Welcome to Northridge Middle School!

To Enroll at NMS, you will need:

· Completed Enrollment Forms

· Recent Grades

· Copy of Birth Certificate

· Immunization Record

· Signed Computer Agreement

· Special Education information – if applicable

· Custody Agreement – if applicable

· Proof of Residency (one of the following):

o Signed current lease/purchase agreement

o Current Voter Registration card

o Recent utility bill

o Recent paycheck or government check

o Recent bank statement

Important information to know:

· Please make your child aware of ALL pertinent information before he/she leaves home. Getting

messages to students at school is disruptive to them and to the class. Messages should be

reserved for emergencies.

· If your student is absent please call 825-9531 as early as possible to report his/her absence. If

you are unable to call during the school day, please leave a message on our voice messaging

system or send in a note with your student. All calls and notes should be directed to the

Attendance Secretary in the front office. If your child misses five or more consecutive school

days, he/she will need to bring in an excuse from their doctor.

· Please send a note to the Attendance Secretary or call the office in the morning if you need to

sign out your student during the school day. We will have your student waiting in the

Attendance Office at the appropriate time.

· If you plan to take your student out for vacation or an educational trip, a vacation form must

be picked up in the office in advance and signed by all teachers and a parent. Failure to get

these forms completed will result in an unexcused absence. Please see the student handbook

for a list of excused absences and further information on vacation requests.

· It is imperative that the school be notified immediately of a change of address, home, cell or

office telephone number, or emergency contact information during the school year.

SSN (required gr 9-12) DOB Home Address Mailing Address Primary Phone ( )Student cell ( ) Is student Hispanic/Latino? Race (check any) Am Indian/Alaskan Native Black Asian White Native Hawaiian/Pac IslanderIs student receiving any special services? (High Ability/GT, IEP, testing accommodations, 504 plan, speech, etc)Student status?

Date: Gr: Gender: Student:

MotherName Address (if not same as student's) Primary # (if not same as student's) ( ) Employer/OccupationWork # ( ) Cell # ( )

FatherName Address (if not same as student's) Primary # (if not same as student's) ( ) Employer/OccupationWork # ( ) Cell # ( )

StepmotherName Employer/OccupationWork # ( ) Cell # ( )

StepfatherName Employer/OccupationWork # ( ) Cell # ( )

GuardianName/Relationship Employer/OccupationWork # ( )Other #/type ( )

GuardianName/Relationship Employer/OccupationWork # ( ) Other #/Type ( )

Parent/Guardian Email

Parent/Guardian InformationStudent Primarily Resides With Student has one or more parent(s)/guardian(s) serving active duty with the US Military?

Name and address of school last attended_____________________________________________________________________________________________

- SIGNATURES REQUIRED ON BACK - SIGNATURES REQUIRED ON BACK -

Please list other children in the familyName Birth Year Relationship Grade

Emergency Contacts Please list two adults other than parents or guardians.

Name/Relationship Phone/Type ( ) Phone/Type ( ) Name/Relationship Phone/Type ( ) Phone/Type ( )

School MessengerMiddlebury Community Schools has an automated phone calling system. We use this tool to call in cases of emergency, to notify you of school closings or delays, or to notify you of any uncleared absences. We can also inform you of any general school announcements (special events etc).

The calling system is currently calling 574/825-1225.Please use this number for the phone calling system (______)__________________.Send me messages in Spanish when available.I do not want to receive any messages from the phone calling system. By choosing this option you testify that you

understand you will receive NO phone calls from the messaging system pertaining to emergencies, closings, delays,absences or school announcements.

I have read and understand this section of the form__________________________________ Date: _____________

Non-Prescription Medication PermissionIf you wish non-prescription medications to be administered to your child at school, as needed during the school year,please check below and sign to give permission. Prior consent was given for any medications marked with an x. Pleasemake any changes. We WILL NOT give medications this school year without a signature for this section of the form.

