LAKESIDE SCHOOL DISTRICT REGISTRATION
LAKESIDE SCHOOL DISTRICT REGISTRATION 2016-2017 Lakeside School District Registration Records To register, students must provide: ⎯ Documentation of student's date of birth including one of the following o Copy of birth certificate o Passport showing student's date of birth o United States military identification showing student's date of birth o Previous school records showing student's date of birth ⎯ Copy of social security card ⎯ Shot record ⎯ Proof of enrollment at previous school o School records o Withdrawal documents o Final report card ⎯ Proof of residency o Current gas, electric, or water utility bill—full bill with ‘service location’ and guardian’s name o Rent receipt or lease agreement with current date (must submit a utility bill within 30 days) o Dated contract for the purchase of home o Dated contract for closing on construction of a new home ⎯ Kindergarten registrants must show proof of a current physical from physician Registration is not complete and student is not enrolled until all information is provided. Student ID # Grade Bus# LAKESIDE SCHOOL DISTRICT BRYANT SCHOOL DISTRICT Enrollment EnrollmentForm Form **Office Use Only** Name School Homeroom Date of Birth Last M Sex F First Middle Social Security Number Address Previous School City Zip Name of Previous School Asian/PI Black Yes Ethnicity Hispanic/Latino City Hawaiian/Pacific No State Native American/Alaskan Native Bus Travel Code Yes Does the student take medication at school? No Primary Phone Number Drives Self White Parent/Guardian Is this student currently under suspension or expulsion from any school or are there procedures in progess pertaining to suspension or expulsion of your child? Yes No No ESL Other Was the previous school providing special services? (mark all that apply) Speech 504 Special Education Student resides with Yes Is student a twin? Street Race Month/Day/Year Both Parents Mother Only Joint Custody Foster Parents Other If other, please explain: Father Only Mother & Stepfather Parent/Guardian Name G/T Grandparent(s) Father & Stepmother Home/Cell Number Work Phone Yes Do you need an interpreter? Email Address Parent/Guardian Name Home/Cell Number Work Phone Do you need an interpreter? Email Address No Yes No The person(s) listed below has permission to check my child out of school (list name and number) 1. 2. 3. 4. Is this student a military dependent? Army Navy Air Force Marines Active Duty Active Duty Active Duty Active Duty Yes Reserves Reserves Reserves Reserves No If yes, please indicate status below: Coast Guard Army National Guard Air Force National Guard Parents Multiple Branch Parent/Guardian Signature Active Duty Reserves Date Dr. Tom W. Kimbrell, Superintendent Shawn Cook, Superintendent 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 www.bryantschools.org Fax: (501) 847-5695 Rev. 1/2016 2837 Malvern Ave., Hot Springs, AR 71901 | Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org LAKESIDE SCHOOL DISTRICT Kindergarten Registration BRYANT SCHOOL DISTRICT Kindergarten Registration Please complete the following information regarding your child’s previous school experience. Student Name Did your child attend a full-time (at least 20 hours per week) four-year-old program before coming t to kindergarten? Yes No If yes, what type of program did they attend? Name of provider/center/facility: Arkansas Better Chance (ABC) Early Childhood Special Education Even Start Public School Preschool Private Preschool Other My child receives/has received the following services: Speech Therapy Physical Therapy Occupational Therapy Resource/Special Education Classes Other Please list the names and ages of any younger siblings in the home: Dr. Tom W. Kimbrell, Superintendent 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Shawn Cook, Superintendent www.bryantschools.org Fax: (501) 847-5695 Rev. 1/2016 2837 Malvern Ave., Hot Springs, AR 71901 | Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org This is a federally mandated form that must be completed for each student Student ID # Grade Bus# **Office Use Only** School Homeroom BRYANT SCHOOL DISTRICT LAKESIDE SCHOOL DISTRICT Home Language Survey/Encuesta DelDelIdioma EnElEl Hogar Home Language Survey/ Encuesta Idioma En Hogar ESL Program/Programa Ingles Como Como Segundo Idioma ESL Program/Programa dedeIngles Segundo Idioma Malvern Ave. 2002837 NW 4th Street Hot Springs, AR 71901 Bryant, AR 72022 Office 501.262.1880 Office (501) 653-5324 Student Information First Name Primer Nombre Date of Birth (Month/Day/Year) Fecha de Nacimiento (mes/día/ano) Grade/Grado Middle Segundo Last Apellido Age Edad M F Sex Sexo Place of Birth (City/State/Country) Lugar de nacimiento (Cuidad/Estado/País) School/Escuela ID Number/Número de identification 1. What month and year did your child enroll in school in the United States? ¿Cuál es el mes y año en que inscribió a su niño en una escuela en los Estados Unidos? 