FULL DAY Application Checklist

Batesville Primary School 760 State Road 46 West Batesville, IN 47006 812-934-4509 www.batesvilleinschools.com/bps Student s Name Last First Middle 2016-2017 FULL DAY Application Checklist The following is required at the time of enrollment: Application Checklist Student Registration Form Financial Agreement Form Student Medical Form Health History Form CHIRP Form Original Birth Certificate (We will be happy to make a copy.) Immunization Records (Health records showing up-to-date shot records.) $100.00 Registration/Materials Fee (payable by Cash, Check, or Money Order made payable to BCSC) $100 Registration/Materials Fee To Be Completed By BCSC Staff Paid by: Cash Personal Check Number Money Order Number Cashier s Check Number Date Received Time Received Received by

Batesville Community School Corporation Student Registration School Year: 2016-2017 (circle grade) PK K 1 2 3 4 5 6 7 8 9 10 11 12 Student s Name Preferred Name Last First Middle Gender: M F Date of Birth: / / Student s Home Phone: mm dd yyyy Physical Address Mailing Address: (if different than physical address) Township of Residence: Adams Butler Laughery Ray Salt Creek County of Residence: Student resides with: (check one) Father/Mother Father Mother Guardian Mother/Stepfather Father/Stepmother Foster Parents Grandparents Other Father Home Address E-mail Address Mother Home Address E-mail Address Stepfather Address Stepmother Address Guardian Address E-mail Address Relationship

IF APPLICABLE- Please complete this section: Is this student subject to any court ordered custody or decree? Yes No If yes, please attach a copy of this decree or order and send to the Principal s Office. Name of person who has custody of this child Date of Custody Emergency & Pick Up Contact Information In case of emergency, illness or accident regarding the student named above, the school is authorized to contact the people listed below. With proper photo ID the persons indicated below are authorized to pick up my child in an emergency and/or under normal circumstances as indicated below. I understand any changes to this list must be submitted in writing. List in Order of Preferred Contact 1) Name Emergency Pick-Up Relationship to student Home Telephone Work Number Cell 2) Name Emergency Pick-Up Relationship to student Home Telephone Work Number Cell 3) Name Emergency Pick-Up Relationship to student Home Telephone Work Number Cell Did your child attend PreSchool Yes No PreSchool attended If so, how many years Parent/Guardian Signature Date

Batesville Primary School 760 State Road 46 West Batesville, IN 47006 812-934-4509 www.batesvilleinschools.com/bps Student s Name Last First Middle 2016-2017 Financial Agreement Form (Full Day) The program fee for the BCSC Little Bulldogs Academy is $24 per school day. Payments for BCSC Little Bulldogs Academy may be made bimonthly, monthly, semi-annually or annually. Payments can be made online at batesvilleinschools.com/bps/ or in the form of cash, personal check, money order or cashier s check. By initialing below, I have indicated the payment option I have selected for the 2016-2017 school year for my child. Bimonthly Payments will be due and made on the 1 st and 15 th of the month with the first payment due on August 1. In the event that either of these dates falls on a day the BCSC Little Bulldog Academy is closed, the payment will be due on the school day prior to the day off. The bimonthly program fee is $216.00. Parent/Guardian Initials Monthly Payments will be due and made on the 1 st of the month with the first payment due on August 1. In the event that either of these dates fall on a day the BCSC Little Bulldog Academy is closed, the payment will be due on the school day prior to the day off. The monthly program fee is $432.00. Parent/Guardian Initials Semi-Annually Payments will be due and made on August 1 and January 1. The semi-annual program fee is $2,160.00 Parent/Guardian Initials Annually Payment will be due and made on August 1. The annual program fee is $4,320.00. Parent/Guardian Initials Payments will be made as indicated above. If at any time I would like to change the frequency of payments, it is my responsibility to complete and submit a new Financial Agreement Form. If a personal check submitted for payment on account is returned for non-sufficient funds or account closure, I understand I am responsible for the full amount of the check plus a $20 returned check fee. If I choose to withdraw my child at any time, I will submit a two-week notice in writing, and a final fee will be calculated. If my account becomes two weeks behind, I understand that termination of services will occur until payment has been arranged. If payment is not arranged and services are terminated, my account will be turned over to a collections agency and the full amount plus collections fees will be owed. Name (Print) Date Signature