___Acetaminophen (Tylenol) ___Antacid (Tums) ___Benadryl___Bismuth tabs (Pepto) ___Ibuprofen ___Menstrual relief (Tylenol & Pemabrom)___Menthol cough drops ___Phenylephrine (decongestant)___Other (please specify)___________________________________________________________________

Parent/Guardian Signature:_______________________________________ Date:______________

Student:_______________________________________Gr:_____DOB: __________

MEDICAL CONDITIONS

__No Medical Conditions

Doctor Name:__________________________________ Phone: (_____)___________

__Asthma

Physician Treating Asthma:_________________________ Phone: (_____)__________Asthma Triggers: __Exercise __Respiratory Infections __Change in Temperature __Other_____________________List Asthma Medications(please provide doctor's note if taken at school)

Medication:___________________________ Dose:__________ When to use:___________________________________Medication:___________________________ Dose:__________ When to use:___________________________________

__Allergies (Please provide doctor's note for any medications taken at school)

Physician Treating Allergies:_______________________________ Phone: (_____)__________Allergy 1:______________________ Reaction:________________________________________________

EpiPen? __Yes __NoMedication:________________________ Dose:_____________ When to use:________________________________

Allergy 2:______________________ Reaction:________________________________________________EpiPen? __Yes __NoMedication:________________________ Dose:_____________ When to use:________________________________

Allergy 3:______________________ Reaction:________________________________________________EpiPen? __Yes __NoMedication:________________________ Dose:_____________ When to use:________________________________

__Seizures

Physician Treating Seizures:___________________________ Phone: (_____)__________Type of Seizures:________________________________ Date of last seizure:____________Is student allowed to participate in Physical Education and other activities? __Yes __No Explain:List Seizure Medications (please provide doctor's note if taken at school)

Seizure Medication:_______________________ Dose:____________ When to use:______________________________Seizure Medication:_______________________ Dose:____________ When to use:______________________________

__Diabetes

Physician Treating Diabetes:_________________________ Phone: (_____)__________Type of Diabetes: __Type I __Type IIWill your student's doctor's office provide a care plan for the current/upcoming school year? __Yes __NoList Diabetes Medications (please provide doctor's note if taken at school)

Medication:__________________________Dose:__________ When to use:________________________________Medication:__________________________Dose:__________ When to use:________________________________

- - -SIGNATURE REQUIRED ON BACK - - -SIGNATURE REQUIRED ON BACK - - -

__Other Medical Condition

Describe:_____________________________________________________________________________Physician Treating Condition:_____________________________________ Phone (_____)__________Will your student's doctor's office provide a care plan for the current/upcoming school year? __Yes __NoList Medications (please provide doctor's note if taken at school)

Medication:____________________________ Dose:__________ When to use:__________________________________Medication:____________________________ Dose:__________ When to use:__________________________________

Other Medical History

Has your student had the Chicken Pox disease? If so, date:____________Please list any broken bones and the date they werebroken:_________________________________________________________________________________________Type and date of any surgery:________________________________________________________________

Note to all Parents/Guardians

If any of the above information changes during the school year, please notify the school nurse.If your child received any immunizations over the summer, turn in updated records to the school office.Please review the school medication policy before sending any medication to school with your child.

I have read the above information and I give permission for the necessary school employees to be notified of my child's medicalcondition(s).

Parent/Guardian Signature:________________________________________Date:________________

Middlebury Community Schools Middlebury, IN

Home Language Survey (HLS)

The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts to determine the language(s) spoken by each student in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 457 U.S. 202 (1982).

Please note that the questions below will be given to all students and answers should be student-specific. If a language other than English is spoken by your student, he or she will be given a test to determine their level of English proficiency. The test results will determine if your student qualifies for any additional services to help them become English proficient.

Please answer the following questions regarding the language spoken by your student

1. What language did your student first learn to speak? _________________________________ 2. What language(s) is spoken most often by your student? _________________________________ 3. What language(s) is spoken by your student at home? _________________________________ 4. Was your student born in the US? If NO, date of entry?_______________ Student’s age_____

Student Name:____________________________________________________Grade: ___________ Parent/Guardian Signature:__________________________________________Date: ____________ By signing here, you certify that the responses above are specific to your student. You understand that if a language other than English has been identified, your student will be given a test to determine if they qualify for English language development services to help them become fluent in English. Students who qualify for services will also be given an annual assessment to monitor their language proficiency.

El Decreto de los Derechos Civiles de 1964, Titulo VI, Cumplimiento de Normas para Minorías en Lenguaje, requiere a los distritos escolares

que determinen el idioma o idiomas que habla cada estudiante. Esta información es esencial para que las escuelas puedan ofrecer instrucción útil a todos los estudiantes de acuerdo con Plyler v. Doe, 457 U.S. 202 (1982).

