1. No category

Brazos Independent School District
Registration Form
2016-2017
ID#:_______________
SSN#:_______________
STUDENT INFORMATION:
_______________________________
FIRST NAME
NICKNAME:_________________
BIRTHDATE:
_________________
MIDDLE
SEX: M
________________
F
___________________________________
LAST NAME
SUFFIX
AGE SEPT 1: ______
GRADE:______________
JR
SR
II
III
IV
RACE:___________________________________
ADDRESS (where student sleeps at night):
STREET:
____________________________________ CITY/ST/ZIP: ___________________________________
MAILING ADDRESS (if different from above address):
STREET OR BOX #: _________________________________ CITY/ST/ZIP: ___________________________________
PARENT / GUARDIAN INFORMATION:
(1ST) FULL NAME: _________________________________RELATION:______________________________________
ADDRESS: _____________________________________
HOME TEL: _____________________________________
CITY/ST/ZIP ____________________________________ WORK TEL: _____________________________________
E-MAIL ________________________________________ CELL # _________________________________________
(2nd) FULL NAME: _________________________________RELATION:______________________________________
ADDRESS: _____________________________________
HOME TEL: _____________________________________
CITY/ST/ZIP ____________________________________ WORK TEL: _____________________________________
E-MAIL ________________________________________ CELL # _________________________________________
EMERGENCY NUMBERS (who you want contacted if we cannot reach you):
NAME: ___________________________________ RELATION:____________________TEL:____________________
NAME: ___________________________________ RELATION:____________________TEL:____________________
PRESENTING FALSE INFORMATION OR RECORDS FOR IDENTIFICATION IS A CRIMINAL OFFENSE UNDER PENAL
CODE 37.10. ENROLLING A CHILD UNDER FALSE DOCUMENTS MAKES THE PERSON LIABLE FOR TUITION OR THE
COST AS PROVIDED BELOW.
TUITION: THE AMOUNT OF EXPENSE REQUIRED FROM LOCAL FUNDS.
I HEREBY CERTIFY THAT ALL INFORMATION SHOWN ON THIS PAGE IS CORRECT.
PARENT/GUARDIAN SIGNATURE: ______________________________________DATE: _____________________
DATE OF BIRTH OF PARENT/GUARDIAN ENROLLING STUDENT: _____________________________________
PARENTS/GUARDIANS OF STUDENTS ENROLLING NEW STUDENTS IN THE DISTRICT MUST FURNISH A PROOF
OF PHYSICAL RESIDENCY (COPY OF UTILITY BILL.)
Brothers/Sisters
Birthday
Grade
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Preferred Language / Idioma preferido
RECORDS REQUEST
Student:
_______________________________________
Birthdate:
_______________________________________
Date Enrolled:
_______________________________________
Previous School Enrolled:
_______________________________________
The aforementioned student has enrolled at
Please send the following:
______ Withdrawal Grades
______ Transcript
______ Test Scores
______ Immunization/Health Records
______ Grading Scale
______ Birth Certificate
______ Social Security Number
Parent/Guardian Signature: ________________________________ Date: _______________
BISD Administrative Signature:_______________________________ Date:
______________
Student Name: ____________________________________________
Grade: __________ Date: _________
1. Does your child have any special health problems?
Yes_____
No _____
2. Has your child ever been placed in a special education program?
Yes_____
No_____
3. Did your child receive speech therapy in previous school?
Yes_____
No_____
4. Has your child ever been placed in an ESL/Bilingual class?
Yes_____
No_____
5. Has your child ever been placed in a gifted/talented program?
Yes_____
No_____
6. Has your child ever been retained?
Yes_____
No_____
If the answer is YES, please name the grade that your child had to
repeat ____________.
7. Did your child, in the previous school, have 504 modifications?
Yes_____
No_____
8. Is there a divorce order that protects this child?
Yes_____
No_____
9. Has your child ever been placed in a Discipline/AEP setting?
Yes_____
No_____
10. Is your child a foster child?
Yes_____
No_____
11. Are the parents/guardians of this child currently active military?
Yes_____
No_____
12. Is there any other information that you feel might be useful to us and
aid us in the placement of your child? _______________________
___________________________________________________
Parent/Guardian Signature: ________________________________ Date: _________
Nombre del nińo: ____________________________________________________
Grado: ___________________________ Fecha: ___________________________
1. ¿Tiene su hijo problemas especiales de salud?
Si_____
No_____
2. ¿Ha sido su hijo colocado en un prgrama de educación especial?
Si_____
No_____
3. ¿Recibio su hijo terapia del habla en su escuela anterio?
Si_____
No_____
4. ¿Ha sido su hijo colocado en clases de ESL/bilingüe?
Si_____
No_____
5. ¿Ha sido su hijo colocado en un programa con talento y talentoso?
Si_____
No_____
6. ¿Ha sido su hijo retenido un grado?
Si_____
No_____
7. ¿Ha tenido su hijo, en el año anterior, modificaciónes 504?
Si_____
No_____
8. ¿Hay una orden de divorcio que protege ha su hijo?
Si_____
No_____
9. ¿Ha sido su hijo colocado en un programa de diciplina/AEP?
Si_____
No_____
10. ¿Es su hijo niño adoptive?
Si_____
No_____
11. ¿Son los papas/guardian del niño actualmente activos en el servicio military?
Si_____
No_____
12. ¿Hay alguna otra información que crea que podria ser útil para nosotros y que nos
ayuda en la colocación de su hijo? __________________________________________
_______________________________________________________________________
_______________________________________________________________________
Firma de Padres/Guardian: _____________________________________________________
Fecha: ___________________________
TEA *Texas Education Agency * Enrollment Questions
2016-2017
Student:______________________________
Date of Birth: ___________________
Male □
Female □
Grade: _______
** Please answer the following questions.
1. Is the student a dependent of a member of the United States military service
on active duty, the National Guard, or a reserve force of the United State
military?
□ Yes
□ No
2. Is the student currently in the conservatorship of the Department of Family
and Protective Services?
□ Yes
□ No
** If yes, please provide one of the following documents:
● DFPS Placement Authorization Form 2085
● or a Court Order.
______________________________
Signature of Parent/Legal Guardian
_________________________
Date
“FOR WE ARE BOUND TOGETHER UNTIL ETERNITY”
www.brazosisd.net
Brazos ISD does not discriminate because of race, age, color, national origin, sex or disability.