2. What language did your child learn when he/she first began to talk? ¿Qué idioma aprendió su hijo cuando primero empezó a hablar? 3. What language is spoken in your home most of the time? ¿Qué idioma se habla en su casa la mayoría del tiempo? 4. What language does your child speak most of the time? ¿Qué idioma habla su hijo la mayoría del tiempo? 5. What language do the parents speak to the student most of the time? ¿Cual es el idioma qué mas le hablan los padres al estudiante? 6. Do you need an interpreter for meetings with teachers or school officials? ¿Necesita un intérprete para las reuniones con los maestros u oficiales de la escuela? Signature of Parent or Guardian/Firma de los Padres/Tutor Legal del Estudiante Yes No Date/Fecha Shawn Cook, Superintendent Dr. Tom W. Kimbrell, Superintendent 2837 Malvern Ave., Hot Springs, AR 71901 | Phone:Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org 200 Northwest Fourth Street, Bryant, AR 72022 (501) 847-5600 Fax: (501) 847-5695 www.bryantschools.org Rev. 1/2016 LAKESIDE SCHOOL DISTRICT BRYANT SCHOOL DISTRICT Request for Student Records from Previous School Request for Student Records from Previous School BRYANT SCHOOL DISTRICT Dear Registrar/Estimado Registrador: Request Student Records Previous recordsfrom including but not School limited to a transcript of all grades, My signature below grants permission for youfor to send all student BRYANT SCHOOL DISTRICT achievement & psychological testing, immunization & health records, birth certificate, Social Security number, Title I, ESL, Gifted & Request for Student Records from Previous School Dear Registrar/Estimado Talented, Speech, SpecialRegistrador: Education, Due Process, and 504 records. My signature below grants permission for you toenvíe send todos all student records including but not limited a transcript of allagrades, Mi firma abajo concede permiso para que usted los expedientes del estudiante, e incluirtopero no limitarse una Dear Registrar/Estimado Registrador: achievement testing, & healthpsicológicas, records, birthinmunizaciones certificate, Social Security number, Title I, ESL, Gifted & transcripción&depsychological todos los grados, los immunization logros y las prubebas y expedientes de salud, certificado de My signature below grantsEducation, permission for you to send all student records including but not limited to a transcript of all grades, Talented, Speech, Special Process, and 504 records. nacimiento, número de seguro social, Due Título I, Inglés segundo idioma (ESL), dotado/talentoso (GT), educación especial y 504. achievement & concede psychological testing, healthlos records, birth certificate, Social Security number, Title I,aESL, Mi firma abajo permiso para immunization que usted envíe&todos expedientes del estudiante, e incluir pero no limitarse una Gifted & Talented, Speech, Special Education, Due Process, and 504 records. transcripción de todos los grados, los logros y las prubebas psicológicas, inmunizaciones y expedientes de salud, certificado de Student Name Birth Date (M/D/Y) Grade Mi firma abajo concede permiso para que usted envíe todos los expedientes del estudiante, e incluir no limitarse a una nacimiento, (ESL), (GT), pero educación especial Nombre número de seguro social, Título I, Inglés segundo idioma Fecha de dotado/talentoso nacimiento Grado y 504. transcripción de todos los grados, los logros yBRYANT las prubebasSCHOOL psicológicas,DISTRICT inmunizaciones y expedientes de salud, certificado de Name of School Last(GT), Date educación Attended especial y 504. nacimiento, número de seguro social, Título I,for Inglés segundoRecords idiomaBirth (ESL), dotado/talentoso Request Student from Previous Student Name Date (M/D/Y) School Nombre de la escuela Ultimo día asistió Grade Nombre Fecha de nacimiento Grado School Address Student Name Birth Date (M/D/Y) Grade Dear Registrar/Estimado Registrador: Name of School Last Date Attended Dirección de below la escuela Nombre Fechaincluding de nacimiento Grado My signature grants permission for you to send all student records but not limited to a transcript of all grades, Nombre de la escuela Ultimo State/Estado día asistió Street/Calle & health records, birthCity/Ciudad Zip/Codigo Postal& achievement & psychological testing, immunization certificate, Social number, Title I, ESL, Gifted Name of School LastSecurity Date Attended School Address Phone Teléfono Fax Number/ Número deUltimo Fax día asistió NombreNumber/ de la escuela