Por favor tenga en cuenta que esta encuesta se les dará a todos los estudiantes. Las respuestas a la encuesta corresponden solamente a su hijo/a. Si en alguna de las tres preguntas escritas abajo, usted identifica un idioma diferente al inglés, la escuela administrará la Prueba del Desarrollo del Inglés para determinar si su hijo/a calificará para el programa de desarrollo del idioma inglés.

Por favor responda las siguientes preguntas acerca del idioma(s) hablado por su estudiante

1.¿Cuál es el idioma o el dialecto nativo de su hijo/hija? _____________________________________ 2.¿Cuál es el idioma(s) más hablado por su hijo/hija? _____________________________________ 3.¿Cuál idioma(s) habla su hijo/hija en casa? _____________________________________ 4.¿Nació el estudiante en los Estados Unidos? ¿Si NO, cuándo entro el niño/a a los Estados Unidos? __________________ ¿Cuantos años tenía? _____ Nombre del Estudiante:_______________________________________________________Grado:___________ Firma del Padre o Guardián:___________________________________________________Fecha:___________ Al firmar aquí, usted certifica que las respuestas a las tres preguntas mencionadas arriba corresponden a su hijo/a. Usted entiende que si se ha identificado un idioma diferente al inglés, su hijo/a tendrá un examen para determinar si él o ella califica para el programa de desarrollo del idioma inglés, para ayudarlo/a a que sea fluente en inglés. Si entra en el programa de desarrollo del idioma inglés, su hijo/a, tendrá derecho a servicios que lo ayudarán a aprender el idioma inglés y tendrá un examen cada año para determinar su nivel de inglés.

OFFICE USE ONLY/ Para Uso de la Oficina Escolar Únicamente

___Original HLS (student new to IN or first time enrollee) ___Unable to locate original HLS from previous IN school

Notes:___________________________________________________________________________________

(C.H.I.R.P) Middlebury

Community Schools

I, , give Middlebury Community Schools permission to (parent/guardian)

release the following information concerning my child to the (name of child)

Indiana State Department of Health's Children and Hoosiers Immunization Registry Program (CHIRP):

Child's name, date of birth and immunization information.

I understand that the information in the registry may be used to verify that my child has received proper immunizations and to inform me or my child of my child's immunization status or that an immunization is due to according to recommend immunization schedules.

I understand that my child's information will be available to the immunization data registry of another state, a healthcare provider, a local health department, an elementary or secondary school that is attended by the individual, a child care center, and the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning, I also understand that other entities may be added to this list though amendment to I.C. 16-38-5-3.

I hereby to the release of such information.

(signature) (date)

(printed name of Parent or Guardian)

( ) Address Telephone Number

Child's Name Grade Level

Northridge Middle School School

Administration Center: 56853 Northridge Drive, Middlebury, Indiana 46540 Phone: (574) 825-9425 Fax: (574) 825-9426 Web: www.mcsin-k12.org

MIDDLEBURY COMMUNITY SCHOOLS' COMPUTER NETWORK/INTERNET ACCEPTABLE USE

AGREEMENT

Student Name (Print) School

I have read or had read to me the Middlebury Community Schools' Computer Network/Internet Acceptable Use Agreement. I will follow the guidelines. If I do not follow these guidelines, I understand I will lose my computer network/Internet privileges.

Student Signature: Date:

PARENT OR GUARDIAN

As the parent or legal guardian of the student named above, I have read and accept the Middlebury Community Schools' Computer Network/Internet Acceptable Use Agreement. I understand this agreement will be kept on file at the school.

I give permission for my child to have access.

Parent/Guardian Signature: Date:

(Questions should be directed to the School Principal or designee)

I DO NOT give permission for my child to have access. I am requesting that my child beprovided with alternative resources and/or activities.

This agreement supersedes all previous agreements approved May 1, 2009

Grade

Required grade 6 and above

Denial to Publish

If you do not want your student’s name, photo, student works or achievements published in any

corporation communications you must complete and submit this form to your student’s school.

For example, this means that anything pertaining to your student will not be included in school

newsletters, honor roll or perfect attendance listings or on any MCS websites.

Student’s printed name____________________________________________

Parent Signature__________________________________________________

*This denial does not include publication outside the jurisdiction of Middlebury Community Schools,

such as newspapers or TV stations.

