Kindergarten Round Up – 2017-18

Anacortes School District 103 2200 M Avenue Anacortes, Washington 98221

Phone: 360-293-1200 / Fax: 360-293-1222 http://www.asd103.org

Kindergarten Round Up – 2017-18

A parent informational meeting will be held on Tuesday, April 25 – 7 p.m. in the Anacortes Middle School Cafeteria. Administrators will be there to answer your questions and concerns.

Kindergarten Round Up will take place on April 27 and 28 from 9 a.m. to 1 p.m. at the Anacortes Christian Church, 1211 M Avenue. On Thursday, April 27, if your child’s last name begins with:

A to E register between 9:00 am to 11:00am F to L register between 11:00 am to 1:00pm

On Friday, April 28, if your child’s last name begins with: M to R register between 9:00 am to 11:00 am S to Z register between 11:00 am to 1:00 pm Questions? Contact Whitney Early Childhood Education Center at 360-293-9536 or the Anacortes

School District Office at 360-293-1200.

Registration packets are available on the District’s website: www.asd103.org

http://www.asd103.org/


ANACORTES SCHOOL DISTRICT 2200 M Avenue Anacortes WA 98221 Phone: (360) 293-1200 Fax: (360) 293-1222

http://www.asd103.org

A Lighthouse for Public Education in Our Community: Ensuring No Child Is Lost Creating Lifelong Learners Inspiring High Achievement Nurturing Responsible Citizenship

KINDERGARTEN ROUND UP INFORMATION - 2017 Dear Parents, We would like to take this opportunity to inform you that Anacortes School District kindergarten registration, also known as “Kindergarten Round Up”, for the 2017 - 2018 school year will take place on Thursday, April 27th and Friday, April 28th. It will be held at the Anacortes Christian Church, 12th and M Avenue, with parking in the lot off N Avenue. All parents are requested to register their pre-kindergarten children at this time. The purpose of Kindergarten Round Up along with the registration data is to assure that your child is healthy and ready to begin school. Vision, hearing, and speech screenings will be provided. Please try to update your child’s immunizations prior to this registration activity. PLEASE BRING YOUR CHILD WITH YOU AND PLAN FOR APPROXIMATELY ONE HOUR. You may want to bring a snack for your child. Please bring immunization records and copies of birth certificates or other legally accepted documents for proof of birth with you at the time of registration. Please note that district policy and State law prescribes that a child must be five years old on or before August 31, 2017 in order to enter Kindergarten. In order to have registration take a minimum amount of time and to make it a pleasant experience for your child, we are requesting that you follow the schedule given below -- if at all possible. Please do not bring younger siblings to Kindergarten Roundup. This activity will take a minimum of one hour after the registration forms are filled out. Registration packets will be available at the District Administration Office, 2200 M Avenue (back entrance of Anacortes Middle School – 2nd floor) beginning Monday, April 11th for those who want to complete the forms in advance. A copy of the registration packet will also be available online at www.asd103.org. On Thursday, April 27, if your child’s last name begins with:

A to E register between 9:00 am to 11:00am F to L register between 11:00 am to 1:00pm

On Friday, April 28, if your child’s last name begins with: M to R register between 9:00 am to 11:00 am S to Z register between 11:00 am to 1:00 pm If you have a child who will be eligible for kindergarten, we urge you to register at this time. Also, if you know anyone who has an eligible child, it would be helpful if you would contact those parents about registration. Parent concerns about possible developmental delays in children Birth – 4 years old may discuss their concerns with staff. The New Kindergarten Parents meeting will be held on April 25th at 7:00 pm in the Anacortes Middle School Cafeteria, 2200 M Avenue. Questions regarding the kindergarten program, transportation, etc will be answered at this time. Sincerely, Anacortes School District Team


New Student Enrollment Form Students Last Updated: 2.2010; 3.2014; 3.2016, 5.2017 3121 F1

STU

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T IN

FO

STUDENT NAME: Legal LAST Name Legal FIRST Name

Legal MIDDLE Name

BIRTHDATE (Month/Day/Year) / /

Has student’s name ever been legally changed? If yes, what was previous name?

