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111111111111111111111111111111EMERGENCY MEDICALAUTHORIZATION FORMTeacherGradeSchoolPURPOSE OF THIS FORM: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured whileunder the school's authority, when parents or guardians cannot be reached. Please be sure to complete each blank.Student LAST NAMEStudentrmsrNAMEStudent Home AddressSex (MlF)CityHome Phone NumberDate of BirthZip CodeStateSiblings in District: First and Last 's NameMother's AddressMother's Home Ph. #Mother's Wk. Ph. #Father's NameMother's Cell Ph. #Father's AddressFather's Home Ph. #Father's Wk. Ph. #Step Parent's NameFather's Cell Ph. #Step Parent's AddressStep Parent's Home Ph. #Step Parent's Wk. Ph. #Step Parent's Cell Ph. #NAMES OF RELATIVE / CARE PROVIDER / ALTERNATE CONTACT (WHO TO CONTACT IN THE ABSENCE OF PARENT! ddressDaytime Phone #RelationshipIf there are any medical conditions, please check this boxNote: Details regarding noted medical conditions should be noted below* * * * * PARTDI OR PART II BELOW MUST BE COMPLETED AND SIGNED* ****PART I - TO GRANT CONSENT. I hereby give consent for the following medical care providers / local hospital to be called.Doctor's NamePhone#AddressDentist's NamePhone#AddressMedical Specialist (optional)Phone#AddressLocal HospitalER Phone #AddressInthe event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (l) the administration f any treatment deemed necessary byabove named doctor, or in the event the desiguated preferred practitioner is not available, by another licensed physician or dentist, and (2) the transfer of the childto preferred hospital or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensedphysicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.Facts concerning the child's medical history including medical conditions (ex. Diabetes, asthma, significant allergies, ADHD, autism, Down Syndrome,hearing/vision impairments, etc.) and medications being taken to which a physician should be alerted:DateSignature of Parent! Guardian --;:::;-:--:--;---;--:---:-: -. :-:-;-:- -;-:-:--:--:--:- -;-NOTE: The above information will be shared with appropriate staff as necessary. This includes, but is not limited to, administrators.drivers.foodservice staff, custodians, coaches and substitute employees. Please notify the school nurse of any concerns.-:- ;;;-;-teachers, support steff, busDO NOT COMPLETE PART II IF YOU COMPLETED PART IPART II - REFUSAL TO CONSENT. I DO NOT give my consent for emergency medical treatment of my child. Inthe event of illness or injury requiringemergency treatment, I wish school/district authorities to take the following action:DateSignature of Parent! Guardian

111111111111111111111111111111Race/Ethnicity ReportingDue to mandated data collection and reporting requirements from the United States Department of Education (USDOE),the Ohio Department of Education is changing the reporting of race/ethnicity information.Please complete the boxes below in regards to your child's race/ethnicity. If you fail to complete the informationbelow, the District will use observer identification to complete this form.BOXlStudent Name:Last NameMiddle NameFirst NameBOX2Is your child of Hispanic/latinoHeritage?DNoOVes(Continue below)Persons of Mexican. Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race.BOX3Is your child multiracial?OVesDNo(Continue below)Persons having origins in two or more of the racial! ethnic groups list below in Box4BOX4BOX5Select more than one of the following if youchecked "Yes" in Box 3 above:D WhitePersons who have origins in any of the original peoples ofEurope, North Africa, or the Middle East.D Black or African AmericanPersons who have origins in any ofthe black racial groupsIn AfricaD AsianPersons having origins in any ofthe original people of theFar East, Southeast Asia, or the India subcontinent, Thisarea includes, for example: Cambodia, China, India, Japan,Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,and VietnamD American Indian or Alaskan NativeSelect one of the following if you checked"No" in Box 3 above:D WhitePersons who have origins in any of the original peoples ofEurope, North Africa, Dr the Middle East.D Black or African AmericanPersons who have origins in any of the black racial groupsin AfricaD AsianPersons having origins in any of the original people of theFar East, Southeast Asia, Dr the India subcontinent, Thisarea includes, for example: Cambodia, China, India, Japan,Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,and VietnamD American Indian or Alaskan NativePersons having origins in any of the original people ofNorth and South America (including Central America) andwho maintain tribal affiliation or community attachmentPersons having origins in any of the original people ofNorth and South America (including Central America) andwho maintain tribal affiliation or community attachmentD Native Hawaiian or Other Pacific IslanderD Native Hawaiian or Other Pacific IslanderPersons having origins in any of the original peoples ofHawaii, Guam, Samoa, or other Pacific Islands.Parent IGuardian Signature,Persons having origins in any of the original peoples ofHawaii, Guam, Samoa, or other Pacific Islands.Oate:,

