Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
Welcome to
Plainfield Community School Corporation Enrollment Packet
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
REQUIRED ENROLLMENT DOCUMENTS Plainfield Community School Corporation requires the following documents for enrollment of all students:
Birth Certificate
Health Records
Proof of Custody (if applicable)
IEP is required for all Special Education students (if applicable)
Proof of Residency: o copy of purchase agreement or rental agreement AND o copy of current gas or electric utility bill
Copy of parent driver's license or state ID
Please bring all documentation with you to enroll your student(s).
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
Top section for office use only 2 Proofs of Residency Required Teacher Assignment_____________________________________ It is necessary to provide option A along with B and/or C. _____________________________________ A._____Current lease/rental agreement, purchase agreement or property tax statement B._____Active and current utility bill C._____Valid IN Driver’s License/State ID with current address State Student #___________________ Student Login__________________________________ Student Password_________________________ PowerSchool#____________________ Guardian PowerSchool Login______________________ Guardian Password________________________
Plainfield Schools Student Enrollment Form Student’s Legal Name: (LAST) _____________________________ (FIRST) __________________________ (MIDDLE) _______________ Student’s Start Date _______________________ School __________________________________ Grade ______ Gender - Circle one: Male Bus Rider? Circle one: Yes
Female No
Date of Birth __________________
Address _________________________________
Age ___________
City _______________________
State ______
Zip ________
Name of House Addition or Subdivision ______________________________________________________________ Is the student currently living at the address above?
Yes
No
Please explain:_________________________
________________________________________________________________________________________________ Number of school age brothers and sisters attending other Plainfield Schools _______ 1. _________________________________ Age _________ Grade _________ School __________________ 2. _________________________________ Age _________ Grade _________ School __________________ 3. _________________________________ Age _________ Grade _________ School __________________
Academic Information and History School district of legal settlement ___________________________________________________________________ Name of last school attended ________________________ Address _________________________________
Phone# _______________
City ____________________
Has your child attended Plainfield Schools before? Circle one: Yes
No
Fax# _______________
State _______
Grade Level _____
Has your child been in an English Language Learning (ELL) program? Circle one: Yes
Zip ________ Year __________
No
At your child’s previous school, was he/she in special education classes? Circle one: Yes
No
If yes, what special education class? (504, LD, EH, etc.) ___________________________________________ At the previous school, did your child receive TITLE I reading/math services? Circle one: Yes At the previous school, did your child received SPEECH services? Circle one: Yes
No
HS Students only: Are you a part of the 21st Century Scholars Program? Circle one: Yes
No
No
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
Parent/Guardian Information Parents are: _____ Together
_____ Separated _____ Divorced _____ Widowed _____ Mother & Father _____ Mother & Stepfather _____ Guardian _____ Mother Only _____ Father & Stepmother _____ Other (explain) _____ Father Only _____ Grandparent(s) _____________________ Does this person have legal custody? Circle one: Yes No If no, who does have legal custody? _______________ Does a court order exist restricting contact with anyone? Circle one: Yes No ***If so, please attach a copy of the actual court document for our school records.
Custodial Parent/Guardian: (Match with the above choice) First _________________________
Last _______________________________
Address ____________________________________
Relationship _______________
City ___________________
Home __________________________ Cell _________________________
State ______
Zip _________
Work __________________________
Email: __________________________________________________________________________________________ Place of Employment ______________________________________________________________________________ Step-Parent/Other Guardian Name: _______ N/A First _____________________
Last ______________________________ Relationship ________________
Home __________________________
Cell _______________________
Work _______________________
Email ______________________________________________________________________________________ Custodial/Shared-Custodial/Non-Custodial Parent/Guardian #2: First _________________________ Last _______________________________ Address ____________________________________
Relationship _______________
City ___________________
Home __________________________ Cell _________________________
State ______
Zip _________
Work __________________________
Email: __________________________________________________________________________________________ Place of Employment ______________________________________________________________________________ Step-Parent/Other Guardian Name: _______ N/A First _____________________
Last ______________________________ Relationship ________________
Home __________________________
Cell _______________________
Work _______________________
Email ______________________________________________________________________________________ *All information will be entered into our PowerSchool data management system unless school is notified of desired alternative.
