REGISTER IN PRESCHOOL!

READY SET REGISTER IN PRESCHOOL! 2013-2014 SCHOOL-BASED PRESCHOOL REGISTRATION FORMS The pre-registration process is essential for introducing new families and students to staff, the classroom environment, and a new school culture. Therefore, similar to past practices and based on principal discretion, each classroom will be permitted to cancel classes for one day per 10 new students pre-registering, not to exceed four days. During this time, please ensure the following elements are completed when you meet with each of your families: Child Health History Home Language Survey Parent Agreement Release Form Family Partnership Assessment and Goals Media Consent Form and Release Request for Emergency and Health Information Prior to child s first day of attendance: Child Health Requirements Certificate of Child Health Examination Can be completed during registration; however, must be completed no later than 45 days of the child s first day of attendance: Ages & Stages : Social-Emotional (ASQ:SE) Please ensure all of these documents are completed and available in each child s folder. The registration process must be completed and entered into IMPACT by June 28th at 5:00 p.m. Note: In accordance with the McKinney Vento Homeless Assistance Act, students in a temporary living situation are eligible for immediate enrollment (see Rights of Homeless Students). QUESTIONS? Contact the Office of Early Childhood Education: 773.553.2010

Chicago Public Schools Complete this Home Language Survey at the student s initial enrollment in a Chicago Public School. This form must be kept in the student s folder. School: Room: Unit: Area: Student Name: English 1. Is a language other than English spoken in your home? No Yes (Language) 2. Does the student speak a language other than English? No Yes (Language) If the answer to either question is yes, the law requires the school to assess your child s English language proficiency. Student ID No.: IMPACT REGISTRATION PROCESS (For Office use only) The Non-English language identified on either question is the Home Language. If two different non-english languages are identified, enter the language identified in question 2 as the Home Language. Enter ENGLISH as a Home Language ONLY when both questions are answered no. Spanish Polish 1. Se habla algún otro lenguaje que no sea inglés en su 1. Czy językiem innym niź angielski mówi się w domu? hogar? No Sí (Lenguaje) Nie Tak (język) 2. Habla el estudiante un lenguaje que no sea el inglés? 2. Czyt uczeń mówi innym językiem niż angielski? No Sí (Lenguaje) Nie Tak (język) Si la respuesta a cualquiera de las preguntas es Sí, la ley requiere que la escuela evalúe la fluidez de su niño en el idioma inglés. Chinese Jeśli udzielili Państwo twierdzącej odpowiedzi na którekolwiek z powyższych pytań, przepisy wymagają, aby szkoła sprawdziła poziom znajomości języka angielskiego waszego dziecka. Arabic 如 果 你 在 兩 個 問 題 中 之 任 一 項 的 答 案 是 是, 則 法 律 規 定 校 方 要 測 試 貴 子 女 的 英 語 通 悉 度 Bosnian/Croatian/Serbian Urdu إذا كانت الا جابة نعم علي أي من السو الین فا ن القانون یحتم علي المدرسة تقییم ابنكم للكفاءة في استخدام اللغة الانجلیزیة. Office of Language and Cultural Education Revised: Mar. 2009 Ukoliko ste na bilo koje od ovih pitanja odgovorili sa Da, škola će biti zakonski dužna da procijeni nivo znanja engleskog jezika kod vašeg djeteta Notes: Signature of School Official Date Signature of Parent/Guardian Date 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 determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available. Questions or concerns, contact your Area Compliance Facilitator.