PRIMARY LANGUAGE SPOKEN AT HOME English Spanish Other _________________

GRADE LEVEL:

GENDER Male Female

District Resident? Yes No

Birthplace: City: State: County: Country:

Birth Certificate RECEIVED BY DISTRICT

Proof of Immunization REQUIRED RECEIVED BY DISTRICT

PRIM

ARY

HO

USE

HO

LD

PRIMARY PARENT/GUARDIAN INFORMATION (Household information where student resides)

Legal Parent/Guardian #1 Last Name

First Name

Primary Phone ( ) Please check if confidential (will not be published)

Second Phone ( ) Home Work Cell

Third Phone ( ) Home Work Cell

Email Employer: Active Military YES NO

Relation to Student: Father Mother Guardian Other: Student Lives with: Both Parents Father only Mother only Grandparents Father/Stepmother Mother/Stepfather Guardian Agency Self Other

Parent/Guardian #2 Last Name

First Name

Email Second Phone ( ) Home Work Cell


Relation to Student: Father Mother Guardian Other:

Employer: Active Military YES NO

Resident Address

Street Apt # City State Zip

Mailing Address (If different From above)

Street Apt # PO Box City State Zip

SECO

ND

HO

USE

HO

LD

SECOND HOUSEHOLD INFORMATION (Student does not primarily reside at this residence) Parent/Guardian #1 Last Name

First Name

Primary Phone ( ) Please check if confidential (will not be published)



Email



Parent/Guardian #2 Last Name

First Name

Email:





Resident Address

Street Apt City State Zip

Mailing Address (If different from above)

Street Apt # PO Box City State Zip

SIBL

ING

S Sibling Name

Sibling Age School Attending

Sibling Name

Sibling Age School Attending

STUDENT ENROLLMENT FORM Date: _________________________


EM

ERG

ENCY

MED

ICAL

IN

FORM

ATIO

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AUTH

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IZAT

ION

EMERGENCY MEDICAL INFORMATION Please list any medications your child will be taking during school hours: ____________________________________________ If the student needs medications/treatment while at school, a Medication at School Authorization Form must be completed for each medication/treatment.

Please list any known allergens: ____________________________________________________________________________ Required treatment for allergies: ______________________________________________________________________________________________ Other life threatening conditions (please provide information in writing to school): ______________________________________________________________________________________________ EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of an accident or illness, every effort will be made to contact the parent/guardian immediately. If the parent/guardian cannot be reached, I authorize school authorities to obtain emergency medical care for my child.

X Legal Parent/Guardian SIGNATURE __________________________________________________________________________Date:_____________________

EMER

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ON

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EMERGENCY CONTACT INFORMATION: When illness, injury or other non-emergency situations occur involving your child, we want to be able to quickly reach family members or other responsible adults. Our first contact is always a parent or guardian, but in the event that a parent/guardian cannot be reached, please list the persons you trust who are available during the day to provide care for your child

STUDENT RELEASE AUTHORIZATION: In the event that the school in unable to contact the parent/guardian, I authorize that my child may be released to the person(s) below:

X Legal Parent/Guardian SIGNATURE __________________________________________________________________________Date:_____________________

EMER

GEN

CY C

ON

TACT

S

PRIMARY EMERGENCY CONTACT LAST NAME FIRST NAME

RELATIONSHIP TO CHILD

HOME PHONE: ( ) CELL PHONE: ( )

Address:

SECOND EMERGENCY CONTACT LAST NAME FIRST NAME



Address:

THIRD EMERGENCY CONTACT LAST NAME FIRST NAME



Address:

FOURTH EMERGENCY CONTACT LAST NAME FIRST NAME



Address:

FIFTH EMERGENCY CONTACT LAST NAME FIRST NAME



Address:


CHIL

D C

ARE

DOES STUDENT ATTEND CHILD CARE? BEFORE SCHOOL AFTER SCHOOL BEFORE AND AFTER SCHOOL

BEFORE SCHOOL CHILD CARE PROVIDER NAME: _______________________________________________________________________

PHONE: __________________________________ _____ CELL PHONE: _____________________________

ADDRESS: ___________________________________________________________________________________________________________

AFTER SCHOOL CHILD CARE PROVIDER NAME: _________________________________________________________________________

PHONE: __________________________________ _____ CELL PHONE: _____________________________

ADDRESS: ____________________________________________________________________________________________________________

Additional Child Care Arrangements: Please provide additional information to school in writing.

