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READY…SET… REGISTER IN PRESCHOOL! 2013-2014 SCHOOL-BASED PRESCHOOL REGISTRATION FORMS This packet includes registration forms needed to enroll your child into the Chicago: Ready to Learn! school-based preschool program. Provide at Registration: By Child’s First Day of Attendance: _____ Home Language Survey _____ Child Health Requirements * _____ Release Form _____ Certificate of Child Health Examination _____ Request for Emergency and Health Information * Families will be informed of additional health regulations at time of registration. _____ Media Consent Form and Release In accordance with the McKinney Vento Homeless Assistance Act, students in a temporary living situation are eligible for immediate enrollment (see Rights of Homeless Students). QUESTIONS? Please contact your child’s school or call the Office of Early Childhood Education: 773.553.2010 PRONTO…LISTOS… ¡A INSCRIBIRSE EN PREESCOLAR! FORMULARIOS DE REGISTRO PARA PREESCOLAR 2013-2014 BASADO EN ESCUELAS Este paquete incluye los formularios necesarios para matricular a su niño/a en el programa preescolar Chicago: Ready to Learn! basado en la escuela. Presentar al momento de registrarse: El primer día de asistencia: ____ Encuesta de Idioma en el Hogar ____ Requerimientos de salud del niño/a * ____ Formulario de Autorización ____ Certificado de Examen Médico del niño/a ____ Pedido de Información de Emergencia y de Salud * En el momento de registrarse las familias serán informadas de las regulaciones adicionales de salud. ____ Formulario de Autorización de Medios y Dispensa De acuerdo con el Acta McKinney Vento de Ayuda a los Sin Hogar, los estudiantes en una situación temporaria de vivienda son elegibles para matriculación inmediata (ver Derechos de los Estudiantes sin Hogar). ¡Preguntas? Por favor contacte la escuela de su niño o llame a la oficina de Educación Preescolar: 773.553.2010. Chicago Public Schools Complete this Home Language Survey at the student’s initial enrollment in a Chicago Public School. This form must be kept in the student’s folder. School: Room: Student Name: Unit: Student ID No.: English IMPACT REGISTRATION PROCESS 1. Is a language other than English spoken in your home? No Yes (For Office use only) (Language) The Non-English language identified on either question is the Home Language. 2. Does the student speak a language other than English? No Area: Yes If two different non-English languages are identified, enter the language identified in question 2 as the (Language) Home Language. Enter ENGLISH as a Home Language ONLY when If the answer to either question is yes, the law requires the school to both questions are answered no. assess your child’s English language proficiency. Spanish Polish 1. ¿Se habla algún otro lenguaje que no sea inglés en su 1. Czy językiem innym niź angielski mówi się w domu? hogar? No Sí (Lenguaje) 2. ¿Habla el estudiante un lenguaje que no sea el inglés? No Sí Nie Tak (język) 2. Czyt uczeń mówi innym językiem niż angielski? (Lenguaje) Nie Tak (język) Si la respuesta a cualquiera de las preguntas es “Sí”, la ley requiere Jeśli udzielili Państwo twierdzącej odpowiedzi na którekolwiek z powyższych que la escuela evalúe la fluidez de su niño en el idioma inglés. pytań, przepisy wymagają, aby szkoła sprawdziła poziom znajomości języka angielskiego waszego dziecka. Chinese Arabic 如果你在兩個問題中之任一項的答案是 “是”, 則法律規定校方 要測試貴子女的英語通悉度。 Bosnian/Croatian/Serbian إذا ﻛﺎﻧﺖ اﻹﺟﺎﺑﺔ ﻧﻌﻢ ﻋﻠﻲ أي ﻣﻦ اﻟﺴﺆاﻟﯿﻦ ﻓﺈن اﻟﻘﺎﻧﻮن ﯾﺤﺘﻢ ﻋﻠﻲ .اﻟﻤﺪرﺳﺔ ﺗﻘﯿﯿﻢ اﺑﻨﻜﻢ ﻟﻠﻜﻔﺎءة ﻓﻲ اﺳﺘﺨﺪام اﻟﻠﻐﺔ اﻻﻧﺠﻠﯿﺰﯾﺔ Urdu Ukoliko ste na bilo koje od ovih pitanja odgovorili sa “Da”, škola će biti zakonski dužna da procijeni nivo znanja engleskog jezika kod vašeg djeteta Office of Language and Cultural Education Signature of School Official Date Signature of Parent/Guardian Date Notes: If the parent/guardian does not speak English and the school does not have staff who speaks the parent/guardian’s language, identify the language spoken by the parent/guardian through any assistance available in the school. If exact name of the language cannot be determined, enter “Other” as a temporary entry. The exact language must be Revised: Mar. 2009 determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available. Questions or concerns, contact your Area Compliance Facilitator. RELEASE FORM CHILD’S NAME ___________________________ DATE __________ SCHOOL NAME ___________________________ ROOM _________ PARENT’S NAME _____________________________ The following people have permission to pick up my child from the Chicago: Ready to Learn! preschool program. SIGNATURE OF PARENT _______________________________________ NAME _______________________ RELATIONSHIP TO CHILD ____________ NAME _______________________ RELATIONSHIP TO CHILD ____________ NAME _______________________ RELATIONSHIP TO CHILD ____________ NAME _______________________ RELATIONSHIP TO CHILD ____________ FORMULARIO DE AUTORIZACIÓN NOMBRE DEL NIÑO ___________________________ FECHA_______ NOMBRE DE LA ESCUELA _____________________ SALÓN________ NOMBRE DEL PADRE _____________________________ Las siguientes personas están autorizadas a recoger a mi niño del programa preescolar Chicago: Ready to Learn! FIRMA DEL PADRE _______________________________________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ Rev. 07/2012 Chicago Public Schools Request for Emergency and Health Information School Name: ______________________________________________________________ Date: _________________ PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a change in this information, immediately notify the school in writing. ___________________ Student ID# __________________________________________________________________________________________ Last Name First Name Middle Name ______________________ Birth Date (mm/dd/yyyy) ___________________________________________________________________________________ Student Home Address __________________ Homeroom # _____________________ Student Home Phone # Confidential Information Box 1 Complete this box only if (1) it reflects your child’s current living situation; OR (2) it reflects your living situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff with enrollment and may enable the student to receive additional services.) Check one box if you are living: in an abandoned apartment/building in a car/park/other public place in a shelter in a temporary foster care placement in a hotel/motel in a residence of other individuals or family Note to School: If any box is checked, see the CPS Education of Homeless Children and Youth Policy (702.5). Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed. Parent/Guardian Contact Parent/Guardian Contact Contact Name Relationship to Student Check all that apply: Lives With Gets Mailings Lives With Gets Mailings Emergency Permission to Pickup Emergency Permission to Pickup Home Address, if different from student’s Home Phone Number, if different from student’s * Cell Phone Number * Email Address *reply N/A if not available Name and Address of Employer Work Phone Number List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student: _________________________ ___________________________________________________________________________________________________________ Name Home Address Telephone # Relationship Confidential Information Box 2 Is there a current Order of Protection or No Contact Order which concerns this student? Yes No Note to School: If “Yes” is checked, please follow the procedures of CPS Policy 704.4. Enter the information into the Legal Alert field and update contact information, as needed, in SIM. Family Doctor’s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency. ____________________________________________________________________________________________________________________________________ Student Health Insurance: (select only one of the three) Illinois Medical Card/All Kids: provide student’s medical ID # __________________________________________(9-digit number located on back of card) No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No Private/Employer Health Insurance: no additional information needed I certify that the information on this form is correct. ______________________________________________________________________________________________________________(Parent/Guardian Signature) Chicago Public Schools Media Consent Form and Release Consent/Release I hereby consent to have my student photographed, video taped, audio taped and/or interviewed by the Board or the news media when school is in session or when my child is under the supervision of the Board. I understand that during the school year, the Board might like to celebrate my child’s accomplishments and work. Therefore, I further consent to allow the Board to release my student’s name, academic/non-academic awards, and information concerning my child’s participation in school-sponsored activities, organizations and athletics. I also consent to the Board’s use of my student’s name, photograph or likeness, voice or creative work(s) on the Internet or on a CD or any other electronic/digital media or print media. As the child’s parent or legal guardian, I agree to release and hold harmless the Board, its members, trustees, agents, officers, contractors, volunteers and employees from and against any and all claims, demands, actions, complaints, suits or other forms of liability that shall arise out of or by reason of, or be caused