PRE-K CHECKLIST – DOCUMENTS NEEDED TO … Ed... · PRE-K CHECKLIST – DOCUMENTS NEEDED TO APPLY ... gas, electricidad) • identificación emitida por el estado o el gobierno (ejemplo:

PRE-K CHECKLIST – DOCUMENTS NEEDED TO APPLY Child’s Name ___________________________________________________ Date Registered __________ Only applications that are completed in full with all requested information and documentation can be considered for placement.

1. A completed Application to Determine Income Eligibility, including required documentation: • proof of program participation: provide documentation as proof of participation in one or more of the

following programs: Early Head Start, Head Start, Foster Care, Homeless, Migrant, (EBT) Food Stamps, (TANF) Families First, (AFDC) Public Assistance Payments

• total household income verification: employer pay stub(s), W-2 form(s), income tax documents, unemployment compensation documentation, workman’s compensation documentation, pension pay stub(s), documentation of retirement income, social security, veteran’s benefit letter, child support and/or alimony documentation, foster care reimbursement(s), SSI documentation

2. Proofs of Residence – shall include two of the following: • property tax records • mortgage documents / property deed • income tax documents • lease agreement/rent receipts including date, amount and names of persons who made and received payments • utility bill (issued within the last 3 months of date of verification - water, gas, electric) • state or government issued ID (example: driver’s license, auto registration) • voter precinct identification • affidavit certifying address as student’s primary residence (student resides Monday through Thursday or the

majority of the nights per month) If you (parent/guardian) do not have proofs of residence, you must provide a letter from the individual that permits you and your family to reside at his/her property. The letter must state the relationship to the student and that the student will reside at his/her property full time for the length of the upcoming school year. The letter must include the address of residence along with two proofs of residence (see required documents listed above).

3. All pages of the application (completed with all requested information, documentation, emergency contact information [names, addresses, telephone numbers], and parent signatures where indicated)

4. Child’s birth certificate - long-form requested – must list name(s) of parent(s) 5. Evidence of a current medical exam and the required immunizations on a Tennessee form 6. Parent’s / guardian’s photo identification - drivers license, photo ID, passport, etc. 7. Legal Documents (child custody, divorce, guardianship, Power of Attorney, if applicable) 8. Home Language Survey

FOR SCHOOL AND CENTRAL OFFICE USE: Signature of LEA Employee: ________________________________________________________________________ INCOME BASED PROGRAM - it is important that all school representatives who take Pre-K applications request documents as proof of all forms of income for every individual that resides in the household. View these documents and make clear notes on pages 1 and 2 of the Application to Determine Income Eligibility for the Voluntary Pre-K Program regarding household income according to guidelines set by the Tennessee Department of Education. DATE OF BIRTH: _________________________ SCHOOL ZONE: ___________________________ AGE: ______YEARS ______MONTHS PRE-K INCOME ELIGIBLE: ___YES ___NO RACE/GENDER: ____________/____________ HEAD START INCOME ELIGIBLE: ___YES ___NO HEALTH/SHOT RECORD: _________________ Application Packet Complete: ___YES ___NO (Nurse: Please initial when health record is okay.) If no, documentation needed: _____________________ ________________________________________________ _____________________________________________ ________________________________________________ _____________________________________________ ________________________________________________ _____________________________________________ DATE APPLICATION COMPLETED: _____________ _____________________________________________

Solo las solicitudes que se han completado en su totalidad con toda la información y documentación solicitada pueden ser consideradas para la colocación.