RELEASE FORM CHILD S NAME DATE SCHOOL NAME ROOM PARENT S NAME The following people have permission to pick up my child from the Chicago: Ready to Learn! preschool program. SIGNATURE OF PARENT NAME RELATIONSHIP TO CHILD NAME RELATIONSHIP TO CHILD NAME RELATIONSHIP TO CHILD NAME RELATIONSHIP TO CHILD

FORMULARIO DE AUTORIZACIÓN NOMBRE DEL NIÑO FECHA NOMBRE DE LA ESCUELA SALÓN NOMBRE DEL PADRE Las siguientes personas están autorizadas a recoger a mi niño del programa preescolar Chicago: Ready to Learn! FIRMA DEL PADRE NOMBRE RELACIÓN CON EL NIÑO NOMBRE RELACIÓN CON EL NIÑO NOMBRE RELACIÓN CON EL NIÑO NOMBRE RELACIÓN CON EL NIÑO

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 I 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 # 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

```` Escuelas Públicas de Chicago Consentimiento de prensa y dispensa de responsabilidad Consentimiento/Dispensa Por la presente autorizo a que mi estudiante sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta de Educación de Chicago o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Entiendo que en el curso del año escolar la Junta quiera celebrar los logros y el trabajo de mi niño. Por lo tanto, también autorizo a la Junta la divulgación del nombre de mi niño, de sus premios académicos y no académicos y de información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. También autorizo a la Junta el uso de fotografías o retratos de mi niño, o de su voz o trabajo creativo, en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. Como padre o tutor legal del niño, libero de toda responsabilidad a la Junta, a sus miembros, síndicos, 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 razón, o puedan ser causadas por el uso del trabajo creativo, fotografía, retrato o voz en televisión, radio o películas, o en medios impresos, Internet o cualquier otro medio electrónico/digital. Es entendido además, y estoy de acuerdo, en que no se me debe a mí, a mi niño, a nuestros herederos, agentes o designados ningún dinero o consideración de ninguna especie, incluyendo el reembolso de cualquier gasto realizado por mí o por mi niño durante la participación en cualquiera de las actividades mencionadas, o por el uso de su trabajo creativo, fotografías, retrato o voz. Entiendo que puedo cancelar este consentimiento mediante una comunicación por escrito al director escolar. También entiendo que esta dispensa es válida por un año escolar, incluyendo el verano siguiente. Instrucciones: marque la caja #1 o caja #2 1. Autorizo lo señalado arriba en la sección consentimiento/dispensa. 2. NO autorizo que mi niño sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Tampoco autorizo que la Junta divulgue el nombre de mi niño, sus premios académicos y no académicos e información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. No autorizo a la Junta el uso del nombre de mi estudiante, fotografías o retratos, de su voz o trabajo creativo en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. Firma padre o tutor, o del estudiante si tiene 18 años o más Nombre en imprenta del padre o tutor, o del estudiante si tiene 18 años o más Nombre del estudiante Fecha Número de ID del estudiante Escuela Entiendo que tengo el derecho de inspeccionar 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 información contenida en los registros. Departamento de Política y Procedimientos Julio 2012

Rev. 07/2012 Request for Emergency and Health Information Chicago Public Schools School Name: Date: PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a change in this information, immediately notify the school in writing. Student ID# Last Name First Name Middle Name Homeroom # Birth Date (mm/dd/yyyy) Student Home Address Student Home Phone # Confidential Information Box 1 Complete this box only if (1) it reflects your child s current living situation; OR (2) it reflects your living situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff with enrollment and may enable the student to receive additional services.) Check one box if you are living: in an abandoned apartment/building in a car/park/other public place in a hotel/motel in a residence of other individuals or family in a shelter in a temporary foster care placement Note to School: If any box is checked, see the CPS Education of Homeless Children and Youth Policy (702.5). Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed. Contact Name Relationship to Student Parent/Guardian Contact Parent/Guardian Contact Check all that apply: Lives With Gets Mailings Home Address, if different from student s Emergency Permission to Pickup Lives With Emergency Gets Mailings Permission to Pickup Home Phone Number, if different from student s * Cell Phone Number * Email Address *reply N/A if not available Name and Address of Employer Work Phone Number List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student: Name Home Address Telephone # Relationship Confidential Information Box 2 Is there a current Order of Protection or No Contact Order which concerns this student? Yes No Note to School: If Yes is checked, please follow the procedures of CPS Policy 704.4. Enter the information into the Legal Alert field and update contact information, as needed, in SIM. Family Doctor s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency. Student Health Insurance: (select only one of the three) Illinois Medical Card/All Kids: provide student s medical ID # (9-digit number located on back of card) No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No Private/Employer Health Insurance: no additional information needed I certify that the information on this form is correct. (Parent/Guardian Signature)

