May 2019
Dear Parents,
To the parents of current Summit students, we thank you for helping to make this another successful year for all of us. We know you feel as proud as we are of your child’s achievements. For new parents to Summit, we will do our best to help your child have a very positive experience.
Enclosed please find: 2019/2020 School Calendar: Please reserve these important dates – 1) First day of school for students: Thursday, September 5 2) Meeting/Dinner for New Parents to Summit: Thursday, September 12 at the Upper School, 6:30 p.m. 3) Back-to-School Night: Lower School – Thursday, September 26 Upper School – Thursday, October 3 4) Parent/Teacher Conferences: Lower School – Thursday, November 14, and Wednesday, March 11 Upper School – Wednesday, November 20, and Wednesday, March 11 5) Annual Benefit at The Pierre Hotel: Monday, November 25, 6:00 p.m.
Required forms must be completed by July 25: Please follow the instructions on each form. Our school office begins to process these required forms during the months of May and June, so please return the forms early in the return envelope provided.
The following school supplies will be distributed to each student on the first day of school: 1) Loose-leaf binder 4) Pencil case 7) Schedule folder 2) Loose-leaf paper 5) Pens and pencils 8) Calculator (not graphing)* 3) Dividers 6) Homework folder
*Upper School parents are required to purchase a TI-84CE calculator for high school math courses.
The last day for students and faculty is Wednesday, June 26, 2019. Our office will remain open through 1:00 p.m. on Friday, June 28. The office will reopen on Wednesday, July 24, 2019 from 8:00 a.m. to 3:00 p.m., Monday through Thursday. If you have any questions or concerns, please contact the office at the Upper School (718-264-2931) or Lower School (718-969-4073).
We anticipate another outstanding school year filled with experiences that will encourage your child to learn and to grow to his or her full potential. We hope you and your family have a wonderful summer.
Sincerely yours,
Richard Sitman Allison Edwards Karen Frigenti Executive Director Upper School Principal Lower School Principal
Calendar 201 9/2020
SEPTEMBER 2019 FEBRUARY 2020 SU M T W TH F SA 9/2 Labor Day – School Closed SU M T W TH F SA 2/3 REAP Begins 2/3 (M), 2/4 (T), 2/6 (Th) 1 2 3 4 5 6 7 9/3-4 Staff Orientation/Conference 9/5 First Day of School 1 2/17-21 Midwinter Recess – School Closed 8 9 10 11 12 13 14 2/24 School Reopens 9/12 New Parents to Summit Meeting – 6:30 PM 2 3 4 5 6 7 8 15 16 17 18 19 20 21 9/16 REAP Begins 9/16 (M), 9/17 (T), 9/19 (Th) 9 10 11 12 13 14 15 22 23 24 25 26 27 28 9/26 Lower School Back-to-School Night 16 17 18 19 20 21 22 29 30 9/30 Rosh Hashanah – School Closed 23 24 25 26 27 28 29
MARCH 2020 OCTOBER 2019 SU M T W TH F SA 3/11 Lower & Upper Schools SU M T W TH F SA 10/1 Rosh Hashanah – School Closed Parent/Teacher Conferences 10/3 Upper School Back-to-School Night Day 1 2 3 4 5 6 7 1 2 3 4 5 Early Dismissal – 12:30 PM 10/9 Yom Kippur – School Closed 8 9 10 11 12 13 14 Parent/Teacher Conferences begin – 1:00 PM 6 7 8 9 10 11 12 10/14 Columbus Day – School Closed 15 16 17 18 19 20 21 13 14 15 16 17 18 19 10/15 Succot – School Closed 22 23 24 25 26 27 28 20 21 22 23 24 25 26 10/21 Staff Conference – No Students 10/22 Lower School at Upper School 29 30 31 27 28 29 30 31 10/28 Junior Parents Meeting
NOVEMBER 2019 APRIL 2020 11/11 Veterans Day – School Closed SU M T W TH F SA SU M T W TH F SA 11/14 Lower School Parent/Teacher Conferences 4/6-13 Spring Recess – School Closed 1 2 11/14 PA’s Lower School Book Fair 1 2 3 4 4/14 School Reopens 3 4 5 6 7 8 9 11/20 Upper School Parent/Teacher Conferences 5 6 7 8 9 10 11 10 11 12 13 14 15 16 11/25 Annual Benefit – The Pierre – 6:00 PM 12 13 14 15 16 17 18 11/26 Lower & Upper Schools Thanksgiving 17 18 19 20 21 22 23 19 20 21 22 23 24 25 Luncheon 24 25 26 27 28 29 30 11/27-29 Thanksgiving Recess – School Closed 26 27 28 29 30
DECEMBER 2019 MAY 2020 SU M T W TH F SA 12/2-3 Thanksgiving Recess – School Closed SU M T W TH F SA 5/14 REAP Ends 5/11 (M), 5/12 (T), 5/14 (Th) 1 2 3 4 5 6 7 12/3 Staff Conference Day – No Students 1 2 5/25 Memorial Day – School Closed 12/4 School Reopens for Students & Staff 5/29 Lower School/Upper School Field Day 8 9 10 11 12 13 14 3 4 5 6 7 8 9 12/23-31 Winter Recess – School Closed 15 16 17 18 19 20 21 10 11 12 13 14 15 16 22 23 24 25 26 27 28 17 18 19 20 21 22 23 29 30 31 24 25 26 27 28 29 30 31
JANUARY 2020 JUNE 2020 SU M T W TH F SA 1/1-3 Winter Recess – School Closed SU M T W TH F SA 6/2 US History/Gov’t. Regents Exam 1 2 3 4 1/6 School Reopens 1 2 3 4 5 6 6/12 Work-Based Learning Assembly 1/16 REAP Ends 1/13 (M), 1/14 (T), 1/16 (Th) 6/16 High School Graduation 5 6 7 8 9 10 11 7 8 9 10 11 12 13 1/17 Staff Conference Day – School Closed 6/17-25 Regents Exams 12 13 14 15 16 17 18 1/20 Martin Luther King Jr. Day – School Closed 14 15 16 17 18 19 20 6/18 8th Grade Moving Up Breakfast & Ceremony 1/21-24 Regents Exams 19 20 21 22 23 24 25 21 22 23 24 25 26 27 6/26 Half Day – Last Day of School 28 29 30 for Staff & Students/Dismissal 12:30 PM 26 27 28 29 30 31
School Closed Staff Only School Closed Staff Only Conference Days: 9/4, 10/21, 12/3, 1/17
Upper School 187-30 Grand Central Parkway | Jamaica Estates, NY 11432 | 718-264-2931 Lower School 183-02 Union Turnpike | Flushing, NY 11366 | 718-969-3944
Required Forms Checklist
Please complete the enclosed forms and return them to the Upper School or Lower School (use the enclosed return envelope). Early returns in May and June are greatly appreciated.
