FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.03Z, 402.305, 402.313, Florida Statutes;

FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: sections 232.03Z, 402.305, 402.313, Florida Statutes; rules 640-3.011, 65C-22.006, 65C-20.011, Florida Administrative Code LAST N FIRST NAME MI DOB (MO/DA/YR) PARENT OR GUARDIAN CHILD'S SS# (optional) STATE IMMUNIZATION IMP Directions: Enter all appropriate doses and dates below. Sign and date appropriate certificate (A-1, 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 (DR 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. DOE Dose 1 VACCINE CODE %4 all‘h DTaP/DTP 2 A Teti Polio' Hill MMR (Combined)' F. (Separate)° G,H,I Hepatitis B9 Varicella" Varicella Disease L Year Dose 2 Dose 3 ta III Lit II • Al . A P Dose 4 Dose 5 .a • lb . SAP • . • I The state immunization ID# is an identifier supplied by the state immunization registry (optional). 2 DTP/DTaP 5 doses required. If the 46 primary dose is administered on or after the 46 birthday a 56 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. 5 Polio 4 doses required. If the 3" dose in an all OPV or all IPV series is administered on or after the 4" birthday, a 48, 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 1" birthday. Second dose (measles) valid if given at least I month after l" dose. A 21" dose of measles (preferably MMR) is required for students in grades K-6 and 7'h grade entry and attendance effective with the 1997/1998 school year. In each subsequent year thereafter, the next highest grades are included. 8 Includes single measles vaccine (G), single mumps vaccine (11) 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 1998/1999 schoollear. In each subsequent year thereafter the next highest grades arc included. Hepatitis B vaccine series is required for preschool entry and attendance effective with the 2001/2002 school year. 10 Varicella is required for entry and attendance in child care and family day care effective July 1, 2001. 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 are 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. EFTA01710219 LAST NAME FIRST MI DOB moroArxit) , Certificate of Immunization for K-12 Eicluding 7th Grade Requirements PART A-I (Immunizations are complete for school entry and attendance grades kindergarten through 12 with the exception of the 7th grade requirement.) DOE Code 1 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 (for kindergarten effective with the 2001/2002 school year) for school attendance as documented on the reverse side of this form. Physician or Clinic Name: Physician or (Print or stamp) Authorized Signature: Address: Date: Certificate of Immunization Supplement for Tb 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 1 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 7. grade effective with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as docurn. Physician or Clinic Na Physician or (Print or stamp) horized Signatur Addr•• Date: --11 St (C)--' . 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 I certtfr 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. . Expiration Date: . . iPhysician or Clinic Name: 05•days after next immuilization.appoiutrnent) (Print or stamp) . . _ . . . • 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 certifr that the physical condition alibis child is such that immunization(s) as indicated in Part C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: Date: DH 6$0 72001, obsoletes earlier editions (Stock Number 5740-000-06SO-6) EFTA01710220 ALTH EXAMINATIONS Date Full NamllM glIllt Phone Race Address Birthdate Student' Name of Parent cr Guardian School A. HEALTH EXAMINATION Height Weight Blood Pressure (1) Normal-N; Abnormal=A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/Nose 3. Head/Scalp 4. Eyes J 5. Visual Acuity (R & L) 6. Ears 7. Auditory Acuity (R & L) 8. NOSe / 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 Prob.) 18. Handicap. physical/ other (Specify) 19. Activity Restrictions (Specify) 20. Abuse. substance/ physical / emotional 21. Nutrition 22. Other B. HEALTH HISTORY (Serious Illnesses Injuries: explain) (attach narrative it additional space needed) C. LABORATORY Hemoglobin/Hematocrit Stool 1O & P) Tuberculin test: Sickle Cell Lead Authorized Signature OH 3040. 10190 (Replaces NRS-li Form 3040 which may be used) (Slack Number 5741-000-3040-2) EFTA01710221 ERs Student's Full Name Address Name of Parent or Guardian STATE OF FLORIDA DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES HEALTH EXAMINATIONS Dale if Mr- Phone Race Sex Birthdate A. HEALTH EXAM NATIO N Height Weight Blood Blood Pressure Normal=N; Abnormal -A N A COMMENT: Abnormal Findings, by number 1. Appearance 2. Skin/Nose 3.1-lead/Scalp 4. Eyes 5. Visual Acuity (R & L) 6. Ears 7. Auditory Acuity (R & L) 8. Nose / 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 Pro b.) 16. Handicap. dirge& • other (Specify) '19. Activity Restrictions (Specify) 20. Alatise. substance/ physical / emotional 2 1.Nutrition 22. Other B. HEALTH HISTORY Serious Illnesses Injuries: explain) • (attach narrative if additional space needed) C. LABORATORY (as Indicated) mylotin/Hematocril Stool (0 &12) Tuberculin test: Lead Sickle Cell NAME: TITLE: ADDRESS: (Please Print) MRS-li Form 3040, Mar 91 (Obsoletes previous ' (Stock Minter: 5744-000-3040.2) tYP resu EFTA01710222 SUR C fleala HRS. OCl/AlliCra Of MUM, WO • FLORIDA CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) (1+) (Florida Statutes 232.032) FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE CHILD'S NAME (PRINTED) SS YR' DOCTOR: PART A OF THIS FORM IS USED ONLY IF TILE CHILD HAS RECEIVED ALL REQUIRED IMMUNIZATIONS LISTED BELOW. IF 110T. SEE REVERSE SIDE. DTP - 5 DOSES REQUIRED 110) PARENT OR GUARDIAN IF THE FOURTH PRIMARY DOSE GF DTP IS ADMINISTERED ON OR AFTER THEFOURTHRIRTHDAY, A FIFTH-DOSETS NOT REQUIF.ED. DT (PEDIATRIC) VACCINE IS ACCEPTABLE IF PERTUSSIS VACCINE-IS-MEDICALLY- CONTRAINDICATE!). (COMPLETE PART C FOR•PERTUSSIS CCNTRAINDICATION.) (V) Td (ADULT) VACCINE (A SERIES OF 3 DOSES) IS ACCEPTABLE.AND'RECOMMENDED FOR CHILOREN:.7 YEARS OF A0E.OR OLDER. (C) POLIO - 4 DOSES REQUIRED IF THE THIRD PRIMARY DOSE CF OPV IS ADMINISTERED ON OR AFTED.THE'FOURTH BIRTHDAY, A FOURTWDOSE is NOT REQUIRED. IPV IS AN ACCEPTABLE ALTERNATIVE :F OPV IS NOT INDICATED. FOLIO VACCINE IS OMITTED FROM THE REQUIRED IMMUNIZATIONS OF GIOLDREN 18 YEARS DF.A5E OR CUTER. MEASLES. MUMPS, MD RUBELLA — 2 DOSES REQUIRED FOR MEASLES 1 DOSE REQUIRED FOR MUMPS MD RUBELLA • MMR COMBINED — 1st DOSE AT 12 MONTHS OF AGE Oft OLDER.(RECOMPSENDED AT 15 MONTHS). (F*) 2nd DOSE REQUIRED PRIOR TO KINDERGARTEN:ENTRANCE , (VAUD IF GIVEN AT LEAST 30 DAYS AFTER 14;005E) MEASLES SINGLE — 1st DOSE AT 12 MONTHS OF AGE OR OLDERBECOMMENDEDAT 15 MONTHS) (G) 2nd DOSE REQUIRED PRIOR TO KINDERGARTENPJIRANCE (VALID IF GIVEN AT LEAST 30 DAYS AFRER.1g.DOSE) MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER. (11`) • . RUBELLA SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER (P) ALL APPROPRIATE DOSES AND DATES INCLUDING BIRTHDATE MUST BE ENTERED, AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN OR AUTHORIZED PERSON AND DATED IN ORDER FOR THE CHILD TO ATTEND SCHOOL I HAVE REVIEWED THE RECORDS AVAILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED CHILD HAS BEE DIPHTHERIA, TETANUS PERTUSSIS, POLIO, MEASLES, MUMPS, AND RUBELLA AS REQUIRE PHYSICIAN OR CLINIC NAME (PLEASE PRINT) )E AUTOMATED STUDENT DATA BASE CODES: • IMMUNIZATION STATUS CODE / 11 VACCINATION CODE EFTA01710223 DATE OF BIRTH CHILD'S NAME (PRINTED) SSO MO DOCTOR: IF THE CHILD HAS NOT RECEIVED THE REQUIRED DOSES LISTED IN PART A, PLEASE COMPLETE DA YR PARENT OR GUARDIAN PART B OR PART C, AS APPROPRIATE, AND SIGN AND DATE. TEMPORARY FOR PRESCHOOL I CERTIFY THAT THE ABOVE NAMED CHILD IMMUNIZATIONS. ADDITIONAL IMMUNIZATIONS CHILDREN HAS ARE RECEIVED NOT #1' AND THE MEDICALLY MEDICAL FOR IMMUNIZATIONS SCHOOL INDICATED EXEMPTION CHILDREN #2 LISTED AT THIS (HRS WITHOUT BELOW TIME. 680 ALL AND HAS #3 - IMMUNIZATIONS COMMENCED PART B) (21 REQUIRED A SCHEDULE #4 . IN PART A TO COMPLETE THE REQUIRED #5 TYPE VACCINE CODES' DATE (MO/DA/YR) DATE (MO/DA/YR) DATE (MO/DA/YR) DATE (MO/DA/YR) DATE (MO/DA/YR) DTP A DT B Td C POLIO D Hib E MMR F AUREOLA (MEASLES) G EXPIRATION DATE (MO/DA/YR) MUMPS H (SHOULD BE 15 DAYS AFTER NEXT APPOINTMENT) RUBELLA I • PHYSICIAN OR AUTHORIZED SIGNATURE DATE PERMANENT MEDICAL EXEMPTION (HES I CERTIFY THAT THE PHYSICAL CONDITION OF THIS CHILD IS SUCH THAT IMMUNIZATION(S) CLINICAL REASONING OR EVIDENCE FOR EXEMPTION FOR EACH VACCINE. 680 - PART C) (31 IS MEDICALLY CONTRAINDICATED. LIST VACCINE(S) AND STATE VALID PHYSICIAN OR CLINIC NAME (PLEASE PRINT) PHYSICIAN'S SIGNATURE DATE HRS Form 680. JAN 93 (Repbces Mat 91 edition which may be ized) (Stock Number 5740-000.0680-6) DOE AUTOMATED STUDENT DATA BASE CODES: ' IMMUNIZATION STATUS CODE / ' VACCINATION CODE EFTA01710224 THE SCHOOL DISTRICT OF PALM BEACH COUNTY ELEMENTARY REPORT CARD Student School Teacher Principal E - V - MARKING CODES - ACADEMIC SUBJECTS GRADES 1 and 2 Excellent S - Satisfactory Very Satisfactory N - Needs Improvement A B C D F GRADES 3-5 - Outstanding (94% - 100%) Above Average (85% - 93%) Average (77% - 84%) Below Average (70% - 76%) Failing (0% - 69%) Incomplete ACADEMIC SUBJECTS Marking Period 1st I 2nd I 3rd 14h M-lh=m-IicS 'care level Hdf a check) 1...ztak....!1.LJAP - o A' pr Composition Language Spelling Handwriting/Penmanship Social Studies Science/Health Grades not given this nine week FINE ARTS REPORT Art Music Marking Period 1121EIMES Physical Education PARENT/GUARDIAN/TEACHER CONFERENCE Conference conducted (Indicate date(s)) Marking Period 1st 12nd 3rd 4th Grade (.5 Year 2000-2001 SOCIAL DEVELOPMENT/CLASSROOMSTUDY HABITS Please work on the area(s) that have a check (/). Marking Period tat I 2nd I 3rd I 4th Overall effort Works cooperatively Works independently Completes classwork on time Completes homework on time Follows classroom rules and routines Uses time wisely Follows directions Accepts responsibility for own actions Comes to class prepared with materials ALTERNATE ASSESSMENTS Indicate those used with a check (/). Skills Checklist(s) Portfolio Audio Cassette Recording Video Recording Computer Program Standardized Test(s) Observations/Written Comments Other ATTENDANCE Regular attendance and punctuality are essential for quality education. Days Present Days Absent Days Tardy Information Included PLACEMENT Marking Period MEMZEIMIT2IMI Marking Period Billaliilla Grade A Special Session • If Special Session program is Indicated, grade placement will be determined by the home school. PBSD 0768 (Rev. 7/99) Goldenrod/1st Period Pink/2nd Period Canary/3rd Period Green/4th Period White/Office Copy EFTA01710225 THE SCHOOL DISTRICT OF PALM BEACH COUNTY 2000- ort for Grades 1-5 SeDEM GRADE 2000-2001 ACADEMIC IMPROVEMENT PLAN STATUS Your child's academic performance was at or above grade level in reading, writing, and mathematics, and an Academic Improvement Plan (AIR) was not necessary. Your child's academic performance was below grade level and an individual Academic Improvement Plan (AIP) was necessary for ❑ reading ❑ writing ❑ mathematics This AIP identified remediation strategies used to assist your child this year. Your child may need another AIP next school year. Your child's academic needs were addressed through his/her Individual Education Plan (IEP), Limited English Proficient (LEP) Plan, or 504 Plan. END-OF-YEAR PERFORMANCE Your child's end-of-year performance level in reading, writing, and mathematics is identified below: TING(COMPOSITION) MATHEMATICS If less than one year below grade level has boon indicated for reading, writing, and/or mathematics, you may be asked to participate in the development of a plan to improve your child's academic performance. This plan will be developed at the beginning of the 2001.2002 school year. If more than one year below grade level has been indicated for reading, writing, and/or mathematics, you must have an LEP Plan, IEP, 504 Plan and/or AIP. You will be asked to participate in the development of a plan(s) to improve your child's academic performance. This plan(s) will be developed at the beginning of the 2001-2002 school year. PROMOTION/RETENTION DECISION As a result of your child's performance this school year, your child is being recommended for: j' Promotion to the next grade level ❑ Promotion to the next grade level with an LEP Plan, IEP, 504 Plan and/or AIP ❑ Good Cause Promotion from fourth grade to fifth grade with an LEP Plan, IEP, 504 Plan, and/or AIP ❑ Retention in the same grade level SUMMER SCHOOL/EXTENDED SCHOOL YEAR RECOMMENDATIONS The promotion/retention decision for your child will be made following the completion of Summer SchooVExtended School Year. ❑ Summer School (for Limited English Proficient students) ❑ Extended School Year (for Exceptional Student Education students) OATE PBSO 1674 (REV. 4/262030 ORIGINAL - Cumu%6ve Folder COPY - School Use COPY - Report Card EFTA01710226 FLATCove5nsive Asia mutt Tell )puny 4WD Florida Comprehensive Assessment Test® Sunshine State Standards Reading Performance Task Student and Parent Report Grade 10 This report shows your results on the FCAT Reading performance tasks. Each performance task on the FCAT requires either a short response or a longer, more detailed response. Short-response tasks are scored out of 2 points and extended-response tasks are scored out of 4 points. ID One of the short-response tasks is shown below with a copy School of your answer. The number of points you earned on all District 50-PALM BEACH performance task items is also included. This task required you to read an informational passage and then answer how a blind painter's determination led to her success. Your Score 0,1,Marteatitereain out of 10 points On all Reading performance task responses (al-11:n der uarit tvira tyr -to co cior ar take Ox-k 14 Ural M-C, %Ulla VG:O not- + OVA- one could do, Artie teepnCS 1/4013%-kr) W Osts %re\ -One err, src cecerre yuccaatftt.4% coot r4 ‘s rcui in rruse U tit 5 (Sit trg sold 1 ice a -true or-fists twootg., teNdq,I Z DIE. 51-1,:i1C,.? EFTA01710227 14 THE SCHOOL DISTRICT OF PALM BEACH COUNTY Grade andlor Course Change El High School 0 Middle School 4-pooLDia Documentation 0 Elementary School STUDENT NAME la test trocgo .W419 ENT NUMBER GRADE LEVEL \ SCHOOL SCHOOL. NUMBER SCH YEAR COURSE TAKEN sippiam eounEtwisQ_ 2331 CHANGE DOCUMENTATION GRADING PERIOD GRADE EXAM • CONDUCT -2:al C\ jFrom From From To To From_ From To To To Change course code From To Reason for change ❑ Recalculated Grade Average ❑ Student Completed Work CI Other (explain below) APPROVAL SIGNATURES (two of three required) Lo \ \ \Ott . DATE bh DATE DATE PBSD 0797 (REV. 511412004) ORIGINAL - Cumulative Folder DATA PROCESSOR CONFIRMATION I confirm that the grade/course change has been implemented. siGvA PRINT NAME -ocDATE Copy - Office File EFTA01710228 JOENT NAME: tai :THDATE Verified by WW1 CoAlkalis: G Yes G No a No. What Typo Verification? iTHPLACE: Dad,p, RREN lie let yL 0 4 CC 17 0973 (REV 3/20417) SCHOOL use In Lnis e until (Ins SEX: RACIAL/ETHNIC GROUP: G Mao Not Hispanic G Black Not Hispania -c Dale First Entered This ()kirk' Hispanic o can IndlanfNatIvo Alaskan G Asian/Pacific Islander O Muhl Racial OR OTHER RESPONSIBLE ADULT AT HOME: I o, PHONE NUMBER: (options!) ' OA Grader Schock Grade: School: (Pada Shoot. Grade: Selma Grade: &Moo: Year ?Etat) . Ct 1 &hoot Year 19 • Saud Year. 19 • School Mac 19 • School Year. 19 • Days Present Days Absect: sDays Piaui* Days Absent Days Present: Days Absent Days Present Days Absent: Days Present: Days Absent C7 OPY REPORT OF CARD COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED Adrast INDCA111,1 Place Promote (P) actin (R) Special Scission (SS) INDICATE Adninisuatree Placomenl (ADMP) Picmole (P1 Nato (R) Special Swan ($S) INDICATE 1110CATE AdrrOntstadv• . Rammed (ADMP) Remote (P) Rosin (R) Spacial Session (SS) Achohlandie Reamers (ADMP) Promote (P) Borah (R) Special Session (SS) INDICATE Administrative Pimento-or (ADMP) Nandi) (P) Retain (R) Spacial Session ($5) School: Grano: Schoot Grade: School: Grans: School: Wade: Schoot I Duck: &Mod 'frac 19 • School YON 19 • School Veer 19 - School Year 19 School Year 19 • Days Present Days Absent Dais Present Days Absent Days Present Days Absent Days Present Days Absent: Days Present I Days Absent COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED COPY OF REPORT CARD INCLUDED INDICATE Administrative Placement (AMP) Promote (P) Rash (R) Spode] Session (5$) INDICATE AchnInlsitallve Placement IADMP) Promote (P) Retain (R) Spodel Swan (SS) INDICATE AttmlnIstratVe Nommen: (ADMP) Promote (P) Rusk (R) Special Session (SS) INDICATE ActnlaWratIve Placement (ADMP) Promote (P) Roth (R) Special knort-in ($5) INDICATE AdmInIstrerive Placement (ADMP) Promote (P) MUM (R) Special Session (SS) EFTA01710229 414OOLDIS\ THE SCHOOL DISTRICT OF PALM BEACH COUNTY (SONIC) (1) STUDENT NUMBER (2) SAC CODE (3) GRADE LEVEL 1 New and Returning Student Registration form r and axcept areas specified office use only . formation is incorrect, correct the information Writing the correct Information above it. At, 4°° tIVA-)NEW STUDENTS: Complete all areas ontoth sides of the RETURNING STUDENTS: Review both sides. If the pre-printed by carefully and lightly crossing out the incorrect information IIIIIIMa m (S) ALSO KNOWN AS • (6) KEY/ (slab) (rbood.) Royal Aim /30ach H. 33 V// (7) INULING ADOFTESD(hease rox d abed name) OFT• no) (Nay) (31•10 NO code) (8) SOCIAL SECURITY NO. topSons9 (9) HOME TELEPHONE NO. !PM SEx e • O n RACEJETISNIC ORIGIN O I-American Indian/Alaskan Native O 8-Black, Non-Hispanic N-I-Hispanic O A-Asian/Pacific Islander O W-White. Non-Hi panic O M-Multiracial (12) DATE OF BIRTH (I 3) PLACE OF BIRTH (city, stale. counIty) AIM Y • . Ph n Aw El. ppcie govoi04) RESIDENT STATUS O O. Foreign Exchange Student ❑O 1. Out-of-county Resident. O 2. Out-of-state Resident CI 3. In-County Resident (1 3) USA ENTRY DATE (MMODYVYY) (la)FEDERAL IMPACT SURVEY YES NO O O A. The student resides on federal property. o Ei B. The student resides In low rent housing. O O c. The parent is employed on federal property located In PS County. O 0 D. The parent is employed on low rent housing located in P8 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 O Air Force O Am's, O Coast Guard O Marines O Nalional Guard O Myr/ indicate with an the longest Migrant Prekindergarten - • Prekindergarten Parent Program Applicable (17) PRESCHOOL ENROLLMENT INFOALIADON Place an X by each program attended. Also, asterisk ("the program your child was in O C. Title 1 PrekindergartenO M. • D. Pre-K Disabilities • N. None O F. Fee for Services • P. Private O H. Head Start O T. Teenage MI L. Readiness Program O Z. Not OS) Is the student a single parent? O YES O NO TRANSFER INFORMATION ("Para; 13e4ch Ft-(23) ave you ever een enrolled In Palm Beach County School? W YES O NO If yes, what school? (21) LAST ATTENDANCE DATE a - L4 - (21) DATE ATTENDED IN Pac HEALTH SCREENING INFORMATION (25 ) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0056(7Xd) Non-invasive screenings may indude 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 ell typos of screenings) RS) I give permission for my child to participate in the sodium fluoride program to prevent tooth decay. O.YES D NO (Permission is valid through grade 6) an Doei your child currently have health insurance? O YES O NO If YES, indicate: O Medicaid tilitHealthy KidslKid Care O Private O Interested in receiving Information NEW STUDENTS TO PALM BEACH COUNTY (28) HOME LANGUAGE SURVEY • OYES O NO 1. Is a language other than English used In the home? If YES, what language? n S O NO 2. Does the student have a first language other than English? If YES, what language? VI YES tANO 3. Does the student most frequently speak a language ether than English? If YES, what language? (29) DISCLOSURES rikES O YES FOR ENTRY INTO P/3C SCHOOL DISTRICT NO 1. Has the student ever been expelled from school? • O YES ANO 3. Has the student ever had any juvenile NO 2. Has the student ever had an arrest resulting in a charge? Justice actions? (30) DIU LIVES WITH: (cheek one) Sother O Father O Both Parents • Other (31) CUSTODY STATUS OF STUDENT(check Mother O Father O Other one) II Shared Custody (sat Is there a urt 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. 03/19/2003) page 1 of 2 EFTA01710230 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW AND RETURNING STUDENT REGIS 1) FATHER CR LEGAL GUARDIAN (Sat 77404 int.9. 7779 (34) DATE OF BIRTH (45) DATE OF BIRTH 5- • Oa - (.0 7 DO ADDRESS (Proof nor.844 OHL aparlmanflonbee) i 127. t 1(4,- I . . rn 6eCL-C-il STATE 2IP CODE I - . (36) CITY STATE PP CODE (V )OCCUPATION (38) HIGHEST ED. LEVEL (CD OCCUPATGli l '.\ AI iS1-16 ST TO HIGHEST ED. LEVEL (39) PLACE OF EMPLOYMENT (50 (IN HOME TELEPHONE (4 I) BUSINESS TELEPHONE (42) Ca UPAGER NURSER (SI) HOME TELEPHONE (S2)BUSINESS TELEPHONE (5.5) CELL/PAGER NUMBER (a3) EMAIL ADDRESS (999704 (64) EMAIL ADDRESS ( EMERGENCY HEALTH AND SAFETY INFORMATION lowed to pick up student (ts) PASSWORD ami ioduracten) (62) NAME (Fat middle MG/. fast) IS(03) ADDRESS WNW comber. emelt:par:mint numb00 (64) cry STATE ZIP 000E (S5) CITY STATE 2V CODE RONC4 Palm &ash P1 -a341 (69)RELAO 0 lief (e.n If school personnel are unable to contact you in caso may we have your permission to call your doctor or emergency services (911) for transport to the hospital? AGER NUMBER (65) RELATIONSHIP (66) TELEPHONE (67) CELUPAGER NUMBER of illness or accident. t.YES .0 NO (69) MEDICAL INIORVATION Dif sluderes Oesset, bensik.f. Seatta issues Senjot (nciutTeo stair, birds, mattes a r wapAbians). mmeasons, or caller chysical knfatioAs (70) FAMILY PHYSICIAN DI) PlifaaAN PHONEFREE OR REDUCED PRICE LUNCH (7)) Have you filled out an appricatron for free and reduced (72) HOSPITAL PREFERENCE I 41MS LOe Sr lunch? OYES • NO fAoseoslIon fa proWded with /Ms ken) PARENTS / GUARDIAN'S OTHER CHILDREN IN PALM BEACH COUNTY SCHOOLS NAME Ode, (75) SCHOOL ATTENDING (76) STUDENT NO. HOP* (TT) GRADE MOTE OF BIRTH (74) OF CHILD (Mt lasf) (79) NAME OF CHILD (KO midcto. lag) (80) SCHOOL ATTENDING (61)STUDENTN040055(47) (62)GRADE (63) DATE OF BIRTH (8A) NAME OF CHILD PR AIM*. NV (85) SCHOOL ATTENDING (OS) STUDENT NO. (opi5onal) (97)GRADE (90)DATE OF BIRTH (89) NAME oFcitto(rest midst fast) (9)) SCHOOL ATTENDING (91)STUDENT NO. WOW (92)GRSOE (93)DATE OF BIRTH PARENT/GUARDIAN SIGNATURE I verify that the information given is true and accurate to the best of my knowledge. FOR OFFICE USE ONLY (M)SCHN1 DEISROENT Na . (96)CCG (5?)aTRY CD (93) EMIG DATE MI C41. (ID)1E40131 MI OD REASSIGN CIL DOB TRANSPCRTADON 0 PI3C Bils a El Pakn Iran PR DEN VERE . 