EFTA01710219.pdf

FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.03Z, 402.305, 402.313, Florida Statutes; rules 640-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST N FIRST NAME MI DOB (MO/DA/YR) PARENT OR GUARDIAN CHILD'S SS# (optional) STATE IMMUNIZATION IMP Directions: Enter all appropriate doses and dates below. Sign and date appropriate certificate (A-1, A-2, B, or C) on reverse side of form. If the child is presenting for the 7 th grade requirement only and has previously filed a Certificate of Immunization (DR 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. DOE Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 VACCINE CODE %4 all‘h ta III Lit II • Al . A P .a • lb . SAP • . • DTaP/DTP2 A Teti Polio' Hill MMR (Combined)' F. (Separate)° G,H,I Hepatitis B9 Varicella" Varicella Disease L Year I The state immunization ID# is an identifier supplied by the state immunization registry (optional). 2 DTP/DTaP 5 doses required. If the 46 primary dose is administered on or after the 46 birthday a 56 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. 5 Polio 4 doses required. If the 3" dose in an all OPV or all IPV series is administered on or after the 4" birthday, a 48, 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 1" birthday. Second dose (measles) valid if given at least I month after l" dose. A 21" dose of measles (preferably MMR) is required for students in grades K-6 and 7'h grade entry and attendance effective with the 1997/1998 school year. In each subsequent year thereafter, the next highest grades are included. 8 Includes single measles vaccine (G), single mumps vaccine (11) 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 1998/1999 schoollear. In each subsequent year thereafter the next highest grades arc included. Hepatitis B vaccine series is required for preschool entry and attendance effective with the 2001/2002 school year. 10 Varicella is required for entry and attendance in child care and family day care effective July 1, 2001. 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 are 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. EFTA01710219  LAST NAME FIRST MI DOB moroArxit) , Certificate of Immunization for K-12 Eicluding 7th Grade Requirements PART A-I (Immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement.) DOE Code 1 I have reviewed the records available and to the best ofmy 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 parentalrecall (for kindergarten effective with the 2001/2002 school year) for school attendance as documented on the reverse side of thisform. Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature: Address: Date: Certificate of Immunization Supplement for Tb 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 1have reviewed the records available, and to the best ofmy knowledge, the above named child has received thefollowing immunizations requiredfor entry and attendance in 7. grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as docurn. Physician or Clinic Na Physician or (Print or stamp) horized Signatur Addr•• . Date: --1 1St (C)--' 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 I certtfr that the above named child has received the immunizations documented on the reverse side of this form 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: . . i 05•days after next immuilization.appoiutrnent) (Print or stamp) . .• _ . .. 