TILLAMOOK School District #9 Teacher: Grade:
HEALTH QUESTIONAIRE
STUDENT’S NAME: _________________________________ BIRTHDATE: ______________ COUNTRY OF BIRTH: ______________ STUDENT’S ADDRESS: __________________________________ PHONE: _____________________ CELL: _____________________
MY CHILD HAS A MEDICAL CONDITION WHICH MAY REQUIRE ATTENTION AT SCHOOL (MEDIC ALERT)
DOES YOUR CHILD HAVE ANY OF THE FOLLOWING? CIRCLE ONE
Hearing Problem NO YES
Speech Problem NO YES
Vision Problem NO YES
Has your child been prescribed Glasses or contact lens? NO YES
Allergies Environmental (dust, etc.) Insect Allergy NO YES
Food Allergy Medicine Allergy
Severe allergic reaction, that a doctor/nurse practitioner NO YES
has prescribed an Epipen or Epipen Jr?
Diabetes (if yes, please circle) Type 1 Type 2 Other NO YES
Digestive Problems (Ulcer, Colitis, Vomiting, etc.) NO YES
Heart Condition NO YES
If yes, what is the medical diagnosis?
Asthma or Other type of breathing problem NO YES
Epilepsy or Seizure Disorder NO YES
If yes, what kind of seizures?
Cancer – has your child ever been diagnosed with cancer? NO YES
If yes, what type of cancer? Is your child still being treated for cancer? YES NO
Headaches which are frequent or severe? NO YES
If yes, what helps your child when a headache occurs?
Has your child had one or more previous head injuries or concussions? NO YES
If yes, when did this occur?
Blood Disorder (Anemia, Hemophilia, Bleeding Disorder) NO YES
Cerebral Palsy NO YES
Orthopedic (Bone) Problem NO YES
Bowel or Bladder Problem NO YES
Kidney Problem NO YES
Skin Problem (eczema, hives, etc.) NO YES
If yes what type of skin problem?
Special Diet NO YES
If yes, type of diet: _____________________ Only students with the appropriate medical documentation on file at
school can have food substitutions in the school breakfast/lunch program.
Learning Difficulties NO YES
If yes, please describe:
Attention Deficit Disorder or ADHD NO YES
Does your child have any other health concerns not listed above? NO YES
If yes, please describe:
**A medication form must be filled out for all medication taken during school.
**To protect your child, this information will be shared with school staff working with your child.
If you would like to speak to the health nurse regarding any special health needs your child may have, please leave
a message at the school office or call the Tillamook Health Department at 503-842-3900.
Parent/Guardian Signature Date:
NO MEDICAL CONCERNS
TILLAMOOK SCHOOL DISTRICT #9
PERMISSION TO RELEASE RECORDS
TO: (Student’s former school/agency)
(Address of former school/agency)
Phone: ____________________ Fax: _____________________
(Student Name) (Date of Birth) (Grade)
(Student Name) (Date of Birth) (Grade)
(Student Name) (Date of Birth) (Grade)
has entered Tillamook School District. I am requesting all records for the above named student(s) which
include:
Student Education Records which include full legal name of student, birth date and place of birth, name of parents/guardians,
date of entry, name of previous school, subject taken, marks received, credits earned, attendance, date of withdrawal, social
security number (if provided), tests related specifically to achievement or measurement of ability.
Health Records which include immunization records, sports physical examinations, health screening records, medication
administration records, and other related documents.
Behavioral Records which include psychological tests, personality evaluations, records of observations and any written
transcript of incident(s) relating specifically to student behavior. TAG identification and records. This should include information
relating to youth’s history of engaging in activity that is likely to place school staff or other student safety at risk, or that requires
appropriate counseling or education.
Special Education Records including, but not limited to, records of eligibility, correspondence with parent/guardian, and all
previous and current IEP’s.
