GRANITE FALLS SCHOOL DISTRICT NO. 332 2014-2019 STRATEGIC PLAN
by user
Comments
Transcript
GRANITE FALLS SCHOOL DISTRICT NO. 332 2014-2019 STRATEGIC PLAN
GRANITE FALLS SCHOOL DISTRICT NO. 332 2014-2019 STRATEGIC PLAN Adopted by the Granite Falls School District Board of Directors on December 4, 2013 Tag Line: “Every Student, Every Day, Every Classroom” Mission Statement: To inspire and facilitate a passion for life-long learning and the pursuit of excellence in every student, every day. Vision Statement: Our students are passionate in pursuit of their goals and aspirations. To that end, they are critical and inspired thinkers, adaptable, collaborative and committed to making a difference in their communities and to the betterment of society. Foundation of our District Beliefs: 1. Powerful teaching and learning. 2. District and Board communication with community and staff that is informing, encouraging, intentional and collaborative. 3. Financial stewardship, assuring optimal use of district resources. 4. A district climate that emphasizes a positive school culture, focused on student safety, a healthy lifestyle, and respect for other students and faculty. District Goals: 1. Quality Learning. Engage and inspire every student through powerful and innovative instruction, fostering development of critical-thinking skills and motivating academic achievement through high expectations. 2. Positive Image. Strengthen our district by countering unfounded perceptions and stereotypes of Granite Falls. Celebrate student successes and civic progress, working collaboratively with district partners—including local government, the chamber of commerce, and service organizations. 3. College- and Career-Ready. Ensure that every student transitions successfully between grades and schools and graduates with the knowledge, skills and attitude to excel in diverse post-secondary opportunities. Foster student achievement through active partnerships with parents, families and our community. GRANITE FALLS HIGH SCHOOL Counseling Center Ginny Schlegel, Counselor Rebecca Delaney, Counselor Porscha Lachapelle, Registrar 1401 100th Street NE Granite Falls, WA 98252 360-283-4394 FAX: 360-283-4419 REQUEST FOR STUDENT RECORDS DATE: ___________________________________ NAME AND ADDRESS OF LAST SCHOOL OF ATTENDANCE: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ STUDENT NAME: _______________________________________ GRADE: _________ BIRTHDATE: ___________________ Request for Transfer of Educational, Psychological, Medical, and Other Confidential Records Be- tween Schools: PLEASE FORWARD: (PLEASE NOTE NEW ADDRESS IN HEADER) 1. Official Transcript of grades and credits. 2. Withdrawal grades to date of leaving for work in progress. (Please include attendance record to date of withdrawal.) 3. HSPE & EOC results (WA state), other Standard tests, and student portfolio project. 4. BECCA petition information/applicable truancy files. 5. All Discipline records. 6. Immunization and health records. 7. Psychological, Special Service, and other confidential records. 8. Entire CUM file (to include all of the above.) REGISTRAR _________________________________________ PARENT OR GUARDIAN SIGNATURE __________________________________ DATE ____________ 12/2014 DATE GRANITE FALLS SCHOOL DISTRICT NEW STUDENT REGISTRATION & STUDENT UPDATE FORM DO NOT WRITE IN SHADED AREA – FOR OFFICE USE ONLY STUDENT SCHOOL NUMBER SCHOOL ENTRY DATE MEDICAL ALERT HOMEROOM NUMBER LOCKER NUMBER BUS ROUTE AM Yes No Has any member of your family ever been enrolled in the Granite Falls School District? Yes No Was this student ever enrolled an early learning program i.e. Preschool, ECEAP, etc? STUDENT NAME: Legal Last Name Legal First Name Legal Last Name BIRTHDATE (Month/Day/Year) PRIMARY HOUSEHOLD Last Name GENDER (M/F) City (parent/guardian where student resides) First Name (parent/guardian where student resides) First Name Last Name EMAIL ADDRESS RESIDENT ADDRESS Street MAILING ADDRESS (If different from above) Country GRADE LEVEL PHONE #1 (include area code) Home Work Cell PHONE #2 (include area code) Home Work Cell Please check if unlisted PHONE #1 (include area code) Home Work Cell Please check if unlisted PHONE #2 (include area code) Home Work Cell Please check if unlisted STUDENT LIVES WITH Both parents Father only Father/Stepmother Mother/Stepfather Guardian Agency Apt # City Please check if unlisted Mother only Grandparents Self State Stepfather/Stepmother Other ZIP Do not distribute Street Apt # SECOND HOUSEHOLD (non-custodial parent/guardian not residing with student) Last Name First Name Last Name State PRIMARY LANGUAGE SPOKEN AT HOME: English Spanish Ukrainian Other _______ Prefers to be called: Legal Middle Name BIRTHPLACE: PM (non-custodial parent/guardian not residing with student) First Name P O Box City State PHONE #1 (include area code) Home Work Cell PHONE #2 (include area code) Home Work Cell Please check if unlisted PHONE #1 (include area code) Home Work Cell Please check if unlisted PHONE #2 (include area code) Home Work Cell Please check if unlisted Please check if unlisted RELATIONSHIP TO STUDENT Both parents Father only Mother only Father/Stepmother Mother/Stepfather Grandparents Stepfather/Stepmother Guardian Agency Self Other (Street/PO Box, City, State, ZIP) ADDITIONAL MAILINGS REQUESTED EMAIL ADDRESS SECOND HOUSEHOLD MAILING ADDRESS Yes SCHOOL PREVIOUSLY ATTENDED SCHOOL DISTRICT PREVIOUSLY ATTENDED HAS STUDENT EVER ATTENDED GRANITE FALLS SCHOOLS? Yes IS THERE A JOINT-CUSTODY OR PARENTING PLAN IN EFFECT? IS THERE A RESTRAINING ORDER IN EFFECT? Restraining order is against: Mother Father ZIP Yes No No Yes PREVIOUS SCHOOL LOCATION (City and State) IF YES, NAME OF SCHOOL ATTENDED No (If yes, plan must be on file with the school) (If yes, legal papers must be on file with the school) No DATE ATTENDED (Month/Year) Copy Attached Copy Attached Other Please complete additional registration information on back… HAS THE STUDENT HAD A BECCA/ATTENDANCE PETITION? Yes No Date: ___________________________________ HAS THE STUDENT EVER BEEN SUSPENDED FOR A WEAPONS VIOLATION? Yes No Date: ___________________________________ HAS THE STUDENT EVER BEEN LONG TERM SUSPENDED/EXPELLED? Yes No Date: ___________________________________ HAS YOUR CHILD EVER QUALIFIED FOR OR BEEN ENROLLED IN A SPECIAL ED PROGRAM? Yes No HAS YOUR CHILD EVER BEEN RETAINED? HAS YOUR CHILD EVER QUALIFIED FOR OR HAD A 504 PLAN? Yes No Yes HAS YOUR CHILD EVER PARTICPATED IN: Title LAP DOES STUDENT ATTEND CHILD CARE? Before school After school Gifted ELL Other ______________________ CHILD CARE PROVIDER Name No If yes, at what grade level(s)____________________ Address Phone Number Before and after school ADDITIONAL CHILD CARE ARRANGEMENTS (Please provide information to school in writing) PLEASE LIST OTHER SIBLINGS ATTENDING GRANITE FALLS SCHOOLS Last Name First Name School Grade SPECIAL INSTRUCTIONS REGARDING RELIGIOUS BELIEFS (Please provide information to school in writing) STUDENT RELEASE AUTHORIZATION When injury, illness or other non-emergency situations occur involving your child, we want to be able to quickly reach families or other responsible adults. In the event we cannot reach a parent/guardian, please list persons you trust who are available during the day to provide care for your child. PRIMARY CONTACT (other than parent/guardian) Last Name First Name PRIMARY CONTACT ADDRESS Street SECONDARY CONTACT (other than parent/guardian) Last Name First Name SECONDARY CONTACT ADDRESS Street RELATIONSHIP TO CHILD City RELATIONSHIP TO CHILD City PHONE #1 (include area code) Home Work Cell State PHONE #1 (include area code) Home Work Cell State PHONE #2 (include area code) Home Work Cell ZIP PHONE #2 (include area code) Home Work Cell ZIP STUDENT RELEASE AUTHORIZATION: In the event that the school is unable to contact the parent/guardian, I authorize that my child may be released to the person(s) listed above. Legal Parent/Guardian Signature ___________________________________________________ Date _____________________ EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize school authorities to obtain emergency care for my child. Legal Parent/Guardian Signature ___________________________________________________ Date _____________________ VERIFICATION OF INFORMATION: The information on this form is true and accurate as of this date. I understand that falsification of information to achieve enrollment or assignment may be cause for revocation of the student’s enrollment or assignment to a school in the Granite Falls School District. Legal Parent/Guardian Signature __________________________________________________ Date _____________________ revised 7/2014 GRANITE FALLS HIGH SCHOOL REGISTRATION PREVIOUS SCHOOL CHECK Name of student _______________________________________________________________ Date of birth __________________________________________________________________ Name of school last attended _____________________________________________________ Phone number of school _________________________________________________________ City and State of school _________________________________________________________ Guardian’s name _______________________________________________________________ Guardian’s phone number _______________________________________________________ Has this student ever been long term suspended or expelled? ___________________________ If so, please give the reasons for the disciplinary action ________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Is this student currently under expulsion, long term or short term suspension? _____________ If so, please explain why and circumstances _________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Result of check ________________________________________________________________ Washington State Ethnicity and Race Data Collection Form The new Federal requirements state that Unknown, Multiracial, and Not Provided are not valid responses to ethnicity or race identification questions. If parents, guardians, or students do not provide ethnicity and race information, districts are responsible for assigning categories based on observation. Student Legal Last Name _______________________________________ Legal First Name ________________________________ Is your child of Hispanic or Latino origin? Yes, check all that apply in section 1 and 2. No, check all that applies in section 2. Section 1. Check all that apply. Cuban Central American Dominican South American Spaniard Latin American Puerto Rican Other Hispanic/Latino Mexican/Mexican American/Chicano