SCH

OO

L H

ISTO

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School previously attended (most recent)

Entry Date Withdrawal Date Previous School Address (Street, City, State and Zip)

Has student ever attended a school in the Anacortes School District?

Yes No

If yes, name of school attended:

School Year:

PRES

CHO

OL/

EA

RLY

CHIL

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CARE

Did student attend preschool/early childhood care center? Yes No

If yes, name of preschool/early childhood care center:

STU

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Has your child ever received services in any of the following programs? Check all applicable programs

Special Education 504 Accommodations Highly Capable ELL Title 1 Services LAP Services Speech

Migrant Services Other

Name of school where services were received ___________________________________________________

Does your child have any past, current, or pending disciplinary actions or any history of violent behavior? Yes No Date ________

Is your child presently on suspension from another school? Yes No If yes, reason _________________________________________

Is your child a military dependent? Yes No Is there a joint-custody or parenting plan in effect? Yes No (If yes, a certified copy of the most recent plan must be on file with the school for enforcement.)

Is there a restraining order against anyone pertaining to your student? Yes No (If yes, most recent certified legal papers must be on file with the school for enforcement.) Restraining order is against Mother Father Other _______________________________________________________

Special instructions regarding religious beliefs (please provide information to the school in writing): _______________________________________________________________________________________________________________


ETH

NIC

ITY

AND

RAC

E Ethnicity and Race

School districts in Washington State are required to report student data by ethnicity and race categories to the state’s Office of Superintendent of Public Instruction. Ethnicity and race categories used in our district are the same as used in all Washington school districts. They are set by the federal government, the Washington State Legislature, and the state Superintendent of Public Instruction. Please complete the following: 1. Is your child of Hispanic or Latino origin?

No, my child is not Hispanic or Latino Yes, my Child is Hispanic or Latino - (Check all that apply): Cuban Puerto Rican South American Dominican Mexican/Mexican American/Chicano Latin American Spaniard Central American Other Hispanic/Latino

2. What race do you consider your child? (Check all that apply)

African American or Black White or Caucasian Asian Asian Indian Cambodian Chinese Filipino Hmong Indonesian Japanese Korean Laotian Malaysian Pakistani Singaporean Taiwanese Thai Vietnamese Other Asian

Native Hawaiian/Other Pacific Islander Native Hawaiian Fijian Guamanian or Chamorro Mariana Islander Melanesian Micronesian Samoan Tongan Other Pacific Islander

Native American Alaskan Native Chehalis Colville Cowlitz Hoh Jamestown S’Klallam Kalispel Lower Elwa Klallam Lummi Makah Muckleshoot Nisqually Nooksack Port Gamble S’Klallam Puyallup Quileute

Quinault Samish Sauk-Suiattle Shoalwater Bay Skokomish Snoqualmie Spokane Squaix Island Stillaguamish Suquamish Swinomish Tulalip Yakima Other Washington Indian

Tribe Other American Indian

Tribe/Alaska Native

PAR

ENT

SIG

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E

“I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Anacortes Public Schools. I agree to notify the Anacortes School District in writing within five (5) school days following any change of my/our residency.”

X Legal Parent/Guardian SIGNATURE _________________________________________________________Date:_____________________

DIS

TRIC

T U

SE O

NLY

DISTRICT USE ONLY Birth Certificate Immunizations District Staff SIGNATURE ______________________________________________________________Date:__________________________

English

May 2014

Office of Superintendent of Public Instruction (OSPI) Home Language Survey

Student Name:

Date:

Birth Date: Gender: Grade:

Form Completed by:

Parent/Guardian Name Relationship to Student

Parent/Guardian Signature If available, in what language would you prefer to receive communication from the school?

Did your child receive English language development support through the Transitional Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__

1. In what country was your child born? ____________________

2. What language did your child first learn to speak?* __________________

3. What language does YOUR CHILD use the most at home?* ____________________

4. What language(s) do parent/guardians use the most when you speak to your child?

_____________________ _____________________

5. Has your child ever received formal education* outside of the United States? (Kindergarten – 12th grade)

_____Yes _____No

”Formal education” does not include refugee camps or other unaccredited programs for children.