Talented, Speech, Special Education, Due Process, and 504 records. Dirección de la escuela Mi firmaAddress abajo concede permiso para que usted envíe todos los expedientes del estudiante, e incluir pero no limitarse a una School Street/Calle on file/ La escuela anterior City/Ciudad State/Estado Zip/Codigo Postal The previous school the los following tendrá losy siguientes transcripción todoswill loshave grados, logros records y las prubebas psicológicas, inmunizaciones expedientesexpendientes: de salud, certificado de Dirección de de la escuela Phone Number/ Teléfono Fax Number/ Número de Fax nacimiento, Título I, Inglés segundo idioma (ESL), dotado/talentoso (GT), educaciónprocesados especial y vencidos 504.Postal IEP número de seguro social, G/T Dotado/talentoso Due Process Records/Expedientes Street/Calle City/Ciudad State/Estado Zip/Codigo 504 ESL/ Inglés segundo idioma Special Education /Educación especial Phone Number/ Teléfono Fax Number/ Número de siguientes Fax The previous tendrá los expendientes: Student Nameschool will have the following records on file/ La escuela Birthanterior Date (M/D/Y) Grade Speech/Habla Title I/Título I Other/Otro IEP G/T Dotado/talentoso Due Process Records/Expedientes procesados Nombre Fecha de nacimiento Grado vencidos The previous school will have the following records on file/ La escuela anterior tendrá los siguientes expendientes: Name 504 of School Last Date Attended ESL/ Inglés segundo idioma Special Education /Educación especial IEP G/T Dotado/talentoso Due Process Records/Expedientes procesados vencidos Parent Signature/Firma Date/Fecha Nombre de la escuela Ultimo día asistió Speech/Habla Title I/Título I Other/Otro 504 ESL/Inglés segundo idioma Special Education /Educación especial School Address Send All Records To: Speech/Habla Title I/Título I Other/Otro Dirección de la escuela Elementary Collegeville Elementary Davis Elementary ParentBryant Signature/Firma Date/Fecha Street/Calle 4818 Highway 5 North City/Ciudad State/Estado Postal 200 NW 4th Street 12001 County LineZip/Codigo Road Send All Records To: Parent Signature/Firma Bryant, ARTeléfono 72022 Bryant, AR 72022 Alexander, AR 72002 Phone Number/ Fax Number/ Número de Fax Date/Fecha Office 501-847-5642 Bryant Elementary Office 501-847-5670 Collegeville Elementary Office Elementary 501-455-5672 Davis Send All Records To: Fax Fax 501-455-2751 200 501-847-0674 NWschool 4th Street 4818 Highway 5 Northanterior tendrá los siguientes 12001 County Line Road The previous will have the following recordsFax on501-847-0732 file/ La escuela expendientes: Lakeside District Lakeside High School Lakeside Middle School Bryant AR Elementary Collegeville Elementary Davis Elementary Bryant, 72022 Office Bryant, AR 72022 Alexander, AR 72002 th IEP G/T Dotado/talentoso Due Process Records/Expedientes procesados Hill Farm Hurricane Creek Elementary Salem Elementary 200 NW 4 Elementary Street 4818 Malvern Highway 5Ave. North 12001 County Line Office 501-847-5642 Office 501-847-5670 Office 501-455-5672 2837 Malvern Ave. 2871 2923 Malvern Ave.Road vencidos 500 HillAR Farm Road 6091 Alcoa Road 2701Salem Road Bryant, 72022 Bryant, AR 72022 Alexander, AR 72002 504 ESL/Inglés segundo especial Fax 501-847-0674 Fax idioma 501-847-0732 FaxSprings, 501-455-2751 Hot Springs, AR 71901 Hot Springs, AR 71901Special Education /Educación Hot AR 71901 Bryant, AR 72022 Benton, AR 72015 Benton, AR 72019 Office 501-847-5642 Office 501-847-5670 Office 501-455-5672 Speech/Habla Title I/Título I Office: Office: 501.262.1880 501.262.1530 Other/Otro Office: 501.262.6244 Office 501-653-5950 Office 501-653-1012 Office 501-316-0263 Fax 501-847-0674 Fax 501-847-0732 Fax 501-455-2751 Hill Farm Elementary Fax Fax: 501.262.2732 500 501-653-5951 Hill Farm Road ParentBryant, Signature/Firma Hill Farm ARElementary 72022 Hurricane Creek Elementary Fax Fax: 501.262.6205 6091501-778-7463 Alcoa Road Salem Elementary Fax 501-794-9043 Fax: 501.262.6248 2701Salem Road Date/Fecha Hurricane Salem Elementary Benton, ARCreek 72015Elementary Benton, AR 72019 Springhill Elementary BethelAlcoa Middle School Bryant Middle 500 Hill Farm Road 6091 Road 2701Salem RoadSchool Office 501-653-5950 Office 501-653-1012 Office 501-316-0263 Send All To: 2716 Northlake Road 5415 Northlake Road 1105 Woodland Drive Bryant, AR 72022 Benton, AR 72015 Benton, AR 72019 Fax Records 501-653-5951 Fax 501-778-7463 Fax 501-794-9043 Alexander, AR 72002 Alexander, AR 72002 Bryant, AR 72022 Office 501-653-5950 Office 501-653-1012 Office Elementary 501-316-0263 Lakeside Intermediate Lakeside Primary Bryant Elementary Collegeville Elementary Davis Office 501-847-5675 Office 501-316-0937 Office 501-847-5651 Fax 501-653-5951 Fax 501-778-7463 Fax 501-794-9043 