Texas Education Agency
Texas Public School Student/Staff Ethnicity and Race Data Questionnaire
The United States Department of Education (USDE) requires all state and local education institutions to
collect data on ethnicity and race for students and staff. This information is used for state and federal
accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal
Employment Opportunity Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to provide this
information. If you decline to provide this information, please be aware that the USDE requires school
districts to use observer identification as a last resort for collecting the data for federal reporting.
Please answer both parts of the following questions on the student’s or staff member’s ethnicity and race.
United States Federal Register (71 FR 44866)
Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one)
Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.
Not Hispanic/Latino
Part 2. Race: What is the person’s race? (Choose one or more)
American Indian or Alaska Native - A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains a tribal affiliation or community
attachment.
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
Black or African American - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
________________________________
Student/Staff Name (please print)
________________________________
(Parent/Guardian)/(Staff) Signature
________________________________
Student/Staff Identification Number
________________________________
Date
This space reserved for Local school observer – upon completion and entering data in student software
system, file this form in student’s permanent folder.
Ethnicity – choose only one:
Race – choose one or more:
_____ American Indian or Alaska Native
_____ Hispanic / Latino
_____ Asian
_____ Black or African American
_____ Not Hispanic/Latino
_____ Native Hawaiian or Other Pacific Islander
_____ White
Observer signature:
Campus and Date:
Agencia de Educación de Texas
Cuestionario de Información de Datos Raciales y de Etnicidad de Estudiantes/Miembros de Personal de las
Escuelas Públicas de Texas
El Departamento de Educación de Estados Unidos (USDE) requiere que todas las instituciones estatales y
locales de educación, recopilen datos sobre etnicidad y raza de los estudiantes y de miembros de personal.
Esta información es utilizada para los reportes estatales y federales así como para reportar a la Oficina de
Derechos Civiles (OCR) y a la Comisión de Igualdad en el Empleo (EEOC).
Al personal del distrito escolar y los padres o representante legal de estudiantes que deseen matricularse
en la escuela, se le requiere proporcionar esta información. Si usted rehúsa proporcionarla, es importante
que sepa que el USDE requiere que los distritos escolares usen la observación para identificación como
último recurso para obtener estos datos utilizados para reportes federales.
Favor de contestar ambas partes de las siguientes preguntas sobre la etnicidad y raza del estudiante así
como del miembro de personal. Registro Federal de Estados Unidos (71 FR 44866).
Parte 1. Etnicidad: ¿Es la persona Hispana/Latina? (Escoja solo una respuesta)
Hispano/Latino – Una persona de origen cubano, mexicano, puertorriqueño, centro o sudamericano o de otra
cultura u origen español, sin importar la raza.
No Hispano/Latino
Parte 2. Raza. ¿Cuál es la raza de la persona? (Escoja uno o más de uno)
Indio Americano o Nativo de Alaska – Una persona con orígenes o de personas originarias de Norte y
Sudamérica (incluyendo América Central), y que mantiene lazos o apego comunitario con una afiliación
de alguna tribu.
Asiático – Una persona con orígenes o de personas originarias del Lejano Este, Sureste de Asia o el
subcontinente indio, incluyendo, por ejemplo a Cambodia, China, India, Japón, Corea, Malasia, Pakistán, las
Islas Filipinas, Tailandia y Vietnam.
Negro o Áfrico-Americano – Una persona con orígenes de cualquier grupo racial negro de África.
Nativo de Hawai u otras islas del pacífico – Una persona con orígenes o de personas originarias de
Hawai, Guam, Samoa u otras Islas del Pacífico.
Blanco – Una persona con orígenes de personas originarias de Europa, el Medio Este o el Norte de
África.
________________________________
Nombre del Estudiante/Miembro de Personal
(por favor use letra de imprenta)
________________________________
Número de Identificación del
Estudiante/Miembro del personal
________________________________
Firma (Padre/Representante legal)
/(Miembro de personal
________________________________
Fecha
This space reserved for Local school observer – upon completion and entering data in student software
system, file this form in student’s permanent folder.
Ethnicity – choose only one:
Race – choose one or more:
_____ Hispanic / Latino
_____ American Indian or Alaska Native
_____ Not Hispanic/Latino
_____ Asian
_____ Black or African American
_____ Native Hawaiian or Other Pacific Islander
_____ White
Observer signature:
Campus and Date:
Acknowledgment of Electronic Distribution of Student Handbook
My child and I have been offered the option to receive a paper copy of or to electronically
access at www.brazosisd.net the ___________________________________________
Brazos Elementary School
Student Handbook and the Student Code of Conduct for 2016–17.
I have chosen to:
 Receive a paper copy of the Student Handbook and the Student Code of Conduct.
 Accept responsibility for accessing the Student Handbook and the Student Code of
Conduct by visiting the web address listed above.
I understand that the handbook contains information that my child and I may need during the
school year and that all students will be held accountable for their behavior and will be subject
to the disciplinary consequences outlined in the Student Code of Conduct. If I have any
questions regarding this handbook or the Code of Conduct, I should direct those questions to
the the appropriate campus principal: Brazos High School principal, Mrs. Mary McCarthy, at
(979) 478-6832 or [email protected]. Brazos Middle School principal, Mr. Clay
Hudgins@(979)478-6814 or [email protected]. Brazos Elementary School principal, Mrs.
Lauren Almanza, at (979) 478Printed name of student:
_________________________________________________________
Signature of student: ____________________________________________________________
Signature of parent: _____________________________________________________________
Date: ____________________________________
Please sign and date this page, remove it from the handbook, and return it to your child’s school
Directory Information Waiver 2016-2017
Release of Directory Information
In accordance with Board Policy concerning Public Information and the Open Records Act, certain
school records called directory information may be released to the public, upon request, without your
consent unless you have previously instructed the school not to release them. The only directory
information that would be released by the Brazos I. S. D. is your child’s name, phone number and
address. All student records including the names, addresses, and phone numbers of students are
available to authorized school personnel for school use only.
1.
2.
3.
4.
Your child’s name may appear on the Honor Roll List.
Your child’s picture may appear in the yearbook.
Scholarship information concerning your child may be shared with colleges and universities.
Your child’s name may be listed in programs such as plays and sporting events which may
include weight and height of athletic team members.
5. Your child may be recognized in District publications, video and audio productions, as well as
area newspapers and other news media. This may include news items relating to your child’s
school work, academic, athletic, or other achievements.
6. Your child’s work may be displayed at District sponsored contests and exhibitions.
SCHOOL USE
Yes____No____
Directory information listed in items 1-6 may be released about my child.
