Please click here to view and print the SEMS New Student

Please click here to view and print the SEMS New Student
South Eastern School District
South Eastern Middle School
Student Registration Packet
Please call 717-382-4851, ext. 2830 to set up an appointment.
In addition to the completed Registration Packet, please bring
along the following pieces of information:
 Two proofs of residency verifications (driver’s license, lease,
bill with printed address)
 Birth Certificate
 Immunization Record
 Grade Report from Previous School
 Custody Paper (if applicable)
 IEP or 504 Plan (if applicable)
South Eastern School District
Fawn Grove, Pennsylvania 17321
Student Registration/Census Form
For Internal Use Only
Grade:
Enrollment Date:
____/____/____
Enrollment Code: _______________
Student ID #:
Date of Withdrawal: ____/____/____
Date of Graduation: ____/____/____
STUDENT INFORMATION
Student’s Name: ___________________________________________________________________________________________
(Last)
(First)
(Middle)
(Jr., III, IV)
Address: _________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Township/Borough: _____________________ *Home Phone _______________________ *Cell Phone _____________________
Birth Date: ____/____/____
Place of Birth: _______________________________________
Gender:
M
F
Attendance Notification #
District Residence Date: ____/____/____
Initial US Entry Date: ____/____/____ (if ELL)
PA Residence Date: ____/____/____
School Entry Date: ____/____/____
School Last Attended (if applicable):
Address:
Phone:________________________________________ Fax:
PARENT/GUARDIAN INFORMATION
2nd CONTACT
1st CONTACT
________________________________
Relationship to Student
3rd CONTACT
___________________________________ ___________________________________
Relationship to Student
Relationship to Student
(ex. Father , Mother, Stepparent)
(ex. Father , Mother, Stepparent)
(ex. Father , Mother, Stepparent)
Name:
Name:
Name:
Address:
Address:
Address:
*Home Phone:
*Home Phone:
*Home Phone:
*Cell Phone:
*Cell Phone:
*Cell Phone:
E-Mail Address:
E-Mail Address:
E-Mail Address:
Employer:
Employer:
Employer:
Address:
Address:
Address:
Occupation:
Occupation:
Occupation:
*Work Phone:
*Work Phone:
*Work Phone:
Access to Student Info:
Y
N
Access to Student Info:
Y
N
Access to Student Info:
*Enter “NA” after a telephone number to exclude it from the district’s “School Reach” notification system.
TRANSPORTATION INFORMATION
If Parent(s) Work, Babysitter’s Name:
Babysitter’s Address:
Babysitter’s Telephone Number:
Provide location where child will board bus:
Bus Assigned:
SESD #41(Revised 5/13/15)
Bus Stop:
Y
N
LIST OTHER CHILDREN RESIDING AT PARENT/GUARDIAN ADDRESSES:
LAST NAME, FIRST
NAME, MIDDLE NAME
DATE OF
BIRTH
RELATIONSHIP TO
PARENT/GUARDIAN
GENDER
RESIDES WITH
LAST SCHOOL
ATTENDED
GRADE
IN ADDITION TO THOSE LISTED ABOVE, LIST OTHER INDIVIDUALS OVER THE AGE OF 18 RESIDING AT PARENT/
GUARDIAN ADDRESSES:
LAST NAME, FIRST NAME, MIDDLE NAME
RELATIONSHIP TO
PARENT/GUARDIAN
OCCUPATION
PLACE OF EMPLOYMENT
TWO EMERGENCY CONTACTS (OTHER THAN PARENTS) FOR EMERGENCY SITUATIONS ONLY, NOT DAILY PICK-UP:
NAME and RELATIONSHIP
ADDRESS
Family Physician
Family Dentist
PHONE
Phone
Phone
Part 1: Ethnicity (choose one) Hispanic/Latino
Not Hispanic/Latino
Part 2: Race: (choose one or mor e, r egar dless of ethnicity )
American Indian/Alaskan
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Student resides with: Both parents
Mother
Father
Joint Custody
Parent & Stepparent
Foster Parent
(Circle all that apply)
Grandparent
Agency
Relative Children’s Home Other*
*If
student resides with other, indicate name and relation to the child :
Status of adult with whom student resides: Single
Married
Separated
Divorced
Widowed
Living Together
Date of most current Court Orders/Custody Decrees:
PLEASE PROVIDE A COPY OF ANY COURT ORDERS/CUSTODY DECREES THAT PERTAIN TO STUDENT OR RESTRICT
ACCESS TO STUDENT.