Health History Prior to Enrollment Page 1 of 6 Child Name Birthdate COPA ID School Room Date Entered in COPA Low Birthweight Underweight Within Normal Range (6-9 lbs.) Overweight Premature INTAKE FORM ONLY: All COPA documents requiring signatures must be generated from COPA. COPA Enrollment Packet 201-201 Revised 05-28-13 Page

Health History Prior to Enrollment Page 2 of 6 Child Name Birthdate COPA ID School Room Date Entered in COPA Yes No *Do you have dental Insurance? If yes, specify dental plan Date of last visit Write in/select Please in Select COPA INTAKE FORM ONLY: All COPA documents requiring signatures must be generated from COPA. COPA Enrollment Packet 201-201 Revised 05-28-13 Page

Health History Prior to Enrollment Page 3 of 6 Child Name Birthdate COPA ID School Room Date Entered in COPA INTAKE FORM ONLY: All COPA documents requiring signatures must be generated from COPA. COPA Enrollment Packet 201-201 Revised 05-28-13 Page

Health History Prior to Enrollment Page 4 of 6 Child Name Birthdate COPA ID School Room Date Entered in COPA INTAKE FORM ONLY: All COPA documents requiring signatures must be generated from COPA. COPA Enrollment Packet 201-201 Revised 05-28-13 Page

Health History Prior to Enrollment Page 5 of 6 Child Name Birthdate COPA ID School Room Date Entered in COPA Please Select Write in/select in COPA Please Select Choices: In process Enrolled Denied Ineligible Refused INTAKE FORM ONLY: All COPA documents requiring signatures must be generated from COPA. COPA Enrollment Packet 201-201 Revised 05-28-13 Page

Health History Prior to Enrollment Page 6 of 6 Child Name Birthdate COPA ID School Room Date Entered in COPA Please Select ect Submit Health History INTAKE FORM ONLY: All COPA documents requiring signatures must be generated from COPA. COPA Enrollment Packet 201-201 Revised 05-28-13 Page

PARENT AGREEMENT FORM CHILD S NAME: DATE SCHOOL NAME: ROOM I wish to have my child take part in the Chicago: Ready to Learn! program. I take full responsibility for his/her safe transportation to and from school. I understand the importance of daily attendance and agree to bring my child to school everyday he/she is well enough to fully participate in the program, including daily outdoor play. Additionally, I will adhere to the school schedule so that my child is dropped off and picked up on time. I understand that I am expected to serve as a parent volunteer. I am willing to attend meetings, workshops or conferences at the school as may be requested. I give my permission for my child to be taken on trips related to the preschool program, including walking trips within the community. Home Visit Preference I understand that the relationship between home and school is vital to a child s future success, and recognize that two home visits a year are an integral part of the preschool program. I prefer to have my child s preschool staff conduct a home visit in the following setting: My home Other place of my choice: SIGNATURE OF PARENT/GUARDIAN

FORMULARIO DE CONSENTIMIENTO DE PADRES NOMBRE DEL NIÑO: FECHA NOMBRE DE LA ESCUELA: SALÓN Yo deseo que mi niño participe en el programa Chicago: Ready to Learn! Asumo total responsabilidad por su transporte hacia y desde la escuela. Entiendo la importancia de la concurrencia diaria y estoy de acuerdo en llevar a mi niño a la escuela todos los días en que se encuentre en condiciones de participar enteramente del programa, incluyendo en los juegos al aire libre. Además, cumpliré con el programa escolar para que mi niño sea dejado y recogido puntualmente. Entiendo que se espera de mí que sirva como padre voluntario. Estoy dispuesto a asistir a reuniones, talleres o conferencias en la escuela, según sea requerido. Doy mi autorización para que mi niño participe en las salidas relacionadas con el programa preescolar, incluyendo caminatas en la comunidad. Preferencia de visita al domicilio Entiendo que la relación entre el hogar y la escuela es vital para el éxito futuro del niño, y reconozco que dos visitas anuales al domicilio son una parte integral del programa preescolar. Prefiero que el personal del programa realice la visita domiciliar de la siguiente manera: En mi casa En otro lugar de mi preferencia: FIRMA DEL PADRE/TUTOR

