New Student Application

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Resurrection Grammar School 116 Milton Road, Rye, NY 10580 ~ 914-967-1218 New Student Application 2018-2019 The following papers must accompany your application: 1. Child s Birth Certificate 2.

1 Resurrection Grammar School 116 Milton Road, Rye, NY ~ New Student Application The following papers must accompany your application: 1. Child s Birth Certificate 2. Child s Baptismal Certificate 3. Medical and TB Screening Update Form completed and signed by a Physician 4. A non-refundable $40.00 Application Fee PLEASE NOTE: All documents must be the original. (Copies will be made and the originals will be returned to you.)

2 Resurrection Grammar School 116 Milton Road, Rye, NY ~ New Student Application Academic Year Date of Application: Montessori PK 4 Grade Applying For: Montessori PK 3 STUDENT INFORMATION Male Female (Please Print) Student Name: [Last] [First] [Middle] Date of Birth: Place of Birth: mm/dd/yyyy [City, State, Zip, Country] Home Address: [Number, Street, City, State, Zip,] Home Phone # Primary Language Spoken by Student at Home: Other Languages Spoken in Home: Student Race/Ethnic Origin: White (Non-Hispanic) Hispanic Asian/Pacific Islander Black (Non-Hispanic) Multiracial American Indian/Alaskan Other Name of Last School Attended: Address: [Number, Street, City, State, Zip] School Type: Public Catholic Private Has your child been tested for any special concerns academic/behavioral/ other? Yes No If yes, please explain: Has your child ever been on medication for educational/behavioral purposes? Yes No If yes, please explain: Has your child ever been referred for special educational services? Yes No If yes, what type, by whom and with what result? Has your child had special educational services provided? Yes No

3 If yes, please explain: School District of Residence: SACRAMENT INFORMATION: Baptism Date: [mm/dd/yyyy] Place of Baptism: [Name of Church, Address, City, State, Zip] First Penance Date: [mm/dd/yyyy] Place of First Penance: [Name of Church, Address, City, State, Zip] First Communion Date: [mm/dd/yyyy] Place of First Communion: [Name of Church, Address, City, State, Zip] Confirmation Date: [mm/dd/yyyy] Place of Confirmation: [Name of Church, Address, City, State, Zip] FAMILY INFORMATION Parents Marital Status: Married Divorced Separated Single Widowed Father: Deceased First Name: Middle Name: Last Name: Address: Home Address: [Number, Street, City, State, Zip,] Employer Employer s Address: [Number, Street, City, State, Zip,] Home Phone # Work Phone # Cell Phone # Religion: Parish *Parishioner of Resurrection: Yes No Envelope #

4 Mother: Deceased First Name: Middle Name: Last Name: Maiden Name: Address: Home Address: [Number, Street, City, State, Zip,] Employer: Employer s Address: [Number, Street, City, State, Zip,] Home Phone # Work Phone # Cell Phone # Religion: Parish *Parishioner of Resurrection: Yes No Envelope # *Definition Of Parishioner - A Parishioner is an individual or a family who is registered at Resurrection Church, regularly attends services at Resurrection Church and has been using the envelope system on a continuing basis. To be eligible for the In-Parish rate, families must contribute a minimum of $ a year or a minimum of $17.00 a week. Families who do not contribute the minimum annual amount will be considered Out-of-Parish and pay the Non-Parishioner rate. Student s Siblings: Name Age School Currently Attending *Optional Information (used for notification of school events, etc.) *Name of Maternal Grandparents: *Mailing Address: * Address: *Name of Paternal Grandparents: *Mailing Address: * Address: Name of Parent Completing Form: Please Print Parent Signature: Date:

5 Resurrection Grammar School 116 Milton Road, Rye, NY ~ EMERGENCY INFORMATION Student s Name: Please list any condition that should be considered in planning your child s school day: Allergies: Does your child have any of the following conditions (check all that apply): Asthma Diabetes Seizures Infectious Disease Other Please Explain: Physician Name: Phone # Dentist Name: Phone # Orthodontist Name: Phone # Emergency Contacts: In the event Resurrection School is unable to contact me, I hereby authorize the following persons to take responsibility of my child: 1. Name Relationship Home Phone # Cell Phone # Work Phone # 2. Name Relationship Home Phone # Cell Phone # Work Phone # 3. Name Relationship Home Phone # Cell Phone # Work Phone # 4. Name Relationship Home Phone # Cell Phone # Work Phone # To the best of my knowledge the above information is complete and accurate. I acknowledge that I have a continuing obligation to inform the school of any changes in my child s health status that are relevant to the information requested by this form. Name of Parent/ Guardian Please Print Date Signature of Parent/ Guardian

