SARANAC LAKE CENTRAL SCHOOL DISTRICT SOCIAL HISTORY- NEW ENTRANTS Please complete this form entirely. WELCOME to the Saranac Lake Central School District. We realize that families are often under pressures that may have an impact on your child’s health or learning. If there is anything about your child’s health or family health that you would like to discuss further or are hesitant to put in writing, please feel free to call your child’s school nurse.

PART A

Student ID # ______________________ Today’s Date _________________________________

Child’s Last Name_________________________________ First___________________________ Middle _______________ Date of Birth ___________________ Place of Birth ___________________________Sex _______ Ethnicity _____________ Mailing Address _________________________________________________________________County ________________ (Street, road or route number and name, city, state, zip code) Directions to home if rural address_________________________________________________________________________ PARENT OR GUARDIAN: Father ___________________________________________

Mother _______________________________________

Address __________________________________________

Address ______________________________________

Home phone #_____________________________________

Home Phone #_________________________________

Cell phone #______________________________________

Cell phone #___________________________________

Employed by______________________________________

Employed by __________________________________

Work phone #______________________________________

Work phone #__________________________________

Occupation________________________________________

Occupation____________________________________

Person to contact in case of emergency ____________________________________Phone___________________________ Child care provider during school hours ___________________________________ Phone___________________________ 1. Please list any other siblings. Begin with the oldest: Last Name, First Name

Date of Birth

M/F Living at home

Living away

1. 2. 3.

LIVING ARRANGEMENTS OF THE CHILD OR UNACCOMPANIED YOUTH: 2. Child lives with: ____ father & mother ____ mother only

____ father only

____ Other *(explain) _____________

____ guardian

_______________________________

By other marriage

*In response to the Commissioner’s Regulations, SLCSD must ascertain if the student enrolling is living in a shelter, with relatives or others due to lack of housing, in an abandoned apartment/building, in a hotel/motel, camping ground, car, train/bus station or other similar situation due to the lack of alternative, adequate housing, or temporarily housed in a shelter awaiting an OCFS permanent foster care placement. Status of parents

____ married

____ father deceased

____ separated

____ divorced

____ mother deceased

____ other

3. Languages spoken in the home: _____________________________________________________________________________ 4. Has your child attended nursery school, day care or Head Start? YES

NO

How long _____________________Name of School ____________________________________ Age at start __________ 5. Your child is:

____ left handed

____ right handed

____ both

6. Does your child have any special interests? ____________________________________________________________________ 7. How many hours of TV does your child watch each day? ________ 8. Does your child exercise regularly? _________________ Describe activities: _________________________________________ __________________________________________________________________________________________________________ DEVELOPMENTAL MILESTONES: 9. Do you feel your child developed at a slower, average, or faster rate than his/her peers? If so, please explain ________________ __________________________________________________________________________________________________________ Have the parents been separated during the child’s life? ____ YES

____ NO

If yes, age of child at the time _______

Have there been any circumstances in this child’s life that you believe were hard for the child and that you think would help us understand your child? ____ YES ____ NO If yes, please explain_________________________________________ ___________________________________________________________________________________________________ Has your child received any professional counseling? ____ YES

_____ NO If yes, describe ____________________

___________________________________________________________________________________________________ Please check any services currently being provided or have been provided in the past: _____ Special Education

_____ Speech

_____ Occupational Therapy

____ Counseling

_____ Physical Therapy

_____ Vision or Hearing

_____ 504 Accommodations

____ Remedial Reading

_____ Remedial Writing

_____ English as a Second Language

Other (explain) _______________________________

Please check any services currently being provided or have been provided by an OUTSIDE AGENCY: _____ Department of Social Services

_____ Mental Health

_____ Probation

_____ Migrant Tutor

_____ School-based Caseworker

_____ Social Security Income

_____ Substance Abuse Counseling

_____ Crime Victim Counseling

_____ Upward Bound

_____ Other (explain) __________________________

Other information you feel might be relevant regarding your child:

Only residents of the Saranac Lake Central School District may enroll/attend Saranac Lake Central Schools. I certify that I am a resident of the Saranac Lake Central School District residing at ______________________________________________ (no post offices boxes, please) ___________________________________________________ Social History completed by Date

________________________________________________ Document reviewed by Date

SARANAC LAKE CENTRAL SCHOOL DISTRICT MEDICAL HISTORY Petrova Elementary School Bloomingdale Elementary School, St. Bernard’s Middle School High School

Nursing Staff Mary Beth Pelletieri Maryalice Smith Lynn Hart Cecily Dramm

897-1551 897-1753 897-1663 897-1454

Please provide complete information.