1. Una solicitud completada de para Determinar la Elegibilidad de Ingresos, incluyendo la documentación requerida: • prueba de participación en el programa: proporcionar documentación como prueba de participación

en uno o más de los siguientes programas: Early Head Start, Head Start, Orfanato, Sin Hogar, Inmigrante, (EBT) Estampillas de Comida, (TANF) Familias Primero, (AFDC) Pago de Asistencia Publica

• verificación total del ingreso familiar: talón(es) de pago del empleador, formulario(s) del W-2, documentos de impuestos, documentación de compensación por desempleo, documentación de compensación del trabajador, talón(es) de pago de la pensión, documentación de los ingresos de jubilación, seguro social, carta de beneficios de veteranos, documentación de manutención de hijos y/o pensión alimenticia, reembolso(s) de cuidado de crianza temporal, documentación de SSI

2. Pruebas de residencia – deberá incluir dos de los siguientes: • registro de impuestos sobre la propiedad • documentos de hipoteca/escritura de propiedad • documentos de impuestos • contratos de arrendamiento/recibos de renta, incluyendo la fecha, la cantidad y los nombres de las

personas que realizaron y recibieron los pagos • facturas de servicios públicos (emitido dentro de los últimos 3 meses de la fecha de verificación - agua,

gas, electricidad) • identificación emitida por el estado o el gobierno (ejemplo: licencia de manejo, registración de auto) • identificación de precinto de votantes • declaración jurada como residencia del estudiante (el estudiante reside de lunes a jueves o la mayoría

de las noches por mes)

Si usted no tiene pruebas de residencia, debe proporcionar una carta del individuo que le permita a usted y a su familia residir en su propiedad. La carta debe indicar la relación con el estudiante y que el estudiante residirá en su propiedad a tiempo completa por la duración del próximo año escolar. La carta debe incluir la dirección de residencia junto con dos pruebas de residencia (vea los documentos requeridos listados arriba)

3. Todas las páginas de la solicitud – completadas con toda la información solicitada, documentación, información de contacto de emergencia (nombres, direcciones, números de teléfono o 3 además de los padres), y firmas de los padres que se indique.

4. Certificado de nacimiento del niño – formulario largo solicitado – debe listar el/los nombre(s) del padre(s)

5. Evidencia de un examen médico actual y las vacunas requeridas en un formulario de Tennessee 6. Identificación con foto de los padres / tutores – licencia de conducir, identificación con foto, pasaporte,

etc. 7. Documentos legales (custodia de los hijos, el divorcio, la tutela, poder notarial, si es aplicable) 8. Encuesta del Lenguaje en el Hogar

1.

2.

3.

4.

5.

1.

2.

3.

4.

5.

(√) (√) (√) Case #

Early Head Start

Part B - Program Participation

Foster Care Migrant

Food Stamps / EBTHead Start Homeless

Families First (TANF)

Total # of household members:

*If submitting proof of qualifying for any of the above programs, you do NOT need to complete Part C.

Section 2

Name(s) of ALL OTHER ADULTS in the Household

( )

Please list information for all other household members

Name(s) of ALL OTHER CHILDREN in the Household

Relationship to Student

Please check (√) if Child /Family /Household member provides documentation of participation, in one or more of the following

programs, currently or during past school year (*Documentation required-See Part D).

SSN of Student:

Mailing Address:

Date of Birth School Grade

( )Cell

Phone #:

Part A - Family Information

Section 1

Home

Phone #:

Work

Phone #:

City: State:

( )

Zip Code:

Name of Student: Date of Application:

Name of Applicant:

Completion of this form DOES NOT qualify your child for the Free or Reduced Meal Program.

Submission of this application is not a guarantee of acceptance into the VPK program.

2018-19

Application to Determine Income Eligibility for the Voluntary Pre-K Program

For Office Use Only

Please Circle One

Income Eligible: Yes / No

If yes, and enrolled, student should be

classified as (L) in student information system

Date of Birth of Student:

(√)

Relationship to Student:

Updated: March 21, 2017

A. D. G. J.

B. E. H. K.

C. F. I.

Printed Name / Title of LEA employee:

Other (Specify): →

Date Reviewed by LEA employee:

Signature of Applicant: Date:

SSN #:

Signature of LEA employee:

I certify that I have examined the above income documentation and verification information.

Completed forms must be maintained in accordance with FERPA.

Pension Stubs

I certify that the above information in this application is correct. I further understand that any falsification of information concerning

income, residence, birth certificate and/or completion of this application and other forms may be reason for dismissal from

Tennessee's Voluntary Pre-K Program.