001)DCF A • 0 Pa-ent/Sludent Trans. 0 WailtEl BIN 2 3 4 5 6 7 8 9 T CZ DOD DOCUVEMAKNOECKLIST 0 Immunizations 0 Birth Records Verificeilon 0 Social Security Number 0 Physical Exams Doh) ESOL PRCGIAM OMIT CIDE (107)0ATAIDMITCCOMMEOBY DOD DATE :H, DATE PlitSO 0636 (Rev. 03/192003) page 2 of 2 EFTA01710231 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 incorrect, correct the information by carefully and lightly crossing out the Incorrect information and writing the correct information above it 2972222:1) DIST:2451 TCHR NBR:225 STOT: CRS:1700100 SEC:1G BLOCI:01 R1.1:175 08/12/02 (3) STUCENTS LEGAL NAME (FM . (1) ALSO KNOWN AS ( OCAL ADDRESS mouse no. 6 greet Maw* (apt noJ fait MOO (410 ado) LOXAHATCHEE FL 33470 (6) ALLLNG ADDRESS MOM no. a greet name) frig 001 (O (stale) (A0 =da) . (7) SOCIAL SECURITY NO. (0) HOME TELEPHONE NO. (0) SIX F(103 RACEIETAINC ORIGIN H 0 I-American Indian/Alaskan Native 0 Balack, Non-Hispanic H-Hispanic • kAsian/Pacific Islander 0 W-YVhie, Non-Hispanic M-Muttiracial on DATE OF BIRTH (12) PLACE (LIW00NYY) DADE COUNTY FL US FLORIDA (1D) RESIDENT STATUS 3 0 0. Foreign Exchange Student 0 1. Out-or-county Resident 0 Out Resident (14) USA ENTRY DATE (MARDEAVYYY) (15) FEDERAL IMPACT SURVEY 2. -of-slate 0 3. In-county Resident YES NO 0 0 A. The student resides on federal property. LI O B. The student resides in low rent housing. n o C. The parent Is employed on federal property located In Palm Beach County. 0 0 D. The parent Is employed on low rent housing located in Palm Beach County 0 • E. The parent is in the uniformed services of the United Slates. (i 6) PRESCHOOL ENROLLMENT INFORMATION Place an X by each program attended. Also, indicate with en asterisk (') the program your child was In the longest. 0 N. Non-subsidized Child Care 0 M. Migrant Pre-K 0 D. Pre-K Disabilthed 0 H. Headstart • I. Pre-K Early Intervention 0 C. Chapter 1 0 S. Subsidized Child Care 0 O. Other 0 0 If E. is YES, is the parent on active duty? Check service below: 0 Air Force • Army 0 Coast Guard 0 Marines 0 National Guard 0 Navy (17) ISIHE STUDENT A SNORE PARENT? NO 0 YES 0 NO Om CURRENT GRADE LEVEL 07 4TRANSEEWINEORMATION ;a6„...-Waiftt 09) NAME OF SCHOOL TRANSFERFtrio FROM (20) CITY CR LOCATION COLAcy- - (2 I) LAST ATTENDANCE DATE (22) LAST GRADE LEVEL (23) LAST PUBLIC SCHOOL ATTEACED IN PALM BEACH COutfry i (24) DATE AT1ENDIED IN PDC HEAIMESOREE listGINFORMATions . I;ie Att., 4, .s.ut 34,,b (25) Students will receive non-invasive health screenings pursuant to Florida Statute § 381.0356(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 chid to receive the screenings, write the words "Do rot screen- here: (This exemption !ma cover el types of screenings) (26) I give permission for my child to participate In the sodium fluoride program to prevent tooth decay. 'YES 0 NO (Permission is vaNd through 6 grade) YES Medicaid 0 Healthy lOds/Kid Care 0 Private (27) Does your chid currently have health insurance? YES 0 NO if YES. indicate: Interested in receiving information SEVIMertiOENTs401PALNhBEACiiicouNTY (28) HOME LANGUAGE SURVEY YES 0 NO 1. Is a language other than English used in the home? ...pci..n ts If YES, what language?*.. If YES, at language? pa ant shh what YES 0 NO 2. Does the student have a first language other than Engbsh? OYES ANO 3. Does the student most frequently speak a language other than English? U YES, at language? ma 4. What language is spoken in the home by the parent or guardian? ct,ft t 4'1 - riled I ck (90) 5. What language is the student's first language? .pct_ r. 11S IS (31) What is the date of entry into an ESOL program? (32) STUDENT LIVESMATH. (chock coat %pother li Father xi Both Parents 0 Other (33) Oscuosunas FOR ENTRY 0/10 PSC SCHOOL DISTRICT YES NO CIrag Pi been 1. Has the student ever expelled from school? • .4 2. Has the student ever had an arrest resulting in a charge? 0 !e1 3. Has the student ever had any gwenile justice actions? CUSTODY STATUS OF STUDENT (check oae) 0 Mother 0 Father 0 Shared Custody 0 Other pp Is there a court order barring either parent from removing or contacting the student during the school day? 0 YES NO If YES, provide the school with a copy of the court order. PBSD 0636 (REV. 02704/2002) page 1 of 2 EFTA01710232 • rtc cnern.nor- snoinnei ur rnLrvI permirn wauPil I T - New ANL, Kt I UNNINto l I ULlt.N I /Chia IS I KA I ION Into( lase PU: Y (37) MOTHER OR LEGAL GUARDIAN (kg mole label. last) PU: n umber) ADDRESS street numter ate anrbnvN numbed But ADDRESS (0044140 cry LOXAHATCHEE FL 33470 STATE 21P CODE an LOXAHATCHEE Ft. 33470 STATE ZIP CODE OCCUPATION RACE OF EMPLOYMENT OCCUPATION kAAvesTOISI CELLPAGER NUMBER CELUPAGER NUMBER :EMEMENCY: IEA43EE {tNR` afilFORMA'f Person(s) other than parent authorized to pick up student (35) PASSWORD (NM 10 characters) NAME inideN• TY lea (41) NAME PA maw India( An( ADDRESS (a9444 rumba. 