EFTA01709707

EFTA01709707 EFTA01709708 IZZ=1=E3 Spring 2003 FLORIDA COMPREHENSIVE ASSESSMENT TEST (FCAT) READING SUNSHINE STATE STANDARDS PERFORMANCE TASKS Student Report Grade 10 This report provides your results on the FCAT 2003 Reading performance tasks. Each performance task on FCAT requires you to respond with either a short response or a longer, more detailed response. Short-response tasks are scored on a 2-point rubric and extended -response tasks are Sawed on a 4-point rubric. One of the short-response tasks is shown below with a Copy Of your answer. The number of points you earned for your answer is ShOwn in the box to the right. This task required you to read a passage about an American zoologist's attempts to rehabilitate two young gorillas in Africa. Describe how Coco and Pucker change as a result of their experience with Dan Fossey. Use details and informatiOn from the story to explain your answer. FCAT 2033 READING PERFORMANCE TASKS Student Name Student Number School Name School Number District Name District Number This Performance Task Response All Reading Performance Task Responses Points Possible Points Earned eah Cao-racurRns wev wccit-r Saivedsatt 63 Ot. reSUR bF their ressyJi -may nealinr10 -Mei( -Per OP- YlutraYIS ,Don SI*RM(ori ociA kfnit.ucc- -Mod rip mitem-t- -VOW May pexv Pj C is iWYtag viedtakti01- ThiCitXp heir Ondfro WAN TRIC.O M161 4-nlsk. 2 12 Data Run Date: 05/07/2003 0084103 853200565 EFTA01709709 FCAT Ibrz.,(c,?reens if Anwar-T1(.0 Spring 2003 FLORIDA COMPREHENSIVE ASSESSMENT TEST (FCAT) MATHEMATICS SUNSHINE STATE STANDARDS PERFORMANCE TASKS Student Report Grade 10 This report provides your results on the FCAT 2003 Mathematics performance tasks. Each performancetask on FCAT requires you to respond with either a short response or a longer, more detailed response. Short-response tasks are scored on a 2-point rubric and extended -response tasks are scored on a 4-point rubric. One of the short-response tasks is shown below with a copy of your answer. The numbe-r of points you earned for your answer is shown in the box to the right. FCAT 2003 MATHEMATICS PERFORMANCE TASKS Student Name Student Number School Name School Number District Name District Number This Performance Task Response All Mathematics Performance Task Responses Points Possible Points Earned 2 16 The students in the senior class al Paradise Island High School have decided to raise money by selling graphing calculators and geometry tool kits. They have set aside 5.3,000 to purchase the items they need to sell. They will spend 575 for each calculator, and 520 for each tool kit. From past experience, they know that twice as many students will buy the calculators as will buy the tool kits The inequality and equation below can be used to determine the number of each nem the senior class should have available to sell, where c is the number of calculators and t is the number of tool kits. 75c t 20t sa 3,000 c = 2t How many tool kits should the senior class put chase' Show your work. co • 30no Li,oc_6,/‹.0brzsct) Ze-0 -aO&l< 3O0O 0, Number of tool kits 17 20(Dab Data Run Date: 05/07/2003 0084104 854200209 EFTA01709710 Ft. I N..•n,.STUDENT HEALTH EXAMINATIONS Phone Birthdate School Date Race A. HEALTH EXAMINATION Hecht Weight Blood Pressure (✓) N_ormal•N; Abnormal•A N A 1 Appearance 2. Skin/Nose 3 Head/Scalp Eyes 5. Visual Acuity IR b U 6. Ears, 7 Auditory Acuity (R 8 L) 8. Nose 1 Throat 9. Mouth. Teeth and Gums 10. Chest / Lungs 11 Heart 12. Abdomen 13 Genitals and Anus 14. Musculo-Skeletal 15 Neurological 16 Alertness 17 Emotional / Mental/ Behavior Prot 18 Handicap. physical/ other (Specify) 19. Activity Restrictions (Specify) 20. Abuse. substance/ Physical / emotional 21 Nutntion 22 Other COMMENT: Abnormal Findings, by number B. HEALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaell i e Tuberculin test Sickle Cell type date result NAME: TITLE: ADDRESS: (Please Print) r-rdl- OH 3040. 10116 (lieplooli 14R5-14 Form 3040 which easy be used) Mock Plumbot. 5744400.3040-2) Authorized Signature -- Date EFTA01709711 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.032, 402.305, 402.313, Florida Statutes; rules 64D-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST NAME PARENT OR GUARDIAN FIRST NAME MI 4:10B NIO/DAJYR CHILD'S SS# (optional) STATE IMMUNIZATION ID#1 Directions: • Enter all appropriate doses and dates below. • Sign and date appropriate certificate (A-I, A-2, B, or C) on reverse side of form. • If the child is presenting for the 7th grade requirement only and has previously filed a Certificate of Immunization (DH 680, Part A-1) with their current Florida school, fill in boxed areas below and complete Part A-2 on the reverse side of this form. • For additional information: See Immunization Guidelines for School and Child Care Facilities for information and instructions on form completion and immunization requirements. Guidelines are available from the local county health department. VACCINE DOE CODE DTaP/DTP 2 A DT3 Td' PoHod HIV MMR (Combined) (Separate G, H, I Hepatitis B9 Varicella 1' Varicella Disease L Dose I Dose 2 Dose 3 Dose 4 Dose 5 MO/DA/YR MO/DA/YR MO/DA/YR MO/DA/YR MO/DA/YR 1 The state immunization ID# is an identifier supplied by the state immunization registry (optional). 2 DTP/DTaP 5 doses required. If the 4th primary dose is administered on or after the 4th birthday a 5th dose is not required. 3 DT (pediatric) is acceptable if pertussis vaccine is medically contraindicated. (Complete Part C for pertussis contraindication.) 4 Td (adult) vaccine is recommended for children 7 years of age or older. S Polio 4 doses required. If the 3'd dose in an all OPV or all IPV series is administered on or after the 4th birthday, a 4th dose is not required. Polio vaccine is not required for children 18 years of age or older. 