111111111111WINTON WOODS CITY SCHOOLSAUTHORIZATION TO RELEASE INFORMATIONEnrolling to enter grade:Parent/GuardianDate of BirthM.I.First Name(print) Student's Last Name(print) Parent/GuardianName:DateSignature authorizing the release of school records to Winton Woods City SchoolsPrint contact namePhoneFaxAddressCityStatePrevious SchooI/Institution NamePhoneFaxAddressCityStatePresent School/InstítuûonNameAttn: Registrar/RecordsZip CodePrint contact nameZip CodeClerkIs student currently under an expulsion or suspension?YESNOIf records are not available, please return our request indicating the reason:( ) No records available() Sending partial recordsReason(s):Students' withdraw date:.!/!/Records Clerk Signature: Discipline Records - Suspensions/ExpulsionsTranscript of subjects and gradesAttendance RecordOhio Proficiency / Standardized Test ResultsHealth RecordsDate: Court Orders (Custody, Restraining, etc)All Other personally identifiable dataPsychological or Other Individual Test Results*lEP & Special Education Records, if applies"504 or other Intervention Plans*Fax or Email records to: (Johnson.Kim@wintonwoods.org)( ) Primary North 73 Junefield Avenue, Cincinnati, Ohio 45218 Phone 513.619.2390 Fax 513.619.2398( ) Primary South 825 Lakeridge Drive, Cincinnati, Ohio 45231 Phone 513.619.2470 Fax 513.619.2479( ) Elementary School 1501 Kingsbury Drive, Cincinnati, Ohio 45240 Phone 513.619.2490 Fax 513.619.2497( ) Intermediate School825 Waycross Road, Cincinnati, Ohio 45240 Phone 513.619.2450 Fax 513.619.2451( ) Middle School147 Farragut Road, Cincinnati, Ohio, 45218 Phone 513.619.2440 Fax 513.619.2452( ) High School 1231 West Kemper Road, Cincinnati, Ohio 45240 Phone 513.619.2420 Counselor Fax 513.619.2415( ) Student Services 8 Enfield Street, Cincinnati, Ohio 45218, Phone 513.619.2320 Fax 513.619.2339( ) Enrollment Center 8 Enfield Street, Cincinnati, Ohio 45218, Phone 513.619.2360 Fax 513.619.2363Please send the above records, if available for this student, as soon as possible. Pursuant to Section 5 Paragraph C of 325 ILCS 5015"any elementary or secondary school requested to forwarded a copy of a transferring student's record to the new school shall complywithin 10 days of receipt unless the record has been flagged pursuant to subsection (a) notification by Dept. of a person'sdisappearance). "WWCS RegistrarDateAdmission Date

FROM THE NURSE'S OFFICEEmergency CardsPlease complete both sides ofthe emergency card (remember to sign the appropriate section for consent on theback of the card). Give names and numbers of those adults preferably in the Winton Woods area who are ableto help your child in case of emergency or illness. Student will only be released to those listed on theemergency card.Medication ProcedureNo student will be given medication at school unless the proper forms have been completed and themedication has been delivered to the school by an adult. A medicationform must be completedby the.physician and parent for each prescription medication and a.form must be completed bythe parent for each over. the counter medication. Use one fonn for each medication. Medications can only be given as directed on thefonn. A physician/parent authorization must be on file in the office before a student can carry and selfadminister an inhaler or Epi-pen.Health Exclusion PolicyThe following categories of students will be excluded from school until the situation has been remedied: A student who has not been fully immunized per state health guidelines. A student with symptoms of a communicable disease. A student with head lice and/or nits. A student with a communicable rash. A student with a temperature of 100 degrees or greater. A student must be fever free without feverreducing medication for 24 hours before returning to school.Head LiceThe Winton Woods City School District has a "no nits" policy, as do most schools in the area. This means thatallHce and nits must be removed from a child's hair before returning to school. Each school has writteninformation detailing how to become free of head lice and nits. If your child has lice or nits, please inform theschool so the rest of his/her class can be checked. We try to maintain confidentiality and try to be sensitive tothe child's need.Screening ProceduresThe State of Ohio has mandated that vision, hearing, and scoliosis screenings be perfonned at certain gradelevels. If you have questions about this, feel free to contact the nurse.Please call with any questions or health 9-2320Winton Woods District Nursesrevised 9/12