Information of Non-Custodial Parent Student also resides with non-custodial parent? Yes
No
Have you provided the school with a copy of custody papers? Yes Restraining Order on file? Yes
No
No
Note: Copies of legal documents MUST be on file in the guidance office to support special custody limitations.
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
Race & Ethnicity (Required for state and federal ethnicity reports) Ethnicity (Check One) Is this individual Hispanic or Latino?
_____ No, Not Hispanic/Latino _____ Yes, Hispanic/Latino (Cuba, Mexico, Puerto Rico, South or Central America or other Spanish culture or origin.)
Race (Choose one or more) _____American Indian or Alaskan Native _____Asian (includes India, Malaysia or Pakistan, Japan, Korea, Philippines, Thailand, Vietnam) _____Black or African American _____Caucasian-White (includes Middle East except Pakistan) _____Native Hawaiian or other Pacific Islander (including Guam, Hawaii, Samoa, other Pacific Islands)
Emergency Contact (other than parents) – used if parents cannot be reached Name ____________________________________________ Relationship to child ___________________________ Phone ___________________________________ Please circle applicable option:
Home
Cell
Work
I have reviewed and understand the information above and find it to be accurate. I realize any false information can negate this enrollment. I hereby give permission for the cumulative academic record, all testing, discipline and attendance records of the above named student to be released to Plainfield Community School Corporation. ____________________________________________ Parent/Guardian Printed
_______________________________________ Relationship
____________________________________________ Parent/Guardian Signature
_______________________________________ Date
*****OFFICE USE ONLY***** Entry Date into Plainfield Schools ____________________ Locker# ___________ Combo# ___________ Bus# _______ Date Records Requested __________
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
KINDERGARTEN QUESTIONNAIRE Child’s full name _____________________________________________________________________________ (First) (Middle) (Last) Name child prefers to be called _________________________________________________________________ Child’s birthdate _______________________________ Language _____________________________________ Did child attend daycare ___________ How Long _______ Where ____________________________________ Did child attend preschool __________ How Long _______ Where ____________________________________ Circle the most appropriate answers: Self-Concept
Strong self-concept
Good self-concept
Insecure
Separation from parent
With ease
Easily most times
With difficulty
Interaction with peers
Outgoing
Follower
Shy
Can recite the ABC’s
Yes
Most of it
Not Yet
Can count to 10
Yes
Somewhat
Not Yet
Can print first name by themselves
Yes
Somewhat
Not Yet
Easily
With help
Not Yet
5-7 times a week
3-4 times a week
1-2 times or not at all
Activity Level
Quiet
Moderately active
Very active
Temperament
Pleasant
Easily upset
Angry
Attention span
Focused
Sometimes distracted
Easily distracted
Impulsiveness
Timid
Watches first, then tries
Adventurous
Most times
Sometimes
Not often
Can cut with scissors How often do you read to your child?
Cooperative Behavior
Please list special things you would like us to know about your child: (example: strengths, limitations, special needs, fears, health and/or behavior concerns) ________________________________________________________________ __________________________________________________________________________________________________ Parent Name (Printed) ___________________________________ Signature ___________________________________ Address _______________________________________________ Telephone Number(s) _________________________
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
Home Language Survey (HLS) The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each student’s home in order to identify their language needs. This information is essential in order for schools to provide meaningful instruction for all students as outline Plyer v. Doe, 457 U.S. 202 (1982) The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district/charter school. The HLS is administered one time, upon initial enrollment, and remains in the student’s cumulative file. Please note the answers to the survey below are student specific. If a language other than English is recorded for ANY of the survey questions below, the WIDA Assessment test will be administered to determine whether or not the student will qualify for additional English language development support. Please answer the following questions regarding the language spoken by the student: 1. What is the native language of the student?