6 Hib is required for child care, family day care and preschool entry and attendance only. 7 First dose valid if given on or after birthday. Second dose (measles) valid if given at least I month after l" dose. A 2"1 dose of measles (preferably MMR) is required for students in grades K-6 and 7'th grade entry and attendance effective with the 1997/1998 school year. In each subsequent year thereafter, the next highest grades arc included. S Includes single measles vaccine (G), single mumps vaccine (H) or single rubella vaccine (I). 9 Hepatitis B vaccine series is required for 7th grade entry and attendance effective with the 1997-1998 school year and kindergarten entry and attendance effective with the 1998-1999 school year. In each subsequent year thereafter the next highest grades are included. Hepatitis B vaccine series is required for preschool entry and attendance effective with the 2001/2002 school year. 10 Varicella vaccine is required for entry and attendance in preschool and kindergarten effective with the 2001/2002 school year. In each subsequent year thereafter, the next highest grades arc included. Susceptible children 13 years of age or older should receive 2 doses, given at least 4 weeks apart. Varicella vaccine is not required if child has documentation of history of varicella disease. EFTA01709712 LAST NAME FIRST MI DOB (MO/DANR) Certificate of Immunization for K-12 Excluding 7th Grade Requirements PART A-1 (immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement.) DOE Code i I have reviewed the records available, and to the best of my knowledge, the above named child has been adequately immunized against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella and hepatitis B (for kindergarten effective with the 1998/99 school year) and varicella, varicella vaccine not indicated if history of disease either physician documented or parental recall or kinde :anen elective with the 2001/2002 school year) for school attendance as documented on the reverse side of this form. Physician or Clinic Name: (Print or stamp) Address: Physician or Authorized Signature Date: Certificate of Immunization Supplement for 7th Grade Requirement PART A-2 (Immunizations are complete for students who enter or attend the 7th grade after the beginning of the 1997/98 school year. Each subsequent year thereafter. the next highest grade will be included in the requirement.) DOE Code 8 I have reviewed the records available, and to the best of my knowledge, the above named child has received the following immunizations required for entry and attendance in 7th grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as documented on the reverse side of this form (boxed areas). Physician or Clinic Name: (Print or stamp) Address: Physician or Authorized Signature: Date: 3- Temporary Medical Exemption PART B (For children in child care, family day care, preschool and grades kindergarten through 12 who are incomplete for immunizations in Part A-I or A-2.) Invalid without expiration date. DOE Code 2 1 cerrifi, that the above named child has received the immunizations documented on the reverse side of this form and has commenced a schedule to complete the required immunizations. Additional immunizations are not medically indicated at this time. Physician or Clinic Name: (Print or stamp) Expiration Date: (t5 days after next immunization appointment) Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DII 450, Pd2000, obsoletes whet canons (Stack Number 5740 MI 01e^ 1) Date: EFTA01709713 THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) New and Returning Student Registration NEW STUDENTS: Complete all non-shaded areas on both sides of the form. RETURNING STUDENTS: Review botlisides. If the pre-printed information is incorrect, correct the Information by carefully and lightly crossing out the incorrect information and writing the correct information above it. • 4.7,jaWIMT:t Ica • (haw) (r.1, cos) RoYAtAim 457itel pi .3till (6) MAILING ADDRESS (nouso no. a neat nem.) Opt_ nal (nth Istata) (z* code) . (9)SEX (10) RACEETHNIC ORIGIN (apobna) 0 1-American Indian/Alaskan Native O - on-Hispanic O H-Hispanic O A-Asia Islander Non-Hispanic O M-Mularacial 0 0 DATE OF BIRTH (12) PLACE OF BIRTH (S)/sralotounliy) aSli . (13) RESIDENT STATUS O O. Foreign Exchange Student O 1. Out-of-county Resident O_ ...,2 Out-of-state Resident OJ 1. In-county Resident (14) USA ENTRY DATE (MMODAYTY) (15) FEDERAL IMPACT SURVEY YES NO O O A. The student resides on federal property. O O B. The student resides in low rent housing. O (7 C. The parent is employed on federal property located in Palm Beach County. • O D. The parent is employed on low rent housing located in Palm Beach County. O O E. The parent is in the uniformed services of the United States. O O If E. is YES, is the parent on active duty? Check service below: . • Air Force O Army O Coast Guard O Marines O National Guard O Navy (16)PFIESCHOCI. ENROLLMENT INFORMATION ' Place an X by each program attended Also. indioste with an asterisk( *) the program your child was in the lonast. 0 N. Non-subsidized Child Care O M. Migrant Pre.l< O D. Pre-K Disabilities . O H. Headstart O I. Pre-K Early Intervention O C. Chapter 1 O S. Subsidized Child Care O O. Other. (1 7) is THE STUDENY A SINGLE P EYES N , (18)CURRENT GRADE LEVEL ef 14 TARN .. .. . -.,,.-. (19) NAME OF SCHOOL TRANSFERRING FROM. (20) CI 1Y OR LOCA1:09 . (21) LAST A N:TANCE DATE (22) LAST GRADE LEVEL (23) LAST PUBLIC SCHOOL ATTENDED IN PALM BEACH COUNTY (T4) CATE Al TENDED IN PDC, C E Etti!„ (25) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056(7)(d). Non-invasive • screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or guardians, however, have the right to request an exemption in writing. It you DO NOT want your child to receive the.screenings, write the words "Do not screen" here: .076661, „ . .. , RIC .0/1 (27) LI:geyalaInloBrVg an 1 d reduced lunch?(This exemption will cover all types of screenings) (26) I give permission for my child to participate in the sodium fiouride program to prevent tooth decasEVIESO N r (Permission is valid through 6 grade) O YES laie15- (Application is ptbvided with this form PAVOIMPOINAZAIAMEACitgq. 