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 certifr that the physical condition alibis child is such that immunization(s) as indicated in Part C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: Date: DH 6$0 72001, obsoletes earlier editions (Stock Number 5740-000-06SO-6) EFTA01710220  ALTH EXAMINATIONS Date Student' Full NamllM glIllt Phone Race Address Birthdate Name of Parent cr Guardian School A. HEALTH EXAMINATION Height Weight Blood Pressure (1) Normal-N; Abnormal=A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/Nose 3. Head/Scalp 4. Eyes J 5. Visual Acuity (R & L) 6. Ears 7. Auditory Acuity (R & L) 8. NOSe / 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 Prob.) 18. Handicap. physical/ other (Specify) 19. Activity Restrictions (Specify) 20. Abuse. substance/ physical / emotional 21. Nutrition 22. Other B. HEALTH HISTORY (Serious Illnesses Injuries: explain) (attach narrative it additional space needed) C. LABORATORY Hemoglobin/Hematocrit Stool 1O & P) Tuberculin test: Lead Sickle Cell Authorized Signature OH 3040. 10190 (Replaces NRS-li Form 3040 which may be used) (Slack Number 5741-000-3040-2) EFTA01710221  ERs STATE OF FLORIDA DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES HEALTH EXAMINATIONS Dale if Mr - Student's Full Name Phone Race Sex Address Birthdate Name of Parent or Guardian A. HEALTH EXAM NATION Height Weight Blood Pressure Normal=N; Abnormal-A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/Nose 3.1-lead/Scalp 4. Eyes 5. Visual Acuity (R & L) 6. Ears 7. Auditory Acuity (R & L) 8. Nose / 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 Prob.) 16. Handicap. dirge& • other (Specify) '19. Activity Restrictions (Specify) 20. Alatise. substance/ physical / emotional 2 1.Nutrition 22. Other B. HEALTH HISTORY Serious Illnesses Injuries: explain) • (attach narrative if additional space needed) C. LABORATORY (as Indicated) tYP mylotin/Hematocril Stool (0 &12) Lead Tuberculin test: Sickle Cell resu NAME: TITLE: ADDRESS: (Please Print) MRS-li Form 3040, Mar 91 (Obsoletes previous ' (Stock Minter: 5744-000-3040.2) EFTA01710222  SUR C fleala • FLORIDA CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) (1+) HRS. OCl/AlliCra Of MUM, WO (Florida Statutes 232.032) FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE CHILD'S NAME (PRINTED) SS YR' PARENT OR GUARDIAN DOCTOR: PART A OF THIS FORM IS USED ONLY IF TILE CHILD HAS RECEIVED ALL REQUIRED IMMUNIZATIONS LISTED BELOW. IF 110T. SEE REVERSE SIDE. DTP - 5 DOSES REQUIRED 110) IF THE FOURTH PRIMARY DOSE GF DTP IS ADMINISTERED ON OR AFTER THEFOURTHRIRTHDAY, A FIFTH-DOSETS NOT REQUIF.ED. DT (PEDIATRIC) VACCINE IS ACCEPTABLE IF PERTUSSIS VACCINE-IS-MEDICALLY- CONTRAINDICATE!). (COMPLETE PART C FOR•PERTUSSIS CCNTRAINDICATION.) (V) Td (ADULT) VACCINE (A SERIES OF 3 DOSES) IS ACCEPTABLE.AND'RECOMMENDED FOR CHILOREN:.7 YEARS OF A0E.OR OLDER. (C) POLIO - 4 DOSES REQUIRED IF THE THIRD PRIMARY DOSE CF OPV IS ADMINISTERED ON OR AFTED.THE'FOURTH BIRTHDAY, A FOURTWDOSE is NOT REQUIRED. IPV IS AN ACCEPTABLE ALTERNATIVE :F OPV IS NOT INDICATED. FOLIO VACCINE IS OMITTED FROM THE REQUIRED IMMUNIZATIONS OF GIOLDREN 18 YEARS DF.A5E OR CUTER. MEASLES. MUMPS, MD RUBELLA — 2 DOSES REQUIRED FOR MEASLES 1 DOSE REQUIRED FOR MUMPS MD RUBELLA • MMR COMBINED — 1st DOSE AT 12 MONTHS OF AGE Oft OLDER.