200 NW 4thElementary Street 4818 Highway North 12001 County Road Springhill Bethel Middle 5School Bryant MiddleLine School 2855 Malvern Ave. 2841 Malvern Ave. Fax 501-847-5677 Fax 501-653-5830 Fax 501-847-5654 Alexander, AR 72002 Bryant, AR 72022 Bryant, AR 72022 2716 Northlake Road 5415 Northlake Road 1105 Woodland Drive Hot Springs, AR 71901 Hot Springs, AR 71901 Springhill Elementary Bethel 501-847-5670 Middle Bryant501-455-5672 Middle School Office Office 501-847-5642 Office Alexander, AR 72002 Alexander, AR School 72002 Bryant, AR 72022 Office: 501.262.2332 Office: 501.262.1921 Bryant High School 2716 Northlake Road 5415 Northlake Road 1105 Woodland Drive Fax 501-455-2751 Fax 501-847-0674 Fax 501-847-0732 Office 501-847-5675 Office 501-316-0937 Office 501-847-5651 801 North Reynolds Alexander, AR 72002Road Alexander, AR 72002 Bryant, AR 72022 Fax: 501.262.3955 Fax: 501.262.6225 Fax 501-847-5677 Fax 501-653-5830 Fax 501-847-5654 Bryant, ARElementary 72022 Office 501-847-5675 Office 501-316-0937 Office 501-847-5651 Hill Farm Hurricane Creek Elementary Salem Elementary Office 501-847-5605 Fax 501-847-5677 Fax 501-653-5830 Fax 501-847-5654 500 Hill FarmSchool Road 6091 Alcoa Road 2701Salem Road Bryant High Fax 501-653-5440 Bryant, ARReynolds 72022 Road Benton, AR 72015 Benton, AR 72019 801 North Bryant501-653-5950 High School Office Office 501-653-1012 Office 501-316-0263 Bryant, AR 72022 801 North Reynolds Road Fax 501-653-5951 Fax 501-778-7463 Fax 501-794-9043 Office 501-847-5605 Dr. Tom W. Kimbrell, Superintendent Bryant, AR 72022 Fax 501-653-5440 Office 501-847-5605 Springhill Elementary Bethel Middle School Bryant Middle School 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Fax: (501) 847-5695 Fax 2716501-653-5440 Northlake Road 5415 Northlake Road 1105 Woodland Drive Shawn Cook, Superintendent Rev. 1/2016 www.bryantschools.org Dr. Tom W. Kimbrell, Superintendent Alexander, AR 72002 Alexander, AR 72002 Bryant, AR 72022 Office 501-847-5675 Office 501-316-0937 Office 501-847-5651 200 Northwest Fourth Street,Dr. Bryant, AR 72022 (501) 847-5600 Fax: (501) 847-5695 Tom W. Kimbrell, Superintendent 501-847-5677 Fax 501-653-5830 Fax 501-847-5654 2837FaxMalvern Ave., Hot Springs, AR 71901 | Phone:Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org Rev. 1/2016 www.bryantschools.org 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Fax: (501) 847-5695 Bryant High School Rev. 1/2016 www.bryantschools.org 801 North Reynolds Road Bryant, AR 72022 Office 501-847-5605 Fax 501-653-5440 LAKESIDE SCHOOLDISTRICT DISTRICT BRYANT SCHOOL StudentResidency Residency Questionnaire Questionnaire Student Your child may be eligible for additional services through Title I, Part A of the No Child Left Behind Act and the Federal McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire. Presently, are you and/or your family living in any of the following situations? Check all that apply. Sharing the housing of others due to loss of housing, economic hardship or similar reason Staying in a shelter (family shelter, domestic violence shelter, youth shelter) Temporarily living in a motel or hotel due to loss of housing, economic hardship, or similar reason Living in a car, park campground, abandoned building, or other inadequate accommodations Living alone as a minor student(s) without an adult (unaccompanied youth) If you checked any of the above please complete the remainder of this form. If you did not check any of the above, you do not need to complete this form. First, Middle, Last Name Date of Birth M/F Month/Day/Year Grade School Name The undersigned parent/guardian certifies that the information provided is accurate Print Parent/Guardian Name (Area Code) Phone Signature Street Address Date City State Zip Dr. Tom W. Cook, Kimbrell, Superintendent Shawn Superintendent 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 www.bryantschools.org Fax: (501) 847-5695 2837 Malvern Ave., Hot Springs, AR 71901 | Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org Rev. 1/2016 LAKESIDE SCHOOL DISTRICT BRYANT SCHOOL DISTRICT BRYANT SCHOOL DISTRICT BRYANT SCHOOL DISTRICT Elementary Emergency Medical Form Elementary Emergency Medical Form Emergency Medical Form Elementary Emergency Medical Form Teacher Teacher Teacher Name Name Name Address Address Address Grade Grade Last Last Grade First First Last Street Street Email Address Parent/Guardian Name Parent/Guardian Name Parent/Guardian Name F Sex F M Bus F Rider Bus Rider Date of Birth Date of Birth Middle First Middle Middle City City Street Parent/Guardian Name Parent/Guardian Name Parent/Guardian Name Email Address Email Address M M Sex Sex CityZip Zip Car BusRider Rider Car Rider Car Date of Birth Month/Day/Year