Required documents needed to register: Birth Certificate
Immunization Records
Three proofs of residency
HARBOR CREEK SCHOOL DISTRICT www.hcsd.iu5.org Phone (814) 897-2100
Clark Elementary Klein Elementary Rolling Ridge Elementary Harbor Creek Jr./Sr. High 3650 Depot Road 5325 East Lake Road 3700 Ridge Parkway 6375 Buffalo Road Erie, PA 16510 Erie, PA 16511 Erie, PA 16510 Harborcreek, PA 16421 Fax: 897-8723 Fax: 580-5419 Fax: 898-1916 Jr. High Fax: 897-2121 Sr. High Fax: 897-2136
STAY CONNECTED WITH HCSD
Website: HCSD.iu5.org
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ANNUAL PUBLIC NOTICE OF SPECIAL EDUCATION SERVICES & PROGRAMS, SERVICES FOR GIFTED STUDENTS, & SERVICES FOR PROTECTED HANDICAPPED STUDENTS
The Northwest Tri-County Intermediate Unit and its Member School Districts, Charter Schools and Private Rehabilitation Residential Institution (PRRI)
Conneaut School District Corry Area School District Crawford Central School District Erie’s Public Schools Fairview School District Fort LeBoeuf School District General McLane School District Girard School District Harbor Creek School District Iroquois School District Millcreek Township School District North East School District Northwestern School District PENNCREST School District Union City Area School District Warren County School District Wattsburg Area School District Erie RISE Leadership Charter School Montessori Regional Charter School Perseus House Charter School of Excellence Tidioute Community Charter School Robert Benjamin Wiley Community Charter School Harborcreek Youth Services
Notice to Parents
According to state and federal special education regulations, annual public notice to parents of children who reside within a school district is required regarding child find responsibilities. School districts, intermediate units and charter schools are required to conduct child find activities for children who may be eligible for services via Section 504 of the Rehabilitation Act of 1973. For additional information related to Section 504/Chapter 15 services, the parent may refer to Section 504, Chapter 15, and the Basic Education Circular entitle Implementation of Chapter 15. Also, school districts are required to conduct child find activities for children who may be eligible for gifted services via 22 PA Code Chapter 16. For additional information regarding gifted services, the parent may refer to 22 PA Code Chapter 16. If a student is both gifted and eligible for Special Education, the procedure in IDEA and Chapter 14 shall take precedence.
This notice shall inform parents throughout the school district, intermediate unit, and charter schools of the child identification activities and of the procedures followed to ensure confidentiality of information pertaining to students with disabilities or eligible young children. In addition to this public notice, each school district, intermediate unit and charter schools shall publish written information in the handbook and on the website. Children ages 3-21 can be eligible for special education programs and services.
HCSD October 27, 2020 Page 1 of 3
If parents believe that the child may be eligible for special education, the parent should contact the school district where the child attends or the Director of Special Education for the NW Tri-County Intermediate Unit identified at the end of this public notice. Children age three through the age of admission to first grade are also eligible if they have developmental delays and, as a result, need special education and related services. Developmental delay is defined as a child who is less than the age of beginners and at least three years of age and is considered to have a developmental delay when one of the following exists: (i) The child’s score, on a developmental assessment device, on an assessment instrument which yields a score in months, indicates that the child is delayed by 25 percent of the child’s chronological age in one or more developmental areas, or (ii) The child is delayed in one or more of the developmental areas, as documented by test performance of 1.5 standard deviations below the mean on standardized tests. Developmental areas include cognitive, communicative, physical, social/emotional and self-help. For additional information you may contact the Early Intervention Department at the Intermediate Unit. (See Evaluation Process below for contact info.)
Evaluation Process Each school district, intermediate unit and charter schools have a procedure in place by which parents can request an evaluation. For information about procedures applicable to your child, contact the school, which your child attends. Parents of preschool age children, age three through five, may request an evaluation in writing by addressing a letter to the Early Intervention Supervisor, NW Tri-County Intermediate Unit #5, 252 Waterford St., Edinboro, PA 16412 or call 1-800-677-8461.