Family Partnership Assessment and Goals Please check, sign and date one category below: ( ) Yes, I am interested in developing family goals as part of the Family Partnership Agreement. I may need information or assistance with: (please check all that apply) Basic Life Skills Housing Child Care Legal Assistance Child Development Literacy Mental Health Education Domestic Violence Employment Health/Nutrition Substance Abuse Parent Involvement Other: My personal goal for this year is: (Example: GED; job training; employment) Steps needed to reach this goal are: I may need assistance to reach this goal: Yes No If yes, please explain: ( ) No, I am not interested in developing family goals, at this time. I understand that I may choose to develop family goals at anytime during my child s enrollment. The process of developing family goals as part of the Family Partnership Agreement has been explained to me. Parent Signature Staff Signature School Date Date Classroom Room

Colaboración Familiar Evaluación y Metas Por favor, marque, firme y póngale fecha a una de las categorías que figuran más abajo. ( ) Sí, estoy interesado en desarrollar metas familiares como parte del Acuerdo de Colaboración Familiar. Necesito información o asistencia con: (por favor marque los que necesita) Nociones Básicas de supervivencia Vivienda Cuidado de niños Asistencia legal Desarrollo infantil Alfabetización Salud Mental Educación Violencia Doméstica Trabajo Salud/Nutrición Abuso de Sustancias Participación de los padres Otro: Mi meta personal para este año es: (Ejemplo: GED; capacitación laboral; trabajo) Los pasos necesarios para alcanzar la meta son: Necesito ayuda para alcanzar esta meta: Sí No Si la necesita por favor explique: ( ) No, no estoy interesado en desarrollar metas familiares en este momento. Entiendo que puedo hacerlo en cualquier momento durante el período de estudio de mi hijo/a. El proceso de desarrollo de metas familiares como parte del Acuerdo de Colaboración Familiar, me ha sido explicado. Firma del padre Staff Signature School Fecha Date Classroom Room

CHILD HEALTH REQUIREMENTS Chicago: Ready to Learn! School-based Preschool Programs All physical exams must be signed and dated by a physician or advanced nurse practitioner, and should include the clinic stamp. The exam must contain the following screenings: Annual Hemoglobin/Hematocrit screening with numerical results. Annual Lead screening with numerical results. Annual Blood pressure. Annual Height/Weight and BMI. Annual Diabetes screening (done by the physician at the time of the physical exam). Annual Hearing/Vision screenings are also required, and will be done by CPS and Chicago Dept. of Family Support Services (DFSS) hearing/vision screeners during the year. However, parents may have their child screened at their pediatrician s office. Annual TB risk assessment for new and Returning Students Students are screened using the Pediatric Risk Assessment Questionnaire Developer by the American Academy of Pediatrics and based on the CDC guidelines. The questionnaire should be done by your health care provider at the time of your child s annual exam. Results from the questionnaire should be documented on the Physical Exam form. Further testing will be required if one or more risk factors are present. All students must show written evidence of up-to-date immunizations. 1. DtaP=Diptheria, Tetanus and Pertussis 2. IPV=Inactivated Polio 3. MMR=Measles, Mumps, and Rubella 4. HIB=Haemophillus Influenzae type B 5. HBV=Hepatitis B 6. PCV=Pneumococcal congugate Vaccine 7. Varicella=Chickenpox Parent Volunteers: Parents who volunteer must submit evidence of being free of Tuberculosis. TB (Tuberculosis) skin test screenings are good for 2 years. Chicago: Ready to Learn! Programas de Educación Temprana localizadas en las escuelas públicas Todos los exámenes físicos deben ser firmados por el doctor ό la enfermera capacitada y debe de incluir el sello de la clínica. El examen debe contener los siguientes análisis: Prueba anual de Hemoglobina/Hematocrito incluyendo resultados numéricos. Prueba de Plomo anual incluyendo resultados numéricos. Presión arterial, Estatura/Pesó y el Cálculo del Índice De Masa Corporal anual. Evaluación de Diabetes anual, hecho por el doctor durante el examen físico. Un examen anual de la Vista/audición es requerido y se hará por las Escuelas Públicas de Chicago (CPS) y el Departamento de Familia y Servicios de Apoyó (DFSS) durante el año. Sin embargo su doctor familiar puede administrar estos exámenes. Cuestionario anual de Tuberculosis para todo estudiante que sea nuevo ό regrese. Los estudiantes son evaluados con el cuestionario pediátrico de riesgo por La Academia Americana de Pediatría y basado en la guía del Centro de Control de Enfermedades. El cuestionario debe ser llenado por el doctor durante el examen físico anual. Los resultados deben ser anotados en el formulario. Si hay más de un factor de riesgo presente un examen adicional posteriormente será requerido. Todos los estudiantes de Head Start deben de mostrar por escrito evidencia que las vacunas estén al día. 1. DTaP= Difteria, Tétano y Tos Ferina 2. IPV = Polio 3. MMR=Sarampión Paperas y Rubéola 4. Hib = Haemophilius Influenza tipo B 5. HepB = Hepatitis B 6. PCV= Neumocócica conjugada 7. VAR= Varicela Padres Voluntarios Padres que son voluntarios deben presentar prueba de no tener Tuberculosis. El examen es válido por 2 años. Revised DE/AP 5/13