by the use of my child’s name, photograph or likeness, voice or creative work(s), on television, radio or motion pictures, or on the Internet, or on a CD, or any other electronic/digital media or print media. It is further understood and I do agree that no monies or other consideration in any form, including reimbursement for any expenses incurred by me or my child, will become due to me, my child, our heirs, agents, or assigns at any time because of my child’s participation in any of the above activities or the above-described use of my child’s name, photograph or likeness, voice or creative work(s). I understand that I may cancel this release by providing written notice to the principal. I also understand that this release is valid for one school year, including the following summer. Instructions: Check Box #1 or Box #2 1. □ I consent as outlined in the above consent/release section. 2. □ I DO NOT consent to my child being photographed, video taped, audio taped and/or interviewed by the Board or the news media when school is in session or when my child is under the supervision of the Board. Furthermore, I do not consent for the Board to release my student’s name, academic/non-academic awards, and information concerning my child’s participation in school-sponsored activities, organizations and athletics. I do not consent for the Board to use my student’s name, photograph or likeness, voice or creative work(s) on the Internet or on a CD or any other electronic/digital media or print media. ____________________________________________ ________________________________________________ Signature of Parent/Guardian/Student if age 18 or older Printed Name of Parent/Guardian/Student if age 18 or older ___________________________________ Student’s Name ___________________________________ Student ID # ___________________________________ Date ___________________________________ School I understand that I have the right to inspect and copy my student’s records, challenge the contents of such records; and limit my consent to the designated records or designated portions of information within the records. Department of Policy and Procedures July 2012 ```` Escuelas Públicas de Chicago Consentimiento de prensa y dispensa de responsabilidad Consentimiento/Dispensa Por la presente autorizo a que mi estudiante sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta de Educación de Chicago o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Entiendo que en el curso del año escolar la Junta quiera celebrar los logros y el trabajo de mi niño. Por lo tanto, también autorizo a la Junta la divulgación del nombre de mi niño, de sus premios académicos y no académicos y de información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. También autorizo a la Junta el uso de fotografías o retratos de mi niño, o de su voz o trabajo creativo, en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. Como padre o tutor legal del niño, libero de toda responsabilidad a la Junta, a sus miembros, síndicos, agentes, oficiales, contratistas, voluntarios y empleados ante cualquiera y todos los reclamos, demandas, acciones, quejas, juicios u otras formas de responsabilidad que puedan surgir por cualquier razón, o puedan ser causadas por el uso del trabajo creativo, fotografía, retrato o voz en televisión, radio o películas, o en medios impresos, Internet o cualquier otro medio electrónico/digital. Es entendido además, y estoy de acuerdo, en que no se me debe a mí, a mi niño, a nuestros herederos, agentes o designados ningún dinero o consideración de ninguna especie, incluyendo el reembolso de cualquier gasto realizado por mí o por mi niño durante la participación en cualquiera de las actividades mencionadas, o por el uso de su trabajo creativo, fotografías, retrato o voz. Entiendo que puedo cancelar este consentimiento mediante una comunicación por escrito al director escolar. También entiendo que esta dispensa es válida por un año escolar, incluyendo el verano siguiente. Instrucciones: marque la caja #1 o caja #2 1. □ Autorizo lo señalado arriba en la sección consentimiento/dispensa. 