EFTA01709707.pdf

EFTA01709707 EFTA01709708  Spring 2003 FLORIDA COMPREHENSIVE ASSESSMENT TEST (FCAT) READING SUNSHINE STATE STANDARDS PERFORMANCE TASKS Student Report IZZ=1=E3 Grade 10 This report provides your results on the FCAT 2003 Reading FCAT 2033 performance tasks. Each performance task on FCAT requires you READING PERFORMANCE TASKS to respond with either a short response or a longer, more detailed response. Short-response tasks are scored on a 2-point rubric and extended-response tasks are Sawed on a 4-point rubric. Student Name One of the short-response tasks is shown below with a Copy Of Student Number your answer. The number of points you earned for your answer is School Name ShOwn in the box to the right. School Number District Name This task required you to read a passage about an American District Number zoologist's attempts to rehabilitate two young gorillas in Africa. All Reading Describe how Coco and Pucker change as a result of their This Performance Performance Task Task Response Responses experience with Dan Fossey. Use details and informatiOn from the story to explain your answer. Points Possible 2 12 Points Earned eah Cao-racurRns wev wccit-r Saiveds att 63 Ot. reSUR bF their ressyJi -may nealinr10 -Mei( -Per OP- YlutraYIS ,Don SI*RM(oriociA kfnit.ucc- -Mod rip mitem-t- -VOW May pexv Pj C isiWYtag viedtakti01- ThiCitXp heir Ondfro WAN TRIC.O M161 4-nlsk. Data Run Date: 05/07/2003 0084103 853200565 EFTA01709709  Spring 2003 FLORIDA COMPREHENSIVE ASSESSMENT TEST (FCAT) FCAT Ibrz.,(c,?reens if Anwar -T1(.0 MATHEMATICS SUNSHINE STATE STANDARDS PERFORMANCE TASKS Student Report Grade 10 This report provides your results on the FCAT 2003 Mathematics FCAT 2003 performance tasks. Each performancetask on FCAT requires you MATHEMATICS PERFORMANCE TASKS to respond with either a short response or a longer, more detailed response. Short-response tasks are scored on a 2-point rubric and extended-response tasks are scored on a 4-point rubric. Student Name One of the short-response tasks is shown below with a copy of Student Number your answer. The numbe-r of points you earned for your answer is School Name shown in the box to the right. School Number District Name District Number This Performance All Mathematics Performance Task Task Response Responses Points Possible 2 16 Points Earned The students in the senior class al Paradise Island High School have decided to raise money by selling graphing calculators and geometry tool kits. They have set aside 5.3,000 to purchase the items they need to sell. They will spend 575 for each calculator, and 520 for each tool kit. From past experience, they know that twice as many students will buy the calculators as will buy the tool kits The inequality and equation below can be used to determine the number of each nem the senior class should have available to sell, where c is the number of calculators and t is the number of tool kits. 75c t 20t sa 3,000 c = 2t How many tool kits should the senior classc put o chase' Show your work. • 30no Li,oc_6, /‹.0brzsct) Ze-0 -aO&l< 3O0O 0, Number of tool kits 17 20 (Dab Data Run Date: 05/07/2003 0084104 854200209 EFTA01709710  STUDENT HEALTH EXAMINATIONS Date Ft. I N..•n,. Phone Race Birthdate School A. HEALTH EXAMINATION Hecht Weight Blood Pressure (✓)N_ormal•N; Abnormal•A N A COMMENT: Abnormal Findings, by number 1 Appearance 2. Skin/Nose 3 Head/Scalp Eyes 5. Visual Acuity IR b U 6. Ears, 7 Auditory Acuity (R 8 L) 8. Nose 1 Throat 9. Mouth. Teeth and Gums 10. Chest / Lungs 11 Heart 12. Abdomen 13 Genitals and Anus 14. Musculo-Skeletal 15 Neurological 16 Alertness 17 Emotional / Mental/ Behavior Prot 18 Handicap. physical/ other (Specify) 19. Activity Restrictions (Specify) 20. Abuse. substance/ Physical / emotional 21 Nutntion 22 Other B. HEALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaelli type date Tuberculin test e Sickle Cell result NAME: TITLE: ADDRESS: (Please Print) r-rdl- Authorized Signature-- Date OH 3040. 