4444( apatite?: number) C(FY STATE. ZIP CODE 2ocak Pa_k m P)dr‘ FJ45.3(11 STATE 2IP COCC RELATIONSHIP cart 111O1 ) EC (40) AUTHORIZED FOR El ENCY PICKUP YES El NO TELEPHONE RELATIONSHIP (42) AUTHORlaiD FOR EIAIRODCYNacuP ❑ YES O NO (43) If school personnel are unable to contact you incase of ithess or accident, may we have you• permission to call your doctor or emergency services (911) for transport to the hospital? RYES O NO Ye) PHYSICIAN PfCtE ERI.R:NEPMN.:?. TaVAS U1/4)gi*E-:MEM/WARMAN: (49) NAME CF CHILD (Mg ant Mildkrintiel) SCNOCI. ATTEIONG STUDENT NO. (GlAbsIG GRADE DATE OF BIRTH (50) NAME CF CHILD Ma( kg mdcUoMAINO SCHOOL ATTENCANG STUDENT NO. Copilot* GRADE DATE OF BIRTH (51) NAME OF CHILD (Ng kg middleIna* WHOM ATTENDING STUDENT no. (OpboeMI) GRADE DATE CF BIRTH (52) NAME OF CHILD gas rus4 marl* nano SCHOOL ATTENDING STUDENT 10. (0P9orta0 GRADE DATE OF BIRTH Have you filled out an application for free and reduced lunch? 0 YES o NO (Application is Provided with this Thm) .:0THER:Mill:DREN)N:RALIN CH:POU (40) MEDCAL INFORMATION (bat stud sits Mnestea. behavior, heath issues. oferpin fir:Wing entries, bats. recedes of amphibiamj inedIaionr, crolhorphyskolkrolakoN PARENT/GUARDIAN SIGNATURE I verify that the information given is true and accurate to the best of my knowledge. '''''' ''' dani ' • • • ••• ...,....... Psysot4 sk**: :(4.3?WitekkaktAtbel:l.•:::•: 6-Cr TE lte3P0R4413.f.n.TPFPiffiliSM:: :itteittf!!!!FtittriNt: 641*:::::*i:•• • • ... :Wide page 2 of EFTA01710233 4.0- tOOL Dis,>, THE SCHOOL DISTRICT OF PALM tStACH CAJUN I Y (aUhtli.i) New and Returning Student Registration 09 73 NEW STUDENTS: Complete all non-shaded areas on both sides of the form. coliIzerdoi RETURNING SUDENTS: Review both sides. If the pre-printd information is Incorrect, correct the information by carefully and lightly -, crossing out theT incorrect iriormation and wilting the correct information above II. 068C DIST:2451 TCHR:ROLAND TNBR:047 STOT: CRS:2103030 SEC:05 BLDG:01 RM:131 08/16/01 (3) STUDENTS LEGAL NAME (16.4 KraL inklello) (4) ALSO KNOWN AS (5) LOCAL ADDRESS (Aeon na et its& non) (s4 on) kW (stain) (Op cede) LOXAHATCHEE FL 33470 (8) MAILING ADDRESS (Asia na A snot ninny (ept (to) (ay) (stele) (*.code) CS SOCIAL SC-CURRY NO. (cotionen (8) HOME TELEPHONE NO. (TO SEX F (10) RACESTHMC CMOS H 0 I-American IndiarJAlaslcan Native O 6-Black Non-Hispanic OW-Hispanic ait A-AsIan/Pacific Island* O W-White, Non-Hispanic O M-Multiraclal (11) DATE OF BIRTH (1460VO/Y7110 (12) PLA DADE COUNTY FL US FLORIDA (13) RESIDENT STATUS 3 O 0. Foreign Exchange Student O 1. Out-of-county Resident O 2. Out-of-state Resident O 3. In-county Resident (II) USA ENTRY OATS faartronyyr (15) FEDERAL IMPACT SURVEY YES NO O fn. A. The student resides on federal property. • 0 B. The student resides in low rent housing. O Iii C. The parent is employed on federal property located in P.B. County. C e D. The parent is employed on low rent housing Vacated In P.B. County. C71 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: O Air Face O Army • Coast Guard O Marines O National Guard O Navy (16) PRESCHOOL ENROLLMENT IIFORMAT)ON Place an X by each program attended. Also, indicate with an asterisk (*) the program your child was in the longest. O N. Non-subsidized Child Care O M. Migrant Pre-K O D. Pre-K Disabilities • H. Headstan O I. Pre-K Early Intervention O C. Chapter 1 O S. Subsidized Child Care • a Other (17) IS THE STUDENT A SPIGLE PARENT/ NO O YES ONO (10) CURRENT GRADE LEVEL 08 _ .. ,... . . .. . ..:1-1WISFER:INFOlkMATION'; teez........ i f (19) NAME OF SCHOCL TRANSFERRING FROM (20) CITY OR LOCATION (21) LAST antispareCE OATS (22) LAST GRADE LEVEL I (23) LAST PUBLIC SCHOOL ATTENDED RI PALM BEACH COWRY DATE ATTENDED IN PE (24) C. ,HEALTH SCREENING INFORMATION FREE OR REDUCED . _ (25) Students vvil receive non-invasive health screenings pursuant to Ronda Statute 381.0056(7)(d). Non-Invasive These be individually PRICE LUNCH v.:: Rscreenings may Include vision, hearing, scoliosis, height, and weight. tests may given 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 to not screen" here: Or) Have you bled out an application or free and (This exemption will cover al types of screenings) (76) I give permission for my child to participate in the sodium fluoride program to prevent tooth decay. O YES C NO (permission is veNd through 6th grade) YES reduced lunch? 0 YES O NO (Application is provided with this form) fitgtaXIMIA :ttAargitA01149 1:fan. ..::.- A, . -•.v., (25) HOME LANGUAGE SURVEY YES NO 0 O 1. Is a language other than English used in the home? If YES, what language? petet LE it ti) O 2. Does the student have a first language other than English? if YES, what language? Spam( c. ii O 6 3. Does the student most frequently speak a language other than English? If YES, what language? (2$) 4. What language is spoken in the home by the parent or ggardian? cpa n Is VS- g n51(1,11r? ail tS In prat 5. What language is the student's first language? rag What is the date of entry into ESOL program? pt) amen UVES wmt (Mann MAP ❑an O Mother O Father ltApoth Parents O Other (33) DISCLOSURES FOR ENTRY INTO PSC SCHOOL DISTRICT YES O HI , 1. Has the student ever been expelled from school? O92. Has the student ever had an arrest resulting in a charge? O 3. Has the student ever had any juvenile justice actions? (31) CUSTODY STATUS OF STUDENT (chook am) O mother • 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 ari.NO If YES, provide the school with a copy of the court order. PBSD 0636 (REV. 5/29/2001) page 1 of 2 EFTA01710234 •..ten, onenar.• ••••••••••• 11 nine on. I tttttt •••• %I 9.06.0...1‘ I EL•0111%.* IIN"I 1%/111 (36) FATHER CR LEGA GUARDIAN .