2. □ NO autorizo que mi niño sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Tampoco autorizo que la Junta divulgue el nombre de mi niño, sus premios académicos y no académicos e información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. No autorizo a la Junta el uso del nombre de mi estudiante, fotografías o retratos, de su voz o trabajo creativo en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. ____________________________________________ Firma padre o tutor, o del estudiante si tiene 18 años o más _____________________________________________ Nombre en imprenta del padre o tutor, o del estudiante si tiene 18 años o más ___________________________________ Nombre del estudiante ___________________________________ Número de ID del estudiante ___________________________________ Fecha ___________________________________ Escuela Entiendo que tengo el derecho de inspeccionar y copiar los registros de mi estudiante, de disputar el contenido de dichos registros; y limito mi consentimiento a los registros designados o porciones designadas de información contenida en los registros. Departamento de Política y Procedimientos Julio 2012 CHILD HEALTH REQUIREMENTS Chicago: Ready to Learn! School-based Preschool Programs All physical exams must be signed and dated by a physician or advanced nurse practitioner, and should include the clinic stamp. The exam must contain the following screenings: Chicago: Ready to Learn! Programas de Educación Temprana localizadas en las escuelas públicas Todos los exámenes físicos deben ser firmados por el doctor ό la enfermera capacitada y debe de incluir el sello de la clínica. El examen debe contener los siguientes análisis: • Prueba anual de Hemoglobina/Hematocrito incluyendo resultados numéricos. • Prueba de Plomo anual incluyendo resultados numéricos. • Presión arterial, Estatura/Pesó y el Cálculo del Índice De Masa Corporal anual. • Evaluación de Diabetes anual, hecho por el doctor durante el examen físico. • Un examen anual de la Vista/audición es requerido y se hará por las Escuelas Públicas de Chicago (CPS) y el Departamento de Familia y Servicios de Apoyó (DFSS) durante el año. Sin embargo su doctor familiar puede administrar estos exámenes. • Annual Hemoglobin/Hematocrit screening with numerical results. • Annual Lead screening with numerical results. • Annual Blood pressure. • Annual Height/Weight and BMI. • Annual Diabetes screening (done by the physician at the time of the physical exam). • Annual Hearing/Vision screenings are also required, and will be done by CPS and Chicago Dept. of Family Support Services (DFSS) hearing/vision screeners during the year. However, parents may have their child screened at their pediatrician’s office. Annual TB risk assessment for new and Returning Students Students are screened using the Pediatric Risk Assessment Questionnaire Developer by the American Academy of Pediatrics and based on the CDC guidelines. The questionnaire should be done by your health care provider at the time of your child’s annual exam. Results from the questionnaire should be documented on the Physical Exam form. Further testing will be required if one or more risk factors are present. All students must show written evidence of up-to-date immunizations. 1. 2. 3. 4. 5. 6. 7. DtaP=Diptheria, Tetanus and Pertussis IPV=Inactivated Polio MMR=Measles, Mumps, and Rubella HIB=Haemophillus Influenzae type B HBV=Hepatitis B PCV=Pneumococcal congugate Vaccine Varicella=Chickenpox Parent Volunteers: Parents who volunteer must submit evidence of being free of Tuberculosis. TB (Tuberculosis) skin test screenings are good for 2 years. Cuestionario anual de Tuberculosis para todo estudiante que sea nuevo ό regrese. Los estudiantes son evaluados con el cuestionario pediátrico de riesgo por La Academia Americana de Pediatría y basado en la guía del Centro de Control de Enfermedades. El cuestionario debe ser llenado por el doctor durante el examen físico anual. Los resultados deben ser anotados en el formulario. Si hay más de un factor de riesgo presente un examen adicional posteriormente será requerido. Todos los estudiantes de Head Start deben de mostrar por escrito evidencia que las vacunas estén al día. 1. 2. 3. 4. 5. 6. 7. DTaP= Difteria, Tétano y Tos Ferina IPV = Polio MMR=Sarampión Paperas y Rubéola Hib = Haemophilius Influenza tipo B HepB = Hepatitis B PCV= Neumocócica conjugada VAR= Varicela Padres Voluntarios Padres que son voluntarios deben presentar prueba de no tener Tuberculosis. El examen es válido por 2 años. Revised DE/AP 5/13 FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 State of Illinois Certificate of Child Health Examination Student’s Name Birth Date Last First Address Middle Street City Sex Race/Ethnicity School /Grade Level/ID# Month/Day/Year Parent/Guardian Zip Code Telephone # Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. 