Dear Preschool Parent,

Welcome to the Pikeville Independent Preschool Program. You are receiving the first step in determining the eligibility of your child for preschool. It is important to note that there is a $1000.00 tuition charge for all preschool students. The only students excluded from the $1000 tuition charge are 3 or 4 year old students with disabilities or 4 year old students “at risk” (income based). It is also important to note that our preschool is designed for children who are at risk for learning difficulty, eligible based on household income or have a disability/IEP. If your child already has an IEP there will be no screening necessary. Please provide that document with the preschool enrollment packet. If a 3 or 4 year old student with disabilities or a 4 year old student “at risk” moves into our district during the school year we are required by law to place this student/s in our classroom. This could possibly result in having to remove your child from our preschool program if we are already at our limit (19).

All potential preschool children must be screened to determine the eligibility process. To have the screening scheduled, we ask that you complete and return the preschool enrollment packet as soon as possible. When we receive this information, we will contact you to schedule a screening time and date for your child.

The screening is the first step toward eligibility. Based on the outcome of the screening, your child may or may not require interventions. This will be further explained to you after the screening has taken place.

Your support in completing and returning the identified pieces is the first important step in providing a high quality preschool program for your children.

Respectfully,

Frosty Davis, Preschool Coordinator

Documents Needed:

ü Registration Packet ~ Available On-line April 1st ü Birth Certificate ~ Student must be five years old by August 1, 2018 ü Current Immunizations ~ including Hepatitis A ü Physical Exam ~ dated no earlier than July 1, 2017 ü Eye Exam ~ dated no earlier than January 1, 2018 ü Dental Screening ~ dated no earlier than January 1, 2018 ü Social Security Card ~ optional ü Insurance Card ü Proof of Income

Preschool Coordinator Pikeville Elementary School Registration Packet

In an effort to make registration easier and faster for you we are providing this electronic packet to be completed at your convenience and printed out. This form can be typed into. Once you complete the packet, please print it out and add your signatures where required. Please bring this completed packet to registration to lessen your wait time.

As you fill in information on Form Page 1 duplicate information will automatically fill in the following pages.

Boxes may be typed into and buttons may be clicked. Many boxes have small arrows indicating drop down boxes. Just click and select the best choice.

When printing, PLEASE DO NOT PRINT DOUBLE-SIDED. Some of the pages must go to different offices.

When enrolling your child, you must present the following documents before your packet is considered compete and we may process your enrollment packet: Required Documents:

● Birth Certificate – Student must be five years old by August 1, 2018 ● Social Security Card ● School Physical Certificate--dated no earlier than July 1, 2017 ● Kentucky Immunization Certificate *NEW* including Hepatitis A ● Vision Examination Certificate--dated no earlier than January 1, 2018 ● Dental Screening Certificate--dated no earlier than January 1, 2018 ● PES Enrollment Packet— available: online: www.pikeville.kyschools.us - April 1, 2018 and Elementary School Office - April 4th

Packets will only be accepted on Tuesdays between 9am-2pm during Summer Enrollment; May 29-August 3, 2018.

Only those students who have turned in all required documents will be eligible to attend KinderCamp, to be held in August 2018. For more information or to schedule an appointment at a later time, please contact: Lara Keene at 432-4196 or [email protected]

PRESCHOOL REGISTRATION In addition to the documents listed above:

• Medicaid Card (if eligible) • Proof of Income For more information concerning preschool enrollment, please contact Frosty Davis at 432-0185 or [email protected]

When printing this form please ensure after clicking File, then Print, Orientation is set to “Auto portrait/landscape” so each page will print properly. PLEASE DO NOT PRINT DOUBLE-SIDED. Some of the pages must go to different offices.