0,14 itItit&e,t, A ,y,t (28) HOME LANGUAGE SURVEY YES N±:),,/ O riff s.. Is a language other than English used in the home? If YES, what language? O 8..-2. Does the student have a first language other than English? If YES, what language? English ?? O B' 3.2. the student most frequently speak a language other than English? If YES, what language? (29) 4. What language is spoken in the home by the parent or guardiap? 5i< (30) 5. What language is the student's first language? Ch./Erb S 4 . (31) What is the date of entry into an ESOL program? (32) STTENT IJVES WITH: kited cone) V2Mother O Father O Both Parents VOtper ‘214t sbPstiCEWKS (33) DISCLOSURES FOR ENTRY INTO PBC SCHOOL DISTRICT YES 14)," O 4. _A. Has the student ever been expelled from school? O rili2. Has the student ever had an arrest resulting in a charge? O NY 3. Has the student ever had any juvenile justice actions? (34)CUST OOY STATUS OF STUMM' V thedrone) i O Mother O Father Shared Custody O Other • (35) Is there a court order barring either parent from removing or contacting the student during the school day? O YES .NO If YES, provide the school with a copy of the court order. - ' PBSD 0636 (REV. 4/6/2001) page 1 of 2 EFTA01709714 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW AND RETURNING STUDENT REGISTRATION (36) FATHER OR LEGAL GUARDIAN 031st mkIdle Alia( Ms° (37 ADDRESS (SOW nomboS 7-4"94 4:1311Tvnlixdpber) IIIIIIIIIIIIIIIIIM CITY STATE ZIP CODE , • . CITY STATE ZIP CODE .4y#6_ pAhn Se:i/g4- a stym • . ..__. , OCCUPATION • 1 \ GC-CUPKTION ' ' ' Fl/(Er EMPLOYMEN'T IIIIIII HOME TELEPHONE BUSINESS TELEPHONE CELIWAGER NUMBER HOME TELEPHONE BUSINESS TELEPHONE • •.• . . . EMAIL ADDRESS (opfkaa0 EMAIL ADDRESS (axis* Ngigq..kraWatt4. 1W.aialici rlifiaggean4cVnt it • .. . W4*.Staitl eitt Person(s) other than parent authorized to pick up student (36) PASSWORD pin 10 tbarsderl) NAME Crs( =doe Wig. fast (41) NAME PIA middle Ms,. MR) ADDRESS (street Jxe er, excel. 40401990199:0590 • ADDRESS (shoot number, street oporfmeof number) • STATE ZIP CODE ilfr& Alin A:9mA H 3.50-ac CITY STATE DP CODE • Trzowile"SHIP(40) AUTHORIZED FOR IMENENCY PICKUP U! .1ES • NO TELEPHONE RELATONSHIP (42) AUTHORIZED FOR EMERGENCY PICKUP 0 YES • NO (43) If school personnel are unable to contact you incase of illness or accident. may we have your permission to call your doctgrkir, . emergency stivices 011) for tranSporloto the hospital? Bla 0 NO (44) MEDICAL INFORMATION five student' anossos, bohanior. health Aso s. artergs, mediations or ortfor physkod NostoCons) I • .... • % (45) FAMILY PHYSICIAN (413) PHYSICIAN PHONE µe7 Does your child currenV have health insurance? BYES 0 NO If YES, indicate: (07) HOSPITAL PREFERENCE . 0 Medicaid airivate 0 Healthy Kids/Kid Cam 0 Interested in receiving information eittiS •i p ER, tpl.PeEtliii,„_, ,,,,,_ cfrk oil _ ,§q. ,pp 73, (49) NAME OF CHILD (fast k( mktile MN) SCHOOL ATTENDING STUDENT NO. (opOona9 GRADE DATE OF BIRTH (50) NAME OF CHILD (toss finds,* irMY80 SCHOOL ATTENDING STUDENT NO. (ackonal) GRADE DATE OF BIRTH (51)NAME OF CHILD (lost Eras mickne Mal) SCHOOL ATTENDING STUDENT NO. (optional) GRADE DATE OF BIRTH (52) NAME OF CHILD (fast Erg mktila Coda.) SCHOOL ATTENDING ( STUDENT NO. (optional) GRADE DATE OF BIRDI PARENT/GUARDIAN SIGNATURE I verify that the information given is true and accurate to the best of my knowledge. ,... ,,.. , . Iiiiitikirg laKSWE P:A? ,&., adyra.%,„,..!, „... ?„„;, v-nk, k•:!:. isinvEr co;pkaniaatrace.... swato ,5"titiiiilai 41.a*I.104:.,rrrol Faisaggigh ca e a.S..4S OSk•rS. hts ita Ms r.,.>,.' • daiazgEtiiit it "i: nilLi; .4.." ; f me -.,. ,it.v .... • • , ' .Vrt" ' Atrn.MF 'I'''." SIGNATURE OF PARENT/G DATE r'hs *VA PBSD 0636 (REV. 4/6/2001) EFTA01709715 4)- .1OOL Oa's% THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) • No New and Returning Student Registration yea/tip(1) STUDENT NUMBER (2) SAC CODE (3) GRADE LEVEL 12 NEW STUDENTS: Complete all areas on both sides of the form except areas specified. RETURNING STUDENTS: Review both sides. II the pre-printed information is incorrect, correct the information by carefully and lightly crossing out the incorrect information and writing the correct information above it. Complete any areas that are blank. DIST TCHR NBR:O47 STDT (4) STuDENT LEGAL NAME Oast first middle) = (5) ALSO KNOWN AS Il= (4) LOCAL ADDRESS (hOUSO PO. S sac name) (apt no) NAY) able) Pro coda) ROYAL PALM BEACH FL 33411 (7) MAILING ADDRESS (house na a sisal name) (apt. no) (ulY) (stale) MP 0,(0!) BO SOCIAL SECURITY NO. Toptrone0 (9) HOME TELEPHONE NO. (10) F 1 (11)RACFJETHMC ORIGIN y • Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 W-White, Non-Hispanic 0 M-Multiracial I-American Indian/Alaskan • A-Asian/Pacific Islander (12) DATE OF MTH (leAUDDIYYYY) (13) PLACE OF BIRTH WA lily Coco I/ Us (14) RESIDENT STATUS 0 0. Foreign Exchange3Student 0 1. Out-of-county Resident ❑2. Out-of-state Resident 0 0 3. In-county Resident (IS) USA ENTRY GATE (AMODDAWY) (Is) FEDERAL IMPACT SURVEY YES NO El 0 A. The student resides on federal property. 0 0 B. The student resides in low rent housing. 0 0 C. The parent is employed on federal property located in PB County. 0 0 D. The parent is employed on low rent housing located in PB County. 0 0 E. The parent is in the uniformed services of the United States. 0 0 If E. Is YES, is the parent on active duty? Check service below: 0 Air Force 0 Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy indicate wilh an he longest. Prekindergarten Prekindergarten Parent Program Applicable (17) PRESCHOOL ENROLLMENT IsFORIAATION Place an X by each program attended. Also. asterisk (') the program your child was In 0 C. Title I Prekindergarten 0 M. Migrant 0 D. Pre-K Disabilities 0 N. None 0 F. Fee for SeMces 0 P. Private 0 H. Head Start 0 T. Teenage 0 L Readiness Program 0 Z. Not pp Is the student a single parent? N 0 YES 0 NO TRANSFER STUDENT Only students transferring from another school complete this section (19) NAME OF SCHOOL TRANSFERRING FROM (20) CITY /STATE icouNre COUNTRY (21) LAST ATTENDANCE DATE (22) LAST GRADE LEVEL (23) Have you ever been enrolled In a Palm Beach County School? 