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MOO RBuIeN Answers I S bIS •• OM oak Oda - - W u boa • to •WOO i• OP OOP Po. Admit Ate. Math HI 34 zcrn, CPY 14.4 •••• SATI and usa M. 1M It Van led niPM=IMIfl allfliall•d= ii al 200 HO 3.* 410 am -del di*. 4. wY ••.e.. fear •• omen ronet* 1.4C4"..4'unt, Oh* N. ...Owl Nis IS — ••••••• d.. ••• Vale l•I •• ••••kl ••••••I woody. •••••61 id I MS Improve Slu'ilsYour ::=.1=1":::: le amain I?. fl• led sis. • flreddlebd • Send% dad aY 'SOW k • sated* roe tr..,76.tr........"'"“"" n" loon.k* Ms (gegen' SS.* war • •••••••••••• •••••••• the arida dand Ida NS I% is.* dd.. lindid 'led* i• w. Dopers ••••• wows areempese Oen. wee • ea •••••••••• now ••• sae.. • we Mira II •••• we sand Mena •• MOO SNOOP •••• IO/ •••••• sena 0•1•••••••••• Se. Fe r. MON a •.M n.. Vorway .Y—•w..^•.ra••••1 PO one • ••••••••• l•••• see 'roma anal an en pm. Fel- "nos geese •••••• User. Ma saa •••••••• • la. Pia• Mr Mina. •••••••••••• ••• • =Mw. =ed geniis's MSG romaown MKS. Ole •••••. • lOpOWn rad a•Ope• i. wee. • P• Wenn. 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IS. r •••• •••• loons. •• eons", ••• • ad, *mato. •••• • •• • •• woo •• •••• often. •••••••••••• ••• • •••• on.... ••••••••••••••••••• •••••••• ••••• ••••••• MM.. • ••• en. • • •••• ••• •••• ••••• • ▪ ••••• ewe. ma lows twee sow •••••• wools rune, •• elf., ••••• Owe •••••••• Po. Do. ••• ••• vs. • ••• cooeuete•••• ogee •• ISIS • ••• mesa saes wa maim m wa EFTA01710352 Students Full Name Address Name of Parent or juardian Select A. HEALTH EXAMINATION He lit STUDENT HEALTH EXAMINATIONS Date ,/e. /Is Phone Aoe Race Sex Dirhdate Blood Pre-sure (I) Normal-It Abnormal =A 1. Appearance 2. Skin/Nose 2 Head/Scalo Nty ( COMMENT: Abnormal Findings, by number 4 Eyes E. Visual Acuity IR 8 L) E Ears i Auditory Acuity IR 8 LI E Nose / Throat 9. Mouth. Teeth and Gums 10. Clital / Lungs 11 Heart 12. Abdomen 13. Borstals and Anus 14 Musculo-Skeletal 15. NetstilOgiCal 16 Alertness 17. Emotional Mental/ Behavior Rub) 18 Handicap. physical/ other (Speedy) 19. Activity Restrictions ISPecifyl 20. Abuse. substance/ physical / emotional 21. Nutrition 22 Other B. HEALTH HISTORY tsercvs I blesses triunes: exerainl /1/ (attach narrative if additional space needed) C. LABORATORY (as indicated) HemoglebintHematoent Stool 10 & -uberculin te8 Load Sickle Cell NAME: ADDRESS: (Please Print) Authorized Signature ate 1 DM 3040. 1046 (Rap-aces HRS-H Form 3010 wh c.h may be us•O) (Sto4.4 N4mOar. 5744.003.3040-2) EFTA01710353 NARRATIVE RECORD Notations by educators, nurses and other designated personnel should be dated and signed. Narration section should include information concerning referrals, follow-up and special consideration to be given students in classroom as a result of screening, as well as teachers' observations, parent conferences, home visitations and services rendered. Educators need only record information concerning teacher observation and educational decisions made for stucents in the classroom as a result of screening and other health information. DATE aitLacai Ail1/4_, ‘---Le attic_ c HRS-H Form 3041, MAY 80 (3) EFTA01710354 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES CUMULATIVE SCHOOL HEALTH RECORD (This form is not intended for physician's use) Special Health Problems - See Narrative Name _ Race L) Sex F School Address, Father's Name Date of Birth Immunization Special Immunization Place Certification: Yes Prcgrams Mother's Name Fl Birth Recorded: of Birth CO (Sri- ?Dial BPGehr Yes El— No O Ear No O A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES Screening and Assessment Grades K-3 K 1 2 3 Screening Date 13. ii, 0 ft Outcome •E a) C a CD CD A O 33 .. CD 16 ZS cc Outcome a) C *E m ? 8 8i 8 G sio=utcome Screening Date 7.! 8 so cc Outcome Vision Hearing Height, Weight & Graphing Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Other Other Screening and Assessment Grades 4-8 4 5 6 7 8 ci, c 'E CD in e 0 o cn o t 0 II cc IOutcome ci) - C 0•-• 0 to Es 0 o co Ts t 0 1S CC IOutcome ai c •E a) e to I' 0 o cn To t 0 115 cc Outcome ci, C '2 m 0 to e. 0 m TO 't 0 15 , CC i Outcome Screening Date 13' ZI:, • CC 4. g o 5 0 Vision Hearing Height, Weight & Graphing .., Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Scoliosis Other Other _ , . _._ EFTA01710355 • atuan Lae % 3"`t-re, , each, jr hipzienrlifie ,avaderenview AgjAri.XaytelaZ atria Aiapi %%Banos Blurt ofAgrAWAV aledetatafeilelata4 Atredhteied Awid ',re/meads EFTA01710356 V., 09 FLORIDA CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) OF MALIII PAO 0.1 flutida Statutes 232.032) FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE RATE OF R'RTH CHILD'S NAME MO DA YR DETOP: PART A OF THIS FORM IS USED ONLY IF THE CHILD HAS MERE() ALL REQUIRED INMUNIZATIOAS LISTED BELOW. IF NOT. SEE REVERSE SIDE. CTP - 5 DOSES REQUIRED • PARENT OR GUARDIAN IF THE FOURTH PR MARY DOSE OF CTP IS ADMINISTERED ON OR AFTER THE FOURTH BIRTHDAY, A FIFTH DOSE IS NOT REQUIRED. CT (PEDIATRIC) VACCINE IS ACCEPTABLE IF PERTUSSIS VACCINE IS MEDICALLY CENTRAINDICATEO (COMPLETE PART C FOR PERTUSSIS CONTRAINDICATION.) ii (ADULT) VACCINE (A SERIES OF 3 DOSES) IS ACCEPTABLE AND RECOMMENDED FOR CHILDREN 7 YEARS OF AGE OR OLDER. POLIO (TCPV) - 4 DOSES REQUIRED MO DA YR MO DA YR MO OA YR MO DA YR IF THE THIRD ETIIMARY DOSE OF TO'V S ADMINISTERED ON OR AFTER THE FOURTH BIRTHDAY, A FOURTH DOSE IS NOT REQUIRED. FOLD VACCINE IS OMITTED FROM THE REQUIRED MMUNIZATIONS OF CHILDREN 18 YEARS OF AGE OR OLDER MEASLES. MUMPS. AND RUBELLA - I DOSE REQUIRED MMP COMBINED - 1 DOSE AT 12 MONTHS OF AGE OR OLDER AND IN 1968 OR LATER (FECOMMENDED AT 15 MONTHS) -OR- MEASLES SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER AND IN 1968 OR LATER (RECOMMENDED AT 15 MONTHS MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLO?(/1, RUBELLA SINGLE - 1 DOSE AT 12 MONTHS OF AGE OR OLDER THE CHILDREN'. ALL AI-VHOPHIVE Dirt TNGL DING BIRTHIDATE MUST BE ENTERED. AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN OR AUTHORIZED PERSON ANA FOR THE CHILD TO ATTEND SCHOOL ist D I HAVE REV AVAILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED CHILD HAS BEEN ADEQUATELY IMMUNIZED AGAINST DIPHTH R _ APOLIO. MEASLES, MUMPS. AND RUBELLA AS REQUIRED BY FLORIDA LAW FOR SCHOOL ATTENDANCE. SUITE 201 ROYAL PALM BEACH, FL 33411 PHONE Q,0 9 a PHYSICIAN OR CLINIC NAME 'PLEASE PRINT) R AUTHIRIZED NATURE DATE EFTA01710357 N JSe STATE OF FLORIDA DEPARTMENT OF HEALTH If REHABILITATIVE SERVICES STUDENT HEALTH EXAMINATIONS rh A 7- ao Lj sex zadi Scalp /4 Eyes 5. Visua Acuity I I! t4-s 1--- G Ears 7. luditor 8. Ncse / Throat ettLatty & 9. Mouth. Teeth and Gums 10. Chest / Lungs II. Heart 12 Abdomen 13. Genitals and Alus 14. Muoculo SkcIval 15. Neurological 16. Alertness 17 Emotional / Mental/ Behavior Prob.) 18. Handicap, physical/ cthec (Specify) 19. Activity Rostricaans ISOM( r) 20. Abuse. substance physical / emcoonal 21. Nutrition 22. Other B. HEALTH HISTORY Serious Illnesses Injules explain) (attach rarrative if adclutianal space needed) C. LABORATORY Hemoak>bin/Flematccse 1 I-17: I:2 DitIthrei -... ctri.,L.O5.; NAMI: TITLE ADD (PiirsiiA'0t(m) PALM BEACH BLVD. SUITE 201 ROYAL PALM sena'. FL 33411 F. Obsolete. previous 'dittos.) (Stock Nunber: 5744-000-3040-2) Stool (O PI Sickle Cell 30.9 LTuberculin Date EFTA01710358 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES CUMULATIVE SCHOOL HEALTH RECORD (This form is not intended for physician's use) Name Address Race Lc) Sex F School Father's Name Mother's Name Special Health Problems • See Narrative__ fir. Date of Birth Al /. / ■ Place of Birth (4 es4 -Palo .3eGeh F1 Birth Recorded. El Yes El— No 0 Immunization Certification: Yes Er No 0 Special Immunization Programs A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES Screening and Assessment Grades K-3 K 1 2 3 c cn c O m ,,, 00 Z.5 (I) Referral Outcome Screening Date Referral Outcome Screening Date IL3 IS 0 tr Outcome Screening Date IReferral Outcome Vision Hearing Height, Weight & Graphing Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Other Other Screening and Assessment c Grades 4-8 4 5 6 7 8 Icrooning Date Referral 'Outcome Icreening Date 4.1. r, O CD EOO, c c co Et, 02 To '- €3) 0 cr Outcome Screening Date Referral Outcome a "E 0 s a t.) u) To I:, IL Outcome Vision Hearing Height, Weight & Graphing Nutrition Dental Health Mental Health Communicable Disease Records Review Physical Assessment Scoliosis Other Other L EFTA01710359 Students Full Name Address cTI inENT HEALTH EXAMINATIONS Date 7/‘/T3 Nans of P e 1 or d s Phone Age Race Sex Girth ate A. HEALTH EXAMINATION Hear (/) Normal-N. Abnormal -A comment I: Aoriormai rindings, Dy numoer Pressure 1 Appearance 2 SiuniNose 3 Head/Scalp 4 Eyes 5. Visual Acuity IF & LI 6. Ears 7 Auditory Acuity (R & 8 Nose / Throat 9 Mount Teeth and Gums 10. Chest r Lunos 11. Heart 12 Abdomen 13. Genitals and Anus 14. Mu5W10•Skelelal 15. Neurological 16. Alertness 17. Emotional Mental/ Behavior Prob1 18 NandCall,DblyS/cal/ other ISPeCI1Y) 19. Actsfity Restrictions iSpeciry) 20. Abuse. substance/ Physical / emotional 21. Nutrition 22. Other B. HEALTH HISTORY sv,..us (Messes Injuries: explain) (attach narrative d additional space needed) C. LABORATORY (as indicated) t-rnoglcbin/Hemafocrit Stool (O & Tuberculin test: LP 1C1 Sickle Cell d NAME: TITLE: ADDRESS: (Please Print) 1 7A /7 5 OH 3040.10/16 (Rapacas HRS-ef Form 3040 when may 0* oseie) (Stock Nwnbsr 57444430 JU0 2) Authorized Signature Date EFTA01710360 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES CUMULATIVE SCHOOL HEALTH RECORD (This form is not intended for physician's use) Name. Adore Special Health Problems - See Narrative Race th Sex F School eatewnese 77(.1 451 Father's Name Mother's Narre MalLDate of Birth Place of Birth CO e54 Fl Birth Recorded: Yes 9 No ❑ Immunization Certification: Yes a' No D Special Immunization Programs A NARRATIVE NOTE IS REQUIRED FOR REFERRAL AND OUTCOME ENTRIES Screening and Assessment Grades K-3 K I 2 3 Screening Date To 0 t:i CC Outcome at .......— Screening Date 7! IS co cc Outcome Screening Date -5 O 71) cc r- Outcome Screening Date 1.a. To 0 cc Outcome Vision Hearing Height, Weight & Graphing Nutrition Dental Health Mental Health Ccmmunicable Disease Records Review Physical Assessment Other Other 4 5 6 7 8 Screening and Assessment Grades a)c E e O tor — co Outcome 3creening Date 45 Outcome 3creening Date — B cr) c .E 0co to.— w Outcome a, c 'Ee— O a) E 8 4-8 e 0 O en TD cc CD en 0) O cc:: -0- cr '5 EFTA01710361 4•--"°-1°° AIN THE SCHOOL DISTRICT OF PALM BEACH COUNTY F 0 a 9-12 Academic 1,k--74O, Improvement Plan (AIP) Marking Period Monitoring Dates: First /D' Second / / Third / / Fourth / / $Y: 04 DC6: FISRT: FCAT: wAP: PRIM: ABS: MA 3 TH:RET: : READ: MATH: 4.0 . —FZ W—ZZ FIRIS —FL LEP: 504: Et READING D WRITING 0 MATHEMATIC orb 014extbook Assessments YED. [(CAT Diagnostic I Practice Tests Siagncstic Soltwae D Otter (see attached) O Palm Beach Wrtes O Portfolio 0 Performance Assessments ❑ FCAT DagnostdPract ce Tess O Diagnostic Software ❑ Other (see *Midler!) ❑ Textbook Assessments 0 Pored 0 0 Performance Assessment ❑ FCAT Diagnostic/Practice Tests 0 Diagnostic Schware 0 Other (see attached) ad)Textbook Assessments El Portioiio Performance Assessments FCAT Dagrostc/Prachce Tests O Diagnostic Software 0 Other (see attached) ❑ Phonemic Awareness Milietter Recognition WV-Phonies: Sound /Symbol Ccrrespondence Decoding/Encoding LW Meaning 0 Structure Visual (Phonics) c),Flue Prevent Words 0 Rafe ving cabulary art Comprehension Types of Writing O Word/Sentence wiring O Paragraph Writng O Composition Writing Awareness /Application