HM Medical Clinic

 

Brownco.k12.in.us

Brown County Schools
Brown County Schools prepares students to achieve success through quality instruction. New Student Enrollment Packet (preschool - grade 6)

Please complete this New Student Enrollment Packet, print and bring it along with the following legal documents to the Brown County
School Administration Office: 1) Birth Certificate 2) Immunization Records 3) Custody Papers (if applicable)
4) Proof of Address
Record Full Legal Name as it appears on their Birth Certificate. Student Cell Phone Student Home Phone Please check this box if you would like someone to contact you regarding any special needs or learning services for this student. The Indiana Department of Education requires the following information regarding language and ethnicity:
This student learned English when he/she learned to speak.
English is the language most often spoken at home.
English is the language most often spoken by the parents of this student.
If you answered "NO" to any of the language questions above, specify the language used.
Student is a foreign exchange student Country of Residency Country of Origin Date of US enrollment (began attending US schools) Is the student Hispanic or Latino? What is the student's race? (Select one or more) American Indian/Alaska Native: A person having origins in any of the peoples of North America and maintaining cultural identification through tribal affiliation or community recognition.
Asian: A person having origins in any of the original peoples of 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 Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
HOUSEHOLD INFORMATION SHEET
Parents and guardians of students attending Brown County Schools may request access to view their student's academic and attendance records via "Skyward Family Access." Please complete the information below to ensure that we have the necessary household information to match parents with students. Please note that you may be asked to provide verification of custody or guardianship for access to the online system. Information for Parent or Guardian #1:
3rd Party Custodial Check this box if the Parent or Guardian #1 Address is the same as the student's. Cell Phone Number Home Phone Number Responsible for Bill Receives School Mailings Information for Parent or Guardian #2:
3rd Party Custodial Check this box if the Parent or Guardian #2 Address is the same as the student's. Cell Phone Number Home Phone Number Responsible for Bill Receives School Mailings Please enter the following information for other children in your household that attend Brown County Schools.
Sibling 1: School Sibling 2: School Sibling 3: School Sibling 4: School Sibling 5: School Sibling 6: School STUDENT HEALTH INFORMATION
A student's health plays an important part in his/her school program. In order to keep your child's health record current, we would appreciate you completing the questions below.
Date of Birth
In case of an emergency when a parent can not be reached, who should we call LOCALLY?
With your authorization, the Health Office staff can administer any of the following over-the-counter medications to your child if
needed. By marking the items below, you are providing that authorization. If left blank, no authorization has been given.
Please check if your student has a history of ANY of the following:
Migraine Headaches Frequent Nosebleeds Use inhaler and/or aerosol treatments Seizure Condition Are there allergens or irritants that are particularly bothersome to your child? Student has a documented food allergy/disability. If yes, obtain a "Physicians Food Allergy/Disability" form from the school nurse.
Student is allergic to bee stings Student has been prescribed an Epi Pen Please describe the allergic reaction(s) your child experiences from bee stings: If you checked any of the items above, please explain.
Special Health Problems or Concerns: Check if student wears glasses Check if student wears contact lenses ATTENTION: If medication is to be given at school, the following procedures must be followed:
* A medication form must be filled out; * All medication, prescription and non-prescription, must be brought in by the parent; * All medication must be in the original container; and * The student's name must be clearly marked on the container.
List Medications (including inhalers and/or aerosol treatments)
Feel free to contact your school nurse at any time with questions or concerns! HEALTH SERVICES
CHIRP Release of Information
I give Brown County Schools, permission to release the information outlined below, concerning my child, to the Indiana State Department of Health's Children and Hoosiers Immunization Registry Program (CHIRP): CHILD'S NAME - FIRST, MIDDLE AND LAST, BIRTHDATE, PARENT OR GUARDIAN NAME, IMMUNIZATION
INFORMATION, ETHNIC BACKGROUND, ADDRESS AND PHONE NUMBER.
I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me of my child's immunization status or that an immunization is due according to recommended immunization I understand that my child's information may be available to the immunization registry of another state, a health care provider or provider's designee, a local health department, an elementary or secondary school, a child care center, the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, a licensed child placing agency and a college or university. I also understand that other entities may be added to this list through amendment to Indiana Code, I.C. 16-38-5-3. I hereby consent to the release of such information.
Name of Parent or Guardian Emergency Treatment Authorization
PLEASE READ CAREFULLY AND SIGN BELOW: 1) In case of an emergency involving your child, it is the policy of Brown County Schools to render first aid treatment while contacting parents/guardians for further instructions. 2) In the event that the parents/guardians cannot be contacted, I give permission to school officials to take action determined to be in the best interest of my child, including emergency medical services. 3) This information may be shared with the appropriate Brown County Schools personnel for health and emergency purposes.
Name of Parent or Guardian INTERNET POLICY: TERMS AND CONDITIONS
All students accessing the Internet will be required to read and sign the corporation's Internet User's Terms and Conditions Contract.
