2011-2012 New Student Enrollment Pack - WEB VERSION

8/7/2019 2011-2012 New Student Enrollment Pack - WEB VERSION

1/23

FELL CHARTER ELEMENTARY SCHOOLEnrollment Package for 2011-2012

Please complete the forms in this package and return completed to:

Fell Charter Elementary School777 Main St.

Simpson, PA 18407

570-282-5199(fax) 570-282-0930

-------------------------------------------------------------------------------------------------------------------

(FOR OFFICE USE ONLY)

Student Name Grade

Date

____ Birth Certificate *

____ Social Security Card *

____ 4x Proof of Residency (Example: Drivers License, Utility Bill, Lease/Mortgage) *

____ Student Enrollment Notification Form

____ Emergency Contact/ Permission Form*

____ Parental Registration Statement

____ Receipt & Acknowledgment of Student Handbook*

____ Home/School Compact

____ Home Language Survey

____ Photo/Videotape Release Form

____ Volunteer Form

____ Certificate of Immunization*

____ Child Health Assessment* ____ Med Admin Form ____ Dental Form* ____ Mobile Dentists Form

____IEP (If applicable)*

* - MANDATORY DOCUMENTS

An Equal Opportunity Education InstituteAcceptance Notification 11-05


2/23

THANK YOU FOR CONSIDERINGFELL CHARTER ELEMENTARY SCHOOL

Home of the

Open since September 2002 and located on Rt. 171 in Simpson, Pennsylvania, Fell CharterElementary School is a tuition free public schoolthat offers a safe learning environment and aresearch-proven effective curriculum that is both rigorous and college-prep.

We work with the management company Mosaica Education Inc. Our school offers a provencurriculum, with a hands on learning approach. We currently offer placement in full dayKindergarten through Eighth (8) Grade Classes.

The recent overwhelming increase of enrollment has warranted us to operate on a space-available basis (a waiting list).

Please be aware that the practiced features and standards of our school are indeed moreaggressive, therefore requiring more parental/guardian involvement than other public schools.Some of our strict school guidelines are as follows:

School hours are 7:45 AM until 3:30 PM

Limit of twenty-five (25) students per classroom

Technology in every classroom

Student discipline and dress codes strictly monitored and enforced Longer than average school year

Strong student accountability measured by national standardized tests

Teacher/Staff accountability measured by yearly parent satisfaction surveys

Parent/Guardian volunteer requirement; two (2) hours monthly

Parental involvement and volunteer time is not only a requirement at Fell Charter ElementarySchool, but is also an important foundation that supports great parent/school parent/studentbonds, positively benefiting our school community. Some examples of opportunities to fulfillyour two hours of monthly service are;

Lunch hour/Cafeteria Duty(helps to assist our children at lunchtime, example

opening snacks and thermos) Teacher-requested Classroom Help (assist with projects, classroom events)

Paragon Night assistance/donations (supplies and clean up help are needed onmonthly basis)

Committee Work Sessions (scheduled sessions to help our school grow and develop)

If you have any questions about our school or enrollment, please contact our schoolPrincipal, Mary Jo Walsh, at (570) 282-5199 or visitwww.fellcharter.org

An Equal Opportunity Education Institute
http://www.fellcharter.org/http://www.fellcharter.org/


3/23

Charter School Student Enrollment Notification Form PDE 2/2008

Instructions for this can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then Charter

School, then Reporting.

Charter School Student Enrollment Notification FormFor School Year

Warning: A child enrolled in another public school or a nonpublic or private school cannot, at the same time,enroll in a charter school.