of FCAT Writing Rubric El FOCUS ❑ Support El Organization 0 Conventions Compositions ❑ Narrative ❑ Expository ❑ Persuasive Number Sense, Concepts andNU Operations ❑ Measurement ❑ Georretry ❑ Al)ebraic Thrikirg O Data Analysis and ProbabiTityNa O Readhg n Content Area Specific Concepts NzoThe Nature of Matter O Energy O Force and Motion ❑ Processes that Shape the Earth ❑ Earth and Space Processes of Lie How Living Things Intend with Mel Environment ❑ The Nature of Science concepts Reading it Content Area Specific Concepts N O a N Fed gIwing ng Schad Day After/Before School /Saturday instructional Artematives O Temporary Skill Groups O Cooperative Learning Groups Uridsd Readng/Nriling Groups Technology O Other (see attached) Assignment Alternative O Time O Quantity O Product Requirements p Child Study Referals rWInstmotional Reading Tutoring ❑ During School Day ID After/Before Schod I Saturday Instructional Alternatives O Temporary Skit Groups O Cooperative Learning Groups O Guided Reading/Writing Groups O Technology 0, Other (see attached) Assignment Alternative O Time ❑ Quantity O Product Requirements O child Study Referrals 0 Instructional Language Arts Tutoring Tutoring D During School Day 0 Outing Sd000l Day O After/Before School; Saturday AfterlB9torora ehcol / Saturday Instructional Alternatives Instruction itemativee ❑ Temperay Skip Groups ----ND. o cooperative Learning Groups ❑ Technology ID Other (see earned/ Assignment Alternative O Time ❑ Quantity El Product Requirements El Child Study Referrals ❑ Irstrudicnal Mathematics 0 Temporary Skil Groups Cooperative Learning Groups D Gutted ReacfinghWiting Groups O Technology O Other (see attached) Assignment Alternative Time U Quantity ❑ Produd Requirements O Child Study Referrals ❑ Instrudinnal Reaeing Student progress will be monitored throughout the school year, and student progress will be reflected on the report card. ❑ Suxessfttly Remediated ❑ Sumessfully Remediated ❑ Successf illy Rertoedated ❑ Successtufy Remediated 0 Requires New AID Next School 0 Requires New AIP Next School ❑ Requires New AIP Next Soled 0 Requires New AIP Next School Year Year Year Year ED Special Services! Placemert ❑ Special Services / Placement 0 Special Services / Placement 0 Special Services I Placement 0 Other (see enacted) 0 Other (see attached) 0 Other (see attached) ❑ Other (see attached) [1] Deficiencies due to non-attendance (refer to Attendance Specialist) Number of Days Absent ParentlGuardlan Contact Commitment/Contribution Check as that appiy D Monitor Attendance / 'rarefies EI Read with Child Every Night O Attend Parent Conferences O Attend Parent Curriculum/ Information Meetings O Check Homework O Reinforce Skills O Sign Daily/Weekly Notes GNATCR£ OF PARENT/ GUARDIAN DATE SIGNATLPE OF PEIS0 1697 (REV. 9/11/20021 ORIGINAL - Cumulative Folder COPY Teacher COPY • Parent/Guardian Pµ EFTA01710362 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW/RETURNING STUDENTS REGISTRATION BACK DI STUDENT S Wilt (CHECK OK) DOT) PATIENTS ❑ MOTHER ❑ FA HER . SHARED CUSPODT I OTHER (32) TRANSPORTED IV( Stpoiem .44 44 i ..... 4/I44 'SR.', by Wm. .1 •04. thew ...twill (III IS THERE A COURT ORDER BARRING EITHER PARENT FROM REITOViNS OI CONTACTING THE STUDENT DURING THE SCHCOL DAM n YES n NO IF YES, PLEASE PROVIDE THE SCHOOL WITH A COPY OF THE COURT ORI1PR I 4 FAT R/ AR IAN DOES FATHER HAVE CUSTODY> OYES 0 NO YES T ' r DIAN DOES MOTHER HAVE CUSTOOW 0 YES 0 NC YES IIIII I .mm. t A" ROYAL PALM BEACH FL 33411 illillill.MM bay,. kat ROYAL PALM BEACH FL 33411 .TA•4 E4:Ep OKTATTIlai 016.0A .04 RACE Of DIATOIAT011 RAM 0/ DMIODANT NOTTS •TOAI INMAN ATOM nom TRAI RASTAS ...ow OM A D RICHEST LEVEL OF EDUCATION COMMTED *PT ONAL) • "'"""` 'a B 0 w-2O, C 0 .0........ CITA011 KAI WWII t. TA TWOUATO 0 .......,../DamouTr TITOSICADCOLDTAI E 0 ",„„uw,`"""):;,17.„„ (37) D H CHEST LEVEL Or EDUCATION COMPETED (OPTIONA.1 0 ''" 0 30/00.. C 0 "4" SCCC4 ❑COADD I•O ❑ISTAOlt AID M ' "" """" ITTOIMICALKOLLIGO E 0 c".`,,,,,"'„ „A.,„," (39) LEGAL GUARDIAN OF Ala) COES LEGAL GUARDIAN NAVE CUSTODY? riEc 0 NC SA Inc As MA tilt C-IAO TAM Mtal -Tr VOMCASEICS lilt WTATE R. C6R em.L•ATRA Rya CA /MAO/ WC Ai Mutratt ream EMERGENCY HEALTH AND SAFETY INFORMATION PART I PERSONIS) OTHER THAN PARENT AUTHORIZED TO PICK UP STLOENT • I35) PASSWORD (LIMIT 10 CHARACTER& HA AATTTARIDO Ace 0021ACTI WNW 1411 NAME ADDRESS PHONE RELATIONSHIP Urn YES 0 NO (42) NAME ADDRESS PHONE RELATIONSHIP U(-4 YES 0 NO (43) NAME ADDRESS PHONE RELATIONSHIP U rl YES 0 NO (44) NAME ADDRESS PHONE RELATIONSHIP uI-1 YES 17 Dan (45) NAME ADDRESS PHONE RELATIONSHIP 0 El YES NO (46) PART II IF SCHOOL PERSONNEL ARE UNABLE TO CONTACT YOU II CASE OF ILLNESS OR ACCIDENT, MAT WE HAVE YOUR PERMISSION TO CALL YOLR UOC 7O14 OR EMERGENCY SERVICES Slit PON TRANSPORT 7O THE HOSPII44( 0 YES . NO (411) FAMAY DOCTOR 48) PHONE NUM3ER 491 HOSPITAL PREFERENCE (50) LIST YOUR CHAPS ILLNESSES. ALLERGIES OR OTHER PHTSICAL LIMITATIONS YOUR CHILDREN IN OTHER PALM BEACH COUNTY SCHOOLS! ISO NAME OF CH LD SCHOCL ATTENDING STUCENT NO (OPTIONAL) GRACE 8)1414 DATE (511 NAME OF CH40 ACTIOCI. ATTENDING STUCENT NO (OPTIONAL) GRACE SLATS DATE (53) NAME OF CHAO SCHOCL ATTENDING STUCENT NO (OPTIONAL) GRACE BIRTH DATE 154) NAME OF GILD SCHOOL ATTENDING STUCENT NO (OPTIONAL) GRACE BIRTH DATE (55) NAME OF CHID SCHOOL AT HEADING STUCENT NO. (OPTIONAL) GRACE SIREN DATE ISO) I VERIFY THAT THE INFORMATION GIVEN IS TRUE AND ACCURATE TO THE BEST CF MT KNOWLEDGE. SIGNATURE OF PARENT OR AGE( GjAROIAPT WTI FOR OFFICE USE ONLY: 19) SEMI WO 1091 ISA: Sliin(NT ARMOR (5§; stinitt I ANctiaci EN FA COPT US 0:l 0 ENTRY TOM E01 i TM 'MEV DATE 08/19/98 'hi) SAE tOif 106D (641 PARENT/GLARDIAN LANGUAGE EN tiEP) GRACE Ltd; Oa IFS) CALENDAR 01 .e7) TEACH! A NO. 1681 REASSIGNMENT CODE OA/ AGM OE•FSE OB4ES4k 0M/MAG RS) TRANSPORTATION 0 YES El Ng 0 1 2 3 4 t) 6 (70) VERIFICATION W BIRTH 1 I 3 4 5 6 7 8 9 T On RAS z 4 B t MI DOCUMENTATION (*CRUST CHECK AND DATE WHEN OCA EC IMMLNIZATIONS 0 OAT( EaDED) VERIFICATION Ol OP Kles RECORDS Doan SODIAk, SECURITY nNO DPT OTIAL g..4 OAT{ PHPSOCAL IIXMAS (73) DATA ENTRY COMPLETED BY: GATE' P650 0636 (REV. 3/58) EFTA01710363 THE SCHOOL DISTRICT OF STUDENT NUMBER: ily10OLO4sTh a\ X 5 PALM BEACH COUNTY NEW/RETURNING STUDENTS VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: NEW STUDENTS: Complete all non-shaded areas on both sides of form RETURNING STLOENTS: Please review both sdes for correctness of typed information. If the information printed is incorrect, please correct it by carefully and lightly crossing out the incorrect information and writing the correct information above it. ,..,,,,,„.