Printed Name of Applicant:

Part D - INCOME VERIFICATION

Name and Signature of LEA employee reviewing this application

W-2 Form Social Security SSI Documentation

Income Tax Form 1040A or 1040

Unemployment Compensation Child Support AFDC / Public Assistance Payment

Workman's Compensation Documentation Alimony Documentation

Retirement Documentation Foster Care Reimbursement

TennCare Verification

Veteran's Benefit Letter TANF Documentation

$ -

$ -

$ - $ -

$ - X

Please check (√) all documents submitted as Proof of Income or Program Participation.

Pay Stub / Verification of pay by employer

$ - X

Total Annual (Yearly) Income

X

$ -

$ -

$ - X $ -

$ - X

Name of Adult Employer (if applicable)

Source of

Income

Code (See

list above)

Monthly Payment or

Wage Amount

Multiplied

by

(X)

How many

months did you

receive this

income in the

last year? Total Amount

Workman's Comp Social Security Alimony

Income Instructions

From the list below, please write the Source of Income Code in the space provided to indicate the source(s) of income for each earning

individual in the household. Also, please write the Monthly Payment or Wage Amount. Multiply the Payment or Wage amount by the

number months you received the income and then calculate the Amount and the Total Annual Income.

Source of Income Codes

GROSS work income Pension(s) Veteran's Benefits SSI Disability

Unemployment Retirement Child Support Other - please list ↓

Any falsification of information concerning income, residence, birth certificate and/or completion of this application and other forms

may be reason for dismissal.

Part C - Total Household IncomePlease list ALL INCOME of all household family members and how often income is received.

Updated: March 21, 2017

(Please Print All Information)

Revised 01/29/16

ROBERTSON COUNTY SCHOOLS PRE-K STUDENT APPLICATION

School _________________________________________________ Application Date _________________________

STUDENT INFORMATION

Child’s Legal Name _______________________________________________________ Date of Birth _____________________ Last First Middle

Social Security Number (optional) _____________________ County/State of Birth ______________________________________

911Street Address ______________________________City _________________________ State _________ Zip Code _________

Mailing Address _______________________________ City _________________________ State _________ Zip Code _________

Where does the child stay at night? (please check one)

� Home/apartment owned or rented by the parent(s)/guardians(s) � Shelters, Transitional housing, awaiting foster care � Unsheltered (cars, parks, campgrounds, temporary abandoned building) � Hotels / Motels � Doubled up (with a relative or friend/family does not have a residence) � Other housing (please explain) ________________ Gender (check one): � Male or � Female Ethnicity (check one): � Hispanic or � Non-Hispanic Race (check all that apply): � Asian � American Indian or Alaskan Native � Black/African American � Pacific Islander or Native Hawaiian � White Transportation (circle one): Car Walk School Bus AM Bus # __________ PM Bus # __________

Other (specify) ______________________________________________________________________________________________

This student lives with: _____ both parents _____ father _____mother _____legal guardian

I/We have legal guardianship of this student: _____ mother _____father _____both _____ other ________________

Are there any restrictions regarding release of student or student information to either natural/legal parent? ___yes ___no

Please explain: _____________________________________________________________________________________________ A copy of court order must be on file

PARENT’S INFORMATION

Father’s Legal Name ___________________________________ Phone Number _____________ Cell Number ______________

911 Street Address ________________________________ City _____________________State ________ Zip Code __________

Mailing Address __________________________________ City _____________________State ________Zip Code __________

Driver License # _______________________ Date of Birth ____________ E-mail Address ______________________________

Employer __________________________________________________ Employer Phone _______________________________

Mother’s Legal Name ___________________________________ Phone Number ______________ Cell Number ____________

911 Street Address __________________________________City _________________State__________ Zip Code ___________

Mailing Address ____________________________________City _________________State__________ Zip Code __________

Driver License # ________________________Date of Birth _____________ E-mail Address ____________________________

Employer __________________________________________________ Employer Phone ______________________________

School Reach Contact Phone Number__________________________________________ (see student handbook for explanation)


Revised 01/29/16

GUARDIAN INFORMATION

To be completed only if the student lives with someone other than a natural/legal parent. A copy of the court order granting custody must be provided upon enrollment.