We apologize for the inconvenience, but you will have to complete one packet for EACH child you have attending PES this year. We cannot combine packets. PIKEVILLE ELEMENTARY SCHOOL ENROLLMENT FORM

Student Information: School Year: 20___ - 20___ Tuition Student: Yes___ No___ Name: ______Gender: _____ Race: ______Birth Cert #: ______Birthdate: ______Social Security #: ______(optional) Birthplace: ______Mother’s Maiden Name: ______Grade: ______

Does an IEP exist?: Yes___ No___ Does a 504 exist?: Yes___ No___ Does student have any health issues/concerns?: Yes___ No___ Name and Address of last school attended: Has your student been previously evaluated, identified, or received services in: ESL: ___ Speech: ___ G/T: ___ Special Education: ___ Legal Guardian Student Lives with this Person: Yes___ No___ (If not the parent do you have court documents on file with us?) Yes___ No___ Male: Female: Full Name: ______Social Security #: ______(optional) Birthdate: ______Home #: ______Email: ______Mailing Address: ______Physical Address: ______Cell #: ______Work Phone#:______City, State, Zip: ______Place of Employment: ______Legal Guardian Student Lives with this Person: Yes___ No___ (If not the parent do you have court documents on file with us?) Yes___ No___ Male: Female: Full Name: ______Social Security #: ______(optional) Birthdate: ______Home #: ______Email: ______Mailing Address: ______Physical Address: ______Cell #: ______Work Phone#:______City, State, Zip: ______Place of Employment: ______Emergency Contact & Pickup Information (please list individuals other than parent) Full Name Relationship to student Gender Work # Home # Cell # Social Security # 1) 2) 3) Other Household Members Transportation: Full Name Relationship to student Gender Birthdate # Grade School Attending AM BUS: PARENT: 1) BUS PM: PARENT: 2) Transportation changes will only be accepted in writing prior to 2:00pm via 3) Email or in person from the guardian. [email protected] Parent/Guardian Signature: ______Parent/Guardian Printed Name(s): ______Date: ______***Office Use Only*** Birth Certificate: _____ Immunization Records: _____ Physical: _____ Vision: _____ Dental: _____ Date Accepted: Grade: _____ Teacher: ______Logged in Book: _____ Brigance Appt: _____ Photo Release: _____ Early Entrance Petition: _____ Early Petition Received: _____ Early Entrance Approved: _____ Time Accepted: PIKEVILLE ELEMENTARY SCHOOL ! Student'Information:' !Name:!______!!!!Grade:!______!! Student’s!Physical/911!Address:!______! City,!State,!Zip:!______! ! Media'Release'Form' ! 'I'DO!give!permission!to!the!school/news!media!to!photograph/videotape!my!child.!! It!is!my!understanding!that!this!photograph/videotape!or!portions!thereof!may!be!used!for!public!viewing.!I!agree!to!allow!my!child! ! to!participate!in!these!projects!without!financial!remuneration,!and!I!understand!that!this!releases!the!school/district!from!any! future!claims,!as!well!as!from!any!liability!arising!from!the!use!of!the!said!photograph/videotape.! !! 'I'DO'NOT!grant!permission!for!the!school/news!media!to!photograph/videotape/interview!my!child!or!to!post!information!on!the! Web!about!my!child.! ! ''''''''! ! !Student'Usage'of'Computers,'Network,'Internet,''and'Telephones! I,!the!student,!understand!and!will!abide!by!the!Pikeville!Independent!School!District's!Acceptable!Use!Procedures!for!the!Network,! !Internet!and!Telephone!Usage.!I!further!understand!that!any!violation!of!the!regulations!stated!in!these!procedures!is!unethical!and!may! constitute!a!criminal!offense.!Should!I!commit!any!violation,!my!access!privileges!may!be!revoked,!school!disciplinary!action!may!be!taken,! and/or!appropriate!legal!action!may!be!pursued.!This!document!shall!be!valid!until!revisions!are!made!to!the!District!Acceptable!Use! ! Policy!or!until!the!student,!parent,!or!guardian!makes!a!written!request!to!change!the!access.!!!!!!!!!!!!!!!!!Parent'Initials:'______! ! !I!agree!to!read,!review!and!discuss!the!District!Acceptable!Use!Procedures!for!the!Network,!Internet!and!Telephone!Usage!with!my! child/student,!which!is!found!in!the!District!Code!of!Acceptable!Behavior!and!Conduct!book,!prior!to!giving!permission!for!access.!!I! !understand!that!a!copy!of!The!District’s!Acceptable!Use!Procedures!for!the!Network,!Internet!and!Telephone!Usage,!The!District!Code!of! Acceptable!Behavior!and!Conduct,!The!Attendance!Policy!and!the!Pikeville!School!Code!of!Conduct!is!available:!1)!On!line!at! !www.pikeville.kyschools.us;!2)!At!the!front!office!of!each!school;!3)!A!copy!is!presented!to!each!student!upon!enrollment!each!year.!!I! understand!that!access!to!the!Network!and!Internet!is!designed!for!educational!purposes.!!The!District!has!taken!precautions!to!eliminate! !controversial materials:!!however,!I!recognize!it!is!impossible!to!restrict!access!to!all!controversial!materials.!!I!will!not!hold!the! District/school/staff!responsible!for!materials!that!my!child!acquires!on!the!Network!or!Internet.!!Further,!I!accept!full!responsibility!for! !supervision!when!my!child’s!use!is!not!in!a!school!setting.!!I!hereby!give!permission!to!issue!an!account!for!my!child!and!certify!that!the! information!contained!on!this!form!is!correct.Parent'Initials:'______! !!