1 MO DA YR 2 MO DA YR 3 MO DA YR 4 MO DA YR 5 MO DA YR TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV Vaccine / Dose 6 MO DA YR DTP or DTaP Tdap; Td or Pediatric DT (Check specific type) Polio (Check specific type) Hib Haemophilus influenza type b Hepatitis B (HB) COMMENTS: Varicella (Chickenpox) MMR Combined Measles Mumps. Rubella Measles Single Antigen Vaccines Rubella Mumps Pneumococcal Conjugate Other/Specify Meningococcal, Hepatitis A, HPV, Influenza Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature ALTERNATIVE PROOF OF IMMUNITY Title Date 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature 3. Laboratory confirmation (check one) Measles Lab Results Date Title Mumps MO DA Rubella Date Hepatitis B Varicella (Attach copy of lab result) YR VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Date Code: Age/ Grade R L R L R L R L R L R L Vision Hearing IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) R L R L R L P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts Printed by Authority of the State of Illinois Sex Birth Date Last First HEALTH HISTORY ALLERGIES Middle School Grade Level/ ID # Month/Day/ Year TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER MEDICATION (List all prescribed or taken on a regular basis.) (Food, drug, insect, other) Diagnosis of asthma? Child wakes during night coughing? Yes Yes No No Loss of function of one of paired organs? (eye/ear/kidney/testicle) Yes No Birth defects? Yes No No Yes No Hospitalizations? When? What for? Yes Developmental delay? Blood disorders? Hemophilia, Sickle Cell, Other? Explain. Diabetes? Yes No Yes No Yes No Surgery? (List all.) When? What for? Serious injury or illness? Yes No Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* Seizures? What are they like? Yes No TB disease (past or present)? Yes* No *If yes, refer to local health department. No Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No Yes No Family history of sudden death before age 50? (Cause?) Yes No Dizziness or chest pain with exercise? Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Yes No Bone/Joint problem/injury/scoliosis? Yes Bridge Plate Other Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian No PHYSICAL EXAMINATION REQUIREMENTS Braces Dental Signature Date Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered ? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born No test needed Test performed in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. Skin Test: Date Read / / Result: Positive Negative mm ______________ Blood Test: Date Reported / / Result: Positive Negative Value ______________ Date LAB TESTS (Recommended) Results Date Hemoglobin or Hematocrit Urinalysis Sickle Cell (when indicated) Developmental Screening Tool SYSTEM REVIEW Skin Ears Endocrine Gastrointestinal Normal Comments/Follow-up/Needs Eyes Results Normal Comments/Follow-up/Needs Amblyopia Yes LMP Genito-Urinary No Nose Neurological Throat Musculoskeletal Mouth/Dental Spinal Exam Cardiovascular/HTN Nutritional status Diagnosis of Asthma Respiratory Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid) NEEDS/MODIFICATIONS required in the school setting Other DIETARY Needs/Restrictions SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child’s participation in PHYSICAL EDUCATION Print Name Address Yes No Modified (If No or Modified please attach explanation.) INTERSCHOLASTIC SPORTS (MD,DO, APN, PA) Signature Phone (Complete Both Sides) Yes No Date Limited RIGHTS OF HOMELESS STUDENTS The Chicago Public Schools shall provide an educational environment that treats all students with dignity and respect. Every CPS homeless student shall have equal access to the same free and appropriate educational opportunities as students who are not homeless. This commitment to the educational rights of homeless children, youth, and youth not living with a parent or guardian, applies to all services, programs, and activities provided or made available by the CPS. A student is considered “homeless” if he or she is presently living: * in a shelter * sharing housing with relatives or others due to lack of housing * in a motel/hotel, camping ground, or similar situation due to lack of alternative, adequate housing * at a train or bus station, park, or in a car * in an abandoned building * temporarily housed while awaiting DCFS foster care placement All Homeless Students Have Rights To: • Immediate school enrollment. A school must immediately enroll students even if they lack health, immunization or school records, proof of guardianship, or proof of residency. • Enroll in: *the school he/she attended when permanently housed (school of origin) *the school in which he/she was last enrolled (school of origin) *any school that non-homeless students living in the same attendance area in which the homeless child or youth is actually living are eligible to attend. • Remain enrolled in his/her selected school for as long as he/she remains homeless or, if the student becomes permanently housed, until the end of the academic year. Academic success is helped when the student remains in the same school. • Priority in certain preschool programs. Parents or guardians are encouraged to seek enrollment in these programs. • Participate in