(RECOMPSENDED AT 15 MONTHS). (F*) 2nd DOSE REQUIRED PRIOR TO KINDERGARTEN:ENTRANCE , (VAUD IF GIVEN AT LEAST 30 DAYS AFTER 14;005E) MEASLES SINGLE — 1st DOSE AT 12 MONTHS OF AGE OR OLDERBECOMMENDEDAT 15 MONTHS) (G) 2nd DOSE REQUIRED PRIOR TO KINDERGARTENPJIRANCE (VALID IF GIVEN AT LEAST 30 DAYS AFRER.1g.DOSE) MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER. (11`) •. RUBELLA SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER (P) ALL APPROPRIATE DOSES AND DATES INCLUDING BIRTHDATE MUST BE ENTERED, AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN OR AUTHORIZED PERSON AND DATED IN ORDER FOR THE CHILD TO ATTEND SCHOOL I HAVE REVIEWED THE RECORDS AVAILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED CHILD HAS BEE DIPHTHERIA, TETANUS PERTUSSIS, POLIO, MEASLES, MUMPS, AND RUBELLA AS REQUIRE PHYSICIAN OR CLINIC NAME (PLEASE PRINT) )E AUTOMATED STUDENT DATA BASE CODES: • IMMUNIZATION STATUS CODE / 11 VACCINATION CODE EFTA01710223  DATE OF BIRTH CHILD'S NAME (PRINTED) SSO MO DA YR PARENT OR GUARDIAN DOCTOR: IF THE CHILD HAS NOT RECEIVED THE REQUIRED DOSES LISTED IN PART A, PLEASE COMPLETE PART B OR PART C, AS APPROPRIATE, AND SIGN AND DATE. TEMPORARY MEDICAL EXEMPTION (HRS 680 - PART B) (21 . FOR PRESCHOOL CHILDREN AND FOR SCHOOL CHILDREN WITHOUT ALL IMMUNIZATIONS REQUIRED IN PART A I CERTIFY THAT THE ABOVE NAMED CHILD HAS RECEIVED THE IMMUNIZATIONS LISTED BELOW AND HAS COMMENCED A SCHEDULE TO COMPLETE THE REQUIRED IMMUNIZATIONS. ADDITIONAL IMMUNIZATIONS ARE NOT MEDICALLY INDICATED AT THIS TIME. #1' #2 #3 #4 #5 TYPE VACCINE CODES' DATE (MO/DA/YR) DATE (MO/DA/YR) DATE (MO/DA/YR) DATE (MO/DA/YR) DATE (MO/DA/YR) DTP A DT B Td C POLIO D Hib E MMR F AUREOLA (MEASLES) G EXPIRATION DATE (MO/DA/YR) MUMPS H (SHOULD BE 15 DAYS AFTER NEXT APPOINTMENT) RUBELLA I • PHYSICIAN OR AUTHORIZED SIGNATURE DATE PERMANENT MEDICAL EXEMPTION (HES 680 - PART C) (31 I CERTIFY THAT THE PHYSICAL CONDITION OF THIS CHILD IS SUCH THAT IMMUNIZATION(S) IS MEDICALLY CONTRAINDICATED. LIST VACCINE(S) AND STATE VALID CLINICAL REASONING OR EVIDENCE FOR EXEMPTION FOR EACH VACCINE. PHYSICIAN OR CLINIC NAME (PLEASE PRINT) PHYSICIAN'S SIGNATURE DATE HRS Form 680. JAN 93 (Repbces Mat 91 edition which may be ized) (Stock Number 5740-000.0680-6) DOE AUTOMATED STUDENT DATA BASE CODES: ' IMMUNIZATION STATUS CODE / ' VACCINATION CODE EFTA01710224  THE SCHOOL DISTRICT OF PALM BEACH COUNTY Grade (.5 ELEMENTARY REPORT CARD Year 2000-2001 Student School Teacher Principal MARKING CODES - ACADEMIC SUBJECTS SOCIAL DEVELOPMENT/CLASSROOMSTUDY HABITS GRADES 1 and 2 Please work on the area(s) that have a check (/). E - Excellent S - Satisfactory Marking Period V - Very Satisfactory N - Needs Improvement tat I 2nd I 3rd I 4th GRADES 3-5 Overall effort A - Outstanding (94% - 100%) Works cooperatively B Above Average (85% - 93%) Works independently C Average (77% - 84%) D Below Average (70% - 76%) Completes classwork on time F Failing (0% - 69%) Completes homework on time Incomplete Follows classroom rules and routines Uses time wisely ACADEMIC SUBJECTS Marking Period Follows directions 14h 1st I 2nd I 3rd Accepts responsibility for own M-lh=m-IicS ' care level Hdf a check) actions Comes to class prepared with materials 1...ztak....!1.LJAP - o A' pr ALTERNATE ASSESSMENTS Marking Period Composition Indicate those used with a check (/). MEMZEIMIT2IMI Skills Checklist(s) Language Portfolio Spelling Audio Cassette Recording Handwriting/Penmanship Video Recording Social Studies Computer Program Standardized Test(s) Science/Health Observations/Written Comments Grades not given this nine week Other ATTENDANCE Marking Period Regular attendance and punctuality are essential for quality education. Billaliilla Days Present FINE ARTS REPORT Marking Period Days Absent 1121EIMES Days Tardy Art Information Included Music Physical