Consent School entities cannot proceed with an evaluation or reevaluation, or with the initial provision of special education and related services, without the written consent of the parents. For additional information related to consent, please refer to the Procedural Safeguards Notice which can be found at the PaTTAN website at www.pattan.net. Once written parental consent is obtained, the school district, intermediate unit, charter schools, or PRRIs will proceed with the evaluation process. If the parent disagrees with the evaluation, the parent can request an independent education evaluation at public expense.
Program Development Once the evaluation process is completed, a team of qualified professionals and the parents determine whether the child is eligible. If the child is eligible, the individualized education program (IEP) team meets, develops the program, and determines the educational placement. Once the IEP team develops the program and determines the educational placement, school district staff, intermediate unit staff or charter school staff will issue a notice of recommended educational placement/prior written notice. Your written consent is required before initial services can be provided. The parent has the right to revoke consent after initial placement.
HCSD October 27, 2020 Page 2 of 3
Confidentiality of Information The school districts, intermediate units, charter schools and PRRIs maintain records concerning all children enrolled in the school, including students with disabilities. All records are maintained in the strictest confidentiality. Your consent, or consent of an eligible child who has reached the age of majority under State law, must be obtained before personally identifiable information is released, except as permitted under the Family Education Rights and Privacy Act (FERPA). The age of majority in Pennsylvania is 21. Each participating agency must protect the confidentiality of personally identifiable information at collection, storage, disclosure, and destruction stages. One official at each participating agency must assume responsibility for ensuring the confidentiality of any personally identifiable information. Each participating agency must maintain, for public inspection, a current listing of the names and positions of those employees within the agency who have access to personally identifiable information.
For additional information related to student records, the parent can refer to the FERPA at the following URL: http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html.
This notice is only a summary of the special education services, evaluation and screening activities, and rights and protections pertaining to children with disabilities, children thought to be disabled, and their parents. For more information or to request evaluation or screening of a preschool or school aged child, public or private, contact the school or district where your child attends. Additionally one may contact the name and number or e- mail listed below:
Christine Carucci Director of Special Education Northwest Tri-County Intermediate Unit #5 252 Waterford Street Edinboro, PA 16412 1-800-677-5610 [email protected]
The school district, intermediate unit and charter school will not discriminate in employment, educational programs, or activities based on race, color, national origin, age, sex, handicap, creed, marital status or because a person is a disabled veteran or a veteran of the Vietnam era. No preschool, elementary or secondary school pupil enrolled in a school district, intermediate unit, or charter school program shall be denied equal opportunity to participate in age and program appropriate instruction or activities due to race, color, handicap, creed, national origin, marital status or financial hardship.
HCSD October 27, 2020 Page 3 of 3
Harbor Creek School District STUDENT REGISTRATION
Integrated Pest Management
Dear Parent(s) or Guardian(s)
The Harbor Creek School District uses an Integrated Pest Management (IPM) approach for managing insects, rodents and weeds. Our goal is to protect every student from pesticide exposure by using an IPM approach to pest management. Our IPM approach focuses on making the school building and grounds an unfavorable habitat for these pests by removing food and water sources and eliminating their hiding and breeding places. We accomplish this through routine cleaning and maintenance. We routinely monitor the school building and grounds to detect any pests that are present. The pest monitoring team consists of our building maintenance, office, and teaching staff and includes our students. Pest sightings are reported to our 1PM coordinator who evaluates the "pest problem" and determines the appropriate pest management techniques to address the problem. The techniques can include increased sanitation, modifying storage practices, sealing entry points, physically removing the pest, etc.
From time to time, it may be necessary to use chemicals to manage a pest problem. Chemicals will only be used when necessary, and will not be routinely applied. When chemicals are used, the school will try to use the least toxic products when possible. Applications will be made only when unauthorized persons do not have access to the area(s) being treated. Notices will be posted in these areas 72 hours prior to application and for two days following the application.
Parents or guardians of students enrolled in the school may request prior notification of specific pesticide applications made at the school. To receive notification, you must be placed on the school's notification registry. If you would like to be placed on this registry, please notify your building principal in writing. Please include your email address if you would like to be notified electronically.
If a chemical application must be made to control an emergency pest problem, notice will be provided by telephone to any parent or guardian who has requested such notification in writing. Exemptions to this notification include disinfectants and antimicrobial products; self-containerized baits placed in areas not accessible to students, and gel type baits placed in cracks, crevices or voids; and swimming pool maintenance chemicals.