Yes____No____
Your child’s name, picture and work produced by your child may appear
on websites maintained by the District. This may include news items
relating to your child’s schoolwork, academic, athletic, or other
achievements.
NON-SCHOOL USE
Yes____No____
Directory information, which is my child’s name, address, and phone
number may be released for non-school use (i.e. vendors, sales persons).
________________________
Student Name (Please Print)
____________
Grade
______________________________________________
Parent Signature
__________________
Campus Attending
_________________
Date
Please return this form, completed and signed, to the office at your child’s campus.
Información del Directorio Renuncia 2016-2017
Divulgación de Información del Directorio
De conformidad con la Política del Consejo relativa a la Ley de Registros Abiertos de Información
Pública, ciertos registros escolares llamados información de directorio pueden ser compartidos con el
público a pedido, sin su consentimiento, a menos que usted haya instruido previamente que la escuela
no de la información. La única información de directorio que sería compartida por el distrito de Brazos
es el nombre, número de teléfono, y la dirección de su niño(a). Todos los expedientes de los
estudiantes, incluyendo los nombres, direcciones y números telefónicos serán disponibles para el
personal autorizado de la escuela para uso de la escuela.
1. El nombre de su hijo puede aparecer en la lista de cuadro de honor.
2. El foto de su hijo puede aparecer en el anuario.
3. La información sobre becas en relación con su hijo puede ser compartida con los colegios y
universidades
4. El nombre de su hijo puede aparecer en programas tales como obras de teatro y eventos
deportivos que pueden incluir el peso y estatura de los miembros del equipo de atletismo.
5. Su hijo puede ser reconocido en publicaciones del Distrito, vídeo y producciones de audio, así
como periódicos de la zona y otros medios de comunicación. Esto puede incluir noticias
relacionadas con el trabajo escolar de su hijo, información académica, y actividades deportivas
u otros logros.
6. El trabajo de su hijo puede ser exhibido en concursos y exposiciones patrocinados por el distrito.
USO DE LA ESCUELA
Yes____No____
La información del directorio que aparece en los temas 1-6 puede ser
publicado de mi hijo.
Yes____No____
El nombre de su estudiante, la imagen y el trabajo producido por su hijo
de su hijo puede aparecer en sitios mantenidos electrónicamente (el
web) por el Distrito. Esto puede incluir noticias relacionadas con el
trabajo escolar de su hijo, sus académicas, actividades deportivas u otros
logros.
USO FUERA DE LA ESCUELA
Yes____No____
La información del directorio, que incluye el nombre , dirección y número
de teléfono de mi hijo puede ser compartido para su uso fuera de la
escuela (es decir, se le dará a vendedores.)
____________________________________
Nombre del estudiante ( letra de imprenta )
______________
Grado
_________________________________________
Firma del Padre
____________________
Escuela que Asiste
_________________
Fecha
Por favor, devuelva este formulario , cumplimentado y firmado , a la oficina de la escuela de su hijo.
Parent’s Objection to the Release of Student Information to Military Recruiters and
Institutions of Higher Education
Federal law requires that the district release to military recruiters and institutions of higher
education, upon request, the name, address, and phone number of secondary school students
enrolled in the district, unless the parent or eligible student directs the district not to release
information to these types of requestors without prior written consent. [See Objecting to the
Release of Student Information to Military Recruiters and Institutions of Higher Education on
page 5 for more information.]
Parent: Please complete the following only if you do not want your child’s information
released to a military recruiter or an institution of higher education without your prior
consent.
I, parent of ______________________________ (student’s name), request that the district not
release my child’s name, address, and telephone number to a military recruiter or institution
of higher education without my prior written consent.
Parent signature ________________________________________ Date
___________________
Please note that if this form is not returned with the other materials identifying what the
district considers directory information, the district will assume that permission has been
granted for the release of this information.
Please sign and date this page, remove it from the handbook, and return it to your child’s school
Consent/Opt-Out Form
Dear Parent:
The district is required by federal law to notify you and obtain your consent for or denial of
(opt-out) your child’s participation in certain school activities. The activities include any student
survey, analysis, or evaluation, known as a “protected information survey” that concerns one or
more of the following eight areas:
1. Political affiliations or beliefs of the student or student’s parents;
2. Mental or psychological problems of the student or student’s family;
3. Sexual behavior or attitudes;
4. Illegal, antisocial, self-incriminating, or demeaning behavior;
5. Critical appraisals of others with whom the student has a close family relationship;
6. Legally recognized privileged relationships, such as with lawyers, doctors, or ministers;
7. Religious practices, affiliations, or beliefs of the student or parents; or
8. Income, other than as required by law to determine program eligibility or to receive
financial assistance under such a program.
This notice and consent/opt-out requirement also applies to the collection, disclosure, or use of
student information for marketing purposes (“marketing surveys”), and to certain physical
exams and screenings.
The district will provide parents with notification as well as an opportunity to review the survey
and consent or opt their child out. Please note that this notice and authority to consent transfer
from the parent to the student when the student reaches 18 or is an emancipated minor under
state law.
Parent Statement Prohibiting Corporal Punishment
A parent has the responsibility of submitting a signed statement to the principal each year if he
or she chooses to prohibit the use of corporal punishment with his or her child. A parent may
reinstate permission to use corporal punishment at any time during the school year by
submitting a signed statement to the principal. Corporal punishment will be administered in
accordance with the law, district policy, and the Student Code of Conduct (SCOC). [See FO and
the SCOC]
Corporal punishment will be administered as soon as possible after an offense and will not be
administered in anger. The principal or a designee may choose not to use corporal punishment
even if the parent has requested its use. Any use of corporal punishment will be documented
on a district form. The principal or a designee will inform the parent when corporal punishment
is used. Paddles used for administering corporal punishment will not be generally displayed and
will be under the control of the principal or designee. Corporal punishment will be limited to
spanking or paddling and will consist of an appropriate number of strikes based upon the size,
age, and the physical, mental, and emotional condition of the student. Before corporal
punishment is used, the district may give the student a choice between other disciplinary
measures and corporal punishment.
Parent Statement Prohibiting Corporal Punishment:
I have read the information on the use of corporal punishment in the Brazos Independent
School District, and I prohibit the use of corporal punishment with my child.
This form must be submitted annually and can be revoked by the parent at any time.