❏ 1. Parent Contact/Emergency Information Form
❏ 2. Final Records Request (for new students)
❏ 3. Health Examination Form • Required for new admissions and before entering grades 3, 5, 7, 9, and 11 • Required annually for students who participate in team sports • Must be signed by a physician
❏ 4. Medication Form • Must be completed each school year and signed by a physician • Prescribed medication must be sent to school in the original pharmacy bottle with signed prescription
❏ 5. Dental Health Certificate • Required for new admissions and before entering grades 3, 5, 7, 9, and 11
❏ 6. NYCDOE Medicaid Reimbursement Form (for new students who reside in NYC)
❏ 7. Recreational Enrichment After-School Program (REAP) Brochure and Registration Form
❏ 8. 2019 Annual Benefit Restaurant Gift Certificate Form • Donate at www.summitqueens.com/restaurant-gift-certificate-fund
❏ 9. Guide to Stay Connected and to Keep Information Handy
❏ 10. Parents’ Association 2019-20 Membership and Volunteer Forms • Register to pay your dues and volunteer online (preferred method) • http://www.summitqueens.com/parents-join-the-pa
Other school forms to be completed online (use the links in the Summit eBlast to access): US Lunch Permission (all Upper School students), LS Swim Questionnaire (new students to Summit’s Lower School), and Summit’s Release Form (all Summit students).
School forms are available online: www.summitqueens.com/about-school-forms-policies
May 2019
Dear New Parents,
We are looking forward to having your child join us in September 2019. In order to accurately plan his/her program, we need a copy of the final report card and high school transcript along with the results of any Regents examinations. Please email, fax, or mail this information to:
For grades 3-8 For grades 9-12 Karen Frigenti, Principal Nancy Morgenroth, Director of Admissions The Summit School The Summit School 183-02 Union Turnpike 187-30 Grand Central Parkway Flushing, NY 11366 Jamaica Estates, NY 11432 E: [email protected] E: [email protected] F: 718-969-4073 F: 718-264-1737
Thank you in advance for your cooperation.
Nancy Morgenroth, M.S. CCC-SLP Director of Admissions
CHILD & ADOLESCENT HEALTH EXAMINATION FORM Please Print Clearly - NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION Press Hard 2 0 1 9 2 0 2 0 TO BE COMPLETED BY PARENT OR GUARDIAN
Child’s Last Name First Name Middle Name Sex Ⅺ Female Date of Birth (Month/Day/Year ) Ⅺ Male __ __ / ______/ ______Child’s Address Ⅺ Yes Ⅺ N City/Borough State Zip Code School/Center/Camp Name District __ __ Phone Numbers THE SUMMIT SCHOOL Number ______Home ______Health insurance Ⅺ Yes Ⅺ Parent/Guardian Last Name First Name Cell ______(including Medicaid)? Ⅺ No Ⅺ Foster Parent Work ______TO BE COMPLETED BY HEALTH CARE PROVIDER If “yes” to any item, please explain (attach addendum, if needed)
Birth history (age 0-6 yrs) Does the child/adolescent have a past or present medical history of the following? Ⅺ Asthma (check severity and attach MAF/Asthma Action Plan): Ⅺ Intermittent Ⅺ Mild Persistent Ⅺ Moderate Persistent Ⅺ Severe Persistent Ⅺ Uncomplicated Ⅺ Premature: ______weeks gestation If persistent, check all current medication(s): Ⅺ Inhaled corticosteriod Ⅺ Other controller Ⅺ Quick relief med Ⅺ Oral steroid Ⅺ None Ⅺ Complicated by ______Ⅺ Attention Deficit Hyperactivity Disorder Ⅺ Orthopedic injury/disability Medications (attach MAF if in-school medication needed) Allergies Ⅺ None Ⅺ Epi pen prescribed Ⅺ Chronic or recurrent otitis media Ⅺ Seizure disorder Ⅺ None Ⅺ Yes (list below) Ⅺ Congenital or acquired heart disorder Ⅺ Speech, hearing, or visual impairment Ⅺ Drugs (list) Ⅺ Developmental/learning problem Ⅺ Tuberculosis (latent infection or disease) Ⅺ Diabetes (attach MAF) Ⅺ Other (specify) ______Ⅺ Foods (list) Dietary Restrictions Ⅺ None Ⅺ Yes (list below) Ⅺ Other (list) Explain all checked items above or on addendum PHYSICAL EXAMINATION General Appearance: Height ______cm ( ______%ile) Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl ⅪⅪ HEENT ⅪⅪ Lymph nodes ⅪⅪ Abdomen ⅪⅪ Skin ⅪⅪ Psychosocial Development Weight ______kg ( ______%ile) ⅪⅪ Dental ⅪⅪ Lungs ⅪⅪ Genitourinary ⅪⅪ Neurological ⅪⅪ Language BMI ______kg/m2 ( ______%ile) ⅪⅪ Neck ⅪⅪ Cardiovascular ⅪⅪ Extremities ⅪⅪ Back/spine ⅪⅪ Behavioral