Each year the district will prepare a new notification registry. If you have any questions, please contact Mike Oleski, IPM Coordinator at 897-2100 or by e-mail at [email protected] .
Sincerely,
Kelly Hess
Superintendent of Schools
Harbor Creek School District
Integrated Pest Management Revised 10-2020 mm Form 09-A16 Student Registration Updated 2021.05.11 Harbor Creek School District
FOOD SERVICE INFORMATION
The Harbor Creek Food Service Department welcomes you to our School District. The following information is to help with your child's lunch account, If you would like an application for free or reduced lunches, you may obtain one from your school office or on our Website. Just click on free or reduced application's under the news and announcements section on the home page. Be assured all financial information is kept private. You may send the completed and signed application to your child's school office or mail to: Harbor Creek School District Food Service 6375 Buffalo Road Harborcreek, PA 16421
You are also able to review your child's lunch account activity and make payments online. Simply go to the Harbor Creek School District webpage and click on HAC & Meals Plus then select the directions and information link for our Meals Plus program. We encourage you to use the Meals Plus system to keep money on your child's account to help make a smooth transition through the lunch line each day, as well as, to review your child's account for accuracy.
If you have any questions, feel free to contact me, Patricia Stadler, at 897-2100 extension 2132.
Thank you.
Patricia Stadler
Student Registration Updated 2020.10.27 mm Harbor Creek School District STUDENT REGISTRATION
Welcome to Harbor Creek! The following documentation is required to be completed and submitted before a student can be admitted: (Please note that additional documentation will be required for Foster Children or Other Children who are residing with a resident adult who is not their parent.)
Proof of Age [24 P.S §13-1304] a. Original or certified official birth certificate or; b. Original or certified baptismal certificate
Immunization Records [24 p.s. §13-1303a] – Certificate of immunization issued in accordance with the rules and regulations of the Pennsylvania Secretary of Health and the Advisory Health Board. Students who are not immunized as required by the PA Dept. of Health, or who are not medically or religiously exempt may not be admitted to school. Children in all grades (K-12) need the following immunizations to attend school: 4 doses of tetanus*(1 dose on or after 4th birthday) 4 doses of diphtheria* (1 dose on or after 4th birthday) 3 doses of polio 2 doses of measles** 2 doses of mumps** 1 dose of rubella (German measles) ** 3 doses of hepatitis B 2 doses of varicella (chickenpox) or evidence of immunity
*Usually given as DTP or DT or Td **Usually given as MMR
Students in 7th Grade also need the following immunizations: 1 dose meningococcal conjugate vaccine (MCV) 1 dose of tetanus, diphtheria, acellular pertussis (Tdap) [if five years have elapsed since last tetanus immunization]
The only exceptions to the school laws for immunization are medical, Philosophical/Strong Moral Ethical Conviction and religious beliefs. If your child is exempt from immunizations, your child may be removed from school during a disease outbreak.
Parental Disclosure Statement [24 P.S. §13-1304a] Parent attestation to whether the student has been or is suspended or expelled for offenses involving drugs or alcohol, weapons or violence. (Page 4 of this packet)
Proof of Residency and Affidavit [24 P.S. §13-1302] Application for registration must be accompanied by three proofs of residency from the following Lists. Proof of Residency documents must indicate the physical address of residence and the name(s) of property owner(s). A child shall be considered a resident of the school district in which his parent or guardian resides, and will be enrolled in the school building he/she would normally attend in accordance with established school district attendance areas.
List A (Must Provide 1) List B (Must Provide 2) Mortgage Document Current Utility Bill (gas, water, electric, or cable, phone or cell phone) Lease Agreement Driver’s License Tax Bill Vehicle Registration Current Credit Card Bill
Student Registration Updated 2021.05.11 Harbor Creek School District STUDENT REGISTRATION FORM Residency /Multiple Family Affidavit Parent or Guardian Own/Rent/Live with a Harborcreek Resident Student’s Name ______Completed by Parent/Guardian or Harborcreek Resident
*Parent or Guardian is to complete only ONE of the following sections and provide all necessary residency documents. (see reverse side)
Parent/Guardian Owns a Home in Harborcreek To be completed by registrants who own or are purchasing a home in Harborcreek Section A I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee.