Name of parent or guardian: _____________________________________________________
Signature of parent or guardian: __________________________________________________
Date: _______________________________________________________________________
Name of student: ______________________________________________________________
Campus: _____________________________________________________________________
Grade:_______________________________________________________________________
Please sign and date this page, remove it from the handbook, and return it to your child’s school
Brazos ISD Parent/Student Agreement
Computer/Network/Internet Acceptable Use
Guidelines 2016 – 2017
STUDENT
I have read the District’s Computer/Network/Internet Acceptable Use Guidelines and
agree to abide by their provisions. I understand that violation of these guidelines may
result in suspension or revocation of Computer/Network/Internet use or access.
Printed Name: _______________________________ Grade: _____________
Signature: __________________________________
PARENT OR GUARDIAN
I have read the District’s Computer/Network/Internet Acceptable Use Guidelines. I
understand that it is a privilege and not a right for my student to have access to the
computer resources provided by Brazos ISD for the use of student. I hereby release
Brazos ISD, Brazos High School, Brazos High School employees, Brazos Middle School,
Brazos Middle School employees, Brazos Elementary School , Brazos Elementary
School employees and any institution affiliated with the District from any and all
claims and damages arising from my child’s inappropriate use of the District’s
Computer/Network/Internet System as stated in the District’s Computer/Network/
Internet Acceptable Use Guidelines.
Check one of the following:
Internet System.
___ I give permission for my child to participate in the District’s Computer/Network/
___ I do not give permission for my child to participate in the District’s Computer/
Network/Internet System.
Signature of Parent or Guardian: _____________________________________
Date: __________
SIGN AND RETURN THIS PAGE ONLY
Brazos Independent School District
Campus: Brazos Elementary School
Gradebook Parent Account
Confidentiality Affidavit
Parent/Guardian:__________________________________________
Last Name
First Name
M.I.
Student’s Name:___________________________________________
Last Name
First Name
M.I.
Address:________________________________________________
Mailing Address
City & State
Zip Code
__________________________________________________________
Physical Address
City & State
Zip Code
By completing the application for this account, you will allow the Brazos Independent
School District (BISD) to make your child’s grades available to you by means of the
Internet on a website that is secure and accessible only by a login and password. Only
you will be able to see your child’s grades. Others will not be able to see the information
of your child unless you share your password with them.
BISD will not make your username/password publicly available. The grades of your
child posted on the website can only be accessed only by someone who knows your
username and password.
Be aware, however, that disclosure by BISD, including the contents of the website, may
occur in the event that such information is required by order of a court subpoena, a
decision or directive from the Attorney General’s office, or other reason required by law.
Please remember that the grades that you see might not include all assignments or tests
that have been completed by your child. As teachers complete the grading of
assignments and tests, the teachers will update the report. If you have any questions
about any item, please contact the teacher by calling the campus office that your child
attends. The teacher will either contact you by phone or e-mail. If you desire further
clarification you may call and schedule a conference with the teacher.
You are permitted to share your username/password only with those whom you
consider to have a legitimate educational interest in your child. You may cancel this
service at any time or change your username/password, by contacting the Gradebook
Site manager of your child’s campus.
By signing and returning this form to the campus office of your child, you understand
that BISD is not responsible for Internet access to your child’s grade reports by persons
who do not have authorization or consent. You also understand that BISD has the right
and authority to revoke your access to the website if the district feels your use of and
behavior on the website violates others rights and confidentiality. In addition by signing
and returning this application, you agree to waive any claims or causes of action that
you may have against BISD by reason of such unauthorized access or revocation of
access privileges.
Parent/Guardian Signature:__________________________________
Date: ___________________
Please choose from the following options to receive your child’s portal ID.
______ I will pick up my child’s Student Portal ID at my child’s campus.
______ Please email me at:______________________________ with my child’s
Student Portal ID
______ Please mail my child’s Student Portal ID to the address listed above.
·
BRAZOS ISD Student Residency Questionnaire
The information on this form is required to meet the law known as the McKinney-Vento Act 42 U.S.C.
lf434a(2), which is also known as Title X, Part C, of the No Child Left Behind Act. The answers yon give
will help the school determine the services the student may be eligible to receive.
Presenting afalse record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of tlie child
under false documents subjects tlie person to liability for tuition or otlier costs. TEC Sec. 25.002(3)(d).
Name of Student ________________________Gender: 0 Male O Female
Middl.e
Last
First
Birth Date
I
I
Month I Day I Year
Grade: _____ S ocial Security#:_____________
(or student identification number)
Check the box that best describes with whom the student resides. (Please note: legal guardianship may be granted onlyby
a court; students living on their own or with friends or relatives who do not have legal guardianship are allowed to enroll
in and attend school. The school cannot require proof of guardianship for enrollment or continued attendance.)
D Parent(s)
D Legal Guardians(s)
D Caregiver(s) who are not legal guardian(s) (Examples: friends, relatives, parents offriends, etc.)
D Other ----'--------------------------------Name of person with whom student resides:-------------------------Address=-------------------------------------City:_________________________ ZIP:____________
Home Phone=#�: _______ _Cell Phone=#·�· ______ Other Emergency#: __________
Length of Time at PresentAddress:_____________________________
Length of Time at Previous Address:_____________________________
Name school where student is enrolled or in which student is attempting to enroll: ______________
Last DistrictAttended:.____ ________ Last School Attended:.______________
Please check only one box that best describes where the student is presently living:
D
D
D
D
D
D
-In my own home, OR
-In an apartment, OR
-In a mobile home, OR
-In a rent house, OR
-In Section 8 housing, OR
-In military housing
-Please check one or both of the boxes below if applicable: (CODE=N)
D My home has no electricity (CODE=TI)
D My home has no l1ll1Illilg water (CODE=TI)
D In. the home ofa friend or relative because I lost my housing (examples: fire, flood, lost job, divorce, domestic violence,
kicked out by parents, parent in milita:ry and was shipped out, parent(s) in jail, etc.) (CODE=D)
Continued on next page
Brazos ISD
Brazos ISD
Brazos ISD Health Services Department
The information you record on this form will become part of your child’s school health record and will remain confidential.
Student Name: ________________________________________________ Grade: ___________________
Does your child have any allergies? (If yes, indicate what type below)
Medication? ____Yes ____ No
What medicine? ______________________________________________
Foods?
____ Yes ____ No
What food? _________________________________________________
Insect Stings? ____ Yes ____No
What insect? ________________________________________________
Does your child require special treatment such as an EpiPen for the allergy?
___YES ___NO
Asthma?
___YES ___NO
Medication used for treatment:
Any seizure disorders?