________________________________
2. What language(s) is spoken most often by the student?
________________________________
3. What language(s) is spoken by the student in the home?
________________________________
4. What is the student’s country of origin?
________________________________
5. Length of time student has been in the United States?
________________________________
Student Name: _____________________________________________________________ Grade: ________________ Parent/Guardian Name: _____________________________________________________________________________ Parent/Guardian Signature: ____________________________________________________ Date: ________________ By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.
For School Use Only: School personnel who administered and explained the HLS and the placement of a student into an English language development program if a language other than English was indicated: Name:_________________________________________________________________ Date: ____________________
The Migrant Education Program (MEP) provides supplemental education and support services to eligible children through national funding. The purpose of the program is to ensure that all migrant students reach the academic standards and graduate with a high school diploma (or complete a GED).
WORK SURVEY Thank you for answering the following questions. If your child is eligible for the Migrant Education Program, they may receive additional educational support. This information is strictly confidential. Parents’ Names: _____________________________________________________________________________________ Address: _________________________________________City:______________________ Telephone: (___) _________ 1.
How long have you lived in this city/school district? _____________________________
2.
Within the last 3 years, has your child(ren) moved from one school district to another within the United States, with a parent, relative or guardian so that person could look for seasonal or temporary work in agriculture? YES ___ NO _____ If you answered NO, please stop.
If you answered YES, please continue. 3.
When was the last time you or anyone in your household has moved to look for, or work in an agricultural activity within the United States? Month________________ Year_________________
4.
Please check any of the agricultural activities listed below that you have looked for or worked in:
_____
Plant or harvest vegetables or fruits
_____
Canning vegetables or fruits
_____
Detassel corn
_____
Sod farm
_____
Tobacco farm
_____
Planting, pruning or cutting trees
_____
Poultry and/or egg farm
_____
Dairy farm
_____
Duck, turkey, chicken, pork or beef processing plant
_____
Flora culture/gladiola farm
_____
Aquaculture/fish hatcheries
_____
Green house or plant nursery
Please list the names of all of the children in the household under 22 years of age. Child’s Name
Date of Birth (D.O.B.)
1. 2. 3. 4. 5.
Revised 9/3/2013
El Programa de Educación Migrante (MEP) provee educación y servicios suplementarios a niños que califican a través de fondos nacionales. El propósito de MEP es asegurar que todos los estudiantes migrantes tengan éxito académico y que se gradúen con su diploma (o que completen el GED) ENCUESTA DE TRABAJO Gracias por contestar las siguientes preguntas. Si su hijo(a) resulta elegible para el Programa de Educación Migrante, podría recibir apoyo educativo adicional. La información es totalmente confidencial. Nombres de los Padres: ______________________________________________________________________________ Dirección: ___________________________________ Ciudad: _______________________ Teléfono: (___)_________ 1. ¿Cuanto tiempo han vivido en esta ciudad/distrito escolar? ___________________________________ 2. Durante los últimos tres años, ¿Se han mudado sus hijos o han cambiado de distrito escolar dentro de los Estados Unidos, solos, con un padre o pariente, para que esa persona pudiera buscar trabajo temporal o de temporada en algo relacionado con la agricultura? SI_____ NO_____ Sí contestó NO, favor de parar aquí. Sí contestó SI, favor de continuar. 3. ¿Cuando fue la última vez que usted o un miembro de su familia se mudó para trabajar en la agricultura? Mes _______________________________ Año _________________________________ 4. Por favor marque en la parte abajo la actividad agrícola en la cual usted buscó trabajo o trabajó. ____ Matadero de patos, pavos, pollos, cerdos o vacas
____ Enlatar o congelar verduras o frutas en la bodega
____ La espiga (maíz)
____ Trabajar en la siembra o cosecha de césped
____ Cultivar tabaco
____ Plantar, emparejar o cortar árboles
____ Pollería o granja de huevos
____ Granja de vacas lecheras
____Plantar o cosechar verduras o frutas
____ Cultivar y cosechar flores
____ Trabajar en un criadero de peces
____ Trabajar en la cría de plantas
Por favor escribe los nombres de todos los niños, menos de 22 años de edad, que viven con usted. Nombre del niño(a)
Fecha de nacimiento
1. 2. 3. 4. 5.