Portfolio
OTHER (specify)
Signature Date
Parent or School Registrar
PLEASE SEND ALL RECORDS TO:
Liberty School South Prairie School East Elementary School
1700 Ninth St 6855 South Prairie Rd 3905 Alder Lane
Tillamook, OR 97141 Tillamook, OR 97141 Tillamook, OR 97141
Ph# (503) 842-7501 Ph# (503) 842-8401 Ph# (503) 842-7544
Fax# (503) 842-1314 Fax# (503) 842-1452 Fax# (503) 842-1246
**Office Use Only: Withdraw Date: ______________ Enrollment Date: ___________________
Subject to ORS 330.260, a district receiving this request shall transfer all education records no later than 10 days after receipt of request. Should
any of the requested records be on file in other departments, please forward this request to the appropriate office. If no records are on file, please
contact the school requesting the records.
Office Use Only:
Date Faxed: ___________________
Second Request: _______________
Student Name:
Current School: Current Grade:
YES NO
Parent Signature: Date:
An awareness of any special services is important in order to plan the most appropriate educational program for a child.
Has your child ever received or participated in the following services?
1. Special Education
a. Currently on an IEP?
i. Speech
ii. Academics (please specify, math/read/write/etc.)
3. Talented and Gifted (TAG)
iii. Other (e.g. vision, hearing)
b. Currently in testing or evaluation process?
c. Previously on an IEP or evaluated?
6. Medication If yes, what type:
4. Extra Academic Assistance If yes, what kind:
If yes, what specific services:
If yes, what special services:
7. Special health issues or concerns If yes, list:
5. Counseling If yes, what issue:
8. Does your child need any special services at this time?
(e.g. Title I, ELL)
9. Has your child received any special services in the past
two years? (Title I, ELL)
10. Would you like one of our administrators to contact you
at this time to discuss any issues or concerns?
Contact number:
2. 504 Plan
Tillamook School District # 9
Confidential Prior Services
~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~
TILLAMOOK SCHOOL DISTRICT NO. 9 2510 – 1st Street
Tillamook, Oregon 97141
By law, if parents are legally separated or divorced, each parent has
equal rights to the custody of the child/children UNLESS a parent has
a court order that indicates which parent has custody of the
child/children.
The school MUST HAVE A COPY OF THE COURT ORDER on file,
otherwise, either parent may check the child out of the school with
proper identification.
If a parent comes in with a court order stating current custody over
the enrolling parent, they may take the child/children after
documents are verified, as needed, and after every effort has been
made to reach the enrolling parent by phone.
I have read the above statement of the law.
Student’s Name Grade
Signature of Parent/Guardian Date
PARENT CUSTODY NOTIFICATION
~~~ Tillamook School District 9 is an equal opportunity educator and employer. ~~~
TILLAMOOK SCHOOL DISTRICT NO. 9 2510 – 1st Street
Tillamook, Oregon 97141
Randy Schild, Superintendent 503/842-2558 • FAX 503/842-6854
IMPORTANT – “Recent Arrivers” Information
What – Beginning in 2012, the Oregon Department of Education requires that we collect information
to determine the number of “Recent Arrivers” in our school district.
Why – Title III is a Federal grant that provides funding for language instruction for Limited English
Proficient and Immigrant Students. Title III will use information about “Recent Arrivers” to help in distributing these funds. Therefore, the Oregon Department of Education is required to provide information about “Recent Arrivers” to the US Department of Education every year.
Who – All new to TSD9 students/families must respond to this questionnaire.
Any student born outside of the US or Puerto Rico, including foreign exchange students and
students born abroad to military members, must be included in the “Recent Arriver” count, if they meet all three criteria.
The Questions Student first and last name: __________________________________________________ Student school : ___________________________________________________________
1. Is the student 3 to 21 years of age? _____Yes _____No
Student date of birth: _________________________________________________
2. Was the student born outside of the United States or Puerto Rico? _____Yes _____No
(This includes foreign exchange students and students born abroad to military members.)
