Barton Elementary School Kindergarten registration is being held the months of February through May. Be prepared to provide proof of residency within the Barton School District (i.e., an electric bill). District registration packets may be picked up in advance in the elementary office. Your child must be 5 years old by August 1, 2016. Enrollment Requirements: 1. 2. 3. 4. 5. 6.

Student Enrollment Form Nurse's Packet (Health History) 1 Utility Bill - electricity (current - from child’s residence, in guardian’s name) Birth Certificate Shot/Immunization Record Physical Exam (Performed by Health Care Professional)

***You will be asked to bring your child for Brigance testing June 1-3.

Kim Williams Professional School Counselor 870-572-7294 (2104)

Yvonne Wooten Professional School Counselor 870-572-7294 (4727)

BARTON-LEXA SCHOOL DISTRICT ENROLLMENT FORM Student Enrollment Form

============================================================================== First Name:______________________Middle Name:___________________Last Name:______________________ SSN:_____-____-_____ Ethnicity (check one): ____Hispanic ____Non-Hispanic

Gender: M or F

Birthdate:______________

Primary Race (check one): ____American Indian/Alaska Native ____Asian ____Black ____Hispanic ____Native Hawaiian/Pacific Islander ____White

Grade:______ Age:______ Additional Race: ____American Indian/Alaska ____Asian ____Black ____Hispanic ____Native Hawaiian/ Pacific Islander ____White

Legal Residence (911 Address): Address:____________________________________City:_________________State:______Zip Code:_____________ Mailing Address: Address:____________________________________City:_________________State:______Zip Code:_____________ Living With (check all that apply): ____Both Parents ____Mother Only ____Father Only ____Grandparents ____Legal Guardian ____Father & Stepmother ____Mother & Stepfather ____Foster Parent ____Institution ____Homeless Are you living with another family? __________________ Father’s Name:____________________Cell Phone:____________Work Phone:____________ Email_____________________________ Employer:_________________________ Mother’s Name:____________________Cell Phone:_________________

Work Phone:__________________

Email__________________________ Employer:_________________________ Emergency Contact Information: Contact Name:_______________________________Relationship:_________________Contact Phone:____________ Method of Transportation (check all that apply): ____Bus ____Parent/Guardian (includes walkers)

Bus #_____

Birth Certificate #:___________________ City of Birth:__________State of Birth:____________ Has the student been expelled from school or are there proceedings pending in any other district? ______________ Has the student been retained? ________ Does the student receive special services? ___________. If so, describe. _____________________________ Language Spoken at Home:__________________

Current grade level: ___________________ Previous grade level: __________________________ Name of the last school the student attended _____________________________ Name of siblings and grade level. ________________________________________________________________________________ ________________________________________________________________________________ Does the student have a nickname or does the student prefer to be called by their middle name? ___________________________________ Pre-School Participation: ____ABC ____Early Childhood ____Headstart ____21st Century ____Private Pre-School ____Public Pre-School ____Not Applicable

Medical Information: Does the student have any allergies? ____________________, If so, please describe. ___________________ Does the student wear glasses? ____________ Does the student have asthma? _______________

Today’s Date:_______________

Parent/Guardians, Please complete the following forms to allow your child to be seen in the Nurse’s Office. No child can be seen unless these forms are completed and on file. NO phone calls will be made to obtain permission from a parent to administer medication or give treatment to a child. NAME OF STUDENT:____________________________________________________GRADE:______________ BIRTHDAY:__________________________SS#____________________________GENDER: MALE / FEMALE RACE: Black, White, Hispanic, Oriental, Native American, Other NAME OF PARENT/GUARDIAN:_______________________________________________________________ MAILING ADDRESS:________________________________________________________________________ CITY:________________________________ STATE:___________________ZIP:________________________ HOME TELEPHONE #:________________________________CELL #:_________________________________ WORK #:__________________________________PLACE OF EMPLOYMENT:__________________________ EMERGENCY NAME AND #:__________________________________________________________________ 2ND EMERGENCY NAME AND #:_______________________________________________________________ PRIMARY CARE PHYSICIAN’S NAME:______________________________PHONE #:____________________ Does your child have Private Insurance?......................................................................................YES or NO Does your child have AR KIDS or MEDICAID?................................................................................YES or NO If so, AR KIDS or MEDICAID #:__________________________________________________Part A or Part B Is your child in good health?........................................................................................................YES or NO Is your child now under the care of a doctor?..............................................................................YES or NO If so, for what condition?___________________________________________________________________ List any medications that your child takes on a daily basis:________________________________________ Does your child require medications to be given at school?.........................................................YES or NO If so, what medications and how often?_______________________________________________________ Does your child have allergies to medications, foods, or insect stings/bites?...............................YES or NO List any allergic reactions your child has had in the past and how it was treated.______________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Does your child require an EpiPen?..............................................................................................YES or NO

Signature of Parent/Guardian_____________________________________________Date:______________

PHYSICIAN’S ORDERS FOR TREATMENT NAME OF STUDENT_____________________________________ DATE OF BIRTH___________ LISTED BELOW ARE MEDICATIONS APPROVED TO BE USED BY THE SCHOOL NURSE TO TREAT MINOR INJURIES AND ILLNESSES OF YOUR CHILD THAT MAY OCCUR AT SCHOOL. PLEASE CIRCLE “YES” IF YOU GIVE PERMISSION FOR THIS TREATMENT OR “NO” IF YOUR CHILD IS NOT TO BE TREATED. MEDICATION:

USED FOR:

YES NO

Hydrocortisone Cream

Minor skin irritations/itching

YES NO

Saline eye wash

Irrigation of eyes

YES NO

Tylenol 325mg

Pain or fever

YES NO

Calamine lotion

Itching due to mild poison ivy or oak

YES NO

Blistex

Cold sores/fever blisters

YES NO

Cough drops with menthol

Sore throat/cough/nasal congestion

YES NO

Hydrogen Peroxide/Alcohol

Topical anti-infective/astringent

YES NO

Maalox/Tums

Indigestion/gas

YES NO

Bactine or Antiseptic

Minor cuts, scratches, sunburn, insect bites

YES NO

Sting Kill

Temporary relief of insect bites/stings

YES NO

Triple Antibiotic Ointment

Preventing infection and aid in healing

COMMENTS:_______________________________________________________________________________ __________________________________________________________________ These are the ONLY medications we are allowed to administer at school. We CANNOT administer ANYTHING for stomach aches, toothaches, etc. These ailments will have to be taken care of at home. Tylenol will be given OCCASSIONALY for a headache, but NOT on a regular basis. Tylenol is damaging to the liver if taken too frequently. No Tylenol will be given for aches and pains without a physician’s order, as it could mask an undiagnosed problem. Old cuts, bruises, burns, etc. will not be treated at school. ONLY minor injuries that occur AT SCHOOL will be treated in the Nurse’s Office. PARENT/GUARDIAN’S SIGNATURE_________________________________________________

QUESTIONNAIRE FOR PARENTS OF STUDENTS WITH ASTHMA (please attach any information that might be useful in caring for your child at school) This information will be handled confidentially and may be shared with appropriate faculty and staff who work directly with your child. 1. How long has your child had asthma? _______________________________________ 2. Please rate the severity of his/her asthma. (circle) Not Severe 0 1 2 3 4 5 6 7 8 9 10 Severe 3. What triggers your child’s asthma attacks? (circle all that apply): illness emotions medications foods weather exercise cigarette smoke chemical odors fatigue other: _____________________________________________ 4. List side effects your child experiences from his/her medications: ________________________________________________________________________ 5. What does your child do at home to relieve wheezing during an asthma attack? (circle all that apply): breathing exercises rest/relaxation drinks liquids takes inhaler Nebulizer oral medications 6. Has your child had asthma education? Yes No

Parent or Guardian’s signature: __________________________________________________

ATTENTION PARENTS AND GUARDIANS

The attached is a letter regarding students and guidelines for the nurse’s office. Please read carefully so you will understand when your child will be allowed to see the nurse and/or call home. It will also help you to decide when your child should be kept home, by explaining the situations in which a student should be sent home once he/she is at school. Please sign this sheet and *KEEP THE ATTACHED LETTER FOR YOUR REFERENCE.* Thank you. I have read the attached letter and understand when my child may be allowed to see the nurse and/or call home.

Student’s Name: ___________________________________________________

Parent’s Signature: _________________________________________________

Date: ____________________________________________________________

BARTON-LEXA PUBLIC SCHOOLS SCHOOL HEALTH & MEDICATION GUIDELINES Dear Parents/Guardians, In order to provide better health services for our students, we feel that we need to change some of the policies and procedures we have been following. The only prescription medications that will be administered at school will be medications that your child takes on a daily basis at least FOUR times a day or medication that a physician orders to be given at a specific time during the school day. We will NOT administer short term medications such as, antibiotics, cough syrups, allergy medications, eye drops, ear drops, etc. These can be taken at home. PLEASE DO NOT ASK THE TEACHERS TO GIVE THESE MEDS. There is always a risk of an allergic reaction to any medication, even if the child has taken the medication in the past. If your child does take an approved medication, we must have the appropriate forms completed and on file. DO NOT send the medications to school by your child. An adult must bring the medication to the nurse and sign permission forms before medications are given at school. New forms have to be completed at the beginning of each school year. The medication MUST be in the most recent container with the child’s name, date, name of medication, dose, time, and any special instructions on the prescription label. You are responsible for bringing in a new month’s supply each month. All medications will be locked in the nurse’s office. NO medication that is to be given THREE times a day will be administered at school unless it is ordered at a specific time by the doctor. If this is the case, we will need a letter or an order signed by your physician that prescribed the medication. We must have all the forms completed and returned BEFORE the medication will be given at school. HAND WRITTEN NOTES ARE NOT ACCEPTABLE! If your child is injured outside of school, please do not tell him/her to see the school nurse. If your child is ill before school, please do not send him/her to school that day. Also, if he/she feels bad before school, do not send a note or tell the child to call home if he/she feels worse. Once at school the only reason we will call home is for the following: vomiting, diarrhea, elevated temp, head lice, broken bone, chest pain, seizures, etc. The school nurse’s office is NOT a clinic. She does not treat or diagnose broken bones, pulled muscles, allergies, stomach aches, chest pain, rashes, colds, etc. The nurse must perform all of the state required screenings and reports, maintain health and immunization records, administer first aid for injures that occur at school that day, administer approved medications, help to maintain health needs of children with chronic diseases, and if time allows, schedule health education for the children. Thank you for your cooperation. We want to keep your children safe and healthy. Sincerely, Barton-Lexa Superintendent **YOUR CHILD CANNOT BRING THEIR MEDICATIONS ON SCHOOL CAMPUS OR ON THE SCHOOL BUS. YOU WILL NEED TO BRING ALL MEDICATIONS TO THE SCHOOL NURSE. CHILDREN WILL BE DISIPLINED FOR BRINGING ANY MEDICATIONS ON THE SCHOOL BUS OR ON CAMPUS. ASTHMATIC AND DIABETIC STUDENTS ARE ALLOWED TO HAVE THEIR MEDICATIONS WITH THEM AT ALL TIMES.