0 YES 0 NO If yes, what school? _ 200 DATE ATTENDED IN PBC All new and returning students compete the remaining form including page 2 (2s) Students vrill receive non-Invasive health screenings pursuant to Florida vision, hearing, scoliosis, height, and weight. These tests may be glen Individually right to request an exemption in vrriting. If you DO NOT want your child (This exemption wit cover at types Statute § 381.0O56(7)(d). Non-invasive screenings may Include or in groups. Parents or guardians, however, have the to receive the screenings, write the words "Do not screen" here: of screenings) (26) I give permission (or my child to participate in the sodium fluoride program (Permission is valid through grade 6) YES (27) Does your child currently have health Insurance? 0 YES 0 NO P If YES, Indicate: 0 Medicaid 0 Healthy Kids/Kd Care U Private to prevent tooth decay. M YES II NO El Interested in receMng Information (25) HOME LANGUAGE SURVEY (chock ail that an*, 0 A language other than English is used in the home. 0 The student has a first language other than English. 0 The student most frequently speaks a language other than English. What language? What language? What language? (29) DISCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT (check aV that apply) 0 The student has been expelled from school. 0 The student has had juvenile justice actions taken against him/her. 0 The student has arrested resulting in a charge. (30) STUDENT LIVES WITH: (check one) 0 Mother 0 Father 0 Both Parents 0 Foster 0 Group Home (31) CUSTODY STATUS OF STUDENT (aeck tee) 0 Mother 0 Father 0 Shared Custody E Other • Other CRS: SEC:OO1 BLDG:O3 RM:212 O6 11 O4 IMPORTANT INFORMATION - MUST BE COMPLETED ($2) Is there a court order barring either parent from removing or contacting the student during the school day? 0 Yes 0 No If YES, provide the school with a copy of the court order. PBSD 0636 (Rev. 03117/2004) page 1 of 2 EFTA01709716 PARENT/LEGAL GUARDIAN INFORMATION (33) FATHER OR LEGAL GUARDIAN (16's( (Mete MAIM 4430 (34) DATE OF BIRTH (44) MOTHER OR LEGAL GUARDIAN (w. middle Witt, last) (45) DATE OF BIRTH (35) ADDRESS Meet number snot aPartmeal number) (46) ADORESS (Heel number, *et apartment number) (36) CITY STATE VP CODE (47) CITY STATE ZI, CODE ROYAL PALM BEACH FL 33411 (37) OCCUPATION (36) HIGHEST ED. LEVEL (48) OCCUPATION (45) HIGHEST ED. LEVEL DISPLACE OF EMPLOYMENT (507 PLACE OF EMPLOYMENT ocs HOME TELEPHONE (41) BUSINESS TELEPHONE (42) CEWPAGER NUMBER (51) HOME TELEPHONE (52) BUSINESS TELEPHONE (53) CELUPAGER NUMBER (43) EMAIL ADDRESS (cpLcnaO (54) EMAIL ADDRESS Osounner) EMERGENCY HEALTH AND SAFETY INFORMATION Provide name(s) of person(s), other than parent, allowed to pick up student. PASSWORD (limit 10 characters) tss) (56) NAME (Ns& middle indiat last) (82) NAME MIL medle Hem( MO (57) ADDRESS (steel number alma( specimen( number) SAME (83) ACORESS (000 IIMIllbOr, street alaatanant Awake) (58) CITY STATE ZIP CODE (64) CITY STATE ZIP COOS (59) RELATIONSHIP OTHER (60) TELEPHONE (31)CELLSAGER NUMBER (85) RELATIONSHIP (86) TELEPHONE (67) CELUPAGER NUMBER (88) STUDENTS ALLERGIES (cheek e)) that apply and specify) 0 None 0 Animals 0 Birds 0 Reptiles 0 Food 0 Other Specify • Amphibians 0 Plants (69) LIST STUDENTS ILLNESS. BEHAVIOR ISSUES, MEDTCATIONS OR PHYSICAL LIMITATIONS (TO) FAMILY PHYSICIAN (71) PHYSICIAN PHONE NAMES OF PARENT'S/LEGAL GUARDIAN'S OTHER CHILDREN (72)NAME OF CHILD (Ent middle Wrist, Iasi) (73) SCHOOL ATTENDING (74) STUDENT NO. (*Prism° (75) GRADE (76) DATE OF BIRTH (77) NAME OF CHILD (Tnt middle Milig les0 (78) SCHOOL ATTENDING (79) STUDENT NO. (opeona0 (80) GRADE (81) DATE OF BIRTH (82) NAME OF CHILD (en( middle indict( MO (63) SCHOOL ATTENDING (64) STUDENT NO. fopeone0 (85) GRACE (86) DATE OF BIRTH INFORMATION VERIFICATION verify that the Information given is true and accurate to the best of my knowledge. SIGNATURE OF PARENT/LEGALGUARDIAN DATE PARENT/GUARDIAN CONSENT I understand and agree that all educational records of my child may be shared with the Districts health care partners and other governmental and social agencies jointly seeing the child or having a legitimate interest in the records, as needed to provide and evaluate health services and government/social services to students. I also understand and agree that my child's medical records or other medical information that I provide to the school, and treatment records or other medical records created by health care personnel at the school will be shared with school officials who have a legitimate educational purpose for accessing such medical records and information. SIGNATURE OF PARENT/LEGAL GUARDIAN DATE FOR OFFICE USE ONLY COB US CAL 01 SL Entry Code E01 SI. Enby Dale 08/11/04 ESP. Entry Dale PBSD 0636 (REV. 03/17/2004) teacher No Reassign. Code Binh Vedgeolion 1 DCF Documentation Checklist Transportation 0 Immunizations ID Binh Records Verification O Social Security Number 0 Physical Exams 0 Address Verifcatinri 0 PBC Bus 0 Palm Iran 0 Parent/Student Transpalation 0 Walk 0 Bike page 2 of 2 EFTA01709717 TEST RECORD INFORMATION PESO 0280 (REV. 7/15197) FRT EFTA01709718 tar- es'? )01.10.nboar ..at.- .414.11taISW/rIgarela.".•IN ,.....4014v0 :4alr........4‘...,-41:taiii. eaL • •. - :p.c....a - - - itte-iteNCA.A.C/i nscaswasuAareArb ,..1104. 