Batesville Community School Corporation Student Medical 2016-2017 Student Name: Last, First Gender Grade/Teacher Medical Information: Family Physician Phone While at school, this student may be given Tylenol or Ibuprofen as needed, following instructions on the container. While at school, this student may be given anti-acid preparation as needed following instructions on the container. If an extreme emergency arises, my child may be taken to an emergency care facility either by an emergency rescue unit or by a school official. I (We) give permission to share medical information with appropriate BCSC staff for the safety of our child. Does your student have insurance coverage. Medical Please inform us of your child s current health conditions, such as allergies, asthma, seizures, vision problems (glasses or contacts), broken bones, physical, handicaps, any recent surgeries, injuries or other illness. This information will only be shared with the staff members who will be working with your child. Medications: Please list your child s medications and reasons for taking them. If a student needs to take medications during the school hours, a permission form to administer medication will need to be filled out by the doctor and parent. This form maybe obtained in the school office. Medication Dose Frequency Reason 1. 2. If there are any changes regarding medical information or immunizations throughout the year, please contact the school nurse. Signature of Parent/Guardian Date Revised 8/9/2014

BATESVILLE COMMUNITY SCHOOL CORPORATION HEALTH HISTORY * Please return on or before the first day of school. Name Date of Birth Address Phone Parent(s) Weight Height Vision: Right 20 / Left 20 / Ears: Right 15 / Left 15 / B/P IMMUNIZATION HISTORY (Mo./Day/Year) DTaP 1) 2) 3) Booster Dates 4) 5) Polio Hib 1) 2) 3) Booster Dates 4) 1) 2) 3) 4) HepB 1) 2) 3) Varicella 1) 2) Chicken Pox disease (Date) MMR 1) 2) HepA 1) 2) Date: Past Medical History Chronic Illness Current Meds at Home Meds for School Allergies Dietary Restrictions Developmental Concerns Restriction from physical activity Yes No Reason Previous/Current OT/PT, Speech Therapy Psycho Social Concerns Physical Exam ( ) Normal ( ) Concerns Recommendations Prior to Starting Kindergarten ( ) None Physician Signature (Printed) Address: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * DENTAL EXAMINATION Name of Child Comments or recommendations: Date Examining Dentist (Printed) Address:

Batesville Community School Corporation 626 N. Huntersville Road *** P.O. Box 121 *** Batesville, Indiana 47006 Gayla Vonderheide, RN, BSN, Director of Health Services Phone 812-934-4509 Fax 812-933-0936 CHIRP FORM I, give the Batesville Community School Corporation, Permission to release the following information concerning my child to The Indiana State Department of Health s Children and Hoosiers Immunization Registry Program (CHIRP): The information released would be name, immunization data and other information such as date of birth or other identifying information as applicable. 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 schedules. I understand that my child s information will be available to the immunization data registry of another state, a healthcare provider, a local health department, an elementary or secondary school that is attended by the individual, a child care center, and the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3. Any questions please contact your School Nurse, Gayla Vonderheide RN, BSN, Director or Health Services. 812-934-4509. I hereby consent to the release of such information. Signature Date Printed Name of Parent or Guardian Address Child s Name School ( ) Telephone Number Grade Level A tradition of excellence ensuring success for tomorrow