Section 2. What race(s) do you consider your child? (check all that apply) African American/Black White Asian Asian Indian Cambodian Chinese Filipino Hmong Indonesian Japanese Korean Laotian Malaysian Pakistani Singaporean Taiwanese Thai Vietnamese Other Asian Native Hawaiian or Other Pacific Islander Native Hawaiian Fijian Guamanian or Chamorro Mariana Islander Melanesian Micronesian Samoan Tongan Other Pacific Islander American Indian or Alaskan Native Alaska Native Chehalis Colville Cowlitz Hoh Jamestown Kalispel Lower Elwha Lummi Makah Muckleshoot Nisqually Nooksack Port Gamble Klallam Puyallup Quileute Quinault Samish Sauk-Suiattle Shoalwater Skokomish Snoqualmie Spokane Squaxin Island Stillaguamish Suquamish Swinomish Tulalip Yakama Other Washington Indian Other American Indian/Alaska Native Parent/Guardian Signature ______________________________________________ Date ________________________________ FOR OFFICE USE ONLY Received by B/10/201-B Date Revised January 2010 Superintendent’s Office 205 N. Alder Ave Granite Falls School District Re. Ethnicity and Race Data Collection Dear families, There was a change in federal and state law that effects how student ethnicity/race data is collected. This change, which occurred in 2010, now requires schools to have this data recorded and eliminates the options of “Unknown”, “Multi racial” and “Not Provided.” For many years, school districts in Washington have been required to report student data by ethnicity and race categories to the state’s Office of Superintendent of Public Instruction (OSPI). No individual student data is provided to the federal government. Federal law requires the state to report the total number of students in various categories in each school to the federal government. These reports help keep track of changes in student enrollment and various statistics such as graduation rates to ensure that all students receive the educational programs and services to which they are entitled. Ethnicity and race categories found on the back of this letter are the same as those used in all Washington school districts. The categories are set by the federal government, the state Legislature, and state Office of the Superintendent of Public Instruction (OSPI). In 2010, the federal government and OSPI changed the reporting categories. As a result of the new categories, we remain required to ask you to identify your child as either Hispanic/Latina or not Hispanic/Latino and by one or more of the 57 racial groups. If your family is Asian, you will now be able to list your child as Chinese or Japanese, or belonging to one or more of the other Asian groups. If your family is Native American, you will be able to list your child’s tribal affiliation. If one parent identifies with one race and the other with another, you will be able to check both races for your child. While families are not required to respond, the federal government is now requiring schools to have this information. Since September 2010, all public schools in Washington must have an ethnicity or race categories identified for each student. If there is no response, schools are required to make the selection. Granite Falls’ staff will not “observe” students for this selection. Without your input, the selections will be marked “Not Hispanic/Latina” and “White.” Families objecting to offering this data may also request in writing to “opt out” and the ethnicity/race data for those children will also default to “Not Hispanic/Latina” and “White.” Please complete the Form on the BACK. For more information about the student data reporting categories for ethnicity and race, you may visit the OSPI link, http://www.k12.wa.us/cedars/CEDARSDataFormQA.aspx or call the Communications Office at 360.691.7717. Sincerely, Linda Hall Superintendent ANNUAL AGREEMENT WITH GRANITE FALLS SCHOOL DISTRICT; Notification of Rights under the Family Educational Rights and Privacy Act (FERPA) & Protection of Pupil Rights Amendment (PPRA) The Family Educational Rights and Privacy Act (FERPA) affords parents and students over 18 years of age (“eligible students”) certain rights with respect to the student’s education records. They are: 1. The right to inspect and review the student’s education records within 45 days of the day the district receives a request for access. 2. The right to request the amendment of the student’s education records that the parent or eligible student believes is inaccurate or misleading. 3. The right to consent to disclosure of personally identifiable information contained in the student’s education records, except to the extent that FERPA authorizes disclosure without consent. (Upon request, the District discloses education records without the consent to officials of another school district in which a student seeks or intends to enroll.) 4. The right to file a complaint with the US Department of Education concerning alleged failures by the District to comply with the requirements of FERPA. The name and address of the Office that administers FERPA is: Family Policy Compliance Office US Department of Education 400 Maryland Ave, SW Washington DC 20202-5901 FERPA also permits a school district to identify certain information that may be publicly released with permission of the parent or eligible student. Directory Information is defined as the student’s name, photograph, dates of attendance, diplomas and awards received, participation in officially recognized activities and sports, weight and height of members of athletic teams, and the most recent previous school attended. Directory information is NOT released for commercial or other purposes not related to school business. If a parent/guardian or eligible student chooses NOT to have directory information publicly released, written notification MUST be presented to the District. PLEASE READ THE BELOW TEXT THOROUGHLY, INDICATE YOUR PREFERENCE, SIGN, & RETURN TO SCHOOL. I understand that once my student’s photograph, together with identifying information, is placed on the Internet, it can be viewed by anyone who has access to the Internet. It is being requested of me to provide consent in order for my child to receive recognition by the school in local media, yearbook, district website/Facebook page, etc. _____________________________________________________________________________________________________ Child’s Name (please print) Grade PLEASE CHECK ALL THAT APPLY: I give permission for my child’s name and photograph to be printed on the Internet or in hard publication for schoolrelated achievements, accolades, yearbook, announcements, etc. I do NOT give permission for my child’s name and photograph to be used on the Internet or in any hard school publication. This means your child’s name/picture will NOT be released for anything – i.e., for winning an educational award; appearing on the honor roll; sports recognition or achievement; or any online forum such as the District website, or “School News” emails. (We never release information for commercial purposes unless the company works in conjunction with the District, such as the school picture company.) I do NOT give permission for my child’s name and photograph to be used or appear in the school YEARBOOK. Do not release any directory information about my student to the military/armed forces. *** If you have any special or specific instructions/limitations, please contact the school directly. *** ________________________________________________ Parent/Guardian Name (please print) (_________)______________________________________________________ Phone X____________________________________________________________________________________________________________________________ Parent Signature Date If you have any questions or concerns regarding this agreement, please contact your child’s school directly. Model Notification of Rights Under the Protection of Pupil Rights Amendment (PPRA) PPRA affords parents certain rights regarding our conduct of surveys, collection and use of information for marketing purposes, and certain physical exams. These include the right to: Consent before students are required to submit to a survey that concerns one or more of the following protected areas (“protected information survey”) if the survey is funded in whole or in part by a program of the U.S. Department of Education (ED)– 1. Political affiliations or beliefs of the student or student’s parent; 2. Mental or psychological problems of the student or student’s family; 3. Sex behavior or attitudes; 4. Illegal, anti-social, self-incriminating, or demeaning behavior; 5. Critical appraisals of others with whom respondents have close family relationships; 6. Legally recognized privileged relationships, such as with lawyers, doctors, or ministers; 7. Religious practices, affiliations, or beliefs of the student or parents; or 8. Income, other than as required by law to determine program eligibility. Receive notice and an opportunity to opt a student out of – 1. Any other protected information survey, regardless of funding; 2. Any non-emergency, invasive physical exam or screening required as a condition of attendance, administered by the school or its agent, and not necessary to protect the immediate health and safety of a student, except for hearing, vision, or scoliosis screenings, or any physical exam or screening permitted or required under State law; and 3. Activities involving collection, disclosure, or use of personal information obtained from students for marketing or to sell or otherwise distribute the information to others. Inspect, upon request and before administration or use – 1. Protected information surveys of students; 2. Instruments used to collect personal information from students for any of the above marketing, sales, or other distribution purposes; and 3. Instructional material used as part of the educational curriculum. These rights transfer to from the parents to a student who is 18 years old or an emancipated minor under State law. The Granite Falls School District has adopted policy regarding these rights, as well as arrangements to protect student privacy in the administration of protected information surveys and the collection, disclosure, or use of personal information for marketing, sales, or other distribution purposes. The District will directly notify parents of this policy at least annually at the start of each school year and after any substantive changes. The District will also directly notify, such as through U.S. Mail or email, parents of students who are scheduled to participate in the specific