Month/Day/ Month/Day/Year Primary Zip Phone Number Primary Phone Num Primary Phone Number Home/Cell Number Home/Cell Number Work Phone Work Phone Home/Cell Number Work Phone Yes No Yes Do you need an interpreter? Do you need an interpreter? Yes No Do you need an interpreter? Home/Cell Number Home/Cell Number Work Phone Work Phone Home/Cell Number Work Phone Yes No Yes Do you need an interpreter? Do you need an interpreter? Yes No Do you need an interpreter? Email Address Email Address Email Address If not available, whom may we call for If not else available, whom elsehelp? may we call for help? If not available, whomName else may we callName for help? Relationship to Student Phone Number Phone Number Relationship to Student Name Relationship to Student Phone Number 1. 1. 1. 2. 2. 2. 3. 3. 3. List any health conditions such asconditions heart disease, epilepsy,diabetes, severe allergies, asthma, ADD, ADHD, eyeADD, or earADHD, eye or ea List any health such diabetes, as heart disease, epilepsy,migraines, severe allergies, migraines, asthma, List any health as or heart diabetes, epilepsy, allergies, migraines, asthma, ADD, eye ear problems, bowelconditions or kidneysuch problems, or disease, anyproblems, chronic issues, etc. Forsevere your child’s appropriate staff mayADHD, be notified of health problems, bowel kidney or any chronic issues, etc. safety, For your child’s safety, appropriate staffor may be notified of h problems, bowel or kidney problems, or any chronic issues, etc. For your child’s safety, appropriate staff may be notified of health information provided. Explain each: Explain each: information provided. information provided. Explain each: No If yes, please Will any medication be given at school? Yes No list If yes, please list Willneed any to medication need to be givenYes at school? Yes No If yes, please list Will any medication need to be given at school? Will your child require anychild accommodations at school due to aatdiagnosed medical conditionmedical or needed medical Will your require any accommodations school due to a diagnosed condition orprocedure? needed medical procedure? WillYes your child accommodations at school due to a diagnosed medical condition or needed medical procedure? No require IfYes yes,any please Noexplain: If yes, please explain: Yes No If yes, please explain: Yes Is your child allergic any medications, foods, insects, ororother? to any medications food? Is your child allergic to or any medications food?No Yes No Is your child allergic to any medications or food? Please list any siblings Please list any siblings Please Name list any siblings Name Name Grade Grade Parent/Guardian Signature Parent/Guardian Signature Parent/Guardian Signature IfYes yes, pleaseNo list If yes, please list If yes, please list Name Grade Name Grade Grade Name Date Date G Date Dr. Tom W. Kimbrell, Superintendent Dr. Tom W. Kimbrell, Superintendent Dr. Tom W. Kimbrell, Superintendent 200 Northwest Fourth Bryant, ARStreet, 72022Bryant, Phone: (501) 847-5600 Fax:847-5600 (501) 847-5695 200 Street, Northwest Fourth AR 72022 Phone: (501) Fax: (501) 847-5695 200 Northwest Fourth Street, Bryant,Shawn AR 72022 (501) 847-5600 Fax: (501) 847-5695 Cook, Phone: Superintendent www.bryantschools.org Rev. 1/2016 www.bryantschools.org www.bryantschools.org Rev. 1/2016 2837 Malvern Ave., Hot Springs, AR 71901 | Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org Rev. 1/20 Benadryl (Diphenhydramine) Yes No Yes Tums (Antacid) No Medication Log Tylenol LAKESIDE SCHOOL DISTRICT Advil 1) 1) BRYANT SCHOOL Emergency MedicalDISTRICT Form Continued Benadryl Tums 1) 1) 2) 2) 2) 2) Elementary Emergency Medical Form Continued 3) 3) 3) 3) 4) 4) 4) of Birth Name Date 4) 5) 5) 5) 5) Last First Middle Month/Day/Year 6) 6) 6) 6) According to school policy, parents should supply medications. Only 6 doses of non prescription medication should be given during the school year without a physician’s A order. B Number AR Kids (Medicaid) If parents are unavailable the nurse determines medical necessity, I give permission for the following nonprescription medication to be Student’s Social Securityand Number given as directed by the label, during school hours, to my child: Medical Insurance Company Tylenol (Acetaminophen) Yes No Advil (Ibuprofen) Yes No Policy Number Benadryl (Diphenhydramine) Yes No Tums (Antacid) Yes No Physician of Choice 1. Medication Log Phone Number Benadryl Tylenol Advil Tums 1) 1) 1) 1) 2. Phone Number 2) 2) 2) 2) In eventmy mychild childshould shouldbebe injured and neither parent can be reached, I, the undersigned, doauthorize hereby authorize of the In3)the the event injured and neither parent can be reached, I, the undersigned, do hereby officials