Date_________________

NORTHRIDGE MIDDLE SCHOOL

56691 Northridge Dr., Middlebury, IN 46540

Phone 574/825-9531 Fax 574/825-9154

REQUEST FOR TRANSFER OF STUDENT RECORDS

To:

According to the Final Regulations of the Family Educational Rights and Privacy Act of 1976 (the Buckley Amendment), it

is no longer necessary to obtain written consent to release records between schools. It states that school officials,

including teachers within the educational institution and officials of the other schools in the school systems in which the

student may intend to enroll, may receive a student’s records without a written consent of the parent (guardian) for

such release.

NAME:____________________________________________BIRTH DATE:_________________________

GRADE:_____________________ has enrolled on ______________________(date).

We would appreciate records including:

• Transcript of grades-including prior years

• Withdrawal grades

• Test Scores

• Health records/birth certificate

• Attendance

• IEP (goals & objectives)

• Individualized Education Program

• LEP Status (Limited English Proficiency)

• Psychological testing information

• Speech/language therapy reports

• Vision/audiology reports

• Original referral forms

• Original HLS (Home Language Survey)

AUTHORIZATION OF PARENT (GUARDIAN)

I give my permission for the release of records for the above named student.

DATE______________ PARENT/GUARDIAN SIGNATURE________________________________________

My Child is currently receiving special services.

Please send to: ATTN: Student Records

Northridge Middle School

56991 Northridge Dr.

Middlebury, IN 46540-9406

Middlebury Community Schools

McKinney-Vento Act Residency and Education Rights Information

(this questionnaire must be completed for EACH student)

In Indiana over 29,000 children experience homelessness each year. The McKinney-Vento Homeless Assistance

Act was created with the goal of ensuring the enrollment, attendance, and success of homeless children and

youth in school.

The McKinney-Vento Act provides certain rights for homeless students. This includes waiving certain

requirements; such as, proof of residency when students are enrolling and allowing eligibility for certain

services, such as free textbooks.

When families and students find themselves in transition due to their housing situation, it is important that they

know their rights regarding education. If students meet the requirements as stated in the McKinney-Vento Act

(42 U.S.C. 11431 et seq., Title VII, Subtitle B), their rights are as follows:

• Students may attend their school of origin or the school where they are temporarily residing.

• Students must be provided a written statement of their rights when they enroll and at least two

additional times per year.

• Students may enroll without school, medical, or similar records.

• Students have a right to transportation to school.

• Students must be provided a statement explaining why they are denied enrollment or any other

services.

• Students must receive services, such as transportation, while disputes are being settled.

• Students are automatically eligible for Title I serves. Educational services for which the homeless student meets eligibility criteria

including services provided under Title I of the Elementary and Secondary Education Act or similar State or local programs, educational programs for students with

limited English proficiency.

According to the U.S. Department of Education, people living in the following situations are considered

homeless:

• Doubled up with family or friends due to loss or economic hardship.

• Living in motels and hotels for lack of other suitable housing.

• Runaway and displaced children and youth-Unaccompanied Youth.

• Homes for unwed or expectant mothers for lack of a place to live.

• Homeless and domestic violence shelters.

• Transitional housing programs.

• The streets.

• Abandoned buildings.

• Public places not meant for housing.

• Cars, trailers (does not include mobile homes intended for permanent housing), and campgrounds.

• Awaiting foster care.

• Migratory children staying in housing not fit for habitation.

Please complete the form and return to your school office. Please direct any questions to your School’s

Principal or the McKinney-Vento Liaison at 574/825-9425.

Middlebury Community Schools RESIDENCY INFORMATION FORM

T his questionnaire is in compliance with the McKinney-Vento Act, U.S.C. 42 § 11432(a). Your answers will help the administrator determine residency documents necessary for enrollment of your student(s). Student ____________________________________ Parent/Guardian _____________________________

School___________________________ Phone ________________________________

Age _____ Grade _____ D.O.B. __________

Address _______________________________________ City _______________ Zip Code _______________

Is this address Temporary or Permanent? (Circle one)

Please choose which of the following situations the student currently resides in (you can choose more than one): House or apartment with parent or guardian Motel, car, or campsite With friends or family members (other than parent/guardian) Shelter or other temporary housing If you are living in shared housing, please check all of the following reasons that apply: Economic situation Temporarily waiting for house or apartment Provide care for a family member Living with boyfriend/girlfriend To enable child to attend a certain school Loss of employment Parent/Guardian is deployed Other (Please explain)_________________________________________________________________ Are you a student under the age of 18 and living without your parents or guardians? Yes No

R esidency and Educational Rights

Students who are in a temporary, inadequate, and homeless living situations have the following rights:

1) Immediate enrollment in the school they last attended or the school in whose attendance area they are currently staying even if they do not have all of the documents normally required at the time of enrollment;

2) Access to free meals and textbooks, Title I and other educational programs, and other comparable services including transportation;

3) To attend the same classes and activities that students in other living situations also participate in without fear of being separated or treated di�erently due to their housing situations.