Immigrant: Yes_____
No____
Education in US School since __________ grade.
(Not attend US schools more than 3 full years)
Home Language: _______________________
Has your child ever received remedial tutoring or special education services?
Yes_____ No _____
If yes, please circle the type(s) below and provide dates of service: From: ____/____/____
To: ____/____/____
IEP:
Autistic
Learning Support (LS)
Occupational Therapy (OT)
Emotional Support (ES)
Life Skills Support (LSS)
Physical Therapy (PT)
Gifted Support (GIEP)
Multiple Disabilities Support (MDS)
Hearing-Impaired Support (HIS)
Vision Impaired Support (VIS)
Speech/Language Support (SLS)
Neurologically Impaired Support (NI)
Title I
504 Plan/Service Agreement
Other:
If the student is currently receiving services, please provide a copy of the program and the contact information.
___________________________________________________
Parent/Guardian Signature
BIRTH RECORD VERIFICATION
BIRTHDATE:
BIRTHPLACE:
CERTIFICATE NO.:
SESD #41(Revised 5/13/15)
STUDENT RESIDENCE VERIFICATION
TYPE OF VERIFICATION:
South Eastern School District
Fawn Grove, Pennsylvania 17321
PROGRAMS FOR LIMITED ENGLISH PROFICIENCY STUDENTS
(Student Home Language Survey)
Date: __________________________
Student Name:
(First)
(Middle)
(Last)
School:
Date of Birth: _________________________
Age:
Address
Parent/Guardian Name (please print):
Parent/Guardian Signature:
1. Is your family and child’s first language English? Check one of the following:
Yes _____ (If yes, stop survey here)
No _____ (If no, please continue survey
2. What language(s) does your child speak most often at home?
3. What language(s) do you use when speaking to your child?
4. What language(s) is spoken most often in your home?
5. What language(s) does your child read?
6.
What language(s) does your child write?
7.
Does your child understand, but not speak a language other than English?
Please list any other Schools your child has attended in the United States?
School
Years
The Civil Rights Law of 1964, Title VI requires that school districts/charter schools identify
limited English proficient (LEP) students. Pennsylvania has selected the Home Language
Survey as the method for the identification. All students enrolled in our District are required
by the Pennsylvania Department of Education to complete the following survey. On behalf of
your child, please complete and return to your child’s school. Thank you for your assistance.
SESD: 55 (6/2013)
SOUTH EASTERN SCHOOL DISTRICT
377 Main Street
Fawn Grove, PA 17321
Permission to Release Student Information
PLEASE FORWARD THIS FORM OR A COPY WITH THE STUDENT RECORDS
For disciplinary records, please check the appropriate box:
Certified disciplinary record enclosed
Student has no disciplinary record
The signature of the following individual certifies the disciplinary records enclosed are the true and accurate discipline records of the
student indicated below.
________________________________________
School Official
______________________________
Position
___________________
Date
PSC 1305-A: Requires the receiving school district in the state of Pennsylvania to request certified disciplinary records from a student’s former school district. Please
accept this form as a request for certified disciplinary records.
1. Student’s Name ________________________________________ Grade ___________ Date of Birth __________________
Date enrolled at South Eastern School District _________________________________
2. I hereby give permission for _______________________________________________________________________
(Name of Previous School)
to release the following information to South Eastern School District, for above-named student(s). It is my understanding that all
information will be utilized only by professional personnel to aid my child in his/her education program.
_____ Title I
_____ Psychological/Psychiatric Evaluations
_____ Cumulative File Date
_____ Reading Recovery
_____ Comprehensive Evaluation Report (ER)
_____ Health/Dental/Immunization Records
_____ IST
_____ Individual Educational Program (IEP)
_____ Discipline Records (weapons, drugs/
_____ 504 Plan
_____ Notice of Recommended Educational
_____ Other
Placement (NOREP)
drug/alcohol, violence)
_____ Standardized Test Scores
_____ Report Cards or Grades to Date
_____________________________Pa Secure ID #
_____ Mutual Exchange of Information (including school counselors, school nurse, teachers, and administrators)
__________________________________________________
Signature of Parent/Guardian/Surrogate Parent
_______________________
Date
IT IS NOT NECESSARY FOR PARENTS TO SIGN A RELEASE WHEN RECORDS ARE BEING PASSED FROM PUBLIC SCHOOL TO PUBLIC SCHOOL.