a tutorial-instructional support program, school-related activities, and/or receive other support services. • Obtain information regarding how to get fee waivers, free uniforms, and low-cost or free medical referrals. • Transportation services: A homeless student attending his/her school of origin has a right to transportation to go to and from the school of origin as long as (s)he is homeless or, if the student becomes permanently housed, until the end of the academic year. CPS staff shall inform homeless parents/guardians or youth of transportation services to and from school and school-related activities. Types of transportation services: * For homeless students: - CTA transit cards, transfer fares, and if a student is age 12 years or older a CTA riding permit * For parents of homeless students: - CTA transit cards for a parent/guardian of homeless Pre-K to Grade 6 students to accompany them to/from school * For preschool through 6th grade, alternative transportation such as busing in parental “hardship” situations where documentation is provided. Examples of “hardship” situations are: - parent employment, job training, or educational program - mental and/or physical disability - children need to be transported to/from schools at different locations - rules of shelter or similar facility will not permit parent/guardian to leave to transport children to/from school - court order, DCFS, or DCFS contract agent requires activities that do not enable parent/guardian to transport children to/from school - other good cause why parent/guardian cannot use public transportation to transport children to/from school Dispute Resolution: If you disagree with school officials about enrollment, transportation or fair treatment of a homeless child or youth, you may file a complaint with the principal. The principal must respond and attempt to resolve it quickly. The principal must refer you to free and low cost legal services to help you, if you wish. During the dispute, the student must be immediately enrolled in the school and provided transportation until the matter in resolved. The Homeless Education Dispute Resolution Process Form is available at all Chicago Public Schools and offices, including the Department of Educational Support for Students in Temporary Living Situations (773)553-2242. Every Chicago Public School has a Students in Temporary Living Situations (STLS) Liaison who will assist you in making enrollment and placement decisions, providing notice of any appeal process, and filling out dispute forms. If you have questions about enrollment in school, or want more information about the rights of homeless students in the Chicago Public Schools, call the CPS Department of Educational Support for Students in Temporary Living Situations at (773)553-2242 or the Chicago Public Schools at (773)553-1000. If you want more information about the rights of homeless students in Illinois, call the Illinois State Board of Education at (1-800) 215-6379. DERECHOS DE LOS ESTUDIANTES SIN HOGAR Las Escuelas Públicas de Chicago prov eerán un amb ien te educativo qu e tr ate a todos los estud ian te s con d ign id ad y r e spe to . Cada alumno sin hogar de CPS tendrá acceso igualitario a las mismas oportunidades educativas gratuitas y apropiadas que los demás. Este compromiso con los derechos educativos de los niños y jóvenes sin hogar, y jóvenes que no viven con un padre o tutor, se aplica a todos los servicios, programas y actividades ofrecidas o hechas disponibles por CPS. Un estudiante es considerado “sin hogar” s i e n l a a c t u a l i d a d v i v e : * en un refugio * comparte alojamiento con familiares u otros debido a la falta de un techo fijo * en un motel/hotel, campamento o situación similar, debido a la falta de alojamiento alternativo, adecuado * en una estación de trenes o de autobuses, parque o automóvil * en un edificio abandonado * alojado temporalmente mientras aguarda ubicación por DCFS (Servicios a Niños y Familias) en un hogar temporario Todos los estudiantes sin hogar tienen derecho a: • Matriculación inmediata en una escuela. La escuela deben inscribirlos inmediatamente aun cuando carezcan de registros de salud o de vacunas, prueba de tutela o de domicilio. • Matricularse en: *la escuela a la que asistían cuando tenían vivienda permanente (escuela de origen) *la última escuela en la que estuvieron inscriptos (escuela de origen) *cualquier escuela en la que sean elegibles los niños o jóvenes de la misma área de asistencia. • Permanecer inscripto en la escuela elegida durante el tiempo que permanezca sin hogar, o si el estudiante consigue vivienda permanente, hasta el fin del año académico. El éxito académico es ayudado cuando el estudiante permanece en la misma