If yes, in what language(s) was instruction given? _____________________ For how many months? ____

6. When did your child first attend a school in the United States? (Kindergarten – 12th grade)

_______________________ Month Day Year

7. Do grandparent(s) or parent(s) have a Native American tribal affiliation?

_____Yes _____No

*WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by parents, guardians, or others) for communication in the student's place of residence. Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing

English

May 2014

The Purpose of the Home Language Survey

The Home Language Survey is given to all students enrolling in Washington schools. The following information should help answer some of the questions you may have about this form.

What is the purpose of the Home Language Survey?

The primary purpose of the Home Language Survey is to help identify students who may qualify for support to help them develop the English language skills necessary for success in the classroom and who may qualify for other services. It is important that this information be correctly recorded since it can affect the eligibility of students for services they need to be successful in school. Testing may be necessary to determine whether or not additional language and academic supports are needed. No student will be placed in an English language development program based solely on responses to this form.

Why do you ask about the student’s first language and language(s) used in the home?

The two questions about the student’s language help us to determine: • if your student may be eligible for assistance with learning English, and • whether staff at the school should be aware of other languages being used by the student at home.

The language your child first learned may be different from the language your child uses for communication at home now. The responses to both of these questions will assist the school in providing instruction appropriate to the individual student’s needs as well as help with communication needs that may arise. Students who first learned a language other than English may qualify for additional supports. Even students who speak English well may still need support in developing the language skills needed to be successful in school.

Why do you ask where the student was born?

This information helps the school district and the state determine if the student meets the definition of immigrant for the purposes of federal funding. This applies even when the student’s parents are both US citizens, but the student was born outside of the United States. This form is not used to identify students who may be undocumented.

Why do you ask about my student’s previous education?

Information about a student’s education will help ensure that the student’s education both within and outside of the United States is considered in any recommendations made for participation in programs and district services. The student’s educational background is also important information to help determine if the student is making adequate progress toward state standards based on their prior educational background.

Thank you for providing the information needed on the Home Language Survey. Contact your school district if you have further questions about this form or about services available at your child’s school.

Spanish (Español)

May 2014

Oficina de la Superintendente Estatal de Enseñanza Pública (OSPI) Encuesta sobre el idioma que se habla en el hogar

Nombre del alumno:

Fecha:

Fecha de nacimiento: Sexo: Grado:

Este formulario fue completado por:

Nombre del padre/madre/tutor: Relación con el alumno:

Firma del padre/madre/tutor: Si está disponible, ¿en qué idioma desea recibir información de la escuela?

¿Su hijo recibió apoyo para el aprendizaje del idioma inglés a través del Programa Estatal de Educación Bilingüe de Transición en la última escuela a la que asistió? Sí__ No__ No sé__

1. ¿En qué país nació su hijo? _____________________

2. ¿Qué idioma aprendió su hijo primero?* ___________________

3. ¿Qué idioma usa más SU HIJO en casa?* _____________________

4. ¿Qué idioma(s) usan más los padres/tutores cuando hablan con su hijo?

_____________________ _____________________

5. ¿Ha recibido su hijo educación formal* fuera de los Estados Unidos? (Kinder a 12.º grado)

_____Sí _____No

"Educación formal" no incluye programas en campos de refugiados ni otros programas no acreditados para niños.

En caso afirmativo, ¿en qué idioma se le dio la instrucción? _____________ ¿Por cuántos meses? ______

6. ¿Cuándo asistió su hijo a la escuela en los Estados Unidos por primera vez? (Kínder a 12.º grado)

_______________________ Día Mes Año

*WAC 392-160-005: "Idioma principal" significa el idioma que el alumno usa con más frecuencia (no necesariamente el idioma que usan los padres, tutores u otros) para comunicarse en el lugar donde vive el alumno.

Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing.

Spanish (Español)

May 2014

Propósito de la Encuesta sobre el idioma que se habla en el hogar

La Encuesta sobre el idioma que se habla en el hogar se proporciona a todos los estudiantes que se inscriben en escuelas de Washington. La siguiente información debería contribuir a responder a algunas de las preguntas que podría tener sobre este formulario.

