Transcription
Superintendent of SchoolsAddison G. DavisPrincipalJoanne GriffithsAssistant PrincipalAnne FioritaCIMINO ELEMENTARYSchool Grade: A Recipient of 5 Star Award10 Year Golden School Award2012 & 2017 National School of CharacterDear student and family of student:Welcome to Cimino Elementary School! To complete your registration and begin classes, you must first provide the followingregistration documents. Please submit all required documentation to our registrar, Bonnie Steele. You can fax them to(813)740-4454 or email them as a PDF attachment to: bonnie.steele@hcps.netItems required for new registrations: (new student to Hillsborough County) *If you are submitting your registration Student Registration Form (attached Form SB45501)via email, please combine all forms Parent’s ID – a parent or legal guardian is required to enroll studentand documents into one PDF file Birth Certificatebefore submission. You may also drop Student’s Social Security Card – to verify SSNyour registration off at our front office. Immunization Record Florida Physical – from a licensed health care provider of the Hillsborough County Health Department, dated within twelve monthsprior to entry of Florida Schools. Recent Report Card / IEP / 504**Please note that all forms Residency Form (attached) – and residency documentsmust be signed and dated.Must provide 2 of the following items:Renting HomeCurrent Signed Lease Agreement (signed by all parties)Current Tampa Electric BillOwn HomeCurrent Tampa Electric BillGeneral Warranty DeedCurrent Property Tax StatementHomestead exemption forms (Signed and approved)(If you are living with a relative, etc., the person who will provide the verification documentation listed above must come with youin person to our office with their photo ID and their proof of residency. Both addresses must match.)If your TECO service is new or recently transferred, TECO will provide a Verification of Service upon request. Just call customerservice at 813-223-0800 and request them to email it to you. Also note that pdf versions of property tax receipts are available onlineat the Hillsborough County Tax Collector site.*Attention Kg – 5th grade students already enrolled in Hillsborough County Public Schools: Transfers within Hillsborough County onlyrequire ID, enrollment form, & residency requirements.If you have any questions, please contact me at: bonnie.steele@hcps.net We are excited to be a part of your educational journeyand look forward to meeting you!Connect with Us HillsboroughSchools.org P.O. Box 3408 Tampa, FL 33601-3408 (813) 272-4000Raymond O. Shelton School Administrative Center 901 East Kennedy Blvd. Tampa, FL 33602-3507
Cimino Elementary SchoolDocumentation Required for RegistrationPARENT/GUARDIAN PLEASE COMPLETE THIS SECTIONStudent’s Name DateWhere was your child previously enrolled?Has your child ever been enrolled in any type of Special Education Program or class?NO YESIf YES, what program Gifted SLD EMH Speech Other?Has your child ever been retained? No Yes If YES, what grade?KINDERGARTENStudent Enrollment (make sure it is signed and any health alerts noted)Proof of Residency Form (must provide two items from list below)Birth Certificate (must be 5 years of age on or before September 1st of the current school year)Social Security CardPhysical Exam (within the last 12 months from the day student starts school)Immunization Record (Form DH680) OR Religious exemption (HRS Form 681) from the Hillsborough Co. Health Dept.K12345Varicella – 2 doses (chicken pox)XXXXXXDPT – 5 doses (final after 4th birthday)XXXXXXPolio - 4 doses (final after 4th birthday)XXXXXXMMR - 2 dosesXXXXXXHepatitis B – 3 dosesXXXXXXTRANSFERS WITHIN HILLSBOROUGH COUNTYStudent Enrollment Card (make sure it is signed and any health alerts noted)Proof of Residency (must provide two items from list below.)Latest Report Card (if available) and Withdrawal PapersIndicate if student is in any special classesOUT OF COUNTY / OUT OF STATE / PRIVATE SCHOOLStudent Enrollment Card (make sure it is signed and any health alerts noted)Proof of Residency (must provide two items from list below.)Physical Exam (within the last 12 months from the day student starts school)Immunization RecordPLEASE GIVE ADDRESS OF SCHOOLBirth CertificateSocial Security CardWithdrawal papers & Report Card to indicate grade levelIndicate if student is in any special classesFax#Documentation for Proof of Residence – Must provide 2 items from listCurrent TECO BillCompleted Homestead ExemptionGeneral Warranty DeedDocuments Needed for Registration FormSigned Lease Agreement (signed by renter/owner)Current Property Tax StatementSigned Copy of Contract for Purchase of Home (buyer/seller)