10116 (lieplooli 14R5-14 Form 3040 which easy be used) Mock Plumbot. 5744400.3040-2) EFTA01709711  FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 64D-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST NAME FIRST NAME MI 4:10B NIO/DAJYR PARENT OR GUARDIAN CHILD'S SS# (optional) STATE IMMUNIZATION ID#1 Directions: • Enter all appropriate doses and dates below. • Sign and date appropriate certificate (A-I, A-2, B, or C) on reverse side of form. • If the child is presenting for the 7th grade requirement only and has previously filed a Certificate of Immunization (DH 680, Part A-1) with their current Florida school, fill in boxed areas below and complete Part A-2 on the reverse side of this form. • For additional information: See Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements. Guidelines are available from the local county health department. VACCINE DOE Dose I Dose 2 Dose 3 Dose 4 Dose 5 CODE MO/DA/YR MO/DA/YR MO/DA/YR MO/DA/YR MO/DA/YR DTaP/DTP2 A DT3 Td' PoHod HIV MMR (Combined) (Separate G, H, I Hepatitis B9 Varicella1 ' Varicella Disease L 1 The state immunization ID# is an identifier supplied by the state immunization registry (optional). 2 DTP/DTaP 5 doses required. If the 4th primary dose is administered on or after the 4th birthday a 5th dose is not required. 3 DT (pediatric) is acceptable if pertussis vaccine is medically contraindicated. (Complete Part C for pertussis contraindication.) 4 Td (adult) vaccine is recommended for children 7 years of age or older. S Polio 4 doses required. If the 3'd dose in an all OPV or all IPV series is administered on or after the 4th birthday, a 4th dose is not required. Polio vaccine is not required for children 18 years of age or older. 6 Hib is required for child care, family day care and preschool entry and attendance only. 7 First dose valid if given on or after birthday. Second dose (measles) valid if given at least I month after l" dose. A 2"1 dose of measles (preferably MMR) is required for students in grades K-6 and 7'th grade entry and attendance effective with the 1997/1998 school year. In each subsequent year thereafter, the next highest grades arc included. S Includes single measles vaccine (G), single mumps vaccine (H) or single rubella vaccine (I). 9 Hepatitis B vaccine series is required for 7th grade entry and attendance effective with the 1997-1998 school year and kindergarten entry and attendance effective with the 1998-1999 school year. In each subsequent year thereafter the next highest grades are included. Hepatitis B vaccine series is required for preschool entry and attendance effective with the 2001/2002 school year. 10 Varicella vaccine is required for entry and attendance in preschool and kindergarten effective with the 2001/2002 school year. In each subsequent year thereafter, the next highest grades arc included. Susceptible children 13 years of age or older should receive 2 doses, given at least 4 weeks apart. Varicella vaccine is not required if child has documentation of history of varicella disease. EFTA01709712  LAST NAME FIRST MI DOB (MO/DANR) Certificate of Immunization for K-12 Excluding 7th Grade Requirements PART A-1 (immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement.) DOE Code i I have reviewed the records available, and to the best of my knowledge, the above named child has been adequately immunized against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella and hepatitis B (for kindergarten effective with the 1998/99 school year) and varicella, varicella vaccine not indicated if history ofdisease either physician documented or parental recall or kinde :anen elective with the 2001/2002 school year)for school attendance as documented on the reverse side of this form. Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature Address: Date: Certificate of Immunization Supplement for 7th Grade Requirement PART A-2 (Immunizations are complete for students who enter or attend the 7th grade after the beginning of the 1997/98 school year. Each subsequent year thereafter. the next highest grade will be included in the requirement.) DOE Code 8 I have reviewed the records available, and to the best of my knowledge, the above named child has received the following immunizations requiredfor entry and attendance in 7th grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose ofmeasles vaccine as documented on the reverse side of thisform (boxed areas). Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature: Address: Date: -3 Temporary Medical Exemption PART B (For children in child care, family day care, preschool and grades kindergarten through 12 who are incomplete for immunizations in Part A-I or A-2.) Invalid without expiration date. DOE Code 2 1 cerrifi, that the above named child has received the immunizations documented on the reverse side of thisform and has commenced a schedule to complete the required immunizations. Additional immunizations are not medically indicated at this time. Physician or Clinic Name: Expiration Date: (Print or stamp) (t5 days after next immunization appointment) Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: Date: DII 450, Pd2000, obsoletes whet canons (Stack Number 5740 MI 01e^ 1) EFTA01709713  THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) 4.7,jaWIMT:t New and Returning Student Registration NEW STUDENTS: Complete all non-shaded areas on both sides of the form. RETURNING STUDENTS: Review botlisides. If the pre-printed information is incorrect, correct the Information by carefully and lightly crossing out the incorrect information and writing the correct information above it. • Ica • (haw) (r.1, cos) (6) MAILING ADDRESS (nouso no. a neat nem.) Opt_ nal (nth RoYAtAim 457itel Istata) pi .3till (z* code) . (9)SEX (10) RACEETHNIC ORIGIN (apobna) A-Asia 0 1-American Indian/Alaskan Native O - on-Hispanic O H-Hispanic O Islander Non-Hispanic O M-Mularacial 0 0 DATE OF BIRTH (12) PLACE OF BIRTH (S)/sralotounliy) (13) RESIDENT STATUS (14) USA ENTRY DATE (MMODAYTY) O O. Foreign Exchange Student a Sli . O 1. Out-of-county Resident ..., Out-of-state Resident O_ 2 (15) FEDERAL IMPACT SURVEY OJ 1. In-county Resident YES NO (16)PFIESCHOCI. ENROLLMENT INFORMATION ' O O A. The student resides on federal property. Place an X by each program attended Also. indioste with O O B. The student resides in low rent housing. an asterisk(*) theprogram your child was in the lonast. O (7 C. The parent is employed on federal property located in Palm Beach County. 0 N. Non-subsidized Child Care O M. Migrant Pre.l< • O D. The parent is employed on low rent housing located in Palm Beach County. O D. Pre-K Disabilities . O H. Headstart O O E. The parent is in the uniformed services of the United States. O I. Pre-K Early Intervention O C. Chapter 1 O S. Subsidized Child Care O O. Other. O O If E. is YES, is the parent on active duty? Check service below: . (17) is THE STUDENY A (18)CURRENT GRADE LEVEL • Air Force O Army O Coast Guard O Marines O National Guard O Navy .. -.,,.-. EYES SINGLE P N , ef 14 TARN .. . (19) NAME OF SCHOOL TRANSFERRING FROM. (20) CI1Y OR LOCA1:09 . (21) LAST A N:TANCE DATE (22) LAST GRADE LEVEL (23) LAST PUBLIC SCHOOL ATTENDED IN PALM BEACH COUNTY (T4) CATE Al TENDED IN PDC, C E Etti!„ . 07„6661, . . . , (25) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056(7)(d). Non-invasive RIC .0/1 • screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or guardians, however, have the right to request an exemption in writing. It you DO NOT want (27) LI:g eyalaIn l oBrVg 1d an your child to receive the.screenings, write the words "Do not screen" here: reduced lunch? (This exemption will cover all types of screenings) O YES laie15- (26) I give permission for my child to participate in the sodium fiouride program to prevent tooth decasEVIESO N r (Application is ptbvided (Permission is valid through 6 grade) with this form PAVOIMPOINAZAIAMEACitgq. 