Head Circumference (age ≤2 yrs) ______cm ( ______%ile) Describe abnormalities:
Blood Pressure (age ≥3 yrs) ______/ ______
DEVELOPMENTAL (age 0-6 yrs) Ⅺ Within normal limits SCREENING TESTS Date Done Results Date Done Results
Blood Lead Level (BLL) Only required for students entering intermediate/middle/junior or high school If delay suspected, specify below __ __ / ______/ ______µg/dL Tuberculosis (required at age 1 yr and 2 yrs who have not previously attended any NYC public or private school Ⅺ Cognitive (e.g., play skills) ______and for those at risk) __ __ / ______/ ______µg/dL PPD/Mantoux placed __ __ / ______/ ______Induration ______mm Lead Risk Assessment Ⅺ At risk (do BLL) PPD/Mantoux read __ __ / ______/ ______Ⅺ Neg Ⅺ Pos ______(annually, age 6 mo-6 yrs) Ⅺ Communication/Language __ __ / ______/ ______Ⅺ Not at risk Hearing Interferon Test __ __ / ______/ ______Ⅺ Neg Ⅺ Pos Ⅺ Social/Emotional ______Ⅺ Pure tone audiometry Ⅺ Normal Chest x-ray Nl Not Ⅺ OAE __ __ / ______/ ______Ⅺ Abnormal Ⅺ Ⅺ (if PPD or Interferon positive) Ⅺ Abnl Indicated Ⅺ Adaptive/Self-Help ______/ ______/ ______—— Head Start Only —— Hemoglobin or ______g/dL Vision Acuity Right ___ / ___ Ⅺ Motor ______Hematocrit (age 9–12 mo) (required for new school entrants __ __ / ______/ ______Left ___ / ______/ ______/ ______% and children age 4–7 yrs) Ⅺ with glasses Strabismus Ⅺ No Ⅺ Yes IMMUNIZATIONS – DATES CIR Number of Child Influenza __ __ / ______/ ______/ ______/ ______/ ______/ ______
Hep B __ __ / ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______MMR __ __ / ______/ ______/ ______/ ______/ ______/ ______
Rotavirus __ __ / ______/ ______/ ______/ ______/ ______/ ______Varicella __ __ / ______/ ______/ ______/ ______
DTP/DTaP/DT __ __ / ______/ ______/ ______/ ______/ ______/ ______Td __ __ / ______/ ______/ ______/ ______/ ______/ ______
__ __ / ______/ ______/ ______/ ______/ ______/ ______Tdap __ __ / ______/ ______Hep A __ __ / ______/ ______/ ______/ ______
Hib __ __ / ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______Meningococcal __ __ / ______/ ______/ ______/ ______
PCV __ __ / ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______HPV __ __ / ______/ ______/ ______/ ______/ ______/ ______
Polio __ __ / ______/ ______/ ______/ ______/ ______/ ______/ ______/ ______Other, specify: ______/ ______/ ______; ______/ ______/ ______
RECOMMENDATIONS Ⅺ Full physical activity Ⅺ Full diet ASSESSMENT Ⅺ Well Child (V20.2) Ⅺ Diagnoses/Problems (list) ICD-9 Code
Ⅺ Restrictions (specify) ______Follow-up Needed Ⅺ No Ⅺ Yes, for ______Appt. date: __ __ / ______/ ______Referral(s): Ⅺ None Ⅺ Early Intervention Ⅺ Special Education Ⅺ Dental Ⅺ Vision Ⅺ Other ______Health Care Provider Signature Date DOHMH PROVIDER __ __ / ______/ ______ONLY I.D. Health Care Provider Name and Degree (print) Provider License No. and State TYPE OF EXAM: NAE Current NAE Prior Year(s) Comments Facility Name National Provider Identifier (NPI)
Address City State Zip Date I.D. NUMBER Reviewed: __ __ / ______/ ______Telephone Fax ( ______) ______– ______( ______) ______– ______REVIEWER:
CH-205 (5/08) SY: 2019-2020
OCCUPATIONAL THERAPY PRESCRIPTION REQUEST
NEW REQUIREMENT: To Be Completed for All Summit Students Mandated for OT Services
STUDENT INFORMATION
STUDENT’S NAME: ______
SEX: ! MALE ! FEMALE DOB: ______
The purpose of this form is to obtain a prescription from your child’s physician authorizing occupational therapy services for the 2019/2020 school year.