Revised 9/3/2013
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
PCSC PARTICIPATES IN C.H.I.R.P. Children and Hoosiers Immunization Registry Program (C.H.I.R.P.) is the free and innovative online system that stores and updates immunizations records of both children and adults in Indiana. It is confidential and free. BENEFITS OF C.H.I.R.P.
Providers can determine when a patient is due or overdue for vaccinations based on up-to-date guidelines.
Providers reduce under and over immunization by viewing immunization records from multiple providers.
Providers can print Official Immunization Cards for day care, school, camp, or employment.
I give the Plainfield Community School Corporation Nurses permission to register my child’s immunization records onto the Indiana State Department of Health’s Children and Hoosiers Immunization Registry Program (C.H.I.R.P.). The information that may be needed is student’s name, date of birth, address, phone number, and parent’s name. I understand that my child’s information will be available to the immunization registry of another state, a healthcare provider, a local health department, an elementary or secondary school that is attended by the individual, a child care center and the office of Medicaid policy and planning or a contractor of the office of Medicaid policy and planning. I also understand that other entities may be added to this list through amendment to I.C. 16-38-5-3. I understand that the information in the registry may be used to verify that my child has received proper immunizations. I understand that it can also be used to inform me of my child of my child’s immunization status or that an immunization is due according to recommended immunization schedules.
I hereby consent to the release of such information.
______________________________________________________________ Parent/Guardian Signature
________________________________ Date
__________________________________________________________________________________________________ Printed Name of Parent/Guardian ______________________________________________________________ Child’s Name
________________________________ Child’s Date of Birth
2016 – 2017 School Year IN State Department of Health School Immunization Requirements Updated November 2015
3 to 5 years old K – 2nd Grade
3 Hep B (Hepatitis B) 4 DTaP (Diphtheria, Tetanus & Pertussis) 3 Polio (Inactivated Polio) 1 MMR (Measles, Mumps, Rubella) 1 Varicella 2 Varicella 3 Hep B 2 Hep A (Hepatitis A) 5 DTaP 4 Polio 2 MMR 3 Hep B 5 DTaP 4 Polio 2 MMR
2 Varicella
Grades 6 to 11
3 Hep B 5 DTaP 4 Polio 2 MMR
2 Varicella 1 Tdap (Tetanus & Pertussis) 1 MCV4 (Meningococcal conjugate)
Grade 12
3 Hep B 5 DTaP 4 Polio 2 MMR
2 Varicella 1 Tdap 2 MCV4
Grades 3 to 5
Hep B The minimum age for the 3rd dose of Hepatitis B is 24 weeks of age. DTaP Four doses of DTaP/DTP/DT are acceptable if 4th dose was administered on or after child’s 4th birthday. Polio Three doses of Polio are acceptable for all grade levels if the third dose was given on or after the 4th birthday and at least 6 months after the previous dose with only one type of vaccine used (all OPV or all IPV). For students in grades kindergarten through 6th grade the final dose must be administered on or after the 4th birthday, and be administered at least 6 months after the previous dose. Live Vaccines (MMR, Varicella & LAIV) Live vaccines that are not administered on the same day must be administered a minimum of 28 days apart. The second dose should be repeated if the doses are separated by less than 28 days. Varicella Physician documentation of disease