Name of CharterSchool:

Address:

Charter SchoolContact Person:

Telephone:Email

Address:

I. Student Information:LastName:

FirstName: MI:

HomeAddress:

City: State: Zip Code:

County: Telephone:

Mailing Address(If Different FromHome Address)


Date Of Birth: Age:

II. School District of Residence and Former School InformationSchool District of

Residence:Former School Information (Other Than Pre-School):

PublicSchool

CharterSchool

HomeSchool Nonpublic School

Student Not Enrolled in School Preceding Enrollment in Charter School Because:

EnteringKindergarten Re-Enrolling Dropout Other

Name of Former School:

Address of FormerSchool:

PreviousGrade:

Withdrawal Date From FormerSchool:

Was Your Child Receiving Special Education Services Based On AnIep? Yes No

If Yes, Do You Have The Childs Special Education Records(Iep)? Yes No

2009-2010

FELL CHARTER ELEMENTARY SCHOOL

777 Main Street, Simpson, PA 18407

Mary Jo Walsh - Principal/CAO

570-282-5199 [email protected]

2010-20112011-2012


4/23

Page 2 of Charter School Student Enrollment Notification Form PDE 2/2008

III. Parent/Guardian Information:

Child Lives With:BothParents

Both ParentsAlternately

MotherOnly

FatherOnly

LegalGuardian

FosterParents Other Adult

Special Custodial Court Instructions:(If Yes, Please Provide a Copy of

Court Order.) Yes No

Complete Parent/Guardian Name and Address Information As Applicable

Fathers Name

Address:


Home Telephone: Work Telephone:

Mothers Name

Address:

City: State: Zip Code:Home Telephone: Work Telephone:

If The Student Is Not Living With Parents, Please Complete This Section.

Guardians Name Or Foster Parents Name Or Other Adult Name

Name:

Address:


My signature on this form indicates my decision to have my child attend the charter school named onpage 1 of this form and signifies my request that appropriate school records be forwarded from theschool district to the charter school. My signature also certifies that my child is not, and will not be,enrolled in another public school, a nonpublic school or a private school at the same time he or sheis enrolled in this charter school.

Signature ofParent/Guardian: Date:

IV. To Be Completed By Charter School:

Verification of Date of Birth: Birth Certificate Other

Proof ofResidency

MortgageStatement Lease

UtilityBill Other

Official Enrollment Date: Anticipated Date of Attendance:

Grade Student Is Entering:

Signature of Charter SchoolRepresentative:


5/23

FELL CHARTER ELEMENTARY SCHOOLEmergency Contact/Permission

I/We understand that providing current emergency contact information is critical to the safety and well-being of my/our child. My/Our signature onthis form certifies my/our understanding and commitment to provide updates (in writing) of any and all changes in contact information, within 24hours of any change to the school administrative assistant/secretary and my childs classroom teacher(s).

1. Name of Child: Age: Date of Birth:

2. Address: City State Zip

Street Number and Name Apt. #

3. Home Phone: Family Email address:

4. Mother/Guardian: Address: Check if Same as Above

Address if different than above:

Occupation: Employer:

Cell Phone: Work Phone:

5. Father/Guardian: Address: Check if Same as Above

Address if different than above:

Occupation: Employer:

Cell Phone: Work Phone:

6. Local Emergency Contacts: Adult persons other than parents/guardians (18 years or older) who may be contacted inthe event of an emergency:

Name: Relationship: Phone:

Name: Relationship: Phone:

7. I/We hereby give permission to the staff of the Fell Charter School to secure emergency medical

treatment by a qualified physician for the above named child while under their supervision:YES NO (circle one)8. Name of childs physician or health clinic:

Address: City State Zip

Phone Number After-Hours Emergency Number

9. Hospital preferred for Emergency Treatment:

10. Health Insurance Policy Name and Number:

11. Please list any special services your child has received in the last three (3) years:

12. Please list any allergies: Date of last Tetanus Shot: / / .

13. Name(s) of Person other than Parent or Legal Guardian to Whom Child maybe released (must be 18 years or older) One name per line:

In the event that I/we can not be contacted and if my designated emergency contact is not available, I/we understandand agree that Fell Charter School will telephone 911 for emergency medical assistance and will follow their directives.

Parent/Guardian Signature: TodaysDate: / /


6/23

FELL CHARTER ELEMENTARY SCHOOL777 Main Street

Simpson, PA 18407(570) 282-5199 Fax (570) 282-0930

PARENTAL REGISTRATION STATEMENT

Student Name

Date of Birth Grade Telephone Number

Parent/Guardian Name

Address

Pennsylvania School Code 13-1304-A states in part, Prior to admission to any school entity, theparent/guardian and other person having control of charge of a student shall, upon registration, provide a

sworn statement or affirmation stating where the pupil was previously suspended or expelled from anypublic or private school of this Commonwealth or any other state for an act or offense involving weapons,alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violence committedon school property.