„,,,,,, REGISTRATION TCHR ThER: 021STDT • 1STR : 1891 : .-.. 8/05/9 8Lar. TIN. P.17 ID STUDENT'S LEGAL •I ID ALSO KNOWN AS 21 LOCAL ADORE55 m MAI. ING AGGRESS KJRM r nuny ...my ir. e6 ir root 2ir, 15) 3TM/a S SOCIAL SECURITY NO. IIIPTI3NAJ IM In ME PHDNE No I(1141 UMAA SEX F ICI I I RAC AVGAlcAs onotAv OR ALASKAN NAIVE B viltoArtc-4mISPANK I 0 A PICIAINFIC,ISLANDER H HISPANIC I W „VON-HISPANIC " .4i$PANIC 0 MMIATiRAGIAt (9) OATS OF BIRTH ma/ow 1'O1 MALE Of B RTH WEST PA1.,01 BEACH R. U A„ FLORID(,,,,,,, OD RESIDENT I STATUS 0. FOREIGN EXCHANGE STUDENT I. OUT-01-COUITT RESIDENT I ll 2. OUT-CFI-STATE RESIDENT 3. IN-COUNTY RESILIENT II2) ENTRY DATE INTO USA FIJI FEDERAL OYES 0I IMPACT AID Mality ND A. THE STUDENT S NO _ B. THE STUDENT as I ywa C THE PARENT TES THE PARENT TES 0 E. THE PARENT IF YES, RESIDES ON RESIDES IN IS MAPIOTED IS EmPtOTEC IS IN THE IS THE PARENT AIR FORCE MERAL LOW RENT ON MOM ON LOW UNIFORMED ON ACEliE I ARMY PROPERTY. HOUSING. RENT SERVICES CUM PROPERTY LOCATED ROSSINI. (CENTER Of THE UNITED 0 TES I COAST cum IN PAINE REACH COUNTY IN PALM BEACH COMM STATES. I NO 0 ITARINIS I NATMNII GUARS 0 NAVY II4 AS THIS CHILD BEEN ENROLLED IS ANT PRESCHOOL? Err C. CHAPTER I 0 0 PRE-K DISABILITIES 0 E PRE-A EARLY INTERIENTION 0 (PLEASE PEACE A CHECAMARK I ye BY EACH PROGRAM ATTENDED. WITH AN ASTERI5A I *I Tilt PROGRAM TOUR CHILD WAS I H HEA)START I I M. MIGRANT PRE-H 0 I N. NON-SUBSIDIZED CH LO CARE ALSO. INDICATE IN THE MINGEST.I 0 OTHER S. SUBSIDIZED CHILD CARE 1I S) IS THE STUDENT A SINGLE PARENT? ill NC M.T. (IS) CURRENT GRADE LEVEL Oa TRANSFER INFORMATION: IIII NAME Of SCHOOL TRANSTERRIMG IRON lie) CII) OR LOCATION OW CATE Of EAST ATTENDANCE 120) GRADE LEvEl al/ LAST PUBIC SCHOOL ATTENDED IN PAM BEACH COUNTY (I2) CATE ATTENDED FREE OR REDUCED PRICE LUNCH AND HEALTH INFORMATION: 123) HAZE YOU FILLED OUT AN APPLICATION FOR FREE OR REOUCEO (APPLICATION IS PROVIDED WITH THIS REGISTRATION FORK* LUNCH* E TPL,iii NO UM HEALTH sCREENiiics, I GIVE PERMISSION FOR MY CHILD TO BE GIVEN MALIN THESE TESTS NAY BE GIVEN INDIMULIALLT OR IN GROUPS. SCREENINGS. E - 0 NO YES (214 SODIUM FLUORIDE. I GIVE PERMISSION FOR MY CRIED TO PARTICIPATE IN TO PREVENT DENTAL DECAY PERMISSION IS VALID THROUGH THE S)DIUM FLUORIDE PROGRAM 0 YES GRADE SIX. YES I NO NEW STUDENTS TO PALM BEACH COUNTY: HOME LANGUAGE SURVEY 1261 WHAT ANGUAGF It SPOKEN IA THE HOME ID THE PARENT or GUNMAN 071 WHAT LANCIIACE IS SPOKEN IN THE HOME 3Y THE STUDENT' 128) DATE OF ENTRY INTO THE ESOL PROMIAM 129) LANGUAGE SURiET I. IS A IINGUAGI OTHER THAN ENGLISH USE) IN THE HOME? 2. 00(5 THE sTUCENT HALE A EMT LANGUAGE OTHER THAN ENGLISH? 3. DUES THE slUEEN1 MOST FREQUENTLY SPEAK A LANGUAGE OTHER THAN ENGLISH? 0115 I YES Olf 5 I NO I NO 0 NO 130/ DISC OSURES IM liftl ten) int; this SCRUM. DISTRICT HAS THE STUDENT EVER T. KEEN EXPELLED FROM SCHOOL? 2. HAD AN ARTIST RESULTING IN A CHARGE? 3. HAD ANT JUVENILE JUSTICE ACTIONS? ,YES OTES ,TES I No I NO Ill NO EFTA01710364 D THE SCHOOL DISTRICT OF STUDENT NUMBER: lil 4HOOLD4 s7A [STR: ail s..;<.,,,-„,..4-./.;;,,,,, .,...,, Q .!../. 1891 TCHR: 08/05/99 1 PALM BEACH COUNTY NEW/RETURNING STUDENTS REGISTRATION TNBR:055STOT: 1001040 EEC t 04 BLDG 00 AMe F4 VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: NEW STUDENTS: Complete all non-shaced areas on both Sides of form RETURNiNG STUDENTS. Pease review both sides for correctness of typed information. If tho information printed s inco rect. please correct it l:N carefully and lightly crossing Out the nCOrrect information and writing the correct information above it. il FRE, SIUCENT S its:, NAM W ALSO KNOWN AS ... .3) LOCAL ADDRESS 14/ MAILING ADDRESS .C, -sa .0 MIMI Wilt APT IN PLAT! In COGS IS/ STUDENT'S SOCIAL SECURITY NO (OPTIONAL) 161 HOME PHONE RO. IT/ SEX F 0 „,,„ 18/ R CE 0 ASCR.CAN INDIAN 0 A ASIAN OR • w voon...,..wc 0 MALI 0 01 ALASKAN NAT« B N.DANC-tiSPANiC 0 H HISPANC 0 M muLTRAGIAL (9) DATE Of BIRTH „O., u n 110 PLACE OF BIRTH WEST PALM BEACH FL U%.„ FLORID(,„„„, II) RESIDENT STATUS 3 1 0. IOREIGN EXCHANGE STUDENT I nin-OF-pueirr RESIDENT I 2. OUT-01-STATE RESIDENT I 3 IM-rnuerf mrsnrra 1121 ENTRY CATE INTO EGA 13/ FEDERAL IIILLLIII IMPACT AID SURVEY V SWUM MS NU A. THE SU ES B. THE STUDENT S C. THE PARENT 1ES D. THE PARENT ' ICS NO E. THE PARENT IF TES RESIDES UN IWIRAL RESIDES RESIDES IN LOW RENT IS EMPLOYED ON FEDERAL IS EMPLOYED ON LOW IS IN TNT UMTOPME0 IS THE PARENT ON ACTIVE I AIR FORCE 0 ARMY PROPERTY. HOUSING. PROPERTY RENT MOUSING SEA/ICES OF DUTY? 0 COAST LOCATED LOCATE) THE .0111(0 0 TES GUARD IN PAIN BEACH COUNTY. IN PALM BEACH COUNTY. STATES. 0 NO 0 MARINES 0 NATIONAL GUARD I NAVY 1141 HAS IRIS CHILD BIEN ENROLLED IN ANT PRESCHOOL? tv... I C. CHAPTER I pU. Plit-1( DISABILITIES F ARE•K FARM INTER:411MM (PLEASE PLACE A thitEGMARK IfrIBY EACH PROGRAM V WITH AN ASTIRISI I Lk 1 THE PROGRAM LOUR CHID i H. NEADSTART p M MIGRANT PM-il I N NON-SURSIOI7F0 CIIIITI CARE ATIENOCLI AISO, INDKATE SAS IN THE IONCEST / 0 0. OTHER 0 S. SUBSIDIZED WILD LAM (ESN IS THE STUDENT A SINGLE PARENT? 