I/We, ______currently reside at ______Registrant Parent/Guardian Legal Name Address
Parent/Guardian Signature: ______Date: ______/______/______
Parent/Guardian Rents/Leases in Harborcreek To be completed by registrants who are renting a home in Harborcreek Section B I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee.
I/We, ______currently reside at ______Registrant Parent/Guardian Legal Name Address
Parent/Guardian Signature: ______Date: ______/______/______
Parent/Guardian Lives with a Harborcreek Resident Section C To be completed by the parent/guardian of the student and the Harborcreek resident with whom a family will reside
I/We understand that all of the information provided here is correct and current. I/We also understand that if residency should change for any reason, it is the responsibility of the resident to notify the Harbor Creek School District and amend the Residency Affidavit. Any false information provided can be punishable by law and will hold all parties responsible for a non-resident fee.
I / We, ______currently reside at ______Parent/Guardian Name Harbor Creek Resident’s Address which is owned leased by ______(______) Harbor Creek Resident’s Name Relationship
Through our notarized signature, we understand that the school district, pursuant to guidelines issued by the Department of Education and their own written policy, may require other reasonable information to be submitted to confirm this sworn statement.
______/______/______Parent or Guardian’s Notarized Signature Date
______/______/______Harbor Creek Resident’s Notarized Signature Date
______/______/______Notary’s Signature Date
Per 24 P.S. §13-1302, a person who knowingly provides false information in the above statement for the purpose of enrolling a child in a school district for which the child is not eligible commits a summary offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three hundred dollars ($300) for the benefit of the school district in which the person resides or to perform up to two hundred forty (240) hours of community service, or both. In addition, the person shall pay all court costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in accordance with 42561 during the period of enrollment. (Registration to attach all relevant Residency Documentation)
This form must be renewed by July 1st of each year for Section C only, and is subject to Central Office approval.
Student Registration Updated 2021.05.11 Harbor Creek School District STUDENT REGISTRATION FORM COMPLETE FOR ALL SECTIONS
THE FOLLOWING ITEMS MUST BE PROVIDED BY ALL RESIDENTS AND/OR PARENTS RESIDING IN HCSD TO COMPLETE STUDENT REGISTRATION:
Proof of Residency [24 P.S. §13-1302 Application for registration must be accompanied by 3 proofs of residency from the following lists. Proof of Residency documents must indicate the physical address of residence and the name(s) of property owners(s). A child shall be considered a resident of the school district in which his parent or guardian resides, and will be enrolled in the school building he/she would normally attend in accordance with established school district attendance areas. List A (Must Provide 1) List B (Must Provide 2) Mortgage Document Current Utility Bill Resident Lease Agreement Driver’s License Tax Bill Vehicle Registration Current Credit Card Bill Parent / Guardian Lives with a Harborcreek Resident PROOF OF RESIDENCE IN HARBORCREEK: HCSD requires evidence that a student resides in the district before the student can be enrolled. If your family is living with another Harborcreek resident temporarily, you may enroll your child by completing & having this Residency Affidavit notarized, which requires both the parent/guardian of the child and the resident to appear before the Central Registration office (or designee). The resident needs to provide the above documents, plus the parent/guardian needs to proved one of the below documents.
Parent List B (Must Provide 2) Living with a Drivers’s License Harborcreek Vehicle Registration Resident Cell Phone Bill Current Credit Card Bill
ACKNOWLEDGEMENT:
I acknowledge and agree to the following statements (initial each one below):
_____ My child resides with me ____ days per week at the address proven, which is my primary residency.
_____ I agree to notify HCSD within five (5) days when I change my residence either within or outside HCSD.
_____ Home visitation and/or other residency verification are part of a periodic process to confirm current residency status.
_____ The District will actively investigate all cases when it has reason to believe that residency status has changed and/or believe that false information has been provided. Verification may include home visits.
_____ The District may refer cases in which false information has been intentionally provided to our solicitor for further investigation.
_____ Investigations that reveal students have enrolled on the basis of providing false information will lead to immediate withdrawal and billing for non-resident fee.
