Vicenza Elementary School Vicenza High School
Vicenza Middle School
VICENZA SCHOOLS REGISTRATION CHECKLIST SCHOOL YEAR 2016-2017 Documents required for school registration at: Vicenza Elementary/ Middle /High Schools Copy of Orders with Dependents listed ______Sponsor’s ID Card (Contractors Only) Immunization Records Previous School Records (if new student) Birth Certificate –Kinder & 1st Grade Students Kindergarten students must be 5 years-old by SEPTEMBER 1 of this calendar year 1st Grade students must be 6 years-old by SEPTEMBER 1 of this calendar year Passport for High School Students only A yearly physical is required for students participating in athletics (Grades 6-12 only) Required registration forms included in packet:
DoDEA-Form 600 – Shaded/Colored Areas for Office Use ONLY DoDEA ESL Form F4 – ESL Home Language Questionnaire Guidance Resources Checklist- Guidance Survey DSM For 149 – Request for Student Records DoDEA Form 700 & 700A – Consents & Authorizations, Internet Usage Agreement Nurse Form & DoDEA Form 2942.0 0-M-F1 - School Health Forms School Transportation Form– Return to Transportation Office Lunch account form – Return to PX Customer Service
Please return all completed forms & documents to the Registrar. DEPARTMENT OF DEFENSE EDUCATION ACTIVITY
ESL Home Language Questionnaire
Privacy Act Notice: Authority to Collect Information: 20 U.S.C. 927(c) and 10 U.S.C. 2164(f), as amended; E.O 9387; the Privacy Act of 1974, as amended, 5 U.S.C. 552a. Principal Purpose: The information will be used within the DoD to determine the services to be provided to a student to assist the child to receive a free appropriate public education. Disclosure to the Agency of the information requested on this form is voluntary; but failure to provide all requested information may result in the delay or denial of student services. DoDEA may disclose information requested in this form to other DoD activities and contracted service providers who require the information to deliver educational services to the child and for valid medical, law enforcement or security purposes, or for use in litigation concerning the delivery of student. Routine Uses: Disclosure of information contained in this form is authorized outside the DoD in accordance with the “Blanket Routine Uses” described at the beginning of the Office of the Secretary of Defense’s compilation of systems of records notices, published at http://www.defenselink.mil./privacy/notice/osd. THIS FORM IS COMPLETED AT THE TIME OF STUDENT ENROLLMENT
Child’s Name: ______Date: ______Grade: ______Date of Birth: ______Age: ______
1. What language is commonly spoken in your home?
___English ___ Another Language (Please specify):______
2. Does the child you are registering speak a language other than English? (Excluding foreign languages studied in school.) ____ No ____ Yes If yes: What language is spoken? ______
3. What language did your child use when he/she first began to talk? ___English ___ Another Language (Please specify)______
4. Has your child attended English speaking schools? _____ No _____ Yes If yes: How many years? ______
5. What language does your child read and/or write? ___English ___ Another Language (Please specify)______
6. What language do you most often use when speaking with your child? ___English ___ Another Language (Please specify)______
7. What language does your child use most often when speaking to you? ___English ___ Another Language (Please specify)______
8. If your child is cared for by another person on a regular basis, what language is most often used? ___English ___ Another Language (Please specify)______
9. Do you as a parent need to communicate with the school in a language other than English? ______No ______Yes If yes, in what language?______
Continued on the next page
DoDEA ESL Program Guide Form F4, March 2007 ESL Home Language Questionnaire (cont.)
If based on the results of this questionnaire it is necessary to conduct an evaluation, I understand and give my permission for:
1. My child to be evaluated using a standardized language proficiency test and/or academic achievement test to determine whether he/she is eligible for English as a Second Language (ESL) services. Additional information may be collected from my child’s teacher(s) and his/her school records.
AND
2. Annual Spring testing to measure my child’s academic and English language progress if eligible for services.
I understand that the ESL Teacher will share the results of the assessments with me when testing is completed.