6 Resurrection Grammar School 116 Milton Road, Rye, NY ~ Request for Information Release for Records TO: Name of Current School School Address Town/City State Zip Code RE: Student Name Grade Entering The above named student has enrolled in the Resurrection Grammar School. Please forward the following records at your earliest convenience to the address above, Attn: Admissions. Transcript Current Report Card Health Records Standardized Tests State Test Scores Any other information that would assist us in the placement of this student Name of Parent/ Guardian Please Print Date Signature of Parent/ Guardian

7 Dear Parent/Guardian: Resurrection s School Health Services program supports your student s academic success by promoting health in the school setting. One way that we provide care for your student is by performing the health screenings as mandated by the State of New York. During this school year, the following screenings will be required or completed at school: Vision Distance acuity for all newly entering students and students in Kindergarten, Grades 1, 2, 3, 5, 7 and 10. Near vision acuity and color perception screening for all newly entering students. Hearing Hearing screening for all newly entering students and students in Kindergarten, Grades 1, 3, 5, 7 and 10. Scoliosis Scoliosis (spinal curvature) screening for all students in Grades 5 9. Health Appraisals A physical examination including Body Mass Index and Weight Status Category Information is required for all newly entering students and students in Pre-Kindergarten or Kindergarten, Grades 2, 4, 7 and 10. Dental Certificates A dental certificate is requested for all newly entering students and students in Kindergarten, Grades 2, 4, 7 and 10. Immunization A physician signed copy of current vaccines should accompany all Health Appraisals. These should include lead screening and PCV vaccines for Pre-K, Dtap, Polio, MMR, Varicella, HBV, and HIB vaccines and a TB screening for all grades. All New York State licensed physicians are aware of the State requirements. A letter will be sent home if there are any findings on the screening done at school that would cause concern or need medical follow-up. Please call the school s Health Office if you have any questions or concerns. School Nurse: Ms. Meg Donohue Phone #: (914) Fax: (914) School: Grammar/Middle Schools mdonohue@resurrectionschool.com

8 HEALTH APPRAISAL FORM NAME: DATE OF EXAM: Date of Birth: Gender: M F School: Grade: IMMUNIZATIONS / HEALTH HISTORY Immunization record attached Sickle Cell Screen: Positive Negative Not done Date: No immunizations given today PPD: Positive Negative Not done Date: Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not done Date: Dental Referral Yes No Not done Date: Significant Medical/Surgical History: Specify current diseases: Asthma Diabetes: Type 1 Type 2 Hyperlipidemia Hypertension Other: ALLERGIES LIFE THREATENING Food: Insect: Other: NONE Medication: Seasonal PHYSICAL EXAM Height: Weight: Blood Pressure: Pulse: Referral Body Mass Index:. Vision - without glasses/contact lenses R L Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L less than 5 th 5 th through 49 th 50 th through 84 th Vision - Near Point R L 85 th through 94 th 95 th through 98 th 99 th and higher Hearing Pass 20 db sc both ears or: R L EXAM ENTIRELY NORMAL Specify Abnormality; Scoliosis: Negative Positive: PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION This student is physically qualified to participate in all Physical Education activities and supervised sports. This student is RESTRICTED FROM participation as CHECKED BELOW: Contact/Collision: field hockey, football, ice hockey, lacrosse, soccer, and wrestling Limited Contact/Collision: baseball, basketball, diving, gymnastics, handball, skiing, softball, volleyball. Strenuous Non-Contact: crew, cheerleading, cross-country, track and field, swimming, tennis. Non Strenuous / Non-Contact: archery, bowling, golf, riflery, Reason for Disqualification: Provider s Signature: Phone: (Stamp below) Print Provider s Name: Fax:

9 PARENT SIGNATURE REQUESTED***************************************************************************************** Yes/No (Circle One): I release the Nurse to inform all those on a Need to Know* basis all pertinent health information for his/her safety during the school year. *Principal, Faculty, Staff directly involved with the student. Exceptions: Parent/Guardian Signature Date