Dear Parents of Students New to the Winton Woods City School District:The Ohio State Department of Health and the Winton Woods City School District Boardof Education require certain immunizations upon entrance to school. The following recordsmust be completed in order for students to fulfill registration requirements:Proof of Immunizations1.DPT (Diptheria, Pertussis, Tetanus) At least four doses are required, If the 4th. dose wasgiven beforethe. th·birthday, a5th dose is required.ORTD (Tetanus, Diptheria) At least 3 doses are required if immunization process isstarted after age six.Tdap or TD Booster (Tetanus, Diptheria, Pertussis) required for grades 7-11If the 3rd dose was given before the 4th2.POLIO At least 3 doses are required.birthday, a 4th dose is required.3.MMR (Measles, Mumps, Rubella) 2 doses are required4.HEPATITIS B 3 doses are required5.Varicella6.Hib (haemophilus-b)7.PPD (Tuberculosiscountry.(chicken pox) 1 dose required for grades 5-8Second dose required for grades K- 4required for pre-school (see guidelines)skin test) required for students entering from a foreignHealth is a very important part of a child's achievement and well-being. It is important foryou to share with us any information about your child's health that requires the cooperationbetween family and school.Sincerely,Patricia D' Arcy, DirectorDepartment of Teaching and Learningpp-88-303bRevised 1/14

111111 II 1111PARENT NOTIFICATION OF HEALTH REQUIREMENTSDATE:STUDENT'SGrade: (student is now entering)NAME:DATEOFBIRm:NAME OF PREVIOUS SCHOOL:CITY/STATE:Gender: M or F:PARENTCONTACTNUMBER:-------- --'PHONENUMBER:Facts concerning this student's medical history (ex: Diabetes, Asthma, Allergies (food,environment, & medicine), physical impairment, conditions requiring medications, etc.)*For severe conditions please contact your School Nurse prior to student starting school.Has this student ever had a positive TB (tuberculosis) skin test?Was a chest x-ray done?Date:Has this student BEEN IN a foreign country in the last 5 years? YESNameofCountryReason for visit:NOLength ofvisit:Returned to United States from visit (Month/Y ear):Has this child ever attended a Winton Woods City School before? Yes or NoIf YES, name of last school attended:Current immunization records MUST BE PROVIDEDin order to complete the enrollment process.I have been informed of the items needed to complete registration for school for my son/daughter.Parent SignatureRevised 9/12

111111111111 11111111111111 IIIIWINTON WOODS CITY SCHOOLSMEDICINE RELEASE FORMAll medications must accompany this form, must be in the original container,and must be delivered to the school by an adult.*THIS SECTION TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN*Use separate form for each medicationStudent's Teacher:Dosage:,Time to be given during school hours(i.e. lunchtime, 12:00p.m. etc.)Description of Medication: Possible side effects:-----------In signing this fonn, I will assume responsibility for safe delivery of the medication to the school, I will beresponsible for providing written notification by myself and my physician of any change in the use of themedication or the prescribed treatment, and I release and agree to hold the Board of Education, its employeesand its officials harmless from any and all liability foreseen or unforeseen for damages or injury resultingdirectly or indirectly from this authorization.Parent/Guardian Signature:Home Phone:Date:Emergency Phone:*TIDS SECTION TO BE COMPLETED BY PHYSICIAN FOR PRESCIPTION MEDICATIONS*Use separate form for each medicationStudent's Name:Medication:Dosage:Time to be given during school hours:(i.e. Lunchtime, 12:00 p.m. etc.)Description of Medication:Possible side effects:Special instructions:---'-Physician's Name: (print)Phone:Physician's Signature:Date:Date of initiation of medication:-------------Date to discontinue: -------This permission is valid only for the current school year.All medication must be picked up from the school by an adult by the last day of school or it will be discarded.A student may carry and/or administer his/her own medication if so ordered,in writing, by both the physician and parent.pp-88-303cRV2/07