Age of onset: ________
___YES ___NO
Type of seizures and medication used for treatment:
Frequent fainting?
Age of onset: ________
___YES ___NO
From what and any treatment:
Headaches?
Age of onset: ________
___YES ___NO
___Migraine ___Other:
Treatment:
Blood Pressure Problems?
Age of onset: ________
___YES ___NO
Medication used for treatment:
Diabetes?
Age of onset? ________
___YES ___NO
Medication used for treatment:
Heart Problems?
Age of onset: ________
___YES ___NO
Medication used for treatment:
Hyperactive Behavior and/or Attention Deficit Disorder?
___YES ___NO
Medication used for treatment:
Emotional Problems?
Age of onset: ________
___YES ___NO
Medication used for treatment:
Vision or Eye Problems?
Age of onset: ________
___YES ___NO
Type of problem and treatment:
Hearing Problems or Ear Disease?
Age of onset: ________
___YES ___NO
Type of problem and treatment:
Speech Problems?
Age of onset: ________
___YES ___NO
Type of problem and treatment:
Bone or Muscle Problems?
Age of onset: ________
___YES ___NO
Type of problem and treatment:
Blood Disorders?
Age of onset: ________
___YES ___NO
Type of problem and treatment:
Dental Problems?
___YES ___NO
Type of problem:
Kidney, Bladder, or Intestinal Problems?
Age of onset: ________
___YES ___NO
Type of problem and medication used for treatment:________________________________________________
Any other medical problems not yet asked?
Problem and treatment:
Does your child have any physical restrictions?
Type of restriction:
(Complete Back)
___YES ___NO
___YES ___NO
Will your child be routinely taking any medication at school?
Name of medication
___YES ___NO
Dosage
What time?
If your child has had the chickenpox, please verify below: (Complete only if your child is new to the
district)
I certify that my child __________________________________, had chickenpox on or about
Name of child
____________________________ and does not need the varicella (chickenpox) vaccine.
Date
______________________________________________________
Signature of Parent/Guardian
EMERGENCY CONTACT INFORMATION
Mother
Work # _______________________________________
Alt. #_________________________________________
Father
Work #_______________________________________
Alt. #_________________________________________
Child’s Doctor
Name: _______________________________________
Phone:_______________________________________
Child’s Dentist
Name:_______________________________________
Phone:_______________________________________
I authorize officials of Brazos ISD to contact directly the physician or dentist name above to render treatment as
deemed necessary in an emergency for the health of my child. In the event of an emergency that the above named
doctor or dentist cannot be reached, I do hereby authorize officials of Brazos ISD to take whatever action deemed
necessary, in their judgment, for the health of my child. I will not hold the school district financially responsible
for the emergency care and/or transportation for my child. I will promptly alert the school of any changes in the
above information.
The district will not authorize major surgery unless the medical opinions of two licensed physicians or dentists,
concurring in the necessity for such surgery, are obtained prior to the performance of any surgery.
Any facts concerning the student’s medical information on this form may be released to the advanced medical care
team upon arrival with the ambulance.
I request my child be taken to _________________________________________ for emergency care.
(Preferred Hospital)
Signature of Parent/Guardian:_____________________________________________________
Date: ____________________
Brazos ISD Departmento de Servicios de Salud
La información que usted escriba en esta forma va ser parte del archivo de salud de su hijo y permanence
confidencial.
Nombre de Estudiante:________________________________________________
Grado:___________
Tiene su hijo alergias? (si la respuesta es sí, índice abajo)
Medicina?
___ Sí ___ No
Que medicina?_______________________________________________
Comidas?
___ Sí ___ No
Que comidas?________________________________________________
A Insectos? ___ Sí ___ No
Que insectos?________________________________________________
Otro?_____________________________________________________________________________________
Necesita su hijo tratamiento especial tal como un Epi Pen para la alergia?
___ Sí ___No
__________________________________________________________________________________________
Asma?
___ Sí ___No
Que clase de medicina usa para el tratamiento:____________________________________________________
Alguna desorden de convulsiónes? Edad cuándo empezaron:_____
___ Sí ___No
Que clase de convulsiones y medicina para el tratamiento:___________________________________________
Se desmaya frecuentemente? Edad cuándo empezaron:_____
___ Sí ___No
Que causa los desmayos y el tratamiento:________________________________________________________
Dolor de cabeza? Edad cuándo empezaron:_____
___ Sí ___No
Migrana:_______Otra clase:______tratamiento:___________________________________________________
Problemas de las presion? Edad cuándo empezo:_____
___ Sí ___No
Que clase de medicina usa para el tratamiento:____________________________________________________
Diabetes? Edad cuándo empezo:_____
___ Sí ___No
Que clase de medicina usa para el tratamiento:____________________________________________________
Problemas del corazon? Edad cuándo empezaron:_____
___ Sí ___No
Que clase de medinina usa para el tratamiento:____________________________________________________
Hiperactividad?Deficiencia de atencion? Edad cuándo empezo:_____
___ Sí ___No
Que clase de medicina:_______________________________________________________________________
Problemas emocionales? Edad cuándo empezaron:_____
___ Sí ___No
Que clase de medicina usa para el tratamiento:____________________________________________________
Problemas de vision o de los ojos? Edad cuándo empezaron:_____
___ Sí ___No
Que clase de problema y tratamiento:____________________________________________________________
Problemas de oir o del oido? Edad cuándo empezaron:_____
___ Sí ___No
Que clase de problema y tratamiento:____________________________________________________________
Problemas de hablar? Edad cuándo empezo:_____
___ Sí ___No
Que clasa de problema y tratamiento:____________________________________________________________
Problemas con los huesos o musculos? Edad cuándo empezo:_____
___ Sí ___No
Que clase de problema y tratamiento:____________________________________________________________
Desorden de sangre? Edad cuándo empezo:_____
___ Sí ___No
Que clase de problema y tratamiento:____________________________________________________________
Problemas dentales? Edad cuándo empezo:_____
___ Sí ___No
Que clase de problema:_______________________________________________________________________
Problemas del riñon, vejiga o interestinos? Edad cuándo empezo:_____
___ Sí ___No
Que clase de problemas y medicina para el tratamiento:_____________________________________________
Algun otro problema que no le preguntamos?
___ Sí ___No
Problema y tratamiento:______________________________________________________________________
Tiena su hijo alguna restricción física?
___ Sí ___No
Clase de restricción:_________________________________________________________________________
Continuado otro lado
Va tomar su hijo alguna medicina regularmente en la escuela?