Legal Guardian’s Name _________________________________ Relationship __________ Phone # __________Cell #__________

911 Street Address _____________________________________ City ___________________State_________ Zip Code _________

Mailing Address _______________________________________ City ___________________State_________ Zip Code _________

Driver License # _____________________________ Date of Birth ____________E-mail Address ___________________________

Employer __________________________________________________ Employer Phone # ________________________________

State Custody? _____ yes _____ no Agency Name ___________________________________________________________

Case Worker _____________________________________________ Case Worker’s Phone # ________________________________

EMERGENCY CONTACT INFORMATION Please list three persons who may be contacted in the event of an emergency if parents/guardians are unavailable.

FIRST CONTACT:

Contact’s Name ___________________________________________Relationship to Child_________________________________

Contact’s 911Street Address ____________________________City ______________________ State ______ Zip Code __________

Contact’s Telephone Numbers: Home # ___________________Cell # _____________________ Work #_______________________

SECOND CONTACT:




THIRD CONTACT:




*It is hereby assumed that the school has your permission to release this student to those listed as emergency contacts.*

OTHER CHILDREN IN THE HOME

Name Birth Date School Name Birth Date School

1. __________________________ __________ _______________ 2. _________________________ _________ __________

3. __________________________ __________ _______________ 4. _________________________ _________ __________

5. __________________________ __________ _______________ 6. _________________________ _________ __________


Revised 01/29/16

SCHOOL/EDUCATIONAL HISTORY

Has this student previously attended a daycare? _____ yes _____no If so, name of daycare:_____________________________

Has this student previously attended school in Robertson County? _____ yes _____no

If so, name of school _______________________________________________________ Dates attended _____________________

What is the last school this student attended? ________________________________County __________________State _________

Was this student suspended or expelled from that school? ___ yes ___ no Enrolled in an alternative program? ___ yes ___ no

Has this student received any of the following services (circle all that apply): Resource Gifted ESL Speech

Has this student had an Individualized Education Plan (IEP)? ___ yes ___ no When (date)? ______________________________

Father’s highest level of education: # of years completed: ____ High School Graduate?____ College? # of years____

Mother’s highest level of education: # of years completed: ____ High School Graduate?____ College? # of years____

MEDICAL INFORMATION

Does this student have any known allergies? ____ yes ____ no Specify ____________________________________________

Is student required to take medication during the school day? ____yes ____ no (Physician orders required- see handbook)

Name/type medication?_______________________________________________________________________________________

Other medical information: ___________________________________________________________________________________

Name of Student’s Doctor___________________________________________________________ Phone #__________________

OTHER FAMILY FACTORS (Check all that apply)

____ Non-English speaking family

____ Homeless family

____ Migrant family

____Parent with a disability (specify)_______________________

____Incarcerated parent

____Child is/has been a victim of abuse/neglect

____Age of primary care giver is 18 years or younger

____Referral from other agency/professional (TEIS, TIPS, DCS, DHS, Physician)

____Does the child have any known or suspected handicapping condition(s)? ___yes ___no (Specify)_______________________

____Does the child reside in foster care? ___yes ___no

____Crisis in family (death of a parent, divorce, single parent household, other) (Specify) ___________________________________

__________________________________________________________________ ___________________________ Parent/Guardian Signature Date


Revised 01/29/16

PRE-K CHILDHOOD HISTORY

Child’s Legal Name: _________________________________________Date of Birth: _________________ ADDITIONAL MEDICAL HISTORY: Nervous tendencies (circle those you have observed): speech defects, bites nails, sucks thumb, grinds teeth, tics/twitches, head banging, rocking, encopresis (soiling pants), enuresis (wetting pants) Temperament: Circle any of the following behaviors your child has exhibited: easily over-stimulated, short attention span, lack of self-control, seems unhappy, withholds affection, hides feelings, impulsive, overreacts to problems, uncomfortable meeting new people, seems to require a lot of attention Please give more detail about any circled: ________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has your child ever seen a counselor or psychologist for anything in the past? If so, explain: _______________ __________________________________________________________________________________________ __________________________________________________________________________________________ FAMILY HISTORY: Is there a history of any of the following in the families of the child’s parents? (Please check) □ Developmental Delay □ Emotional Problems □ Seizures □ Learning Problems Has this child lived in another household at any time since birth? □Yes / □No If yes, how long? ____________ Has the family group changed through death, divorce, adoption, or other since this child’s birth? □Yes / □No If yes, please describe: (Include age of child when event occurred): ___________________________________ __________________________________________________________________________________________ Please list all brothers and sisters and any other children living with the family: Name Age Gender Relationship Living in the home? _________________________________ ____ ______ _______________ ________________________ _________________________________ ____ ______ _______________ ________________________ _________________________________ ____ ______ _______________ ________________________ _________________________________ ____ ______ _______________ ________________________ Are there persons living in the home other than the parents and children? If so, please list: _________________ __________________________________________________________________________________________ How many times have you moved since your child was born? ________________________________________ How does your child get along with parents and other family members? ________________________________ What jobs or responsibilities does your child have at home? _________________________________________ What kind of discipline is used at home? ________________________________________________________ What do you enjoy most about your child? _______________________________________________________ __________________________________________________________________________________________ What do you feel is most difficult about your child? ________________________________________________ __________________________________________________________________________________________ Describe social opportunities and interests within the home, school and community that your child enjoys: (Example: sports, church, family outings, extra-curricular activities, clubs, hobbies, etc.) __________________ __________________________________________________________________________________________ Respondent’s Signature:____________________________________ Relationship to child: _____________


Revised 01/29/16

STUDENT HEALTH HISTORY

Student Name ___________________________________________________ GRADE________________DOB_________________ Home Address _______________________________________________________________________________________________ Parent Phone #________________________ Parent Cell #_______________________ Parent Work #_________________________ Parent Name (please PRINT) ____________________________________________________________________________________ Emergency Contacts 1) ____________________________________________________ Relationship___________ Phone # ________________________ 2) ____________________________________________________ Relationship___________ Phone # ________________________ 1. Does the student have any significant medical illness or medical condition? YES NO Please circle: ADD ADHD ASTHMA DIABETES SEIZURES (please list type of seizure) Please list any other medical condition/information: ________________________________________________________________ Will student need an inhaler/nebulizer or medication at school? YES NO Does student take ADD/ADHD medication at home? YES NO Will student need to have seizure medication available at school? YES NO If history of seizures, when was your child’s last seizure? _____________________________________________________________ 2. Is the student currently taking medications? YES NO If yes, please list medication _________________________When is it taken? ____________________________________________ 3. Does the student have any significant allergies to food, insects, medications, etc.? YES NO Please list allergies ____________________ What happens if exposed?_________________________________________________ Does the student require an Epi-Pen? YES NO If an Epi-Pen is needed, parent/guardian must provide Epi-Pen, doctor’s order, and parental consent. Food Allergies require a doctor’s note on file. Please let your school nurse know in order to assist you. 4. Has the student had any injuries such as concussion, fracture, dislocation, etc.? YES NO If yes, when and please describe injury:___________________________________________________________________________ 5. Has the student had any episodes of fainting, loss of consciousness, or dizziness? YES NO If yes, when: ___________________What treatment was received: ____________________________________________________ 6. Has the student had any surgery or hospitalization? YES NO If yes, when and why: _________________________________________________________________________________________ 7. Is student currently under doctor’s care? YES NO If yes, for what: ______________________________________________________________________________________________ 8. Any emotional concerns? YES NO Please describe: ______________________________________________________________________________________________ 9. Does the student wear: Contacts? YES NO Glasses? YES NO Dentures/Partials? YES NO Bridge Work? YES NO 10. Does the student have any hearing problems or wear hearing aids? YES NO 11. Any recent immunizations? YES NO If yes, please provide a copy for the school nurse to place in student’s cumulative record. 12. Is there any reason the student cannot participate in Physical Education Classes? YES NO If yes, why: _________________________________________________________________________________________________ Name of Student’s Doctor: ___________________________________ Phone #: ________________ Date of last visit: ___________

***If your child requires medication at school, please contact the school nurse for information. The only medication a student is allowed to carry at school is an inhaler and/or epi-pen and a doctor’s authorization is required. STUDENTS ARE NOT TO CARRY ANY OTHER MEDICATIONS WITH THEM AT SCHOOL! All prescription medications require a doctor’s order and parental consent. Over the counter medications require only a parental consent. Please see your school nurse regarding any questions for medications or medical procedures. Please notify the school nurse if any information changes on this form during this current school year. ***Health History Informed Consent: Your signature gives permission for school staff to take precautions and procedures to protect your child in the classroom and to foster academic success. Your signature gives informed consent to share your child’s health information with school staff and healthcare providers on a need-to-know basis for care/emergency plans.


Revised 01/29/16

PARENT/GUARDIAN Signature_________________________________ Phone # _________________Date__________________

PRE-K SKILLS CHECKLIST

Child’s name: ____________________________________________ Date: _______________

Dear Parents, In planning an appropriate program for your child we need you to complete the following checklist. Please indicate yes or no, based on observations you have made about your child’s development. Directions: Mark yes or no to each of the skills listed below. Yes, my child performs the skill consistently and without assistance. No, my child does not perform the skill consistently and needs assistance completing the skill. Cognitive ___yes ___no Identifies objects based on color ___yes ___no Identifies shapes (circle, square, triangle) ___yes ___no Remains on task for approximately 10 minutes without supervision (sitting quietly

for a story, TV, music, or playing with toys) ___yes ___no Enjoys being read to, pointing to pictures and listening attentively ___yes ___no Counts to 10 ___yes ___no Tells own age and name Fine Motor ___yes ___no Uses pencils and crayons appropriately ___yes ___no Puts together a simple puzzle (3-5 pieces) ___yes ___no Can draw a simple face (circle with marks for eyes, nose, and mouth ___yes ___no Using child scissors can cut across a piece of paper Language ___yes ___no Correctly answers simple questions (What or who was that?) ___yes ___no Follows simple two step directions ___yes ___no Carries on an appropriate conversation with adult to express needs, wants, and ideas ___yes ___no Uses four to six words in a sentence regularly Gross Motor ___yes ___no Kicks a large ball ___yes ___no Walks up and down stairs alternating feet ___yes ___no Jumps landing on both feet ___yes ___no Rides tricycle using pedals and maneuvering with handle bars ___yes ___no Runs, changing direction without stopping Social ___yes ___no Plays with one or two others, sharing, taking turns ___yes ___no Sits without moving when involved in an activity ___yes ___no Looks at a person when speaking Self Help ___yes ___no Eats most foods using a spoon or fork with little spilling ___yes ___no Drinks from an open cup with little spilling ___yes ___no Dresses independently (except for tying shoes and difficult buttons) ___yes ___no Washes and dries hands without assistance ___yes ___no Goes to toilet properly by self with few accidents ___yes ___no Wipes self after toileting


Revised 01/29/16

Parents of Pre-K and Kindergarten Children

Student Registration Form

Student Name: _________________________________________________________________ School Name: __________________________________________________________________

YES --- Check this box if your child participated in Dolly Parton’s Imagination Library program. Note: If your child participated, he/she would have received one free book a month by mail with the logo shown above. The first book received was “The Little Engine That Could”

If you participated in the Imagination Library, please indicate in the box to the left the age of your child when he/she received the first book? Please mark “0” if your child began at or a little after birth; mark a “1” if your child was one year old, a “2” if he/she was 2 years old, etc.

If your child is less than five years old and you are interested in participating in the Imagination Library Program, please call toll-free at 1-877-99Books.