activities or surveys noted below and will provide an opportunity for the parent to opt his or her child out of participation of the specific activity or survey. The District will make this notification to parents at the beginning of the school year if the District has identified the specific or approximate dates of the activities or surveys at that time. For surveys and activities scheduled after the school year starts, parents will be provided reasonable notification of the planned activities and surveys listed below and be provided an opportunity to opt their child out of such activities and surveys. Parents will also be provided an opportunity to review any pertinent surveys. Following is a list of the specific activities and surveys covered under this requirement: Collection, disclosure, or use of personal information for marketing, sales or other distribution. Administration of any protected information survey not funded in whole or in part by ED. Any non-emergency, invasive physical examination or screening as described above. Parents who believe their rights have been violated may file a complaint with: Family Policy Compliance Office U.S. Department of Education 400 Maryland Avenue, SW Washington, D.C. 20202-5901 Updated 8/14 2015–16 Letter to Households (Public Schools) National School Lunch Program/School Breakfast Program Exhibit 3 (use w/ Exhibit 2) Dear Parent/Guardian: This letter tells how your children can get free or reduced-price meals, as well as information on other benefits. The cost of school meals is shown below. Breakfast will be served at no cost to those children who qualify for free and reduced-price meals. Lunches will be served at no cost to rd children who qualify for free meals and to those who qualify for reduced-price meals in kindergarten through 3 grade. All other students th th (preschool and 4 – 12 grades) will be charged the rates shown below. REGULAR REDUCED-PRICE Grade Level Breakfast Lunch Snack Breakfast K-3 Lunch All Other Students $ .40 Snack K-5 $ 1.75 $ 3.00 $ $ 0.00 $ 0.00 6-12 $ 1.75 $ 3.25 $ $ 0.00 $ $ .40 $ $ $ $ $ $ $ $ $ WHO SHOULD FILL OUT AN APPLICATION? Fill out the application if: Total household income is the SAME or LESS than the amount on the chart You receive Basic Food, take part in the Food Distribution Program on Indian Reservations (FDPIR), or receive Temporary Assistance for Needy Families (TANF) for your children You are applying for foster children that are under the legal responsibility of a foster care agency or court Turn in the application to your child's school or Food Service office. Questions? Contact Viki Perrault 360 283 4310 Be sure to submit ONLY ONE application per household. We will notify you if the application is approved or denied. If any child you are applying for is homeless (McKinney-Vento), or migrant, check the appropriate box. . WHAT COUNTS AS INCOME? WHO IS CONSIDERED A MEMBER OF MY HOUSEHOLD? Look at the income chart below. Find your household size. Find your total household income. If members in the household are paid at different times during the month and you are unsure if your household is eligible, fill out an application and we will determine your income eligibility for you. The information you give will be used to determine your child's eligibility for free or reduced-price meals. Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals regardless of personal use income. If you have questions about applying for meal benefits for foster children, please contact us at . INCOME CHART Effective from July 1, 2015 to June 30, 2016 Household Size Annual Monthly Twice Per Month Every Two Weeks 1 2 3 4 5 6 7 8 $21,775 29,471 37,167 44,863 52,559 60,255 67,951 75,647 $1,815 2,456 3,098 3,739 4,380 5,022 5,663 6,304 $ 908 1,228 1,549 1,870 2,190 2,511 2,832 3,152 $ 838 1,134 1,430 1,726 2,022 2,318 2,614 2,910 $ 419 567 715 863 1,011 1,159 1,307 1,455 +7,696 +642 +321 +296 +148 For each additional member add: Weekly HOUSEHOLD is defined as all persons, including parents, children, grandparents, and all people related or unrelated who live in your home and share living expenses. If applying for a household with a foster child, you may include the foster child in the total household size. HOUSEHOLD INCOME is considered to be the income each household member received before taxes. This includes wages, social security, pension, unemployment, welfare, child support, alimony, and any other cash income. If including a foster child as part of the household, you must also include the foster child’s personal income. Do not report foster payments as income. WHAT MUST BE ON THE APPLICATION? A. For households not getting any assistance: • Student’s name • Names of all household members • Income by source for all household members • Adult household member's signature • Last 4 digits of social security number of the adult household member who signs the application, (or check the "I do not have a social security number" box if the adult signing does not have a social security number) Complete Parts 1, 2, 3, and 4. Parts 5 and 6 are optional. B. For a household with only a foster child(ren): • Student’s name • Adult household member's signature Complete Parts 1 and 4. Parts 5 and 6 are optional. You may also send the school a copy of the court documentation showing the foster child(ren) was placed with you instead of filling out an application form. C. For household with a foster child(ren) and other children: Apply as a household and include foster children. Follow the directions for “A. Households not getting any assistance” and include the foster child’s personal use income. D. For a family getting Basic Food/TANF/FDPIR: • List all student names and case number where appropriate • If the student is not the one with a case number, enter the household member’s name and their case number • Adult household member's signature Complete Parts 1 and 4. Parts 5 and 6 are optional. FORM SPI NSLP Exhibit 3 (Rev. 6/15) Page 1 Bulletin 016-15 OSPI/Child Nutrition Services May 2015 Exhibit 3 WHAT IF I’M NOT RECEIVING BASIC FOOD DOLLARS? If you have been approved for Basic Food but do not actually receive Basic Food dollars, you must apply for free and reduced-price meal benefits by filling out a meal application and returning it to your child’s school. DO MY CHILDREN AUTOMATICALLY QUALIFY IF THEY HAVE A CASE NUMBER? Yes. Children on TANF or Basic Food may get free meals without the household having to complete an application. These children are identified by the school using a data matching process. This matched list is then made available to your child’s school food service staff. The students on this list get free meals if their schools have the free and reduced-price breakfast and/or lunch program (not all schools do). Please contact us immediately if you feel your children should be receiving free meals and are not. If you do not want your child to participate in the free meal programs using this method, please notify the school. IF ANYONE IN MY HOUSEHOLD HAS A CASE NUMBER, WILL ALL CHILDREN QUALIFY FOR FREE MEALS? Yes. If someone else in the household has a case number, other than a student or a foster child, you must fill out an application and send it to your student’s school. Please contact us immediately if you feel other children in your household should be receiving free meals and are not. BASIC FOOD – CAN I QUALIFY FOR ASSISTANCE IN BUYING FOOD? Basic Food is the state’s food stamp program. It helps households make ends meet by providing monthly benefits to buy food. Getting Basic Food is easy! You can apply in person at the local DSHS Community Service Office, by mail, or online. There are other benefits too. You can learn about Basic Food by calling 1-877-501-2233 or by logging on to http://www.foodhelp.wa.gov/basic_food.htm. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, or receive Family Subsistence Supplemental Allowance payments, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so. HEALTH COVERAGE To inquire about or apply for health care coverage for kids in your family, please visit http://www.wahealthplanfinder.org or you may call Washington Health Plan Finder at 1-855-923-4633. WHAT IF MY CHILD NEEDS SPECIAL FOODS? All meals served meet the federal food guidelines. Students who are identified as disabled by their doctor may need different foods. These substitute foods will be made available at no extra charge if your child’s doctor fills out the necessary paperwork. If your child needs this assistance, please contact us. PROOF OF ELIGIBILITY The information you provide may be verified at any time. You may be asked to send additional information to prove your child is eligible to receive free and reduced-price meals. FAIR HEARING If you do not agree with the decision on your child's application or the process used to prove income eligibility, you may talk with Linda Hall - Superintendent , the fair hearing official. You have the right to a fair hearing which may be arranged by calling the school/school district at this number 360 691 7717 . REAPPLICATION You may apply for benefits any time during the school year. If you should have a decrease in household income, an increase in household size, or become unemployed, or receive Basic Food, TANF, or FDPIR, you may be eligible for benefits and may fill out an application at that time. NONDISCRIMINATION The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or if all or part of any individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Ave S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at mailto:[email protected]. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish). USDA is an equal opportunity provider and employer. FORM SPI NSLP Exhibit 3 (Rev. 6/15) Page 2 Bulletin 016-15 OSPI/Child Nutrition Services May 2015 Granite Falls School District Check here if you received meal benefits last year. 2015–16 HOUSEHOLD APPLICATION FOR FREE AND REDUCED-PRICE MEALS your child's school or Food Service Office Complete, sign and return this application to Grade Monthly School Student Income 2X Month MI Date of Birth Every 2 weeks Student’s Last Name Student’s First Name Weekly List all students living with you that are attending school. If the student is a foster child, indicate this by placing an “x” in the appropriate box. Include any personal income received by the student and make an “x” in the correct box for how often it is received. If you have written a case number for any of your children, skip to Section 4. However, if you have written a case number only for the foster child and want to apply for all students in the household, you must proceed to Section 2. If any child you are applying for is homeless (McKinney-Vento), or migrant, check the appropriate box. Homeless Migrant Foster Child 1. Exhibit 2 Does the student receive Basic Food, TANF, or FDPIR? If YES, you must list a case number and check the appropriate box. Basic Food TANF FDPIR $ Case # $ Case # $ Case # $ Case # $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly 2X Month Every 2 weeks Any Other Income Not Already Listed Weekly Monthly 2X Month Weekly Pensions, Retirement, Social Security (SSI) Every 2 weeks Monthly 2X Month Every 2 weeks Child Support, Alimony Weekly Monthly 2X Month Weekly Names of ALL other household members (do not include names of students listed above) Earnings from work (before any deductions) Every 2 weeks Case # List the names of all other household members - Enter income (in whole dollars) and CHECK how often it is received. If any household member does not receive income, write 0. If you enter 0 or leave income sections blank, you are promising that there is no income to report. If you write a case number for another household member, skip to Section 4. However, if the case number is only for the foster child(ren), you must proceed to Section 3. Foster Child 2. Does any household member receive Basic Food, TANF, or FDPIR? If YES, you must list a case number and check the appropriate box. Basic Food TANF FDPIR Case # Case # Case # Case # Case # 3. 4. Total Household Members (include all people living in your household): Signature and Social Security Number – I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. I understand my child’s eligibility status may be shared as allowed by law. Last 4 digits of your social security number: OR, if you do not have a social security number, check the box: Printed Name of Adult Household Member Mailing Address City & Zip Code FORM SPI NSLP Exhibit 2 (Rev. 6/15) Street Address (if available) Home Phone Adult Household Member Signature Work/Cell Phone Date Email Address Page 1 Bulletin No. 016-15 OSPI/Child Nutrition Services May 2015 Exhibit 2 5. Children’s Racial and Ethnic Identities (Optional) Mark one or more racial identities: Asian White Black, or African American 6. Mark one ethnic identity: Hispanic or Latino Not Hispanic or Latino American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Other Benefits – Please check the box in front of the programs that you wish to share your child’s free or reduced price meal status with in order to qualify for a reduction in fees: Scholarships Advanced Placement Testing By signing below, I allow the information contained on this application to be shared with the other program(s) I have indicated. Parent/Guardian Signature Date This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced-price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (Basic Food), Temporary Assistance for Needy Families (TANF) Program, or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced-price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. SCHOOL USE ONLY DO NOT WRITE BELOW THIS LINE ANNUAL INCOME CONVERSION: Weekly x 52; Every Two Weeks x 26; Twice a Month x 24; Monthly x 12. Do NOT convert to annual income unless household reports multiple pay frequencies. LEA APPROVAL/DENIAL Basic Food/TANF/FDPIR Household Income Household Foster Child (categorically free) APPLICATION APPROVED FOR: Free Meals Reduced-Price Meals Date Notice Sent FORM SPI NSLP Exhibit 2 (Rev. 6/15) Total Household Size Total Household Income $ Income Approved by (check one): weekly every two weeks 2 times a month monthly annual APPLICATION DENIED BECAUSE: Income Over Allowed Amount Incomplete/Missing Information Other: Signature of Approving Official Date Page 2 Bulletin No. 016-15 OSPI/Child Nutrition Services May 2015 Granite Falls School District Electronic Network Use Agreement (Revised 8-21-2000) As a condition of my right to use the electronic data network in the Granite Falls School District, the K-20 network and the Internet, I understand and agree to the following: 1. The use of electronic networks in the Granite Falls School District is a privilege that may be revoked by the Granite Falls School District, the Washington School Information Processing Cooperative (WSIPC), or other administrators of the K-20 network at any time for violation of the following conditions of use. a. Abusive conduct is prohibited. Abusive conduct includes but is not limited to: - Placing unlawful information on the network - Damaging computers, computer systems, or computer networks - Improperly accessing or misusing the files for other users - Harassing, insulting or attacking others - Using obscene, abusive or otherwise offensive or objectionable language in public or private messages. b. Communication intended to facilitate commercial, political, religious, or illegal activities is prohibited. c. Violating copyright and trademark laws is prohibited. d. Transmitting or intentionally receiving sexually explicit or other material generally considered inappropriate for use in school is prohibited. e. Revealing any user’s personal details to users outside the Granite Falls School District network is prohibited. This includes, but is not limited to, phone number, address, or physical description. f. Any user identified as a security risk or having a history of problems with other computer systems may be denied network access. g. If a user can identify a security problem on the local District network, or elsewhere on the Internet, the user must notify the System Administrator. Any user found exploiting a security problem, or demonstrating a security problem to users other than the System Administrator will lose network access. h. Individual accounts are issued to one and only one user. The use of another user’s account or allowing others to use one’s own account is strictly prohibited. The user is liable for any use of the account. Only the user and System Administrators will have access to users’ accounts. Passwords will conform to security guidelines and remain confidential. i. Installing unauthorized software for use on district computers is prohibited. j. Vandalism will result in loss of access. Vandalism is defined as any malicious attempt to harm or destroy data. This includes, but is not limited to, the uploading or creation of software with malicious intent (viruses, etc.). Vandalism also includes the altering or reconfiguring of any network hardware, except under supervision of the System Administrator. k. Resale, lease, or intentionally wasting of the local District network or K-20 shared bandwidth, electronics, or other equipment is strictly prohibited. 2. The Granite Falls School District and/or WSIPC will be the sole arbiter(s) of what constitutes abusive conduct or violation of Granite Falls School District or K-20 policies. 3. WSIPC and/or the Granite Falls School District staff has the right to review any material stored on the network and to remove any materials which they, in their sole discretion, believe may be unlawful, obscene, abusive, or otherwise objectionable, and I hereby waive any right to privacy which I may otherwise have in and to such material. 4. The Granite Falls School District has the right to monitor storage disk space utilization by users and limit it as necessary. 5. That all information and services contained on the network is placed there for general information purposes and is, in no way intended to refer to, or be applicable to, any specific person, case or situation. 6. The Granite Falls School District and/or WSIPC will not be liable for any damages due to information gained and/or obtained via use of the Granite Falls School District electronic network, including without limitation access to public networks. 7. The Granite Falls School District does not guarantee that the network will be error free and that services will be uninterruptible. The Granite Falls School District and/or WSIPC will not be liable for any loss of data or inability to use the network. 8. The user will abide by such rules and regulations of usage as may be promulgated from time to time by WSIPC and/or the administrators of K-20, including, without limitation, K-20 Acceptable Use Policy. 9. In consideration for the privilege of using the K-20 network and in consideration for having access to public networks, I hereby release WSIPC and/or the Granite Falls School District, its operators, and any institutions with which they are affiliated from any and all claims and damages of any nature arising from my use, or inability to use, K-20, including, without limitation, the types of damages identified in paragraphs 4 and 5 above. 10. The Granite Fall School District reserves the right to revoke and deny access at its discretion. I understand and will abide by the above Use Agreement. I further understand that any violation of the regulations above is unethical and may constitute a criminal offense. Should I commit any violation of the terms and conditions herein, my access privileges may be revoked, school disciplinary action and/or appropriate legal action may be taken. (Please Print) First Name User Signature Last Name Middle Initial Date PARENT OR GUARDIAN *(If the user is under the age of 18, a parent or guardian must also read and sign this agreement.) As the parent or guardian of this student, I have read the Electronic Network User Agreement. I understand that this access is designed for educational purposes. Granite Falls School District has taken precautions to eliminate sexually explicit material. However, I also recognize it is impossible for the Granite Falls School District to completely prevent access to these and other controversial materials and I will not hold them responsible for materials acquired on the network. Further, I accept full responsibility for supervision if and 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. (Please Print) Parent or Guardian’s Name Parent or Guardian Signature Date Granite Falls School District Student Health Registration Form This questionnaire is designed to aid school staff in anticipating any health concerns that might affect your child’s safety or learning. Student Name ______________________________________________Grade ____________Sex ______ Date of Birth ________________ MEDICAL Does your child have a doctor or nurse practitioner? Yes ___ No ___ Name of child’s doctor or nurse practitioner _____________________________________________ phone number ____________________ In the past 12 