits on the Federal Income Eligibility Guidelines. 3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. 4. Can homeless, runaway and migrant children get free meals? Yes, children who meet the definition of homeless, runaway or migrant qualify for free meals. If you haven t been told your children will get free meals, please call or your child s school to see if they qualify. 5. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Eligibility Chart, shown on this application. 6. Should I fill out an application if I got a letter this school year saying my children are approved for free or reduced price meals? Please carefully read the letter you got and follow the instructions. Call your child s school if you have questions. 7. My child s application was approved last year. Do I need to fill out another one? Yes. Your child s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for free meals for the new school year. 8. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application. 9. Will the information I give be checked? Yes, we may ask you to send written proof. 10. If I don t qualify now, may I apply later? Yes. You may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free or reduced price meals if the household income drops below the income limit on the Federal Income Eligibility Guidelines. 11. What if I disagree with the school s decision about my application? You should talk to school officials. You also may ask for a hearing to have the decision reviewed. 12. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals. 13. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them. 14. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include it, but not if you get it only sometimes. If you have lost a job or had your hours or wages reduced, use you current income. 15. We are in the military, do we include our housing allowance as income? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. 16. My spouse is deployed to a combat zone. Is the combat pay counted as income? No, if the combat pay is received in addition to the basic pay because of the deployment and it wasn t received before the deployment, combat pay is not counted as income. Contact your child s school for more information. 17. My family needs more help. Are there other programs we might apply for? To find out how to apply for apply for other assistance benefits contact your local assistance office. 18. The free and reduced lunch statistics allow our schools to receive technology funding from the federal government. It provides access to the Internet and distance learning services. Please help us by returning this form Letter to Household
12 INSTRUCTIONS FOR APPLYING If your household receives benefits from the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program, follow these instructions: Part 1: List all child(ren) s attending this district by name, school, grade. Part 2: Complete the name of the household member receiving SNAP benefits and the SNAP case number. Part 3: Skip this part. Part 4: Sign the form. The last four digits of a Social Security Number are not necessary. Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. Part 6: If the household does not want the student s eligibility information shared with Medicaid or ARKids 1st then check this box. If NO ONE in your household receives SNAP benefits AND if all child(ren) in your household is/are foster child(ren): Part 1: List all the child(ren) in the household attending school at this district by name, school, and grade. Check the box for each child(ren) that is the legal responsibility of welfare agency or court. Part 3: Skip this part. Part 4: Sign the form. A Social Security Number is not necessary. Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. Part 6: If the household does not want the student s eligibility information shared with Medicaid or ARKids 1 st then check this box. ALL OTHER HOUSEHOLDS, including households with both foster and non-foster children in the same household and WIC households, follow these instructions: Part 1: List each child s name, school, and grade. Check the box for each child(ren) that is the legal responsibility of welfare agency or court. Part 2: If the household does not have a SNAP case number skip this part. If a SNAP case number is listed skip to Part 4 of this form. Part 3: Follow these instructions to report total household income for the month. Column 1: Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them. Next to each person s name list the gross income for each type of income received for the month, and how often the money is received. Gross income is the amount earned before taxes and other deductions. Column 2: Gross income from work and how often it was received. List the gross income (not take home pay) each person earned from work. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person receives the income (for example: weekly, every other week, twice a month, or monthly). For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm or rental properly. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person got it. Column 3: List the amount each person got for the month from welfare, child support, alimony, Column 4: List the amount each person got for the month from pensions, retirement, Social Security Supplemental Security Income (SSI), Veteran s benefits (VA benefits), Column 5: List the amount each person got for the month from ALL OTHER INCOME SOURCES, including Workers Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household and any other income. Do not include the SNAP benefits, federal education benefits and foster payments received by the family from the placing agency. If you are in the Military Housing Privatization Initiative do not include this housing allowance. Column 6 Check if no income: If the person does not have any income, check the box. Part 4: An adult household member must sign the form and list the last four digits of his or her Social Security Number, or mark the box if he or she doesn t have a Social Security Number. Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. Part 6: If the household does not want the student s eligibility information shared with Medicaid or ARKids 1st then check this box. Instructions for Applying School Year
13 Part 1. Children in School at this District Names of all children in school at this district (First, Middle Initial, Last) School Name Grade Check if a foster child (legal responsibility of welfare agency or court). If all children listed below are foster children, skip to part 4 of this form. Part 2. SNAP Benefits: If any member of your household receives Supplemental Nutrition Assistance Program (SNAP) benefits, provide the name and case number for any household member that receives benefits and skip to Part 4. If no one receives SNAP benefits, skip to Part 3. Name: Case Number: - - _ Part 3. Total Household Gross Income You must tell us how much and how often A. Name (List everyone in household) B. Gross income and how often it was received Example: $100/monthly $100/twice a month $100/every other week $100/weekly Pensions, Retirement, Social Security, SSI, VA Earnings from work before deductions Income / How often Welfare, child support, alimony Income / How often benefits Income / How often $ / $ / $ / $ / All Other Income Income / How often $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / Part 4. Signature and Last Four Digits of Social Security Number (Adult Must Sign) An adult household member must sign the application. If Part 3 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (See Statement on the back of this form.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: X Social Security Number: xxx-xx- (last 4 digits only) Print Name: Phone Number: Date: I do not have a Social Security Number Address: City, State, Zip: Part 5. Children s racial and ethnic identities. Mark one box in each category (optional). Choose one or more (regardless of ethnicity): Choose one ethnicity: Asian American Indian or Alaska Native Hispanic or Latino White Native Hawaiian or Other Pacific Islander Not Hispanic or Latin Black or African American Part 6. Disclosure (Optional) I do not want school officials to share information from my free and reduced price meal application with Medicaid or the State Children s Health Insurance Program (ARKids 1 st ). Don t fill out this part. This is for school use only. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12 Total Income: Per: Week, Every 2 Weeks, Twice a Month, Month, Year Household size: SNAP* (food stamps): Categorically Eligible: Date Withdrawn: Eligibility: Free Reduced Denied Reason: _ Determining Official s Signature: FREE AND REDUCED PRICE SCHOOL MEALS HOUSEHOLD APPLICATION Determination Date: C. Check if NO income Application
14 Your children may qualify for free or reduced price meals if your household income falls within the limits on this chart. FEDERAL INCOME CHART For School Year Household size Yearly Monthly Weekly 1 21,590 1, ,101 2, ,612 3, ,123 3, ,634 4, ,145 4,929 1, ,656 5,555 1, ,167 6,181 1,427 Each additional person: 7, *SNAP: Supplemental Nutrition Assistance Program (formerly the Food Stamp Program) Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), case for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. Non-discrimination Statement: The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individual s who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. Letter to Household
15 Revised VAN BUREN SCHOOL DISTRICT 2221 POINTER TRAIL EAST VAN BUREN, ARKANSAS Student Media Release Form The Van Buren School District request signatured permission to use your child s name, recognizable picture or video image in any district approved media release. Throughout the year, children s pictures may be used in local TV spots, local paper(s), district newsletter and/or school sponsored websites as the district makes an effort to make the public aware of positive things happening within our schools. Please complete the information below and indicate with your signature your permission or denial of permission to use your child s name, recognizable picture or image in any VBSD media release or school sponsored website. Student s Name: Grade: School: Print Date: I hereby give permission to use my child s name, recognizable picture, and/or image in any VBSD news release or school sponsored website. Parent Signature OR: I hereby request that my child s name, picture, and/or image NOT be used in any VBSD news release or school sponsored website. Student s Teacher: Parent Signature Please return completed form to the principal s office of your child s school for placement in their permanent file.