Note Federal Register, Part II HEW—Privacy Rights of Parents and Students. Vol: 41,#118-24673
“99.31 prior consent for disclosure not required”
(a) An educational agency or institution may disclose personally identifiable information from the education records of a student without the written consent of the
parent of the student or the eligible student if the disclosure is (1) to other school officials, including teachers, within the educational institution or local educational
agency who have been determined by the agency or institution to have legitimate educational interests; (2) to officials of another school or school system in which
the student seeks or intends to enroll, subject to the requirements set forth in 99.34.
The above information is to be sent to:
Delta-Peach Bottom Elementary School
1081 Atom Road
Delta, PA 17314
Fax - 717-456-6042
Fawn Area Elementary School
504 Main Street
Fawn Grove, PA 17321
Fax - 717-382-1326
Stewartstown Elementary School
17945 Barrens Road North
Stewartstown, PA 17363
Fax – 717-993-5256
South Eastern Intermediate School
417 Main Street
Fawn Grove, Pa 17321
Fax 717-382-4786
South Eastern Middle School
375 Main Street
Fawn Grove, PA 17321
Fax – 717-382-9033
Kennard-Dale High School
393 Main Street
Fawn Grove, PA 17321
Fax – 717-382-4258
PLEASE FORWARD THIS FORM OR A COPY WITH THE STUDENT RECORDS
SESD: 45 (06/15)
SOUTH EASTERN SCHOOL DISTRICT
STUDENT RESIDENCY QUESTIONNAIRE
Dear Parent or Guardian,
Your responses to these questions will help staff determine what residency documents are
necessary for enrollment of your child(ren), and further help us determine if we have additional
resources we can offer you and your family. Thank you for your cooperation.
1. Student Name:
Birth Date:
Person completing form:
Relationship to child:
2. In what type of setting is the student living now:
Check one box below –
SECTION A
SECTION B
□ In an emergency or transitional shelter
□ Sharing the housing of other persons due to loss of
□ None of the choices in
Section A apply
housing, economic hardship, or similar reason
□ In a motel, hotel, campsites, or cars due to a lack of
alternative adequate accommodations
□ In a car, park, public spaces, abandoned building,
substandard housing, bus or train stations, or similar settings If you checked this section, you
do not need to complete the
remainder of this form. Submit
Other places not designed for, or ordinarily used as, a
the form to school personnel now,
regular sleeping accommodation for human beings
after signing the reverse side.
□
CONTINUE to Section C
section.
SECTION C
if you checked any box in this
● What was the event that caused your family to move?
_____________________________________________________________________________
● Do you consider this living situation to be a temporary situation, or something more long
term?______________________
SESD: 71 (06/15)
Please
Explain:_______________________________________________________________________
_____________________________________________________________________________
● When was the last day your son/daughter was enrolled in school?_______________________
3. Contact Number for the person completing this form:
4. The student lives with:
Check all that apply
□ Parent(s) or legal guardian
□ Relative, friend(s), or other adult(s)
□ Alone
□ Other:_________________________
5. Contact person at school last attended (if known):________________________________
____________________________________________________
Signature of Parent/Legal Guardian ~ or individual enrolling child:
SESD: 71 (06/15)
__________________
Date
SOUTH EASTERN SCHOOL DISTRICT
Verification Under 24 P.S. 13-1304-A
Parental Registration Statement
I.
Sworn Statement
Student Name ___________________________________________________________
Date of Birth _____________________________
Grade ______________________
Parent or Guardian Name __________________________________________________
Address ________________________________________________________________
_______________________________________
Telephone # __________________
I hereby verify that my child has ______ or has not ______ been previously suspended or
expelled from any public or private school in Pennsylvania or elsewhere for an act or
offense involving weapons, alcohol or drugs or for the willful infliction of injury to
another person or for any act of violence committed on school property.
I acknowledge that the foregoing statements are true and that the statements are made
subject to the penalties of 18 Pa. C. S. §4904 (b) relating to penalties for unsworn
falsifications to authorities.