814.4*.uwatea. FLORIDA :1 ID ral SCHOLARSHIP PROGRAM Verification of Receipt (NOTE: This is not the application for the scholarship.) I verify that I have received and read the initial eligibility requi of the Florida Bri ht Futures Scholarship Program for the year Name (please print) Signature Date 912,1-1/2)01 Please return to your high school guidance counselor AnNIESAI NUMBER EXTENSION Wag EVA EFTA01709719 THE SCHOOL DISTRICT OF PALM BEACH COUNTY DIRECTIONS: Write in the aooroonate code number or letter in the corresoondino boxes. Student Discipline Referral EFTA01709720 Parent/Guardian of ROYAL PALM BEACH, FL 33411 RE: GRADE: 12 Date: El School: Phone: Dear Parent/Guardian: regret to inform you that on your son/daughter was notified that a suspension was being consi ered based on the following incident(s): DISOBED/INSUBORDINAT REP DISOBED/INSUBORD Section 1006.09(1)(b), Florida Statutes, provides that a school principal may suspend a student from school. In accordance with section 1006.09(1)(b),F.S. , a meeting was held in my office on 12/07/2004 at which your son/daughter had the opportunity to explain why the suspension should not be imposed, after receiving oral and written notice of the charges and an explanation of the evidence against him or her. On the basis of the evidence available, i am hereby suspending from school attendance for a period of 3 school days effective In accordance with Section 1003.01(5)(a),F.S. , your son/daughter is remanded to your custody with specific homework assignments to complete during the suspension. Please contact my office to obtain these assignments. Please be advised that Section 984.13(1)(b),F.S., allows a law enforcement officer to take your son/daughter into custody when the student is suspended and is not in the presence of the parent/guardian. Your son/daughter will be in violation of this suspension if he/she is on any public school premises and/or any other school -sponsored activities without prior permission from the principal or designee. It is most important that you contact the principal/designee prior to your son/daughter returning to school. c fl SCHOOL STUDENT GRD RACE SU N ATE DAYS ESE 504 LEP 12 w 003 N N N PBSD 0262 (REV. 4/04) EFTA01709721 4---p,00,44,,, THE SCHOOL DISTRICT OF PALM BEACH COUNTY tOja Grade andlor Course Change Documentation $11JOS SCHOOL ECTION MASER CHANGE DOCUMENTATION GRADING PERIOD GRADE EXAM CONDUCT 7 Y From To From From To To From From From To To To IZ High School ❑ Middle School 0 Elementary School Change course code From To Reason for change 0 Recalculated Grade Average ❑ Student Completed Work Other (explain below) ,deitutte tc./ebd pm-e2-7.4,0--ez et:1,J devmpard. APPROVAL SIGNATURES (two of three required) /21)1DATE DATE SIGNATURE Of AREA ADIRN,STRATOR DATE PESO 0797 (REV. 0/14/2004) ORIGINAL Cumulative Folder DATA PROCESSOR CONFIRMATION I confirm that the grade/course change has been implemented. SIGNATUR /A? y DATE PRINT NAME Copy - Office File EFTA01709722 WI LLLLL P.0. Box 3050 Bcca Raton, FL 33431.095..) Attn: Boca Matl Unit AV 01 048153 993048229 A..€0OT 'ROYAL PALM BtACM, FL 354'1.6103 0 BELLSOUTH Mobility' pn is now X cingular WIRELESS billing statement en lined FIRSTCLASSMAX U.S. POSTAGE PAID OTS EFTA01709723 • " ' wiatilSS P.O. 80x 3050 Sitca Raton, FL 33431.OS5S Attn: Soca mall Unit Ay ni nagisl onlmmon A":ccr ROYAL PALM BEACH. FL 354,I.ilo3 OD BELLSOUTH Mobility' to is now >:< angular WIRELESS billing statomont on losod FIRST{XASSMAR. US. POSTAGE PAID OTS EFTA01709724 SVPWICILSOA OF [LCCTIONS 301 N. OWE AVENUE. ROOM 105 PALMOCACII. 33S0i-4?fl DO SOMETHING - VOTE I 111,...1 CI 0,2"),, US POSTAGL PAII Vt1 Palm u.r.ICIr I F-inal Randal 11 RETURN SERVICE REQUESTED VOTER IDENTIFICATION PALM BEACH COUNTY. FLORIDA ricanuncesmaartet REORIROJIINIOM 45114/41 MIN ROYAL • M BEACH L 3341 1 SUPERCOR a EtICKINS firamAnave.V. t. IYOUR PRECINCT RUNNIER IS. YOUR POLLING lOCAllON IS. s, go • r.... ; ra..-i I a...c c.v. • I UGIBUE TO IR ACH A l CI SOMME 01N ua weInn sisal v wan nag Win n.' . 14 ... 16 8S A :1g PRE St NY THIS CAM AT YOUR PRECINCT WREN YOU VOTE SEE REVERSE VOX FOR CHNIGE.OF.ADORESS *MALICIA) , NO11FY M fliC110,4$ aclCE ~MAIM W ANY INFOAMATON ON TICS CAM IS NC OAK a. RLOGIRATION IIIIII1111111II1III1,11„Aha,611“Jhli lilt The Sunshine State ialr AL PALI !E aD Nan Lan RrA1 esna nom OflATT 064041 00-0040 ORGAN D01404 WE ORM* CIStOTS. OPV• Oi • INS VOI100 Oral/a comer,. sobnety rarNai LI, le. 2301 EFTA01709725 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW AND RETURNING STUDENT REGISTRATION i (36) FATHER OR LEGAL GUARDIAN (Ng "Able weak sow I 37 TN R r L -1 PDORESS (NNW iwAnt.f. nn,.( NS: CRY STATE ZP COOE STATE Zip COo€ A/MI irecic.4 a 339/4OCCUPATION PLACE OF EMPLOYMENT HOME raiPHONE I BUSINESS TELEPHONE CELUPAGER NUMBER SUSMESS TELEPHONE J WAIL ADDRESS (optoima0 WAIL ADORESS (0060,10) LEMEFIGENCY HEALTH AND SAFETY,-INFORMATION ,. . • -?-c-4 . :.4sug;---;. . ,•;‘,:w *4-14,w, Person(s) other than parent authorized to pick up student dm PASSWORD Arm ro otaiToCte:3) (3S) NAME gat. mdcaeinilia( Imo (At) NAME Oat A400* MO* WO ADDRESS (Moot Ofeet •Partmea numb.) ADDRESS 04Amt ntabee. ante( apartment WY A iitt, 49fin gerth STATE ZIP COOS ty 3.30z4. CiTY STATE ZIP CODE C pcbtot113 (40)AUTHORIZED FOR EME:VENCY POW D'IES 0 NO RELAY/Cf.:SHIP (M2) AUTHORIZED FOR EMERGENCY PICKUP 0 YES 0,NO (43) If school personnel are unable to contact you Incase of airless or accident, (44) MEDICAL INFO(LMATION 0ist stmloes !esse; basImmor. heath hmeations) may we have your permission to call your doctor or . emergency services (911) for transport to the hospital? Ef<S 0 NO issues. Sews. nx s. ce oftve panted (45) FAMILY PHYSICIAN ill tPiCIAN PHONE (M6) Does your child currently have health insurance? IVES 0 NO If YES, indicate: :47) HOSPITAL PREF ERL NCL 0 Medicaid gilivate 0 Healthy Kids/Kid Care 0 Interested in receiving information RARENTSiGUARDIAN'S OTHER CHILDREN 1N7:1211:11/113aceiTh011#S ta,, 116P4S, sot NAME Of CHILD pm. most rnoole sa,aii SCHOOL ATTENDING STUDENT NO (op0:040 GRACE DATE OF 12M3D4 (50) NAME OF CHILD OAR first. mickla it,) ...flan ATTENDING STUDENT NO. (tipAbre) GRADE DATE OF BIRTH MI NAME OF CHILD (MA gra muse SW) mini ATTENDING STUDENT NO. (002nN) GRADE DATE OF RIM (S2) NAME OF CHILD ant try. nag* at40 SCHOOL ATTENONG STU004T NO. (0priNNO GRADE DATE OF BIRTH I PARENT/GUARDIAN SIGNATURE FOR OFFICE USE ONLY (S3)SCH NO. (5<)STUDE NT NO (55) COO (56) ENTRY CODE I(5T) SAC (SS) GRADE LEy k11:;Aer. gttah4">14 -9 W al° MEM . 