REQUIREMENTS TO ENTER SCHOOL HEALTH HISTORY: requirements in effect It is very important that you have your students health history completed before the first day of school. This is a very important piece of information for the schools. MINIMUM IMMUNIZATION REQUIREMENT FOR SCHOOL ENTRY Based on the current recommendations of the AAP and the ACIP, the minimum immunization requirements for school attendance have been revised as follows and will be effective as of the 2013-2014 school year. When a child enrolls in a school corporation, for the first time or any subsequent time and at any level, his parents must show either that he has been immunized or that a current religious or medical objection is on file. The immunization series must be completed by August 5th before your child enters school. Please call your family doctor to schedule immunizations. Immunizations are also available at the: Ripley County Health Department in Versailles Parents should call 812-689-0506 to schedule an appointment. MMH Wellness Clinic 1051 State Road 229 North (behind Main Source Bank) Appointments can be scheduled by calling 812-934-0699 Tuesdays, 12:30-7:00 Thursdays, 10:00-12:00 and 1:00-5:00 Pre-Kindergarten 3-5 year olds 4 doses of diphtheria-tetanus-acellular pertussis (DTaP), diphtheria-tentanus-pertussis (DTP), or pediatric diphtheria-tetanus vaccine (DT) or any combination of the three are required. 3 doses of either oral polio (OPV) or inactivated polio (IPV) vaccine in any combination 3 doses of Hepatitis B vaccine (3 rd dose must be on or after 24 weeks of age). 1 dose of measles (rubeola) vaccine, on or after the first birthday. 1 dose of mumps vaccine, on or after the first birthday. 1 dose of rubella (German measles) vaccine, on or after the first birthday. 1 dose of varicella (chickenpox) vaccine on or after the first birthday or physician written documentation of history of chicken pox disease, including month and year of disease. OVER PLEASE Kindergarten Grade 5 Requirements listed on back!

Kindergarten 5 doses of diphtheria-tetanus-acellular pertussis (DTaP), diphtheria-tentanus-pertussis (DTP), or pediatric diphtheria-tetanus vaccine (DT) or (4 doses are acceptable if the 4th dose was administered on or after the 4 th birthday and at least 6 months after the 3 rd dose). 4 doses of any combination of IPV or OPV. The 4 th dose must be administered on or after the 4 th birthday, and at least 6 months after the previous dose. (3 doses of all OPV or all IPV are acceptable if the 3 rd dose was administered on or after the 4 th birthday, and at least 6 months after the 2 nd dose). 3 doses of Hepatitis B vaccine (3 rd dose must be given on or after 24 weeks of age and no earlier than 16 weeks after the first birthday. 2 doses of measles (rubeola) vaccine, on or after the first birthday. 2 doses of mumps vaccine, on or after the first birthday. 1 dose of rubella (German measles) vaccine, on or after the first birthday. 2 doses of varicella (chickenpox) vaccine on or after the first birthday and separated by 3 months or physician written documentation of history of chicken pox disease, including month and year of disease. 2 doses of Hepatitis A vaccine (HepA) are required for all students entering Kindergarten Grade 1 5 doses of diphtheria-tetanus-acellular pertussis (DTaP), diphtheria-tentanus-pertussis (DTP), or pediatric diphtheria-tetanus vaccine (DT) (4 doses are acceptable if the 4th dose was administered on or after the 4 th birthday and at least 6 months after the 3 rd dose). 4 doses of any combination of IPV or OPV by age 4-6, (3 doses of all OPV or IPV are acceptable if the 3rd dose was administered on or after the 4th birthday). 3 doses of Hepatitis B vaccine (3 rd dose must be on ofr after 24 weeks of age). 2 doses of measles (rubeola) vaccine, on or after the first birthday. 2 doses of mumps vaccine, on or after the first birthday. 1 dose of rubella (German measles) vaccine, on or after the first birthday. 2 doses of varicella (chickenpox) vaccine on or after the first birthday or physician written documentation of history of chicken pox disease, including month and year of disease. 2 doses of Hepatitis A vaccine (HepA) Grades 2-5 5 doses of diphtheria-tetanus-acellular pertussis (DTaP), diphtheria-tentanus-pertussis (DTP), or pediatric diphtheria-tetanus vaccine (DT) (4 doses are acceptable if the 4th dose was administered on or after the 4 th birthday and at least 6 months after the 3 rd dose). 4 doses of any combination of IPV or OPV by age 4-6, (3 doses of all OPV or IPV are acceptable if the 3rd dose was administered on or after the 4th birthday). 3 doses of Hepatitis B vaccine (3 rd dose must be on ofr after 24 weeks of age). 2 doses of measles (rubeola) vaccine, on or after the first birthday. 2 doses of mumps vaccine, on or after the first birthday. 1 dose of rubella (German measles) vaccine, on or after the first birthday. 2 doses of varicella (chickenpox) vaccine on or after the first birthday or written history of disease. Parental history of chickenpox disease is acceptable proof of immunity. A signed written statement from the parent/guardian indicating month and year of disease is sufficient. 2 doses of Hepatitis A vaccine (HepA)