_____________________________________________
(Signature of Parent or Guardian)
II.
Supporting Information
___________________
(Date)
Complete this section if the child was previously
Suspended or expelled for any offenses listed in Section I.
Name of School __________________________________________________________
Reason(s) for Suspension/Expulsion __________________________________________
________________________________________________________________________
________________________________________________________________________
Date of Suspension/Expulsion _______________________________________________
________________________________________________________________________
________________________________________________________________________
SESD: 47 (6/03)
South Eastern School District
New Entrant Student Emergency Card
Student Name: ___________________________________________________________________________
Is your student covered by
health insurance? __Yes__No
dental insurance? __Yes__No
vision insurance? __Yes__No
Potassium Iodide Program:
South Eastern School District participates in the Pennsylvania Department of Health Potassium Iodide (KI) program.
Should a radiation emergency occur, the media would broadcast official recommendations to the public for
protective actions including the possible use of KI. Distribution through the school system is being given high
priority for the reason that children are much more sensitive to the ill effects of radioactive iodine than are adults.
KI should NOT be taken by anyone who is allergic to iodine. A KI fact sheet is included in the Student
Handbook or by contacting the Pennsylvania Department of Health at 1-877-PA-HEALTH or visiting the website
at www.health.state.pa.us.
**Please place a check beside one of the following:
`
___YES, I DO want my child to be given potassium iodide, when instructed by public health officials, in
the event of a radioactive emergency during school hours.
South Eastern School District will make a reasonable attempt at supervising students taking the
KI tablet, and will not be held liable for any adverse reactions to the KI tablet. I release the South Eastern
School District, its administrators, employees, faculty, and staff from the voluntary participation of my child
in the KI distribution effort.
___NO, I DO NOT want my child to be given potassium iodide, when instructed by public heath officials,
in the event of a radioactive emergency during school hours.
PLEASE NOTE: The best protective action in a radiation emergency is evacuation.
Standing Order Medications:
School personnel have my permission to use the first aid supplies listed in the student handbook and the non-prescription
medications listed below to treat my child as needed.
**Please check the items below that health room staff may give to your child during the school day.
___ Antacid (liquid or tablet)*___ Generic Tylenol* ___ Cough Drops ___ Generic Advil/Motrin*
_____ Generic Zyrtec* (to treat allergy symptoms)
*All non-prescription medications listed above will be administered by (appropriate) weight or age.
School personnel have my permission to transport or to make arrangements for transportation of my child to emergency
medical care in the event that the persons listed cannot be contacted.
Parent/Guardian Signature:
___________________________________________________________________
PARENTS ARE RESPONSIBLE TO NOTIFY THE SCHOOL AS SOON AS POSSIBLE OF ANY CHANGES IN
HEALTH, IMMUNIZATION STATUS OR CONTACT INFORMATION.
PLEASE TURN OVER TO FINISH COMPLETING INFORMATION
ANNUAL HEALTH HISTORY
Student Name:_______________________________________________________________
TO THE PARENT OR GUARDIAN: The information requested on this form will be of help to the school nurse in
determining the health status of your child. The information provided will be kept confidential and shared with school
staff and bus drivers only when the school nurse and/or school physician believes that it is in the best interest of your
child’s health, safety and education. Please feel free to contact the school nurse if you have any questions or information
you wish to share.
(CIRCLE YES or NO)
1. SHOULD YOUR CHILD BE RESTRICTED FROM PARTICIPATION IN SCHOOL SPORTS OR GYM?
YES / NO
If yes, please provide recommendations from your physician, in writing.
2. DOES YOUR CHILD REQUIRE A SPECIAL DIET?
YES / NO
If yes, please specify________________________________________________________________________
3. HAVE THERE BEEN ANY CHANGES IN YOUR FAMILY DURING THE PAST YEAR WHICH MAY AFFECT
YOUR CHILD?
YES / NO
If yes, please explain________________________________________________________________________
4. DOES YOUR CHILD
a) have trouble seeing?
b) need to wear glasses/contacts lenses?
If yes please X all that apply: Needed for Constant Wear_____
c) have trouble with ears or hearing?
d) need to wear hearing aids/amplification system?
e) is preferential seating required?