months, did you have problems obtaining medical care for your child? Yes ___ No ___ DENTAL Does your child have a dentist? Yes ___ No ___ Name of child’s dentist ______________________________________________________________ phone number ___________________ Did your child receive a dental exam in the last 12 months? Yes ___ No ___ Don’t know ___ Describe the condition of your child’s teeth? Good ___ Fair ___ Poor ___ Don’t know ____ In the past 12 months, did you have problems obtaining dental care for your child? Yes ___ No ___ INSURANCE Does your child have medical insurance coverage? Yes ___ No ___ Don’t know ___ Name of provider ______________________________ Does your child have dental insurance coverage? Yes ___ No ___ Don’t know ___ Name of provider ________________________________ Does Medicaid insure him/her? (Apple Health for kids) Yes ___ No ___ Don’t know ___ MEDICAL HISTORY Have you ever been told by a physician or health care professional that your child has: ___ Asthma ___ Seizure disorder ___ Bleeding disorder ___ Diabetes ___ Bone/muscle disease ___ Skin condition ___ Heart condition ___ Mental health condition (i.e., depression, anxiety, eating disorder) _______________________ ___ ADD/ADHD ___ Learning disability ___Other Does your child experience any of the following? ___ Nose bleeds ___ Frequent ear aches ___ Overweight for age ___ Physical disability ___ Poor appetite ___ Frequent stomachaches ___ Frequent headaches ___ Fainting spells ___ Tires easily ___ Emotional concerns ___ Underweight for age ___ Other _______________________ Do any of the above condition(s) limit/effect your child at school? _____________________________________ LIFE-THREATENING CONDITIONS Does your child have a life-threatening health condition? Yes* ____ No ____ Describe: __________________________________________ *If yes, a meeting with the school nurse is required. Washington State Law requires medication or treatment orders and a health care plan be in place prior to starting school. ALLERGIES Plants ________ Animals ________ Food ________ Molds ________ Drugs _________ Bees ________ Other _______________________ Please describe the allergic reaction and treatment for each checked allergy _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Do you plan for your child to receive school prepared meals? Yes* ___ No ____ *an additional form must be completed for food allergies MEDICATION Does your child take any medication? Yes ___ No ___ If yes, name of medication: ______________________________________________ Purpose _____________________________________ Will medication be needed at school? Yes* ___ No ___ *If your child needs to take medication at school, please contact the office for the necessary authorization form. This form must be completed prior to any medication being brought to school. HEARING/VISION Do you have concerns about your child’s hearing? Yes ___ No ___ Does your child wear hearing aids? Yes ___ No ___ Do you have concerns about your child’s vision? Yes ___ No ___ Does your child wear glasses or contacts? Yes ___ No ___ SPEECH/LANGUAGE Do you have concerns about your child’s speech and/or language? Yes ___ No ___ Do others have difficulty understanding your child? Yes ___ No ___ If yes, please explain __________________________________________________________________________________ AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT I understand the information given above will be shared with appropriate school staff to provide for the health and safety of my child. If either I or an authorized emergency contact person cannot be reached at the time of a medical emergency, I authorize and direct school staff to send my child to the most easily accessible hospital or physician. I understand I will assume full responsibility for payment of any transport or emergency medical services rendered. Parent/Guardian Signature ____________________________________________________________________ Date __________________ Revised 02/2014 Granite Falls School District Immunization Requirements TO: Parents of Granite Falls School District Students FROM: Health Services Department THE ATTACHED CERTIFICATE OF IMMUNIZATION STATUS MUST BE SUBMITTED ON OR BEFORE THE FIRST DAY OF SCHOOL IN ORDER FOR YOUR CHILD TO ATTEND SCHOOL. Washington State Law requires certification of immunization for all school children. School must exclude children from attending who do not provide proof of, or exemption from, meeting immunization requirements (RCW 28A.210 & WAC 180-38 & 246-100-166). COMPLETE THE CERTIFICATE OF IMMUNIZATION STATUS BY: • Entering the month, day and year, when each required dose of a vaccine was given. (If you do not know the specific day, the health services professional will assume the first of the month.) OR • Completing one of the statements of exemption. (Please note that your child will be excluded from school for the duration of an outbreak of a vaccine-preventable disease for which your child has been exempted.) OR • Notifying the school that a schedule of immunization has been started and will be completed in accordance with your doctor’s recommended schedule. Immunizations are available from your health care provider. • Bring records of your child’s immunization to the school to assure that your child received the correct vaccine. YOU MUST SIGN THE CERTIFICATE INDICATING YOUR INFORMATION IS CORRECT. Please contact your child’s school if you need further assistance in completing the certificate. Updated 5/14 Kindergarten – 5th Grade 6th Grade 7th – 12th Grade Parents - Are Your Kids Ready for School? (Measles, Mumps, Rubella) 2 doses Recommended, but not required. 2 doses OR Healthcare provider verifies child had disease 2 doses OR Healthcare provider verifies child had disease (Chickenpox) Varicella Parent/Guardian Resource Required Immunizations for School Year 2014-2015 Polio* MMR (Diphtheria, Tetanus, Pertussis) 2 doses DTaP/Td/Tdap* Hepatitis B 4 doses 4 doses 2 doses 5 doses 5 doses DTaP AND 1 dose Tdap 5 doses DTaP AND 4 doses 3 doses 3 doses 3 doses 1 dose Tdap DOH 348-295 December 2013 *Vaccine doses required may be fewer than listed. Students must meet minimum intervals and ages to be in compliance with the requirements. Talk to your healthcare provider or school staff if you have questions about school immunization requirements. Find information on other recommended vaccines not required for school: www.immunize.org/cdc/schedules/ If you have a disability and need this document in another format, please call 1‐800‐525‐0127 (TDD/TTY call 711). Certificate of Immunization Status (CIS) DOH 348-013 January 2015 Office Use Only: Reviewed by: Date: Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Information System. Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I give permission to my child’s school to share immunization information with the Immunization Information System to help the school maintain my I certify that the information provided on this Symbols below: Required for School and Child Care/Preschool child’s school record. form is correct and verifiable. Required for Child Care/Preschool Only ■ Recommended, but not required Parent/Guardian Signature Required Date Parent/Guardian Signature Required Date Vaccine Dose Date Month Day Year Hepatitis B (Hep B) 1 2 3 or Hep B - 2 dose alternate schedule for teens 1 2 ■ Rotavirus (RV1, RV5) 1 2 3 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) 1 2 3 4 5 Tetanus, Diphtheria, Pertussis (Tdap) 1 ■ Tetanus, Diphtheria (Td) 1 2 Haemophilus influenzae type b (Hib) 1 2 3 4 ■ Influenza (flu, most recent) Vaccine Dose Date Month Day Year Pneumococcal (PCV, PPSV) 1 2 3 4 5 Polio (IPV, OPV) 1 2 3 4 Measles, Mumps, Rubella (MMR) 1 2 Varicella (chickenpox) 1 2 ■ Hepatitis A (Hep A) 1 2 ■ Human Papillomavirus (HPV) – does not print from the IIS; write dates in by hand 1 2 3 ■ Meningococcal (MCV, MPSV) 1 2 If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option 1, 2, OR 3 below (see # 5 on back) 1) Chickenpox disease verified by printout from the Immunization Information System (IIS) Must be marked by printout (not by hand) to be valid. 2) Chickenpox disease verified by healthcare provider (HCP) If you choose this box, mark 2A OR 2B below. 2A) Signed note from HCP attached OR 2B) HCP sign here and print name below: Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Date Printed Name: 3) Chickenpox disease verified by school staff from the Immunization Information System If the child can show immunity by blood test (titer) and hasn’t had the vaccine, ask your HCP to fill in this box. Documentation of Disease Immunity I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached. Diphtheria Hepatitis A Hepatitis B Hib Measles Mumps Polio Rubella Tetanus Varicella Other: _______________ _______________ Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name: Date Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. #1 To print with information filled in: First, ask if your healthcare provider’s office puts vaccination history into the WA Immunization Information System (Washington’s statewide database). If they do, ask them to print the CIS from the IIS and your child’s information will fill in automatically. Be sure to review all the information, sign and date the CIS, and return it to school or child care. If your provider’s office does not use the IIS, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below): EXAMPLE #2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the Vaccine Dose Month Date Day Year Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) “Vaccine” column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as DTaP 01 12 2011 1 mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here DTaP 03 20 2011 2 #4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, DTaP 06 01 2011 3 Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #5 If your child had chickenpox (varicella) disease and not the vaccine, use only one of these three options to record this on the CIS: 1) If your child’s CIS is printed directly from the IIS (by your healthcare provider or school), and disease verification is found, box 1 is automatically marked. To be valid, this box must be marked by the IIS printout (not by hand). 2) If your healthcare provider can verify that your child had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your provider, or 2B if your provider signs and dates in the space provided. Be sure your provider’s full name is also printed. 