_____ I understand that a person who knowingly provides false information for the purpose of enrolling a child in a school district for which the child is not eligible commits a summary offense and shall, upon conviction for such violation, be sentenced to pay a fine of no more than three hundred dollars ($300) for the benefit of the school district in which the person resides or to perform up to two hundred forty (240) hours of community service, or both.
_____ I understand that the person shall pay all court costs and shall be liable to the school district for an amount equal to the cost of tuition calculated in accordance with 24 P.S. 25-2561 during the period of enrollment.
______/______/______/______/______Parent/Guardian Signature Date Resident Signature Date
A RESIDENCY AFFIDAVIT FOR SECTION C IS VALID FOR THE CURRENT SCHOOL YEAR ONLY AND MUST BE RENEWED BY JULY 1ST OF EACH SCHOOL YEAR. FAILURE TO RENEW THIS FORM WILL DELAY CONTINUED ENROLLMENT.
Student Registration Updated 2021.05.11
Harbor Creek School District
FORM 200 STUDENT REGISTRATION FORM FOR OFFICE USE ONLY
Student Number Registration Date PA Secure ID # Building Enrolled Building Code Entry Code Grade
First Day Attendance Agency Name Agency Phone Social Worker Homeless Homebound Foreign Exchange Student (239A) Guardianship (1302) Foster Child (1305) Institutionalized Child (1306) Special Education
Has the student previously attended Please complete this section:
the HC School District? Y N Student Information Student Last Name, First Name, Middle Initial Date of Birth Grade Entering Male Female Is there a Court Order involving this student? Y N (If YES, please provide a copy to the school office, otherwise we are unable to abide by its contents.) Ethnicity Hispanic Not Hispanic Race Native Hawaiian/ American Indian/ Alaskan Native Black/ African American Pacific Islander Asian Multi-racial Hispanic White/Caucasian Street Address: Apt or Lot # City: Zip Code: Home Phone #:
Name of Previous School: Address of Previous School: (street, city, state, zip) Phone #:
Date of US Entry: Date of PA Entry: Date of 9th Gr. Entry: Parent(s) in Military Yes No Is this student currently receiving SPECIAL EDUCATION services? Yes No
Student Program Information Check ALL services that your child is currently receiving: Individualized Education Plan Gifted Individualized Education Plan
(Special Education Services) (Gifted Education Services) Section 504/Chapter 15 Service Agreement Early Intervention Program (Special Accommodations for Health/Physical needs) Autistic Support Blind/Visually Impaired
Deaf or Hearing Support Emotional Support
ESL (English as a Second Language) IST (Instructional Support Team)
Life Skills Support Physical Support
Remedial Math (Extra Help) Remedial Reading (Extra Help)
Speech/Language Support Other
Student Registration Updated 2021.05.11
Harbor Creek School District
FORM 200 STUDENT REGISTRATION FORM
Parent/Guardian Child Resides Number of Parents in Household (please choose one): 1 2 With (Check all Information that apply) Parent #1 Name: Mr. Mrs. Ms. Dr. Parent #1 Address, City, State, Zip (if different from student):
Parent #1 Cell #: Home #: Work #: Email: Circle priority # Parent #2 Name: Mr. Mrs. Ms. Dr. Parent #2 Address, City, State, Zip (if different from student):
Parent #2 Cell #: Home #: Work: Email: Circle priority # Guardian Name: Mr. Mrs. Ms. Dr. Guardian Address, City, State, Zip (if different from student): Relationship to Student
Guardian Cell Cell#: Home#: Guardian Alt #: Guardian Email: Circle priority # Emergency Contact #1 Mr. Mrs. Ms. Dr. Relationship to Name: Student
Emergency Cell#: Home#: Alt. # Contact Emergency Contact #2 Mr. Mrs. Ms. Dr. Relationship to Name: Student
Emergency Cell#: Home#: Alt. # Contact
Birthdate Name Grade School (mm/dd/year)
Other Adults or Children in Residence
Signature of Parent or Guardian: Date:
Student Registration Updated 2021.05.11
PA1304 Harbor Creek School District
FORM 6375 Buffalo Road, Harborcreek, PA 16421 www.hcsd.iu5.org (814)897-2100
Parental Disclosure Statement
Student Name Date of Birth Grade Parent or Guardian Name Address Telephone Number
Pennsylvania School Code §13-1304-A states in part “Prior to admission to any school entity, the parent, guardian or other person having control or charge of a student shall, upon registration provide a sworn statement or affirmation stating whether the pupil was previously or is presently suspended or expelled from any public or private school of this Commonwealth or any other state for an action of offense involving a weapon, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property.”