0 TES NO NO (161 UNREST GRADE EMT 07 TRANSFER INFORMATION: 1171 NAME OF SCHOOL TRANSFERRING FROM LIED CITY OR LOCATION 119/ DATE OF EAST ATTENDANCE 1201 GRADE LEVEL NI/ LAST PURL MIMI. ATIMIDEU IN PALM BEACH COUNTY 1221 DATE At ENLEU FREE OR REDUCED PRICE LUNCH AND HEALTH INFORMATION: 123) HAZE YOU FILLED CUT AN APPLICATION FOR FREE OR REDUCED LUNCH? APPLICATION IS PROVIDED WITH THIS REGISTRATION FORM) 0 TES Er.:.----Eu LIE) HEALTH SCREENINGS: I GIVE PERMISSION FOR MY CRIED TO BE GIVEN IRALTH SCIREFNIES. THESE TESTS MAY BE GIVEN INDIVIDUALLY OR IN :ROMPS YES 0 NS p NO 12E4 SODIUM FIUORIDF: I GIVE PERMISSION FOR MI [SILO TO PARTICIPATE IN TIE SODIUM FEMME PROGRAM TO PREVENT DENTAL DECAY. PERMISS ON IS VALID TIROLGH GRADE SIX. YES Ill YES 0 NO NEW STUDENTS TO PALM BEACH COUNTY: HOME LANGUAGE SURVEY (26) WHAT LANGUAGE IS SPOKEN II IMO HOME BY THE DAEMON or GUARDIAN: 1 ' \ r,..,,,\,4t1/4 s PhIA5WI WHAT ,ANWACE is STOLEN IN THE HOME BY THE STUMNI? e.-. ..,\Isk 1211 DATE OF ENTRY NTO THE (SOL MOEN" 1231 UNGVAGL SURTET L. Ii A LANGUAGE OTHER THAN !MAISIE USED IN TEE ROME? 2. GOES IRE STUDENT HAVE A 'IRS! LANGUAGE OTIIR THAN ENGLISH? 3. DOES THE STUDENT MOST TRECIUENTlf SPEAK A LANGUAGE OTHER THAN ENGLISH? Ei NO 1301 ousao>om, IM in. ...! 40.0 On SCHOOL DISTRICT AS THE STUDENT EVER: I MEN EXPELLED /NOM SCAM? 2 hAD AN ARREST MSATERG IN A VOW 3 PAO ANT ,NPRIIII1 ADM( ACTIGNIT O EFTA01710365 HE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEM/RETURNING STUDENTS REGISTRATION BACK STUDENT S WI 'N (CHECK ONE) OTN PARENTS 0 MOTHER n FATHER ll SEARED CUSTODY U OTHER UV NSIOR'ED BY Shady., .. mud Harm. MM. by Guam e non *rot) (33) IS THERE A COUR' ORDER BARRING EITHER PARENT FROM REARITHAL OR CONTACTiN3 THE STIJOENT DURING THE SCHOOL CA.?) IF YES. PLEASE PROVIDE THE SCHOOL THE COURT nixnnt M YES :HO WITH A COPY OF I F T / i DOES f ATIER NAVE CUSTODY , OYES 0 NO YES IDS) MG ' N DOES MOTHER NAVE CUSTODY, D YES 0 NO YES MM.. max. lAS4 ROYAL PALM BEACH FL 33411 vat, wet sADOL1 LAST ROYAL PALM BEACH FL 33411 t SA 1651 240 4004 OLOSATai &WARD. ALAS Oi sm4404•4444 nam ore 4.mnvmma m0m4 nal .n.ns now m0441 ROW PA4414 Mat -UM AD D• rii4HrsrisvEr OTTCLICITR511 COMPLETED (OPTIONAL) n"en4•"-sic"'“ B 0 '''''':Isccan c n , soma — KADOSCI ....., POST -144044•Jv E 0 ..0.41444.1COullit MI AtteammAtoste.c caA4mAn .. Arm. IlT) HIGHEST Weft OF EDJCATIDN COMPLETED (0,TiONAL) AO "P4Tay,."°°' B D a— .0 — c ORAIN4 Am n 0 SW 4011.50:00 ,44 E 0 11154•CALCOu404 RA❑ aLlcaktal IIAACUAR 04 wow OYES • .4. "" M4APA4IP )g) LEGAL GUARDIAN (IC APO) Rest eAs DOES LEGAL GUARDIAN HAVE CuSTOEY) El NO w,(ai LAST PC.it ACcilsi CITY ITA/1 2d COpI A.,. ,A ...,,,..... a Atm,. Arndt EMERGENCY HEALTH AND SAFETY INFORMATION PAnT I FERSOND) CINER THAN PARENT AUTHORISED TO KS UP STUDENT 1341 PASSWORD (Lim I ID CHARACTERS( my 4,44mm$200004 14400PC• 4.44-44 rii s L ko '41 ADDRESS PHONE RELATIONSHIP S;i4e, 4 I42) ADDRESS le".'.RELATIONS -OP 1,4i'r .....e IC TES 0 NO 43 MANE ADDRESS PMCNE RE,ATONS4IP • s YES NOgmai pc 1441 NAME ADDRESS PHONE RELATIONSHIP 0 YES In NO G$42104 A NAM ADDRESS /NONE RELATIONSHIP 0 YES 0 ta NID: PART II IF 50.001 PERSONNEL APE INIAERE TO ONTACT YOU IN CASE OF ((NESS OR ACCIDENT, MAY WE .445E VDUR PERMISSION TO CALL YOUR DOCTOR OR EMERGENCY SERVICES (SI ll FOR TRANSPORT TO THE HOSPITAL' 0 yes 0 No (471 faun DOCTOR 14G) THOSE Num(hR 141) HOSPITAL PREFERENCE (so: LIST YOUR CHAD'S ILLNESSES. ALLERG£S OR OTHER PHYSICA. LIMITATIONS YOUR CHILDREN IN OTHER PALM BEACH COUNTY SCHOOLS: OH NAME OF CtiRLD SCHOOL ATTENDING STUDENT •10. (01-10NALI GRADE MTH DATE (52) NAME OF CHID SCHOOL ATTENDING STUDENT NO. lOrIONALI GRADE BIRTH DATE (53) MAME OF CHILD SCHOOL ATTENDING STUDENT •10. (OPTIONAL) GRADE BIRTH DATE ISA) NAME Of CHILD SCHOOL ATTENDING STUDENT NO. IOPIONALI GRADE BIRTH DA•E (55) NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE BIRTH DAVI ISM I VERIFY THAT THE INFORMATION GIVEN IS TRUE MID ACCURATE T3 THE REST Of MY KNOWLEDGE. SIGNATURE UI PARENT OR LEGAL GUARDIAN DATE FOR OFFICE USE ONLY: On 5 MLR NU. 1691 1541 SI VAN' NLAU31 N (SD) STUDENT LANGUAGE EN SD) CUR US iblI MITI LUCIE E01 (biT LATE, URft 08/16/99 MO) SM. LODE 1060 IDS) GLADE EMI. 07 (65) CAlt743AR 01 16T1 TEACHER NO. (441 PAREMMUAROIAN LANGUAGE EN EOM REASSIGNMENT CODE DA•ADM DE•Ea OD-ISOL OM-NAG ISO. TRANSPORTATION Ei vis 0 Ng, C I 2 ;‘. 4 5 0 NI VliutiCATTON OF DIRER i I D 4 6 0 7 IS S T (III WS z A D t 17.1/ COCIALEMEAT ON EHE:IAIST CHM AND DATE WIEN RECOY£T 00ATE iPALAJMEATiONS 0 DATE 11IlisiCATION of 'NTH RECORDS °GATT Sor ou. TISPC,UR h0 LOPOVAD TY 0 OATt. fARY51CAL EXAMS OW DATA ENTRY (OWIETIO BY: DAM PESO 06M1 (At,. EFTA01710366 .STUDE. Legal SEX F RACIAL/ETHNIC GROUP O Hispanic arNhite. Not Hispanic O American Indian/Native Alaskan O Black, Not Hispanic O Asian/Pacific Islander STUDENT NUMBER • " ' ' n ace, until final.) BIRTHDATE: Verified by Birth Certificate: Y Yes If Not, Whet Type Verification? , caw In, eack Fi I NAME OF PARENT(S) OR LEGAL GUARDIAN OR OTHER RESPONSIBLE ADULT AT HOME P G OA BIRTHPLACE: Wes-i- -Pain, -Paeaell ci C--•••-" CURRE Name Street City T SCH OL: enCil in this space, until final.) Da e First Entered This District 9 -P-5.