2415 Jones Ave. Pueblo, Colorado 81004 January 11, 2016 Dear PSAS Families, It is time again when PSAS students must re-enroll. This is an annual event that provides PSAS valuable updated information about which students are planning to return. We then use this information to plan enrollment and manage our waiting list for the 2016-2017 school year. The items needed to complete reenrollment are:
Completely filled out reenrollment packet. $50.00 Activity ($120.00 for families with 3 or more children attending PSAS) Students entering 6th Grade for the 2016-2017 school year must turn in an updated immunization record by the first day of school for 2016-2017 school year. This record must show their updated TDAP vaccination.
Completed enrollment packets must be returned to the front office by March 11, 2016 to ensure that your child is placed at PSAS for the 2016-2017 school year. Only completed packets with activity fee will be accepted. If a packet is determined to be incomplete, it will be returned to you for completion and your child will not be guaranteed enrollment until the packet is turned in complete. Due to the importance of completed packets and money transactions for activity fees, please do not send reenrollment packets with students. Enrollment packets are only accepted at the Front Office. They will not be accepted by teachers in classrooms. Students with attendance or academic issues may be required to have a meeting with the Principal or Assistant Principal to create a “Success Plan” for the next school year as a part of their reenrollment. If your child will be placed on a “Success Plan” you will be contacted by the administration team to set up a meeting time to discuss this plan. If you have any questions regarding reenrollment please call Mrs. Samuelson at the Front Office at 404-2680. Sincerely,
Brian Repola Director of Pueblo School for Arts and Sciences.
Pueblo School for Arts and Sciences
Date Received_____________________
2016-2017 Reenrollment Form
Received By_______________________
Payment______________
Student Information: Grade Entering 2016-2017___________________ Student’s LEGAL FULL NAME (as it appears on Birth Certificate) Last:___________________________________________
First:______________________________ Middle:_________________ Suffix:_________
Home Address and Contact Information: Street Address:________________________________ Apt. #________________ City:_____________________ State:___________ Zip:_____________
Mailing Address:
Check here if same as home address
Street Address:_________________________________ Apt #_________________ City:_____________________ State:___________ Zip:____________ Primary Phone Number for automated calls from school : __________________________________
Parent/Guardian Information Name:__________________________________________ Relationship to Student:__________________ Email:_________________________________
Residence Address:______________________________________________________________________ Home Phone:_________________ Cell Phone:____________
Use for automated calling Work Phone:_______________
Use for automated calling
Check if parent/guardian resides with student
Use for automated calling
Use for sending texts
Parent/Guardian Information Name:_________________________________________ Relationship to Student:__________________ Email:_________________________________ Residence Address:_________________________________________________________________ Home Phone:_________________ Cell Phone:____________
Use for automated calling Work Phone:_______________
Use for automated calling
Check if parent/guardian resides with student
Use for automated calling
Use for sending texts
Additional parent/guardian information may be provided in Emergency Contacts. Note: When a student does not reside with both parents, additional information must be on file so that the school can determine who is responsible for the student. If there are applicable documents, such as custody papers and guardianship, a copy should be provided to the school.