State of Illinois Certificate of Child Health Examination FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 Student s Name Last First Middle Birth Date Month/Day/Year Sex Race/Ethnicity School /Grade Level/ID# Address Street City Zip Code Parent/Guardian Telephone # Home Work IMMUNIZATIONS: To be 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 attached explaining the medical reason for the contraindication. Vaccine / Dose DTP or DTaP 1 MO DA YR 2 MO DA YR 3 MO DA YR 4 MO DA YR 5 MO DA YR 6 MO DA YR Tdap; Td or Pediatric DT (Check specific type) Polio (Check specific type) TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV Hib Haemophilus influenza type b Hepatitis B (HB) Varicella (Chickenpox) COMMENTS: MMR Combined Measles Mumps. Rubella Single Antigen Vaccines Measles Rubella Mumps Pneumococcal Conjugate Other/Specify Meningococcal, Hepatitis A, HPV, Influenza Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician s Signature 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. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date MO DA YR (Attach copy of lab result) VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Date Age/ Grade Vision Hearing R L R L R L R L R L R L R L R L R L Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year HEALTH HISTORY ALLERGIES (Food, drug, insect, other) Diagnosis of asthma? Child wakes during night coughing? TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER Yes Yes No No MEDICATION (List all prescribed or taken on a regular basis.) Loss of function of one of paired organs? (eye/ear/kidney/testicle) Birth defects? Yes No Hospitalizations? Developmental delay? Yes No When? What for? Blood disorders? Hemophilia, Yes No Surgery? (List all.) Yes No Sickle Cell, Other? Explain. When? What for? Diabetes? Yes No Serious injury or illness? Yes No Head injury/concussion/passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No Heart problem/shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/high blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with Yes No Family history of sudden death Yes No exercise? before age 50? (Cause?) Eye/Vision problems? Glasses Contacts Last exam by eye doctor Dental Braces Bridge Plate Other Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Bone/Joint problem/injury/scoliosis? Yes No Signature Date PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes 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.) Questionnaire Administered? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm Blood Test: Date Reported / / Result: Positive Negative Value LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Urinalysis Sickle Cell (when indicated) Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Ears Endocrine Gastrointestinal Eyes Amblyopia Yes No Genito-Urinary LMP Nose Throat Mouth/Dental Cardiovascular/HTN Neurological Musculoskeletal Spinal Exam Nutritional status Respiratory Diagnosis of Asthma Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid) NEEDS/MODIFICATIONS required in the school setting Other 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 (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited Print Name (MD,DO, APN, PA) Signature Date Address Phone (Complete Both Sides) Yes Yes No No

To be completed by the parent (please print): Illinois Department of Public Health PROOF OF SCHOOL DENTAL EXAMINATION FORM Student s Name: Last First Middle Birth Date: / / Address: Street City ZIP Code Telephone: (Month/Day/Year) Name of School: Grade Level: Gender: Male Female Parent or Guardian: Address (of parent/guardian): To be completed by dentist: Oral Health Status (check all that apply) Yes No Yes No Yes No Yes No Yes No Dental Sealants Present Caries Experience / Restoration History A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1 st molars. 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 considered sound unless a cavitated lesion is also present. Soft Tissue Pathology Malocclusion 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. Preventive Care sealants, fluoride treatment, prophylaxis Other periodontal, orthodontic Please note Signature of Dentist Date Address Street City ZIP Code Telephone 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 www.idph.state.il.us Printed by Authority of the State of Illinois P.O.#346085 5M 10/05

Departamento de Salud Pública de Illinois FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR Para ser completado por el padre/madre (por favor impresión): Nombre del Estudiante: Apellido Nombre Inicial Fecha de Nacimiento: / / (Mes/Día/Año) Dirección: Calle Ciudad Código Postal Número de Teléfono: Nombre de la Escuela: Grado: Sexo: Masculino Femenino Nombre del padre/madre o encargado: Dirección 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 Yes No Yes No Yes No Yes No Dental Sealants Present Caries Experience / Restoration History A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1 st molars. 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 considered sound unless a cavitated lesion is also present. Soft Tissue Pathology Malocclusion 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. Preventive Care sealants, fluoride treatment, prophylaxis Other periodontal, orthodontic Please note Signature of Dentist Date Address Street City ZIP Code Telephone Departamento de Salud Pública de Illinois, División de la Salud Oral 217-785-4899 TTY (sólo para personas con impedimento auditivo) 800-547-0466 www.idph.state.il.us Impreso con Autoridad del Estado de Illinois