PLEASE PRINT FIRMLYNAME OF STUDENT(LAST)DISTRICT STUDENT NUMBERCimino Elementary SchoolTEACHER OR HOMEROOMEMERGENCY INFORMATION:GRADEThis card must be completed by the parent or legal guardian.(JR, 2D, 3D, 4T)(FIRST)STATE STUDENT NUMBER(MIDDLE)DATE OF BIRTHMM DD YYMALEFEMALEMAILING ADDRESS – (STREET NUMBER & NAME, CITY, ZIP CODE)RESIDENTIAL ADDRESS – (IF DIFFERENT FROM MAILING ADDRESS) (STREET NO. & NAME, CITY, ZIP) (IF RURAL LOCATION, PLACE DIRECTIONS ON REVERSE)PARENT/LEGAL GUARDIAN (LAST, FIRST, INITIAL)PARENT/LEGAL GUARDIAN (LAST, FIRST, INITIAL)EMPLOYER NAMEEMPLOYER NAMEBUSINESS PHONE/EXTENSIONPLEASE PRINT FIRMLYAUTHORIZATION FOR STUDENT RELEASE AND EMERGENCY INFORMATION CARDTHIS BLOCK FOR SCHOOL USE ONLYSCHOOL YEARSCHOOL NAMEMOBILE NUMBERBUSINESS PHONE/EXTENSIONENTRYCODEENTRYDATECHILD OF MILITARY FAMILY?YES NOMilitary Family Includes:1) members on active duty or2) members for 1 year following:medical discharge due to injuryretirementdeath due to active duty injuryHOME PHONEMOBILE NUMBEREMAILEMAILRELATIONSHIPP – PARENTO – OTHERTO STUDENT:G – LEGAL GUARDIANS – SURROGATE(CIRCLE ONE)A – GUARDIAN AD LITEMN – NO PARENT/GUARDIAN REQUIREDPERSON(S) TO CONTACT IF PARENT CANNOT BE REACHEDDAYTIME PHONENAME (STUDENT MAY BE RELEASED TO THIS PERSON)RELATIONSHIPP – PARENTO – OTHERTO STUDENT:G – LEGAL GUARDIANS – SURROGATE(CIRCLE ONE)A – GUARDIAN AD LITEMN – NO PARENT/GUARDIAN REQUIREDPERSON(S) TO CONTACT IF PARENT CANNOT BE REACHEDDAYTIME PHONENAME (STUDENT MAY BE RELEASED TO THIS PERSON)HOSPITAL PREFERENCEPHYSICIAN NAME & PHONE NUMBERDENTIST NAME & PHONE NUMBERCURRENT HEALTH PROBLEMSEXPLANATION OF HEALTH PROBLEM(S) AND/OR MEDICATION(S) STUDENT IS TAKINGASTHMA DIABETES SEIZURESHEART CONDITION ALLERGIESOTHERIn the case of accident, serious illness, or emergency, the school may contact Emergency Management Services (EMS), 911. If EMS must transport your child, payment of fees will be assumed by the parent/legalguardian. The school will make every effort to contact the parent/legal guardian. If the school is unable to contact the parent/legal guardian, every effort will be made to notify other persons listed on the emergency card.I have reviewed and understand the conditions of this document and I understand that if I desire to have mychild released to persons other than those listed above, I must provide a list of those persons in writing, withaddresses and telephone numbers, to the principal of the school.XSignature of Parent/Legal GuardianDateREGISTRATION INFORMATIONStudent’s Social Security Number - -*** Notice ***HCPS collects Social Security Numbers for the purposes of creating a unique numerical identificationwithin the HCPS system and for required reporting to the Department of Education. Enrollment will notbe denied to a student because the student or student’s parent/legal guardian does not provide a SocialSecurity Number.BirthplaceCityStateCountryFirst-time Hillsborough County StudentYes No Did the student relocate/move to Hillsborough County from ANOTHER county, state or country within the past year?If yes, City State County Country(Last School attended by the Student) Public Private Home Education (Include the dates attended and complete address information below)School Name Dates AttendedStreet Address City StateZip Code CountyIf the student ever attended a Hillsborough County Public School, name of schoolHome Language SurveyYes No Is a language other than English used in the home?Yes No Did the student have a first language other than English?Yes No Does the student most frequently speak a language other than English?Primary language spoken in the home by the Parent/Legal GuardianStudent’s Native LanguageState/Federal Mandated InformationYes No Is either head of household a law enforcement officer, firefighter, or judge/justice?Yes No Is either parent in the military, employed as a federal civilian, or residing in a housing project?Yes No Did your family ever travel to look for work on a farm or do paid farm labor?Yes No Is the student a single parent with either custody or joint custody of a minor child?Yes No Has the student ever been expelled, arrested resulting in a charge, or had juvenile justice actions?Yes No Has the student ever had any referrals to mental health services?Date student first entered a United States school: Month (MM) / Day (DD) / Year (YYYY)If foreign born, how many years has the student attended a school in the United States?Yes No Is the student of Hispanic or Latino ethnicity?Check all applicable races American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian or other Pacific IslanderWhiteStudents with Individual Educational Plans (IEPs) have protections under Part B of the IDEA, and are entitled to a free appropriate public education. As parent/legal guardian, I give permissionfor the school district to release, exchange, review, and utilize my child’s personally identifiable information to assist in the provision of school health services, and for this information to bedisclosed to the Agency for Health Care Administration to facilitate verification of Medicaid eligibility; and/or, as applicable, to seek reimbursement from Medicaid for services provided atschool. I understand that my child will continue to receive all services per his/her IEP, at no charge, whether or not I give consent. I understand that I may withdraw my consent at any time, andthat my state/private benefits are not affected.Signature of Parent/Legal GuardianDateDistribution: Original – Student Cumulative Folder, Copy – Data ProcessorSB 45501 (Rev. 08/22/2018)Page 1 of 1
Page 1 of 2STATE OF FLORIDASchool Entry Health ExamTo Parent/Guardian: Please complete and sign Part I — Child’s Medical History.State law for school entry requires a health examination by a legally qualified professional. Additional requirements may be determinedby local school districts.(Please Print)Name of Child (Last, First, Middle)Birth DateSexAddress (Street)SchoolGradeCity and ZIP CodeHome Telephone NumberParent/Guardian (Last, First, Middle)PART I — CHILD’S MEDICAL HISTORYTo Parent/Guardian: Please check answers to questions 1 through 8 below in the column on the left.(Please explain any “Yes” answers in the space provided below.)1. Yes2. Yes3. Yes4. Yes5. Yes6. Yes7. Yes8. YesNoNoNoNoNoNoNoNoAny concerns about general health (eating and sleeping habits, weight, etc.)?Any other specific illness or social/emotional or behavioral problems?Any allergies (food, insects, medication, etc.)?Any prescription medication (daily or occasionally)?Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)?Any hospitalization, operation, or major illness (specify problem)?Any significant injury or accident (specify problem)?Would you like to discuss anything about your child’s health with a school nurse?To Parent/Guardian: Please explain any “Yes” answers from above.I am the parent/guardian of the child named above. I give permission for the information on PARTS I and II of this formprovided about my child to be reviewed and utilized only by the staff of this school and any school health personnel providingschool health services in the district for the limited purpose of meeting my child's health and educational needs.Signature of Parent/GuardianDatePartnership for School Readiness Recommendations for Prekindergarten and KindergartenTo Parent/Guardian: Please obtain the services listed below in order to find any problems. Please work with your health care provider tocorrect or treat any problems that may reduce your child’s ability to learn in school. (These services are recommended but not required.)1. Comprehensive Vision Examination (3-5 years of age)Date of Exam:Results of Exam:Health Care Provider:(check one) OptometristPlease describe any corrective action for any problems detected andany accommodations required.Ophthalmologist2. Comprehensive Dental ExaminationDate of Exam:Results of Exam:Please describe any corrective action for any problems detected andany accommodations required.Dentist:3. Hearing ScreeningDate of Exam:Results of Exam:Health Care Provider:DH3040-CHP-07/2013Please describe any corrective action for any problems detected andany accommodations required.
2021-2022Cimino ElementaryNew Student Profile Input Form2020 – 2021Student Name: Grade:Phone:Parent/Guardian Name: Phone:( )PLEASE COMPLETE THE INFO BELOWYour input will be used by Cimino’s Placement Committee as we consider the best homeroomplacement for your child. To ensure that all students have equal opportunities to experience anyand/or all of the instructional professionals at Cimino, we ask that you not request a particularteacher. Writing a teacher’s name on this form will render it invalid.Please indicate with a check mark only the descriptors that would be important considerations:My child works best when the classroom is very quiet and structured.My child works best when the classroom environment frequently allows formovement and choices.My child works best when he/she is highly challenged academically.My child needs extra time and additional supports to master standards.What academic or social areas do you consider to be a strength for your child?What academic or social areas would you like to see your child develop next year?Is there anything else the placement committee needs to consider when placing your child?