111111111111STUDENT NETWORKAND INTERNET ACCEPTABLE USE AND SAFETY AGREEMENTPlease complete the following information:Student User's Full Name (please print):Homeroom/Advisory:.Student ID:School:Grade:Parent/Guardian's Name (please print):--'- Please see back side for parent/student signaturesTo access e-mail and lor the Internet at school, students under the age of eighteen (18) must obtain parent permission and mustsign and return this form. Students eighteen (18) and over may sign their own forms.Use of the Internet is a privilege, not a right. The Governing Board's Internet connection is provided for educational purposes only.Unauthorized and inappropriate use will result in a cancellation of this privilege.The Board has implemented technology protection measures, which protect against (e.g. block/filter) Internet accessto visualdisplays/depictions/materialsthat are obscene, constitute child pornography, or are harmful to minors. The Board also monitorsonline activity of students in an effort to restrict access to child pornography and other material that is obscene, objectionable,inappropriate and lor harmful to minors. Nevertheless, parents/guardians are advised that determined users may be able to gainaccess to information, communication, and/or services on the Internet that the Board has not authorized for educational purposesand/or that they and/or their parents/guardians may find inappropriate, offensive, objectionable or controversial.Parents/Guardians assume this risk by consenting to allow their students to participate in the use of the Internet. Students accessingthe Internet through the school's computers assume personal responsibility and liability, both civil and criminal, for unauthorized orinappropriate use of the Internet.The Board has the right, at any time, to access, monitor, review and inspect any directories, files and/or messagesresiding on or sentusing the Board's computers/networks.Messages relating to or in support of illegal activities will be reported to the appropriateauthorities.As the parent/guardian of this student, I have read the Student Network and Internet Acceptable Use and Safety Policy andGuidelines, and have discussed them with my child. I understand that student accessto the Internet is designed for educationalpurposes and that the Board has taken available precautions to restrict and lor control student accessto material on the Internetthat is obscene, objectionable, inappropriate and/or harmful to minors. However, I recognize that it is impossible for the Board torestrict access to all objectionable and lor controversial materials that may be found on the Internet. I will not hold the Board (orany of its employees, administrators or officers) responsible for materials my child may acquire or come in contact with while on theInternet. Additionally, I accept responsibility for communicating to my child guidance concerning his/her acceptable use of theInternet -i.e., setting and conveying standards for my daughter/son to follow when selecting, sharing and exploring information andresources on the Internet. I further understand that individuals and families may be liable for violations.7540.03 Fl/page 1 of 2NEDLA 2009

Parent/GuardiansTo the extent that proprietary rights in the design of a website hosted on the Board's servers would vest in my child upon creation, I.agree to assign those rights to the Board.Please check each that applies: , ;I give permission for my child to use and accessthe Internet at school and for the Board to issue an Internet/e-mail accountto my child.I give permission for my child's image (photograph) to be published online, provided only his/her first name is used.I give permission for the Board to transmit "live" images of my child (as part of a group) over the Internet via a web cam.I authorize and license the Board to post my child's classwork on the Internet without infringing upon any copyright mychild may own with respect to such class work. , understand only my child's first name will accompany such classwork.Parent/Guardian's Signature:Date:StudentI have read and agree to abide by the Student Network and Internet Acceptable Use and Safety Policy and Guidelines. I understandthat any violation of the terms and conditions set forth in the Policy and Guidelines is inappropriate and may constitute a criminaloffense. As a user of the Board's computers/networkand the Internet, I agree to communicate over the Internet and theNetworking in an appropriate manner, honoring all relevant laws, restrictions and guidelines.Student's Signature:Date:-,-Teachers and building principals are responsible for determining what is unauthorized or inappropriate use. The principal may deny,revoke or suspend access to the Network/Internet to individuals wh

*Duetostate laws and/or board policy, Winton Woodsrequires the above documents tobeshown toschool officials whenyour child(ren)is being registered. Thankyouinadvance forproviding thesedocuments. Office hours forregistration are: Mon-Fri 8:00am - 3:00pm Phone (513) 619-2360 Fax(513) 619-2363 OS/2013