K-8 Registration Kit

 

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hope community academy 720 payne avenue st paul mn 55130 tel 651-796-4500 fax 651-796-4599 www.hope-school.org dear family thank you for your interest in hope community academy i am pleased that you are considering our school as an educational choice for your child hope community academy seeks to provide students in pre-school through eighth grade the knowledge and skills to achieve academic excellence personal growth and success in a safe positive and diverse learning environment in this folder you will find information about the school registration forms and our school handbook please take a moment to review the handbook as it contains much information about the day-to-day procedures of the school i appreciate your interest and invite you to come and see the school please feel free to contact me with any questions you might have or to set up an appointment for a tour i have enclosed my business card with all of my contact information for your convenience sincerely maychy vu maychy vu director

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hca new student registration family name primary family last name student information please list each children in the same household currently attending hope community academy name grade first name only except if different from family name father name address city/state/zip home work cell email my children will not be returning to hope community academy mother name household information address city/state/zip home work cell email students resides at 1 household 100 of the time father mother both other student has special custody arrangements if so please provide the office with a copy of the custody agreement students resides at multiple households other parent grandparent guardian name address city/state/zip mandatory items copies of the following items must be returned to hope by mail or fax before your child can begin school child s birth certificate social security card immunization record early childhood screening for children entering kindergarten home work cell email

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full name name to be used at school student gender male female date of birth age on the date of registration child resides with birthplace city state zip social security number education information registering for grade k 1 2 3 4 5 last grade attended k 1 2 3 4 5 6 school last attended student has an iep yes no referred by name and phone number student s ethnic origin african-american asian pacific latino american indian caucasian other in case of an emergency the school will attempt to contact you if the school is unable to do so please provide us with the names of three persons who we may contact to care for your child inform them that you have provided the school their name name emergency contacts telephone relationship name telephone relationship name telephone relationship in an emergency when i or my physician cannot be contacted hope community academy has my permission to have my child transported by ambulance to the emergency of the nearest hospital the hospital and its medical staff have my authorization to provide treatment that the attending physician deems necessary and appropriate the cost of the ambulance will be my responsibility your signature date

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release of official education records student name birth date school that student previously attended name address telephone dates of enrollment school that record information is to be released to hope community academy 720 payne avenue st paul minnesota 55130 please release the official education records including do not send original files copies only please grades for current school year cumulative records standardized test results health records psychological service reports if any special education information if any social worker involvement if any limited english proficiency if any state assigned student id number other information which may be helpful in planning and implementing the student s program at hope in accordance with revised federal and state statutes permission of the parent or adult student is no longer required when authorized school personnel request records.

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release of pre-school screening records if your child s pre-school screening did not take place at hope community academy please complete this form student name birth date pre-school screening location name address telephone school that record information is to be released to hope community academy 720 payne avenue st paul minnesota 55130 please release the pre-school screening records special education records and any other information which may be helpful in planning and implementing the student s school program at hope community academy i the undersigned give permission for the release of information as designated above parent/guardian signature date

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health care summary student name gender m f birth date address street city state zip code mother/legal guardian home phone work phone cell phone father/legal guardian home phone work phone cell phone identify any allergies food medication insects other this child may have is a modified diet necessary if yes please describe is any condition present that might result in an emergency if yes please describe student currently has or had in the past any of the following conditions if yes explain below condition asthma adhd/add behavioral/developmental problems congenital problem cystic fibrosis dental problem diabetes eating disorder bowel problem eye problems speech problem yes no condition hearing problem heart disease hospitalizations menstrual problems mental health emotional problems orthopedic problems seizure disorder stomach problems surgeries wears glasses or contacts other yes no s if you answered yes to any of the above please explain over

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list all medications prescription and over-the-counter the student takes on a regular basis medication if a prescription name of doctor condition treated dosage time given if determined to be necessary the health office at hope community academy may apply to this student s skin hydrocortisone cream 1 and/or an antibiotic ointment please contact the school 651-796-4500 if you do not want these medications used on your child student s physician phone last seen student s dentist phone last seen name of any other health care provider phone last seen

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home language questionnaire student name gender m f birth date dear parent or guardian in order to help your child learn your child s teachers need to determine which language your child uses most please respond to the following questions 1 which language did your child learn first english hmong other 2 which language is most often spoken at home english hmong other 3 which language does your child usually speak english hmong other 4 can an adult family member or extended family member speak english yes no 5 can an adult family member or extended family member read english yes no please sign below and have your child return this questionnaire to his or her teacher thank you parent or guardian signature date over for hmong translation