16 Dear Parent/Guardian: VAN BUREN SCHOOL DISTRICT 2221 POINTER TRAIL EAST VAN BUREN, ARKANSAS (479) FAX (479) VAN BUREN SCHOOL DISTRICT The Arkansas Department of Education passed new rules governing nutrition standards in Arkansas Public Schools. These new rules will have an immediate effect on what food items parents are allowed to send to school. Please note the following rules, sign, and return the bottom portion indicating you have read and understand. Elementary students will not have access to vended (sold or given away) food and beverage items anytime, anywhere on school premises during the declared school day. This policy does not apply to students with special needs indicated in the student IEP or to school nurses providing health care to individual students. Students may be given any food and/or beverage items for up to nine (9) different school events each school year to be determined and approved by school officials. Nutritional foods may be used for instructional purposed. The school as part of the planed instructional program may also distribute nutritional snacks (kindergarten snacks for example). This policy does not restrict what parents may provide for their own child s lunch or snack. To meet state regulations (law), we must ask parents to not provide food/beverage items to other children at school for events such as birthday parties. Parents may provide food/beverage items upon request to support one of up to nine (9) allowable events such as Valentine s Day. Thank you for your cooperation. Name of School Name of Student Print Name of Teacher Grade of Student This is to certify that I have received a copy of the new Arkansas Department of Education Nutrition regulation changes and that I have read and understand these changes. Date Print Signature of Parent or Guardian
17 VAN BUREN SCHOOL DISTRICT 42 POLICIES FOR STUDENTS RIDING SCHOOL BUSES 1. Be at the bus stop at the scheduled time. Stand back about (10) feet from the bus stop and wait for the door to open before moving closer. 2. When entering or leaving the bus, do so in quickly and in an orderly manner. 3. Remain seated while the bus is in motion. 4. Speak softly while riding the bus, so that the driver is not distracted. 5. Keep food and drinks off the bus. 6. Keep tobacco of all kinds off the bus. 7. Keep isles of the bus clear of books, equipment, etc. 8. Keep all parts of the body inside the bus except to unload. 9. Foul language and unnecessary physical contact with others students will not be tolerated. 10. FOLLOW THE DIRECTIONS OF THE DRIVER AT ALL TIMES. The bus driver has the same authority on the bus as the teacher has in the classroom. 11. Students who must cross the road after leaving the bus in the afternoon must go to a point about (10) feet in front of the bus and wait. CROSS THE ROAD ONLY AFTER THE DRIVER OR STUDENT PATROL HAS SIGNALED YOU TO DO SO. 12. Students must obtain written permission from the principal, or other school authority, to ride any bus other than their own. PARENTS AND STUDENTS ARE REMINDED THAT RIDING A BUS IS A PRIVILEGE. FAILURE TO ABIDE BY THE RULES MAY RESULT IN THE LOSS OF THIS PRIVILEGE. Parents should contact the principal of the school the student attends if there is a question about the rules, discipline, etc. Questions concerning bus routes should be directed to the Transportation Supervisor at the Administration Building ( ) These Acts of the Arkansas Legislature should be of interest: Act 814 of 1977 makes it unlawful for any persons (student or adult) to threaten, curse or use abusive language to a school bus driver in the presence of students. Act 36 of 1987 makes parents of a minor child responsible for reimbursing the school for any damages caused by a minor child up to $5, The following statement must be signed by the parent or guardian of the students who are being transported by the school district. Remove the part of this notice below the dotted line, sign and return to the child s teacher As a Parent of Guardian, I do hereby acknowledge that I have received and read the policies relating to students riding school buses in the Van Buren School District. Name of Student Address School now attending Signature of Parent of Guardian No. of Miles to School Phone # Bus #