Home Technology Survey Information

Do you have a computer at home? Yes No Is the computer less than 5 years old? Yes No

What type of device(s) do you own? (Check all the apply): Desktop Laptop Tablet Chromebook

Do you have Internet Access at home? Yes No If your have internet at home, what type? Cable Modem DSL (telephone company) Satellite Dish Dial-Up Access If no, do you use cellular service (i.e. 3G, 4G, LTE, etc.) to access the web, email, or social media? Yes No

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' Parent/Guardian'Printed'Name:'______' ' ' ' Parent/Guardian'Signature:'______' ' Date:'______' ! PIKEVILLE ELEMENTARY SCHOOL

Student Information: Name: ______Grade: ______

FERPA Notice

The Family Educational Rights and Privacy Act (FERPA), a federal law, requires that the Pikeville Independent School District, with certain exceptions, obtain your written consent to the disclosure of personally identifiable information from your child’s education records. However, Pikeville Independent Schools may disclose appropriately designated “directory information” without written consent, unless you have advised the District to the contrary in accordance with District procedures. The primary purpose of directory information is to allow the Pikeville Independent Schools to include this type of information from your child’s education records in certain school publications. Examples include:

A playbill, showing your student’s role in a drama production; The annual yearbook; Honor roll or other recognition lists; Graduation programs; and Sports activity sheets, such as for wrestling, showing weight and height of team members.

Directory information, which is information that is generally not considered harmful or invasion of privacy if released, can be disclosed to outside organizations without a parent’s prior written consent. Outside organizations include, but are not limited to, companies that manufacture class rings or publish yearbooks. In addition, two federal laws require local educational agencies (LEAs) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon request with three directory information categories-names, addresses and telephone listings-unless parents have advised the LEA that they do not want their student’s information disclosed without their prior written consent.

If you do not want Pikeville Independent Schools to disclose directory information from your child’s education records without your prior written consent, you must notify the District in writing by September 1st. Pikeville Independent School has designated the following information as directory information:

Student Name Participation in officially recognized activities and sports Address Telephone listing Weight and height of members of athletic teams Electronic mail address Photograph Degrees, honors and awards received Date and place of birth Major field of study Dates of attendance Grade level The most recent educational agency or institution attended

Behavior & Discipline Policy I understand a copy of the District Code of Acceptable Behavior and Discipline, the Attendance Policy, the Acceptable Use Policy and a copy of the Pikeville Elementary School Code of Conduct is available: Parent Initials: ______- On line at www.pikeville.kyschools.us - Front office of each school - Copy presented to each student upon enrollment

My child and I have read, understand, and agree to abide with the contents in this Code book. (One option must be marked.) I DO want corporal punishment I DO NOT want corporal punishment used as a discipline option for my child. I understand that in place of corporal punishment a one-day suspension will be used.