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menyuam npe qip hnub yug nyob zoo niamtxiv ua ntej yuav pab tau koj tus menyuam nws tus xib fwb yuav tsum tau paub seb tus manyuam hais lus twg heev tshaj thov teb cov qhaub lus ntawm no 1 yam lus twg tus menyuam xyaum hais ua ntej as kiv hmoob lwm yam lus 2 yam lus twg tsev neeg siv heev tshaj hauv tsev as kiv hmoob lwm yam lus 3 yam lus twg koj tus menyuam swm hais dua as kiv hmoob lwm yam lus 4 puas muaj neeg hauv tsev los sis txheeb ze hais tau lub as kiv muaj tsis muaj 5 lawv nyeem puas tau lus as kiv muaj tsis muaj thov kos npe rau daim ntawv hauv vaj tse hais lus hmong language questionnaire no es muab xa nrog koj tus menyuam tuaj rau nws tus xib fwb ua tsaug niam/txiv kos npe hnub date

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bus pick-up and drop-off please notify hope community academy of any changes to this information we are unable to comply with changes to bus pick-up and drop-off instructions unless a revised form is completed signed and on file in our office please complete one form for each child enrolled at hope student name grade teacher pick-up address pick-up street address city state zip phone number for this address is this a day-care address yes no drop-off address drop-off street address city state zip phone number for this address is this a day-care address yes no complete the following only if different from pick-up or drop-off addresses home address home street address city state zip phone number for this address is your student in the hope after school program yes no print parent/guardian name parent/guardian signature date

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parent authorizations field trip permission i give my permission for my child to attend and be transported on all field trips during the school year i understand that i will receive specific information regarding the field trip prior to the actual trip including transportation by licensed bonded services my child also has permission to participate in walking field trips around the school neighborhood parks parent/guardian signature date media release during the school year staff of hope community academy and media may want to interview photograph or videotape your child for use in publications television reports and public presentations the pictures may be of groups of students or individuals and the students names may be used i give my permission for my child to be photographed and interviewed and grant permission to hope community academy to use my child s photo and/or videotaped image and interview information for the purpose of informing the public about and promoting enrollment at hope community academy this permission will expire one year from the date of this consent parent/guardian signature date internet i give my permission for my child to have individual access to the internet i understand that students and families may be held liable for violations of the internet use policy i also understand that some materials on the internet may be objectionable but i accept responsibility for guidance of internet use by setting and conveying standards for my daughter/son to follow when selecting sharing or exploring information parent/guardian signature date

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immunization history fill in the mo/day/yr information for children 2 months of age and older if child received a combined shot like hib-hep b write the date in all the boxes that apply vaccine doses that are circled are not required by law child care immunization record name birthdate date of enrollment signatures must be on file before a child attends child care diphtheria tetanus pertussis dtap ·3 doses during 1st year at 2-month intervals ·4th dose at 12-18 months ·5th dose at 4-6 years or at school entrance indicate vaccine type dtap or dt polio ipv and/or opv ·3 doses at 2-18 months ·4th dose at 4-6 years or at school entrance vaccine dose mo day yr 1 2 3 4 5 vaccine dose a b for children who are 15 months or older and who have received all the immunizations required by law for child care mo day yr i certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care signature of parent/guardian or physician/nurse practitioner/physician assistant/public clinic date 1 2 3 4 vaccine dose measles mumps rubella mmr ·required for children 15 months and older ·must be given on or after 1st birthday ·2nd dose at 4-6 years haemophilus influenzae type b hib ·3-4 doses for children at 2-15 months ·1 dose given after 12 months or older required ·1 dose for previously unvaccinated children 15-59 months ·not indicated for children 5 years or older varicella chickenpox ·1st dose between 12-18 months ·2nd dose at 4-6 years or at school entrance required for kindergarten pneumococcal conjugate vaccine pcv ·2-4 doses for children 2-24 months ·consider for unvaccinated children at 24-59 months in child care ·not indicated for children 5 years or older hepatitis b hep b­required for kindergarten ·3 doses between birth and 18 months mo day yr for children who are younger than 15 months or have not received all required immunizations i certify that the above-named child has received the immunizations indicated in order to remain enrolled this child must receive all required vaccines within 18 months from initial enrollment date signature of physician/nurse practitioner/physician assistant/public clinic date 1 2 vaccine dose mo day yr 1 2 3 4 vaccine dose c for children who have a history of disease or are medically exempt from vaccine s the following immunizations are not indicated because of medical reasons history of disease or laboratoryconfirmationofadequateimmunity see below for varicella disease mo day yr signature of physician/nurse practitioner/physician assistant date 1 2 disease date dose vaccine 1 2 3 4 dose vaccine 1 2 3 dose vaccine 1 2 3 dose vaccine 1 2 dose vaccine 1 2 mo day yr starting september 2010 before september 2010 a parent can sign for children who are 18 months or older who have a history of varicella disease i certify that varicella immunization is not indicated for the above-named child due to a history of varicella disease that i have diagnosed or had adequately described to me by the parent to indicate past varicella infection in year signature of physician/nurse practitioner/physician assistant before september 2010 a parent can sign date mo day yr d if the parent/guardian conscientiously opposes immunizations i understand that not following vaccination recommendations may endanger the health or life of my child and others that my child might come in contact with i hereby certify by notarization that i am opposed to all immunizations i am opposed to only the vaccines indicated vaccines i oppose rotavirus ·2-3 doses between 2 and 6 months mo day yr signature of parent/guardian date subscribed and sworn to before me this day of 20 influenza laiv or tiv ·1 dose annually for children 6 months or older hepatitis a hep a ·2 doses separated by 6 months for children 12-24 months 1sttimeinfluenzaimmunizationrequires2doses mo day yr signature of notary public a copy of the notarized statement will be forwarded to the commissioner of health mo day yr notary public stamp minnesota immunization program 651-201-5503 or 1-800-657-3970 mdh 8/2011