PRESCRIPTION FOR OCCUPATIONAL THERAPY [CHECK BOX BELOW]
❏ Occupational Therapy Service is necessary. ICD Code:______
This prescription will be in effect for one year: September 1, 2019 until August 30, 2020.
PRESCRIBING PHYSICIAN / PHYSICIAN ASSISTANT / NURSE PRACTIONER
______PRINT PHYSICIAN’S / PA’S / NP’S NAME PHYSICIAN’S / PA’S / NP’S SIGNATURE
______PRINT PHYSICIAN’S / PA’S / NP’S LICENSE NUMBER PHYSICIAN’S / PA’S / NP’S NPI NUMBER
ADDRESS: ______
CITY: ______STATE: ______ZIP CODE: ______
TELEPHONE: ______DATE: ______
FOR A PARENT WHO HAS ALREADY PROVIDED AN OT PRESCRIPTION FOR THEIR CHILD, PLEASE NOTE THAT A NEW PRESCRIPTION IS REQUIRED FOR EACH NEW SCHOOL YEAR.
HOW TO RETURN COMPLETED FORM: 1) PARENTS MAY INCLUDE THIS COMPLETED FORM IN THE PROVIDED ENVELOPE ALONG WITH OTHER SCHOOL FORMS BEING RETURNED TO THE SUMMIT SCHOOL. OR 2) PHYSICIANS/PHYSICIAN ASSISTANTS/NURSE PRACTIONERS MAY DIRECTLY RETURN THIS COMPLETED FORM VIA FAX TO THE SUMMIT SCHOOL AT 718-969-4073.
2019-20 School Year New York State Immunization Requirements for School Entrance/Attendance1
NOTES: Children in a prekindergarten setting should be age-appropriately immunized. The number of doses depends on the schedule recommended by the Advisory Committee on Immunization Practices (ACIP). For grades pre-k through 11, intervals between doses of vaccine should be in accordance with the ACIP-recommended immunization schedule for persons 0 through 18 years of age. Doses received before the minimum age or intervals are not valid and do not count toward the number of doses listed below. Intervals between doses of vaccine DO NOT need to be reviewed for grade 12 except for interval between measles vaccine doses. See footnotes for specific information for each vaccine. Children who are enrolling in grade-less classes should meet the immunization requirements of the grades for which they are age equivalent.
Dose requirements MUST be read with the footnotes of this schedule.
Prekindergarten Kindergarten and Grades Grades Grade Vaccines (Day Care, 1, 2, 3, 4 and 5 6, 7, 8, 9, 10 12 Head Start, and 11 Nursery or Pre-k)
Diphtheria and Tetanus 5 doses toxoid-containing vaccine or 4 doses and Pertussis vaccine 4 doses if the 4th dose was received 3 doses (DTaP/DTP/Tdap/Td)2 at 4 years or older or 3 doses if 7 years or older and the series was started at 1 year or older
Tetanus and Diphtheria toxoid-containing vaccine Not applicable 1 dose and Pertussis vaccine booster (Tdap)3
Polio vaccine (IPV/OPV)4 4 doses 4 doses or 3 doses or 3 doses if 3 doses if the 3rd dose was received the 3rd dose 3 doses at 4 years or older was received at 4 years or older
Measles, Mumps and 1 dose 2 doses Rubella vaccine (MMR)5
Hepatitis B vaccine6 3 doses 3 doses 3 doses or 2 doses of adult hepatitis B vaccine (Recombivax) for children who received the doses at least 4 months apart between the ages of 11 through 15 years
Varicella (Chickenpox) 1 dose 2 doses 1 dose vaccine7
Meningococcal conjugate Grades 2 doses vaccine (MenACWY)8 7, 8, 9 and 10: or 1 dose Not applicable 1 dose if the dose was received at 16 years or older
Haemophilus influenzae type b conjugate vaccine 1 to 4 doses Not applicable (Hib)9
Pneumococcal Conjugate 1 to 4 doses Not applicable vaccine (PCV)10
Department of Health SY: 2019-2020
MEDICATION FORM
STUDENT CONTACT INFORMATION
STUDENT’S NAME: ______
SEX: q MALE q FEMALE DOB: ______AGE: ______
Please list below all medications that your child is currently taking both at home and in school. This form must be updated each year. If your child is receiving medication during the school day, the prescribing physician must sign below. All medication must be sent to school in its original vial.
PRESCRIPTION MEDICATION (LIST ALL DAILY MEDICATION)
SCHEDULE/TIME DRUG NAME ROUTE DOSAGE ADMINISTER AT Specify qam, qhs, bid, Specify by mouth, SCHOOL tid, or qid topically or injection ❏ Yes ❏ No
❏ Yes ❏ No
❏ Yes ❏ No
❏ Yes ❏ No
❏ Yes ❏ No
❏ Yes ❏ No
PRESCRIBING PHYSICAN: ______PRINT PHYSICIAN’S NAME PHYSICIAN’S SIGNATURE TELEPHONE: ______DATE: ______
INSTRUCTIONS FOR EMERGENCY MEDICAL CONDITIONS (A SEPARATE ACTION PLAN WILL BE REQUIRED FOR EACH CONDITION AT A LATER DATE) MEDICAL CONDITION TREATMENT Asthma: ❏ Yes ❏ No ❏ Inhaler ❏ Nebulizer
Diabetes: ❏ Yes ❏ No ❏ Insulin
Severe Allergies: ❏ Yes ❏ No ❏ EpiPen ❏ Benadryl
Food: ______Insect: ______
Drugs: ______Other: ______
Seizure Disorder: ❏ Yes ❏ No
PERMISSION TO ADMINISTER PRESCRIPTION MEDICATION
I authorize The Summit School nurse to administer the prescription medications listed above to my child as directed by my child’s physician.