Family Resource Center Information

The Pikeville Independent Family Resource Youth Services Center offers services or referrals to services that include but are not limited to preschool child care, after-school childcare, family literacy, health services, social services, career exploration and development, substance abuse education and counseling, family crisis and mental health counseling and basic needs assistance. FRYSC has two (2) center sites located at Pikeville Elementary School and Pikeville High School.

Dear Parents, Pikeville Independent FRYSC coordinates donations from community programs, churches and agencies to provide Thanksgiving and Christmas assistance to students enrolled in our schools. If your student is in need of assistance, please contact FRYSC Center Staff by calling Pikeville Elementary: Amanda Hartsock at 432-4196 or Pikeville High School: Elisha Justice 432-0185. A parent/guardian of a student in need of holiday assistance MUST contact FRYSC staff on or before October 15th of each academic year. Failure to contact center staff and provide current contact information and clothing sizes will prevent services from being delivered.

Parent/Guardian Printed Name: ______

Parent/Guardian Signature: ______Date: ______

PIKEVILLE ELEMENTARY SCHOOL ! Student'Information:' ' ' ' ' ' ' ' !Name:!______!!!!!!!Grade:!______!!!!!!!Gender:!_____!!!!!!!Race:!______!! Student’s!Physical/911!Address:!______! City,!State,!Zip:!______! !Parent’s!Name(s):!______! Parent’s!Home!#:!______!!!!!! Parent!#1!Cell!#:!______! ! Parent!#2!Cell!#:!______!! !!

! School3Related'Student'Trip'Permission'Slip'and'Medical'Release'Form'for'the'upcoming'school'year' (Office'Copy'–'Pikeville'Elementary'School)' ' ! All'school3related'trips'for'the'upcoming'school'year.' (Sports'and'Academic'Coaches'will'require'an'additional'permission'form'for'their'trips.)' ! ' From!time!to!time!during!the!school!year,!various!classes!will!go!on!field!trips!in!connection!with!their!class!work.!!In!order!to!avoid!repetition!in!securing! ! your!permission!for!these!trips,!this!form!will!cover!all!trips!to!be!taken!throughout!the!school!year.! ! In!addition,!in!the!event!of!accident!or!sudden!illness!while!on!the!schoolOrelated!student!trip,!I!authorize!school!personnel!to!contact!the!physician(s)! ! listed!on!my!child’s!school!enrollment!data!forms!and!authorize!those!physician(s)!to!render!such!treatment!as!may!be!deemed!necessary!in!an! emergency,!for!the!health!of!said!child.!In!the!event!physician(s),!parent(s),!or!other!persons!designated!by!the!parent!cannot!be!contacted,!school! ! personnel!are!hereby!authorized!to!take!whatever!action!is!deemed!necessary!in!their!judgment,!for!the!health!of!said!child.! ' ! I!will!not!hold!the!school!district!financially!responsible!for!the!emergency!care!and/or!transportation!for!said!child.! ! Mode!of!Transportation!SCHOOL'BUS! ! ! Cost!to!Student,!if!applicable!!!$'VARIES'PER'TRIP'TAKEN! ! ! I!hereby!give!permission!for!my!child!to!participate!in!the!above!mentioned!schoolOrelated!student!trip(s).! ! ! I!DO!NOT!give!permission!for!my!child!to!participate!in!the!above!mentioned!schoolOrelated!student!trip(s).! ! ! Known'Allergies'to'Drugs'and'Anesthetics:!______! ! ______!