Please complete the following: I hereby swear or affirm that my child was was not previously suspended or expelled, or is is not presently suspended or expelled from any public or private school of this Commonwealth or any other state for an act or offense involving weapons, alcohol or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property. I make this statement subject to the penalties of 24 P.S. §13-1304-A(b) and 18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities, and the facts contained herein are true and correct to the best of my knowledge, information and belief.
If this student has been or is presently suspended or expelled from another school, please complete: Name of the school from which student was suspended or expelled: Dates of suspension or expulsion: (Please provide additional schools and dates of expulsion or suspension on back of this sheet.) Reason for suspension/expulsion (optional)
(Signature of Parent or Guardian)
(Date)
Any willful false statement made above shall be a misdemeanor of the third degree. This form shall be maintained as part of the student’s disciplinary record. An equal rights and opportunities school district.
Student Registration Updated 2021.05.11
200A Harbor Creek School District
FORM
HCSD Home Language Survey Date Student’s Name School Grade The Office of Civil Right (OCR) requires that school districts/charter schools/full day AVTS identify limited English Proficient (LEP) students in order to provide appropriate language instructional programs for them. Pennsylvania has selected the Home Language Survey as the method for the identification.
Please complete the following:
1. What is the language that your child first learned to speak? 2. Does the student speak a language other than English? Yes/No If yes, what language (Do not include languages learned in school.) 3. Is a language other than English spoken in the child’s home? 4. Has the student attended any United States school in any 3 years during his/her lifetime? If the answer to #4 is Yes please complete the following. Name of School State Dates Attended
______Signature of Parent/Guardian
Or
______Signature of person completing this form (if other than parent/guardian):
*The Harbor Creek School District has the responsibility under federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, Harbor Creek School District has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district may conduct screenings or ask for related information about students who are already enrolled in the district as well as from students who enroll in the school district in the future.
PLEASE RETURN THIS COMPLETED FORM TO YOUR CHILD’S SCHOOL.
Home Language Survey Pink
Student Registration Updated 2021.05.11
216 Harbor Creek School District
FORM
Release of records
To Whom it May concern: The below listed student has registered with the Harbor Creek School District effective ______. Please forward his/her school records to highlighted school below. School records should include transcript of grades, materials from both categories such as grades earned this year and/or withdrawal grades, standardized test scores, attendance, birth certificate, IEP, psychological records, speech, dental, health and immunization records, intake/ discharge summaries, drug and alcohol treatment and any other pertinent information.
Student’s Name: (Last, First, Middle) Student’s PA DOB: Grade: Secure ID #
Previous School or Agency: Address: Phone # Fax: You are hereby authorized to release copies of the following requested records: STANDARD RECORDS SPECIAL EDUCATION RECORDS Transcripts Most Recent IEP Attendance Evaluation/Re-evaluation Reports Discipline 504 Plan (Protected Handicapped) Test Scores Gifted Program Withdrawal Grades Health Records 339 Documentation Records are to be sent to the HCSD school listed below: Clark Elementary Klein Elementary Rolling Ridge Elem. HC Jr./ Sr. High Attn: Office Attn: Office Attn: Office Attn: Guidance Office 3650 Depot Rd. 5325 East Lake Rd. 3700 Ridge Parkway 6375 Buffalo Rd. Erie, PA 16510 Erie, PA 16511 Erie, PA 16510 Harborcreek, PA 16421 Phone: Phone: Phone: Phone: 814-897-2100 x 5500 814-897-2100 x 4100 814-897-2100 x 3300 814-897-2100 x 1211 FAX: 814-897-8723 FAX: 814-580-5419 FAX: 814-898-1916 FAX: 814-897-2136 Please note: Any information received by the Harbor Creek School District will be placed in a file to which parents have access and the capacity to release to a third independent agency. The professional staff of the Harbor Creek School District monitors this access. Information will be destroyed when it is no longer useful for educational purposes. I may revoke this release at any time except to the extent that the person who is to make the disclosure has already acted on it. Except as noted above, this release will expire one year from now unless revoked earlier in writing., All information released or obtained will be handled confidentially in compliance with the Family Education Rights and Privacy Act (FERPA).