3) If school staff access the IIS and see verification that your child had chickenpox, they will mark box 3. #6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your healthcare provider fill in this box. Ask your provider to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports. #7 Be sure to sign and date the CIS, and return to the school or child care. Vaccine Trade Names in alphabetical order Trade Name Vaccine (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf) Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Ipol Infanrix Kinrix (Knrx) Menactra MenHibrix (Mnhbrx) Menomune Menveo Pediarix (Pdrx) IPV DTaP DTaP + IPV MCV or MCV4 Meningococcal C/YHIB-PRP MPSV or MPSV4 Meningococcal DTaP + Hep B + IPV PedvaxHIB Pentacel (Pntcl) Pneumovax Prevnar Hib DTaP + Hib + IPV PPSV or PPV23 PCV or PCV7 or PCV13 Twinrix (Twnrx) Vaqta Varivax Hep A + Hep B Hep A Varicella ProQuad (PrQd) MMR + Varicella Recombivax HB Rotarix RotaTeq Hep B Rotavirus (RV1) Rotavirus (RV5) ActHIB Adacel Afluria Boostrix Hib Tdap Flu Tdap FluLaval FluMist Fluvirin Fluzone Flu Flu Flu Flu Cervarix HPV2 Gardasil HPV4 Daptacel Engerix-B Fluarix DTaP Hep B Flu Havrix Hiberix HibTITER Hep A Hib Hib Vaccine Abbreviations in alphabetical order Abbreviations Full Vaccine Name DT Diphtheria, Tetanus DTaP DTP Flu (IIV or LAIV) Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Abbreviations Hep A (HAV) Hep B (HBV) Hib HPV (For updated lists, visit https://fortress.wa.gov/doh/cpir/iweb/homepage/completelistofvaccinenames.pdf) Full Vaccine Name Hepatitis A Hepatitis B Haemophilus influenzae type b Abbreviations Human Papillomavirus OPV MPSV or MPSV4 MMR / MMRV Full Vaccine Name Meningococcal Polysaccharide Vaccine Measles, Mumps, Rubella / with Varicella Abbreviations Rota (RV1 or RV5) Full Vaccine Name Td Tetanus, Diphtheria Oral Poliovirus Vccine Tdap Tetanus, Diphtheria, acellular Pertussis TIG Tetanus immune globulin VAR or VZV Varicella Inactivated Poliovirus PCV or PCV7 or Pneumococcal Conjugate Vaccine PCV13 Vaccine Hepatitis B Immune Meningococcal Pneumococcal Polysaccharide HBIG MCV or MCV4 PPSV or PPV23 Globulin Conjugate Vaccine Vaccine If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY call 711). Influenza IPV Rotavirus DOH 348-013 January 2015 Granite Falls School District AUTHORIZATION FOR ADMINISTRATION OF MEDICATION AT SCHOOL Student Name: ____________________________________________ Birth Date: ___________________________________ School: __________________________________________________ Grade: ______________________________________ THIS PORTION TO BE COMPLETED BY A LICENSED HEALTH PROFESSIONAL (LHP) PRESCRIBING WITHIN THE SCOPE OF THEIR PRESCRIPTIVE AUTHORITY (Please clearly print legible instructions) Name of Medication Dosage Method of Administration Time(s) to Be Take _________________________________ ___________ __________________________ _______________________ Diagnosis or reason for medication: _________________________________________________________________________ If give PRN, specify the minimum length of time between doses: _________________________________________________ I request and authorize this student to carry their medication. ____ Yes ____ No I request and authorize this student to self-administer their medication. ____ Yes ____ No This student has been instructed and has demonstrated the ability to properly manage self-administration of medication. Possible medication side effects: ___________________________________________________________________________ Emergency procedure in case of serious side effects: ___________________________________________________________ I request and authorize the above-named student to be administered the above identified medication in accordance with the instructions indicated above from _______________ (date) to ________________ (date) (not to exceed current school year). There exists a valid health reason which may make administration of the medication advisable during school hours. _________________________________________________ Date of Signature _________________________________________________ Licensed Health Professional (LHP) _________________________________________________ Telephone Number _________________________________________________ Name (please print) THIS PORTION TO BE COMPLETED BY THE PARENT/GUARDIAN I request this medication to be given as ordered by the licensed health professional. I give Health Services Staff permission to communicate with the medical office about this medication. I understand oral medications may be administered by nonlicensed staff members who have been trained and are supervised by a Registered Nurse. Medication information may be shared with school staff working with my child and 911 staff, if they are called. All medication supplied must be brought to school in its original container with instructions as noted above by the licensed health professional. I request and authorize my child to carry and/or self-administer their medication. ____ Yes ____ No _______________________________________________ Date of Signature ___________________________________________________ Parent/Guardian Signature Telephone numbers: ______________________ (home) _____________________ (work) ________________________ (cell) Reviewed by Registered Nurse: _____________________________________________________ Date: _________________ Revised 02/2014 STUDENT HOUSING QUESTIONNAIRE 205 N Alder Avenue, Granite Falls, WA 98252 360-691-7717 Fax 360-691-6477 The answers to the following questions help determine educational services your child(ren) may be eligible to receive through the McKinney-Vento Homeless Assistance Act. Are you ‘doubled up’ with another family due to a loss of housing or economic hardship? Are you living in a motel/hotel due to lack of housing? Are you living in a shelter? Are you living in a car, park, campsite or location not usually used for sleeping accommodations? Is this student awaiting foster care? As a student, are you living with someone other than your parent? Yes Yes Yes Yes Yes Yes No No No No No No If you answered YES to any of the above questions, please complete the remainder of this form. If you answered NO to all of the above questions, you may stop here. Student Name: _____________________________________________________________________________ First Middle Last Date of Birth: ________________ Age: _____ Grade: _____ Name of School: _________________________ Current Address: ___________________________________________________________________________ Street City Zip Phone/Contact Number: ___________________________________ Do you have other children that attend a school in the Granite Falls School District? Name ________________________ Date of Birth: _____________Age ___ Grade ___ School ______________ Name ________________________ Date of Birth: _____________Age ___ Grade ___ School ______________ Name ________________________ Date of Birth: _____________Age ___ Grade ___ School ______________ I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and accurate. Signature of person completing form: _________________________________ Date:____________________ Relationship to the student(s): Parent Guardian Self Other ___________________ For School Staff Only: If “Yes” is checked for any question above, please give this form to the School Counselor or Administrator Rev. February 2014 McKINNEY-VENTO HOMELESS ASSISTANCE ACT 205 N Alder Avenue, Granite Falls, WA 98252 360-691-7717 Fax 360-925-6477 INTAKE AND REFERRAL Send completed form to McKinney-Vento Liaison (Carol Panagos, Director of Special Programs) Date: _______________ Student Name: ____________________________________________________________ First Middle Unaccompanied youth? Yes No Last Date of Birth: ___________ Age: ___ Grade: ___ Name of School: ______________________ Information obtained by: ______________________________________________________________________ Parent/Guardian Name: __________________________________________________________________________________ (Leave blank if student is unaccompanied) Nighttime address: ______________________________________________________________________________________ Street City Zip Contact phone: __________________________ Email: _______________________________________________________ Where does the student stay at night? (Please check one box.) “Doubled Up” with another family due to a loss of housing or economic hardship; A motel/hotel; At an emergency or transitional shelter; Student is awaiting foster care placement; In a location not usually used for sleeping accommodations; (cars, parks, campsite, public places, abandoned buildings, substandard housing, transportation stations or similar settings) Are there other children/siblings in the family who are also homeless? (names, ages, grade/school) _______________________________________________________________________________________________ Are there programs the student(s) has been participating in or is in need of? (i.e., gifted, bilingual, special education (IEP), 504, Title I/LAP, band, athletics, clubs) ____________________________________________________________ What school did the student(s) attend when permanently housed? _______________________________________ Is there any other information we need to know? ____________________________________________________ _______________________________________________________________________________________________ Does the student need assistance with any of the following? Assistance acquiring previous school records School Supplies ECEAP for preschoolers Medical/Dental Other _________________________________ School Fees Housing BELOW FOR USE BY McKINNEY-VENTO HOMELESS LIAISON ONLY Skyward Unaccompanied Youth Meals Notify Admin/Counselor ____________________ Signature of School District Liaison:__________________ Transportation: E-Mail Transportation Department ORCA Card “In Lieu Of Agreement” & Expense Statement Cooperating District __________________________________ Correspondence: Welcome Letter National School Meal Program Eligibility Letter Parent “In Lieu Of Agreement” and Letter o Expense Statement forms Re-Verification Letter for new school year o Follow up telephone contact Denial Letter and Appeals Disclosure English Office of Superintendent of Public Instruction (OSPI) Home Language Survey Student Name: Birth Date: Date: Gender: Grade: Form Completed by: Parent/Guardian Name Relationship to Student Parent/Guardian Signature If available, in what language would you prefer to receive communication from the school? Did your child receive English language development support through the Transitional Bilingual Instruction Program in the last school your child attended? Yes__ No__ Don’t Know__ 1. In what country was your child born? ____________________ 2. What language did your child first learn to speak?