•. mi:Wto in:' bael) PU: Y on MOTHER OR LEGAL GUARDIAN (lis4 man, inatite. Last) PU: Y allinalliwter) partment number) CITY STATE ZIP CODE LOXAHATCHEE FL 33470 CITY STATE ZIP CODE LOXAHATCHEE FL 33470 OCCUPATION C I ze-4- a_Atill ° 0 n butfor OCCUPATION HA( Qs rti I LS b PLACED PLACE OF EMPLOYMENT HOME TELevr1UNE I CELUPAGER NUMBER HOME PHO CELJPAGER NUMBER EMAIL ADDRESS (00.10.0 EWE. ADDRESS (optional) EMERGENCY REACTANNO. -SAFErt. INFORMATION : . . •I'e' ?: Person(s) other than parent authorized to pick up student (313) PASSWORD (3mit 10 characters) (39) NAME gab middle Mine. 1.140 (41) NAME rest meidl• butt ADDRESS (01064 number, street nairm. Opelfillell number) ADDRESS (shed number, street norm% apartmalt number) CITY STATE ZIP COLE CITY STATE DP CODE TELEPHONE RELATIONSHIP (40) AUTNOREED FOR EMERGENCY PICKUP 0 YES 0 NO TELEPHONE RELATIONSHIP (42) AUTHORIZED FOR EMERGENCY PCIWP • YES 0 NO (C) If school personnel are unable to contact you In case of illness or accident, may we have your permission to call your doctor or emergency lervices (91 ) for transport to the hospital? teYES 0 NO (44) MED.CAL MIFORMATION Oaf Midgets alt.tial, behavior, bath issues, eagle* medicebons. en ether physkal breations) (45) FAMILY PHYSICIAN (46) PHYSSOAN PHONE (48) Does your child currently have health insurance? IX YES 0 NO If Y S. indicate: (47) HOSPITAL PREFERENCE icaid 0 Private Healthy Kidslied Care 0 Interested in receiving information AtEat4.49.a.010000,0.01 DE .100.44101DtAD,‘D,WW3 - (49) NAME OF CHILD rot mMIM WU SCHOOL ATTENDING STUDENT NO. Mptcmd) GRADE DATE OF BIRTH (93) NAME OF CHILD Oat Map; kit) SCHOOL ATTENDNO STUDENT NO. Mauna° GRADE DATE OF &RN (51) NAVE CO CHILD fist middle. les0 SCHOOL ATTENDING STUDENT NO. (upfront.° GRADE DATE OF GIRTH (52) NAME CF CHILD rust middle. IMO SCHOC4. ATTENDING STUDENT NO. (optional) GRADE DATE OF BIRTH PARENT/GUARDIAN SIGNATURE verify that the information given is true and accurate to the best of my knowledge. IFARV,:figigEWSAten sr ols COB US 56)ENTRY CD. E01 (57)ENTRY DATE 08/14/01 MGM 06 (59)C/4- 01 (CO) TEACHER NO. (t1)REASSIGN CODE (62)TRMISPORTATION 0 P8C Bus # 0 Peke Tree 031174R711VERF. 1 2 3 459(54) INS A • ParenVStudent Tray. 0 Walk II Bee 6 7 8 9 T BZ (65) OFtNINNTATION CHEMIST (0NG sed Me ..hen Re4886) 0 Immunizations (date) 0 Birth Records Verif. (de e) 0 Soc. Sec. No. (date) 0 Physical Exams (date) (65)LIATA ENTRY DOWLETED BY DATE PBSD 0536 (REV. W6/2001529/2001) page 2 of 2 EFTA01710235 SI14-33-H1R3 HEALTH INFORMATION 06/12/00 12.32.34 STUDENT ID LEGAL NAME: LAS CURRENT SCHOOL MEDICAL REASON IMMUNIZATION: 1 VACCINE STATUS: DTP: DT: TD: POLIO: MMR: MEASLES: MUMPS: RUBELLA: HIB: HEPATITIS B: STU ID FIRST E 04 HR SECT EFFECTIVE DATE EFFECTIVE DATE TB TEST RESULT S 408 TATUS A SEX H MIDDLE APP DATE ENTERED 08 30 / BIRTHDATE EXPIRATION DATE / / HEALTH EXAMINATION Y SCREENING FOR HEARING PROBLEMS: Y I MEDICAL ALERT PH: ( SCREENING FOR VISION PROBLEMS Y CONTACT EFTA01710236 igtecinAlt or nes H3S FLORIDA CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) (11 (Florida Statutes 232.032) FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE DATE OF BIRTH SS FKPART A OF THIS FORM IS USED ONLY IF THE CHILD HAS RECEIVED ALL REOUIRED IMMUNIZATIONS LISTED BELOW. IF NOT, SEE REVERSE SIDE. .5 DOSES REQUIRED (K) *;.>-• • IF, THE FOURTH PRIMARY DOSE OF DTP IS ADMINISTERED'ON OR'AFTER'THEEOCIATH:BIRTHDAY, A FIFTH.DOSE IS NOT REQUIRED. 5:DT (PEDIATPJC) VACCINE IS ACCEPTABLE IF PERTUSSIS VACCINE IS MEDICALLY CONTRAINDICATED. (COMPLETE PART C FOR PERTUSSE CONTRAINDICATION.) (B') : . i:eldc(AEOLT) VACCINE (A SERIES OF 3 DOSES) IS ACCEPTABLE AND.RECOMMENDED FOR CHILDREN 7 YEARS OF AGE OR OLDER. (C') PARENT OR GUARDIAN 4 BUSES REQUIRED lin rt IFTHE THIRD PRIMARY DOSE OF OPV IS ADMINISTERED . ON OR AFTER THE FOURTH BIRTHDAY, A FOURTH DOSE IS NOT REQUIRED. , -WV IS AN ACCEPTABLE ALTERNATIVE F OPV NOT-INoICATEEI: . • • • POLIO VACCINE S WITTED FROM THE REGUIREDJMMUNIZATIONB0FCHILDREN 18•YEARS OF AGE OR OLCER. CMEASLES. MUMPS. AND RUBELLA - 2 DOSES_MOMBED RIB MEASLES 1 DOSE REQUIRED FOR MEASLES RUBELLA MMR COMBINED — 1st DOSE AT 12 MONTHS OF AGE CR OLDER (REQUMMEPIDED AT 15 MONTHS) (P) 2nd DOSE REQUIRED PRIOR TO KINDERGARTEN ENTRANCE (VALID IF GIVEN AT LEAST 30 DAYS AFTER 1st DOSE) .7911- MEASLES SINGLE — 1st DOSE AT 12 MONTHS OF AGE OR'OLDER.'IRECOMMENDED AT 1.51MoNTHB); (G."•} 2nd DOSE REWIRED PRIOR TO KINDERGAMENIENTRANCE " (VALID IF GIVEN AT LEAST 30 DAYS AFTER 1st DOSE) MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER (H') • RUBELLA SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER (I') K:r4$.): i'APtisCFRLATE DOSES AND DATES INCLUDING BIRTHDATE MUST BE ENTERED, AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN OR AUTHORIZED ;AND:DATED IN ORDER FOR THE CHILD TO ATTEND SCHOOL 6e:st-i• r SEWED .THE RECORDS AVAILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED CHILD HAS BE Rip TETANUS, PERTUSSIS, POLIO, MEASLES, MUMPS, AND RUBELLA AS REQUIRE PHYSICIAN CR CLINIC NAME (Fl FASF PRINT) ?cE"AUTOMATED STUDENT DATA BASE CODES IMMUNIZATION STATUS CODE / VACCINATION CODE EFTA01710237 111 Students Full Name Addre Name of Parent or Guardian *Mkt t (Jr rIS11111.0% . DEPARTMENT OF HEALTH & REHABILITATIVE SERVICES EALTH EXAMINATIONS Date Phone Race LiifM r Sek—e— Birliadate A. HEALTH EXAMINATION Normal-N; Abnormal -A 1. Appearance N A 2. Ski/Nose a Head/Scalp 4. Eyes 5. Visual Acuity (R 8 L) 6. Ears 7. Auditory Acuity (R 8 L) 8. Nose / Throat 9. Mouth. Teeth and Gums 10. Chest / Lungs 11. Heart 12. Abdomen 13. Genitals and Anus 14. Muscuto-Skeletal 15. Neurological 16. Alertness 17. Emotional / Mental/ Behavtr Prob.I 18. Handicap. physical/ other (Specify) 19 Activity Restrictions (Specify) 20. Abuse, substance/ physical / emotional 21. Nutrition 22. Other COMMENT: Abnormal Findings, by number B. HEALTH HISTORY Serious illnesses injuries: explain, (attach riarrate's if additional space needed) C. LABORATORY (as indicated) al HemogistinrHernalocrit Stool (0 8 PI Tuberculin test: Lead Sickle Cell NAME: TITLE: ADDRESS: (Please Print) 12S-I1 Form 3040, Mar 91 (0bsotetcs previous (Stock Number: 5744.0C0.3040.2) EFTA01710238 ID: SCHOOL: DISTRICT: 50-PALM BEACH Your 2004 Reading Results Your Reading score Is on grade leveL You answered many of the questions on the FCAT comoctly. Tu califoacion de Lecture esta al niveL Respondste a rrouthas de las pregunlas del FCAT correctamento. NOILekti ou nan nivo Has la. Ou repair: eve nan kesyon FCAT yokonlitteman. 