______Parent/Guardian Signature Date Witness Signature
______Student Signature (14 years or older for Mental Health Records) Age Date (18 years or older for Educational Records)
Consent to obtain/release confidential Revised 2020.10.27 mm Form # 216 - Yellow Ed./Med./Health Info
Student Registration Updated 2021.05.11
FORM 216 Harbor Creek School District Annual Health Assessment Please complete both sides of this form and return to school
Student Name: ______D.O.B: ______Grade: ______
Preferred hospital in emergency: ______Does your student have health insurance? YES NO
The school nursing staff has non-aspirin pain medication and antacid that may be given at the nurse’s discretion. Please indicate which type of medication your child is permitted to have and sign below. The school has standing orders, which includes a list of approved treatments and medications recommended by our school physician.
Tylenol (Acetaminophen) Yes No Motrin (Ibuprofen) Yes No Antacid (Tums) Yes No Parent/guardian signature:
Please list any medications, dosage and reason for medication taken on a daily basis:
Medication Name Dosage Reason for Medication
Please read the following & CIRCLE any health concerns/conditions that your child has.
If you CIRCLE any of the following, please send in supporting documentation from your physician. Include any diagnoses, medication orders, activity restrictions, action plans, or special accommodations needed for the school environment.
*************************************************************************************************** LIFE-THREATENING ALLERGIES/REACTIONS: Yes No
If yes, to what? ______
Type of Reaction (circle): Mild Moderate Severe
Please describe reaction: ______
Is an Epi-Pen prescribed: Yes No ************************************************************************************************************************* ASTHMA: Yes No Is an inhaler prescribed for school? Yes No ADD/ADHD: Yes No Is medication prescribed during school hours? Yes No EPILEPSY/SEIZURE DISORDER: Yes No Date of last seizure: ______Emergency seizure medication prescribed: Yes No Medication Name: ______
Please Complete Reverse side
Updated 2019.03.28 Harbor Creek School District
Does your child currently have or had in the past any of the following conditions (please circle and describe below if needed):
Autism Spectrum Kidney/Bladder Disorder Concussion/Brain Injury
Recent Hospitalization Stomach/Bowel Neuro/Muscular Condition
Heart condition Skin Condition Diabetes/Thyroid issue
Cancer/Blood disorder Anxiety /Mood Disorder Other Respiratory Condition
Hearing Difficulty/Hearing Aides Vision Problems/Glasses Recent Injury/Illness/Surgery
Please describe any of the above conditions you circled: ______
______
***************************************************************************** Dental Exams: Complete ONLY for Grades 1, 3, and 7:
The Pennsylvania School Code provides for periodic dental examinations in grades 1, 3, and 7. The school dentist will be performing dental exams in the fall of each school year. Please indicate your preference below.
My child receives a regular dental exam. I will provide a copy for the school health record. Exam date: ______Dentist Name: ______
I give my permission for my child to be examined by the school dentist.
Signature for permission for school dentist to examine your child: ______
Physical Exams: Complete ONLY for Grades K, 6, and 11: The Pennsylvania School Code provides for periodic physical examinations in grades 6 and 11. If your child has not had either an athletic or annual physical within one year of the current school year, the school physician will provide a physical examination, free of charge, at a date to be determined. Please indicate your preference below.
My child received a physical exam by our family physician. I will provide a copy for the school health record. Exam date: ______Physician Name:______
My child received a sports physical within the last school year (Sport: ______)
I give my permission for my child to be examined by the school physician.
Signature for permission for school physician to examine your child: ______
Please sign below if the medical and health information on this form can be shared with your child’s teachers, bus drivers, coaches, and other school staff as deemed necessary to best provide for your child during school hours.
Parent/Guardian Signature: Date: ______
Updated 2019.03.28