YES / NO
YES / NO
Near Vision_____
Distant Vision____
YES / NO
YES / NO
YES / NO
5. DO YOU HAVE ANY CONCERNS REGARDING YOUR CHILD TO DISCUSS WITH THE SCHOOL NURSE?
If yes, please call to set up an appointment.
YES / NO
My signature below indicates that I have read and understand the information on both sides of this form.
__________________________
Date
_____________________________________________________________________
Signature of Parent / Guardian
On behalf of the School Health Services, thank you for taking time to complete this important update of your child.
SOUTH EASTERN SCHOOL DISTRICT
7th – 12th Grade Student Health History
NAME OF CHILD
BIRTHDATE
GRADE
REQUIRED EXAMINATIONS
Pennsylvania State Law, under the School Health Code, requires:
* Physical Examination for original entry (Pre-K, K or 1st), Grades 6 & 11
* Dental Examinations for original entry (Pre-K, K or 1st), Grades 3 & 7
EXAMINATIONS
Physical Examinations: The School Health Act of Pennsylvania requires a physical examination for all children in grades 6 & 11,
and all new students entering South Eastern School District whose records do not include a physical examination. This required exam
may be dated one year prior to the start of school or sooner. Your family physician or school physician may meet the requirement.
______ I plan to have my child’s physical examination done by our family physician.
______ Schedule my child’s physical examination with the school physician.
Dental Examinations: The School Health Act of Pennsylvania requires a dental examination for all children in grades 3 & 7, and all
new students whose records do not include a dental examination. This required exam may be dated one year prior to the start of school
or sooner. Your family dentist or the school dentist may meet the requirement.
______ I plan to have my child’s dental examination done by our family dentist.
______ Schedule my child’s dental screening with the school dentist (complete a Mobile Dentist registration form).
SCREENING TESTS
Pennsylvania State Law, under the School Health Code, requires screening tests for: Growth & Vision (Pre-K-12), Hearing (Pre-K-3,
7 & 11) and Scoliosis (6 & 7). The School Nurse will complete these screening tests and inform parents/guardians of abnormal results.
IMMUNIZATION REQUIREMENTS:
A copy of your student’s immunization record is required at time of registration.
Childern in ALL grades (K-12) need the following vaccines:
TETANUS:*4 doses - 1 dose on or after 4th birthday
DIPTHERIA:* 4 doses – 1 dose on or after 4th birthday
POLIO: 3 doses
MEASLES:** 2 doses
MUMPS:** 2 doses
RUBELLA:** 1 dose (German measles)
HEPATITIS B: 3 doses
VARICELLA: evidence of immunity or 2 doses (chickenpox)
* Usually given as DTP, DT or Td
** Usually given as MMR
7th Grade ADDITIONAL immunization Requirements for entry:
MENINGOCOCCAL (MCV): 1dose
TETANUS, DIPTHERIA, PERTUSSIS (TDAP): 1 dose- if five years have elapsed since last tetanus immunizations
The only exemptions to the school law for immunizations are medical reasons, religious beliefs or philosophical/strong moral
ethical convictions. An Immunization Exemption Form must be completed and on file at school. If your child is exempt from
immunizations, he or she may be removed from school during an outbreak.
Signature of Parent/Guardian_____________________________________________ Date _______________
Reviewed by ______________________________________________________________________________
Please complete side two of this form.
SESD Revised 4/2014
Assessment of Student Health
To the best of your knowledge has your child had any problem with the following? Please check yes or no.
Condition
Allergic Reaction (Severe)
Allergies (Food, Insect, Drugs, Latex)
Allergies (Environmental, Seasonal)
Asthma or Breathing Problems
Behavior or Emotional Problems
Birth Defects
Bleeding Problems
Cerebral Palsy
Chicken Pox Disease
Cystic Fibrosis
Developmental Problems
Diabetes
Ear or Hearing Problems
Eating Disorders
Eye or Vision Problems
Growth Disorder
Head Injury/Concussion
Heart Problems
High Blood Pressure
Hospitalization (Why, When)
Kidney/Urinary Problems
Lead Poisoning/Exposure
Limits on Physical Activity
Meningitis
Orthopedic/Bone Problems
Seizures
Sickle Cell Disease
Speech Problems
Stomach/Intestinal Problems
Tumors/Cancer
Other (Please Explain)
Yes
Does your child take any medication? Please Circle:
No
No
Comments
Yes
Name(s) of Medication(s): _________________________________
Is your child on any special treatments? (nebulizer, glucose testing, catheterization, etc.) Please Circle:
No
Yes
Treatment(s) ______________________________________________
Will your child need medication or treatment during the school day?