0,14 itItit&e,t, A ,y,t (28) HOME LANGUAGE SURVEY YES N± :),,/ O ff ri s..Is a language other than English used in the home? If YES, what language? O 8 ..-2. Does the student have a first language other than English? If YES, what language? O B '2.3. the student most frequently speak a language other than English English? ? If YES, what language? ? (29) 4. What language is spoken in the home by the parent or guardiap? 5i< (30) 5. What language is the student's first language? Ch./Erb S 4 . (32) STTENT IJVES WITH: kitedcone) (31) What is the date of entry into an ESOL program? V2 MotherO Father O Both Parents (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT VOtper ‘ 214t sbPstiCEWKS YES 14)," (34)CUSTOOY STATUS OF STUMM' i thedrone) O 4_A. . Has the student ever been expelled from school? O ril i 2. Has the student ever had an arrest resulting in a charge? O Mother O Father V Shared Custody O NY 3. Has the student ever had any juvenile justice actions? O Other • (35) Is there a court order barring either parent from removing or contacting the student during the school day? O YES .NO If YES, provide the school with a copy of the court order. - ' PBSD 0636 (REV. 4/6/2001) page 1 of 2 EFTA01709714 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW AND RETURNING STUDENT REGISTRATION (36) FATHER OR LEGAL GUARDIAN 031st mkIdle Alia( Ms° (37 ADDRESS (SOW nomboS 7-4" 94 4:1311Tvnlixdpber) IIIIIIIIIIIIIIIIIM CITY STATE ZIP CODE CITY STATE ZIP CODE , • . .4y#6_ pAhn Se:i/g4- a s tym • . ..__. , OCCUPATION GC-CUPKTION ' ' ' • 1 \ /(Er Fl EMPLOYMEN'T IIIIIII HOME TELEPHONE BUSINESS TELEPHONE CELIWAGER NUMBER HOME TELEPHONE BUSINESS TELEPHONE • •.• . . . EMAIL ADDRESS (opfkaa0 EMAIL ADDRESS (axis* Ngigq..kraWatt4. 1W. a ialici rlifiaggean4cVnt it eitt •.. . W4*.Staitl Person(s) other than parent authorized to pick up student (36) PASSWORD pin 10 tbarsderl) NAME Crs( =doe Wig. fast (41) NAME PIA middle Ms,. MR) ADDRESS (street Jxe er, excel. 40401990199:0590 • ADDRESS (shoot number, street oporfmeof number) STATE ZIP CODE CITY STATE DP CODE • ilfr& Alin A:9mA H 3.50-ac (40) AUTHORIZED FOR TELEPHONE RELATONSHIP (42) AUTHORIZED FOR • T rzow ile"SHIP IMENENCY PICKUP EMERGENCY PICKUP U! .1ES • NO 0 YES • NO (43) If school personnel are unable to contact you incase of illness or accident. (44) MEDICAL INFORMATION five student'anossos, bohanior. health Aso s. artergs, mediations or ortfor physkod NostoCons) may we have your permission to call your doctgrkir, I • .... • % . emergency stivices 011) for tranSporloto the hospital? Bla 0 NO (45) FAMILY PHYSICIAN (413) PHYSICIAN PHONE µe7 Does your child currenV have health insurance? BYES 0 NO If YES, indicate: (07) HOSPITAL PREFERENCE . 0 Medicaid airivate 0 Healthy Kids/Kid Cam 0 Interested in receiving information eittiS •i p ER, tpl.PeEtliii,„_, ,,,,,_ cfrk oil _ ,§q.,pp 73, (49) NAME OF CHILD (fast k( mktile MN) SCHOOL ATTENDING STUDENT NO. (opOona9 GRADE DATE OF BIRTH (50) NAME OF CHILD (toss finds,* irMY80 SCHOOL ATTENDING STUDENT NO. (ackonal) GRADE DATE OF BIRTH (51)NAME OF CHILD (lost Eras mickne Mal) SCHOOL ATTENDING STUDENT NO. (optional) GRADE DATE OF BIRTH (52) NAME OF CHILD (fast Erg mktila Coda.) SCHOOL ATTENDING STUDENT NO. (optional) GRADE DATE OFBIRDI ( PARENT/GUARDIAN SIGNATURE Iiiiitikirg laKSWE I verify that the information given is true and accurate to the best of P:A? my knowledge. ,... ,,.. , adyra.%,„,..!, „... ?,&.,„„;, v-nk , k•:!: . . isinvEr co;pkaniaatrace....swato ,5"titiiiilai 41.a*I.104:.,rrrol Faisaggigh . ca e a.S..4S r.,.