______PRINT PARENT/GUARDIAN NAME PARENT/GUARDIAN SIGNATURE DATE
DENTAL HEALTH CERTIFICATE
Parent/Guardian: New York State law (Chapter 281) permits schools to request a dental examination in the following grades: school entry, K, 2, 4, 7, & 10. Your child may have a dental check-up during this school year to assess his/her fitness to attend school. Please complete Section 1 and take the form to your dentist for an assessment. If your child had a dental check-up before he/she started the school, ask your dentist to fill out Section 2. Return the completed form to the school's medical director or school nurse as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Last First Middle Child's Name:
Birth Date: / / Sex: __ Male Will this be your child's first visit to a dentist? __Yes ____ No Month Day Year _ Female
Grade School: The Summit School
Have you noticed any problem in the mouth that interferes with your child's ability to chew, speak or focus on school activities? _Yes _No
I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand this assessment is only a limited means of evaluation to assess the student's dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with x-rays if necessary to maintain good oral health. I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctor-patient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below.
Parent/Guardian Signature ______Date: ______Section 2. To be completed by the Dentist
I. The Dental Health condition of ______on ______(date of exam) The date of the exam needs to be within 12 months of the start of the school year in which it is requested. Check one:
____ Yes, The student listed above is in fit condition of dental health to permit his/her attendance at the public schools.
____ No, The student listed above is not in fit condition of dental health to permit his/her attendance at the public schools.
NOTE: Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling or infection related to clinical evidence of open cavities. The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.
Dentist's name and address (please print or stamp) Dentist's Signature
Optional Sections - If you agree to release this information to your child's school, please initial here:.______II. Oral Health Status (check all that apply), __Yes __No Carries Experience/Restoration History - Has the child ever had a cavity (treated or untreated)? [A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].
__ Yes __ No Untreated Caries - Does this child have an open cavity? [At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark brown coloration of the walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present].
__Yes __No Dental Sealants Present
Other problems (Specify): ______III. Treatment Needs (check all that apply)
__ No obvious problem. Routine dental care is recommended. Visit your dentist regularly. __ May need dental care. Please schedule an appointment with your dentist as soon as possible for an evaluation. __ Immediate dental care is required. Please schedule an appointment immediately with your dentist to avoid problems.
REQUEST FOR CONSENT FOR MEDICAID REIMBURSEMENT
The Department of Education is writing to ask for your assistance as we work to provide services for your child. Our schools can receive additional funding for some of the services that are provided to students, like your child, who have individualized education plans (IEPs). In order for our schools to receive this funding, we need your consent to (1) access and provide to the state and federal Medicaid programs personally identifiable information from your child’s special education records about the special education evaluations, programs and services that are provided to your child and (2) access your child’s Medicaid benefits to pay for these services. Please read the information below, complete the attached form and return it to your child’s school.
Thank you for your assistance in ensuring that our public schools receive as much funding as possible for the critical supports that are provided to our students.
--- Why am I being asked to sign this consent form?
The New York City Department of Education (NYC DOE) uses Medicaid funding to help meet some of the costs of providing special education services to students. With your consent, the NYC DOE can submit claims for evaluations and services that are provided to your child. You are not required to sign up for Medicaid in order for your child to receive the services on his/her IEP.
What information about my child will be provided to state and federal Medicaid programs?
The NYC DOE will provide personally identifiable information about the special education evaluations and services provided to your child. This information may include the IEP, progress notes, attendance records, evaluations and other records and information about evaluations and services provided to your child.
Is there any cost to me or to my family?
There is no cost to you or your family. You will not be required to incur any expenses, premiums, costs or co- payments for the provision of these services. The services that are provided to your child in and outside of school will not be affected in any way. If your family receives Medicaid benefits, your coverage will not be canceled, the lifetime coverage in place will not decrease and services that your family receives will not be affected in any way by the accessing of Medicaid benefits. You will not be required to sign up for or enroll in Medicaid for your child to receive the services on his/her IEP. You will not risk the loss of eligibility for home and community based waivers, if any, that are based on your total health-related expenditures.
Can I change my mind about allowing the NYC DOE to access my child’s information and submit claims to the Medicaid program? What if I do not provide my consent?
You may change your mind about this consent at any time. To change your decision, complete a new form and send it to your child’s school. The NYC DOE must still provide special education and services to your child at no cost to you even if you do not consent or you withdraw your consent at a later date. CONSENT TO RELEASE INFORMATION FOR MEDICAID REIMBURSEMENT
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Please select one choice below, sign and date the document, and return this form to your child’s school.
Yes, I understand and agree that the NYC DOE may access my child’s special education o records, which may include the Individualized Education Program (IEP), progress notes, attendance records, evaluations and other records and information about services and evaluations that may be provided to my child and release this personally identifiable information to State and Federal Medicaid agencies as necessary to claim Medicaid reimbursement. I agree that the NYC DOE may access my child’s Medicaid benefits to pay for special education and services provided as per my child’s IEP.
______
SIGNATURE OF PARENT OR GUARDIAN DATE
No, I do not give permission for the NYC DOE to access my child’s special education records o to claim Medicaid reimbursement for special education services provided to my child.