62) Mppril 463 Btft WERE A. V "nil No I verify that the information given is true and accurate to the best of my knowledge. (66)DATA /GUARDIA DATE REV:10636 (REV 416,2001) page 2 of 2 EFTA01709726 12t r emae (Form: 23(3 SSN: NA 2004 Ain No 0017 ASVAB RV RESULTS ASVAB Results 12th Credo Standard Scores 12th Grade Standard Score Bands Percentile Scores 12th 12th 12th Gtaile Grad. Grade Females Males Students Career Exploration Scores 'Verbal Skills Math Skills Science and Technical Skills ASVAB Tests General Science (GS) Arithmetic Reasoning (AR) Word Knowledge (WK) Paragraph Comprehension (PC) Mathematics Knowledge (MK) Electronics Informations (ED Auto and Shop Information (AS) Mechanical Comprehension (MC) Military Careers Score 5 Military Entrance Score (AFQT) 85 EXPLANATION OF YOUR ASVAB STANDARD SCORES Your ASVAB results are reported as standard scores in the above graph. Your score on each test is identified by the "X" in the corresponding bar graph. You should view these scores as esti:micro( your true skill level in that area. If you took the test again, you probably would receive a somewhat different score. Many things, such as how you were feeling during testing, contribute to this difference. This difference is shown with gray score bands in the graph of your results. Your standard scores are based on the ASVAB tests and composites based on your grade level. The score bands provide a way to identify some of your strengths. -Overlapping score bands mean your true skill level is similar in both areas, so the real difference between specific scoresmightnot be meaningfullf the score bands do not overlap, you probably are stronger in the area that has the higher score band. YOUR ASVAB PERCENTILE SCORES Your ASVAB results are reported as percentile scores in the three columns to the right of the graph. Percentile scores show how you compare to other students- males and females, and for all students - in your grade. For example, a percentile score of 65 for an 11th grade female would mean she scored the same or better than 65 out of every 100 females in the 11th grade. For purposes of career planning, knowing your relative standing in these comparison groups is important. Being male or female does not limit your career or educational choices. There are noticeable differences in how men and women score in some areas. Viewing your scores in light of your relative standing both to men and women may encourage you to explore areas that you might otherwise overlook. You can use the Career Exploration Scores to evaluate your knowledge and skills in three ggeeen- eral areas (Verbal, Math, and Science and Techni- cal Skills). You can use the ASVAB Test Scores to gather information on specific skill areas. To- gether, these scores provide a snapshot of your current knowledge and skills. This information will help you develop and review your career goals and plans. The ASVAB is an aptitude test. It is neither an absolute measure of_your skills and abilities nor a perfect predictor of your success or failure. A high score does not guarantee success, and a low score does not guarantee failure, in a future edu- cational program or occupation. For example, if you have never worked with shop equipment or cars, you may not be familiar with the terms and concepts assessed by the Auto and Shop Informa-lion test. Taking a course or obtaining a part- timejobin thisareawouldincreaseyour knowl- edge and improve your score if you were to take it again. USING ASVAB RESULTS IN CAREER EXPLORATION Your career and educational plans may change over time as you gain more experience and learn more about your interests. Exploring Ca- reers: The ASVAB Career aplonftion Guide can help you learn more about yourself and the world of work, to identify and explore potential goals, and develop an effective strategy to real- ize your goals. The Guide will help you identify occupations in line with your interests and skills. As you explore potentially satisfying careers,you will develop your career explora- tion and planning skills. Meanwhile, your ASVAB results can help go: in making well-informed choices about hi high school courses. We encourage you to discuss your ASVAB results with a teacher, counselor, parent, family member or other interested adult. These indi- viduals can hap you to view your ASVAB results in light of other important information, such as your interests, school grades, motiva- tion, and personal goals. MILITARY CAREERS AND ENTRANCE SCORES Two more scores can be especially use- ful to you. The Military Careers Score is a composite of the ASVAB verbal, math, mechanical, and electronics tests. The Military Careers Score provides a link to occupations described in Military Careen. You will be able to see how well your skills, abilities, and career interests match those of Service personnel cur- rently working in military occupations. lvlilitaly Careers provides you with a clear image of what workers do in these occupations, as well as other useful in- formation about the occupations. The Military Entrance Score (also called AFQT, which stands for the Armed Forces Qualification Test) is the score used to determine your qualifications for entry into any branch of the United States Armed Forces or the Coast Guard. The Military Entrance Score predicts in a general way how well you might do in training and on the job in military occu- pations. Your score reflects your stand- mg compared to American men and women 18 to 23 years of age. USE OF INFORMATION Personal identity information (name, so- cial security number, street address, and telephone number) and test scores will not be released to any agency outside of the Department of Defense (DoD), the Armed Forces, the Coast Guard, and your school. Your school or local school system can determine any further re- lease of information. The DoD will use your scores for recruiting and research purposes for up to two years. After that the information will be used by the DoD for research purposes