10 RYE CITY SCHOOL DISTRICT HEALTH CARE SERVICES Rye, New York NEW STUDENT HEALTH HISTORY (To be filled out by parent or guardian) Student s Name: Sex: Grade: Address: Telephone: Date of Birth: / / Birthplace: Father s Name: Mother s Name: Family Physician: Telephone: Family Dentist: Telephone: Health History: Individual providing health history: Does this child have an ongoing health concern? (asthma, diabetes, etc.) If yes, please describe: Yes No Does this child have any allergies? Yes No If yes, please list: Has the allergy required emergency treatment? Yes No If yes, please explain: Is there a history of any hospitalizations, significant injuries or surgery? Yes No If yes, please describe: Are there any current medical concerns/injuries? Yes No Head Eyes Nose Ears Throat Neck Chest Respiratory Cardiovascular Gastrointestinal Genitourinary Neurological Musculoskeletal (include any past fractures, etc.) Does this child take any medication regularly at home? Yes No Require medication at school? Yes No If yes, please describe: Please list any additional concerns or information: List any significant medical concerns in family: Mother Siblings Other Father Grandparents Who lives with the child in his/her primary household? Does child spend a significant amount of time in another household? Yes No If yes, please describe: Who has legal custody of this child? Describe any custody arrangements: Any additional concerns or pertinent information (use back as needed): Parent/Guardian Signature: Date: 1/31/11

11 RYE CITY SCHOOL DISTRICT HEATH CARE SERVICES Rye, New York STUDENT TUBERCULIN SCREENING REPORT FORM Tuberculin Screening must be performed within 24 months of entering the Rye City School District NAME DOB SCHOOL GRADE EITHER A OR B MUST BE COMPLETED BY THE PRIMARY CARE PROVIDER Universal tuberculin testing is not recommended in the U.S. due to the high rate of false positive results. However, tuberculin testing is indicated for children with the following risk factors for TB: Immigration from a country with a high incidence of TB (most countries of Asia, Africa, Central and South America). Travel to a high-incidence country for more than one month (where housing was with family members, not hotels). Household contact with parents or others who immigrated from a country with a high incidence of TB and tuberculin status unknown (consider for testing at ages 1, 5, 12). Exposure to individuals in the past 5 years who are HIV-infected, homeless, residents of nursing homes, institutionalized, user of illicit drugs, incarcerated (test all groups every 2-3 years). HIV infection (test yearly), diabetes mellitus, chronic renal failure, malnutrition, reticuloendothelial diseases, other immunodeficiencies or receiving immunosuppressive therapy. A. Tuberculin testing not indicated (see above) (PCP must initial and sign below) B. PPD (Mantoux): Tine or Mono-Vac tests are not accepted. 1. Date Placed Date Read Result in mm If Tuberculin Skin Test is Positive, now or previously, the following are required: 1. Date of Positive PPD: Date: / / 2. Chest X-ray: (Please attach copy of report) Date: / / Normal Abnormal (Describe) 3. Clinical Evaluation: Normal Abnormal (Describe) 4. Treatment: No (Please explain) Yes (Drug, Dose, Frequency, Dates) Healthcare Provider Signature/Stamp: Date: / / (Required) Telephone: ( ) Fax: ( ) 1/31/11

12 Dental Health Certificate- Optional Parent/Guardian: New York State law (Chapter 281) permits schools to request an oral health assessment in the following grades: school entry, K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your registered dentist or registered dental hygienist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist/dental hygienist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible. Section 1. To be completed by Parent or Guardian (Please Print) Child s Name: Last First Middle Birth Date: / / School: Month Day Year Sex: Male Female Grade Will this be your child s first oral health assessment? Yes No Have you noticed any problem in the mouth that interferes with your child s ability to chew, speak or focus on school activities? Yes No I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below. Parent s Signature Date Section 2. To be completed by the Dentist/ Dental Hygienist I. The dental health condition of on (date of assessment) The date of the assessment needs to be within 12 months of the start of the school year in which it is requested. Check one: Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools. No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools. NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school. Dentist s/ Dental Hygienist s name and address (please print or stamp) Dentist s/dental Hygienist s Signature Optional Sections - If you agree to release this information to your child s school, please initial here. II. Oral Health Status (check all that apply). Yes No Caries Experience/Restoration History Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity]. Yes No Untreated Caries Does this child have an open cavity? [At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pits 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]. Yes No Dental Sealants Present Other problems (Specify): II. Treatment Needs (check all that apply) No obvious problem. Routine dental care is recommended. Visit your dentist regularly. May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation. Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.

Dental Health Certificate

Dental Health Certificate Parent/Guardian: New York State law (Chapter 281) permits schools to request an oral health assessment in the following grades: school entry, K, 2, 4, 7, & 10. Your child may