! ! ! ! ! Emergency'Information'Form'

In!case!of!emergency!and!neither!you!nor!the!people!you!have!listed!as!an!emergency!contacts!on!your!school!enrollment!forms!can!be!contacted,!your! !child!will!be!taken!to!the!nearest!health!care!facility.!

!Is!your!child!on!any!routine!medication?! ___!Yes! ! ___!No! If!yes,!what!condition:!!______!

!Does!your!child!have!a!history!of!heart!disease,!diabetes,!T.B.,!nervous!disorder,!epilepsy,!bee!sting,!ear!infection,!seizures,!asthma,!allergies,!etc?!!Please! describe:!!______!

!______!

!Student’s!Physician:!______! ! Phone:!______!

I!give!my!permission!for!my!child!to!be!taken!by!ambulance/school!personnel!to!a!health!care!provider!for!emergency!treatment!in!the!event!I!cannot!be! !located.!!I!will!be!responsible!for!any!fees.!!Parent'Initials:!!______! ! ! !! ! ! ! Parent/Guardian'Printed'Name:'______' ' ' ' Parent/Guardian'Signature:'______' ' Date:'______' ! Pikeville'Independent'Schools'222222''Home'Language'Survey' School&______&&& Grade&______& School&Year&______&

Child’s&Name:&&&______&____&&&&&______&&&&&&&______& & & !!!!(First!Name)! ! !!!!!!!!!!(Middle!Name)! !!!!!! !!!!!!!!!!!!! ! (Last!Name)! Parent/Guardian’s&Name:&&&______&&&&&&______& ______& & & &&&&& &&&& &(First!Name)! ! !!!!!!!!(Middle!Name)! !!!!!!!!!!!! !!!!!!!!(Last!Name)! &______&&&&&&&______& ______& & & &&& & !!(First!Name)! ! !!!!!!!!(Middle!Name)! !!!!!!!!!!!!! !!!!!!!!(Last!Name)! Mailing&Address:&______&&&&______&&&&______&&&______& & & & Street/P.O.!Box! ! ! ! City! ! State! ! Zip! Physical&Address:&______&&&&______&&&&______&&&______& Street! ! ! ! City! ! State! ! Zip! Phone&Numbers:&&______&&______&&______&&______&&______& ! ! ! Home! !!!!!!!!!!!!!!Work! ! Cell!#1! ! Cell!#2!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Other! 1. Child’s&date&of&birth:&&&&&&&&&&&______& Was&your&child&born&in&the&United&States?&&&&&&&&&YES&&&&&&&&&&&&&&&&&&&&No&&&&&&&If&YES,&in&which&State?&&&______& If&NO,&in&what&other&country?&&&&&&&&&______& If&NO,&date&child&entered&the&U.S.:&______&&(Month/&Day/Year)& 2. Has&your&child&attended&ANY&school&in&the&United&States&for&any&three&(3)&years&during&their&lifetime?&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& & YES&&&&&&&&&&&&&&&&&&&&NO& If&YES,&please&provide/list&school&name(s),&state&and&dates&attended:& Name&of&School&______&State&______&&Dates&______& Name&of&School&______&State&______&&Dates&______& Name&of&School&______&State&______&&Dates&______& 3. What&is&the&language&most&frequently&spoken&at&home?&______&