Any questions about these rights can be directed to the local McKinney-Vento Liaison at (574) 825-9425 or the State Coordinator at (317) 234-4827. By signing below, I acknowledge that I have received and understand the above rights. ______________________________________________________________________________ Signature of Parent/Guardian/Unattached Youth Date ______________________________________________________________________________ Signature of McKinney-Vento Liaison Date

The Migrant Education Program (MEP) provides supplemental education and support services to eligible children

through national funding. The purpose of the program is to ensure that all migrant students reach the academic

standards and graduate with a high school diploma (or complete a GED).

WORK SURVEY

Thank you for answering the following questions. If your child is eligible for the Migrant Education Program, they may

receive additional educational support. This information is strictly confidential.

Please list the names of all of the children in the household under 22 years of age.

Child’s Name Date of Birth School Gr

Parent’s Names:________________________________________________________________________________________________

Address:_________________________________________________City:____________________ Phone: (_____)________________

1. How long have you lived in this city/school district?_________________________

2. Within the last 3 years, has your child(ren) moved from one school district to another within the United States,

with a parent, relative or guardian so that person could look for seasonal or temporary work in agriculture?

YES____ NO_____. If you answered NO, please stop.

If you answered YES, please continue.

3. When was the last time you or anyone in your household has moved to look for, or work in an agricultural

activity with the United States? Month______________________ Year________________________

4. Please check any of the agricultural activities listed below that you have looked for or worked in:

___Plant or harvest vegetables or fruits ___Canning vegetables or fruits

___Detassel corn ___Sod farm

___Tobacco farm ___Planting, pruning or cutting trees

___Poultry and/or egg farm ___Dairy farm

___Duck, turkey, chicken, or beef processing plant ___Flora culture/gladiola farm

___Aquaculture/fish hatcheries ___Green house or plant nursery

Middlebury Community Schools Student Transfer Request

School Year 2018-2019

Return this form to the Administrative Office: Attn: Dr. Robby Goodman 56853 Northridge Drive, Middlebury, IN 46540

PLEASE NOTE:

· TRANSFERS ARE GRANTED FOR ONLY ONE YEAR AT A TIME: YOU MUST RE-APPLY EACH SCHOOL YEAR

· THE FIRST DAY 2nd SEMESTER TRANSFER REQUESTS WILL BE ACCEPTED IS November 7, 2018.

· THE DEADLINE FOR SUBMITTING 2nd SEMESTER TRANSFER REQUESTS IS FEB 1, 2019.

· REQUESTS WILL BE PROCESSED AS SOON AS SUBMITTED.

· REQUESTS RECEIVED AFTER FEB 1, 2019 WILL NOT BE CONSIDERED FOR TRANSFER.

· THERE IS NO TUITION FEE TO ATTEND FOR THE 2018-19 SCHOOL YEAR.

TODAY’S DATE: _______________________ Student Name: ______________________________________________________________________________ Home Address: ______________________________________________________________________________ City: ________________________________________ Zip: ___________________________ Birthdate: ______________________ Home Phone Number: __________________________ Please provide daytime contact information below, in case we need to discuss this transfer request with you: Parent Name: ____________________________________________ Phone Number: ___________________

School student is expected to attend based on your home address: ______________________________________

School student now attends (in their LAST semester of 2018-19) ______________________________ Grade ______

School student wishes to attend as a transfer student in 2018-19 ____________________________ Grade ______

Does the student have an IEP, or receive special education services? ____ YES ____ NO

Is either parent an employee of Middlebury Community Schools? ____ YES ____ NO

If YES, give name and workplace _______________________________________________________________________

Reason for requesting transfer:

Regarding Transportation: MCS does not provide transportation across school boundaries. Students may be transported on MCS buses from their school to the Boys/Girls Club after school, but may not utilize bus service to or from anywhere else in the district. Kindergarten students are not eligible for Boys and Girls Club attendance.

I understand that, if approved, this transfer is conditional on my student maintaining satisfactory attendance and behavior.

________________________________________ ________ SIGNATURE OF PARENT/GUARDIAN DATE

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