5K Enrollment

5K Enrollment
Woodruff Primary School
Child Information
Child's Name
First NameLast Name
Middle Name
Name Called
Sex
MaleFemale
Is the student Hispanic or Latino?
YesNo
Date of Birth
MonthDayYear
Date
Social Security Number
What is the student's race? (Check all that are appropriate.)
AsianBlack or African AmericanAmerican Indian or Alaska nativeNative Hawaiian or Other Pacific IslanderWhite
Home Address*
Street Address
City
Postal / Zip Code
Mailing Address (If different from Home Address)
Street Address
City
Postal / Zip Code
Current Child Care Provider - The child lives with:
Both ParentsMotherFatherGrandparentOther
Mother's/Guardian's Name
First Name
Street Address Line 2
Last NameMiddle Initial
Postal / Zip Code
Primary Contact Number
Is your primary contact number a:
Land LineCellWork
Secondary Contact Number
Is your secondary contact number a:
Land LineCellWork
Place of Employment
Mother's Educational Level:
Less than a High School DiplomaGEDHigh School DiplomaAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate
Mother's/Guardian's Email:
Father's/Guardian's Name
First Name
Last Name
Middle InitialState / Province
Postal / Zip Code
Primary Contact Number
Is your primary contact number a:
Land LineCellWork
Secondary Contact Number
Is your secondary contact number a:
Land LineCellWork
Place of Employment
Father's Educational Level:
Less than a High School DiplomaGEDHigh School DiplomaAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate
Father's/Guardian's Email:
Family Income previous 12 Months:
$0 - $10,000$10,000 - $20,000$20,000 - $30,000$30,000 - $40,000$40,000 - $50,000$50,000 - $60,000Over $60,000
List all other children in the family:
Child #1
Name
School Attending
AgeState / Province
Postal / Zip Code
Child #2
Name
School Attending
AgeState / Province
Postal / Zip Code
Child #3
Name
School Attending
AgeState / Province
Postal / Zip Code
I attest that I am the parent or legal guardian and all information provided is true and accurate.
Signature
Clear
Date
MonthDayYear
Date
Additional Information
Who in your family has participated in a school district Family Literacy Program, such as adult literacy, adult education (GED, High School diploma, ESL), parent education, child development, or parent and adult/child interactive literacy?
Both ParentsMotherFatherGuardian/GrandparentNo one
Did your child ever participate in school district Literacy Services?
YesNo
If yes, how long?
1 Year2 Years3 Years4 or more years
Does your child have a current Individual Education Program (IEP) or Section 504 plan?
YesNo
The IEP is for which disability?
EmotionalLearningSpeechPhysicalOther
Did your child weigh less than 5.5 pounds at birth?
YesNo
Home Language Survey (HLS)
The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 457 U.S. 202 (1982
The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district / charter school. The HLS is administered one time, upon initial enrollment in South Carolina, and remains in the student's permanent record.
Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the survey questions below, the W-APT will be administered to determine whether or not the student will qualify for additional English language development support.
Please answer the following questions regarding the language spoken by the student:
What is the language that the student first acquired?
What is the primary language(s) most often spoken by the student?
What is the language used in the home, regardless of language spoken by the student?
In what language do you wish to have communication from the school?
Student Name
Parent/Guardian Name
Grade LevelState / Province
Parent/Guardian Name
By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.
Signature
Clear
Date
MonthDayYear
Date
Spartanburg School District Four Proof of Residency
Student Name:
First
Street Address Line 2
MiddleLast
Postal / Zip Code
Date
MonthDayYear
Date
Parent/Guardian Name
FirstLast
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
All applicants must submit at least one document from the following list. Original documents are required at the time of enrollment; photocopies and partial pages may be unacceptable.
●Residential property tax receipt
●Current lease/rental agreement
●Current mortgage agreement
Please list the names and ages of your other children that you plan to enroll in a Spartanburg District Four School.
My signature attests that I have legal custody of my student, my student resides with me, and I am a legal resident of Spartanburg School District Four at the address reported above.
Signature
Clear
Date
MonthDayYear
Date
South Carolina Department of Social Services Child Care Regulatory Services
GENERAL RECORD AND STATEMENT OF CHILD’S HEALTH FOR ADMISSION TO CHILD CARE FACILITY
This form is to be completed for each child at the time of enrollment in the child care facility, updated as needed when changes occur, and maintained on file at the facility.
GENERAL INFORMATION:(to be completed by Parent or Guardian)
Child’s Name:
First Name
Middle Initial
Last Name
Nick Name
Date of Birth:
MonthDayYear
Date
Enrollment Date:
MonthDayYear
Date
Child's Current Home Address
Street Address
Street Address Line 2
City, State, ZipState / Province
Postal / Zip Code
Parent/Guardian’s Full Name:
Home Phone:
Work Phone:
Other Phone:
Parent/Guardian’s Full Name:
Home Phone:
Work Phone:
Other Phone:
You must have two individuals who have the authority to obtain emergency medical treatment for the child.
1. Person responsible if parent/guardian unavailable for emergency medical services:
Full Name
Relationship
Address
Street Address
Street Address Line 2
City, State, ZipState / Province
Postal / Zip Code
Telephone Number(s):
Family Code Word(s):
2. Person responsible if parent/guardian unavailable for emergency medical services:
Full Name
Relationship
Address
Street Address
Street Address Line 2
City, State, ZipState / Province
Postal / Zip Code
Telephone Number(s):
Family Code Word(s):
If Child is a drop-in, indicate hours of care: FROM
am/pm TO
HEALTH INFORMATION:(to be completed by Parent or Guardian)
Name of Family Physician or Health Resource
Address
Street Address