______Parent Signature Date
To be completed by ESL Teacher: Recommendation: _____ Proficiency Testing _____ Records Review _____ No ESL Services Required
Signature of ESL Teacher: ______Date: ______
Distribution: Original to Student’s Cumulative File, Copy to ESL Teacher
DoDEA ESL Program Guide Form F4, March 2007 Vicenza Elementary/Middle/High School Unit 31401, Box 11, APO AE 09630
GUIDANCE RESOURCE CHECKLIST
______Student Name DOB/place of Birth Grade
SCHOOLS ATTENDED: ONLY FOR STUDENTS IN GRADES 7 -12:
SCHOOL YEAR: GRADE: NAME OF SCHOOL/ CITY, STATE:
SPECIAL NEEDS: In order to help determine proper placement for your child, please provide the following background information: FOR OFFICIAL USE ONLY Provider Notified: Date YES NO
a. Does your child have any special educational needs? ______b. Did your child receive services (in the entire educational history, K-12) from one or more of the following specialists?
Compensatory Education Teacher ______
Reading Improvement Teacher ______
Remedial Math/Reading Teacher ______
Speech / Language Therapist ______
Special Education Teacher ______
Learning Development / Disabilities Resource Teacher ______
Gifted Education: i) Has your child been formally assessed? ______ii) My child was found eligible: ______
Honors/Advanced Placement Teacher ______
Teacher for Hearing/Visually Impaired ______
Psychologist ______
Other Specialist (please specify) ______
c. Individual Education Plan Program (IEP): i) Has your child been previously assessed: ______ii) My child has an active IEP: ______
d. Does your child have a 504 PLAN from the previous school? ______e. Has your child repeated any grade? If yes which grade: ______f. Does your child have any physical problem that would prevent her/him from taking part in the normal P.E. program? ______If Yes please specify below: g. Did your child receive physical therapy? ______h. Did your child attend Sure Start or Head Start? ______i. Exceptional Family Member Program (EFMP: My Child is eligible/enrolled in EFMP ______
Is there anything else you want us to know about your child? You may want us to know about his/her main interest and hobbies or what sort of discipline he/she responds best to.
IF YOU ANSWERED “YES” TO ANY OF THE QUESTIONS ABOVE, THE SPECIALIST WILL BE NOTIFIED AND WILL CONTACT YOU. ______Sponsor’s Signature & Date REQUEST FOR STUDENT RECORDS DATE:______
PRIVACY ACT NOTICE AUTHORITY: Title V, USC Section 552a. PRINCIPLE PURPOSE: To authorize release of student records ROUTINE USES: Used by schools to request records for newly enrolled students. EFFECT OF NON-DISCLOSURE: Records will not be made available and credit for previous academic achievement may not be granted.
FROM: VICENZA ELEMENTARY / MIDDLE / HIGH SCHOOLS REGISTRATION OFFICE UNIT 31401, BOX 11 APO, AE 09630
Vicenza Elementary School contact: Vicenza Middle School contact: Vicenza High School contact: DIALING FROM U.S.A.- FAX # (011)39-0444-716743 DIALING FROM U.S.A.- FAX # (011)39-0444-715823 DIALING FROM U.S.A.- FAX #( 011)39-0444-717220 TELEPHONE #(011)39-0444-618640 TELEPHONE #(011)39-0444-618673 TELEPHONE #(011)39-0444-618605 Email Address: [email protected] Email Address: [email protected] Email Address: [email protected]
Address & Contact Info of Student’s Previous School
To: FAX#:
TELEPHONE#:
EMAIL:
The student(s) named below has (have) enrolled in our school. Please provide to us a copy of his/her (their) academic and special school records.