¿Cuál es el propósito de la Encuesta sobre el idioma que se habla en el hogar?

El propósito principal de la Encuesta sobre el idioma que se habla en el hogar es contribuir a identificar a los estudiantes que podrían calificar para obtener ayuda con el fin de desarrollar las habilidades del idioma inglés necesarias para tener éxito en la clase y de recibir otros servicios. Es importante que esta información se registre correctamente, ya que puede afectar la elegibilidad de los estudiantes para recibir los servicios que necesitan para tener éxito en la escuela. Es posible que sea necesario evaluarlos a fin de determinar si precisan servicios de apoyo adicionales en relación con el idioma y académicos. Ningún estudiante será asignado al programa de desarrollo del idioma inglés solo en función de las respuestas a este formulario.

¿Por qué preguntan acerca de la primera lengua del estudiante y del (de los) idioma(s) que se habla(n) en el hogar?

Las dos preguntas sobre el idioma del estudiante nos ayudan a determinar: • si el estudiante puede ser elegible para obtener ayuda con el aprendizaje del inglés, y • si el personal de la escuela debería conocer otros idiomas utilizados por el estudiante en su hogar.

El idioma que su hijo aprendió primero puede ser distinto del idioma que su hijo utiliza para comunicarse en el hogar ahora. Las respuestas a estas dos preguntas ayudarán a la escuela a proporcionarle instrucción adecuada según las necesidades individuales del estudiante, y también contribuirán con las necesidades de comunicación que puedan surgir. Los estudiantes que primero aprendieron un idioma que no sea inglés pueden calificar para obtener servicios de apoyo adicionales. Incluso los estudiantes que hablan bien inglés podrían precisar apoyo para desarrollar habilidades del idioma necesarias para tener éxito en la escuela.

¿Por qué preguntan dónde nació el estudiante?

Esta información ayuda al distrito escolar y al estado a determinar si al estudiante le corresponde la definición de inmigrante a los fines del financiamiento federal. Esto se aplica incluso cuando ambos padres del estudiante son ciudadanos estadounidenses, pero el estudiante nació fuera de los Estados Unidos. Este formulario no se utiliza para identificar a estudiantes que quizás sean indocumentados.

¿Por qué preguntan sobre la educación anterior del estudiante?

La información sobre la educación de un estudiante contribuirá a garantizar que la educación del estudiante tanto dentro como fuera de los Estados Unidos sea tenida en cuenta en las recomendaciones para la participación en programas y servicios del distrito. Los antecedentes educativos del estudiante también constituyen información importante para ayudar a determinar si el estudiante está avanzando lo suficiente hacia los estándares estatales en función de sus antecedentes educativos anteriores.

Gracias por proporcionar la información necesaria en la Encuesta sobre el idioma que se habla en el hogar. Comuníquese con su distrito escolar si tiene otras preguntas sobre este formulario o sobre los servicios disponibles en la escuela de su hijo.

S:\Dist Office Share\Superintendent Office\Student Placement and Registration\KRU 2017-18\5_Kindergarten Roundup Developmental Background.docS:\Dist Office Share\Superintendent Office\Student Placement and Registration\KRU 2017-18\5_Kindergarten Roundup Developmental Background.doc

H:\Kindergarten Roundup 2007\Developmental Background

ANACORTES SCHOOL DISTRICT 2200 M Avenue Anacortes WA 98221 Phone: (360) 293-1200 Fax: (360) 293-1222


A Lighthouse for Public Education in Our Community:

Ensuring No Child Is Lost Creating Lifelong Learners Inspiring High Achievement Nurturing Responsible Citizenship

S:\Dist Office Share\Superintendent Office\Student Placement and Registration\KRU 2017-18\6_Roundup Immunizations Required letterhead.doc