Please complete the following:

I hereby swear or affirm that my child was was not previously suspended or expelled fromany public or private school of this Commonwealth or any other state for an act or offense involvingweapons, alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violencecommitted on school property. I make this statement subject to the penalties of 24 P.S. 13-1304-A (b)and 18 PA C.S.A. 4904, relating un-sworn falsification to authorities, and the facts herein are true andcorrect to the best of my knowledge, information, and belief.

Signature of Parent/Guardian Date

Name of the school from which your student was suspended or expelled and the reason for suspensionand/or expulsion.

School Date

Reason

School Date

Reason

Any willful false statement made about shall be a misdemeanor of the third degree. This information shall be maintainedas part of the students disciplinary record.


7/23

FELL CHARTER ELEMENTARY SCHOOL

Receipt and Acknowledgementof Student Handbook

By signing below, we acknowledge that we have received a current Fell Charter Elementary SchoolStudent Handbook, that we have fully read the handbook, and that we understand and agree to abide byall the policies specified within.

______________________________ ______________________________(Student Please print name) (Parent/Guardian Please print name)

Date: ___________________

Learning Methodology Questions

Please take a moment to answer the following questions as completely as possible so we can betterserve your childs learning needs.

1. How do you believe your child(ren) learns best?

2. How many times a week do you assist with your childs homework?

3. What is your academic goal for your child?

4. What do you believe is your childs best academic subject?

5. Why?


8/23

FELL CHARTER ELEMENTARY SCHOOLHome/School Compact

To help all children achieve high standards

Parents/Guardians must Check their childs backpack daily

Schedule a regular time for homework and provide a quiet place to work

Communicate with teachers about their childs needs

Support their childs teachers

Encourage their child to read daily

Read to their child

Sign and return notes, progress reports, and report cards to school in a timely manner

Schedule time in their routine to become active and attend school functions

Ensure that their child is not over-scheduled with extracurricular activities

Make learning a family-oriented process

Students must Write their homework assignments in a planner

Complete their homework/classwork and return it on time

Come to school prepared with all necessary materials

Follow directions

Respect staff and peers with words and actions

Respect and follow school rules so that all students can learn

Work efficiently and take pride in their work

Ask for help when needed

Take notes and reports home to parents

Student Name (Please Print)

Student Signature Date

Fell Charter Elementary Staff have agreed to do the following (but not limited to)

Always put the child first

Provide a safe and secure learning environment

Communicate regularly with families:o In a constructive manner

o On school happenings

o On academic progress

o On behavior issues

Teach to the individual needs and level of every student by developing and implementing

Personalized Student Achievement Plans Use a variety of learning methods

Asses student progress frequently and in a variety of ways

Welcome parents and community members into the school and classrooms



9/23

FELL CHARTER ELEMENTARY SCHOOLHome Language Survey

This form must be completed for all students registered atFell Charter Elementary School

Student NameLast First Middle

Date of Birth

Parent/Guardian:

Please answer the questions below accurately and completely. This information is necessary to providethe most appropriate placement and instruction for your child and will not be used for any other purposes.

Thank you for your cooperation.

1. Is there a primary language other than English spoken at home? Yes No

2. Does your child speak a language other than English? Yes No

If yes, what language(s)?

Parent/Guardian Signature Date



10/23

FELL CHARTER ELEMENTARY SCHOOLPhotograph/Videotape Permission

Dear Parent/Guardian:

From time to time Fell Charter Elementary School records student activities through the use ofphotography and/or videotape. Generally the resulting material is used internally to serve as a form ofdocumentation of school/student activity and as a learning tool for both students and faculty. On occasionphotographs and/or videotapes may be used for advertising purposes to promote enrollment at FellCharter Elementary School or as a backdrop to employment recruitment efforts.