history, including month and year, is proof of immunity for children entering preschool through 8th grade. Parental report of disease history is acceptable for grades 9-12. Tdap There is no minimum interval from the last Td dose. MCV4 Individuals who receive dose 1 on or after their 16th birthday only need 1 dose of MCV4. Hep A The minimum interval between 1st and 2nd dose of Hepatitis A is 6 calendar months For children who have delayed immunizations, please refer to the 2016 CDC “Catch-up Immunization Schedule” to determine adequately immunizing doses. All minimum intervals and ages for each vaccination as specified per 2016 CDC guidelines must be met for a dose to be valid. A copy of these guidelines can be found at http://www.cdc.gov/vaccines/schedules/
Año académico 2016 - 2017 Departamento de Salud del Estado de Indiana Requisitos de Vacunación de la Escuela Actualizado en noviembre de 2015 De 3 a 5 años 3 Hep B (Hepatitis B) 4 DTaP (Difteria, tétanos y tos ferina) 3 Polio (Poliomelitis inactivada) 1 MMR (Sarampión, paperas, rubéola) 1 Varicela 2 Varicela Jardín de infantes y 2.º grado 3 Hep B 2 Hep A (Hepatitis A) 5 DTaP 4 Polio 2 MMR
De 3.º a 5.º grado
3 Hep B 5 DTaP 4 Polio 2 MMR
De 6.º a 11.º grado 3 Hep B 5 DTaP 4 Polio 2 MMR
12.º grado 3 Hep B 5 DTaP 4 Polio 2 MMR
2 Varicela
2 Varicela 1 Tdap (Tétano y pertusis) 1 MCV4 (Meningocócica conjugada) 2 Varicela 1 Tdap 2 MCV4
Hep B La edad mínima para la 3.ª dosis de Hepatitis B es 24 semanas de edad. DTaP Cuatro dosis de DTaP/DTP/DT son aceptables si la 4.ª dosis se administró en el 4.º cumpleaños del niño o después de esa fecha. Polio Tres dosis de polio son aceptables para todos los niveles de grados si la tercera dosis se administró en el 4.º cumpleaños o después de esa fecha, o bien, al menos 6 meses después de la dosis anterior con un solo tipo de vacuna utilizada (todas OPV o todas IPV). Para los alumnos que estén en el jardín de infantes hasta 5.º grado, la dosis final se debe administrar en el 4.º cumpleaños o después de esa fecha, y debe administrarse al menos 6 meses después de la dosis anterior. Para los alumnos que estén en el jardín de infantes hasta 5.º grado, la dosis final debe administrarse en el 4.º cumpleaños o después de esa fecha, y debe administrarse al menos 6 meses después de la dosis anterior. Vacunas vivas (MMR, Varicela y LAIV) Las vacunas vivas que no se administran el mismo día se deben administrar con una diferencia mínima de 28 días. La segunda dosis debe repetirse si las dosis se administraron con una diferencia de menos de 28 días. Varicela La documentación médica de los antecedentes de enfermedades, incluidos el mes y el año, es la prueba de inmunidad para los niños que ingresan en preescolar hasta 7.º grado. El informe de los padres sobre antecedentes de enfermedades es aceptable para los grados 8.º a 12.º. Tdap No hay ningún intervalo mínimo desde la última dosis de Td. MCV4 Las personas que reciben la 1ª dosis en su 16º cumpleaños o después de esa fecha solo necesitan 1 dosis de MCV4. Hep A El intervalo mínimo entre la 1.ª y la 2.ª dosis de Hepatitis A es de 6 meses calendario. Para los niños que se han retrasado con su vacunación, consulte el “Programa de Actualización de Vacunas” del Centro para el Control y la Prevención de Enfermedades (CDC, por sus siglas en inglés) de 2015, a fin de determinar las dosis de vacunación de forma adecuada. Para que una dosis sea válida, deben cumplirse todas las edades e intervalos mínimos para cada vacuna especificados según la Guía del CDC de 2015. Una copia de estas guías puede encontrarse en http://www.cdc.gov/vaccines/schedules/.