3. Has the student attended school in the United States for less than a total of three full school
years? _____Yes _____No
Date the student first attended school in the United States _____________________________
Has the student left US schools at any time since that date? _____Yes _____No
If Yes, please give dates that student was not in US schools. ___________________________
____________________________________________________________________________
Parent signature _________________________________ Date: ________________________
TILLAMOOK SCHOOL DISTRICT 9
Student Residency Questionnaire
Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, and/or Federal McKinney-Vento Education Act.
Eligibility can be determined by completing this questionnaire.
1. Are you and/or your family in any of the following situations? Check if true
A. Student staying with friends or couch surfing and not living with parent/guardian
B. Staying in a shelter or transitional housing
C. Sharing housing with others due to loss of housing, money difficulties or similar reason
D. Living in a car, park, campground, RV, public space, abandoned building, or housing not appropriate for your family
E. Temporarily living in a motel or hotel
2. Have you moved across school districts in the past 3 years to seek or obtain temporary or seasonal work
in any type of fishing, agriculture, forestry or dairy?
Yes
STOP
If you did not check any boxes, stop and do not continue. Turn the form in with the rest of your registration packet. If you did check any of the boxes in section 1 or 2 above, please continue filling out the form.
3. Student Name
First Middle Last
M/F
D.O.B.
Grade
School Name
4. Are there other children in the home?
(Check one) ____Yes ____ No How many?_________
Print Parent/Guardian Name Signature Date
____________________________________________ Phone number where you can be reached
Please submit this form with your registration packet.
************************************************************************************************************************************ For District Use Only: If parent has checked boxes in #1 or #2, make copy for school counselor.
Return original form to the District Office, Office of Student Success.
Transportation/Emergency Form 2015-2016 - Liberty and South Prairie
Tillamook School District #9(All information is strictly confidential)
Circle Grade (School) : K 1 (Liberty) 2 3 (South Prairie)
Father/Guardian's Name:
Father's/Gaurdian's Cell:
Father's/Guardian's Work Phone:
Monday [ ] Pick Up Name & Address:
[ ] Bus Rt # ______
Tuesday [ ] Pick Up Name & Address:
[ ] Bus Rt # ______
Wednesday [ ] Pick Up Name & Address:
[ ] Bus Rt # ______
Thursday [ ] Pick Up Name & Address:
[ ] Bus Rt # ______
Friday [ ] Pick Up Name & Address:
[ ] Bus Rt # ______
Bus Rt # Name Address
Phone
Parent/Guardian's Signature Date
Mother's/Guardian's Cell:
Mother's/Guardians Work Phone:
Emergency
or Early
Release
Teacher:
Student's Name:
Regular Transportation Schedule
ONLY AUTOMATED CALLS FROM THE DISTRICT WILL BE MADE.
IF YOUR CHILD IS NOT PICKED UP 10 MINUTES PRIOR TO THE BUSSES LOADING,
THEY WILL BE TRANSPORTED TO THE ADDRESS GIVEN BELOW.
EMERGENCY RELEASE
Home Phone:Home Street Address:
Mother/Guardian's Name:
Student Name: _____________________________ Teacher: _____________________________
TILLAMOOK SCHOOL DISTRICT #9
Field Trip Permission Slip
2015-2016
Dear Parent,
This permission slip will allow your child to attend local activities without
having to get a new permission slip signed by you each and every time.
You will be notified of all off campus activities via the school newsletter
and/or teacher information flyers. Any out-of-town field trips will require a
specific permission slip to be signed by you prior to your child attending.
Local field trips include but are not limited to such activities as:
Performances at the High School
Bowling
Farm Festival
Field Trips to local businesses
Activities at other schools
Library
______________________________________________________
Parent Name (Please Print)
_____________________________________ ____________
Parent Signature Date
□ Liberty
□ SPrairie
□ East
King Fluoride Tablet Program
2015-2016
The King Fluoride Program is given in your child’s school through the Oral Health Section of the
Department of Human Services, Office of Family Health. The program has two ways for the
teachers/nurses to give fluoride. The American Dental Association and The American Academy
of Pediatrics recommend both programs. The programs are for areas that do not have the right
amount of fluoride in their drinking water to help fight cavities. The programs are the Daily
Tablet Program and the Weekly Rinse Program. Both programs can help fight cavities.