5 4 2 Spring 2004 Florida Comprehensive Assessment Test (FCAT) SSS Reading Student and Parent Report Grade 08 High Low Your 2004 Reading Content Scores Content Areas Points Earned points po *ye Percent Compared to other students IMININIEINNIONI Words/Phrases Main Idea/Purpose Comparisons ReferenCe/Research LeLow, /ADM iddle, li.HIgh 3000 2500 2000 0 O u.LL1500 1000 500 0 Your Reading FCAT Score History Year Grade Tested Achievement Level 2001 I 2002 2003 2004 'These scores show your achievement on the day you were tested. If you were to take this same test again, it is likely that your 2004 FCAT Reading score would be between 1815 and 1967. 3 4 5 6 7 Grade Tested 10 ■ Your Score 0 On Grade Level (Achievement levels 3 and Wove aro considered on isr above grade levet) La labia de b derechs muestra los 'Welts 48 rendirriento del FCAT y bs rangos do carder-16n del FCAT porn cads nlve'. El nivel do renSirniento 3 represent° et 0-abaio"al Myer. Antes de 2002. a los ostudentes soles otorgaba ens calficackfin quo segula una escalade Iros Motes. Tablo Id adwat la monk° Nivo Rannman nan FCAT a ak Nochol Not FCAT a pou cask NNo. Nivo rannmen 3 reprezente travay 'nen Miro leas' Ia. Anvan 2002, yo to reptile ycn nechel not ki gat Ma chit laden pou ekkr yo. Chan of FCAT Achievement Levels and FCAT Scores Reading grade Level 1 Level 2 41iiiikeii; , Level{ Level 5 3 864045 1046-1197 illiiklitlie: 1489-1865 1866-2514 4 2954314 1315-1455 4450017310: 1690-1964 1965-2638 5 474-1341 13424509 ?j910;40: 1762-2056 20592713 6 539-1449 1450-1621 Ft604:10SC 1860-2125 2126-2758 7 671-1541 1542-1714 4 i$€ 1945-2180 2181-2767 a amuses iese-1881 lisg2447. ;2073-2281 2282.2790 9 772-1771 1772.1971 Itgt2k2A4.3,:; 2146-2297 2296-2943 10 8444851 1852.2067 ,iaillIficil-f !W,. 2219-2310 2311-3008 On grado4evel Prior to 2002, a th.030-dg. scale score was reported for students Reading Content —Content soores gNe more specific Information about the skills on the FCAT. Grade level expectations for students include: Callficacionos do contenido do lecture Las calificaciwes do contonide proporcionan Information 0141.5 especifica sotto las habilidedes en el FCAT. Las expectafivas al nNel del grado pars nos Not Kontnl pou Lektl Not pou koninl yo bay enfOmasyon ki pi ograk sou kcnperans el& la nan FCAT a. Men sa yo Mann do eley la dapre nivo klas la: a Words/Phrases — uses skila to determine word estudiantes Lncluyen: moaning, includng word parts and relationships • hie/Prez —Mize apthici pco doh:graben styllikasyon between words. • Palabrastrases —usa la habilidad pant determiner moyo, sa Ns di disk pall nan mo yo epi retasyon Id • Main Idea/Purpose — determines a slated or et signIdcado de una palebra. Incluyondo Lis panes genyen ant moyo. implied essential message, details. author's do patebras y las rolaciones entre patabras. • Ida PrenslpaUObjektlf — doteminen yon mesa) purpose, or plot. • Idea principal/Proposito —determine un mensal° esansyel kl degree oswa sljere, bay delay sou • Comparisons — knows smllar and different. cause esencial exprow o cmplicito, dinettes del propose* cteektif °Sera plan °to a. and died, and contrast. del outer 0 el rugumento. • Konparezon — konnen menm ak &bran, Wiz ak ate, • Reference/Research — uses information from a . Compareciones — conoce similar y dderente. Cause epi kontras. variety of sources to reach conclusions. y °facto y contrasto. .Referans/Rechech — blew enfernasyon Id soli nen • Referenciannvestigacien — usa is informacidn do rye sous pou dedwi konklizyon. Data Run Date: 0570312004 una variodad deMentes pare Heger a conclusions. NT=Nist Tested. NR•No4 Reported, NF'Not Found EFTA01710239 Spring 2004 Florida Comprehensive Assessment Test (FCAT) SSS Mathematics Student and Parent Report Grade 08 NAME: ID: SCHOOL: 1691-CRESTWOOD MIDDLE DISTRICT: 50-PALM BEACH Your 2004 Mathematics Content Scores 5 4 3 44 1 High Low Content Areas Number Sense Measurement Geometry Algebraic Thinking Data Analysis PointS Earned Pods Possitto Percent Compared to other students Your Mathematics FCAT Score History Year Grade Tested Achievement Level 2001 2002 2003 2004 'These scores show your achievement on the day you were tested. If you were to take this same test again, it is likely that your 2004 FCAT Mathematics scae would be between 1776 and 1862. 3000 2b00 2C00- 0 0 co 1500-E- LL 1000 500 7 10 Grade Tostod ■ Your Score i] On Grade Level (Acteevemem Øb 3 ond above are considered on or above grade level.) La tabla de la deecha meets bs niveles de renditriento del FCAT y los ranges de calificacta del FCAT pare cede robed. El nivel do renclimiento 3 representa el kabaleal elver. Antes de 2002, a los estudentes se lea otorgaba Lena ca.:Lac:4n qua segula ma escalade tres dines. Table ki adwat la montre film Rannman nan FCAT a ak Nedhit Nett FCAT a you chak Nivo. Nivo rannrnan 3 repramme Um•ay 'flan Mine Hass la. Anvan 2002, yo te regale yon noshed net ki gen hva chit laden pau elev yo. Chad of FCAT Achievement Levels and FCATScores Mathematics G