PART B

Student ID#__________________________ Today’s Date: ________________________________

Child’s Last Name _____________________________ First _______________________ Middle _________________________ Date of Birth _________________________________ PRENATAL 1. Were there any complications or problems during pregnancy, labor or delivery for this child? ____ YES ___ NO If yes, please explain: ___________________________________________________________________________________________ FAMLY MEDICAL HISTORY 2. Does anyone in your family have a history of (check those that apply):  Allergies  Hepatitis  Arthritis  Kidney Disease  Learning Disability Mental Retardation  Cerebral Palsy Tuberculosis Speech Problems Hearing Problems Visual Problems Heart Disease Other ________________________________________________

 Asthma Cancer  Diabetes

CHILD’S HISTORY 3. Has the child had any of the following: (record the date of illness or circle NO) Allergies_________________NO Anemia___________________NO Arthritis ___________________NO Asthma__________________NO Orthopedic Problems ________NO Bee Sting Allergy____________NO Birth Defects _____________NO Chicken Pox _______________NO Seizures or Convulsions_______NO Diabetes_________________NO Severe Headaches___________NO Head Injury/Concussion_______NO Whooping Cough__________NO Heart Disease ______________NO Other (name)________________NO 4. History relative to the ear: a. How many colds or sore throats does your child have every year? ___________ b. Has your child had more than two ear infections in the past year? YES NO c. Does your child stand very close to the TV or to you when you speak? YES NO d. Does your child respond when you call him/her from another room? YES NO e. Has your child been to a speech specialists? ____________ Dr.’s name________________________________________ Results___________________________________________________________________________________________ f. Does your child have tubes in his/her ears? YES NO g. Has your child been to an ear-nose-throat specialist? ____________ Results____________________________________ 5.

History relative to the eye: a. Does your child have excessive rubbing, blinking or squinting? YES NO b. Does your child have trouble seeing things far away? YES NO Close up? YES NO c. Does your child have a history of crossed eyes? YES NO Recurring sties? YES NO d. Does your child complain of dizziness or headaches? YES NO e. Has your child been seen by an eye specialist? YES NO Dr.’s name_______________________ Date _________ Results _______________________________________________________________________

6. History relative to allergy/asthma: a. Has your child been tested for allergies? YES NO Dr.’s name ___________________________________ Date _______________ Results___________________________________________________________________________ b. List allergies: _________________________________________________________________________________________ ____________________________________________________________________________________________________ c. Is your child receiving medication, shots or other treatments (for example inhaler, nebulizer, etc.)? YES NO Name of medication and dosage___________________________________________________________________________ d. What triggers an asthma/allergy attack in your child? _________________________________________________________

CURRENT MEDICAL CARE 7. Name of Doctor _____________________________________________ Date of last visit __________________________ Address____________________________________________________ Phone __________________________________ 8. Name of Dentist _____________________________________________ Date of last visit __________________________ Address ____________________________________________________ Phone__________________________________ 9. Are there any other medical personnel treating your child?

YES

NO

Name ______________________________

10. Is your child on any medication on a regular basis? YES NO Medication ________________________________ Diagnosis ____________________________________ Dosage_____________________________________________ 11. Is your child allergic to any medications?

YES

NO

If yes, please list __________________________________

Other information you feel might be relevant regarding your child:

_______________________________________________ Medical History completed by Date

_________________________________________________ Medical History reviewed by Date

Saranac Lake Central School District 79 Canaras Avenue Saranac Lake, NY 12983 (518) 891-5460 district office (518) 891-6773 district fax www.slcs.org