Please Circle: No
Yes
Medication(s):___________________________________________________________________________________
Treatment(s):_____________________________________________________________________________________
All Medications and Treatments administered at school require a completed Authorization for Medication during School Hours form.
Please contact the School Nurse if you have any concerns regarding your child that you would like to discuss.
Parent/Guardian Signature _______________________________________ Date _______________
Page 1 of 4: STUDENT HISTORY
H511.336 (Rev. 9/2012)
PARENT / GUARDIAN / STUDENT:
Private or School
PHYSICAL EXAMINATION
Complete page one of this form before
student’s exam. Take completed form to
OF SCHOOL AGE STUDENT
Bureau of Community Health Systems
Division of School Health
appointment.
Student’s name __________________________________________________________________________
Today’s date___________________________
Date of birth ________________________
Gender:  Male
Age at time of exam___________
 Female
Medicines and Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal/nutritional) the student is currently taking:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Does the student have any allergies?  No  Yes (If yes, list specific allergy and reaction.)
 Medicines
 Pollens
 Food
 Stinging Insects
Complete the following section with a check mark in the YES or NO column; circle questions you do not know the answer to.
GENERAL HEALTH: Has the student…
YES
NO
1. Any ongoing medical conditions? If so, please identify:
 Asthma  Anemia  Diabetes  Infection
Other_________________________________________________
Has the student…
31. FEMALES ONLY: Had a menstrual period?
 Yes
If yes: At what age was her first menstrual period? ______
How many periods has she had in the last 12 months? ______
Date of last period: ___________
4. Ever had a seizure?
5. Had a history of being born without or is missing a kidney, an eye, a
testicle (males), spleen, or any other organ?
DENTAL:
YES
Last dental visit:  less than 1 year
YES
NO
8. Had headaches with exercise?
SOCIAL/LEARNING:
 1-2 years  greater than 2 years
Has the student…
9. Ever had a head injury or concussion?
34. Been told he/she has a learning disability, intellectual or
developmental disability, cognitive delay, ADD/ADHD, etc.?
10. Ever had a hit or blow to the head that caused confusion, prolonged
headache, or memory problems?
35. Been bullied or experienced bullying behavior?
YES
NO
40. Had concerns about weight; been trying to gain or lose weight or
received a recommendation to gain or lose weight?
15. Been prescribed glasses or contact lenses?
YES
NO
16. Ever used an inhaler or taken asthma medicine?
41. Used (or currently uses) tobacco, alcohol, or drugs?
FAMILY HEALTH:
42. Is there a family history of the following? If so, check all that apply:
 Anemia/blood disorders
 Inherited disease/syndrome
 Asthma/lung problems
 Kidney problems
 Behavioral health issue
 Seizure disorder
 Diabetes
 Sickle cell trait or disease
 Other________________________________________________
17. Ever had the doctor say he/she has a heart problem? If so, check
all that apply:
 Heart murmur or heart infection
 High blood pressure
 Kawasaki disease
 High cholesterol
 Other:_____________________
18. Been told by the doctor to have a heart test? (For example,
ECG/EKG, echocardiogram)?
19. Had a cough, wheeze, difficulty breathing, shortness of breath or
felt lightheaded DURING or AFTER exercise?
20. Had discomfort, pain, tightness or chest pressure during exercise?
21. Felt his/her heart race or skip beats during exercise?
YES
NO
22. Had a broken or fractured bone, stress fracture, or dislocated joint?
43. Is there a family history of any of the following heart-related
problems? If so, check all that apply:
  Brugada syndrome
 QT syndrome
 Cardiomyopathy
 Marfan syndrome
 High blood pressure
 Ventricular tachycardia
 High cholesterol
 Other________________
44. Has any family member had unexplained fainting, unexplained
seizures, or experienced a near drowning?
23. Had an injury to a muscle, ligament, or tendon?
24. Had an injury that required a brace, cast, crutches, or orthotics?
45. Has any family member / relative died of heart problems before age
50 or had an unexpected / unexplained sudden death before age
50 (includes drowning, unexplained car accidents, sudden infant
death syndrome)?