(IUTCC) Before a student may use the Internet, parents must read and sign the Internet User's Terms and Conditions Contract. This will indicate that parents are aware that their student could access inappropriate materials. Although the school corporation may use technical means to limit student Internet access, these means do not provide a foolproof method for enforcing the provisions of local acceptable use policies. Adult supervision will be maintained. Parents will accept responsibility if the student accesses the school's Internet connection from home. School staff using the Internet will be required to read and sign an Internet User's Terms and Conditions Contract. (IUTCC) Account managers may be obligated to access school accounts because of storage issues, normal monitoring, or specific concerns.
Therefore, an individual's school Internet account is not totally private and is subject to review. It is a violation of school policy for students to purchase goods and services via the Internet. In the event of such a violation, all financial obligations are the responsibility of the parent and student. Staff members at each building will coordinate security, management, and account responsibilities associated with the school corporation's Internet resources and accounts. Any user who wishes to subscribe to Internet services such as listservs or news groups must have permission of the building Internet coordinators. All provisions of the Brown County Schools Internet Policy are subordinate to local, state, and federal statute. Student:
I have read, understand, and will abide by the BCS Internet Policies and Guidelines in the student agenda and the above stated Terms and Conditions. I further understand that should I violate said policies, I will be subject to disciplinary action as described in this document.
Student Signature I have read the BCS Internet Policies and Guidelines in the student agenda and the above stated Terms and Conditions. I understand the student and parent responsibilities as described in this Please Check one of the following: I give my permission for him/her to participate in educational activities using the internet. This authorization will remain valid unless the school is notified in writing by the parent/guardian. I do NOT give my permission for him/her to use the internet. I prefer that my student be given an alternative assignment.
Brown County Schools
Brown County Schools prepares students to achieve success through quality instruction. PERMISSION REQUEST FOR STUDENT RECORDS
Student's Full Legal Name Last Grade Attended The above named pupil has enrolled in Brown County Schools. Please Transfer his/her complete transcript of grades, health and dental records (including sports physical), psychological records, standardized test scores, attendance & discipline records, along with the State I.D. number. Kindly include the grade earned at the time of withdrawal. Thank you! Parent/Guardian Name Send records requested to the school selected below: Brown County High School Brown County Junior High School Brown County Intermediate School 235 School House Lane 95 School House Lane 260 School House Lane Nashville, IN 47448 Nashville, IN 47448 Nashville, IN 47448 812-988-6606 Phone 812-988-6605 Phone 812-988-6607 Phone Helmsburg Elementary School Sprunica Elementary School Van Buren Elementary School 5378 Helmsburg School Rd 3611 E Sprunica Rd 4045 State Road 135 S Morgantown, IN 46160 Nineveh, IN 46164 Nashville, IN 47448 812-988-6651 Phone 812-988-6625 Phone 812-988-6658 Phone Emergency Dismissal Form
In case of an emergency, or if it is necessary to dismiss school early, we need to know where to send your child/children. Please provide the following information: Parent/Guardian Name Name and Phone of any other person responsible for your child/children in case you cannot be If school is closed for any reason, where should your child/children go? SPECIAL NOTES TO REMEMBER: 1) Any medication must come with a note from the doctor, in the original container, and a signed permission slip from parent if it is to be given at school. 2) According to corporation policy, a note must be sent and a phone call received if your child is to be absent from school. 3) Please be certain that the "Student Health Form" has been completed. Parent Signature and Date: Distribution of Student Demographic Information
The 'Military' flag is used to exclude student information from being sent to military recruiters. The 'High Ed' flag is used to exclude student information from being sent to institutions of higher education. The 'Public' flag is used to exclude student information from being sent outside the district such as newspapers and other media. The 'Local' flag is used to exclude student information from within the district like yearbooks, photographs, sports information such as rosters and programs or articles where students' directory information is identified.
Please check any/all boxes that you DO NOT want your student's demographic information to be distributed to.
Parent Signature and Date: Family Educational Rights and Privacy Act This serves as Brown County Schools' notification to parents and eligible students of their rights in accordance with the Family Educational Rights and Privacy Act (FERPA). Parents or eligible students may restrict the release of Directory Information. Consistent with federal law Brown County Schools has defined Directory Information as the following types of information: Telephone number (s) Major Field of study Participation in officially recognized activities and sports Height and weight of members of athletic teams Date of attendance ("from and to" dates enrolled) Degrees and awards received Most recent previous school attended Video tape not used in a disciplinary matter Student work for display at the discretion of the teacher (no grade of the work displayed) Brown County Schools
Brown County Schools prepares students to achieve success through quality instruction. Book Rental
I understand that I am financially responsible for book rental fees and any charges the school may access for but not limited to lost books, cafeteria fees, after school care, pre-school, library books, extracurricular activities, fund raisings and tuition. I shall also be responsible for all reasonable costs of the collection of this account, which may include but not limited to, late fees, client collection fees, collection agency fees, reasonable attorney fees and court costs on any outstanding balance. Responsible Party Signature and Date:

Source: http://www.brownco.k12.in.us/pre-6enrollmentpacket.pdf