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Please fill out additional form on back of paper
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Pueblo School for Arts and Sciences
Student Name______________________________
2016-2017 Reenrollment Form Emergency Contacts: Please provide at least one local emergency contact OTHER THAN THE PARENTS/GUARDIANS LISTED ON PAGE TWO and any day care provider’s information. Name:_______________________________________________
Relationship to Student:______________________
Check if resides with student
Home Phone:_______________________ Work Phone:___________________ Cell Phone:___________________________
Name:_______________________________________________
Relationship to Student:______________________
Check if resides with student
Home Phone:_______________________ Work Phone:___________________ Cell Phone:___________________________
Name:_______________________________________________
Relationship to Student:______________________
Check if resides with student
Home Phone:_______________________ Work Phone:___________________ Cell Phone:___________________________
I, the undersigned, do hereby authorize officials of PSAS to contact directly the persons named as emergency contacts for the health of said child. In the event persons named or parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the said child. I will not hold PSAS financially responsible for the emergency care and/or transportation for said child. Parent/Guardian Print: ___________________________________________________ Phone: (
) ___________________________________
Parent/Guardian Signature:________________________________________________ Date:__________________________________________
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Pueblo School for Arts and Sciences
Student Name______________________________
2016-2017 Reenrollment Form Household Information Student Lives With (Check Only One) Both parents, same household
Both parents, different households
Father Only
Mother Only
Father/Stepmother
Mother/Stepfather
Legal Guardian
Relative
Foster Parent
Non-Relative
Our current living situation is (Check One): The following questions address the McKinney-Vento Act 42 U.S.C 11435. The responses help us determine if your student is eligible for additional services. We rent/lease/own our own apartment/condo/house. We live in a temporary shelter or in “temporary assisted housing” being paid for partially or completely by an organization like Posada or DSS, due to an emergency economic situation. We are living “doubled up” due to economic emergency-not to save money or for cultural preference We are living in a hotel/motel as a guest—not because we own it or work there. We are living in a situation due to economic emergency not described above (please specify):
PSAS Parent/Guardian/Student Requirements For Enrollment As Parent/Guardian, I fully understand that it is my commitment and responsibility to fulfill the following requirements for admission and continued enrollment in the Pueblo School for Arts and Sciences. I agree to support and adhere to all policies of PSAS including those in the Parent/Student Handbook. I agree to pay the activity fee. Once the child is accepted as a student at PSAS, monies become non-refundable. I will make an effort to participate in fundraising activities. I will make efforts to complete and document a minimum of 18 hours voluntary service to the school as stipulated in the Parent/Student Handbook. I understand that my child will complete homework and school projects on time and in a quality manner. I will attend with my child and actively participate in ALL student led conferences as well as the parent/teacher conferences. My child and I will support a safe and productive learning environment. I understand that my child MUST have prompt and regular school attendance including kindergarten level, and in accordance with Colorado State Law. I agree to participate in the implementation of Response to Intervention Plan, if needed. I understand that my child will complete all academic requirements and community service projects.
Parent/Guardian Signature____________________________________________________
Date__________________________
Parent/Guardian Signature____________________________________________________
Date__________________________
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Pueblo School for Arts and Sciences
Student Name______________________________
2016-2017 Reenrollment Form Health Information is confidential and will be shared with school staff on a need to know basis. Does your child have any of the following health problems? (Check all that apply) Autism Spectrum Disorder
Autoimmune problems
ADD/ADHD
Asthma
Blood Disease
Bone/Joint
Bowel/Bladder Issues
Cancer
Diabetes
Eating Disorder
Emotional Concerns
Glasses/Contacts
Hay Fever/Allergies
Head Injury/Concussion
Heart Condition
Migraines
Seizures
Sleep Disorder
Vision Concerns
Stomach
Hearing Impaired
None
Other
Comments/concerns:
Allergies: Does your child have any significant allergies that school personnel should know about?
Yes
No
If yes, list allergy and symptoms of allergic reaction:________________________________________________________________________________________ How is it treated?____________________________________________________________________________________________________________________ Note: If your child has a food allergy, please contact the Kitchen Manager at PSAS at 404-2680, Ext. 129 Medications: Does your child take medications? Will this medication be given at school?
Yes Yes
No No
If yes, what is it for?____________________________ Please note that PSAS requires a medication form to be filled out by parent and physician
Activity Restrictions: Has your child’s doctor placed any current restrictions on your child’s physical activities?
Yes
No
If yes, please describe and provide written documentation from your physician. Doctor’s Name: _________________________________________________________ Dentist’s Name:__________________________________________________________ Health Insurance:
Yes
No
Medicaid:
Phone:___________________________________ Phone:___________________________________ Yes
No
CHP+
Yes
No
I give permission for the information contained on this Health Information History to be shared with adults in the school setting that will be working with my child, on a need to know basis. I consent to authorize PSAS to release information related to health and or other Medicaid eligible services for Medicaid reimbursement for such services. It is the responsibility of the parent/guardian to notify the school nurse whenever there is any change in the student’s health status or care. If at some time you wish to withdraw this permission, please contact the school nurse.