Education PLACEMENT PARENT/GUARDIAN/TEACHER CONFERENCE Conference conducted (Indicate date(s)) Marking Period 1st 12nd 3rd 4th Grade A Special Session • If Special Session program is Indicated, grade placement will be determined by the home school. PBSD 0768 (Rev. 7/99) Goldenrod/1st Period Pink/2nd Period Canary/3rd Period Green/4th Period White/Office Copy EFTA01710225  THE SCHOOL DISTRICT OF PALM BEACH COUNTY 2000- ort for Grades 1-5 Se DEM GRADE 2000-2001 ACADEMIC IMPROVEMENT PLAN STATUS Your child's academic performance was at or above grade level in reading, writing, and mathematics, and an Academic Improvement Plan (AIR) was not necessary. Your child's academic performance was below grade level and an individual Academic Improvement Plan (AIP) was necessary for ❑ reading ❑ writing ❑ mathematics This AIP identified remediation strategies used to assist your child this year. Your child may need another AIP next school year. Your child's academic needs were addressed through his/her Individual Education Plan (IEP), Limited English Proficient (LEP) Plan, or 504 Plan. END-OF-YEAR PERFORMANCE Your child's end-of-year performance level in reading, writing, and mathematics is identified below: TING(COMPOSITION) MATHEMATICS If less than one year below grade levelhas boon indicated for reading, writing, and/or mathematics, you may be asked to participate in the development of a plan to improve your child's academic performance. This plan will be developed at the beginning of the 2001.2002 school year. If more than one year below grade level has been indicated for reading, writing, and/or mathematics, you must have an LEP Plan, IEP, 504 Plan and/or AIP. You will be asked to participate in the development of a plan(s) to improve your child's academic performance. This plan(s) will be developed at the beginning of the 2001-2002 school year. PROMOTION/RETENTION DECISION As a result of your child's performance this school year, your child is being recommended for: j' Promotion to the next grade level ❑ Promotion to the next grade level with an LEP Plan, IEP, 504 Plan and/or AIP ❑ Good Cause Promotion from fourth grade to fifth grade with an LEP Plan, IEP, 504 Plan, and/or AIP ❑ Retention in the same grade level SUMMER SCHOOL/EXTENDED SCHOOL YEAR RECOMMENDATIONS The promotion/retention decision for your child will be made following the completion of Summer SchooVExtended School Year. ❑ Summer School (for Limited English Proficient students) ❑ Extended School Year (for Exceptional Student Education students) OATE PBSO 1674 (REV. 4/262030 ORIGINAL - Cumu%6ve Folder COPY - School Use COPY - Report Card EFTA01710226  )puny 4WD Florida Comprehensive Assessment Test® FLAT Sunshine State Standards Reading Cove5nsive Asia mutt Tell Performance Task Student and Parent Report Grade 10 This report shows your results on the FCAT Reading performance tasks. Each performance task on the FCAT requires either a short response or a longer, more detailed response. Short-response tasks are scored out of 2 points and extended-response tasks are scored out of 4 points. ID School One of the short-response tasks is shown below with a copy of your answer. The number of points you earned on all District 50-PALM BEACH performance task items is also included. Your Score This task required you to read an informational passage and then answer how ,Marteatitereain 0 ,1 On all Reading performance a blind painter's determination led to her success. out of 10 points task responses (al-11:n d er uarit