-9g. Withdrawal Date Withdrawal Date Withdrawal Date .1kr..,, a I --P. h-r, 'lead, F I i FLORIQPi PERMANENT RECORD CARD CATEGORY A - Education Records GRADES K-5 School Year: 19- c) a •19 Grade: 9 t Grad e i Grade: •19 - • • Grade- School Vac 19 -h., Grad @: s..9_7_ School Year 19 4'3 -19 95/School Tear 19 al aSchool Year ;19 4.P___. Days Present: /7/ Days Absent Days Present: 1% Days AD flu Days Present Days Absent: Days e 7r——i Data.nnt Days Present f i-r,ct Days Absent: Subject Subject le ubject Teacher Subject Teacher Mark Subject Teacher i. u. LOS i n. 17nraIMMIS rMa Mlitial N Illl ill I I li2trorraM liriratt IFTOTET IMI IIMAMaAliAllila. Itzi•Di ", Eu. I Grade: 4 t. ‘ I Grade: ,4.: I. 14 A i ,e- ; g I .:,A E .A. • A4; it • E SCIENCE and HEALTH rtim ,t IlrirdEX II ria"741.911FM I n READING NGUAGE SPELLING :EL'1•]47;DIG3. Tirign CIENCE and EALTHHANDWRITING it:WM[4c= IdelridelEd LUBI Or= RM.. BEHAVIOR CODE AVERAGE Indicate: Promote (P) Retain (RI Summer School (SS School: SOCIAL STUDIES SCIENCE H BEHAVIOR AVERAGE and A TN SCIENCE and HEALTH BEHAVIOR CODE AVERAGE EHAVIOR CODE VERAGE CODE BEHAVIOR CODE AVERAGE Indicate: Promote (P) Retain (R) Summer School (SS Indicate: Promote (P) Retain (R) Summer School (SS) Indicate: Promote (P) Retain (R) Summer School (Ss) SS Indicate: Promote (El Retain VD Summer School (SS) School: S I rat School: Grade: Sctmot Grade I School Year: 19- C -19 ril School Year: 19 -19 School Year: 19x•18__ School Year: 19_-19_ School Year 19 -19 Days Presentr Days Absent Days Present Days Absent: Days Present: Days Absent: Days Present Days Absent: Dam Present: Days Absent: Subject arbor Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark Subject Teacher Mark READING MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS READING READING READING READING LANGUAGE ANGUAGF LANGUAGE i ANGUACE LANGUAGE SPELLING SPEI LING SPELLING SPELLING SPELLING HANDWRITING HANDWRITING HANDWRITING SOCIAL STUDIES HANDWRITING HANDWRITING SOCIAL STUDIES SOCIAL STUDIES SOCIALSTUDIES SOCIAL STUDIES SCIENCE and HEALTH SCIENCE end HEALTH SCIENCE end HEALTH SCIENCE and HEALTH SCIENCE and HEALTH BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE Indicate: Promote 01 Retain (R) Summer SeenolISSI Indicate: Promote (P) Retain IR) Summer School (SS) Indicate: Promote (P) Retain IRE Summer School fESI Indicate: Promote (P) Retain (R) Summer School ISSL Indicate: PromoteIP/ Retain(R) Summer SchgoUSSI PB5D0932 01.9340 EFTA01710367 THE SCHOOL DISTRICT OeldiLNI BE71eI1320 ELEMENTARY REPORT CARD tt . Student Teacher MARKING CODES - ACADEMIC SUBJECTS GRADES 1 and 2 E - Excellent S - Satisfactory V - Very Satisfactory N - Needs Improvement A - B - C - D - F - 1 - GRADES 3-5 Outstanding (94% - 100%) Above Average (85% - 93%) Average (75% - 84%) Below Average (65% - 74%) Failing (0% - 64%) Incomplete . ACADEMIC SUBJECTS •~. r; Pi."' • 4 .. .irate Composition Language Spellin. Handwriting/Penmanship Social Studies Science/Health • Grades not given this nine w FINE ARTS REPORT Marking Period Art. Music Physical Education PARENT/GUARDIAN/TEACHER Marking Period CONFERENCE . 1•t 2nd an, I Conference conducted (Indicate"dato School Principal SOCIAL DEVELOPMENT/CLASSROOM STUDY HABITS Please work on the area(s) that have a check (✓) tit 2nd 3rd , 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 (.1"). Marking Period 1•t 2nd and oh 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 Marking Period PLACEMENT • Grade Special Session if Special ssion program is indicated, grade placement WA be determined by the home scribal. PBSD 0700 (Rev. 7/94) Goldenrod/1st Period PInkfteceBerJO: .::;,Denaryard Period Green/4th Period •wotworna, copy , EFTA01710368 TlaHOOL DISTRICT OF PALM BEACH COUNTY rcl 1997-1998 END-OF-YEAR REPORT CARD INSERT for GRADES 1-5 Dear Parent(s)/Guardian(s), Grade In a continuing effort to keep you informed, this report card insert is being provided to notify you of your child's progress toward meeting the school district's desired levels of performance In reading, writing, and mathematics. Your child's end-of-year performance level in reading, writing, and mathematics is identified beloyi. READING YeING (COMPOSITION) MATHEMATICS id At or above grade level At or above grade level IlAt or above grade level O Below grade level* O Below grade level* O Below grade level* *If Below grade level has been indicated for reading, writing, and/or mathematics, you will 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 1998-1999 school year. Sincerely, e PBSD 1674 (NEW 5/15/98) White/Cumulative Folder Yellow/Report Card EFTA01710369 `STUDE • Legal • SEX IAL/ETHNIC GROUP 0 Hispanic RAC Le<thite, Not Hispanic 0 American Indian/Native Alaskan El Black, Not Hispanic 0 Asian/Pacific Islander STUDENT NUMBER , al.) BIRTHDATE: Verified by Birth Cenificate: i!E Yes If Not, Whet Type Verification? NAME OF PARENT(S) OR LEGAL GUARDIAN OR OTHER RESPONSIBLE -ADULT AT HOME P G OA BIRTHPLACE: Wes-l- —Poin-, -P-eciej, RI , CURRENT SCH 01.: use Name Street City Iker I 11/4 Irn encil in thi -"Sec ch it til final.) Date First Entered This District 8-as-9a Withdrawal Date Withdrawal Date Withdrawal Date I FLORIDA PERMANENT RECORD CARD CATEGORY A • Education Records GRADES K-5 • Grade: School: Grade ( ride: Gredo3 ' Greg: K School Year: 19- 4:1 a -19 . •41S Scheel Year: 19 93 -19 65/School Year 19 -19.fiL. School Year: 19 -19 act,School Year-19 -.gO. 9 -S-2— Days Present: 17/ Days Absent: , Days Present: 1% Days Ab nt: Days Present Days Abair, 172 Days present /7 Days A• Days Present ,q Days Absent Subject Teacher Subject „ bject Teacher Subject Teacher M rk Subject Teacher Mark ... _., • t • _. 1 .. L , Aj; ii I .., IAL T DIE SCIENCE and .