4. If&available,&in&what&language&would&you&prefer&to&receive&communication&from&the&school?& ______& 5. Please&check&if&your&child&is:& A. ___&Native&American&Indian&&&&&&&&&&&&&&&&&&&&&&&&C.&___&Native&Pacific&Islander& B. ___&Alaska&Native&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&D.&___&Native&U.S.&Virgin&Island& 6. Is&your&child’s&firstYlearned&OR&home&language&anything&other&than&English?&&&&&&&&&&&&&YES&&&&&&&&&&NO& If'you'responded'“YES”'to'question'number'6'above,'please'answer'the'following'questions:' 7. In&what&country&did&your&child&most&recently&reside?&______' 8. Which&language&did&your&child&learn&when&he/she&first&began&to&talk?& ______' 9. What&language&does&your&child&most&frequently&speak&at&home?& ______' 10. What&language&do&YOU&most&frequently&speak&to&you&child?' '''''''''''''''''Father'______'''''''''''''Mother'______' 11. Please&describe&the&language&understood&by&your&child&(CHECK&ONLY&ONE)' A. '___'Understands&only&the&home&language&and&NO&English' B. '___'Understands&only&the&home&language&and&SOME&English' C. ___'Understands&the&home&language&and&English&EQUALLY.' D. ___'Understands&mostly&English&and&some&of&the&home&language' E. ___'Understands&only&English' '

Parent/Guardian'Signature'______''''Date'______'

Kentucky Migrant Education Program Parent Employment Survey

! Versión en español en el otro lado de la hoja !!!! !

The !Migrant Education Program (MEP) is authorized by Title 1, Part C of the Elementary! and Secondary Education Act (ESEA). The KEDC Regional Migrant Education Program (606-547-1414) provides a variety of educational services to families who work in agriculture, regardless of their nationality or legal status. This program is free of charge to all eligible families and may include tutoring, free lunch eligibility, educational field trips, summer programs, parent involvement activities, emergency needs and referrals to other services as needed. A program employee may contact you for further information if needed.

Child’s Name: ______

Birthdate: ______Grade: ______School: ______

1. In the past three years, has your family lived in another Kentucky school district, another state, and/or another country? Yes ______(continue to #2) No ______(stop here) ______2. In the past three years, has anyone in your household had a job working with any of these products (not including your own property) on a farm, in a field, in a greenhouse, in a nursery, or in a factory? Please circle all that apply.

! ! ! ! ! Livestock (cattle, Eggs Chickens ! Crops (wheat, corn, Vegetables Processing (meat,

pigs, sheep, dairy, soybeans, etc.) fruit, vegetables, ! etc). trees, etc.) ! ! !

! ! ! ! ! ! ! ! Tobacco Fruits Hay Nursery, Sod, Trees, Timber, !Soil Preparation Greenhouse Plants, Flowers ! Flowers If you circled one or more, continue to #3. None of these ______(stop here) ______

! 3. Parents’ Names: ______

Address: ______

City: ______State: ______Zip Code: ______Telephone: ______Please list all children in the household less than 22 years of age: ! Name Date of Birth Grade School

SCHOOL/HOMEROOM:______GRADE: ______

CONSENT FOR SCHOOL HEALTH SERVICES/MEDICATION ADMINISTRATION PIKE COUNTY HEALTH DEPARTMENT/PIKE COUNTY SCHOOL SYSTEM/PIKEVILLE INDEPENDENT SCHOOLS

CHILD'S NAME:______BIRTHDATE:______GENDER ______RACE: ______

ADDRESS:______

CHILD’S SOCIAL SECURITY #: ______HOME PHONE:______WORK PHONE:______

EMERGENCY CONTACT NAME:______PHONE ______(Other than Parent) KY MEDICAID ID# (if applicable):______NUMBER IN HOUSEHOLD:______

MANAGED CARE ORGANIZATION: (circle one) AETNA WELLCARE ANTHEM HUMANA PASSPORT MCO POLICY NUMBER:______

STUDENT'S DOCTOR:______DOCTOR’S PHONE:______

STUDENT’S DENTIST:______DENTIST’S PHONE:______SEIZURES______

ALLERGIES/ASTHMA (food, insects, medication, latex, fluoride, other)______DOES YOUR CHILD REQUIRE AN EPI-PEN PRESCRIPTION FOR ANY ALLERGIES? YES______NO______CURRENT MEDICATIONS______CHRONIC MEDICAL ILLNESSES______