Nombre de medicina
___ Sí ___No
Dosis
Que hora?
Si su hijo ha tenido varicela, por favor verifíca abajo: (Completa solo si su hijo es nuevo en el distrito.)
Yo certífico que mi hijo _____________________________________, tuvo varicela en ________________
Nombre del niño
Fecha
y no necesita la vacuna de varicela.
____________________________________
Firma de Padre/Guardian
AUTORIZACIÓN MÉDICA DE EMERGENCIA
Madre
# de Trabajo______________________________
Otro #___________________________________
Padre
# de Trabajo_______________________________
Otro #____________________________________
Doctor del Niño
Nombre:_________________________________
Telefono:_________________________________
Dentista del Niño
Nombre:__________________________________
Telefono:_________________________________
Yo autorizo a los oficiales del distrito escolar de Brazos a ponerse en comunicación directamente con las
personas nombradas en este documento y autorizo el doctor y dentista nombrado para darle el
tratamiento necesario en caso de emergencia para el salud de mi hijo. En el evento de un emergencia en
que no se puedan poner en comunicación con las personas, nombradas, los oficiales de la escuela tienen
mi concentimiento de tomar cualquier acción necesaria para el bienestar de mi hijo. No hago al distrito
escolar responsable por el cobro de la asistencia emergencia y/o transportacion de mi hijo. Avisaré a la
escuela de cualquier cambio en la información anterior de este documento.
El districto no autorizará cirugía importante a menos que se obtenga los opiniones médicos de dos
médicos o dentistas , concurriendo en la necesidad para tal cirugía, se obtengan antes del funcionamiento
de cualquier cirugía.
Cualquier hecho referente a la información médica del estudiante sobre esta forma se puede lanzar al
equipo avanzado de la asistencia médica sobre llegada en la ambulancia.
Solicito a mi hijo que lo llevan a ________________________________ para el astistencia de emergencia.
(Hospital Preferido)
Firma de Padre/Guardián:____________________________________________________
Fecha:_______________________________
TB Questionnaire
Name of Child____________________________________________________________Date of Birth ________________
Organization administering questionnaire______________________________________ Date_______________________
Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung
disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by
the child.
Adults who have active TB disease usually have many of the following symptoms: cough for more that two weeks duration,
loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats.
A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI).
Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if your
child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis.
The skin test is not a vaccination against TB.
We need your help to find out if your child has been exposed to tuberculosis.
Place a mark in the appropriate box:
Yes
No
Don't
Know
TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting over two
weeks), or coughing up blood. As far as you know:
has your child been around anyone with any of these symptoms or problems? or
has your child had any of these symptoms or problems? or
has your child been around anyone sick with TB?
Was your child born in Mexico or any other country in Latin America, the Caribbean, Africa,
Eastern Europe or Asia?
Has your child traveled in the past year to Mexico or any other country in Latin America, the
Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks?
If so, specify which country/countries?______________________________________
To your knowledge, has your child spent time (longer than 3 weeks) with anyone who is/has
been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the
United States from another country?
Has your child been tested for TB?
Has your child ever had a positive TB skin test?
Yes___ (if yes, specify date ____/____)
Yes___ (if yes, specify date ____/____)
No___
No___
For school/healthcare provider use only
***************************************************************************************************
PPD administered
Yes___
No___
If yes,
Date administered _____/_____/______ Date read ______/______/_______ Result of PPD test __________ mm response
Type of service provider (i.e. school, Health Steps, other clinics) _______________________________________________
PPD provider
__________________________________________
signature
Provider phone number
______________________________________
printed name
___________________________________
City ________________________________________________ County ________________________________________
If positive, referral to healthcare provider
Yes___
No___
If yes, name of provider _______________________________________________________________________________
EF12-11494 TB Questionnaire for Children (Rev. 08/04)
Cuestionario de Tuberculosis
Nombre del niño o niña
_____________________________________________________________________________________
Organización ____________________________________________________________ Fecha
___________________________
La Tuberculosis (TB) es una enfermedad causada por gérmenes de TB y en la mayoriá de los casos es trasmitida por una
persona adulta con tuberculosis pulmonar activa. Se transmite a otra persona por la tos y por el estornudo al expelir
gérmenes de TB al aire que pueden ser respirados por los niños.
Los adultos que tienen la enfermedad activa casi siempre tienen varios de los siguientes síntomas: tos con duración de más
de dos semanas, pérdida de apetito, pérdida de peso de diez libras o más en un período corto de tiempo, fiebre, escalofríos y
sudores nocturnos.
Una persona puede tener gérmenes de TB en su cuerpo pero no tener la enfermedad activa. Esto se llama infección latente
de TB (o LTBI por su sigla en inglés).
La TB es prevenible y curable. La prueba tuberculínica, también llamada PPD o prueba de Mantoux, se utiliza para saber si
su niño o niña ha sido infectado/a con el germen de TB. No se recomienda ninguna vacuna para prevenir la tuberculosis.
La prueba tuberculínica no es una vacuna contra la tuberculosis.
Necesitamos de su ayuda para saber si su niño/niña ha sido expuesto/a a la tuberculosis.
Sí
No
No se
sabe
La tuberculosis puede causar fiebre de larga duración, pérdida de peso inexplicable, tos severa
(con más de dos semanas de duración), o tos con sangre. ¿Es de su conocimiento si:
su niño o niña ha estado cerca de algún adulto con esos síntomas o problemas?
su niño o niña ha tenido algunos de estos síntomas o problemas?
su niño o niña ha estado cerca de alguna persona enferma de tuberculosis?
¿Su niño o niña nació en México en o cualquier otro país de América Latina, el Caribe, Africa,
Europa Oriental o Asia?
¿Su niño o niña viajó a México o a cualquier otro país de América Latina, el Caribe, Africa,
Europa Oriental o Asia durante el último año por más de 3 semanas?
Si su respuesta es positiva, favor de especificar a qué país o países.
¿Es de su conocimiento, si su niño o niña pasó un tiempo (más de 3 semanas) con alguna
persona que es o ha sido usuario de droga intravenosa (IV), infectado por VIH, en la prisión, o
haya llegado recientemente a los Estados Unidos?
¿A su niño o niña se le ha realizado la prueba tuberculínica recientemente?
No___
¿Su niño o niña alguna vez tuvo reacción positiva a la tuberculina?