In order for the school to produce materials for both internal and external uses we need your permissionto use photo and/or video images of your child. Please put a check in the appropriate box and sign belowto indicate your preference of permission for the following:

1. I/We (do) give permission for my/our child to be photographed/videotaped and the resulting

photographs/videotape to be used and displayed within the school as well as, to be used for

public display and/or published for the benefit of the school.

2. I/We (do not) give permission for my/our child to be photographed/videotaped and the

photographs/videotape to be publicly displayed and/or published.

Please Note: There is no payment or any other form of compensation for use of your childs image if aphotograph and/or video image of your child is used either internally or externally as explained in theexamples above.

Please Print:

Students Name:

Grade: Teachers Name:

Parent/Guardian Name:

Sign Below:

/ /Parent/Guardian Signature Date Signed



11/23

FELL CHARTER ELEMENTARY SCHOOLVolunteer Form

Volunteers may be involved in on-campus activities, but are also encouraged to contribute their time and talent toorganizing extracurricular activities and community outreach projects. All parents/guardians are expected to volunteer2 hours each month per parent/guardian in the household. Any family member parent, sibling, grandparent, or family

friend may complete the hours for the family. A number of volunteer options are available both in the school and fromhome or work. Volunteer hours are logged and records are kept on file. Contact the school administrative team forvolunteer suggestions. Also, refer to the school newsletter throughout the year for ways to be of service. The followingis a partial list of ways to fulfill the volunteer commitment.

During School Hours Volunteers* May . . .

Assist with any content area Share about your work or career Work with a student one on one Help teachers with classroom dcor -- posters,

bulletin boards, hallway art displays Organize completed work into folders Photocopy homework or project packets Assist or play with children during lunch/recess Work in the main office Clean school equipment or school grounds Answer office phone Volunteer with the Student Leadership Volunteer with the student musicals Tutor students after school Pick up and return books from the public library

After School Hours Or From Work Or HomeVolunteers* May . . .

Assist with the school website Host a talk at work to promote the school Organize a family drive to enlist in Target, Office

Depot, or Wal-Mart Card Programs that donate tothe school

Share any fund raising experiences and ideas Provide general grounds maintenance Buy or send in Paragon supplies Organize Scholastic book orders for teachers Pick up and return books from the public library Shop for school supply donations pencils, pens,

paper towels, wet wipes, bleach wipes, Ziploc bagsare needed throughout the year

Request your office to donate art supplies Photocopy homework and project packets

*All types of volunteer service require successful completion of a criminal & child abuse background check, with copiessubmitted to the school, prior to volunteering.

All volunteers must complete volunteer application, and may be fingerprinted (for federal and state clearance).Volunteers receive structured training, and must follow all policies and procedures defined by the School. The Chief

Administrative Officer (CAO) reserves the right to relieve the volunteer of his or her responsibilities at any time.

I/We understand that Volunteering is a requirement.

/ /Parent/Guardian Signature Date



12/23

FELL CHARTER ELEMENTARY SCHOOLSchool Health Services

School Registration Health Forms

Dear Parents/Guardian:

Attached are the health forms required for each student. A copy of immunizationdates, the Health Data Form, and the Emergency Contact Form must be presentedat the time of registration. Please notify the Fell Charter Elementary School nurse ofany changes to this information that may occur during the school year.

A physical examination is a required Pennsylvania State mandate for students first

entering school either in Kindergarten or as a new student, and again in sixth grade. Anexamination done by the family physician within twelve months prior to the opening ofschool or during the school year will be accepted as the required examination and mustbe recorded on the enclosed physical form.

Our school health program also recommends regular dental examinations. Dentalexaminations are required for students first entering school either in Kindergarten or asa new student, and also in third grade, and seventh grade. An examination done by aprivate dentist within twelve months prior to the opening of school or during the schoolyear will be accepted as the required examination and must be recorded on theenclosed dental form.

All immunizations must be up-to-date. If the student is not current with his/herimmunizations, he/she will not be admitted until they are updated. Any student 13 yearsand older must have a second dose of the varicella vaccine. Please see the attachedform for the new vaccine regulations for the 2011-2012 school year. Theserequirements do allow for medical and religions exemptions.