>,.' • daia zgEtiiit it "i: nilLi; hts ita Ms OSk•rS .4. ." ; f me -.,. ,it.v .... •, ' .Vrt " ' Atrn.MF 'I'''. SIGNATURE OFPARENT/G DATE r'hs *VA " PBSD 0636 (REV. 4/6/2001) EFTA01709715  (1) STUDENT NUMBER (2) SAC CODE (3) GRADE LEVEL 4)- .1OOL Oa's% THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) • No New and Returning Student Registration 12 yea/tip NEW STUDENTS: Complete all areas on both sides of the form except areas specified. RETURNING STUDENTS: Review both sides. II the pre-printed information is incorrect, correct the information by carefully and lightly crossing out the incorrect information and writing the correct information above it. Complete any areas that are blank. DIST TCHR NBR:O47 STDT CRS: SEC:OO1 BLDG:O3 RM:212 O6 11 O4 (4) STuDENT LEGAL NAME Oast first middle) (5) ALSO KNOWN AS = Il= (4) LOCAL ADDRESS (hOUSO PO. S sac name) (apt no) NAY) able) Pro coda) ROYAL PALM BEACH FL 33411 (7) MAILING ADDRESS (house na a sisalname) (apt. no) (ulY) (stale) MP 0,(0!) BO SOCIAL SECURITY NO. Toptrone0 (9) HOME TELEPHONE NO. (10) 1(11)RACFJETHMC ORIGIN y • I-American Indian/Alaskan Native 0 B-Black, Non-Hispanic 0 H-Hispanic F • A-Asian/Pacific Islander 0 W-White, Non-Hispanic 0 M-Multiracial (12) DATE OF MTH (13) PLACE OF BIRTH WA lily Coco (14) RESIDENT STATUS (IS) USA ENTRY GATE (leAUDDIYYYY) 0 0. Foreign Exchange3Student (AMODDAWY) 0 1. Out-of-county Resident I/ Us (Is) FEDERAL IMPACT SURVEY 0 ❑2. Out-of-state Resident YES NO 0 3. In-county Resident El 0 A. The student resides on federal property. (17) PRESCHOOL ENROLLMENT IsFORIAATION Place an X by each program attended. Also. indicate wilh an 0 0 B. The student resides in low rent housing. asterisk (') the program your child was In he longest. 0 0 C. The parent is employed on federal property located in PB County. 0 C. Title I Prekindergarten 0 M. Migrant Prekindergarten 0 0 D. The parent is employed on low rent housing located in PB County. 0 D. Pre-K Disabilities 0 N. None 0 0 E. The parent is in the uniformed services of the United States. 0 F. Fee for SeMces 0 P. Private Prekindergarten 0 H. Head Start 0 T. Teenage Parent Program 0 0 If E. Is YES, is the parent on active duty? Check service below: 0 L Readiness Program 0 Z. Not Applicable 0 Air Force 0 Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy pp Is the student a single parent? N 0 YES 0 NO TRANSFER STUDENT Only students transferring from another school complete this section (19) NAME OF SCHOOL TRANSFERRING FROM (20) CITY /STATE icouNre COUNTRY (21) LAST ATTENDANCE DATE (22) LAST GRADE LEVEL 200 DATE ATTENDED IN PBC (23) Have you ever been enrolled In a Palm Beach County School? 0 YES 0 NO If yes, what school? _ All new and returning students compete the remaining form including page 2 (2s) Students vrill receive non-Invasive health screenings pursuant to Florida Statute § 381.0O56(7)(d). Non-invasive screenings may Include vision, hearing, scoliosis, height, and weight. These tests may be glen Individually or in groups. Parents or guardians, however, have the right to request an exemption in vrriting. If you DO NOT want your child to receive the screenings, write the words "Do not screen" here: (This exemption wit cover at types of screenings) (26) I give permission (or my child to participate in the sodium fluoride program to prevent tooth decay. M YES II NO (Permission is valid through grade 6) YES (27) Does your child currently have health Insurance? 0 YES 0 NO P If YES, Indicate: 0 Medicaid 0 Healthy Kids/Kd Care U Private El Interested in receMng Information (25) HOME LANGUAGE SURVEY (chock ail that an*, 0 A language other than English is used in the home. What language? 0 The student has a first language other than English. What language? 0 The student most frequently speaks a language other than English. What language? (29) DISCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT (check aV that apply) 0 The student has been expelled from school. 