escuela. • Prioridad en ciertos programas preescolares. Se alienta a padres y tutores a buscar inscripción en esos programas. • Participar en programas de tutorías-apoyo de instrucción, actividades escolares relacionadas y/o a recibir otros servicios de apoyo. • Obtener información relacionada a dispensas y uniformes gratuitos, además de servicios médicos de bajo costo o gratuitos. • Servicios de transporte: Un estudiante sin hogar que asista a su escuela de origen tiene el derecho a recibir transporte hacia y desde la escuela de origen durante el tiempo en que permanezca en esa situación, o, si el estudiante consigue alojamiento permanente, hasta el fin del año académico. Personal de CPS debe informar a los padres/tutores de los estudiantes sin alojamiento sobre los servicios de transporte hacia y desde la escuela, y para las actividades escolares relacionadas. Tipos de servicios de transporte: * Para los estudiantes sin hogar: - Tarjetas de tránsito de CTA, transferencias, y si el estudiante tiene 12 años o más, el permiso para viajar en CTA * Para los padres de estudiantes sin hogar: - Tarjetas de tránsito de CTA para que los padres/tutores de estudiantes sin hogar acompañen hacia y desde la escuela a niños desde preescolares al 6º. Grado * Para preescolares al 6o. grado, transporte alternativo como autobuses en los casos de padres en “dificultades” documentadas. Ejemplos de situaciones difíciles son: - empleo de los padres, capacitación laboral o programa educativo - discapacidad mental y/o física - niños que necesiten ser transportados desde y hacia la escuela en lugares diferentes - reglas del refugio o instalación similar que no permitan salir al padre/tutor para transportar al niño hacia o desde la escuela - orden de la corte, de DCFS o contrato de un agente del DCFS que requiera actividades que no permitan al padre/tutor transportar al niño hacia y desde la escuela - otra causa válida por la cual el padre/tutor no pueda usar el transporte público para llevar y traer al niño de la escuela Solución de disputas: Si usted no está de acuerdo con las autoridades escolares sobre la matrícula, transporte o tratamiento justo de un niño o joven sin domicilio, puede presentar una queja al director. Este debe responder e intentar resolverlo rápidamente. El director debe referirlo a servicios legales gratuitos o de bajo costo para que lo ayuden, si así lo desea. Durante la disputa, el estudiante debe ser matriculado inmediatamente en la escuela y recibir transporte hasta que el tema sea resuelto. El Formulario del Proceso para Resolver Disputas está disponible en todas las escuelas públicas de Chicago y oficinas, incluyendo el Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda (773) 553-2242. Cada escuela pública de Chicago tiene un enlace para los Estudiantes en Situaciones Temporales de Vivienda (STLS) que lo ayudará con las decisiones de matrícula y ubicación, le informará sobre el proceso de apelación y con el llenado de los formularios de disputa. Si tiene alguna pregunta sobre la matrícula escolar, o quiere saber más sobre los derechos de los estudiantes sin hogar en las Escuelas Públicas de Chicago, llame al Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda al (773) 553-2242, o al número de las oficinas centrales (773)553-1000. Si necesita más información sobre los derechos de los estudiantes sin hogar en Illinois, llame a la Junta de Educación de Illinois por el (1-800) 215-6379. 2013-14 School-Based Early Childhood Program SCHOOL TRANSITION/MODIFICATION FORM Deadline: June 24, 2013 by 3:00 p.m. This form is to be used only under the following circumstances: A) Your child is in a closing school and you want consideration for placement in a school other than your welcoming school. Note: Under this option you are not relinquishing your current placement until new registration occurs. B) You submitted a 2013-2014 School-Based Preschool Application, but have been placed on a wait list. Note: Under option B families who previously submitted a 2013-2014 School-Based Preschool Application are welcome to apply to another school-based preschool with available school-based options. C) You have been offered placement in a school that you no longer desire.