* __________________ 3. What language does YOUR CHILD use the most at home?* ____________________ 4. What language(s) do parent/guardians use the most when you speak _____________________ _____________________ to your child? 5. Has your child ever received formal education* outside of the United States? (Kindergarten – 12th grade) _____Yes _____No If yes, in what language(s) was instruction given? _____________________ For how many months? ____ ”Formal education” does not include refugee camps or other unaccredited programs for children. 6. When did your child first attend a school in the United States? (Kindergarten – 12th grade) _______________________ Month Day Year 7. Do grandparent(s) or parent(s) have a Native American tribal affiliation? _____Yes _____No *WAC 392-160-005: "Primary language" means the language most often used by a student (not necessarily by parents, guardians, or others) for communication in the student's place of residence. Note to district: A response of a language other than English to question #2 OR question #3 triggers ELL placement testing May 2014 English The Purpose of the Home Language Survey The Home Language Survey is given to all students enrolling in Washington schools. The following information should help answer some of the questions you may have about this form. What is the purpose of the Home Language Survey? The primary purpose of the Home Language Survey is to help identify students who may qualify for support to help them develop the English language skills necessary for success in the classroom and who may qualify for other services. It is important that this information be correctly recorded since it can affect the eligibility of students for services they need to be successful in school. Testing may be necessary to determine whether or not additional language and academic supports are needed. No student will be placed in an English language development program based solely on responses to this form. Why do you ask about the student’s first language and language(s) used in the home? The two questions about the student’s language help us to determine: if your student may be eligible for assistance with learning English, and whether staff at the school should be aware of other languages being used by the student at home. The language your child first learned may be different from the language your child uses for communication at home now. The responses to both of these questions will assist the school in providing instruction appropriate to the individual student’s needs as well as help with communication needs that may arise. Students who first learned a language other than English may qualify for additional supports. Even students who speak English well may still need support in developing the language skills needed to be successful in school. Why do you ask where the student was born? This information helps the school district and the state determine if the student meets the definition of immigrant for the purposes of federal funding. This applies even when the student’s parents are both US citizens, but the student was born outside of the United States. This form is not used to identify students who may be undocumented. Why do you ask about my student’s previous education? Information about a student’s education will help ensure that the student’s education both within and outside of the United States is considered in any recommendations made for participation in programs and district services. The student’s educational background is also important information to help determine if the student is making adequate progress toward state standards based on their prior educational background. Thank you for providing the information needed on the Home Language Survey. Contact your school district if you have further questions about this form or about services available at your child’s school. May 2014 -Granite Falls School DistrictTRUANCY INTERVENTION AGREEMENT Attendance in important for academic success, and unexcused absences may be an early warning sign for unaddressed problems with school and future dropout. When youth fail to attend school, they are considered truant. Washington law requires children from age 8 to 17 to attend a public school, private school, or to receive home-based instruction (homeschooling) as provided in RCW 28A.225.010. The BECCA state law requires schools to notify the Juvenile Court when students are in violation of this statute. After one unexcused absence in a month, the school is required to inform the parent in writing or by phone. As a Granite Falls School District student, I am aware of the following attendance expectations: • I will attend school every day, attend all scheduled classes on time, all period long; • I understand that when I accumulate five (5) unexcused absences in any month (one unexcused day consists of more than half the school day) the school may file a BECCA petition with the Juvenile Court (However, the school MUST file a petition after seven (7) unexcused absences in a month or ten (10) unexcused absences in a school year); • I understand that if I miss twenty (20) consecutive unexcused days of school, I will be withdrawn from my school of attendance; • I understand that if the Attendance Secretary or Registrar does not receive a request for records within ten (10) days of my withdrawal, a BECCA petition will be filed with the Juvenile Court; • I understand that in addition to the state law require school attendance, Granite Falls Schools have their own attendance policies, including those that address excessive number of excused absences. _______________________________ Printed Student Name ________________________________ Student Signature _______________________________ Parent Signature ________________________________ Date About the Becca Bill Becca’s Story In 1993, a 13-year-old runaway named Rebecca Hedman was murdered in Spokane, Washington, far from her home in Tacoma. A group of parents and Legislators came together and successfully pushed for legislation that was passed in 1995, known as the “Becca” Bill. These laws were designed to prevent situations like Becca’s, from happening again by confronting poor attendance, truancy, and the needs of at-risk youth. What can parents/guardians do? If you are concerned about your child’s attitude towards school and about his/her attendance record, contact your child’s teacher, counselor and/or school principal. With the combined insights into your child’s needs and interests, we can work together to design an individualized plan to help your child stay in school. If your child is missing school due to a chronic health condition, we can arrange for you to meet with our district Nurse to develop a plan to maximize school attendance. GRANITE FALLS SCHOOL DISTRICT FAMILY EMERGENCY PLAN -EMERGENCY INFO. & STUDENT RELEASE_____________________________________________________________________________ STUDENT’S LAST NAME: ____________________________ STUDENT’S FIRST NAME: ____________________________ ADDRESS: ____________________________________________ PHONE NUMBER: ______________________________ BUS #: _____________________ GRADE: ______ NAME OF SIBLING(S) ENROLLED AT SAME SCHOOL: _______________________________________________________ __________________________________________________________________________________________________ PARENT/GUARDIAN #1 NAME: ____________________________________________________ HOME PHONE: ______________________________ WORK PHONE: _______________________________ CELL PHONE: _____________________________ __________________________________________________________________________________________________ PARENT/GUARDIAN #2 NAME: ____________________________________________________ HOME PHONE: ______________________________ WORK PHONE: _______________________________ CELL PHONE: _____________________________ __________________________________________________________________________________________________ PRIMARY EMERGENCY CONTACT NAME: _____________________________ RELATIONSHIP: ______________________ HOME PHONE: ______________________________ WORK PHONE: _______________________________ CELL PHONE: _____________________________ __________________________________________________________________________________________________ If the primary emergency contact individual (listed above) is unavailable, I authorize my child __________________to be released to the following individual(s) in the event of an unexpected emergency/disaster. 1. NAME: ________________________________________________ HOME PHONE: _____________________________ CELL PHONE: _________________________________________ 2. NAME: ________________________________________________ HOME PHONE: _____________________________ CELL PHONE: _________________________________________ 3. NAME: ________________________________________________ HOME PHONE: _____________________________ CELL PHONE: _________________________________________ If possible, please provide contact information for a friend or family member, who lives out-of-state or area, who can be contacted in the event of a local telephone service interruption or area disaster: 4. NAME: ________________________________________________ HOME PHONE: _____________________________ CELL PHONE: _________________________________________ MEDICATIONS OR CONDITIONS THAT REQUIRE ATTENTION IF A CHILD NEEDS OVERNIGHT CARE AT THE SCHOOL ARE AS FOLLOWS: __________________________________________________________________________________________________ __________________________________________________________________________________________________ (Please provide 72 hours of the essential medication and complete required “Medication Authorization” form.) EMERGENCY MEDICAL RELEASE: In the event of a severe emergency or natural disaster such as an earthquake, it is recognized that I may not be able to be reached. Should such an incident occur, I authorize the Granite Falls School District to refer my child __________________________________ as appropriate for any necessary medical treatment. It is my intent and understanding that this medical release be used only in case of extreme emergency when attempts to reach me have failed. PARENT/GUARDIAN SIGNATURE _____________________________________ DATE SIGNED _____________________ EMERGENCY