Tennessee Migrant Education Program – Occupational Survey

This project is funded under a Grant Contract with the State of Tennessee January 2017

Examples: Plant, pick and sort crops

such as tomatoes, tobacco, cotton,

strawberries, etc. Soil preparation,

irrigation, fumigation, etc.

Your child may qualify to receive FREE educational services. Please answer the following questions to help us determine their eligibility. Once completed, return this form to the school.

If you answered “YES” to any of the questions above, please answer the following questions.

For school use only: Please send all surveys with at least one “YES” response to your district migrant liaison. All qualifying surveys should

be uploaded to the TNMigrant site. Please notify the MEP that new surveys have been uploaded. Questions? Call (931)212-9539

SCHOOL DISTRICT: STUDENT STATE ID: ENROLLMENT DATE:

Student Name: (Last Name, First Name)

Grade: Date:

Parent/Guardian Name: School:

1. Has your family moved within the last 3 years to another city, county, or state, in order to work in the agricultural and fishing

industries? Yes☐ No ☐

If yes, please indicate which family member: ☐Mother ☐Father ☐Children ☐Other

2. Do you or someone in your immediate family currently work in any of the occupations listed below? Yes ☐ No☐

If yes, please indicate which occupation and which family member: ☐Mother ☐Father ☐Children ☐ Other

☐ Meat and Food Processing/Packing

☐ Agriculture/Field Work

☐ Dairy/Cattle Raising

☐Nursery/Greenhouse

☐ Forestry

☐ Fishing/Fish Processing

3. If your current job is not in agriculture or fishing, did you or someone in your immediate family work in any of the occupations listed

above in the last three years? Yes ☐ No☐

If yes, where? City: _________________ State:______________

How long have you been in this county in Tennessee? ______ Weeks _________Months ______Years

Home Address City State Zip Code

Telephone number, please include area code. ( )

Examples: Fruit,

vegetables, chicken,

pork, beef, etc.

Examples: Planting,

potting, pruning,

watering, etc.

Examples: Soil preparation,

planting, growing, cutting trees, etc.

Examples: catch,

sort, pack,

transport fish, etc.

Examples: Feeding,

milking, rounding up,

etc.

Parental Consent Form for Sharing Immunization Record with Tennessee Immunization Information System Tennessee and Federal law allow for the sharing of immunization records between schools, health care providers, and public health agencies if parental consent is provided to the school. One way this is done is by each of these entities contributing the immunization records they have to one computer system that is available only to schools, health care providers, and public health agencies called the Tennessee Immunization Information System (TennIIS). This immunization record service system is operated by the Tennessee Department of Health and contains only basic name and address information, plus immunization records, including vaccines names and dates, from area doctors’ offices and other health care providers. Our school district uses this immunization record service. This service makes it much easier for us to get copies of your child’s immunization record, a requirement for school entry under Tennessee law. We also share records of immunization not already in the system with this service so you or your child’s healthcare providers can access complete immunization information in the future. Additionally, your child’s immunization information will be accessible to you through your healthcare provider and to colleges and universities to satisfy their immunization enrollment requirements. This information is used solely to help protect your child and prevent disease by documenting and improving immunizations in our community. The information can only be shared with those entities authorized by Tennessee law (Tenn. Code Ann. § 63-2-101) to receive it. If you choose to not have your child’s immunization information in this system, it does not affect any school services. Should you be unable to locate copies of immunization records when needed in the future, however, it may mean a long record search or repeat immunizations for your child, which would involve more work for you, your child’s clinic, and/or school staff to verify your child’s immunization status as part of Tennessee’s School Immunization Law. I authorize Robertson County Schools to release my child’s immunization record to the public health immunization registry. I understand this information can only be used to improve the quality and timeliness of immunization services and to help schools enforce the School Immunization Law. This includes any immunization information the school currently has on my child plus any it may obtain while the student attends this school. □ I do authorize □ I do not authorize Child’s Name: ____________________________________ Date of Birth: ___/___/____ Parent’s signature: ________________________________________ Date: ___/___/____