Medical Office Registration Form

PARSONS UNIFIED SCHOOL DISTRICT 2017-2018 RETURNING HIGH SCHOOL STUDENT ENROLLMENT FORM (Please Print)STUDENT INFORMATION (MAKE ANY CHANGES ON CENSUS VERIFICATION SHEET) Legal Name | Last: First: Middle:  9th  11th Alias/Nickname:  10th  12th STUDENT HEALTH AND MEDICAL 1. Health/Medical A. Does this student have any health problems (hearing, vision, allergies, heart, asthma, etc.? (If Yes, please provide a description below and provide a copy of medical records pertinent to health  Yes  No problem)B. Does this student have any health restrictions? (If Yes, list below)  Yes  NoC. Does this student have a family doctor or primary care physician? (If Yes, list below)  Yes  No D. Name: Office Phone #: ( ) 2. Medications A. Is this student taking medication at home? (If Yes, list below)  Yes  NoB. Is this student taking medication at school? (If Yes, list below)  Yes  No  I hereby authorize USD 503 personnel to release and exchange health information relating to the above-named student to: Health provider/physician and consent to inclusion of immunization data in the Kansas Immunization Registry. I understand that if my child is injured or seriously ill and the school nurse, principal, or designee cannot notify me by phone, that they have my permission to secure medical attention for my child and use the ambulance services if necessary. I understand that I will be responsible for the costs of such medical services and care. 3. Over-the-counter Medications: A. Would you like the school to provide over-the-counter medication on a PRN or “as needed” basis?  Yes  No (If Yes, please respond to next question) B. Would you prefer this student receives: Acetaminophen (Tylenol) – [500 mg 1-2 tablets by mouth every 4-6 hours as needed  Acetaminophen  Ibuprofen for pain, low-grade fever (less than 100 degrees), or generalized discomfort] (Tylenol) (Motrin) or Ibuprofen (Motrin) – [100 mg 1-2 tablets by mouth every 6 hours as needed for pain, low-grade fever (less than 100 degrees), or generalized discomfort]  I hereby give permission for my child to take the above listed medications at school on a PRN, or “as needed” basis. I certify that the child named above has received at least one dose of the medication (s) requested below and has not had adverse reactions to it. I understand that any trained school employee who administers these medications to my child in accordance with the following written instructions shall not be liable for damages as a result of an adverse drug reaction suffered by my child as a result of administering such drug. This permission slip shall remain in effect throughout the students’ enrollment in USD 503. PARENT/GUARDIAN PERMISSIONS (BY SIGNING AT THE END OF THE FORM YOU ARE ACCEPTING ALL THAT YOU MARKED) FIELD TRIPS We believe that field trips are of great value in our school program and encourage teachers to plan for such trips as extensions or enrichment of classroom experiences. Supervision of students is provided by the classroom teacher with the help of additional personnel as needed. Parents will be informed in advance of the location and time of all field trips. If, for some reason, you do not want your child to participate in a specified field trip, you are to notify the school upon receipt of the notice of the trip.My child has permission to participate in the Parsons District Schools field trips for the current school year.  My child DOES NOT have permission to participate in the Parsons District Schools field trips for the current school year.KANSAS COMMUNITIES THAT CARE (KCTC) STUDENT SURVEY This survey is taken by 6th, 8th, 10th, and 12th grade students statewide. It is a valuable tool to help us understand how students perceive things such as substance use and bullying. It gives us insight into the problems students face and shows what we can do to help them succeed. The information is essential to local and state grant funding and to planning effective prevention programs in our school and community. The survey is available to view at http://www.kctcdata.org.You may also be interested in the following: *It is completely anonymous. – Students will not be asked for their names on the questionnaire, nor will anyone be able to connect any individual student with his/her responses. School staff will not see any one student’s responses, but only summaries of results. To further guarantee anonymity, results will not be reported on any particular question without sufficient response from enough students. (Cont. on next page)*Participation is entirely voluntary. – Your child may decline to participate in the survey, or may simply skip any particular question they do not wish to answer. *Annual participation is important. – Even if your child has participated in previous surveys, annual data is extremely helpful in determining the 1 PARSONS UNIFIED SCHOOL DISTRICT 2017-2018 RETURNING HIGH SCHOOL STUDENT ENROLLMENT FORM (Please Print) effectiveness of previous efforts and changes in program areas. *The survey is provided by the Kansas Department for Aging and Disability Services Behavioral Health Services and administered by the Southeast Kansas Education Service Center Grants and Evaluation Department.  My child has permission to participate in the Kansas Communities That Care Student Survey.  My child DOES NOT have permission to participate in the Kansas Communities That Care Student Survey. DRUG TESTING INFORMED CONSENT THE FOLLOWING IS TO BE COMPLETED BY THE STUDENT: I understand and agree that participation in extracurricular activities is a privilege that may be withdrawn for violations of the Policy for Student Drug Testing of Parsons High School Students. I have read the Policy for Drug Testing of Parsons High School Students and understand the consequences that I will face if I am selected for a random drug test and have a positive test results. I understand that when I participate in any extracurricular activity as defined in the Board Policy, I will be subject to random urine drug testing, and if I refuse or test positive, I will not be allowed to practice, or participate in any athletic program or extracurricular activity. I have read the attached consent.I understand this is binding while a student at Parsons High School during the current school year. I hereby give consent for testing. I refuse/DO NOT give consent for testing.THE FOLLOWING IS TO BE COMPLETED BY THE PARENT/GUARDIAN: I have read the Policy for Drug Testing of Parsons High School Students and understand the responsibilities of my son/daughter/ward as a participant in extracurricular activities through Parsons High School. I understand a positive test result or refusal to submit a sample will result in consequences including suspension from activities as per policy for my student. I understand that my son/daughter/ward, when participating in extracurricular activities as defined in the Board Policy, may be subjected to random urine drug testing, and if they refuse or test positive, will not be allowed to practice or participate in any athletic program or extracurricular activity.I understand this is binding while my son/daughter/ward is a student at Parsons High School during the current school year. I hereby give consent for testing. I refuse/DO NOT give consent for testing. STUDENT TECHNOLOGY USAGE AGREEMENT & STUDENT ONLINE SAFETY PLEDGE I have read the USD 503 Acceptable Usage Policy for the use of district technology resources (i.e., internet, computers, printers, USB drives, etc.) As a student user of USD 503 technology, I agree to comply with all of the provisions of the current Acceptable Use Policy. ** Acceptable Use Policy is available online at http://www.vikingnet.net/district_information/technology/plans_and_policies or a paper copy is available in the office. I want to use USD 503 computers and the Internet at school and I agree to follow these rules:  I will not give my name, address, telephone number, school or my teachers’/parents’ names, addresses or telephone numbers to anyone that I meet on the Internet.  I will not give out my email password to anyone (even my best friends) other than my teachers/parents.  I will not fill out any form or request online that asks me for any information about my school, my family, or myself without first asking for permission from my teachers/parents. I will tell my teachers/parents if I see any inappropriate language or pictures on the Internet, or if anyone makes me feel nervous or uncomfortable online. I will never agree to get together with someone I “meet” online without first checking with my teachers/parents. If my teachers/parents agree to the meeting, I will be sure that it is in a public place and that I am accompanied by an adult at all times. I will not use any articles, stories, or other works I find online and pretend it is my own. Plagiarism is not allowed.  I will not use inappropriate language online. I will practice safe computing and check for viruses whenever I borrow a disk from someone, download something from the Internet or receive an attachment. (Cont. on next page) I will be a good online citizen and not participate in any activity that hurts others or is against the law or my school’s policy. If I have questions as to what is appropriate, I will ask my teachers/parents.2 PARSONS UNIFIED SCHOOL DISTRICT 2017-2018 RETURNING HIGH SCHOOL STUDENT ENROLLMENT FORM (Please Print)STUDENT: I acknowledge & accept this agreement.PARENT: I acknowledge & accept this agreement. ARMED FORCES RECRUITING The “No Child Left Behind Act of 2001” passed certain new requirements with respect to Armed Forces Recruiter Access to Students and Student Recruiting Information as follows:  Duty to Provide Information to Military Recruiters – Unless the parent states otherwise, the District must provide, upon request by military recruiters access to high school students’ names addresses and telephone numbers.  Consent – Either the high school student or the parent of the student may request that the students’ name, address and telephone number not be released without prior parental consent. Schools are required to notify parents of the option to make a request and shall comply with their request.  Access to Students – Each district shall provide military recruiters the same access to high school students as is provided to higher education institutions, community colleges and prospective employers. I understand that once either the student or parent has objected to release information, only a parent may change it. A parent must notify the principal in writing that the students’ information may be released. I CONSENT to release this students’ information to Military Recruiters.I OBJECT to release this students’ information to Military Recruiters. AUTHORIZED STUDENT DATA DISCLOSURE In accordance with the Student Privacy Act and board policy IDEA, student data submitted to or maintained in a statewide longitudinal data system may only be disclosed as follows. Such data may be disclosed to:  The authorized personnel of an educational agency or the state board of regents who require disclosures to perform assigned duties.  The student and the parent or legal guardian of the student, provided the data pertains solely to the student.Student data may be disclosed to authorized personnel of any state agency, or to a service provider of a state agency, educational agency, or school performing instruction, assessment, or longitudinal reporting, provided a data-sharing agreement between the educational agency and other state agency or service provider provides the following:  purpose, scope and duration of the data-sharing agreement;  recipient of student data use such information solely for the purposes specified in agreement;  recipient shall comply with data access, use, and security restrictions specifically described in agreement; and  student data shall be destroyed when no longer necessary for purposes of the data-sharing agreement or upon expiration of the agreement, whichever occurs first. *A service provider engaged to perform a function of instruction may be allowed to retain student transcripts as required by applicable laws and rules and regulations. Unless an adult student or parent or guardian of a minor student provides written consent to disclose personally identifiable student data, student data may only be disclosed to a governmental entity not specified above or any public or private audit and evaluation or research organization if the data is aggregate data. “Aggregate data” means data collected or reported at the group, cohort, or institutional level and which contains no personally identifiable student data. The district may disclose:  student directory information when necessary and the student’s parent or legal guardian has consented in writing;  directory information to an enhancement vendor providing photography services, class ring services, yearbook publishing services, memorabilia services, or similar services;  any information requiring disclosure pursuant to state statutes;  student data pursuant to any lawful subpoena or court order directing such disclosure; and  student data to a public or private postsecondary educational institution for purposes of application or admission of a student to such postsecondary educational institution with the student’s written consent. As the parent of legal guardian, I acknowledge that I have been provided with notice of authorized student data disclosures under the Student Data Privacy Act. I CONSENT to the district disclosing student data concerning my student. I OBJECT to the district disclosing student data concerning my student. *If I chose to revoke my consent, I recognize that I may do so at any time by putting such request in writing and submitting it to the office at my student’s school. JOPLIN REGIONAL PROSPERITY INITIATIVE3 PARSONS UNIFIED SCHOOL DISTRICT 2017-2018 RETURNING HIGH SCHOOL STUDENT ENROLLMENT FORM (Please Print) I understand and acknowledge that in an effort to register information and scores in the ACT database for Cherokee and Labette County, KANSASWORKS, Labette Community College, Labette County High School, Coffeyville Community College Columbus Campus, and the Joplin Regional Prosperity Initiative have entered into a Memorandum of Understanding to share scores for all residents of Cherokee and Labette Counties who complete Work Keys assessments in Applied Math, Locating Information or Reading for Information at a KANSASWORKS locations located within Local Area V.Based on the above information, I hereby authorize KANSASWORKS to share my individual Work Keys assessment scores for Applied Math, Locating Information and/or Reading for Information with the Joplin Regional Prosperity Initiative as the RegiSTAR, provided I score a minimum of 3 (three) on any of the assessments above. I understand that my scores will not be shared if I fail to score at least a 3 (three) on any one of the assessments above.STUDENT: I acknowledge & accept this agreement. PARENT: I acknowledge & accept this agreement.ALCOHOL SCREENING POLICYAlcohol use by a student is illegal and poses a serious threat not only to the students’ own safety and well-being, but also to the safety and well- being of the entire school community. Therefore, alcohol use by students will not be tolerated during or after school hours, on school property, or at any school-sponsored event or activity. When determining whether or not alcohol has been used or consumed by a student at a school related function, or whether they are intoxicated, the safety of the student involved and the safety of the other students, school staff and members of the general public, are the school district’s primary concern. If a supervising administrator believes that a student has used alcohol based on the observation of behavior, lack of coordination, or smelling alcohol on the student’s breath, he or she may take action to confirm the suspicion. As assessment of a student’s possible or suspected alcohol use may be aided by utilizing breath alcohol testing devices, such as breathalyzers, which indicate the presence or absence of alcohol in a person’s system. The intended purpose of having breath alcohol testing available is to prevent alcohol use by students. School Administration have been trained by Parsons Law enforcement officers to administer the alcohol breathalyzer tests pursuant to manufacturer’s instructions. These tests may be conducted by school administration or officers from the Parsons Police Department, including School Resource Officers. Any student who is determined to be under the influence of alcohol will be dealt with by the Parsons Police Department according to the law. That includes the possible issuance of a criminal citation, transportation to the County Jail for processing, and later court appearances, as other possible circumstances. A student’s participation in any extracurricular activity, including, but not limited to, sports and dances, is a privilege, not a right; therefore, students who wish to take part in extracurricular activities, and their parents guardians or other responsible persons will be required to sign a form acknowledging that they have read and understand the alcohol screening policy. BREATHALYZER TESTING POLICY BEFORE ADMITTANCE TO DANCEIn a general effort to maintain an alcohol-free environment at school dances, all students and guests of students in attendance at school sponsored dances will be required to take a breathalyzer test upon entry. Students will enter at one entrance point for the dance or activity so the breathalyzer test may be administered. If the breathalyzer registers that a student has been drinking alcohol, a second test will be administered after a 10 minute interval. Students will not be allowed to leave by themselves after a positive test. If the student’s test comes up positive again, the student will be questioned and his/her parents will be contacted to come pick up the student. Students who receive two positive test results will be subject to discipline up to and including suspension and expulsion. Any student refusing to take the breathalyzer test will not be allowed to attend the dance. Included in the Student Handbook is the alcohol and drug policy. Students and their guests will be screened by alcohol breathalyzers at school dances and may be screened at other school activities. Any student who wishes to bring a guest to a school dance must provide the principal with a breathalyzer test submission form, signed by the guest and the guest’s parent(s), prior to attending the dance. As a condition of admission to a school-sponsored activity, a signed copy of the Alcohol Screening Acknowledgement must be on file at the school. Every student attending school or school-related events or activities (whether within or outside the school district), is expected to follow the Student Handbook. ALCOHOL SCREENING ACKNOWLEDGEMENTExtracurricular activities are an important part of the overall educational program at Parsons High School. A well-rounded education is not only academically oriented, but also includes physical, social, and emotional development. We at Parsons High School believe that students will be productive, responsible citizens of the society in which they live. As a condition of admission to school-sponsored dances, a signed copy of this form will be on file at the school to acknowledge that I have received, read, and understand the USD 503 Alcohol Screening policy.  STUDENT: I acknowledge & accept this agreement. PARENT: I acknowledge & accept this agreement.PICTURE OPT IN 4 PARSONS UNIFIED SCHOOL DISTRICT 2017-2018 RETURNING HIGH SCHOOL STUDENT ENROLLMENT FORM (Please Print)I consent to the use of my/my child’s, portrait, picture or photograph as part of Parsons USD 503; in the Yearbook, Yearbook on DVD, Newspaper, Video Productions, Newsletter, Website, Athletic Programs, and/or Channel 14 as needed throughout the year.  STUDENT: I acknowledge & accept this agreement. PARENT: I acknowledge & accept this agreement. PHS BULLYING (CYDER-BULLYING) CONTRACTThis contract serves to prove a student’s knowledge about the definition of the consequences for bullying, and to inform parents of school policy regarding aggressive and inappropriate behavior among students. Bullying when done using a computer, smartphone or social media websites is referred to Cyber-Bullying. By signing this contract, (Student’s Name), hereafter referred to as “Student”, understands that:  Bullying can be physical, verbal, or emotion.  Bullying consists of, but not limited to: Name calling, violence, theft, rumors, exclusions, threats, intimidation, put-downs and pranks.  Students should all be treated with courtesy and equality regardless of age, gender, race, religion, orientation, size, disability, intelligence, athletic ability or popularity.Student Pledges to uphold the following Rules:  To abide by the school’s policy concerning bullying and harassment (ZERO TOLERANCE).  To report incidents of bullying to a trusted teacher or staff member.  To encourage others to treat all students with respect and courtesy.  To help make the school a place where everyone feels safe, heard and respected.Student understands that any incidents of bullying will result in the appropriate consequences eliminated the behavior. STUDENT: I acknowledge & accept this agreement. PARENT: I acknowledge & accept this agreement. TELEPHONE CONSUMER PROTECTION ACT (TCPA) OPT IN CONSENT I give USD503 and Parsons High School permission to contact me via my cellular device for automated phone calls and SMS text messages for general messages regarding school closures/delays, security alerts, absence notifications, cafeteria balances, upcoming school activities and more. By signing, I verify that I am the owner of this cellular device and its user contract. If there are any phone numbers that I do not want contacted, I will let the High School know of these numbers. PARENT: I acknowledge & accept this agreement. My signature acknowledges the information on this form to be true and accurate. I understand that this information will be used by USD 503 during the 2016-2017 school year and could require updating during the students duration with USD 503. As the parent/guardian, I acknowledge I am responsible for updating pertinent information regarding this student as needed. Parent/Legal Guardian Signature: Print Name: Date: ______My signature acknowledges the information on this form to be true and accurate. I understand that this information will be used by USD 503 during the 2016-2017 school year and could require updating during the my duration with USD 503. As the student, I acknowledge I am responsible for communicating any pertinent information changes to/from my parent/legal guardian if necessary. Student Signature: Print Name: Date: ______5

Medical Office Registration Form

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