- • BEHAVIOR CODE ‘ A : ; I I I / 1 I I I ATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS A. /1/4219'te aUITOMIIII UITITIT IMI MI IN Irrfifla M U READ( G I IlltucoLuilIMINII I I Ell.ma•thatimcS II Illk•folat I 1 • = Mia/IMPailill Mr E MEILINsIWIUIRIc IM II : . Ear' I I I I I Cal !tuiesclaitua B.m...m.inta l Icyltalcipm.4-MI IENC1. E and . • LY$Ie1M Mira BEHAVIOR CODE AVERA E Indicate: Promote (P) Retain IR) Summer School (S$) it:201•1 :*, SCIENCE and H BEHAVIOR CODE AVERAGE a'i . L 1St • LA-'-= SCIENCE and BEHAVIOR CODE AVERAGE .EHAVIOR CODE VERA Indicate: Promote IP) Retain (R) ' Summer School (SS) cam emote (E) mein IR) ummer School (SS) ‘'S 3Indicate: Promote (P) Retain (R) Summer School 1551 MI Indicate: Promote IP) Retain IR) Summer School 1551 Gra • hoot (Grade: School: I a• School: G School: Grade: School Year 18- 19 School Year: 19_-19_ School sear 19_-19_ School Year: 19_-19— School Year: 19 •19 Days Present:i Days Absent: Days Present: Days Absent: Days Present: Days Absent Days Present: Days Absent: Days Present: — Days Absent: Subject • Subject Teacher Mark Subject Teacher Mark Subject • Teacher Mart Stabled Teacher Mark MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATICS MATHEMATIOI READING READING • READING READING READING LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE SPFI I ING SPELLING SPELT ING SPELLING SPELL ING HANDWRITING HANDWRITING HANDWRITING HANDWRITING HANDWRITING SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES SOCIAL STUDIES SCIENCE and HEALTH SCIENCE and HEALTH SCIENCE and HEALTH SCIENCE and HEALTH SCIENCE and HEALTH BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE BEHAVIOR CODE AVERAGE Indicate: Promote (P) Retain (R) Summer School ($5) Indicate: Promote (P) Retain (RI Summer School 1551 Indicate: Promote IP) Retain (R) Summer School (SS) Indicate: Promote (P) Retain (R) Summer School MS) Indicate: Promote IP) Retain (RI • Summer School (55) EFTA01710370 4BOOL THE SCHOOL DISTRICT OF PALM BEACH COUNTY STUDENT NUMBER: ~~NREGISTRATION S DISTR: 1691 TCHR AIM TNBR:O59STDT 08/09/00 CRS:2002100 SEC:06 BLDG:00 RM:801 rur (I) STUDENT'S LEGAL NAME (2) ALSO KNOWN AS mat litSI «r .• (3) LOCAL ADDRESS (4) MAILING ADDRESS cv 4C(.4160. ST4IIT NAM, one HMI 2, LCDZ L,,, HtA? 1,0 coat (5) STUDENT'S SOCIAL SECURITY NO. BB HOME PHONE NO. (7) I I SEX p FEMALE MALE 18) I II RACE W I Otatt.:smi:Atig=lvE B lieL0f-KHISPANIC i I A gr:Flinsuoven H HISPANIC i w :e,,74,s,..i. I M MULTIRACIAL IS/ DATE OF BIRTH mcqui DAY IVO OM PLACE OF BIRTH WEST PALM BEACH FL US an r FLORIDA . . tot.rinv (I I) RESIDENT I STATUS 3 • 0. FOREIGN EXCHANGE STUDENT I. OUT-OF-COUNTY RESIDENT I I 2. 3. OUT-Of-STATE RESIDENT IN-COUNTY RESIDENT . (12) ENTRY DATE INTO USA (13) FEDERAL I I I YES YES YES YES YES IMPACT AID SURVEY. I NO A. THE STUDENT I NO B. THE STUDENT I NO C. THE PARENT I NO D. THE PARENT I NO E. THE PARENT IF YES. I RESIDES ON RESIDES IN IS EMPLOYED IS EMPLOYED IS IN THE IS THE PARENT AIR FORCE FEDERAL LOW RENT ON FEDERAL ON LOW UNIFORMED ON ACTIVE I ARMY PROPERTY. HOUSING. RENT SERVICES DUTY? PROPERTY HOUSING I OF COAST LOCATED LOCATED THE UNITED I YES GUARD IN IN I PALM BEACH COUNTY. PALM BEACH COUNTY. STATES. NO I MARINES I NATIONAL GUARD I NAVE (MI HAS THIS CHILD BEEN ENROLLED IN ANT PRESCHOOL? 0 C. CHAPTER I I 0. PRE-K DISABILITIES I I. PRE-K EARLY INTERVENTION PLEASE -PLACE A CXECKMARK (1.1 BY EACH PROGRAM WITH AN ASTERISK ( */ THE PROGRAM TOUR CHILD I H. HEADSTART I IA. MIGRANT PRF-K 0 N. NON-SUBSIDIZED CHILD CARE ATTEN3EO. WAS I I ALSO, INDICATE IN THE LONGEST.) 0. OTHER S. SUBSIDIZED CHILD CARE (16) IS THE STUDENT A SINGLE PARENT/ NO I YES I NO (OS) CURRENT GRADE LEVEL 08 TRANBFERLINFORMATASNI Ill) NAME OF SCHOOL TRANSFERRING FROM WO CITY OR LOCATION (ID) DATE OF LAST ATTENDANCE IRO) GRADE ;FILL UN LAST PUBLIC SCHOOL ATTENDED IN PALM BEACH COUNTY (22) DATE ATTENDED FREE OR REDlyggpfPRiggIMOGOVIDAFAISitairsgStigN: 123) HAVE YOU FILLED OUT AN APPLICATION FOR FREE OR REDUCED LUNCH? (APPLICATION IS PROVIDED WITH THIS REGISTRATION FORM/ I ITS 9 NO 12e) HEALTH SCREENINGS: I GIVE PERMISSION FOR MY CHILD TO BE GIVEN NON-INVASIVE HEALTH SCREENINGS. THESE TESTS MAY BE GIVEN INDIVIDUALLY OR IN CROUPS. YES FOR EXAMPLE: VISION, HEARING, SCOUOSIS, HEIGHT A WEIGHT I IFS S nn 125) SODIUM FLUORIDE: I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN THE SODIUM FLUORIDE PROGRAM YES E 'as TO PREVENT DENTAL DECAY. PERMISSION IS VALID THROUGH GRADE SIX. i NO NMS.XleMgtittSITO PALM. BEACA,POUNTY;;;;; ;Ppinplgte the 1909W,ipaus.eclictris UM HOME LANGUAGE SURVEY (a's 26.20) I. A THAN I YES I NO II ye; what loacrege? IS LANGUAGE OTHER ENGLISH USED IN THE HOME? 2. DOES THE STUDENT HAVE A FIRST LANGUAGE OTHER THAN ENGLISH? I YES I NO II yes. YAM langasof? 3. DOES THE STUDENT MOST FREQUENTLY SPEAK A LANGUAGE OTHER THAN ENGLISH? I YES I NO II yes, wk.' luggage? 117) WHAT LANGUAGE IS SPLICER IN THE HOME BY THE PARENT ee GUARDIAN? (281 WHAT LANGUAGE IS THE STUDENT'S FIRST (151) LANGUAGE? UM DATE OF ENTRY INTO AN ESOL PROGRAM • (30) DISCLOSURES FOR ENTRY lato this School Olorld HAS THE STUDENT EVER: I. Been expelled from scbool? 2. Had are arrest reselling In a charge? 3. Had my Ovalle justice actions? I ES IIES ,YES I NO ono ONO VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: NEW STUDENTS: Complete all non—shaded areas on both sides of form RETURNING STUDENTS: Please review both sides for correctness of typed information. If the information printed is Moo rect. please correct it by carefully and lightly crossing out the incorrect information and writing the correct information above it. PBSO 0030 Mee 4/00) EFTA01710371 THE SCHOOL DISTRICT OF PALM BEACH COUNTY - NEW/RETURNING STUDENTS REGISTRATION BACK fr, (31) STUDENT LIVES WITH (CHECK ONE) 0 BOTH PARENTS 0 MOTHER i li FATHER 0 SHARED CUSTODY i OTHER ,. -•• .(32) TRANSPORTED BY: SloeIsm will two tionsportod to/Itow school lirldimo if oilier ihsa Parsed WIS 0 G El CONTACTING THE STUDENT DURING THE SCHOOL DAY] 0 YES 0 NO IF YES, PLEASE PROVIDE THE SCHOOL WITH A COPY OF THE MART ORDER . 4 FATHER/ DOES FATHER HAVE CUSTODY? OYES ONO YES (3:51 MO DOES MOTHER HAVE OUSTCOTT AYES 0 NO YES Mint FliiiiiIIIIIIIIIII ROYAL PALM BEACH FL 33411 Off alli MOM ROYAL PALM BEACH FL 33411 WI • Ml[ nCC0( CCCOATOr occwavon • • RALF OF WP101.1440 Heal OF DiPiontrriT NOM /One MS= NIOVt HOW Mai MUMS. 1.40/4 (361 HIGHEST LEVEL OF EOUCATKAN COMPLETED (OPTIONAL) CM SCSOOL AO unitsar"°°1 B 0 "6" ""CS to ;.,sr, C 0 latra•ATO D 0 ser.2,":7,:"" E 0 71""r4".?:,,vo (37) HIGHEST LEVEL Of LDUCATION COMPLETED (OPT L1 AO il"UnsIAR•al 11°.31 Bn SOW /OW SO•1001. '6-1 MANS 9-1.1 C El'=„4": D D f,0:4( 10ST•SICOODAAV E n Tiornsucousix 1-J IGRAZUMS w. MOM (381 LEGAL GUARDIAN (IF ANT) DOES LEGAL GUARDIAN HAVE CUSTODY? 