No___
Sí___ (si sí, especifique la fecha ____/____)
Sí___ (si sí, especifique la fecha ____/____)
Solamente para uso de la escuela o del proveedor de servicios médicos
***************************************************************************************************
***
¿Se administró PPD?
Sí___
No___
Si sí,
Fecha en que fue administrada_____/_____/_____ Fecha de lectura _____/______/_____ Resultado de la prueba_____
mm
Tipo de proveedor de servicio (ej.: escuela, Health Steps, otras clínicas)
____________________________________________
Administrador de PPD ___________________________________________
_____________________________________
firma
nombre en letra de molde (imprenta)
Número de teléfono del administrador de PPD ___________________________________
Ciudad________________________________________________
Condado_______________________________________
Si resultó positivo, ¿se refirió al proveedor de servicios de salud?
Si sí, nombre del proveedor (médico o clínica, etc.)
____________________________________________________________
EF12-11494A (Rev. 08/04)
Sí___
No___
Parents and Guardians
You can take advantage of our
Text Messaging Service
Our school utilizes the SchoolMessenger
system to deliver text messages, straight
to your mobile phone with important
information about events, school closings,
safety alerts and more.
You can participate in this free service* just
by sending a text message of “Y” or “Yes”
to our school’s short code number, 67587.
You can also opt out of these messages at
any time by simply replying to one of our
messages with “Stop”.
SchoolMessenger is compliant with the Student Privacy Pledge, so you can rest
assured that your information is safe and will never be given or sold to anyone.
Opt-In from
your mobile
phone now!
Just send
“Y” or “Yes”
to 67587
Information on SMS text messaging and Short Codes:
SMS stands for Short Message Service and is commonly referred to as a "text message". Most cell phones support this type
of text messaging. Our notification provider, SchoolMessenger, uses a true SMS protocol developed by the
telecommunications industry specifically for mass text messaging, referred to as “short code” texting. This method is fast,
secure and highly reliable because it is strictly regulated by the wireless carriers and only allows access to approved providers.
If you’ve ever sent a text vote for a TV show to a number like 46999, you have used short code texting.
©2015 West Corporation [0111515]. All rights reserved. May not be reproduced without expressed written permission.
Child Nutrition Program
August 2016
The Brazos Independent School District participates in the National School Lunch and School Breakfast
Program which require us to follow Federal Nutrition Guidelines. The guidelines allow us to offer
students nutritionally balanced lunch and breakfast meals daily.
Children from households that meet Federal Income guidelines are eligible for free or reduced price
meals at $0.30 for breakfast and $0.40 for lunch. Applications for free and reduced priced meals are
given to all students at the beginning of school as part of the student packet. Applications are also
available in the front office at each campus.
A new application must be completed each school year. Complete one per household.
2016-2017 Meal Prices
Breakfast
Student –Pre-K-12th
Student Reduced
$1.30
$0.30
LUNCH
Student- Pre-K-5th
Student 6th – 12th
Reduced Price
$2.45
$2.70
$0.40
Meal prices are for a complete meal. For all incomplete meals a la carte prices will be charged.
Complete Breakfast - A minimum of ½ cup serving of fruit + 2 additional food items.
Complete Lunch – Choose at least 3 of 5 meal components offered (Fruit, Vegetables, Milk, Meat,
Grain), Additionally at least one of those choices must be a ½ cup serving of fruit or vegetable.
CHILD NUTRITION POLICY
ELEMENTARY - Students have a seven dollar charge limit, when the child’s account reaches the seven
dollar negative balance, the student will not receive the published lunch. These students will receive an
alternate meal (cheese sandwich, fruit, milk) until their negative balance is paid. Students with a
negative amount on their account are not allowed to purchase breakfast or al-a-carte items, including
milk.
MIDDLE SCHOOL & HIGH SCHOOL – These students are allowed to charge one tray only. The next day,
if money is not received on their account, they will be given an alternate meal (cheese
sandwich,fruit,milk) until their negative balance is paid in full. Students with any negative amount are
not allowed to purchase breakfast, a-la-carte items, including milk.
All school cafeterias have computerized point of sale/cash register systems that maintain a record of all monies
deposited and spent for each student and said record will be made available to the parent upon request. Meals
can be paid for in advance and balances maintained in their child’s account to minimize the possibility that the
child may be without meal money on any given day. Payments may be made at the point of sale or in advance.
Brazos ISD provided a service called Lunch Money Now; this program will permit parents to access their student’s
cafeteria account via the internet. This access will provide the parent with the ability to do several things including
checking the student’s balance, viewing the students purchase history, and making deposits to the child’s lunch
account. Parents are also able to subscribe for email warnings when their child’s account dips below a specified
amount reminding the parent that their child’s balance needs attention.
For more information about Nation School Lunch or School Breakfast Program, including free and reduced-priced
meals, call the Brazos ISD Child Nutrition Office, Georgina Matula (979)478-6006 or email [email protected].
Brazos ISD
Child Nutrition Department
August 2016
Dear Parents:
The Child Nutrition Department will not modify a student’s diet without a
physician’s statement. If your child has a life threatening food allergy/disability
which would require their diet be altered in any way from the school menu, you
are required to have a physician fill out this form with substitutions or
modifications clearly communicated so that the appropriate measures may be
taken. No substitutions or modifications will be made without this form signed
by a physician.
If your child does not have any life threatening food allergies/disabilities, you do
not have to complete this form. If your child’s medical or health needs change,
please notify the Child Nutrition Department immediately.
Please return completed form to your child’s campus Child Nutrition Manager or
to the Child Nutrition office at 16621 Hwy 36 S, Wallis, TX 77485 or mail to P. O.
Box 458, Wallis, TX 77485.
If you have any further questions or need additional information, please contact
me.
Georgina Matula
Child Nutrition Director
(979) 478-6006
[email protected]
Brazos ISD Child Nutrition Programs
Food Allergy/Disability Substitution Request
2016/2017
Student’s Name______________________
Age: _________________________
School:
Grade/Classroom________________
_______________________
Identify the Student’s disability: ______________________________________________
Food Allergy/Special Nutritional or Feeding Needs
Please indicate your child’s special needs below:
 Diabetic
 Lactose Free  Peanut Allergy
 Other: ________________
For Use by Physician Only
Non Allowable
may be substituted with
__________________
__________________
__________________
__________________
Allowable Food
________________________
________________________
________________________
________________________
I certify that the above named student needs to be offered food substitutes as described above
because of the student’s medical allergy or disability indicated above. (Use back of form if
needed.)