Street Address Line 2
City, State, ZipState / Province
Postal / Zip Code
Telephone
Emergency Care Provider - Emergency Facility Name
Address
Street Address
Street Address Line 2
City, State, ZipState / Province
Postal / Zip Code
Telephone
DSS Form 2900 (MAR 10) Edition of OCT 07 is obsolete.
Name of Dental Care Provider
Address
Street Address
Street Address Line 2
City, State, ZipState / Province
Postal / Zip Code
Telephone
Health Insurance Provider:
Certificate of Immunization:
Yes:NoOther
My child has the following health conditions such as allergies, asthma, diabetes, epilepsy, etc., and/or takes the following medications on a regular basis:
Additional Comments:
I certify that to the best of my knowledge that my child is in good mental and physical health and able to participate in the child care program at Woodruff Primary School Child Care Center.
Child's Name
Date:
MonthDayYear
Date
Signature
Clear
DSS Form 2900 (MAR 10) PAGE 2
Consent for Medical Emergency Treatment Woodruff Primary School Child Care Center
Some conditions require immediate medical attention. If there is an emergency situation for your child, Woodruff Primary School Child Care Center must have your written consent to request immediate medical help. Woodruff Primary School Child Care Center will make every attempt to contact you as well as other persons listed in the contact information. However, in the event we believe your child’s life may be at risk or there is a risk of permanent injury, we will seek immediate medical attention, including transport and treatment of your child using the following:
Director/caregiver/nurse will quickly assess the child’s condition 911 or EMS will be called if deemed necessary First Aid and/or CPR will be administered if needed Parent/Guardian and/or Emergency Contact persons will be contacted Poison Control will contacted if child had exposure to toxic substance Child’s physician will be notified of the incident and action taken
Having read the above statement and having had an opportunity to ask and have answered any questions regarding the above statement, my signature below verifies my agreement to the medical treatment plan for my child.
Child’s Physician: ________________________________ Phone Number: Address:
Hospital of Choice: ______________________________ Phone Number: Address:
Contact Information: Parent/Guardian: Home # _______________ Work # _______________ Cell Parent/Guardian: Home # _______________ Work # _______________ Cell Emergency Contact: Home # _______________ Work # _______________ Cell Emergency Contact: Home # _______________ Work # _______________ Cell
Parent Signature: ___________________________
Director: _____________________________________________ Date:
Discipline and Guidance Policy Woodruff Primary School
DISCIPLINE comes from the word disciple. A disciple is a person who learns from someone else. The Child Development Education Pilot Program believes that good discipline is a learning process that involves compassion, caring, sensitivity, and guidance. The goal of good discipline is to help the child develop self-control, responsibility, and problem solving skills. It is important for children to learn that conflicts are a natural part of life. There are no “bad” children, only inappropriate behaviors. The program is based on mutual respect of the child as an individual with changing needs and desires and the child’s respect for the classroom environment, materials, teachers and classmates.
There are many ways that the teachers will encourage good discipline practices. These include:
A well planned physical environment and curriculum Acting as role models for the children Setting reasonable and positive expectations Respecting feelings Trusting each child to succeed Offering good, reasonable choices Calmly talking about problems Always reinforcing good behavior
Punishment or harsh treatment does not encourage the goals of good discipline. Our program does not allow corporal punishment by any staff or parent/guardian. Corporal punishment is defined as any treatment that humiliates or treats the child disrespectfully. This includes, but is not limited to spanking, belittling, shaming, shaking depriving food, water, naps, outside time, or bathroom facilities, unsupervised isolation, or improperly restricting the movement of the child. It is our strong belief that these methods work against the healthy growth and development of a child.
With groups of children interacting, there will be conflicts. The teachers will implement proven healthy strategies that are appropriate to the situation. Some guidance techniques that staff may use include, but are not limited to the following:
● Conflict Resolution – Teachers help children learn skills and language to work out disagreement with their peers.
● Redirecting the Child – Quite often, children need to be given concrete alternative suggestions for behavior to focus their energy in a positive way.
● Positive Encouragement – Teachers praise the appropriate behavior, being careful not to give much attention to the negative behavior.
● Natural Consequences – By helping a child realize that arriving late for group time activities will result in missing their turn.
● Removing the Child from the Group – This is handled in a calm manner without unnecessary stress to allow the child regain self-control.
Each child has different needs and requirements to develop self-control, judgment, and problem-solving skills. We will, therefore, work individually with each child and his/her parents to establish a positive program of discipline.
More information about our school-wide discipline program can be found by going to http://teacherweb.com/SC/WoodruffPrimarySchool/HomePage/SDHP1.stm and clicking on “Instructional Programs” and then “Conscious Discipline”.
Signature
Clear
Date
MonthDayYear
Date
Should be Empty:

5K Enrollment

Child Information

Additional Information

Home Language Survey (HLS)

Spartanburg School District Four Proof of Residency

GENERAL RECORD AND STATEMENT OF CHILD’S HEALTH FOR ADMISSION TO CHILD CARE FACILITY

Child’s Name:

Discipline and Guidance Policy Woodruff Primary School