NAME OF STUDENT DATE OF BIRTH ATTENDED YOUR SCHOOL (Last, First, MI) FROM TO Last Grade
______
Manuela DeMuri – Vicenza Elementary School, Registrar Alisa Pehrson – Vicenza Middle School, Registrar Paola Battaiola – Vicenza High School, Registrar ______Signature Requesting official Name and Title
AUTHORIZATION
I, ______, do hereby request and authorize the release of records and files for the above named student(s). (Signature of parent or guardian, or student if 18 years old or older) DATE
DSM Form 149 April 1986 May be reproduced locally. NURSE’S FORM / PACKET 1 COPY REQUIRED PER STUDENT
FOR OFFICE PERSONNEL ONLY
GRADE _____ SY______
TEACHER ______
SCHOOL HEALTH RECORD
STUDENT’S NAME ______M F BIRTHDATE ______(LAST) (FIRST) (MIDDLE) (GENDER) (day) (mo) (yr)
SPONSOR’S NAME ______RANK ______SSN#(last 4 digits)
ADDRESS: CMR BOX APO AE HOME PHONE
SPONSOR’S UNIT ______DUTY PHONE
SPOUSE’S WORK PHONE ______
SPOUSE’S CELL PHONE ______
LOCAL EMERGENCY CONTACT NAME ______& PHONE ______DEPARTMENT OF DEFENSE EDUCATION ACTIVITY STUDENT HEALTH HISTORY PRIVACY ACT STATEMENT: AUTHORITY: 10 U.S.C. sections 2164 and 20 U.S.C. sections 921-932. PRINCIPAL PURPOSE: To obtain health information about a student enrolling in Department of Defense Education Activity (DoDEA) schools and programs to protect and enhance student health and to promote a safe school environment. ROUTINE USES: DoDEA may release information without prior consent within the DoD when needed to perform an official DoD duty, in accordance with 5 U.S.C. section 552a(b)(1). DoDEA also may release information outside the DoD, in accordance with 5 U.S.C. section 552a(b)(2-12), and the “Blanket Routine Uses,” published at http://www.defenselink.mil/privacy/notice/osd. Examples of release may include for valid medical, law enforcement or security purposes, or for use in litigation involving the DoD. DISCLOSURE: Disclosure to the Agency of the information requested on this form is voluntary; but failure to provide all requested information may result in the delay or denial of student services. NAME (Last, First, Middle Initial) Check: Date of Birth: Female ______/_____/_____ Male (mm / dd / yyyy) MEDICAL HISTORY: CHECK () ALL THAT APPLY AND EXPLAIN BELOW OR ATTACH ADDITIONAL PAGE(S). VISION RESPIRATORY ASTHMA ALLERGIES (A SHSG Form H-3-7 should be completed.) Wears glasses for reading Bronchitis Date of Diagnosis: Bee/Wasp sting Wears glasses full time Cystic fibrosis Drugs Wears contacts Sinusitis Inhaler needed: Environmental @ school * YES NO Food Color deficiency Other @ home YES NO Other CARDIOVASCULAR Lactose intolerance HEARING Sickle cell disorder PSYCHIATRY (The school will need a letter from the doctor stating Frequent ear infections Heart murmur Anorexia that the student is lactose intolerant.) Ear tubes Hemophilia/Other Bulimia Seasonal Other Insertion date: Bleeding disorders Autism Are tubes currently in place: PROCEDURES: (A SHSG Form H-4-9 should be completed.) Right? YES NO ADD/ADHD My child will/may require special health care Left? YES NO Hearing loss: Right Rheumatoid heart disease Depression procedures during the school day. (See page 2.) Left RESTRICTIONS Other Other Substance abuse history My child has a condition that warrants restriction of ENDOCRINE MUSCULOSKELETAL Suicidal activities during school hours. (See page 2) Diabetes Muscular Dystrophy Other MEDICATIONS Other Scoliosis NEUROLOGICAL My child takes daily medication at home. DERMATOLOGY Other Cerebral Palsy My child will need medications during school hours. (* See page 2.) Eczema