Children who need medication during school hours or who have other special needs areadvised to speak with the school nurse. Please refer to the medication policy forms inthis packet.

Thank you for your cooperation and attention in completing these very important forms.Please contact the school nurse if you have any questions.



13/23

FELL CHARTER ELEMENTARY SCHOOLSchool Health Services

Health Data Form 2011-2012

Information provided on this form will enable school personnel to deal most effectively with your childs

health considerations and allow him/her to receive the maximum benefits from his/her educationalexperience. Attach additional paperwork if necessary.

Students Name Grade DOB M/F

Fathers Name Mothers Name

Guardian (if other than parent)

Students Physician Students Dentist

Does your child take medication on a daily basis? Yes / No

Medication ReasonWill he/she need to take the medication during school hours? Yes / No

Has your child ever had an allergic reaction to any medication? Yes / NoName of medication ReactionTreatment in case of exposure

Is your child allergic to specific foods or other substances? Yes / NoFood/Substance ReactionTreatment in case of exposure

Has your child ever had an allergic reaction to Bee/Wasp stings? Yes / NoMedication ReactionTreatment in case of exposure

Does your child have any other health problems? Yes / NoCondition(s)Condition(s)

Has your child been hospitalized for surgery, serious illness, or accident? Yes / NoComments

Does your child have difficulty with Vision? Yes / NoDoes your child have difficulty with Hearing? Yes / NoDoes your child have difficulty with Speech? Yes / No

Is there anything more about your childs health that you believe is important for the school to know?Yes / No

May this information be shared with other school personnel, as necessary for the health of your child?Yes / NoSignature of Parent/Guardian Date


14/23

CERTIFICATE OF IMMUNIZATION

Last Name: First Name: Middle Name:

Childs Date of Birth:

______/______/______

Home Phone: Parent/Guardian Name:

Home Address: Grade:

VACCINECIRCLE APPROPRIATE ITEM

ENTER MONTH, DAY. AND YEAR EACH IMMUNIZATION WAS GIVEN

DOSESDiphtheria and Tetanus(DtaP, DTP, Td, or DT)

1) ___/___/___ 2) ___/___/___ 3) ___/___/___ 4) ___/___/___ 5) ___/___/___

Polio (OPV or IPV) 1) ___/___/___ 2) ___/___/___ 3) ___/___/___ 4) ___/___/___

Hepatitis B 1) ___/___/___ 2) ___/___/___ 3) ___/___/___

Measles Mumps Rubella (MMR) 1) ___/___/___ 2) ___/___/___Or Measles Serology:Date: ___/___/____ titer:

Varicella (Vaccine or Disease) 1) ___/___/___ 2) ___/___/___Rubella Serology:Date: ___/____/____ titer:

Other 1) ___/___/___ 2) ___/___/___ Mumps disease diagnosed by a physician: YesDate: ____/____/____

Doses required by law for new school enterers (K or 1stGrade) are shaded in gray.Age appropriate dose(s) of varicella vaccine or history of disease and 3 doses Hepatitis B vaccine required for entry into

7

th

grade.

To the best of my knowledge, this child has received the minimum required immunizations. Source: Written Verbal Both

Signed:______________________________________________________________________ Date: ______/______/______(PHYSICIAN, PUBLIC HEALTH OFFICIAL, SCHOOL NURSE, OR OTHER DESIGNEE)

Statement For Exemption To Immunization Law (If applicable)

MEDICAL EXEMPTION

The physical condition for the above named child is such that immunization would endanger life of health.