______
SIGNATURE OF PARENT OR GUARDIAN DATE 12
September 16, 2019 – January 16, 2020 Program Calendar
September 2019 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
October 2019 November 2019 S M T W T F S S M T W T F S REAP 1 2 3 4 5 1 2 6 7 8 9 10 11 12 3 4 5 6 7 8 9 Recreational Enrichment 13 14 15 16 17 18 19 10 11 12 13 14 15 16 After-School Program 20 21 22 23 24 25 26 17 18 19 20 21 22 23 27 28 29 30 31 24 25 26 27 28 29 30 Fall 2019
December 2019 January 2020 S M T W T F S S M T W T F S 1 2 3 4 5 6 7 1 2 3 4 8 9 10 11 12 13 14 5 6 7 8 9 10 11 15 16 17 18 19 20 21 12 13 14 15 16 17 18 22 23 24 25 26 27 28 19 20 21 22 23 24 25 29 30 31 26 27 28 29 30 31
The Summit School Larry Litwack 187-30 Grand Central Parkway REAP dates are shaded. Program Coordinator Jamaica Estates, New York 11432 718-264-2931 x219 http://www.summitqueens.com Email: [email protected] 12
Course Descriptions Fall 2019
Cartooning & Illustration Monday/Christian Torres Photography Club Thursday/Joan Bamforth Christian has taught at the Riverdale Country School and is currently a Join our digital photography club. Learn how to use a digital camera to take a freelance illustrator. Students will learn to create cartoon characters and variety of different pictures. At the end of this semester, you will create your comic strips with coordinating illustrations or freehand workshops. Various own photo book as a keepsake or as a gift for someone special. techniques and mediums will be explored. Role Playing Club Tuesday/Ian Oakley Chess Intermediate/Advanced Thursday/Matthew Looks Sign up for Role Playing! Role-playing games are a verbal, non-digital, game We are offering something very special to a select group of students: learn played by roughly 4-9 people at a time in which players attempt to solve chess from a member of our staff, Matthew Looks, who is a National Chess problems and survive hardships fully imagined and arbitrated by a central player Master. This intermediate to advanced chess course is designed to provide or game master. Role-Playing is the capacity for exploring consequence guidance and strategy for those who know the rules of the game. without the possibility of physical or emotional distress. Players must deal with the actions of their characters as understood and arbitrated by a game master. 3D Creation & Design Tuesday/Greg Broas In this afterschool program students will begin to explore 3D design through Science Club Tuesday/Joan Bamforth multiple computer programs. Students will learn how to design projects in a Wanted: Students who like to experiment and have fun. If you enjoy doing 3D environment as well refining their spatial awareness skills. The students science experiments and solving problems, this is the club for you! Join us for a will be using intuitive software that will provide them with a foundation for fun-filled afternoon of exploring. We may even make an experiment that you creating 3D models. can eat. Garage Band Workshop Thursday/Gary Raheb Sports Club Tuesday/Larry Litwack & Tom Schaefer Learn to write and record melodies and chords, short songs and A variety of sports are selected by the students each session. Teamwork, skills, arrangements of your own creation. We will combine software, real and strategy will be developed. Such sports as floor hockey and dodge ball to instruments and vocal tracks. Projects will be collaborative in the spirit of basketball and baseball, all have fun in a noncompetitive and lively way. making music as a group. Our work will be recorded in Garage Band. Studio Art Workshop Thursday/Nancy Handy Guitar Workshop Thursday/Tom Schaefer Explore your creativity by learning to use a wide variety of mixed media. Do you want to learn guitar and play your favorite songs? Join Tom Schaefer Students will learn basic and advanced techniques in drawing, painting, for this unique guitar workshop. We will cover guitar playing, voice papermaking, printmaking, collage, sculpture, bookmaking, and more! performance, and song writing. You must have your own guitar. Table Top Games Thursday/Ian Oakley Life Coaching for Young Adults Monday/Justin Lyons OTR/L Modern board games have a lot to offer with socialization, critical thinking and Join our OT, Justin Lyons, this course helps teenagers focus on who they are, strategy. Students will have fun learning new skills and competing against each where they want to go, and how to do it with all the stresses that come with other. Along the way they will gain insight into how they learn, how they work adolescence and life. With the proper tools and skills, live life to the fullest with each other and how they react to wins and losses. Titles include, Pandemic, and make goals become reality. Seven Wonders, Settlers of Catan, Forbidden Island, Sushi Go, Castles of Burgundy, Mint Works, Deep Sea Adventure, The Resistance, and many more! Performing Arts Monday/Tom Schaefer, Rita Quintas, Diane Graff Weights Thursday/Dennis Moeller & Maria Alvarez There will be an open cast call for actors, dancers, singers, narrators, artists, Students will work out in our new state-of-the-art fitness room. Students stage managers and costume designers to collaborate on a REAP will receive cardiovascular and weight training while learning how to use presentation of a popular musical production at the end of the semester. our new treadmills, ellipticals, bikes, weight machines, and free weights. A training program will be tailored to the individual needs of each student.
September 16, 2019 to January 16, 2020 3:00 p.m. - 4:30 p.m.
RECREATIONAL ENRICHMENT AFTER-SCHOOL PROGRAM (REAP) FALL 2019 REGISTRATION FORM
Student Information
Last Name ______First Name ______
Date of Birth ______Class ______
Address ______
Telephone ______
Parent/Guardian Information
Name ______Cell Phone ______
Day Phone ______Fax ______
Email ______
Transportation Information: Dismissal is at 4:30 p.m. Parents must arrange transportation home.