only. Visit: www.asvabprogram.com Use Access Code: Access code expires: July 1st SEE YOUR COUNSELOR FOR FURTHER INFORMATION DD FORM 13044 1 JUL 02 - PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE EFTA01709727 4frortDia. THE SCHOOL DISTRICT OF PALM BEACH COUNTY X Grade andlor Course Change 4 Documentation I (E1 High School 0 Middle School 0 Elementary School -1111111•111Cal GRADE LEVEL 72 Sai YEAR COU7JAKEN 6 CHANGE DOCUMENTATION GRADING PERIOD GRADE EXAM CONDUCT From To From From To To From From From To To To Change course code From To Reason for change ❑ Recalculated Grade Average EI Student Completed Work El Other (explain below) 6—laegie_ PROVAL SIGNATURES (two of three required & ( SIGNATURE OF AREA ADMINISTRATOR DATE PBSD 0797 (REV. 511412004) ORIGINAL - Cumulative Folder DATA PROCESSOR CONFIRMATION I confirm that the grade/course change has been implemented. SIGaDATE Q -or PRINT NAME Copy • Office File EFTA01709728 STUDENT N STUDENT NAME: 7)15-71 0 (9 6C 120t) PREVIOUS COURSES COMPLETED c/ SY T COURSE NO# COURSE TITLE SA CREDIT CREDIT CREDIT FINAL FLGS HC PS TAKEN DS 0_6 3 CODE ATTP EARN SCHL ■ COUNSELOR DATE:, ^!7 OP: • DATE: r73-/ -0 y EFTA01709729 iv THE SCHOOL DISTRICT OF PALM BEACH COUNTY %1/4,49,ez Grade / Course Change Documentation ( IL_ —11I'd GENERAL INFORMATION STUDENT NAME 4M CO CciSf CTION NUVBER en GRADE LEVEL /1 RCM YEAR COURSE TAKEN 02003— e) V , CHANGE DOCUMENTATION. rGRADING PERIOD GRADE EXAM CONDUCT A/46, FrOm From To From To To From From From To To To Change course code From To Reason for change: 0 Recalculated Grade Average Student Completed Work 0 Other (explain below) APPROVAL SIGNATURES (two et three required) SIGMA FURS OF TEACHER S SIGNATURE OF AREA ADMINISTRATOR 07-0?-.0K DATE DATE DATA PROCESSOR CONFIRMATION . PBS() 0797 (REV. 9/12/2001) SIGNATURE OF DATA PROCESSOR ORIGINAL - Cumulative Folder Copy-Office File DATE EFTA01709730 Spring 2003 Florida Comprehensive Assessment Test (FCAT) SUNSHINE STATE STANDARDS Grade 10 Student Report The. Florida Department of Education believes that student has the ability to learn and succeed. The purpose of the FCAT is to ensure that Florida's public schools are providing the best uca ion possible, and preparing students to succeed In the competitive 21st Century Job market. Working with teachers, the State has developed a measurementsystem that allows you to track a student's academic achievement from year to year and determine if a year's worth of learning has occurred In a year's time. This system also allows you to compare a student's score to a score that represents 'oracle lever achievement. If a students score Is above the 'grade lever score, then they are performing at a level above their current grade. If it is below, they are in need of Improvement. Using the 'Content Scores,' you are able to Identify any specific academic skills needing Improvement. Below you will find your 2003 FCAT Reading and Mathematics scores" as well as your scores from previous years. The chart on the right side of the page shows your score compared to the score that represents grade level achievement. 2003 Reading Content Sco es Content Areas Points Points Possible Earned Words/Phrases 9 Main Idea/Purpose 14 Comparisons 13 I Reference/Research 16 I Year Grade Tested Achievement Level FCAT Score • 2001 L 2002 2003 2000 ss CO U LL1000 500 Reading Grades Grads 4 Grades Grades Grader 11+ • Your Sco e ❑ On Grade Level 2003 Mathematics Content Scores Content Areas Points Points Earned Number Sense 11 Measurement 10 Geometry 14 I I Algebraic Thinking 14 I I Data Analysis 11 I Year Grade Tested Achievement Level FCAT Score • 2001 2002 2003 FCAT Score Mathematics Grads 3 Gush. 4 Grades Grade Gras ■ Your Soo e O On Grade Level • These scores show your achievement on the day you were tested. If you had taken this test numerous times, it is likely that all of your scores would have been within a certain range. Your 2003 FCAT Reading scores probably would have been between 2197 and 2381. Your 2003 FCAT Mathematics scores probably would have been between 2106 and 2172. NT = Not Tested NR =Not Reported NA= Data Not Available Data Run Date: 05/09/2003 0165053 EFTA01709731 Florida Comore entire Assessment Test Spring 2003 student Name Florida Comprehensive Assessment Test (FCAT) Stu eat umber NORM-REFERENCED TEST I! e and Number GRADE 10 Student Report This report shows your results from the FCAT National Norm-Referenced Test. The FCAT Norm-Referenced Test measures your achievement on a test that was given to a national sample of students. Your norm-referenced scores in Reading Comprehension and in Mathematics Problem Solving describe your performance in relation to the performance of students throughout the nation. Your scores are shown below. SUBJECT SCORES Scale Score Reading Comprehension Mathematics Problem Solving National Percentile Rank Stanine The Scale Score expresses your performance on the test and allows for comparisons from year to year. Reading Comprehension Scale Scores range from 527 to 817. Mathematics Scale Scores range from 568 to 863. The National Percentile Rank and Stanine Indicate your relative standing in comparison to the national reference group. National Percentile Ranks range from 1 to 99. Stanlnes range from 1 to 9. If you took the test again, your National Percentile Rank might be slightly higher or lower than stated here. However, your National Percentile Rank would probably fall within a certain range. For Reading Comprehension, your National Percentile Rank should be between 47 and 78. For Mathematics, your National Percentile Rank should be between 88 and 97. CONTENT SCORES Number of Questions on Test Number of Correct Responses Number of Questions Attempted Reading Comprehension 51 initial Understanding 8 I Interpretation 22 I Critical Analysis 9 I Strategies 12 I Mathematics Problem Solving 48 I Problem Solving 6 I Algebra 6 I Statistics 6 I Probability 5 I Functions 5 I Geometry -Synthetic 7 I Geometry -Algebraic 4 I Trigononetry 3 Discrete Math 3 Precalculus 3 Data Run Date: 04/30/2003 0145471 EFTA01709732 • • A;mow. WIRILI$$ P.O. Box 3050 Boca Raton, FL 33431.0960 Attn: Boca Mail Unit till AV 01 048153 993048229 An5DGT ROYAL PALM BEACH, FL 33411.6103 &BELLSOUTH Mobility is now >a< angular WIRELESS billing statement enclosed FIRST•CIAS Ala US. POSTAGE PAID OTS • • ...