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 317-839-2578
CONSENT FOR RELEASE OF INFORMATION Attention: Guidance Office/Registrar/Student Records
Date:
Previous School: Phone Number:
Fax Number:
Student Name: Date of Birth:
Grade:
The student named above has applied to enroll in Plainfield Schools. Per parent request, please fax the student educational records to the school checked below: Plainfield High School Plainfield Community Middle School Brentwood Elementary School Central Elementary School Clarks Creek Elementary School Van Buren Elementary School
1 Red Pride Drive, Plainfield, IN 46168 P: 317-838-3622 F: 317-838-3685 709 Stafford Road, Plainfield, IN 46168 P: 317 838-3672 F: 317-837-7225 1630 East Oliver, Plainfield, IN 46168 P: 317-839-4802 F: 317-838-3991 110 Wabash Street, Plainfield, IN 46168 P: 317-839-7707 F: 317-838-3646 401 Elm Drive, Plainfield, IN 46168 P: 317-839-0120 F: 317-838-7316 225 Shaw Street, Plainfield, IN 46168 P: 317-839-2575 F: 317-838-3993
NOTE: Please include any special education, speech or 504 documentation/records. Thank you for your prompt attention to this request. PREMISSION TO RELEASE RECORDS I hereby give permission for the records and test information of the above named student to be released to the above mentioned school. Parent/Guardian Printed Name: Parent/Guardian Signature: Relationship:
Date:
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
VOLUNTEER AGREEMENT BACKGROUND INFORMATION AUTHORIZATION AND RELEASE Please check one of the options below that applies to you: Parent/Guardian _____ Student Teacher_____ Other_____ Please explain: _______________________________ It is MANDATORY to have this background check on file for any volunteering in the classroom, to include field trips. If you have filled this form out in the past with Plainfield Schools, it is not necessary to fill it out again. STUDENT(S): SCHOOL(S): TEACHER(S): ___________________________________ _____________________________ __________________________ ___________________________________
_____________________________
__________________________
___________________________________
_____________________________
__________________________
Dear Volunteer: Volunteering with the Plainfield Community School Corporation involves contact with our student population. Therefore, we request that you complete the questions below to assist us in evaluating your suitability to work with students. All volunteers must provide us with background information; you are not being singled out from other volunteers for closer inspection. Any misrepresentation or omission of facts may be grounds for disqualification from further consideration. Conviction of a crime or any affirmative answer provided by you on this form is not an automatic ban to volunteering. Plainfield Community School Corporation will consider the nature of the conviction or alleged conduct underlying an affirmative response, the date of the alleged conduct, and your intervening conduct. _____Yes _____No
A. If you are now working, is your conduct as an employee or the quality of your work the focus of any investigation by your current employer?
_____Yes _____No
B. Have you ever resigned from a job after being disciplined by your employer or after being offered the opportunity to resign rather than be terminated?
_____Yes _____No
C. Have you ever been investigated for, charged with, plead guilty, or “no contest” to any crime involving the sexual abuse of any person or indecency with a minor?
_____Yes _____No
D. Have you ever been charged with a crime, other than a minor traffic offense, where the court has deferred further proceedings without entering a finding of guilt and placed you on probation in public service, or an education program?
_____Yes _____No
E. Have you ever been convicted of any crime?
__________________________________________ SIGNATURE
_____________________________ CONTACT PHONE #
___________________ DATE
If you answered yes to any of the above questions, explain the circumstances of each on a separate sheet and attach it to this volunteer application. (page 1 of 3)
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
VOLUNTEER AGREEMENT BACKGROUND INFORMATION AUTHORIZATION AND RELEASE
AUTHORIZATION AND RELEASE I understand that if I am a volunteer for the Plainfield Community School Corporation, I must obtain a Limited Criminal History. Therefore, I authorize local, state, and federal agencies to provide this information concerning the matters described herein for inspection by the school corporation. I understand that I must provide the school corporation with my legal name and date of birth so they may process my “Limited Criminal History” information. I also understand that I may not volunteer with the school until a copy of the Limited Criminal History information has been obtained. I EXPRESSLY WAIVE IN CONNECTION WITH ANY REQUEST FOR, OR PROVISION OF SUCH INFORMATION, ANY CLAIMS, CAUSES OR ACTIONS, INCLUDING WITHOUT LIMITATION, DEFAMATION, INFLECTION OF EMOTIONAL DISTRESS, INVASION OF PRIVACY, OR INTERFERENCE WITH CONTRACTUAL RELATIONS THAT I MIGHT OTHERWISE HAVE AGAINST THE SCHOOL CORPORATION, IT’S OFFICIALS, EMPLOYEES, TRUSTEES OR AGENTS, OR AGAINST ANY PROVIDER OF SUCH INFORMATION. I have read this authorization and release of all claims, and I expressly agree to the terms set out herein.