tvira tyr -to co cior ar take Ox-k 14 Ural M -C, %Ulla VG:O not- + OVA- one could do, Artie 4/013%-kr) teepnCS 1 W Osts %re\ -One err, src cecerre yuccaatftt.4% coot r4 ‘s rcui in rruse U tit 5 (Sit trg sold 1 ice a -true or -fists twootg., teNdq, I Z DIE. 51-1,:i1C,.? EFTA01710227 4-pooLDia THE SCHOOL DISTRICT OF PALM BEACH COUNTY El High School 14 Grade andlor Course Change 0 Middle School Documentation 0 Elementary School ENT NUMBER GRADE LEVEL STUDENT NAME la test trocgo .W419 \ SCHOOL. NUMBER SCH YEAR COURSE TAKEN SCHOOL sippiam eounEtwis 2331 Q_ CHANGE DOCUMENTATION GRADE EXAM • CONDUCT GRADING PERIOD From From To -2: al C\ j To From_ From From To To To Change course code From To Reason for change ❑ Recalculated Grade Average ❑ Student Completed Work CI Other (explain below) APPROVAL SIGNATURES (two of three required) DATA PROCESSOR CONFIRMATION I confirm that the grade/course change has been implemented. Lo \ \ \Ott . DATE DATE bh siGvA DATE -oc DATE PRINTNAME PBSD 0797 (REV. 511412004) ORIGINAL - Cumulative Folder Copy - Office File EFTA01710228  JOENT NAME: SEX: RACIAL/ETHNIC GROUP: Hispanic G Mao Not Hispanic o can IndlanfNatIvo Alaskan tai G Black Not Hispania G Asian/Pacific Islander O Muhl Racial PHONE NUMBER: (options!) ' :THDATE Verified by WW1 CoAlkalis: G Yes G No a No. What Typo Verification? -c iTHPLACE: Dad,p, OR OTHER RESPONSIBLE ADULT AT HOME: OA RREN SCHOOL use In Lnis e until (Ins lie let Grader Schock Grade: Dale First Entered This ()kirk' School: (Pada I o, Shoot. Grade: Selma Grade: &Moo: Year ?Etat) . Ct 1 &hoot Year 19 • Saud Year. 19 • School Mac 19 • School Year. 19 • Days Present Days Absect: s Days Piaui* Days Absent Days Present: Days Absent Days Present Days Absent: Days Present: Days Absent 7 C OPY OF REPORT CARD COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED INDCA111,1 INDICATE INDICATE 1110CATE INDICATE Adra st Adninisuatree AdrrOntstadv• . Achohlandie Administrative Place Placomenl (ADMP) Rammed (ADMP) Reamers (ADMP) Pimento-or (ADMP) Promote (P) Picmole (P1 Remote (P) Promote (P) Nandi) (P) actin (R) Nato (R) Rosin (R) Borah (R) Retain (R) Special Scission (SS) Special Swan ($S) Spacial Session (SS) Special Session (SS) Spacial Session ($5) School: Grano: Schoot Grade: School: Grans: School: Wade: Schoot I Duck: &Mod 'frac 19 • School YON 19 • School Veer 19 - School Year 19 School Year 19 • Days Present Days Absent Dais Present Days Absent Days Present Days Absent Days Present Days Absent: Days Present I Days Absent COPY OF COPY OF COPY OF COPY OF COPY OF REPORT CARD REPORT CARD REPORT CARD REPORT CARD REPORT CARD INCLUDED INCLUDED INCLUDED INCLUDED INCLUDED yL INDICATE INDICATE INDICATE INDICATE INDICATE Administrative AchnInlsitallve AttmlnIstratVe ActnlaWratIve AdmInIstrerive Placement (AMP) Placement IADMP) Nommen: (ADMP) Placement (ADMP) Placement (ADMP) 0 Promote (P) Promote (P) Promote (P) Promote (P) Promote (P) 4 Rash (R) Retain (R) Rusk (R) Roth (R) MUM (R) CC Special knort-in ($5) Special Session (SS) 17 Spode] Session (5$) Spodel Swan (SS) Special Session (SS) 0973 (REV 3/20417) EFTA01710229  414OOLDIS\ THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SONIC) (1) STUDENT NUMBER (2) SAC CODE (3) GRADE LEVEL New and Returning Student Registration 1 NEW STUDENTS: Complete all areas ontoth sides of the form axcept areas specified office use only . A t, A-) RETURNING STUDENTS: Review both sides. If the pre-printed r formation is incorrect, correct the information 4°°tIV by carefully and lightly crossing