Dear Parent/Guardian: As a condition for school attendance, Washington State law requires that all students be immunized against certain preventable diseases or provide school personnel with written notification of exemption, with a signature from your child’s health care provider. A copy of the Washington State Department of Health document showing Vaccines Required for School Attendance, Grades K-12 for the 2017-2018 school year is included in this registration packet for your information. An official Washington State Certificate of Immunization Status (CIS) form has been included with this Kindergarten Round Up package. Completely fill in the month, day and year, for each dose of vaccine received. Parent/Guardian signature is required on this form. Documentation of disease immunity by blood test (titer) must be recorded on a CIS form and signed by a licensed health care provider. Verification of varicella disease by provider must also be documented on this form. A parent cannot document or verify either of these disease verifications. If you are claiming a personal, medical or religious exemption, please sign and complete part one of a Certificate of Exemption form. Your child’s provider will need to sign and complete part two of this

form and clearly identify which vaccines you are requesting exemption from. The general objective of this immunization law is to help prevent disease and protect both your child and the community.

Again, please understand that compliance with the law is required for school attendance.

Sincerely Anacortes School District Nurses

Statement of Exemption to Immunization Law

Your child may be exempted (excused) from immunization for medical, personal or religious reasons. Your child’s health care provider must sign a Certificate of Exemption form. However, if there is an outbreak of a vaccine-preventable disease that your child has not been immunized against, your child may be excluded from school, preschool or childcare until the outbreak is over.

If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). DOH 348-295 December 2016

Parents - Are Your Kids Ready for School?

Required Immunizations for School Year 2017-2018

Hepatitis B

DTaP/Td/Tdap (Diphtheria, Tetanus,

Pertussis) Vaccine doses required may

be fewer than listed

Polio Vaccine doses required

may be fewer than listed

MMR (Measles, Mumps,

Rubella)

Varicella (Chickenpox)

Kindergarten – 5th Grade

3 doses within the correct timeframes





OR Healthcare provider verified

child had disease

6th – 12th Grade 3 doses within the correct timeframes

5 doses DTaP

AND

1 dose Tdap, all within the correct timeframes




OR Healthcare provider verified

child had disease (Exceptions are allowed for

certain students)

Students must get vaccine doses at correct timeframes to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements.

Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/

Parent/Guardian Instructions: To see which vaccines are required for school, find your child’s grade and look only at that row going across to find the vaccines and number of doses required.

http://www.immunize.org/cdc/schedules/

Certificate of Immunization Status (CIS) For Kindergarten-12th Grade / Child Care Entry

Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System.

Child’s Last Name: First Name: Middle Initial: Birthdate (MM/DD/YY): Sex: ____________________________________________________________________________________________________________________________________________________

I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my child’s school record. ______________________________________________________________ Parent/Guardian Signature Required Date

I certify that the information provided on this form is correct and verifiable.

______________________________________________________________ Parent/Guardian Signature Required Date

♦ Required for School and Child Care/Preschool Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Date MM/DD/YY

Documentation of Disease Immunity Healthcare provider use only

If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider I certify that the child named on this CIS has: a verified history of Varicella (Chickenpox). laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. Diphtheria Mumps Other: Hepatitis A Polio __________ Hepatitis B Rubella __________ Hib Tetanus Measles Varicella

Licensed healthcare provider signature Date (MD, DO, ND, PA, ARNP) Printed Name

● Required Only for Child Care/Preschool

Required Vaccines for School or Child Care Entry

♦ DTaP / DT (Diphtheria, Tetanus, Pertussis)

♦ Tdap (Tetanus, Diphtheria, Pertussis)

♦ Td (Tetanus, Diphtheria)

♦ Hepatitis B 2-dose schedule used between ages 11-15

● Hib (Haemophilus influenzae type b)

♦ IPV / OPV (Polio)

♦ MMR (Measles, Mumps, Rubella)

● PCV / PPSV (Pneumococcal)

♦ Varicella (Chickenpox) History of disease verified by IIS

Recommended Vaccines (Not Required for School or Child Care Entry)

Flu (Influenza)

Hepatitis A

HPV (Human Papillomavirus)

MCV / MPSV (Meningococcal)

MenB (Meningococcal)

Rotavirus

Office Use Only:

Reviewed by: Date:

Signed Cert. of Exemption on file? Yes No

To print with immunization information filled in: Ask if your healthcare provider’s office enters immunizations into the WA Immunization Information System (Washington’s statewide

database). If they do, ask them to print the CIS from the IIS and your child’s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at https://wa.myir.net. If your provider doesn’t use the IIS, email or call the Department of Health to get a copy of your child’s CIS: [email protected] or 1-866-397-0337.