Your teacher/nurse has chosen to use the Daily Tablet Program. Every school day, school
children who take part in the Daily Tablet Program will be given a fluoride tablet. Each child
chews this tablet for 30 seconds, swishes the mixture for 30 seconds, and then swallows.
If your child is already taking daily fluoride tablets or home fluoride given by your dentist, do not
enroll them in this program. Home use is a better way to take fluoride because your child can
take it on weekends, holidays and vacations. Tablets should be taken every day. If your child is
not taking fluoride tablets at home, the school program is a good way to get started.
Do not enroll your child in the Tablet Program if the drinking water source for your home has
fluoride in it. You can find this out by calling the number on your water bill. If your drinking water
comes from a private well, you can have your well water tested for fluoride.
There is no cost for this voluntary program. Your child must be at least 3 years old and must
return this signed permission slip.
For any questions please contact: Laurie Johnson, Prevention Specialist at 971-673-0339.
King Fluoride Tablet Program Permission Slip
Child’s Name _____________________________________________________(Please print)
Teacher’s Name __________________________________________room _____ Grade ___
Yes. My child is age three or older and I want my child to take part in the daily Fluoride
Tablet Program.
No. I do not want my child to take part in the Fluoride Tablet Program.
___________________________________________ ___________________
Parent/Guardian Signature Date
Tillamook School District 2015-2016
Title 1 Rights/Responsibilities 2015
Student Name: ___________________
Teacher: ________________________
My child is a student at Tillamook School District. I understand that Tillamook School District
has a Title I schoolwide program. Title I is a federally funded program and its purpose is to help
disadvantaged students meet the same high standards expected of all children.
As a parent of a student in a Title I schoolwide program, I have the following rights and
responsibilities:
1. I can ask questions of the classroom teacher, Title I staff, school principal and the district
Title I coordinator regarding my child’s academic progress and the academic program at
East.
2. I can participate in the review of policies and programs.
3. I can ask for information regarding what services my child is receiving, who is providing
those services and what qualifications this person holds (professional licenses, degrees,
state qualifications).
4. Parenting resources are available for me to check out at the Tillamook School District
library.
5. I am responsible for fulfilling my duties as a parent as outlined in the Tillamook School
District partnership agreement.
I also acknowledge receipt of the following materials which more specifically explain the Title I
program at Tillamook School District and my rights and responsibilities:
1. Tillamook School District Partnership Agreement for 2015-2016
2. Title I Brochure
3. Parent Handbook
Parent signature ____________________________________________
Date ________________________________________
□ Liberty
□ SPrairie
□ East
Title 1 Compact Form.2015
□ Liberty
□ SPrairie
□ East Tillamook School District Partnership Agreement 2015-2016
Tillamook School District 9 is committed to setting High Academic Standards and teaching students to be Safe, Healthy, Responsible Citizens who Respect Diversity and become Life Long Learners. As a Teacher I will do my personal best to:
Provide a safe, positive, and respectful learning environment. Promote life long learning and Life Skills. Consistently enforce classroom and school rules. Strive to meet student’s individual needs. Collaborate with students, staff and families.
Signature_________________________________________ Date___________________ As a Student I will do my personal best to:
Respect others. Follow classroom, school and bus rules. Complete and turn in assignments including homework. Practice Life Skills. Listen and follow directions.
Signature________________________________________ Date____________________ As a Parent I will do my personal best to:
Provide my child with nutritious food and plenty of rest. Ensure regular attendance. Supervise completion of homework. Provide time for my child to read or to be read to each day. Support school by being involved and informed of activities, assignments and policies.
Signature________________________________________ Date___________________
As a Principal I will do my personal best to:
Provide a safe and enriched learning environment Promote communication and collaborate between students, staff and families Provide leadership that will address staff, students and families’ needs and concerns. Promote life long learning and Life Skills.
Signature________________________________________ Date___________________