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 if they 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 6 th 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 rights 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 Públicas de Chicago proveerán un ambiente educativo que trate a todos los estudiantes con dignidad y respeto. Cada alumno sin hogar de CPS tendrá acceso igualitario a las mismas oportunidades educativas gratuitas y apropiadas que los demás. Este compromiso con los derechos educativos de los niños y jóvenes sin hogar, y jóvenes 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 si en la actualidad vive: * en un refugio * comparte alojamiento con familiares u otros debido a la falta de un techo fijo * en un motel/hotel, campamento o situación similar, debido a la falta de alojamiento alternativo, adecuado * en una estación de trenes o de autobuses, parque o automóvil * en un edificio abandonado * alojado temporalmente mientras aguarda ubicación por DCFS (Servicios a Niños y Familias) en un hogar temporario Todos los estudiantes sin hogar tienen derecho a: Matriculación inmediata en una escuela. La escuela deben inscribirlos inmediatamente aun cuando carezcan de registros de salud o de vacunas, prueba de tutela o de domicilio. Matricularse en: *la escuela a la que asistían cuando tenían vivienda permanente (escuela de origen) *la última escuela en la que estuvieron inscriptos (escuela de origen) *cualquier escuela en la que sean elegibles los niños o jóvenes de la misma área 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 año académico. El éxito académico es ayudado cuando el estudiante permanece en la misma escuela. Prioridad en ciertos programas preescolares. Se alienta a padres y tutores a buscar inscripción en esos programas. Participar en programas de tutorías-apoyo de instrucción, actividades escolares relacionadas y/o a recibir otros servicios de apoyo. Obtener información relacionada a dispensas y uniformes gratuitos, además de servicios médicos 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 situación, o, si el estudiante consigue alojamiento permanente, hasta el fin del año académico. Personal de CPS debe informar a los padres/tutores de los estudiantes sin alojamiento sobre 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 tránsito de CTA, transferencias, y si el estudiante tiene 12 años o más, el permiso para viajar en CTA * Para los padres de estudiantes sin hogar: - Tarjetas de tránsito de CTA para que los padres/tutores de estudiantes sin hogar acompañen hacia y desde la escuela a niños desde preescolares al 6º. Grado * Para preescolares al 6o. grado, transporte alternativo como autobuses en los casos de padres en dificultades documentadas. Ejemplos de situaciones difíciles son: - empleo de los padres, capacitación laboral o programa educativo - discapacidad mental y/o física - niños que necesiten ser transportados desde y hacia la escuela en lugares diferentes - reglas del refugio o instalación similar que no permitan salir al padre/tutor para transportar al niño hacia o desde la escuela - orden de la corte, de DCFS o contrato de un agente del DCFS que requiera actividades que no permitan al padre/tutor transportar al niño hacia y desde la escuela - otra causa válida por la cual el padre/tutor no pueda usar el transporte público para llevar y traer al niño de la escuela Solución de disputas: Si usted no está de acuerdo con las autoridades escolares sobre la matrícula, transporte o tratamiento justo de un niño o joven sin domicilio, puede presentar una queja al director. Este debe responder e intentar resolverlo rápidamente. El director debe referirlo a servicios legales gratuitos o de bajo costo para que lo ayuden, si así 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 está disponible en todas las escuelas públicas de Chicago y oficinas, incluyendo el Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda (773) 553-2242. Cada escuela pública de Chicago tiene un enlace para los Estudiantes en Situaciones Temporales de Vivienda (STLS) que lo ayudará con las decisiones de matrícula y ubicación, le informará sobre el proceso de apelación y con el llenado de los formularios de disputa. Si tiene alguna pregunta sobre la matrícula escolar, o quiere saber más sobre los derechos de los estudiantes sin hogar en las Escuelas Públicas de Chicago, llame al Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda al (773) 553-2242, o al número de las oficinas centrales (773)553-1000. Si necesita más información sobre los derechos de los estudiantes sin hogar en Illinois, llame a la Junta de Educación de Illinois por el (1-800) 215-6379.