_______________________________________________ APPLICANT’S SIGNATURE
_____________________________________________ APPLICANT’S LEGAL NAME PRINTED
___________________________________ APPLICANT’S DATE OF BIRTH
_________ MALE
_________ FEMALE
OPTIONAL: _____ _____ _____ _____ _____ _____
AMERICAN INDIAN ASIAN BLACK HISPANIC MULTI-RACIAL WHITE (page 2 of 3)
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
VOLUNTEER AGREEMENT BACKGROUND INFORMATION AUTHORIZATION AND RELEASE
PCSC Volunteer Confidentiality Agreement Thank you for your willingness to volunteer your talents to help our students and our school! We certainly appreciate your time and know that our schools are better because of people like you! Please take a moment to read and sign the following confidentiality agreement to help us protect all of our students. Again, thank you for being a PCSC school volunteer. I,__________________________________________ (printed name), understand and agree that any and all information gained while assisting in a classroom or any other part of the school building in one or more of the PCSC schools must be held in confidence. This confidence applies not only to specific students with whom I may be involved, but to all other students who are part of the environment observed. Furthermore, any student names that may be learned as part of my work or seen as part of classroom displays or activities shall not be conveyed to any other individual at any time. As part of volunteering with PCSC, I may be privy to certain sensitive and/or confidential information regarding the students and/or families served by PCSC. This includes, but is not limited to, any of the following: a) educational information related to students’ academic performance or behavior, b) medical information, or c) other types of private or sensitive material. I understand the importance of confidentiality and respect the rights of the students, teachers, schools, and families that PCSC services. I agree to abide by all school rules and visitation policies, including those pertinent to building security (i.e. signing in an out and wearing a name badge) so that building personnel are aware of my presence. I agree to comply with all the requests of the classroom teacher or other school employee with whom I am working and to perform my duties so that I do not disrupt the education process of the students in the class or the school building. I understand that the classroom teacher’s priority will be the instruction of students an my duties may not unduly disrupt that learning environment.
______________________________________________ VOLUNTEER’S SIGNATURE
__________________________ DATE
______________________________________________ VOLUNTEER’S PRINTED NAME
__________________________ DATE
______________________________________________ SCHOOL PERSONNEL’S SIGNATURE
__________________________ DATE
(page 3 of 3)
Plainfield Community School Corporation 985 Longfellow Lane Plainfield, IN 46168 www.plainfield.k12.in.us 317-839-2578 P 317-838-3664 F
Transportation Data Form Please check applicable school below. Brentwood _____ Central _____ Clarks Creek _____ Van Buren _____ This form must be completed and returned to the school for your child to receive bus service. In order to establish bus routes, it is necessary to know if your child will be riding a bus and where your child will be picked up and dropped off. Please complete the following information: Child’s Name _______________________________________
Grade ___________________
Home Address ____________________________________ Home Phone # _______________
Parent/Guardian Name ______________________________ Cell Phone # ________________
No, my child will not be riding the bus.
I will provide my own transportation.
Yes, my child needs bus service. Parents must choose ONE consistent Pick Up Point and One consistent Drop Off Point at home or Daycare. Pickup point and drop off point may not vary daily and must be in your child’s Elementary District. Address of PICK UP Point ______________________________________________________ Address of DROP OFF Point ____________________________________________________ Daycare/Babysitter’s Name _____________________________ Phone # ______________ Emergency Contact Name _______________________________ Phone # _____________ A parent or designated individual must be at the Bus Stop when your Kindergarten child is delivered. *Please notify your child’s school if your address changes. A new Transportation Form must be completed before changes can be made to your child’s bus service. __________________________________________ Parent Signature
__________________________ Date Revised 3/6/14