Side AStudent Residency FormComplete Side A of this form if the Parent/Guardian can provide Proof of Residence.This form defines the student enrollment category and verifies residence when enrolling a student in a Hillsborough CountyPublic School.Student Name:School:Student Number:Date of Birth:Student Address:1. What is the current student residence?Family owned houseHomesteadedYesNoFamily rented apartment/houseLicensed foster care placement (update D Screen)Co-residing and no residency documents (parent has not experienced a loss of housing) (update B and DScreens)If co-residing, the party with whom the family resides must sign below and provide two (2) proofs ofresidency. In this circumstance, this form is valid for one school year only and expires at the end of theschool year.Acknowledgement: I certify that the family referenced above is residing with me at the above address.Print the name of party with whom student residesSignatureDatePlease check the documents being provided to the school for verification of residence (2 are required):Homestead exemptionCurrent electric billLease agreementProperty tax receiptContract for purchase of homeWarranty deed2. The undersigned certifies that all information contained in this form is accurate. Per HCPS Policy 2431,students are not guaranteed the ability to participate in the athletic program if they transfer schools. Contact the AssistantPrincipal for Administration for more information.Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true(FS 92.525). A person who knowingly makes a false declaration is guilty of the crime of perjury by false writtendeclaration, a felony of the third degree.Print Name of Parent/GuardianDistribution: Data ProcessorSB 60711 (Rev. 5/14/2020)Signature of Parent/GuardianDateSide A
Student Residency FormSide BComplete Side B of this form to determine a student’s eligibility under the federal McKinney-VentoHomeless Education Act. Eligible students are to be immediately enrolled even if they are missing therequired documentation.This form defines a student enrollment category and verifies residence for enrollment in a Hillsborough County Public School.Student Name:School:Student Number:Date of Birth:Student Address:Questions 1-3 must be completed to determine eligibility.1. Describe the current residence of the student:Living in an emergency/transitional shelters (e.g. FEMA Trailers) or abandoned in a hospital (McKinney-Vento Code A)Sharing the housing of other persons due to loss of housing or economic hardship or other similar reason;doubled-up (McKinney-Vento Code B)Living in a car, parks, temporary trailer parks or campgrounds due to lack of alternative adequate accommodations, publicspaces, abandoned buildings, substandard housing, bus or train stations, public or private place not designed foror ordinarily used as a regulars sleeping accommodation for human beings or similar settings (McKinney-VentoCode D)Living in a hotels or motels due to lack of alternative adequate accommodations(McKinney-Vento Code E)2. Is the student an “Unaccompanied Homeless Youth” (not living in physical custody of a parent/legal guardian)and identified under McKinney-Vento (code UAC field)?YesNo3. Reason for residency status:Check One ReasonCauseMan-Made Disaster (Major)EarthquakeFloodingHurricaneMortgage Foreclosure-Homeless family loses own home due to foreclosureOther homeless causesTropical StormTornadoUnknownWildfireSCHOOL CODE (office use)DEFHMNSTUWThe undersigned certifies that all information contained in this form is accurate. This form is valid for oneschool year only and expires at the end of the school year. Per the HCPS policy 2431.01, students are not guaranteedthe ability to participate in the athletic program if they transfer schools. Contact the Assistant Principal for Administration for moreinformation.Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true(FS 92.525). A person who knowingly makes a false declaration is guilty of the crime of perjury by false writtendeclaration, a felony of the third degree.Print Name of Parent/GuardianSignature of Parent/GuardianDateData processors – This form (SB 60711) must be coded into the student database upon enrollment (on B, D, and E screens).The original document is maintained in a file located in the data processor’s office. This form should not be placed in thestudent’s cumulative folder.Distribution: Data Processor, Administrator, School Social Worker, and District Homeless Liaison via fax (813) 384-3979.SB 60711 (Rev. 5/14/2020)Side B
CIMINO ELEMENTARY SCHOOL4329 CULBREATH RD.VALRICO, FL 33596(813) 740-4450FAX (813) 740-4454bonnie.steele@hcps.netCIMINOCOUGARSRequest for RecordsTo: Name of Previous SchoolAddress:City, State, Zip:Phone Number:Fax Number:X UrgentFor ReviewPlease CommentPlease ReplyPlease RecycleThe student listed below has enrolled in the School District of Hillsborough County.Please forward the permanent academic records, health records, confidential records,and other available guidance materials, psychological evaluations and social historiesto the school indicated by the above return address.Student Name: LastFirstMiddleDate of BirthGradeParent Signature – Indicates permission to fax or email recordsDateBonnie Steele, Data Processor / School Official SignatureDateParental permission is not required when authorized school personnel request records.(Family Educational Rights and Privacy Act, Final Rule on Education Records, Federal Register, June 17, 1976, Vol.41, No. 18, page 24673).
If your TECO service is new or recently transferred, TECO will provide a Verification of Service upon request. Just call customer service at 813-223-0800 and request them to email it to you. Also note that pdf versions of property tax receipts are available online at the Hillsborough County Tax Collector site.