out the incorrect information and Writing the correct Information above it. IIIIIIMa m (S) ALSO KNOWN AS • (6) KEY/ (slab) (rbood.) (7) INULING ADOFTESD(hease rox d abed name) OFT• no) Royal Aim /30ach H. 33 V// (Nay) (31•10 NO code) (8) SOCIAL SECURITY NO. topSons9 (9) HOME TELEPHONE NO. !PM SEx O n RACEJETISNIC ORIGIN O I-American Indian/Alaskan Native O 8-Black, Non-Hispanic N -I-Hispanic e • O A-Asian/Pacific Islander O W-White. Non-Hi panic O M-Multiracial (12) DATE OF BIRTH (I3) PLACE OF BIRTH (city, stale. counIty) 04) RESIDENT STATUS (13) USA ENTRY DATE AIM Y (MMODYVYY) • Ph n Aw El. (la)FEDERAL IMPACT SURVEY . ppcie govoi O O. Foreign Exchange Student ❑O 1. Out-of-county Resident. O 2. Out-of-state Resident YES NO CI 3. In-County Resident O O A. The student resides on federal property. (17) PRESCHOOL ENROLLMENT INFOALIADON Place an X by each program attended. Also, indicate with an o Ei B. The student resides In low rent housing. asterisk ("the program your child was in the longest O O c. The parent is employed on federal property located In PS County. O C. Title 1PrekindergartenO M. Migrant Prekindergarten O 0 D. The parent is employed on low rent housing located in P8 County. • D. Pre-K Disabilities • N. None - • O O E. The parent is in the uniformed services of the United States. O F. Fee for Services • P. Private Prekindergarten O H. Head Start O T. Teenage Parent Program O O If E. Is YES, is the parent on active duty? Check service below MI L. Readiness Program O Z. Not Applicable O Air Force O Am's, O Coast Guard O Marines O Nalional Guard O Myr/ OS) Is the student a single parent? O YES O NO ("Para; 13e4ch Ft- TRANSFER INFORMATION (21) LAST ATTENDANCE DATE a - L4 - (21) DATE ATTENDED IN Pac (23) ave you ever een enrolled In Palm Beach County School? W YES O NO If yes, what school? HEALTH SCREENING INFORMATION (25 ) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056(7Xd) Non-invasive screenings may indude 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. If you DO NOT want your child to receive the screenings, write the words "Do not screen' here: (This exemption will cover ell typos of screenings) RS) I give permission for my child to participate in the sodium fluoride program to prevent tooth decay. O.YES D NO (Permission is valid through grade 6) an Doei your child currently have health insurance? O YES O NO If YES, indicate: O Medicaid tilitHealthy KidslKid Care O Private O Interested in receiving Information NEW STUDENTS TO PALM BEACH COUNTY (28) HOME LANGUAGE SURVEY • OYES O NO 1. Is a language other than English used In the home? If YES, what language? n S O NO 2. Does the student have a first language other than English? If YES, what language? VI YES tANO 3. Does the student most frequently speak a language ether than English? If YES, what language? (29) DISCLOSURES FOR ENTRY INTO P/3C SCHOOL DISTRICT rikES NO 1. Has the student ever been expelled from school? • O YES ANO 3. Has the student ever had any juvenile O YES NO 2. Has the student ever had an arrest resulting in a charge? Justice actions? (30) DIU LIVES WITH: (cheek one) (31) CUSTODY STATUS OF STUDENT(check one) S other O Father O Both Parents Mother O Father II Shared Custody • Other O Other (sat Is there a urt 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. 03/19/2003) page 1of 2 EFTA01710230 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW AND RETURNING STUDENT REGIS 1 ) FATHER CR LEGAL GUARDIAN (Sat 77404 int.9. 7779 (34)DATE OF BIRTH (45) DATE OF BIRTH