QUABBIN REGIONAL SCHOOL DISTRICT Dr. Maureen M. Marshall, Superintendent of Schools 872 South Street Barre MA 01005 Phone: 978-355-4668 Fax: 978-355-6756 Web: www.qrsd.org

BARRE · HARDWICK · HUBBARDSTON · NEW BRAINTREE · OAKHAM

_____________________________________________________________________________________________ EOE: Quabbin Regional School District’s Policy of nondiscrimination will extend to students, staff, the general public and individuals with whom it does business; and will apply to race, color, national background, religion, sex, disability, economic status, political party, age, handicap, sexual orientation, gender identity, homelessness and other

human differences.

Welcome to Ruggles Lane School!

In order to enroll your child(ren) to our school, you will need to complete the following documents

listed below:

Record Release (so we may obtain all records from your prior school)

Enrollment Form

Home Language Survey

Ethnicity Form

One Call

Emergency Information

Please bring these documents to the school office (mail during the summer months) along with an original birth certificate (it will be copied and returned to you); a current physicians report including immunizations and lead screening information. If you have any questions, please call me at 978-355-2934 ext. 301 or email tconsolmagno@qrsd.org. Thank you. Teresa Consolmagno Office Manager

BARRE · HARDWICK · HUBBARDSTON · NEW BRAINTREE · OAKHAM _____________________________________________________________________________________________ EOE: Quabbin Regional School District’s Policy of nondiscrimination will extend to students, staff, the general public and individuals with whom it does

business; and will apply to race, color, national background, religion, sex, disability, economic status, political party, age, handicap, sexual orientation, gender identity, homelessness and other human differences.

QUABBIN REGIONAL SCHOOL DISTRICT

RECORD RELEASE FORM Release to:

Ruggles Lane School

105 Ruggles Lane

Barre, MA 01005

Phone: 978-355-2934 Fax: 978-355-2870

RE: _______________________________ Grade_______ Date________

In compliance with State and Federal laws, permission is required of a parent, legal

guardian, or eligible student before any records can be released to an outside agency,

school, or college.

In order to comply with the law, your signature is necessary.

I hereby grant permission for release of the following documents to the above named

school:

___________School Records

___________Special Education Records

___________Health Records

___________Written/Oral evaluations or assessments

Signature of Parent or Guardian: ___________________________Date:_____________

Previous school attended:___________________________________________________

Street/City/State/Zip_______________________________________________________

Tel.#_________________________________ Fax#______________________________

QUABBIN REGIONAL SCHOOL DISTRICT

ENROLLMENT FORM for

RUGGLES LANE SCHOOL

BUS: __________________ YOG: ____________

Last Name: ______________________________________ Birth Date: ____________________________

First Name: ______________________________________ City/State of Birth: ______________________

Full Middle Name: ________________________________ Gender: ___________ Grade: ___________

Street Address: ______________________________________________________________________________

PO Box: ______________________________________________________________________________

City: _________________________________________ Zip code: ____________________________

Home Phone: ____________________________________ Cell: ________________________________

Adults with whom student resides:

Name: _____________________________________ Relationship: __________________________

Cell Number: ______________________________Email address: ___________________________________________

Name: _____________________________________ Relationship: __________________________

Cell Number: ______________________________Email address: ___________________________________________

Name: _____________________________________ Relationship: __________________________

Cell Number: ______________________________Email address: ___________________________________________

CONTINUED ON BACK

OFFICE USE ONLY

Start Date: __________________________

Grade: _____________________________

LASID: ____________________________

SASID: _____________________________

BUS: __________________ YOG: ___________ ____________________________

Is he/she a returning student to our district? Yes _____No _____ If yes, last grade attended was _________

Is he/she a School Choice student? Yes____No_______ Foster Child? Yes______No ____

Does he/she have a 504 Plan? ____Yes ____No or Individualized Educational Plan (IEP)? _____Yes ______No

Other Adults with shared/partial custody, not residing with student:

Name: _________________________________________ Relationship: __________________________

Address: ___________________________________________________________________________________

Phone Number: ___________________________ Email: _____________________________________________

Name: _________________________________________ Relationship: ____________________________

Address: ___________________________________________________________________________________

Phone Number: __________________________ Email: ______________________________________________

*Is there a Custody Agreement? YES or NO (please circle one) If yes, please indicate below.

Mother has custody, father has shared/partial custody YES_____ NO _____

Father has custody – mother has shared/partial custody YES _____ NO _____

Is there any other legal matters other than a Custody Agreement? YES _____ NO ____ If yes, please explain below.

_________________________________________________________________________________________________

*Copies of court orders or any other legal documentation is required to place on file with the school. Without

documentation, the school cannot withhold any school related information.

_____________________________________ ___________________________

Parent/Guardian Signature Required Date

RUGGLES LANE SCHOOL

Dear Parent\Guardian,

The State of Massachusetts has become a member of MIC3 (Military Interstate Children’s

Compact on Educational Opportunity for Military Children) and as a result, the Massachusetts

Department of Secondary and Elementary Education is asking Quabbin Regional School District

to provide information regarding families that are eligible for assistance.

The goal of the compact is to replace the widely varying policies affecting transitioning military

students. The compact leverages consistency. It uses a comprehensive approach that provides a

consistent policy in every school district and in every state that chooses to join. The compact

addresses key educational transition issues encountered by military families including enrollment,

placement, attendance, eligibility and graduation. For more information about MIC3 visit

www.mic3.net.

What Children Are Eligible for Assistance Under the Compact?

Children of

Active duty members of the uniformed services, National Guard and Reserve on active

duty orders.

Members or veterans who are medically discharged or retired for (1) year.

Members who die on active duty.

What Children Are Not Eligible for Assistance Under the Compact?

Children of

Inactive members of the National Guard and Reserves.

Members now retired are not covered above.

Veterans not covered above.

Dept. of Defense personnel, federal agency civilians and contract employees not defined

as active duty.

Please fill out the below form and return it to your child’s school at your earliest convenience.

My child ___________________________ is eligible for MIC3 due to the below criteria:

(please print child’s name)

______ Has a parent who is an active duty member of the uniformed services, National

Guard and Reserve on active duty orders.

______ Has a parent who is a member or veteran who has been medically discharged or

retired for (1) year.

______ Has a parent who is a member and who died on active duty.

Parent’s signature: ______________________________________ Date: ___________

EOE: Quabbin Regional School District’s Policy of nondiscrimination will extend to students, staff, the general public and individuals with whom it does business; and will apply to race, color, national background, religion, sex, disability, economic status, political party, age, handicap, sexual orientation, gender identity, homelessness and

other human differences.

QUABBIN REGIONAL SCHOOL DISTRICT

Student Name: __________________________________________________________ School Attending: ___________________________________________________________ Ethnicity: Choose One

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race.

Not Hispanic or Latino

Race: Choose all that apply

American Indian or Alaska Native

A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American

A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Ruggles Lane Elementary SchoolStudent Verification Sheet

First: Middle:Last Name: Nickname:

Gender: Grade:Home Phone Counselor:

Physical Address: City, State Zip:

Mailing Address: City, State Zip:

City/Town ofDate of Birth: Native Language:

Who has legal custody ? Mothe Father Guardian Other

Contact 1Name (incl Maiden

Current Information Corrections

Relationship:Home Language:Citizenship:Physical Address:Mailing Address:City, State ZIP:Home Phone:Work Phone:Cell Phone:Primary email:Occupation:Employer Name:

Contact lives with student Contact may pick up student Receive grade mailings Receive conduct mailings Receive other mailings

Name:Relationship:Home Language:Citizenship:Address:Mailing Address:Home Phone:Work Phone:Cell Phone:Primary email:Occupation:Employer Name:

Contact lives with student Contact may pick up student Receive grade mailings Receive conduct mailings Receive other mailings

Contact 2 Current Information Corrections

Emergency

Name:Current Information Corrections

Relationship:Home Phone:Work Phone:Cell Phone:Email:

1

Emergency

Name:Current Information Corrections

Relationship:Home Phone:Work Phone:Cell Phone:Email:

2

Other Children (Name(s), Date of Birth, Current School in QRSD)

Do you give permission for theInternet/Network Use According to AcceptableUse PolicyUse of student's photo in publications

Use of photo on WebpageUse of name on Webpage

Y N Y N

Parents/Guardian Signature: Date:

Student’s Name_____________________________ Date of Birth ______________ Grade_____

2/1/15dlt

Standing Orders A complete copy of standing orders is available at the Health Office.