ofofficials the Bryant 3) 3) 3) Lakeside School District, to directly contact the person named on this form. Also, I, the undersigned, do hereby authorize the named School District, to directly contact the person named on this form. Also, I, the undersigned, do hereby authorize the named physicians to 4) 4) as may be deemed necessary in 4)an emergency for the health of 4) physicians to render such treatment said child. In the event physicians render such treatment as may be deemed necessary in an emergency for the health of said child. In the event physicians or other named 5)otheronnamed 5) cannot 5) are or person onbe this form be contacted, theauthorized officials hereby authorized take5) whatever action is deemed person this form cannot contacted, the officials are hereby to take whatever action to is deemed necessary judgment in their necessary in their judgment for the health of aforesaid child. I will not hold the Lakeside School District financially responsible for for the health of aforesaid child. I will not hold the Bryant School District financially responsible for the emergency care and/or 6) 6) 6) 6) transportation saidand/or child and give permission thisgive Emergency Medical given to any medical personnel involved the emergencyfor care transportation for for saida copy childof and permission for aform copytoofbethis Emergency Medical form to be given in rendering medical care orinvolved transporting child. Also, I give care permission for the Bryant School to bill Medicaid/AR Kids First,School when to any medical personnel inB rendering medical or transporting child. Also,District I give permission for the Lakeside A AR Kids (Medicaid) Number applicable, for vision and hearing screenings. District to bill Medicaid/AR Kids First, when applicable, for vision and hearing screenings. Student’s Social Security Number Parent/Guardian Signature Medical Insurance Company Date Policy Number Physician of Choice Dr. Tom W. Kimbrell, Superintendent 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Phone Number www.bryantschools.org 1. 2. Fax: (501) 847-5695 Rev. 1/2016 Phone Number In the event my child should be injured and neither parent can be reached, I, the undersigned, do hereby authorize officials of the Bryant School District, to directly contact the person named on this form. Also, I, the undersigned, do hereby authorize the named physicians to render such treatment as may be deemed necessary in an emergency for the health of said child. In the event physicians or other named person on this form cannot be contacted, the officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of aforesaid child. I will not hold the Bryant School District financially responsible for the emergency care and/or transportation for said child and give permission for a copy of this Emergency Medical form to be given to any medical personnel involved in rendering medical care or transporting child. Also, I give permission for the Bryant School District to bill Medicaid/AR Kids First, when applicable, for vision and hearing screenings. Parent/Guardian Signature Date Dr. Tom W. Kimbrell, Superintendent Shawn Cook, Superintendent 2837 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Fax: (501) 847-5695 www.bryantschools.org Malvern Ave., Hot Springs, AR 71901 | Phone: 501.262.1880 | Fax: 501.262.2732 | lakesidesd.org Rev. 1/2016 LAKESIDE SCHOOL DISTRICT Communication System BRYANT SCHOOL BRYANT DISTRICT SCHOOL DISTRICT Elementary Emergency Elementary Medical Emergency Form Medical Form BRYANT SCHOOL DISTRICT BRYANT SCHOOL DISTRICT Elementary Emergency Medical Form Grade Sex Elementary Emergency M F Sex M BusFRider Car Bus Rider Rider Teacher Teacher Medical Form Grade Lakeside’s communication system allows for up to 2 voice calls, 2 texts, and 1 email address per student. Name Name Date of Birth Date of Birth M BusFRider Bus Rider Car Rider Middle Month/Day/Year M Address Name Name Address Date of Birth Date of Birth Primary Zip Phone Number PrimaryM P Middle Month/Day/Year Teacher Grade SexcannotMbe called.) (Personal phone numbers F Sex Teacher Gradeonly. Work numbers BRYANT SCHOOL BRYANT DISTRICT Last SCHOOL DISTRICT Last First FirstMiddle Elementary Emergency Elementary Medical Emergency Form Medical Form Voice Call:SCHOOL BRYANT DISTRICT Street Street First City FirstMiddle City Zip Last BRYANT DISTRICT Last SCHOOL Elementary Emergency Medical Form Grade Sex Elementary Emergency M F Sex Teacher Teacher Medical Form Grade Address Address Name Teacher M BusFRider Car Bus Rider Rider Home/Cell Number Home/Cell Work Phone Work NumberNumber Street City Zip Phone Number Primary P Street City Zip Primary Name Date Birth Date of Birth Yes No Do you need