25. Needed an x-ray, MRI, CT scan, injection, or physical therapy
following an injury?
26. Had joints that become painful, swollen, feel warm, or look red?
28. Ever had herpes or a MRSA skin infection?
NO
39. Shown a general loss of energy, motivation, interest or enthusiasm?
14. Had any problem with his/her eyes (vision) or had a history of an
eye injury?
27. Had any rashes, pressure sores, or other skin problems?
YES
38. Been worried, sad, upset, or angry much of the time?
13. Noticed or been told he/she has a curved spine or scoliosis?
Has the student…
NO
37. Exhibited significant changes in behavior, social relationships,
grades, eating or sleeping habits; withdrawn from family or friends?
12. Ever been unable to move arms or legs after being hit or falling?
SKIN:
YES
36. Experienced major grief, trauma, or other significant life event?
11. Ever had numbness, tingling, or weakness in his/her arms or legs
after being hit or falling?
Has the student...
NO
33. Name of student’s dentist: ________________________________
7. Had frequent muscle cramps when exercising?
BONE/JOINT:
 No
32. Has the student had any pain or problems with his/her gums or teeth?
6. Ever become ill while exercising in the heat?
Has the student...
NO
30. Had a history of urinary tract infections or bedwetting?
3. Ever had surgery?
HEART/LUNGS:
YES
29. Had groin pain or a painful bulge or hernia in the groin area?
2. Ever stayed more than one night in the hospital?
HEAD/NECK/SPINE: Has the student…
GENITOURINARY:
YES
NO
QUESTIONS OR CONCERNS
46. Are there any questions or concerns that the student, parent or
guardian would like to discuss with the health care provider? (If
yes, write them on page 4 of this form.)
I hereby certify that to the best of my knowledge all of the information is true and complete. I give my consent for an exchange of
health information between the school nurse and health care providers.
Signature of parent / guardian / emancipated student_____________________________________________________ Date_______________
Adapted in part from the Pre-participation Physical Evaluation History Form; ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of
Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.
Page 2 of 4: PHYSICAL EXAM
STUDENT’S HEALTH HISTORY (page 1 of this form) REVIEWED PRIOR TO PERFOMING EXAMINATION: Yes 
No 
Other 
Height:
(
) inches
Weight:
(
) pounds
BMI:
(
)
BMI-for-Age Percentile: (
Pulse:
(
*ABNORMAL FINDINGS / RECOMMENDATIONS / REFERRALS
DEFER
K/1  6  11 
NORMAL
Physical exam for grade:
*ABNORMAL
CHECK ONE
)%
)
/
)
Corrected

Blood Pressure: (
Hair/Scalp
Skin
Eyes/Vision
Ears/Hearing
Nose and Throat
Teeth and Gingiva
Lymph Glands
Heart
Lungs
Abdomen
Genitourinary
Neuromuscular System
Extremities
Spine (Scoliosis)
Other
TUBERCULIN TEST
DATE APPLIED
RESULT/FOLLOW-UP
DATE READ
MEDICAL CONDITIONS OR CHRONIC DISEASES WHICH REQUIRE MEDICATION, RESTRICTION OF ACTIVITY, OR WHICH MAY AFFECT EDUCATION
(Additional space on page 4)
Parent/guardian present during exam: Yes

No 
Physical exam performed at: Personal Health Care Provider’s Office

School 
Date of exam______________20______
Print name of examiner _______________________________________________________________________________________________________
Print examiner’s office address___________________________________________________________________ Phone_______________________
Signature of examiner______________________________________________________________________ MD DO PAC CRNP 
Page 3 of 4: IMMUNIZATION HISTORY
HEALTH CARE PROVIDERS: Please photocopy immunization history from student’s record – OR – insert information below.
IMMUNIZATION EXEMPTION(S):
Medical
Date Issued:___________ Reason: __________________________________________________ Date Rescinded:___________
Medical
Date Issued:___________ Reason: __________________________________________________ Date Rescinded:___________
Medical
Date Issued:___________ Reason: __________________________________________________ Date Rescinded:___________
NOTE: The parent/guardian must provide a written request to the school for a religious or philosophical exemption.