** Note:** For details on this please contact an application site prior to submitting . Child’s Information: Last Name: _______________________________ First Name: __________________________ Date of Birth: ___ ___/___ ___/___ ___ ___ ___ If option A, please provide student ID #: _________________ and current school placement____________________________. If option B or C**, please provide application ID #: _________________. Does the child have an Individualized Education Program (IEP)? ☐ Yes ☐ No Parent/Guardian Information: Last Name: _____________________________________ First Name: ___________________________________ Phone: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Alternative Contact Number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Mailing Address: ________________________________ Apt #_________________ Chicago, IL _____________ ☐ Check here if this is a shelter or temporary living situation School-Based Early Childhood Program Choices: Please select up to 3 Chicago Public Schools Early Childhood Programs. List your choices in order of preference and only select programs you are willing to accept. Include the school code and name. Session Choices: Enrollment in a session will occur during school registration. Please reference the school locator for program offerings to determine whether a school offers sessions you are willing to accept. Program Request: Choice School Code School Name 1 | | | | | 2 | | | | | 3 | | | | | Please submit this form to a Chicago: Ready to Learn! Application Representative at an application site, fax it to the Office of Early Childhood Education at 773.553.2011, or send via e-mail to [email protected]. This form must be received no later than June 24, 2013 by 3:00 p.m. Please keep a copy of this form for your records. A placement letter will be mailed in mid-July to the address provided on this form. For more information, please visit www.cps.edu/readytolearn or call the Chicago: Ready to Learn! Hotline: 312.229.1690. Parent/Guardian Signature: ________________________________________________________ Date: _________/__________/________________ Programa Preescolar 2013-14 Basado en Escuelas TRANSICIÓN ESCOLAR/FORMULARIO DE MODIFICACIÓN Plazo final: 24 de junio de 2013, a las 3:00 p.m. Este formulario deberá usarse solamente bajo las siguientes circunstancias: A) Su hijo está en una escuela que va a cerrar y usted quiere ubicarlo en otra que no es la asignada como receptora. Nota: En este caso usted no está renunciando al lugar que tiene asignado hasta que ocurra el nuevo registro. B) Usted presentó la solicitud para el Programa Preescolar 2013-2014, pero ha sido colocado en lista de espera. Nota: En la opción B, las familias que sometieron previamente una solicitud pueden hacerlo en otra escuela que tenga opciones abiertas. C) Se le ha ofrecido un lugar en una escuela que a usted no le interesa más. ** Nota:** Para obtener más detalles en este caso contacte a uno de los sitios de inscripción antes de presentar su solicitud. Información del niño: Apellido: _______________________________ Nombre: __________________________ Fecha de Nacimiento ___ ___/___ ___/___ ___ ___ Para la opción A, por favor ponga el ID del estudiante _________________ y la escuela a la que fue asignado. ________. Para las opciones B o C**, por favor coloque el ID de la solicitud: _________________. ¿Tiene el niño un Programa de Educación Individualizada (IEP)? ☐ Sí ☐ No Información del Padre /Tutor Legal Apellido _____________________________________ Nombre__________________________________ Teléfono: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Número de contacto alternativo: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Dirección de correo: ________________________________ Apt #_________________ Chicago, IL _____________ ☐ Señale aquí si se trata de un refugio o de una dirección temporaria. Opciones de Programa de Educación Preescolar Basado en la escuela: Por favor seleccione hasta 3 Programas de Educación Preescolar de las Escuelas Públicas de Chicago. Coloque las escuelas elegidas en orden de preferencia y elija solamente programas que está dispuesto a aceptar. Incluya el nombre y código de la escuela. Opciones: El registro en una sesión se hará durante la matriculación en la escuela. Por favor, vea el localizador de escuelas para conocer la oferta de programas y determinar si una escuela ofrece sesiones que usted está dispuesto a aceptar. Pedido de programa: Elección Código de la Escuela Nombre de la Escuela 1 | | | | | 2 | | | | | 3 | | | | | Por favor entregue este formulario al representante de Chicago: Ready to Learn! en uno de los lugares de inscripción, envíelo por fax a la Oficina de Educación Preescolar al 773.553.2011, o por correo electrónico a [email protected]. Este formulario debe recibirse antes del día 24 de junio de 2013 a las 3:00 p.m. Guarde una copia del mismo para su archivo. Una carta de ubicación se le enviará por correo a la dirección que figura en este formulario a mitad del mes de julio. Por más información visite www.cps.edu/readytolearn, o llame a la línea directa 312.229.1690 de Chicago: Ready to Learn! Firma del Padre/Tutor legal ________________________________________________________ Fecha: _________/__________/________________