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Pueblo School for Arts and Sciences
Student Name______________________________
2016-2017 Reenrollment Form Volunteer Agreement Form At the Pueblo School for Arts and Sciences, we highly value the work and efforts of our volunteers. We thank you for your dedication and time spent with us to benefit our students. As a school, we are required to observe federal law protecting the privacy of our students and staff. Please read the information in this “Volunteer Agreement Form” and sign and date on the indicated line.
I understand that as a volunteer in the Pueblo School for Arts and Sciences (PSAS) that ALL student and staff information is confidential. I agree not to access, review, disclose, or use confidential student or staff information without specific direction and authorization from a PSAS administrator. I also understand that even when I am no longer a volunteer in PSAS, any confidential information I have learned must continue to be kept confidential. I understand that any breach of this confidentiality requirement will result in my immediate termination as a volunteer and could result in legal action against me. The term “confidential information” includes any and all personal identifying information related to a specific student, their family or any staff member. Examples of this include, but are not limited to : Attendance records, phone numbers, academic, behavioral, medical or disability records and any other observed or recorded information on these persons. I understand that I must comply with all PSAS policies and school rules applicable to school staff, as well as all directions from school administrators and staff while serving as a volunteer. I further understand that my ability to serve as a volunteer may be terminated at the discretion of the Director and Principal, if at any time they determine it is in the best interest of PSAS.
___________________________________________________________________________________________________________________________ Signature Parent/Guardian
Printed Name
Date
___________________________________________________________________________________________________________________________ Signature Parent/Guardian Blue
Printed Name Please fill out additional form on back of paper.
Date
Pueblo School for Arts and Sciences
Student Name______________________________
2016-2017 Reenrollment Form Parent Permission and Release Form Parent Permission for Excursions: On occasion, children will be given the opportunity to participate in field trips. On excursions, children take school buses, walk or use some other means of transportation. If you sign in the space below, your child will be allowed to join in these field trips during the current school year. PSAS will send information home before each excursion-by note, by newsletter, by calendar or by some other means-to provide information on the place to be visited and the date of the excursion. At that time, you may revoke your permission for your child to go on this specific excursion. PSAS is not responsible for student injury sustained on any excursion or field trip. I have read the foregoing information and consent to my child being taken on field trips or excursions during the school year. Parent/Guardian Signature:____________________________________________________________________________________ Date:___________________________
Parent Permission for Media: PSAS uses a variety of different media outlets throughout the year to include but not limited to: PSAS Media: Facebook, weekly newsletter, website all supervised by PSAS staff. I give permission for my child to be represented in/on PSAS created media. ______________ Yes Public Media: Television, local newspaper etc.. I give permission for my child to be filmed/photographed/interviewed by public media outlets. ______________Yes
_____________No
__________No
Parent/Guardian Signature:____________________________________________________________________________________ Date:_________________________________
Acknowledgement The information contained on this Enrollment Form is true and correct. In accordance with Colorado Revised Statues Sections 22-33-104 and 22-33-107, I acknowledge my obligation to ensure that every child under my care and supervision who is six years old by August 1 and under seventeen years old attends school. The only exceptions shall be illness and other absences excused by the Principal or Assistant Principal. I understand all children new to PSAS are enrolled conditionally until records, including discipline records, from the schools previously attended are received by PSAS. In the event the child’s records indicate a reason to deny admission, the student’s conditional enrollment status shall be revoked. Parent/Guardian Signature_______________________________________________________
Date_________________________________________
“Teaching and learning from bell to bell” is an essential belief at PSAS. Classes begin each day promptly at 7:55 am and dismiss at 3:15 for the regular school day. It is crucial that our child be on time, every day, in order to gain maximum benefit from our educational programs. We also request that children not be taken out of school for any non-emergency situation or appointment during the day. This includes arriving late and checking out early. Appointments should be scheduled for times other than school days, whenever possible.
I will make every effort to have my child in school, on time, all day, every day.
Parent/Guardian Signature:_____________________________________________________________________________________________________________________________ Parent/Guardian Signature:_____________________________________________________________________________________________________________________________
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