an interpreter? Do of you need an interpreter? M BusFRider Bus Rider Teacher Grade Sex M F Sex Car Rider Grade Email Address Email Address Last Last First FirstMiddle Home/Cell Middle Month/Day/Year M Parent/Guardian Name Number Work Number Parent/Guardian Name Home/Cell Number Work Phone Guardian name for voice call SCHOOL DISTRICT Parent/Guardian Name Parent/Guardian Name Guardian name for voice call BRYANT Elementary Emergency Medical Form Name Address Address Name Parent/Guardian Name Parent/Guardian Name Text: Email Address Street Street First Last Email Address Last Date of Birth Do of you need an interpreter? Date Birth No Do you needHome/Cell an interpreter? Home/Cell Number Number Work Yes Phone Work City FirstMiddle City Zip Primary Zip Phone Number PrimaryM P Middle Month/Day/Year Yes No Do you need an interpreter? Do you need an interpreter? Email Address AddressEmail Address Parent/Guardian Address MNumber F Home/Cell Bus Rider Rider Teacher Grade Sex Name Work NumberNumber Guardian name for text Parent/Guardian Name Home/Cell Work PhoneCar Primary Street City Zip Phone P Street City Zip Primary Number If not available, whom If not else available, may we whom call forelse help? may we call for help? Do you need an interpreter? Yes No interpreter? Do Relationship you need an to Name Name Relationship to Student Student Phone Name Date of BirthPhone Number Email Address Email Address Parent/Guardian Name Home/Cell Number Work 1. 1. Parent/Guardian Number Home/Cell Number Work Phone Guardian text Last name forName First Middle Month/Day/Year If not available, may we call for help? If not available, whom else may we whom call forelse help? Do you need an interpreter? No Do Relationship you needHome/Cell an to interpreter? Name Student Phone Parent/Guardian Name Parent/Guardian Name Relationship Home/Cell Number Number Work Yes Phone Work 2. 2. Name to Student Phone Number Address Email Address Email Address 1. 1. Email address: Street City Yes Number No Do you needZip an interpreter? Do you Primary need an Phone interpreter? 3. 3. Email Address Email Address Parent/Guardian Name Work 2. Parent/Guardian Name Home/Cell Number Home/Cell NumberWork Phone 2. Parent/Guardian Home/Cell Number Work Phone List anyavailable, health conditions List any such health heart conditions disease, such diabetes, aswe heart disease, severe diabetes, allergies, epilepsy, migraines, severe allergies, asthma,migraines, ADD, ADHD, asthma, eye or ADD, ear ADHD If not whom If not else available, mayaswe whom callName forelse help? may callepilepsy, for help? Do youmay need interpreter? Yes Do youyour needchild’s an to interpreter? problems, bowel orproblems, kidney bowel oror kidney any chronic problems, issues, or any etc. chronic For your issues, child’s safety, For appropriate safety, staff appropriate bean notified staff of health mayNo be no 3. Nameproblems, Name Relationship toetc. Student Relationship Student Phone Number Phone 3. Yes No Do you need an interpreter? Email Address Emailprovided. Address Explain each: information provided. information Explain each: 1. 1. Email Address List any health conditions such aswe heart disease, diabetes, epilepsy, severe allergies, asthma, ADD, If not available, whom may callepilepsy, for help? List any health conditions such heart diabetes, severe allergies, migraines, asthma,migraines, ADD, ADHD, eye or ear ADHD If not available, whom else mayaswe call disease, forelse help? bowel oror kidney problems, or any issues, For your child’s safety, appropriate staff mayPhone be no Name Relationship to Student problems, bowel orproblems, kidney any chronic issues, etc. chronic For your child’s safety, appropriate staff may be notified of health 2. 2. Nameproblems, Relationship toetc. Student Phone Number information provided. Explain each: Parent/Guardian Name Home/Cell Number Work Phone information provided. 1. Explain each: 1. any medication Yesat school? No If Yes yes, pleaseNo list If yes, please list Will Will any tomedication be given at need school? to be given 3. 3.need Yes No Do you need an interpreter? 2. 2. Email Address Will yourhealth child conditions require Will your anysuch accommodations child require anysuch ataccommodations school dueepilepsy, to a diagnosed at school due medical to a diagnosed condition medical neededcondition medical or procedure? needed medical proce List any List any health as heart conditions disease, diabetes, as heart disease, severe diabetes, allergies, epilepsy, migraines, severeor allergies, asthma, migraines, ADD, ADHD, asthma, eye or ADD, ear ADHD Yes No If yes, Yes please No explain: If yes, please explain: Yes No If yes, please list Will any medication need to be given at school? Yes No If yes, please list Will any medication need toproblems, be given at school? problems, bowel or problems, kidney bowel or kidney anyhelp? chronic problems, issues, or any etc. chronic For your issues, child’s etc.safety, For your appropriate child’s safety, staff may appropriate be notified staff of health may be no If not available, whom else may weor call for 3. 