18 SERVICIOS DE SALUD DEL DISTRITO ESCOLAR DE VAN BUREN Regrese estos formularios únicamente si Usted NO QUIERE que su hijo participe en una o ambas evaluaciones EVALUACION BMI El acta 1220 del 2003, es una acta emitida por la Asamblea General de Arkansas, para coordinar los esfuerzos a nivel estatal para combatir la obesidad de los niños y las enfermedades relacionadas con la obesidad y para mejorar la salud de las próximas generaciones de los habitantes de Arkansas. Antes de que termine el año escolar, las enfermeras del Distrito conducirán la evaluación BMI. Esta evaluación se llevará a cabo en todas las escuelas individualmente y haremos todos los esfuerzos posibles para proteger la privacidad de su hijo. Nosotros le notificaremos cuando tengamos los resultados. SI Usted quiere que su hijo participe en esta evaluación, por favor tire esta página a la basura. Por el contrario, Si Usted NO quiere que su hijo participe en este proceso de evaluación, llene el formulario y regréselo a la escuela de su hijo el día de mañana. Si Usted tiene alguna pregunta, comuníquese con la enfermera de la escuela de su hijo. YO NO QUIERO que mi hijo participe en el proceso de evaluación BMI. Firma del Padre de Familia Maestro Titular o Maestro del 1er periodo Grado ************************************************************************************************************************** EVALUACION DE ESCOLIOSIS En cualquier momento del año escolar, las enfermeras realizaran una evaluación para determinar si los niños tienen Escoliosis. Escoliosis es una desviación lateral de la columna vertebral que puede tomar la forma de una S o de una C. En el ochenta y cinco por ciento de los casos no existe una causa conocida para tener escoliosis y usualmente es hereditaria. Este tipo de escoliosis se desarrolla primeramente entre las edades de años y ocurre con más frecuencia en las niñas que en los niños. Si se hace una detección temprana de la escoliosis, se puede iniciar un tratamiento y casi toda la desviación puede ser prevenida. El proceso de evaluación es muy sencillo; la enfermera observará la espalda del alumno mientras el/ella se para rectamente y mientras se dobla hacia enfrente. Para observar esta condición, se le pedirá a cada alumno que se quite la camisa o la blusa (las niñas pueden usar su brasier o sujetador o la parte de arriba de un traje de baño de dos piezas). La evaluación se conducirá en privado, estando presentes solo el alumno y la enfermera. Cualquier curvatura o joroba en la espalda que descubramos durante esta evaluación podría indicar que se necesitaran hacer mas estudios. Nosotros le notificaremos si encontramos algún problema. Nuestra recomendación será que lleve a su hijo al doctor de su preferencia para que le haga una evaluación. Nosotros esperamos que todos los estudiantes participen en esta evaluación. SI Usted quiere que su hijo participe en esta evaluación por favor tire esta página a la basura. Por el contrario, Si Usted NO quiere que su hijo participe en esta evaluación, por favor llene el formulario que se encuentra abajo y regréselo al maestro de su hijo. Por favor tome nota de que no aceptaremos llamadas telefónicas. Si su hijo esta recibiendo tratamiento por algún problema con su espalda, por favor háganoslo saber por escrito. Yo NO QUIERO que mi hijo sea evaluado para ver si tiene escoliosis. NOMBRE DEL ESTUDIANTE: GRADO: MAESTRO TITULAR: FIRMA DEL PADRE DE FAMILIA: Translator: W. Fountain revised 5/04/11.
19 This handbook does not supersede Van Buren School District Board Policy. After reading the student handbook section with your child, this page must be signed, dated and returned to your child s home room teacher. Thank you, I have read and discussed the material in this handbook with my child. I understand and agree my child will abide by the rules and regulations set by the Van Buren School District. Date: Parent/Guardian Signature: Student Signature: Grade: Homeroom Teacher:
20 Technology Acceptable Use Policy Technology Acceptable Use Policy Form Student Agreement and Parent Permission Form I have been given a copy of the VBSD Acceptable Use Policy and I have read the policies contained herein. Student Name (Please Print) Student Signature Parent/Guardian Signature School Grade Date Before access may be granted, signature of user must be submitted on this form to the school office. As a user of the VBSD Network, I have read and hereby agree to comply with the Acceptable Use Policies. User Name (Please Print) User Signature Parent/Guardian As a parent/legal guardian of the student signing above, I grant permission for my child to access networked computer services. I have read and agree to the Acceptable Use Policies, and I understand that I may be held responsible for violations by my child. I understand that some material on the Internet may be objectionable; therefore, I agree to accept responsibility for guiding my child and conveying to him/her appropriate standards for selecting, sharing, and/or exploring information and media. Parent/Guardian Name(Please Print) Date Parent/Guardian Signature City/State/Zip Phone
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