0 YES ❑ NO ,as. 1.44 WOOL( IAD .064g ^Witt, WV fTAfs. it coot FM. S 0,0.4VF S PART I: PERSONS) OTHER THAN PARENT AUTHORIZED TO PICK UP STUDENT . (39) PASSWORD: ROM 10 CHARACTERS) W. 0#1,0:02/0 Ng C.MOKOICY MCP/ ADDRESS RCLATIONSITP SOTHER itr • El YES NO 1421 ADDRESS PHONE RELATIONSHIP Ah• YES 0 NO (43) ADDRESS PHONE RELATIONSHIP n U YES 0 NO (44) NAME ADDRESS PHONE RELATIONSHIP n LJ YES (3 N° (45) NAVE ADDRESS PHONE FtELATIONSTOP n u YES 0 NO (46) PART IL 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 SERVICES (911) FOR TRANSPORT TO THE HOSPITAL? n YES 0 NO (47( FAMILY DOCTOR (48) PHONE HAWED 491 HOSPITAL PREFERENCE (50) LIST YOUR CHAD'S ILLINESSES, BEHAVORAT HEALTH ISSUES, ALLERGIES. MEDICATIONS TAKEN, OR OTHER PHYSICAL LIMITATIONS: (59 DOES YOUR CHILD CURRENTLY HAVE HEALTH INSDRANCE? OYES 0 NO II hiss, Oman isdkato--...0 Mmlinid CI Flabby Kids/KM Cue 0 Pthesto 0 Lowdoss4 a witoiving Ommokis raWIFOA. 13 fit) OM PH: ' "'"".''' (62) NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE BIRTH DATE S i ' (531 NAME OF CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL] GRADE BIRTH DATE • 4. (541 NAME Of CHILD SCHOOL ATTENDING STUDENT NO. (OPTIONAL) GRADE BIRTH DATE , ' '..:. 455) NAME OF CHILD SCHOOL ATTENDING STUDENTNO. (OPTIONAL) CR.40€ BMW DATE . . • • • (56) NAME OF CHILD SCHOOL ATTENDING STUD-TIT NO. (OPT.ONAL) GRADE BIRTH DATE *1 I. . (57) I VERIFY THAT THE INFORMATION GIVEN IS TRUE AND ACCURATE TO THE BEST DE MT KNOWLEDGE. 5?L. (,- 6) aNA U E 9F F EIPL GUARDIAN DATE FOR OFFICE USE ONLY: (:. ,cii.:LL ..0. ,,, STL'EliNT !.L'I.',3fil . .,61: II 7.1.1" I. UACL ' EN 71; CU.; .: E01 i ;41.‘BILE 08/16/00 I 1060 .., 1091). ..; t6b,„.PAH NT,/ kaint;i: r,,:,..,cu,Lci t. EN . I (C': CHt.1 US j OF. 1 IL/I LAiCIJ1H 01 1'HI TrAC,grt 210. r/;•-. PF.Y.SICNWP, - C Li> r•C'.• DC,•(5C al.} SU: 0.•.1.•'S •3( lt:SSVcW,U,Vt:•, 11,1dS 11 NN "a N ! : I f„ E i : I II ()•2! , •-•'.' UK ;!.,Ps1A-:,:.. ? 3 : f, , • '• -in. 0 vli. r to ) 1, 1:".1.: ciur CL!...?“7ED Bu P650 0636 (REV. 4/001 EFTA01710372 i..lai.,.thil.ctativt . THE SCHOOL DISTRICT OF. STUDENT NUMBER: • , • 1 N Ae,,,ccdpNEW/RETURNING 4 PALM BEACH COUNTY STUDENTS VERIFICATION FOR NEW/RETURNING STUDENTS: TO THE PARENTS OR GUARDIANS: NEW STUDENTS: Complete all non—shaded areas on both sides of form RETURNING STUDENTS: Please review both sides for correctness of typed Information. If the Information printed is Moo rect. please correct it by carefully and lightly crossing out the incorrect Information and writing the correct information above it REGISTRATION IISTR:1761 TCHR: TNBR:504STDT: HaIRM: 504 MAY PATA (I) STUDENT'S LEGAL NAME 121 ALSO KNOWN AS LAST THSI MOM CT) LOCAL ADDRESS (4) MAILING ADDRESS " m 1 Fl I I 1 i m ..rer ica. ... SiPiif PAM API. t STATL sr iWI (6) STUDENT'S SOCIAL SECURITY NO. (OPTIONAL) 16) HOME PHONE NO. (7) If4MALE I SEX F UNaL5 MALE (8) I I RACE W OR MA ALASKAN 101 OR ALASKAN NATTVE B r/LOActi-KmiSPANIC i I A IICAACDRISLANCIER PACIFIC ISLANDER H HISPANIC I I W WHITE NON-HISPANVC NI ImATIRACIAL (9) DATE Of BIRTH MONTI MY VIM (ID) PLACE OF BIRTH WEST PALM BEACH FL US CITY STATE FLORIDA CMYTAY (II) RESIDENT I STATUS 3 D. FOREIGN EXCHANGE STUDENT I. 01/7-0E-COUNTY RESIDENT I I 2. 3. OUT-OF-STATE IN-COUNTY RESIDENT RESIDENT (IV ENTRY DATE INTO USA (13) FEDERAL I 0 0 IMPACT AID SURVEY YES NO A. THE STUDENT YES NO B. THE STUDENT i YES cla NO C. THE PARENT YES NO D. THE PARENT Yu NO E. THE PARENT IF YES, RESIDES ON RESIDES IN IS EMPLOYED IS EMPLOYED IS IN THE IS THE PARENT AIR FORCE LOW UNIFORMED ON I FEDERAL RENT ON FEDERAL ON LOW ACTIVE ARMY PROPERTY. ROUSING. RENT SERVICES DUTY/ PROPERTY HOUSING OF I COAST I LOCATED IN LOCATED IN THE UNITED TES I GUARD PALM PALM STATES. I BEACH COUNTY. BEACH COUNTY. NO MARINES I NATIONAL GUARD I NAVY (141 HAS THIS CHILD BEEN ENROLLED III ANY PRESCHOOL.? C. CHAPTER I D. PRE-K DISABILITIES E. PRE-X EARLY INTERVENTION p0 (PLEASE PLACE A ONEXMARK 10/BY EACH PROGRAM WITH AN ASTERISK ( * I THE PROGRAM YOUR CHILD I N. NEADSTART I M. MIGRANT PRE-K I N. NON-SUBSIDIZED CHILD CARE ATTENDED. WAS I I ALSO. INDICATE IN THE LONGEST.) D. OTHER S. SUBSIDIZED CHILD CARE (IS) IS THE STUDENT A SINGWAREMT? I YES . I ND Ile CURRENT GRACE LEVEL 05 mlow-steterfatimmitaa. (I7) NAME OF SCHOOL TRANSFERRING FROM (181 CITY OR LOCATION OM DATE OF LAST ATTENDANCE (20) GRADE LEVEL ao LAST PUBLIC SCHOOL ATTENDED IN PALM BEACH COUNTY (221 DATE ATTENDED Vifft,E,POIVIREDUCED PRICE LUNCH ANO-HEALTH •INFDSMATIONL ,, - (23) NAVE YOU FILLED OUT AN APPLICATION FOR FREE OR REDUCED (APPLICATION IS PROVIDED WITH THIS REGISTRATION FORM) LUNCH? P ° I YES . NO ig (24) HEALTH SCREENINGS: I GIVE PERMISSION FOR MY CHILD 70 BE GIVEN HEALTH THESE TESTS MAY BE GIVEN INOIWDUALLT OR IN GROUPS. SCREENINGS. YES I YES I NO (25) SODIUM FLUORIDE: I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE. IN TO PREVENT DENTAL DECAY. PERMISSION IS VALID THROUGH THE SODIUM FLUORIDE PROGRAM YES GRADE SIX. I YES I NO ;4:NEW STUDENTS. 0 PALM BEACH COUNTY: HOME LANGUAGE SURVEY (26) WHAT LANGUAGE IS SPOKEN IN THE HOME BT THE PARENT xi GUARDIAN: (27) Y/HAT LANGUAGE IS SPOKEN IN'THE HOME BY THE STUDENT? (28) DATE OF ENTRY INTO THE ESOL PROGRAM 129) LANGUAGE SURVEY I. IS A LANGUAGE OTHER THAN ENGLISH USED IN THE HOME? 2. 0014 THE STUDENT RAVE A FIRST LANGUAGE OTHER THAN ENGLISH? 3. DOES THESTMENT MOST FREINANTLY SPEAK A LANGUAGE OTHER THAN ENGLISH? I YES I YES I YES I NO I NO I NO PLOD 0636 (Am 6/97) EFTA01710373 higW/NelUNNINU STUDENTS MEGISTRATION BACK (30) STUDENT ll LIVES WITH (CHECK ONE) BOTH PARENTS II MOTHER D FATHER 0 SHARED CUSTODY P.OTHER 131) S . StoLM will be icansport• to rem It ool b