0 The student has had juvenile justice actions taken against him/her. 0 The student has arrested resulting in a charge. (30) STUDENT LIVES WITH: (check one) (31) CUSTODY STATUS OF STUDENT (aeck tee) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home 0 Mother 0 Father 0 Shared Custody E Other • Other IMPORTANT INFORMATION - MUST BE COMPLETED ($2) Is there a court order barring either parent from removing or contacting the student during the school day? 0 Yes 0 No If YES, provide the school with a copy of the court order. PBSD 0636 (Rev. 03117/2004) page 1 of 2 EFTA01709716 PARENT/LEGAL GUARDIAN INFORMATION (33) FATHER OR LEGAL GUARDIAN (16's( (Mete MAIM 4430 (34) DATE OF BIRTH (44) MOTHER OR LEGAL GUARDIAN (w. middle Witt, last) (45) DATE OF BIRTH (35) ADDRESS Meet number snot aPartmeal number) (46) ADORESS (Heel number, *et apartment number) (36) CITY STATE VP CODE (47) CITY STATE ZI, CODE ROYAL PALM BEACH FL 33411 (37) OCCUPATION (36) HIGHEST (48) OCCUPATION (45) HIGHEST ED. LEVEL ED. LEVEL DISPLACE OF EMPLOYMENT (507 PLACE OF EMPLOYMENT ocs HOME TELEPHONE (41) BUSINESS TELEPHONE (42) CEWPAGER NUMBER (51) HOME TELEPHONE (52) BUSINESS TELEPHONE (53) CELUPAGER NUMBER (43) EMAIL ADDRESS (cpLcnaO (54) EMAIL ADDRESS Osounner) EMERGENCY HEALTH AND SAFETY INFORMATION Provide name(s) of person(s), other than parent, allowed to pick up student. tss) PASSWORD (limit 10 characters) (56) NAME (Ns& middle indiat last) (82) NAME MIL medle Hem( MO (57) ADDRESS (steel number alma( specimen( number) (83) ACORESS (000IIMIllbOr, street alaatanant Awake) SAME (58) CITY STATE ZIP CODE (64) CITY STATE ZIP COOS (59) RELATIONSHIP (60) TELEPHONE (31)CELLSAGER NUMBER (85) RELATIONSHIP (86) TELEPHONE (67) CELUPAGER NUMBER OTHER (88) STUDENTS ALLERGIES (cheek e)) that apply and specify) 0 None 0 Animals 0 Birds 0 Reptiles • Amphibians 0 Plants 0 Food 0 Other Specify (69) LIST STUDENTS ILLNESS. BEHAVIOR ISSUES, MEDTCATIONS OR PHYSICAL LIMITATIONS (TO) FAMILY PHYSICIAN (71) PHYSICIAN PHONE NAMES OF PARENT'S/LEGAL GUARDIAN'S OTHER CHILDREN (72)NAME OF CHILD (Ent middle Wrist, Iasi) (73) SCHOOL ATTENDING (74) STUDENT NO. (*Prism° (75) GRADE (76) DATE OF BIRTH (77) NAME OF CHILD (Tnt middle Milig les0 (78) SCHOOL ATTENDING (79) STUDENT NO. (opeona0 (80) GRADE (81) DATE OF BIRTH (82) NAME OF CHILD (en( middle indict( MO (63) SCHOOL ATTENDING (64) STUDENT NO. fopeone0 (85) GRACE (86) DATE OF BIRTH INFORMATION VERIFICATION PARENT/GUARDIAN CONSENT verify that the Information given is true I understand and agree that all educational records of my child may be shared with the Districts and accurate to the best of my health care partners and other governmental and social agencies jointly seeing the child or having knowledge. a legitimate interest in the records, as needed to provide and evaluate health services and government/social services to students. I also understand and agree that my child's medical records or other medical information that I provide to the school, and treatment records or other medical records created by health care personnel at the school will be shared with school officials who have a legitimate educational purpose for accessing such medical records and information. SIGNATURE OF PARENT/LEGALGUARDIAN DATE SIGNATURE OF PARENT/LEGAL GUARDIAN DATE FOR OFFICE USE ONLY Documentation Checklist Transportation COB US CAL 01 teacher No 0 Immunizations 0 PBC Bus SL Entry Code E01 Reassign. Code 08/11/04 ID Binh Records Verification 0 Palm Iran SI. Enby Dale Binh Vedgeolion 1 ESP. Entry Dale DCF O Social Security Number 0 Parent/Student Transpalation 0 Physical Exams 0 Walk 0 Bike 0 Address Verifcatinri PBSD 0636 (REV. 03/17/2004) page 2 of 2 EFTA01709717  TEST RECORD INFORMATION PESO 0280 (REV. 7/15197) FRT EFTA01709718  tar- es'? )01.10.nboar . .at.- .414.11taISW/rIgarela.".•IN ,.....4014v0 :4al r ........4 ‘...,-41:taiii. eaL • •. - :p.c....a 814.4*.uwatea. - - - itte-iteNCA.A.C/i nscaswasuAareArb,..110 4. FLORIDA Verification of Receipt :1 ID ral (NOTE: This is not the application for the scholarship.) requi I verify that I have received and read the initial eligibility year of the Florida Bri ht Futures Scholarship Program for the Name (please print) Signature SCHOLARSHIP PROGRAM Date 912,1-12/ )01 Please return to your high school guidance counselor AnNIESAI NUMBER EXTENSION Wag EVA EFTA01709719 THE SCHOOL DISTRICT OF PALM BEACH COUNTY DIRECTIONS: