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Levy School's Annual Consent Packet .docx


Austin T. Levy School Annual Consent Packet


The documents below are required to be filled out and returned prior to your child’s first day of school, each year. Be sure to carefully review and sign the attached consent forms to signify your consent preferences. Completing this packet PRIOR to arrival at OPEN HOUSE will limit the paperwork you MUST complete

at open house or later that evening.


Form

Completed

Student Daily Dismissal Form

Student’s Emergency Dismissal Form

Multi-purpose Consent Forms (Page 1 and 2)

Emergency Card “Cheat Sheet” (Optional)

Levy Parent-Teacher Forum

Student Health Inventory

Aramark Free and Reduced Lunch Application



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Student’s Daily Dismissal Form


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Child's First Name Child’s Last Name


Grade:

Teacher’s Name:


Please choose ONE of the options below. Check off all of the boxes and fill all of the blanks for that option:


Option1:


My child will ride the bus daily. His/her bus number is . And he/she will be dropped off at this address:


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This address is our home address.

This is our day care provider’s address. His/her name is:


Option 2:

My child is a parent pick-up daily. The following people have my permission to pick up my child:


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Option 3:

My child will have a varied schedule at the end of the day. He she will do the following each day. (Write the bus number or check next to parent-up to indicate your plan for that day).


Monday: Take Bus #

or Be a Parent Pick-up:


Tuesday: Take Bus #

or Be a Parent Pick-up:


Wednesday : Take Bus #

or Be a Parent Pick-up:


Thursday: Take Bus #

or Be a Parent Pick-up:


Friday: Take Bus #

or Be a Parent Pick-up:



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Parent Signature Date

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Student’s Emergency Dismissal Form

Child's First Name Child’s Last Name

Grade:

Teacher’s Name:


Please choose ONE of the options below. Check off all of the boxes and fill all of the blanks for that option.


Option1:

In the event of an unscheduled early dismissal, my child will follow his/her usual DAILY DISMISSAL PLAN.


Option 2:

In the event of an unscheduled early dismissal, my child will go on bus: to


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This address is our home address.

This is an emergency contact person:


Option 3:

In the event of an unscheduled early dismissal, my child will be a parent pick-up.


I have explained this procedure to my child and he/she is aware of these instructions.



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Parent Signature Date


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Multi-purpose Consent Form

Page 1 Child's First Name Child’s Last Name


Grade:

Teacher’s Name:


The checkboxes below give your options regarding consent on the attached documents. Please take time to review the documents and check and sign EACH consent area.


Walking Field Trips:

I have read the attached and my child has permission to participate in any trips to which our class will walk. Although this permission slip is valid throughout the year, I understand that I will be notified by the teacher as to when these trips take place.


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Parent Signature Date


Computer and Network Acceptable Use Policy:

As the parent/guardian of the above named student, have read the attached Burrillville School Department “Computer and Network Acceptable Use Policy and I understand and agree to all the provisions, rules and regulations outlined within. I hereby give permission for my child to use the Network service provided by the Burrillville School Department. I do understand the child is required to follow this policy. I further understand that there is a potential for my son/daughter to access information on the Network that is inappropriate for students and that every reasonable effort will be made on the part of the faculty and staff of the Burrillville School Department to monitor access to information, but that my son/daughter is ultimately responsible for restricting himself/herself from inappropriate information.


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Parent/Guardian Name Parent/Guardian Signature Date


Photo Permission Form:

Choose the below box that best meets the level of consent given.

I have read the attached and I DO NOT give permission for my child’s picture/video/name to be used as part of any news releases, publications, online or printed media.

I have read the attached and I DO give permission to include my child’s name or picture

in any news releases, publications, online or printed media (including the school newsletters).

I have read the attached and I ONLY give permission to include my child’s name or

picture to be in our school’s newsletters.


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Parent/Guardian Name Parent/Guardian Signature Date Multi-purpose Consent Form

Page 2 Child's First Name Child’s Last Name


Grade:

Teachers Name:


Handbook Acknowledgement:

The Austin T. Levy School Student Handbook can be accessed online at www.bsd.ri.net Please review the handbook with your child and sign below to acknowledge you have done so.


I have reviewed this handbook with my child online

I do not have a computer and would like to request a paper copy of the handbook



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Parent/Guardian Name Parent/Guardian Signature Date


Levy Breakfast Program:

Choose the box below that best meets the level of consent given.

I have read the attached and my child MAY participate in the breakfast program.

I have read the attached and my child MAY NOT participate in the breakfast program.


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Parent/Guardian Name Parent/Guardian Signature Date


Emergency Card “Cheat Sheet” (Optional)


On the night of open house you will need to fill out three emergency cards. Filling out the sheet below and bringing it with you to the open house will ensure that you have all the information

you will need to complete the cards. THIS FORM WILL NOT BE COLLECTED AND DOES NOT REPLACE FILLING OUT ALL 3 CARDS BEFORE THE START OF SCHOOL.


You will need the following information: Child’s Name:


Social Security Number (Optional):


Childs Date of Birth:

Child’s Bus #:


Child’s Teacher:

Grade Child is Entering:


Address:


Phone #:

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Father/Guardian’s Name Address (if different from above) Home Tel. # Office Tel. # Cell/Pager #



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Mother/Guardian’s Name Address (if different from above) Home Tel. # Office Tel. # Cell/Pager #



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Mother’s Email Father’s Email


Child resides with: Both Parents Mother Father Other (specify):


Race/Ethnicity: Native American Asian Black (Not Hispanic) Hispanic White (Not Hispanic) (Optional)



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Family Physician's Name Address Tel. #



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Name of Before/After School Day Care (if applicable) Address Contact Tel. #


Emergency Card “Cheat Sheet” (Continued)


Emergency Contacts (only people on this list will be allowed to pick up your child):


Emerge ncy Contact #1 Relationship to Child Address Tel. # Cell/Pager #


Emerge ncy Contact #2 Relationship to Child Address Tel. # Cell/Pager #


Emerge ncy Contact #3 Relationship to Child Address Tel. # Cell/Pager #


Are there any restrictions and/or legal documents on file?

No

Yes and I understand that a copy will be required (i.e. custody, visitation, restraining orders).


Austin T. Levy Parent-Teacher Forum

2014-2015 Family Directory


The Austin T. Levy School has made it a procedure to not allow students to hand out birthday party invitations in school However, we understand that birthday parties and play dates are

important to the social development of young children. The PTF would like to develop a ‘Family Directory’ that will give parents the means to communicate with each other outside of school. Please complete the form below if you would like your family information printed in this directory.

Please check the box below if you do NOT want to be in the directory. This directory will be distributed to each Levy student.


PLEASE RETURN THIS FORM BY SEPTEMBER 13TH. FORMS SUBMITTED AFTER THIS DATE WILL NOT BE INCLUDED IN THE DIRECTORY.


Child’s Name:


Child’s Teacher:


Parent’s Email:


YES, I give the Austin T. Levy Parent-Teacher Forum permission to print my child’s name, parents’ names, addresses and telephone number in the Family Directory.

NO, I do not give the Austin T. Levy Parent-Teacher Forum permission to print my

child’s name, parents’ names, addresses and telephone number in the Family Directory.



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Parent Signature Date


Burrillville School System Student Health Inventory


Grade:

Teacher:

Homeroom:


Name:

Date of Birth: Tel. #: _


Address:

Town:

Zip: _

Resides with: Mother Father Both Stepmother Stepfather Other


Father’s Name (Guardian): Work Tel. #:


Mother’s Name (Guardian): Work Tel. #:


Name of Family Doctor:

Tel. #:


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Brothers & Sisters:

(M)

(M)

(F)

(F)

Age Age

Grade Grade

(M)

(F)

Age

Grade

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Does student have any known medical conditions? Yes

No

If yes, please explain below:


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Does student take an medications? Yes No

If yes, what medication:

What dosage:

How often?

For what condition?

**************************************************************************************************************************************** Please fill in the year your child has had any of the following diseases or medical conditions

Allergies Asthma Chicken Pox Convulsions

Hearing Heart Hepatitis Kidney Disease

Pneumonia Rheumatic Fever Scarlet Fever Tuberculosis Active: Yes


No

Diabetes Epilepsy

Measles Mumps

Visual Defect Glasses: Yes No

Other:


Please list an other known allergies: _ Allergic Reaction: What happens when exposed?


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Has student had any accidents or injuries? Yes

No

Date:

Type:

Recent Operations: Yes

No

Date:

Type:

Is student undergoing medical treatment at this time? Yes

No

If yes, reason:


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Child’s Physician: May your child participate in a dental exam at school? Yes

Tel. # No


To Facilitate continuity of medical care while in the school setting, I give permission for any pertinent medical information to be shared with appropriate school faculty.


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Parent/Guardian Signature Date

Here is where there would be several pages of information regarding the consent information and scanned documents (such as the handbook and lunch forms).


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