Indicate your transportation plans below.
❑ I will pick up my child. ❑ My child will travel home independently.
❑ My child will be picked up by ______
❑ I need car pool information. (Destination) ______
❑ I am interested in private bus service or car service. (Depending on need).
Medical Information: Medication is administered between 3:00 p.m. and 4:30 p.m. TIME NAME OF MEDICATION DOSAGE
Allergies ❏ Food: ______❏ Insect Bites: ______❏ Medication: ______❏ Other: ______
Does your child require the administration of an EpiPen during a severe allergic reaction? ❏ Yes ❏ No Administered By: ❏ Staff ❏ Student
Medical Alerts ❏ Asthma Does your child require the use of an inhaler? ❏ Yes ❏ No Administered by: ❏ Staff ❏ Student
❏ Glasses ❑ Seizure Disorder ❑ Other: ______
OVER FALL 2019
AFTER-SCHOOL ACTIVITY SELECTIONS: INDICATE 1st AND 2nd CHOICE OF ACTIVITY
For more information, please contact:
Larry Litwack at 718-264-2931 x219 Email: [email protected]
ACTIVITY MONDAY TUESDAY THURSDAY SUBTOTAL 11 SESSIONS 12 SESSIONS 14 SESSIONS CARTOONING & ILLUSTRATION ! 1 ! 2 Fee: $425.00* CHESS INTERMEDIATE/ADVANCED ! 1 ! 2 Fee: $400.00 3D CREATION & DESIGN ! 1 ! 2 Fee: $425.00* GARAGE BAND WORKSHOP ! 1 ! 2 Fee: $375.00* GUITAR WORKSHOP ! 1 ! 2 Fee: $400.00* LIFE COACHING FOR YOUNG ADULTS ! 1 ! 2 Fee: $375.00 PERFORMING ARTS ! 1 ! 2 Fee: $450.00* PHOTOGRAPHY CLUB ! 1 ! 2 Fee: $400.00* ROLE PLAYING CLUB ! 1 ! 2 Fee: $375.00* SCIENCE CLUB ! 1 ! 2 Fee: $400.00* SPORTS CLUB ! 1 Fee: $375.00* STUDIO ART WORKSHOP ! 1 ! 2 Fee: $375.00 TABLE TOP GAMES ! 1 ! 2 Fee: $375.00* WEIGHTS – WEIGHT ROOM! ! 1 ! 2 Fee: $375.00* * Material Fee Included. Please make your check payable to: Summit School Enrichment. Subtotal: Return this form and payment to: The Summit School Attn: REAP 187-30 Grand Central Parkway, Jamaica Estates, NY 11432 Registration Fee: + $30.00
Amount Due:
PARENT PERMISSION:
❏ I give permission for my child to participate in REAP.
Parent/Guardian Signature ______Date ______SAVE THE DATE: Summit’s Annual Benefit Monday, November 25, 2019 at The Pierre Hotel in New York City
THE SUMMIT SCHOOL REQUESTS
$25 [Please take another moment to write a check or make your donation online at www.summitqueens.com/restaurant-gift-certificate-fund]
We ask every family to donate a minimum of $25 to The Summit School to help us purchase restaurant gift certificates for Summit’s 2019 Annual Benefit. Used in our silent auction, restaurant gift certificates are one of the most popular items and often sell for twice face value. Help us maximize everyone’s efforts as plans for this year’s benefit get underway.
QUESTIONS: Email [email protected] ------DONATE ONLINE [PREFERRED] GO TO: www.summitqueens.com/restaurant-gift-certificate-fund
DONATE BY MAIL: Complete and return this form by July 25, 2019 Send to The Summit School, Restaurant Certificates, 187-30 Grand Central Parkway, Jamaica Estates, NY 11432 Please make checks payable to The Summit School; indicate “Restaurants” in the memo field. Enclosed is my contribution towards the purchase of restaurant gift certificates for Summit’s 2019 Annual Benefit. ☐ $25 ☐ $50 ☐ $75 ☐ $100 ☐ Other______
SELECT ONE: ☐ PLEASE CHARGE BY CREDIT CARD: VISA MC AMEX DISC ☐ ENCLOSED IS MY CHECK
______Parent/Guardian Name Student Name
______FOR CREDIT CARD: Name on Credit Card Credit Card Number Exp Date Security Code
The Summit School is a 501(c)(3) nonprofit organization. All contributions are tax deductible to the extent permitted by law. Thank you. Find It Here! To help keep information about The Summit School at your fingertips and to make i sure our communications are reaching you, please refer to this handy guide.
Stay Connected Summit eBlasts are sent from The Summit School primarily communicates electronically via email with parents. We use Constant Contact, which is the following email addresses: an email service provider, and send communications out sometimes weekly, depending upon activities and events. [email protected] To make sure that our eBlasts from the school, the Parents’ [email protected] Association, and some of our staff are getting into your email’s In Box, please add the addresses listed on the [email protected] right to your address book. If all else fails, check Spam. [email protected] [email protected] Gmail users: Summit’s emails will probably land in your Promotions tab. Gmail automatically sorts and delivers your email in Primary, [email protected] Promotions, or Social tabs. [email protected]
Access our eBlast archive via Summit’s website: About > News / eBlasts [email protected] [email protected] [email protected]
Find It On Summit’s Website – www.summitqueens.com Most everything you need to know about Summit can be found on our website, from school forms to calendars to directions to REAP’s latest offerings to Annual Benefit forms. Use our guide below to keep information at your fingertips. But remember, you can always call our staff in the school’s front office.