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child care immunization record instructions immunizationinformationmustbeonfilebefore a child attends child care who should complete and sign this form who signs depends on the child s age and situation either the parent/guardian healthcareprovider,orchildcareprovidercanfillinthechild simmunization history · if the child is at least 15 months old and has had all the shots required by law a parent or guardian can sign the form in section a · if the child is younger than 15 months or has not had all the shots required by law then a health care provider must sign in section b saying the child has begun the required shots or can t for medical reasons · starting in september 2010 if the child is 18 months or older and has had varicella disease chickenpox a health care provider must sign in section c before september 2010 a parent can sign · if a parent or guardian objects to a certain shot or all shots the parent or guardian must complete section d and have it notarized by a notary public notes for parents 1 give your child s immunization history to the child care provider when you enroll minnesota law minn stat.121a.15 requires children enrolled in a minnesota child care to be immunized against certain diseases or have a legal exemption this form is designed to provide the child care provider with the information required by law this or another form documenting immunizations or an exemption mustbekeptonfilewiththechildcareprovider.electronicimmunizationrecords are an allowable form 2 keep track of your child s shots and tell your child care provider each time your child gets a shot it will save you time if you keep a shot record for each of your children be sure to have the record updated each time your child receives a shot childcarewillbethefirstofmanytimesyouwillneedtheshotrecord.youwill also need this record for school camp college and if you go to a new doctor or clinic 3 if your child is not up to date on his or her shots you can catch up by law you have 18 months after enrolling for your child to have all his or her requiredshots.yourchilddoesn thavetorestartadelayedseries minnesota children are still getting diseases like measles mumps and rubella these diseases are contagious they can spread rapidly especially among groups of children who have not received their shots and some of them like pertussis whooping cough are much more serious for children than they are for adults as a parent you can protect your children by making sure they get all their shots most shots are due by 2 years of age 4 if your child has had chickenpox he or she does not need a varicella shot but starting in september 2010 if the child is 18 months or older and has had varicella disease chickenpox a health care provider must sign in section c before september 2010 a parent can sign notes for child care providers 1 be sure you have a complete immunization history on file for all children 2 months of age and older when the provider gives parents immunization information about enrollment for child care the provider must use this form or a similar form approved by mdh as required by law however the record that is kept on file that documents immunizations or an exemptiondoesnothavetobethisspecificform.theformthatmustbekept onfilecanbethisoranotherformdocumentingimmunizations;thiscaninclude a report printed off of miic the state immunization registry or another electronic healthrecordsystem.theinformationmustbeonfilebeforethechildenrolls.if a child enrolls at a younger age you must obtain immunization information when they reach 2 months of age 2 keep track of the date when each child s required immunizations are due by law if a child is 2 months of age or older and has not yet received all their required shots you should note the date when these immunizations will be due by law 18 months after the child enrolls in your facility unless they are otherwise exempt minnesota law requires preschoolers in child care to have shots for dtp polio mmr pcv hib and varicella if the child has had chickenpox disease he or she does not need a varicella shot but starting in september 2010 they must have a health care provider s signature to document the year the child had chickenpox immunization against hepatitis a hepatitis b rotavirus,andinfluenzaarenotrequiredbylaw;however,itisstronglyrecommended for children in child care 3 be sure each child s immunization history clearly indicates whether or not they received pertussis vaccine dtapanddtpcontainpertussisvaccine dt does not nationwide there has been an increase in pertussis disease whooping cough if an outbreak of pertussis occurs in your child care center you will need to be able to quickly identify which children are protected and which are not 4 remind parents to immunize children on time as a child care provider you are in an excellent position to help remind parents about immunizations makesuretheimmunizationrecordsyouhaveonfileforeachchildareupto date and regularly remind parents when shots are due ask your local health department for an updated immunization schedule each calendar year so you will have the latest information on hand questions if you have a question about immunizations call your clinic or your local public health department immunization program p.o box 64975 st paul mn 55164-0975 651-201-5503 or 1-800-657-3970 www.health.state.mn.us/immunize ic#140-0163 mdh 8/2011

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