SIGNIFICANT MEDICAL / SOCIAL HISTORY (Including Injuries) ______

SIGNIFICANT FAMILY MEDICAL HISTORY Hypertension High Cholesterol Diabetes Other______Please check any of the following, which you will allow your child to be given, and state dosage if necessary. All doses not specified will be given according to the child’s age and weight using manufacturer’s guidelines. Advil/Motrin (Ibuprofen) Benadryl Orajel (toothache) Chloraseptic (sore throat) Aloe Vera (for burns) Cold Remedies (cough syrup, decongestant) Sun Screen (SPF 15 or above) Antacids (Maalox, Tums, etc.) Diarrhea Medication Topical Antiseptics Antibiotic Ointment (Neosporin) Eye Drops (Visine, Murine, etc) Tylenol (acetaminophen) Anti Nausea/Anti Vomiting Hall Mentho-lyptus cough drops Anti-itch Spray or Lotion (insect bites, etc.) Hydrocortisone Cream (for itching)

Additional instructions of consideration:______The following information will aid the School Nurse in making an accurate assessment of your child in case of illness or emergency.Please check the appropriate space if your child has ever had any of the following: Anemia Asthma Persistent Cough Exposed to Tuberculosis Birth Defects Chest pain Leukemia Shortness of breath Diabetes Seizures Sleep Problems Head, Eyes, Ears, Throat Problems Chicken Pox Unexplained Weight Loss/Gain Stomach or Bowel Problems Blood Transfusion Rheumatic Fever Unexplained tiredness Joint or Muscle Pain or Anaphylactic Episodes Stiffness

IF THIS INFORMATION SHOULD CHANGE, PLEASE NOTIFY THE SCHOOL NURSE, IMMEDIATELY!!! I consent to care at the school provided by the Pike County Health Department which may include screenings such as Scoliosis screening, vision and hearing exams, assessments, lab tests, treatment, first-aid, over the counter medicine, and any other health service given to me/my child by staff or agents of the Pike County Health Department. I understand that no guarantees are being made as to the effect of any exam or treatment on me/my child. I like-wise release the staff from any liability related to the administering of the above medications to my child so long as the treatment is provided according to the above instructions. I authorize the school health clinic to release medical information about my child, as permitted by the Health Insurance and Portability and Accountability Act of 1996 (HIPPA), to his/her primary care provider and to share pertinent medical information (history of allergies or significant medical history) with school staff who may need to provide care to my child in an emergency. I understand that the sharing of this information is on a need to know basis only. I also understand that the information obtained for the school physical, including immunization information, will be released to my child’s school. If my child has Medicaid or KCHIP, I also authorize the school clinic to release this information to those agencies so that the Medicaid or KCHIP can be billed for visits to the school clinic. This permission can be revoked at any time. No services will be provided unless the signed form is returned. I agree to provide the agency nurse an order from my child’s physician for any prescription medications before they can be given. I also understand by signing this consent, I acknowledge that I may request a copy of the Pike County Health Department’s Privacy Notice by calling the Pike County Health Department’s main office at 437-5500 or have access to a copy of the Pike County Health Department’s Privacy Notice located at www.pikecountyhealth.com/v3/uploads/documents/pchd_hipaa_pp.pdf .

Signed:X______Printed:______Date:______(Parent or Guardian) (Parent or Guardian) PCHD 126 (Rev. 3/20/17) PIKE COUNTY HEALTH DEPARTMENT BRIGHT SMILES @ SCHOOL Patient Registration and Consent Form

Please complete form and return if you would like for your child to have the services listed below. Please fill out this form today and return it to your child’s teacher. Please print (All questions refer to the child for whom services are requested.) With your permission, a dental hygienist will provide your child with:

• A dental assessment of the condition of the mouth and teeth • Dental Sealants (long-lasting plastic coatings over the back teeth) • An age-appropriate dental cleaning • Oral Hygiene Instruction including nutrition counseling • Fluoride Varnish (to prevent future cavities) • A personal Dental Report Card

(If NO services are needed, please complete CHILD’S NAME ONLY)

1. ______2. ______-______-______3. _____/_____/______4. SEX (Check One) q MALE q FEMALE CHILD’S NAME: Last First Middle SOCIAL SECURITY # BIRTHDATE 5. ______MAILING ADDRESS CITY COUNTY STATE ZIP

6. ______7.______8. ETHNICITY (Check One) qHISPANIC or LATINO q NOT HISPANIC OR LATINO SCHOOL GRADE/TEACHER

9. RACE (Check One) q WHITE q BLACK or AFRICAN AMERICAN q AMERICAN INDIAN or ALASKA NATIVE qASIAN qNATIVE HAWAIIAN

10. Parent/Guardian Name: ______Relationship to child:______Phone (H) ______(C) ______(W) ______

11. Does your child have a dentist? YES NO If so, who? ______Date of last cleaning: ______

12. Does your child need premedication before a cleaning? YES NO 13. Does your child have any allergies to food or to medicine? YES NO If yes, please list______

14. List any current medication your child takes (include over the counter medication or herbal medication) ______15. Does your child have any illnesses, diseases, or conditions including, ADHD, asthma, heart conditions, diabetes, contagious diseases? Yes No Please explain: ______

16. Does your child have a Medicaid Card? (Check One) q Yes qNo qApplied/ Pending qKCHIP If Yes, MEDICAID Card Number ______If yes to Medicaid check one: q Aetna Better Health (Coventry) qWell Care qAnthem qHumana Care Source qPassport

CONSENT FOR HEALTH SERVICES: (Expires 1 year from date signed) Of my own free will I consent to care which may include screening, exams, treatment, and any other health service given to me by staff or agents of this health department. I understand that no Guarantees are being made as to the effect of any exam or treatment on me. I also understand I may be tested for (HIV) infection, Hepatitis B, or any other disease carried by blood or body fluids if a health care worker is exposed to my blood, body fluids or tissue. This program does not take the place of regular check-ups at a dental office. The preventive dental services are being done by a Public Health Registered Dental Hygienist without the on- site presence of a dentist, according to KRS 313.040. The Dentist Board member for your county is Dr. James Justice of Elkhorn Dental, who is supportive of the standards of practice of the public health hygienists and work with your Board of Health to develop and adopt protocols for these services.

This form, when signed and filled in, contains Protected Health information and the information is to be protected according to the health Insurance Portability and Accountability ACT (HIPAA). I understand by signing this consent, I acknowledge that I have access to a copy of the Pike County Health Department’s Privacy Notice located at www.pikecountyhealth.com/v3/uploads/documents/pchd_hipaa_pp.pdf or I may request a copy by calling Pike County Health Department’s main office at (606) 437-5500. I understand that my child may be screened to check the retention of these sealants by the public health dental hygienist during the following school year. ______Signature of Parent/Guardian or other Authorized Person Date

Please sign and date this section if you have Medicaid (PAYMENT FOR SERVICE/ASSIGNMENT OF BENEFITS) qASSIGNMENT OF BENEFITS: I request that payment of authorized medical insurance benefits be made to the local health department on my behalf, for services received. I also authorize the local health department to release medical information about me to Medicare, Insurance and other third party payors to determine payment for services. This constitutes permission to release medical information regarding sexually transmitted diseases, if applicable, to third party payors pursuant to KRS 214.420. I have read the above and have had an opportunity to ask questions. I understand the above statement as it applies to me and my child. My signature below indicates I do consent, authorize or declare as stated above. ______Signature of Parent/Guardian or other Authorized Person Date

Please return to your child’s homeroom teacher. If you have any questions, please contact the Pike County Health Department at (606) 437-5500 DEN-127 REV. 3/15/18