GASTROINTESTINAL Frequent headaches My child may need emergency medications during Other Hernia Migraines school hours. (* See page 2.) GENITOURINARY Other Spina Bifida * MEDICATIONS DURING SCHOOL HOURS: SHSG: H-3-2, 3-3 and/or Bladder control problems DENTAL Seizures 3-8 forms must be signed by the physician and a parent; and must accompany Urinary tract infections Braces Sleep disorder prescribed medications that are to be given during school hours. The medication will be in the original container properly labeled by the physician or pharmacy. Other Other Other All medications will remain at school for the duration of the prescription. DoDEA FORM 2942.0 -M-F1 (SHSG: H-1), November 16, 2011 PREVIOUS EDITION IS OBSOLETE. Page 1 of 2 DEPARTMENT OF DEFENSE EDUCATION ACTIVITY STUDENT HEALTH HISTORY Explain any of the above here or attach additional pages. Identify any special health care procedures that your child may require during the school day:
Identify any condition that warrants a restriction of student activity, specify the nature and duration of the limitation and any other information that would help the school assist your child:
Identify any condition that warrants daily and/or emergency administration of medicine for your child and list those medications:
Parent/Sponsor’s Signature: Primary phone #: Date:
DoDEA FORM 2942.0 -M-F1 (SHSG: H-1), November 16, 2011 PREVIOUS EDITION IS OBSOLETE. Page 2 of 2 BUS OFFICE LOCATED AT VICENZA MIDDLE SCHOOL OFFICE - DSN 637-8679/ CIVILIAN 0444-618679
DEROS: Today's Date: TO: Vicenza Student Transportation Office Unit 31401, Box 11, APO AE 09630
DATE SERVICE DESIRED (Day/Month/Year) School Year 2017-2018
PLEASE PRINT CLEARLY: STUDENT INFORMATION
STUDENT'S NAME SCHOOL GRADE (PUT X IN APPROPRIATE BLOCK) LAST FIRST MI Gender DOB Age PK SS KN 1 2 3 4 5 6 7 8 9 10 11 12
SPONSOR'S NAME LAST FIRST MI RANK DUTY # HOME PHONE#
SPOUSE Last: First MOTHER'S CELL PHONE #
LOCAL QUARTERS ADDRESS (Street Name & #) CITY/TOWN FATHER'S CELL PHONE #
CMR PO BOX APO
ASSIGNED TO: (UNIT/ACTIVITY/SECTION) E-Mail ADDRESS
IN ACCEPTING TRANSPORTATION FOR MY DEPENDENTS ON DoDDS SCHOOL BUSES, I ACCEPT THE RESPONSIBILITY FOR THEIR CONDUCT AND ACTIONS WHILE THEY ARE PASSENGERS ON OR NEAR THE SCHOOL BUS. I FURTHER UNDERSTAND THAT EVIDENCE OF FAILURE TO COMPLY WITH THE RULES OF CONDUCT OUTLINED IN THE STUDENT/PARENT HANDBOOK AND ON THE ATTACHED SHEET OR WITH ANY INSTRUCTIONS OF DoDDS OFFICIALS, DRIVERS OR SAFETY ATTENDANTS COULD RESULT IN SUSPENSION OR TERMINATION OF SCHOOL BUS RIDING PRIVILEGES FOR MY DEPENDENTS.
SIGNATURE OF PARENT OR SPONSOR REMARKS: This section filled in by School Bus Office personnel:::
ASSIGNED AM ROUTE/STOP: ASSIGNED PM ROUTE/STOP:
Special considerations: Seat Assignment:
SPONSORS OF STUDENTS GRADES KINDERGARTEN THROUGH 3RD MAY DESIGNATE RESPONSIBLE ADULTS TO ESCORT THEIR CHILD TO/FROM SCHOOL BUS STOP. FULL NAME PHONE NUMBER(S)
SBO Initials: PROMPTLY REPORT ANY CHANGE OF ADDRESS OR TELEPHONE NUMBER BY TELEPHONING THE STUDENT TRANSPORTATION OFFICE
All information on this form may be shared with the DoDDS school system. Please see reverse for acknowledgement of the receipt of the School Bus Rules and Behavior Standards MEMORANDUM FOR STUDENT TRANSPORTATION OFFICE, UNIT 31401, BOX 11, APO AE 09630
SUBJECT: Reference DoDEA Regulation 2051.1 Review of School Bus Rules and Table of Consequences Acknowledgement of Receipt of Understanding
I acknowledge that I have received a copy of the School Bus Rules and Table of Consequences for students while on DoDDS school buses.