• Tr' .....••••••ArWIV.,” • 4. :Is neeIWO.WA nrt1/4•4• vv. ••.; EFTA01709733 I rit IWO n •-•• SUPERVISOR Of ELECTIONS 301 N OLIVE AVENUE. ROOM 106 VI PALM REACH. FL 33401-4795 DO SOMETHING - VOTE US POSTAGE PAD lAbsl Palm Rnach, FL Permrl Number 169 FEC•tillt•DO•itaa•Plit RETURN SERVICE REQUESTED VOTER IDENTIFICATION PALM BEACH COUNTY. FLORIDA ousnunos DOS. Rwapa IL St 05/10/01 R 0 8 SENT 11113 CAM AT YOUR PRECINCT WHEN YOU YOU FOR CHANGE ORADORESS INSTRUCHON‘ NOWT TIE ELECTIONS OFFICE IMMEDIATELY W ANY INFORMATION ON 11113 CARD IS INCORRECT, LIIllIluhJI1L1JL1JLll 1111 lilt III1 1 II I The Sunshine State a Oa PEST 00311.0 F SOS 0140-01 OPE° DLPLICAR 0003-00 ORGAN DONOR svi DRARA RUIN Sands "MN* consINAss *Newt TRM Eob,rWr vegan., by APR EFTA01709734 (13) RECENT STATUS 0 0. Foreign Exchange Student 0 I.Out-of-county Resident 0 2, Out-of-state Resident al In-county Resident (16) pRESCHOOt ENROLLMENT INFORMATION Pima an x by each pograen attended Also, indicate with an asterisk (line program yOur did was in the ionsiest. 0 N. Non-subsidized Child Care 0 M. Migrant Pre-K 0 D. Pre-K Disabilities 0 H. I-leadstart 0 I. Pre-K Early Intervention 0 C. Chapter 1 0 S. Subsidized Child Care 0 O. Other (17) LS THE moon A ( 8) CURRENT GRADE LEVE 0 YES 7 SINGLE P O(14) USA ENTRY DATE (44/MDEvrern THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SDPBC) New and Returning Student Registration NEW STUDENTS: Complete all non-shaded areas on both sides of the form. RETURNING STUDENTS: Review both sides. If the pre-printed information is int/affect, Correct the information by carefully and lightly crossing out the incorrect information and writing the correct information above it. () (6) MAILING AD/DRESS (not (7) SOCIAL SECURITY NO. (11) DATE OF BIRTH (t2) PUCE OF BIRTH (004tasimuniro (10) RACEETHNiC ORIGIN (*Mona, 01-American Indian/Alaskan Native 0 B-Black. Non-Hispanic 0 H-Hispanic 0 A-AsiaruPacific Islander g4-While, Non-Hispanic 0 M-Multiracial (15)FrnFRN IMPACT SURVEY YES NO O 0 A. The student resides on federal property. O 0 B. The student resides in low rent housing. O 0 C. The parrot is employed on federal property located in Palm Beach County. O 0 D. The parent is employed on low rent housing located in Palm Beach County. O 0 E. The parent is in the uniformed services of the United States. O 0 If E. is YES, is the parent on active duty? Check service below: 0 Air force 0 Army 0 Coast Guard 0 Mannes 0 National Guard 0 Navy 9) NAME OF SC1400L TRANSFERRING FROM (22) LAST GRADE LEvEt. (23)LAST PUBLIC SCHOOL ATTENDED W4 PALM BEACH GOWN 1251 Students will receive non-invasive health screenings pursuant to Florida Statute §381.0056(7)(d). Non-invasive screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or guardians, however, have the right to request an exemption in writing. If you DO NOT want your child to receive the screenings, write the words *Do not screen.' here: (This exemption will cover all types of screenings) (26) I give permission for my child to participate in the sodium flouride program to prevent tooth decasfV'ESO NO (Permission is valid through 6 grade) ta$1.03k€ UmIGUAGE SURVEY YES NC11, O No Is a language other than English used in the home? If YES. what language? O rit2. Does the student have a first language other than English? if YES. what language? O 847 Does the student most frequently speak a language other than English? II YES, what language? rzai 4. What language is spoken in the home by the parent or guardian? e1'041/ SA (30) 5. What language is the student's first language? Ana 4r//S lj uvEs want (chock one) (31) What is the date of entry into an ESOL program? (33)D1SCLO‘UPFS FOR ENTRY INTO PBC SCHOOL DISTRICT YES O A. Has the student ever been expelled from school? O V. Has the student ever had an arrest resulting in a charge? O 3. Has the student ever had any juvenile justice actions? NO 111 AST ATTFISIOAMCE DATE (24) DATE •A TTENDED IN PBC (27) Have you filled ou e t an application for fre and reduced lunch? 0 YES RicC (Application is pawided with this form Mother 0 father 0 Both Parents Vothe, agh-bhtkatirs (34)CUSTOOY STATUS OF STUDENT "Schork one) 0 Mother 0 Father Q'Shared Custody 0 Other (as) Is there a court order baning either parent from removing or contacting the student during the school day? 0 YES If YES, provide the school with a copy of the court order. PBSD 0636 (REV. 4/6/2001) page 1 of 2 EFTA01709735 - nian orat.ti COUNTY - NEW AND RETURNING STUDENT REGISTRATION (35)FATIM-R OR LEGAL GUARCKAN Real mine kiss roo4 (3 MOTI AOOQ AA (stripe( numbo, IVOR aportemiat tuen(s) CITY STATE ZIP CODE STATE ETP CODE /1, c.pA-in, Sees fi 3.011 OCCUPATION RACE OF EMPLOYMENT • •:.0.Acir -"` Nat TELEPHONE BUSINESS TEt EPI4ONE j CEUPAGER NUMBER .. • zassza.• BUSINESS TELEPHONE EMAIL ADORES 5:05Imm EMU. ADDRESS (0001100 EMERGENCY HEALTH AND SAFETY INFORMATION T.' ' ' -/ ', . Person(s) other than parent authorized to pick up student (U) PASSWORD pernit 10 charades's) 09) RNA( t.,-, • (4)) NAAR (fat mkkAs mbal. Iasi) ....1.a....mr...-•••••••• ADDRESS Wean nuentxv. street womnat numbed STATE ZIP CODE Afin g€ Pf 3,472CM STATE ZIP CODE :opONSHIP (40) AUTHOR/fe y FOR a: 0 NORELATIONSHIP (42) AUTHOR2f0 FOR EMERGENCY PICKUP DYE 0 NO (43) pschool personnel are unable to contact you may we have your permission to call your doctor - emergency services (911) for transport to the incase of illness or accident,awn. or hospital? EKS 0 NO (4) MEDICAL INFORIAATION OS MAW, Orospa tsMistAM boat sioroos. modkmicers. or oils "star lindolions) (45)FA/MLY PHYS/CIAN IA IAN PHONE NO Does your child currently have health insurance? L7YES 0 No If YES, indicate: (0)H