3. information provided. information Explain provided. each: Explain each: Name Relationship to Student Phone Number Will your child conditions require anysuch at school due to a diagnosed medical or needed medical proce Will yourhealth child conditions require anysuch accommodations ataccommodations school due to a diagnosed medical condition neededcondition medical procedure? List any health as heart disease, diabetes, epilepsy, severeor allergies, migraines, asthma, ADD, 1. any List as heart disease, diabetes, allergies, ADD, ADHD, eye or ear ADHD Yesepilepsy, Nosevere If yes, Yes please migraines, list No If yes,asthma, please list Is your childNo allergic Is your toYes any child medications allergic to orany food? medications or food? No If yes, please explain: Yes If yes, please explain: bowel oror kidney problems, or any issues, etc.safety, For your child’s safety, appropriate staff may be no problems, bowel orproblems, kidney problems, any chronic issues, etc. chronic For your child’s appropriate staff may be notified of health information Explain each: 2. information provided. Explain provided. each: Yesat school? No If Yes yes, pleaseNo list If yes, please list Will any medication Will need any tomedication be given at need school? to be given Please anyallergic siblings Please list anyallergic siblingsto Yes please list No If yes, please list Is your child medications Yes or food? No If yes, Is3.yourlist child to any medications orany food? Name Name Grade Name Grade Name Grade Will your child require Will your any accommodations child require anyataccommodations school due to a diagnosed at school due medical to a diagnosed condition or medical neededcondition medical or procedure? needed medical proce Yes No If yes, Yes please No explain: If yes, please explain: Yes No If yes, please list Will any medication need to be given at school? List any health conditions such as heart disease, diabetes, epilepsy, severe allergies, migraines, asthma, ADD, ADHD, eye or ear Yes No If yes, please list Will any medication need to be given at school? Please list any siblings Please list any siblings problems, bowel or kidney problems, or any chronic issues, etc. For your child’s safety, appropriate staff may be notified of health Name Grade Name Name Grade Name Grade Will Explain your child require anyataccommodations at school due to a diagnosed medical needed medical proce information provided. each: Will your child require any accommodations school due to a diagnosed medical condition or neededcondition medical or procedure? Yes No If yes, Yes please list No If yes, please list Is your child allergic Is your to any child medications allergic to or any food? medications or food? Yesplease No If yes, please explain: Yes No If yes, explain: Parent/GuardianParent/Guardian Signature Signature Date Dr.medications TomYes W. Dr. Superintendent W. Please list anyallergic siblings Please list any siblings YesKimbrell, No Superintendent If yes, please list Is your child allergic to or food? No IfIfyes, please Will any medication need to be given at school? YesKimbrell, NoTom yes, pleaselist list Is your child to any medications orany food? Shawn Cook, Superintendent Parent/Guardian Signature Name Grade Name Grade NameDate Parent/GuardianName Signature Date Date Grade 200 Northwest Fourth 200 Street, Northwest Bryant, Fourth AR 72022 Street, Bryant, Phone: AR(501) 72022 847-5600 Phone: (501) Fax: (501) 847-5600 847-5695Fax: (501) 847-5695 Will your child require at school due to 501.262.1880 a diagnosed medical condition or needed medical procedure? 2837 Malvern Ave.,any Hotaccommodations Springs, AR 71901 | Phone: | Fax: 501.262.2732 | lakesidesd.org www.bryantschools.org www.bryantschools.org Rev. 1/2016 Dr. Tom W. Kimbrell, Superintendent Please list anyexplain: siblings Dr. Tom W. Kimbrell, Yeslist any Nosiblings If yes, please Superintendent Please Name Grade Name Name Grade Name 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Grade 200 Northwest Fourth Street, Bryant, AR 72022 Phone: (501) 847-5600 Fax: (501) 847-5695Fax: (501) 847-5695 www.bryantschools.org Parent/GuardianParent/Guardian Signature Signature www.bryantschools.org Date Date Rev. 1/2016 Is your child allergic to any medications or food? Yes No If yes, please list
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