I hereby authorize the school nurse or designee to: (please initial all that apply)

____administer epinephrine for signs of anaphylactic shock

____administer acetaminophen (Tylenol) according to weight, as needed for complaints of headache, fever,

or pain

____administer ibuprofen (Motrin) according to weight, as needed for complaints of muscular discomfort or

headache

____administer throat lozenges/cough drops as needed for sore throat and/or cough

____administer Tums (or equivalent) for indigestion

____administer Anbesol (or equivalent) for mouth/gum pain

____apply over the counter antibiotic ointment for minor wounds, as needed

____apply calamine lotion (or equivalent) for complaints of itching skin related to minor skin irritations (for

example: poison ivy, bug bites)

____I would like my child to participate in the weekly fluoride program (for student in grades 1 – 6)

All students must have written authorization from their parent/guardian to receive these medications at school. Medication

will be administered according to school protocol. Your initials on the above lines and signature below fulfill this

requirement. Please note this does NOT pertain to prescription medications.

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

PLEASE NOTE: ANY MEDICATIONS/TREATMENTS, OTHER THAN THOSE LISTED ABOVE,

THAT NEED TO BE GIVEN AT SCHOOL MUST BE ACCOMPANIED BY A DOCTOR’S ORDER.

Please list any allergies, the student’s reaction to it, and treatment.

Allergy-example Reaction-example Treatment-example Example-peanuts Example- hives Epi pen, must sit at nut free table

Allergy Reaction Treatment

*Does this student require an Epi- pen? Yes No

*Does this student require an inhaler or nebulizer treatments? Yes No

Please list any medications that this student takes on a regular basis (include prescriptions and over-the-counter

medications.)____________________________________________________________________________________

*Does this student need to take medications during school hours? Yes No

Please list any medical conditions/concerns/comments not listed above:

*If you answered YES to any of these questions, please contact the school nurse for further instructions.

Doctor’s Name: ______________________________________ Doctor’s Phone: ______________________________

I give permission for the school nurse to share necessary medical information with staff members responsible for my child

at school. _____yes _____no (initial one, please)

X_________________________________________ _________________

Parent/Legal Guardian Signature Date

HOME LANGUAGE SURVEY Authority: Title VI; EEOA; M.G.L. c. 69, § 1I; c. 71A §§ 5, 7; 603 CMR; ELE 18

In order to help your child succeed in school, we ask that you please answer the following questions for each child in your family. Your answers will help us in creating the best possible educational program for your child.

1. What language did the child first understand or speak? _____________

2. What language do you use most often when speaking with the child at home? _____________

3. What language does the child use most often when speaking with you at home? _____________

4. What language does the child use most often when speaking with other family members? ______

5. What language does the child use most often when speaking with friends? _____________

6. What language(s) does the child read? ___________ _____________ _____________

7. What language(s) does the child write? ___________ _____________ _____________

8. What year did the child start attending school? In the U.S.A. _______ Elsewhere _________________

9. Has the child attended school every year since that year? ___Yes ____No

If no, please explain: ______________________________________________________________

10. Would you prefer oral or written (circle one or both) communication from the school in English or in your home language?

Please specify which home language >>> _____________

____________________________________ _____________________________________ Parent /Guardian – Please print. Signature of Parent /Guardian

Please do not write below this line.

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

To be completed by Principal or Designee before ELE Placement All information in the spaces below must be provided.

(OVER)

Enrollment

School: ___________________

Date: ____________________

Grade:___________________

Student

1st name:____________________

Last:_____________________________

SASID:____________________________

Student

D.O.B. ____________________

Y.O.G. _________(High School only)

Address:___________________

__________________________

Relationship to Student of Person Completing Survey

Mother / Father / Guardian / Other (Specify.) ___________________

Recommendation

Proficiency Testing / Records Review / No ELE Services

Principal’s/Designee’s Signature __________________________ __________________________

Date

QQUUAABBBBIINN RREEGGIIOONNAALL SSCCHHOOOOLL DDIISSTTRRIICCTT

QUABBIN REGIONAL SCHOOL DISTRICT Ruggles Lane School Dear Parent/Guardian, The Quabbin Regional School District now uses a district –wide automated notification system. The system automatically delivers telephone messages to you when there is an emergency affecting a school or district, a school cancellation, delayed opening, or dismissal, or an important announcement for the school community. This system can access only two telephone numbers per household. We are asking that you provide us with two phone numbers for your child. The school district does need to be able to contact you in the event of an emergency. You may opt out of this service for school cancellations, delays, early dismissals and announcements. If the emergency notification system is not working properly for you, please contact Teresa Consolmagno at 978-355-2934 ext. 301 or send an email to tconsolmagno@qrsd.org. Thank you for your assistance in this matter. Please feel free to call the school office with any questions.

PLEASE RETURN TO SCHOOL OFFICE Student Name: ___________________________________ Grade___:____________ First emergency phone #: __________________________________ Second emergency phone #: ________________________________ Email: __________________________________________________ Parent Signature: _________________________________________