VACCINE
DOCUMENT: (1) Type of vaccine; (2) Date (month/day/year) for each immunization
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Diphtheria/Tetanus/Pertussis (child)
Type: DTaP, DTP or DT
Diphtheria/Tetanus/Pertussis
(adolescent/adult)
Type: Tdap or Td
Polio
Type: OPV or IPV
Hepatitis B (HepB)
Measles/Mumps/Rubella (MMR)
Mumps disease diagnosed by physician
Varicella: Vaccine
Date:__________
Disease
Serology: (Identify Antigen/Date/POS or NEG)
i.e. Hep B, Measles, Rubella, Varicella
Meningococcal Conjugate Vaccine (MCV4)
Human Papilloma Virus (HPV)
Type: HPV2 or HPV4
Influenza
Type: TIV (injected)
LAIV (nasal)
Haemophilus Influenzae Type b (Hib)
Pneumococcal Conjugate Vaccine (PCV)
Type: 7 or 13
Hepatitis A (HepA)
Rotavirus
Other Vaccines: (Type and Date)
Page 4 of 4: ADDITIONAL COMMENTS (PARENT / GUARDIAN / STUDENT / HEALTH CARE PROVIDER)
H514.027 (08/2011-under review)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
PRIVATE DENTIST REPORT
OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE
NAME OF SCHOOL ___________________________________________ DATE __________________ 20 ___
NAME OF CHILD
AGE
_________________________________________________
Last
First
Middle
SEX
M
GRADE
SECTION/ROOM
F
ADDRESS
______________________________________________________________________________________________
No. and Street
City or Post Office
Borough/Township
County
State
Zip
REPORT OF EXAMINATION
TOOTH CHART
1
2
32
31
UPPER
LOWER
RIGHT
4
5
6
A B C
30 29 28 27
T S R
3
7
D
26
Q
8
E
25
P
9
F
24
O
10
G
23
N
11
H
22
M
LEFT
12 13
I
J
21 20
L
K
14
15
16
19
18
17
Upper
Lower
UPPER
Upper
LOWER
Lower
Is The Child Under Treatment?
Yes
No
Treatment Completed
Yes
No
__________________________________________
Date of Dental Examination
__________________________________________
Signature of Dental Examiner
__________________________________________
Address
__________________________________________
Print Name of Dental Examiner
Sapphire - Parent Welcome Letter
The South Eastern School District implemented a new Student Information System called Sapphire in
2014-2015. This is a real-time integrated system that shares data between departments. Parents will be
able to use one account to see attendance, schedules, grades, announcements and student information
for all their children. We are able to provide you with more information and work toward becoming more
paperless. Registration is easy and instructions are listed below:
If you registered last year, your account information and passwords stay the same and you will
not need to register again.
Step 1: Prepare
You must have an email account in order to create an account. If you do not have an email account,
there are many free email sites such as mail.yahoo.com and mail.google.com.
You will need to data enter the grades and birth dates of your children so they will be linked under one
account.
Step 2: Create your parent account
*Any legal guardian who wishes to access the system should create an account.
 Go to www.sesdweb.net
 Click Parent
 Click Sapphire
 Click Community Portal
 Click “Community Portal Application and Acceptable Use Policy Form”
 Enter keyword sesdsapphire
 Read the user agreement
 Click Yes
 Click Continue
 Enter applicant, children and login information.
 Click “Save Form and Continue”
 If desired, you may print a copy of the form for your records. You will automatically receive an
email with your form details.
When your form is approved, you will receive an email notification with your pin. We anticipate approval
will take up to five business days at the start of school year. Forms should be processed in less than 24
hours after the initial set of requests are processed. Record your username, password and pin and store
it in a safe location.
Your account will remain active as long as you have children enrolled in the district. You do not need to
create a new account each year.
Step 3: Log into Sapphire after you receive your pin
 Go to www.sesdweb.net
 Click Parent
 Click Sapphire
 Click Community Portal
 Enter username, password and pin.
Frequently Asked Questions:
If you forget your password, click on the “Forgot your password” link on the login page. Your password
will be emailed to you.
If you forget your pin, email the Help Desk at [email protected] or call 717-382-4843 x6333.
The user manual and any other related information can be found at the following link:
http://www.sesdweb.net/sapphireparentinfo.
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