To fill out the form by hand: #1 Print your child’s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as MM/DD/YY). If your child receives a combination vaccine (one shot that protects against

several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements.

If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section.

#4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS.

Reference guide for vaccine trade names in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine

ActHIB® Hib Fluarix® Flu Havrix® Hep A Menveo® Meningococcal Rotarix® Rotavirus (RV1)

Adacel® Tdap Flucelvax® Flu Hiberix® Hib Pediarix® DTaP + Hep B + IPV RotaTeq® Rotavirus (RV5)

Afluria® Flu FluLaval® Flu HibTITER® Hib PedvaxHIB® Hib Tenivac® Td

Bexsero® MenB FluMist® Flu Ipol® IPV Pentacel® DTaP + Hib + IPV Trumenba® MenB

Boostrix® Tdap Fluvirin® Flu Infanrix® DTaP Pneumovax® PPSV Twinrix® Hep A + Hep B

Cervarix® 2vHPV Fluzone® Flu Kinrix® DTaP + IPV Prevnar® PCV Vaqta® Hep A

Daptacel® DTaP Gardasil® 4vHPV Menactra® MCV or MCV4 ProQuad® MMR + Varicella Varivax® Varicella

Engerix-B® Hep B Gardasil® 9 9vHPV Menomune® MPSV4 Recombivax HB® Hep B

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-013 December 2016

Reference guide for vaccine abbreviations in alphabetical order For updated list, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine

Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 Meningococcal Conjugate Vaccine OPV Oral Poliovirus

Vaccine Tdap Tetanus, Diphtheria, acellular Pertussis

DTaP Diphtheria, Tetanus, acellular Pertussis

Hep B Hepatitis B MenB Meningococcal B PCV / PCV7 / PCV13

Pneumococcal Conjugate Vaccine VAR / VZV Varicella

DTP Diphtheria, Tetanus, Pertussis Hib Haemophilus

influenzae type b MPSV / MPSV4 Meningococcal Polysaccharide Vaccine

PPSV / PPV23 Pneumococcal Polysaccharide Vaccine

Flu (IIV) Influenza HPV (2vHPV / 4vHPV / 9vHPV)

Human Papillomavirus MMR Measles, Mumps,

Rubella Rota (RV1 / RV5) Rotavirus

HBIG Hepatitis B Immune Globulin IPV Inactivated

Poliovirus Vaccine MMRV Measles, Mumps, Rubella with Varicella

Td Tetanus, Diphtheria

Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand.

https://wa.myir.net/

mailto:[email protected]

https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf

https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf

Anacortes School District

STUDENT HEALTH INFORMATION

Information on this form is to be filled out (updated) for each new school year. Please complete both sides of this form and return

to your school as soon as possible.

Name: ________________________________________________ Birthdate: ______________ Gender: ___________ Last First MI

School: __________________________________________ Grade: ______ Today’s Date: ______________________

LIFE THREATENING CONDITIONS Does your child have a life-threatening health condition? Yes* __ No __

*If yes, a meeting with the school nurse is required prior to starting school.

󠄵 My child has NONE of the health concerns/conditions listed above.

HEALTH CONDITIONS

󠄵 My child has NONE of the health concerns/conditions listed above.

PLEASE SEE OTHER SIDE

󠄵 Asthma *Severe – (If this box is checked, please answer the following questions.)

Yes 󠄵 No 󠄵 Does child use rescue inhaler routinely for asthma symptoms?

Yes 󠄵 No 󠄵 Has your child been hospitalized for asthma in the past year?

Yes 󠄵 No 󠄵 Has your child used steroids (Prednisone) for asthma symptoms in the past year?

If mild or moderate asthma, see box below - HEALTH CONDITIONS

󠄵 Allergy/Anaphylaxis - *Severe - with Epipen/epinephrine prescription (for example: food, insect stings.)