Signed: __________________________________________Date: _____/______/______ Ph sicians Si nature

RELIGIOUS EXEMPTIONIncludes a strong moral or ethical conviction similar to a religious belief

The parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to suchimmunizations. State your reasons for requesting religious exemption: ___________________________________

____________________________________________________________________________________________

Signed: _________________________________________Date: _____/______/_____ Parent/Guardian Signature


15/23

CHILD HEALTH ASSESSMENT

Student Information: Page 1 of 2

Last Name: First Name: Middle Name:

Childs Date of Birth:

______/______/______

Home Phone: Parent/Guardian Name:

Home Address:

Check Present Grade: K 1 2 3 4 5 6 7 8 9 10SP ED

RACE/ETHNICITY: African American (Non-Hispanic) American Indian / Alaskan Native Asian / Pacific Islander

Hispanic Multiracial White (Non-Hispanic)

Consent:

I/We hereby give my/our consent as the parent/guardian of the above named child to release, discuss orotherwise inform the school of my/Our childs health condition and any health concerns:

Parent/Guardian Signature: ______________________________Date Signed: ____/_____/_____

Heath History and Medical Information Pertinent to Routine Care:

Emergency Care: None Yes; describe:

Allergies to Food or Medicine: None Yes, describe:

Height Weight Head Circumference Blood Pressure

_______IN/CM %of ILE ______ ______LB/KG %of ILE ______ ______IN/CM %of ILE ______ ______/______

Physical Examination:

Physical Examination Normal Abnormal Comments

Head/Ears/Eyes/Nose/Throat

Teeth

Cardio/Respiratory

Abdomen/GI

Genitalia/Breasts

Extremities/Joints/Back/Chest

Skin / Lymph Nodes

Neurological / Tone

Developmental (E.G. DDST)


Date of Exam: _____/______/_____


16/23

CHILD HEALTH ASSESSMENT

Childs Name: Page 2 of 2

Screening Tests:

Recommendations/Health Care Providers Signature:

HEALTH PROBLEMS OR SPECIAL NEEDS

NO Problems YES, Describe:

Recommended Treatment Medication - Special Care(Attach Additional Sheets as Necessary)

Medical Care Provider:

NEXT APPOINTMENT: (MONTH/YEAR)

________/_________Address:

Phone:

______________________________________________________ Date: _____/______/_____ MDSignature of Attending Physician or CRNP DO

CRNP

NOTE: Age appropriate health services and immunizations must follow the schedule recommended byThe American Academy of Pediatrics.


Screening Tests Normal Abnormal Comments

LEAD

ANEMIA (HGB/HCT)

URINALYSIS (UA)

HEARING

VISION

DATE OF DENTISTSLAST EXAMINATION


17/23

FELL CHARTER SCHOOLSchool Health Services Medication Policy

It is the policy of the Fell Charter School that medication is to be given outside of schoolhours whenever possible. However, if it is essential that a student receive medication duringschool hours, the following criteria MUST be met before medication may be administered:

1. The physician and parent/guardian must sign a medication request/consentforms for each prescription and nonprescription medication.

a. If a parent/guardian completes and signs the Parent Consent Form, aprescription label will be accepted for 5 (five) school days in lieu of thePhysicians Request Form. This allows the parent/guardian ample timeto have the physician form completed. A faxed order from thephysician will be accepted.

b. Include name of student, name of medication, dosage, time to begiven, duration of order.

2. All medication must be in the original container/package. Prescriptionmedication must have a current prescription label attached, with thestudents name on the label.

3. All medications must be delivered to the school by an adult and given to anurse, teacher, administrator, or secretarial staff member along with theproper consent/request paperwork. Parents/Guardians should make every effort tospeak with the nurse about the medication.

4. All medications must be kept in the custody of the school nurse.a. In certain circumstances, students may carry their asthma medication

on their person if the following criteria are met :1) The physician must indicate on the Physician Request Form that

the student may carry the asthma medication on his/her personand that he/she is has demonstrated the ability to self-administerthe medication.

2) The parent/guardian must indicate on the Parent Consent Form

that thestudent may carry the medication on his/her person and thathe/she is capable of self-administration.

3) The student must demonstrate to the nurse that he/she usesproper technique when administering medication.

4) The student must notify the school nurse following each use ofthe asthma inhaler.

5) If the asthma medication is made available to other children, themedication will be confiscated. Parents/Guardians will benotified. This action will result in the handbook policiesregarding distribution of drugs to be followed.

b. With this self-administration of asthma medication policy, the FellCharterSchool bears no responsibility for ensuring that the medication istaken.

Medication requests must be renewed each school year and medicationsshould be picked up at the end of each school year, or they will be disposedof 10 days after the last day of school.