COMMUNICATION DISTRICT WEBSITE: The District has an “Emergency Info” page that will be updated regularly in the event of a school emergency, concern, closure or delay, www.gfalls.wednet.edu FLASH ALERT: Sign-up to receive email and phone text notification of school closures or schedule changes at http://flashalert.net/ SCHOOL MESSENGER: You can receive automated voice calls from the school regarding any school emergency, closure or delay information. LOCAL RADIO/TV: These outlets will post up-to-date information regarding school closure info. If you sign up with flash alert, you will be notified the same time the media is notified of school closure/delays. TRANSPORTATION INFORMATION _________________________________________________________________________ Student Name Bus # (if applicable) _____________________________________________________________________________________ Parent/Guardian Name Date _______________________________________________________zip____________________________ Pick-up address _______________________________________________________zip____________________________ Drop-off address (if drop-off address is different from pick-up address indicated above) _____________________________________________________________________________________ Name of adult at pick-up address Name of adult at drop-off address _____________________________________________________________________________________ Special needs (if applicable) STUDENT WILL ARRIVE AT SCHOOL: (please circle all that apply) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY School Bus School Bus School Bus School Bus School Bus Walk Walk Walk Walk Walk Daycare Daycare Daycare Daycare Daycare Parent Drop-off Parent Drop-off Parent Drop-off Parent Drop-off Parent Drop-off Other: Other: Other: Other: Other: STUDENT WILL LEAVE SCHOOL: (please circle all that apply) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY School Bus School Bus School Bus School Bus School Bus Walk Walk Walk Walk Walk Daycare Daycare Daycare Daycare Daycare Parent Drop-off Parent Drop-off Parent Drop-off Parent Drop-off Parent Drop-off Other: Other: Other: Other: Other: Updated 4/14 TRANSPORTATION INFORMATION _______________________________________________________zip____________________________ Complete Home Address (include apartment number if applicable) CONTACT INFO (please indicate all contact numbers): Parent/Guardian home phone: ___(______)________________________________ Parent/Guardian work phone: ___(______)_________________________________ Parent/Guardian cell phone: ___(______)__________________________________ _____________________________________________________________________ Parent/Guardian Signature Date Granite Falls School District provides a complete transportation/bus schedule for all schools. The transportation schedule includes bus numbers, times and locations. Bus routes and times are subject to change and can be accessible by going to the district website at www.gfalls.wednet.edu. For questions contact the Transportation Department at 452-335-1508. Limited bus routes are used throughout the year for snow, ice, or other situations that cause buses to alter normal routes. During inclement weather, the District will notify FlashAlert with updates to school closures or delays. Register with FlashAlert (http://www.flashalert.net) to receive email and text notifications. FlashAlert alerts the radio/TV outlets the same time you would be notified if registered. The District will do everything we can to inform you of this information by 6:00am, but limited routes may be used without notification due to conditions/time in order to provide safe transportation. Please make sure your child’s school has up-to-date emergency numbers and email contacts. CO-OP Transportation: Granite Falls/Lake Stevens Pupil Transportation Department 425.335.1508, Office Hours: 6:00 am – 4:30 pm Staff Contacts: Sheila Winters, Supervisor Liz Snyder, Driver Trainer Carrie Anderson, Dispatcher Taryn Proudsworth, Assistant Dispatcher Bill Reynolds, Router Nina Hoffar, Secretary Updated 4/14 Copy of Driver’s License is Required for Clearance WASHINGTON STATE PATROL Identification and Criminal History Section PO Box 42633, Olympia, WA 98504-2633 REQUEST FOR CRIMINAL HISTORY INFORMATION CHILD/ADULT ABUSE INFORMATION ACT RCW 43.43.830 THROUGH 43.43.845 A REQUESTING AGENCY/ADDRESS B PURPOSE ESD/School District Volunteer - no fee Non-Profit Busn./Org. – no fee (Excluding Granite Falls School District Agency Schools & ESD’s) Attn. Profit Business/Org. - $10 Adoptive Parent - $10 205 North Alder Avenue Address Granite Falls, WA 98252 Fees: Make payable to Washington State Patrol by cashier’s check, money order, or commercial business account. City/State/Zip I certify this request is made pursuant to and for the purpose indicated . Authorized Signature NO PERSONAL/CERTIFIED CHECKS ACCEPTED. Date Principal Title C APPLICANT OF INQUIRY Applicant’s Name: Last First Middle Alias/Maiden Name: Date of Birth: Sex: Race: Month/Day/Year Driver’s Lic. Number/State: / Secondary dissemination of this criminal history record information response is prohibited unless in compliance with RCW 10.97.050 D IDENTIFCATION DECLARING NO EVIDENCE WASHINGTON STATE PATROL IDENTIFICATION & CRIMINAL HISTORY SECTION (THIS PORTION MAILED BY REQUESTING AGENCY) As of this date, the applicant named below shows no evidence Pursuant to RCW 43.43.830 through 43.43.845. WSP Use Only Granite Falls School District Requesting Agency X Applicant’s Signature Valid Two Years From Issue X Right Thumb Print Optional Applicant’s Name X Address X City/State/Zip 3000-240-430 (3/93 Please complete reverse side Granite Falls School District DISCLOSURE FORM Pursuant to Chapter 43.43.830 RCW (revised, 2007) & RCW 9A.42.100 (revised, 2002) In accordance with RCW 43.43.830, applicants and prospective volunteers are required to complete this disclosure form. In addition, applicants who have been offered employment or volunteer assignments as outlined in said law, will be required to complete a Request for Criminal History form, possibly including fingerprinting. These requests will be forwarded to the Washington State Patrol for disclosure of any applicable charges or finding. Applicants may be employed on a conditional basis pending completion of such background investigation. Volunteers will be retained on the same conditional basis. Answer yes or no to each listed item. If the answer is yes to any item, explain in the area provided, indicating the charge or finding, the date, and the court(s) involved. 1. Have you ever been convicted of any crimes against persons as defined in Section 1 of Chapter 486, Laws of 1987, and listed as: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree assault of a child; first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first or second degree theft; forgery; first degree arson; first degree burglary; first or second degree manslaughter; first, second, or third degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; endangerment with a controlled substance; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; first or second degree custodial sexual misconduct; malicious harassment; first, second, or third degree child molestation; first or second degree sexual misconduct with a minor; commercial sexual abuse of a minor; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of these crimes as they may be renamed in the future? Answer If yes, explain below. ___ 2. Have you ever been found in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted or exploited any minor or to have physically abused any minor? Answer If yes, explain below. 3. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor? Answer If yes, explain below. 4. Have you ever been found in a disciplinary board final decision to have sexually abused or exploited any minor or to have physically abused any minor? Answer If yes, explain below. 5. Have you been convicted of possession of an illegal or controlled substance or of a crime to manufacture, delivery, or If yes, explain below. possession with intent to manufacture or deliver a controlled substance? Answer __________________________________________________________________________________________________ Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I understand that my continued employment is conditional upon the fingerprinting and background checks that the Granite Falls School District will conduct. Applicant Signature Date Volunteer Confidentiality Statement Thank you so much for volunteering to help in the Granite Falls School District. We appreciate you giving of your time and talent. Our students’ safety is a priority to us and for that reason we require that volunteers sign a confidentiality and discrimination statement. Please sign and return this form at your earliest convenience. Thank you. I understand that information regarding students, families, staff and the organization may be confidential in nature and that as a volunteer for the Granite Falls School District I will adhere to the following: 1. Respect the confidential nature of any verbal or written communication I receive regarding students, families, staff, and the organization. 2. Keep personal information confidential at school and after I leave school. 3. Be discreet in any verbal communications by not discussing students, staff, or families in front of others. 4. Immediately report directly to the principal or site administrator any information disclosed to me concerning a child’s safety. 5. Make reasonable efforts to assure that each student is protected from harassment or discrimination. 6. Not harass nor discriminate against any student, staff member or volunteer on the basis of race, color, religion, sex, age, national or ethnic origin, political beliefs, marital status, handicapping condition, sexual orientation, or social and family background. I also understand that relationships developed with children at school should remain at school and that for the protection of both the student, staff and volunteer, volunteers should not be left alone with a child that is out of view of school personnel or another adult volunteer. I understand that permission to communicate with a student outside the regular school day must be granted by the student’s parent/guardian; the Granite Falls School District cannot and will not grant this permission. Volunteer’s Name (Please Print) ____________________________________ Volunteer’s Signature ____________________________________________ Date: _________________________