Allergen(s): _______________________________________________________________________________________________

Other: ___________________________________________________________________________________________________________

󠄵 Diabetes – Date of diagnosis: _____________________ My student has 󠄵󠄵 insulin pump 󠄵󠄵 insulin pen 󠄵 injected insulin

󠄵 Seizure Disorder - My student needs emergency medication for Seizures. Name of medication: ______________________________________

󠄵 Special Health Care Planning – My child has special health care needs such as – wheelchair, tube feedings, breathing tube, catheter, intravenous

tubes or other. Please describe your child’s condition(s): __________________________________________________________________________

_________________________________________________________________________________________

ALERT TO PARENTS/GUARDIAN: The school must know of LIFE THREATENING conditions (for example severe allergy with anaphylaxis,

diabetes, asthma) prior to the start of school, as these may require an Individual Health Plan (per RCW 28A.210.320). Contact your school nurse to

begin the process for the student health care plan.

Check any of these conditions which your child has or has had:

󠄵 ADD/ADHD 󠄵 Blood Disorder 󠄵 Concussions 󠄵 Hearing/Vision 󠄵 Orthopedic/Bone

󠄵 Allergies mild or moderate (circle one) 󠄵 Bowel/Bladder 󠄵 Dental 󠄵 Heart problems 󠄵 Skin Condition 󠄵 Asthma mild or moderate (circle one) 󠄵 Cancer 󠄵 Headaches/Migraines 󠄵 Mental Health Conditions 󠄵 Other

If you have checked any of the above medical conditions/concerns, please explain: ___________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

Has your student ever visited a hospital or an emergency room for the medical issue? YES / NO (circle) If yes, date ________________________________________

____________________________________________________________________________________________________________________________________

MEDICATONS List any medications taken by student:

Medication Taken: __________________________________________ For _______________________󠄵 At Home 󠄵 At School



SHARING HEALTH CARE INFORMATION

In order to provide a safe and healthy environment for your student, the school nurse may need to share

information about your student’s health condition with teachers and essential school staff. If you have questions,

please contact your school nurse.

CONTACT INFORMATION

Please provide correct and current contact numbers and inform school office of any changes.

Name of Health Care Provider: _________________________________________ Phone: ___________________

Name of Dentist: _______________________________________________________ Phone: ___________________

_______________________________________________________

Student’s Name

_____________________________________________________ _____________________________________________________ Parent/Guardian name printed Signature

__________________________________________ ___________________

Relationship to student Today’s date

3/2017

If your student needs to take any medication (over the counter, prescription, herbal) at school, a medication

authorization form is required. This form must be completed by physician and parent prior to any medication being

brought to school. This form is available through the ASD web site or any school office.

Anacortes School District 103

2200 M Avenue Anacortes, Washington 98221

Phone: 360-293-1200 / Fax: 360-293-1222


Library Card Partnership Program The Anacortes School District partners with the Anacortes Public Library to provide library cards to all district students, regardless of whether or not they live in city limits.

All students will receive one card for the entire course of their time with Anacortes Schools. If they lose their card, they should contact their school’s librarian.

New students can get a card from their school’s librarian.

If you would not like your child to participate in this program, please fill out the Opt Out Form below and return it to your school’s librarian within one week of your child’s enrollment at their school.

Anacortes Public Library Card OPT OUT Form Return to your child’s school as soon as possible if you DO NOT want your child to

receive an Anacortes Public Library Card.

I choose to have my child OPT OUT of the offer of a FREE, Anacortes Public Library card. Date _________

Parent/Guardian (print) ________________________________________________

Parent/Guardian (signature) ___________________________________________

Student Name _____________________________________ School_____________________

Grade_____

PLEASE COMPLETE ONE FORM PER CHILD AND RETURN IT TO YOUR CHILD’S SCHOOL LIBRARAN.

OPT-OUTS remain in effect for your child’s entire enrollment with ASD. If no documentation is on file, it will be assumed that permission has been granted for access to, and usage of, the Anacortes Public Library. For more details, please go to the Anacortes Public Library website or contact Diana Farnsworth (360) 293-1910 ext 2980, or Jeffrey Vogel (360) 293-1910 ext 2051.


http://library.cityofanacortes.org/client/en_US/default

Documents

Kindergarten Round Up – 2017-18