I have explained these rules and table of consequences to my child (ren) and I expect these rules to be followed by my child (ren). I I understand the consequences for misbehavior, which could include suspension or loss of school bus riding privileges.
Printed Name of Parent/Guardian Signature
Date Signed
CERTIFICATE Reference: DoD Regulation 4500.36.R. paragraph 6-10.a. (4) "Each incoming sponsor is required to certify in writing that he/she has been advised by the Installation or Community Commander (or representative) regarding the school bus commuting area, and understands that if family housing is obtained outside the bus commuting zone, transportation of any dependant student between residence and an existing school bus stop within the communing area is the sponsor's responsibility". This will be filed in the Housing Referral Office for the length of the sponsor's tour and any extensions thereof.
THEREFORE I certify that I understand the limits of the Vicenza/Verona School Bus Commuting Zone. If I change quarters to an area outside of this zone, I fully understand that I will not be authorized transportation services unless I transport my dependent(s) student to an established stop within the commuting zone.
Printed Name of Parent/Guardian Signature
Date Signed Parents are to take this form to PX Customer Service 1: Obtain the student ID number from the school 2 : With the student’s ID number fill this form out and open a lunch account at the Main Exchange Customer Service 3 : On the same day parents open a lunch account at the Main Exchange Customer Service, they must go online and apply for Free & Reduce Price meal at https://freeandreducedapps.aafes.com/ Once you have opened an account with PX we encourage you to monitor your child(ren)’s account(s) to make sure there is a sufficient amount of money to cover lunches.
AAFES Lunch Account Application
STUDENT’S INFORMATION
DODEA STUDENT ID # ______(issued by school registrar)
First Name:______
Last Name:______
Grade:______
School, Check one: H.S. 929 or Villagio 930
SPONSOR’S INFORMATION
First Name:______
Last Name:______
Unit and APO Address:______
______
______
Home Phone:______
Work Phone:______
E-mail:______FOOD AND MEAL INFORMATION
May the student purchase food items in addition to those
served on the advertised menu? (THESE ITEMS ARE FULL
PRICE REGARDLESS OF FREE/REDUCED STATUS.)
YES NO
If yes, would you like to limit the amount your child can spend each day?
YES NO
If yes, please list the daily spending limit: (Calculate, Reduced $.40 or
Elementary $2.50 or Middle/High school $2.75, plus A La-Carte items)……….$____.___
************************************************************************************************************************************ FOR USE BY AAFES Date Processed:______Processed By:______Student PIN Number: (6 DIGIT #)
PX will Issue 6 DIGIT PIN #
************************************************************************************************************************************* SCHOOL LUNCH DODEA STUDENT ID#
INFORMATION ______
( You will need this when you sign up at AAFES for a lunch account.) Horizon PIN—Provided by AAFES
______
SET UP A LUNCH ACCOUNT WITH AAFES Visit the AAFES customer service and set up a lunch account for your child. Please have student ID number provided by the school registrar’s office available. Your child will be given a 6 digit PIN to use when purchasing the school lunch. This PIN will deduct cost of meals from your prepaid account. Families on Free or Reduced meal program will still need a lunch account as well. For more information on lunch, menus, prices, etc. go to www.aafes.com/about-exchange/school-lunch-program/ APPLICATIONS FOR FREE OR REDUCED LUNCH PROGRAM Apply online at https://freeandreducedapps.aafes.com/ ** Do NOT include Housing allowance in total income. MY PAYMENTS PLUS (MPP) ACCOUNT All DoDEA Europe parents are encouraged to create an account with My Payments Plus (MPP). An MPP account is free and will allow you monitor and manage lunch account online or through a phone ap. It will also send you a trigger email when your AAFES lunch account is low. MPP does charge a small % fee for lunch account deposits, but the account and trigger email is absolutely free. You are not required to deposit through MPP. Even with an MPP account you can still make payments at AAFES customer service or the cafeteria for free. Go to www.MyPaymentsPlus.com For information and assistance, please see your School Liaison Officer (SLO) Find your SLO at : Europe.armymwr.com/slo