LOOKING FOR: FIND IT AT: Addresses and Telephone Numbers, Upper School & Lower School Home page, scroll to the bottom Annual Benefit: Information, Forms [PDF] & Links Giving > Annual Benefit Calendar for the Current School Year, on screen or download [PDF] About > Calendar Calendar to upload to your Smartphone [ICS] About > Calendar Campaign for Kids: Information & Contacts for Participation Giving > Campaign for Kids Directions to the Upper & Lower Schools (driving or public transportation) About > Directions eBlast Archive: Back issues of Summit’s News & PA events About > News / eBlasts Forms for School, Health & Dental [PDF] About > School Forms & Policies Join the PA: Online registration or download a PA membership form [PDF] Parents > Join the PA K-12 Emergency Alert / Update your information anytime About > Emergency Alerts OPT’s Telephone & Transportation Information About > Student Transportation PA Meetings & Small Talks Schedule & Call-In Instructions [PDFs] Parents > PA Meetings PA Officers, Committee Coordinators & Class Reps Parents > Be Involved PA Student or Parent Event Registration Links About > News & eBlasts > Archive REAP After-School Program Brochure & Application [PDF] REAP > After School Program School Directory: Usually published and distributed to parents in early October Call the front office if you need to via Summit eBlast [PDF]; this eBlast is not saved in our archive. receive a link to download [PDF] School Policies [PDF] About > School Forms & Policies Summit’s Swim-A-Thon: Information & Links Giving > Swim-A-Thon Volunteer: Online registration or download a PA volunteer form [PDF] Parents > Be Involved Work-Based Learning Program WBLP> About
Join the PA. Build spirit and community at Summit.
It’s the best investment you can make! Membership in the PA is an investment that will enhance your whole family’s experience at Summit. Only with everyone’s involvement can we continue to keep Summit a great school – that’s why we’re here – and also provide the social and learning opportunities that supplement our children’s academic experiences.
Some Key PA Activities & Events: • Staff development for teaching and clinical teams (throughout the year) • In-school student assemblies (throughout the year) • Social, sporting, and cultural events for our children (throughout the year) • Parent education workshops and speaker programs (throughout the year) • Lower School Book Fair (November) • Staff appreciation events (winter and spring)
2019/2020 ANNUAL MEMBERSHIP (ONLINE REGISTRATION PREFERRED) Select your membership option and complete payment AND parent information. Questions? Email the Parents’ Association at [email protected].
How to Register and Pay: Two registration and payment methods are available: ONLINE OR PRINTED FORM. 1. ONLINE REGISTRATION: Go to http://www.summitqueens.com/parents-join-the-pa OR 2. COMPLETE THIS PRINTED FORM. Mail your completed form with your payment to: The Summit School PA, 187-30 Grand Central Parkway, Jamaica Estates, NY 11432
STEP 1: SELECT YOUR MEMBERSHIP OPTION (*$80 SILVER IS RECOMMENDED) ! $120 GOLD ! $80 SILVER* ! $40 BRONZE ! OTHER______
STEP 2: SELECT PAYMENT OPTION – CREDIT CARD OR CHECK – AND COMPLETE INFORMATION ! PLEASE CHARGE $______TO MY CREDIT CARD. Select one: VISA MC AMEX DISC
______Name on Credit Card Expiration Date
______Credit Card Number Security Code ! ENCLOSED IS MY CHECK FOR $______PAYABLE TO: SUMMIT PA.
STEP 3: COMPLETE PARENT/GUARDIAN INFORMATION " My contact information can be given to other parents. 20 - ______9 Parent’s/Guardian’s Name(s)
______Primary Email Preferred Phone Number
______Child’s Name Class Number (if known) "Upper School !Lower School
______Second Child’s Name Class Number (if known) "Upper School !Lower School PAFORM_MEMBERSHIP201 Volunteer. Build spirit and community at Summit.
The success of the Summit Parents’ Association’s programs depends not only on annual dues but also on the participation of our parent volunteers. Parental involvement strengthens the bonds between home and school and helps create a feeling of community among parents. We are always looking for willing hands and fresh talent for our many and varied activities. There are a number of different ways to help.
Questions? Email the Parents’ Association at [email protected].
Which committees/activities are you interested in this year? (Check as many as you like.)
! Annual Benefit (Assist with the November annual fundraiser.) ! Life At Summit (Organize educational speakers and workshops for parents in both schools.) ! Lower School Book Fair (Assist with setup, sales, and breakdown for this annual fall event.) ! School Spirit (Organize Lower School and Upper School social activities, including Movie Night, Comedy Night, bowling, and other social/fun events.) ! Staff Appreciation Luncheons (Assist with setup, serving, and breakdown at the Lower or Upper School)
Tell us about yourself:
Skills, experience, or areas of interest?
! Event Coordination ! Editorial/Writing ! Graphic Design ! Fundraising ! Other (list below)
______
Have any contacts who can help the PA/Summit? If so, list them below or contact the PA.
! Caterers ! Venue Providers ! Performers ! Ticket Providers ! Other (list below)
______
20 - Volunteer Contact Information Return this form to Summit’s PA, Volunteers, 187-30 Grand Central Parkway, Jamaica 9 Estates, NY 11432. We look forward to working with you!
______Parent’s Name(s)
______Primary Email Preferred Phone Number
______PAFORM_VOLUNTEER201 Child’s Name Class Number (if known) !Upper School "Lower School