*Fell Charter School is not responsible for injury/damages that result from theadministration of medication in accordance with Parent/Guardian and Physician request.


18/23

FELL CHARTER SCHOOLSchool Health Services

PHYSICIAN/PARENTS

REQUEST FOR MEDICATION ADMINISTRATION

Dear Physician:

Please fill out the form below for your patient to receive medications during school hours.

This form may be faxed to the school nurse @ 282-0930. Thank you.

Student Name: __________________________ DOB: ____________ Grade: ______

Diagnosis: ______________________________________________________________

Name of Medication: _______________________________________

Dosage: __________________________________________________

Route of Administration: ___________________________________

Time to be Given: _________________________________________

Possible Side Effects: ______________________________________

Duration of Medication Order: ______________________________

If PRN, describe indications: ______________________________________________

_______________________________________________________________________

Significant side effects: ___________________________________________________

_______________________________________________________________________

Contraindications: ______________________________________________________

Curtailment of specific school activity (gym, recess): __________________________

Is student capable of self-administration supervised by a responsible adult if thenurse is not available? ___________________________________________________

Is student able to carry asthma medication on his/her person and correctly self-

administer this medication within guidelines of school medication policy?

_______________________________________________________________________

Special instructions: _____________________________________________________

_______________________________________________________________________

Date: _____________ Physician Signature: _____________________________

***********************************************************************

I hereby release the Fell Charter School and its employees from any liability

for any injury that may result out of the administration of the above medication in

accordance with this request.

Date: _____________ Parent/Guardian Signature: _______________________


19/23Thursday, February 05, 2009 (2).MAX


20/23Thursday, February 05, 2009 (3).MAX


21/23


22/23

FELL CHARTER ELEMENTARY

SCHOOLCLASS SUPPLY LIST

2011-2012** - items appreciated as donations

Kindergarten

1 pair round tip childrens

scissors

1 two-pocket plastic folder

2 boxes of baby wipes or

disinfectant wipes

1 box of tissues

1 oversized T-shirt or smock4 glue sticks

1 (24) pack crayons

1 (8) pack washable markers

1 pack of large beginner pencils

First Grade Supply List

1 (24) pack of crayons

1 package of pencils1 pair of school scissors

3 two-pocket folders

5 spiral notebooks1 1 3-ring binder

1 oversized old t-shirt or smock

2 glue sticks

1 pencil box

1 boxes of tissues

1 box of baby wipes


Second Grade

1 5-subject notebook

1 pencil box1 (24) pack crayons


1 pack colored pencils1 pack pencils

1 pair of school scissors

4 2-pocket folders

1 oversized T-shirt or smock

1 old sock or washcloth for

whiteboard

1 box baby wipes

1 box tissues

Third Grade


1 (8) pack of washable markers

1 pack colored pencils

1 package of pencils1 pair school scissors

1 highlighters


4 spiral notebooks

1 glue stick

1 pencil box

1 marbled composition notebook

1 binder

1 12 ruler with cm & in

1 oversized old t-shirt or smock

**1 box of tissues

**1 box of baby wipes

Fourth Grade

4 one subject notebooks

4 2-pocket folders

1 marble composition book

1 pack pencils

1 art/pencil box containing:

-crayons or colored pencils

-scissors

-small sharpener

-glue (stick or bottle)-eraser(s)

**paper towels

**tissues

Fifth Grade


1 pack of washable markers2 pens

1 package of pencils

1 pack colored pencils

1 highlighterDry Erase Marker

Erasers


6 spiral notebooks per half year

(12 total)

1 pair of scissors

2 glue sticks

1 box of tissues

1 small personal dictionary

1 calculator

1 Protractor

6th - 8th Grades

#2 pencils

black or blue pens

1 box of tissues

2 binders1 pack colored pencils

1 pack crayons

1 pack washable markers

1 small pencil sharpener

2 glue sticks

1 bottle glue

1 ruler

6 notebooks

4 folders

1 flash drive (thumb drive)


23/23

Documents

2011-2012 New Student Enrollment Pack - WEB VERSION