______________________________
Name of Physician
_____________________
Telephone Number
______________________________
Signature of Physician (Required)
_____________________
Date
I understand that if my child’s medical or health needs change, it is my responsibility to notify the
school.
____________________________
Signature of Parent/Guardian
______________________
Date
Daytime Contact Phone Number______________________________________
*Note: The Child Nutrition Department will attempt to accommodate the substitutions as requested
but reserves the right to modify the menu based on product availability.
Copies to:
 Nurse
Child Nutrition Office
 Campus file (Caft. Manager)
In accordance with Federal law and U>S. Department of Agriculture policy, this institution is prohibited from discriminating
on the basis of race, color, national origin, sex age or disability. To file a complaint of discrimination, write U.S> Department
of Agriculture, Director, Office of Adjudication and Compliance, 1400 Independence Avenue, SW, Washington, D.C. 202509410 or call (800) 7953272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.
SCHEDULE OF BENEFITS FOR ALL INDIVIDUAL ACCIDENT-ONLY PLANS
Medical Maximum:
$25,000 for each Injury
1-Year-Renewable
52 Weeks from the date of Injury
90 days from the date of Injury
$0.00
Policy Term:
Benefit Period:
Initial treatment Period-:
Deductible:
Inpatient
Inpatient Hospital:
Doctor Visits:
Usual & Customary Charges up to $750.00 per day/ 6 days marinmm (mcludes. fucili.ty and services)
Usual & Custonwy Charges up to $40.00 per day
Outpatient
Ambulatory Surgical Center:
Doctor Visitx:
Physiotbempy:
Medical Emergency;
Medical Emergency Doctoi::
Diagnostic X-my:
CAT Scan/MRI:
Laboratoty Procedures:
Usual & Cu.stomm:y Cha!:ges up to $2,000.00 (facility chm:ge)
Usual & Custonwy Charges up to $40.00 per day
$50.00 l "visit/$25.00 per visiHhereafter up to 5 visits toial ((limited to 1 visit per day)
Usual & Custmnmy Cha!:ges up 1D $175.00 (furnse ofemeigency room facility and services wifhin 72 hams oflajucy)
Usual & Custonwy Charges up to $40.00
Usual & Customary Cha!:ges up to $200.00 and $50.00 for�g
Usual & Customary Cha!:ges up to $500.00 and $50.00 for�
Usual & Customary Charges up to $50.00
Other (Inpatient and/or Outpatient)
Surgeon:
Anesthetist:
Assistant Smgeon:
Ambulance:
Dental Treatment:
Orlhopeclic Braces & Appliances:
Post Surgical Durable Meclical
Equipm ent:
Eye Glasses, Contact Lenses and
and Hearing Aid Replacement:
Prescriptlon Drugs:
75% of Usual & Customary Charges up to $2,000.00 (limited to primary procedure including :removal ofsurgical
Implanted pins within two years ofinjmy)
25% of smgeon benefit
25% of surgeon benefit
Usual & Customary Charges up to $1,000.00 (first trip to Hospital only)
Usual & Customary Charges up to $5,000.00 (benefitx paid on Injmy to Sound, Na.tm:Bl Teeth only)
Usual & Customazy Charges up to $500.00
Usual & Customary Charges up to $150.00
Usual & Customary Cha!:gcs (as a result of a covered Injury only)
$15 per prescription
POLICY EXCLUSIONS AND Lll\flTATIONS FOR ALL INDIVIDUAL ACCIDENT-ONLY PLANS
Benefits will not be paid for: a) loss or expense caused by, contnlmted to, or resulting from: orb) treatment, services or supplies for, at, or related to:
• .Acupuncture.
• Air travel except while as a fare-paying passenger on a regularly scheduled commercial air cm:rie:r; travel in or upon, sitting in or upon, alighting to
or from, or working on or around any motorcycle or recreational vehicle including, but not limited to, two or three-wheeled motor vehicle; four­
wheeled all terrain vehicle (ATV); jet ski; ski cycle; snowmobile or off-road motorized vehicle not requiring licensing as a motor vehicle.
• .Artificial aids such as eyeglasses, con'lact lenses, hearing aids, or examinations or prescriptions therefore 1lllless specifically provided for in the
Sche.dule of Benefits.
• Cosmetic surgery of any kind, except reconstmctive surgery as a direct result of a covered I:qjuzy.
• Dental treatment, except fur aecidental Iajury to Sound, Na.tm:Bl Teeth.
• Elective Surgery or Elective Treatmellt.
• Food poisoning or bacte:r:ial infections (except an infection occmring 'lbrough an apen vist"'ble wound); cysts or skin lesions such as blisters or boils; .
tumors; over-exerting (not to include heat stroke); fainting; neuritis, lumbago, hernia, regardless of how caused; illness or disease in any fonn.
• Bursitis, muscle teais, repetitive motion injuries, shin splints, strains, tennis elbow aggravation, and treatment of stress fraclmes.
• Tmnmtfrzations, preventive medicines or vaccines, ex:cept where required for treatment of a covered Injury.
• Intoxicants and narcotics. The Company is not liable for any loss sustained or contracted in comequence of the Insured being intoxicated or under
the influence of any narcotic unless the narcotic is administered on the advice of a Doctor.
• Injury for which benefits are paid or payable by workers' compensation or employer's liability or occupational disease law.
• Injury where the Insured is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator's license (except in a
· Driver's Education Program).
• I:qjuzy where the Insured is riding in or driving any type of motor vehicle as part of a speed contest or sche.duled mce, including testing such vehicle
on a track, speedway, or proving ground.
• War, declared or undeclared (a pro-rata. premium will be refunded upon request for such period not covered); participation in a riot or civil disorder;
or while a member of fue Armed Services.
• Orlhodontics (braces) for any reason, damage to, or loss of orthodontics.
• Play or practice of interscholastic High School Football.; ex:cept where the coverage is elected.
• Participatlng in or attending any School-Sponsored overnight activities, except where 24-Hour coverage is elected.
• Pre-existing Conditions or aggravation of a Pre-existing Condition, as defined. A Pre-existing Condition is a disease or physical condition for which
the Insured :received medical advice or treatment during the three months before the Insured's Effective Date of Coverage.
• Stroke or cerebrovascular accident or event; cardiovascular aecident or event; myocardial infarction or heart attack; coronary thrombosis; anew:ysm..
•
•scuba diving, surfing. roller skating,, ice ska.ting, or riding in a rodeo.
•
pa:raclmting, hang gliding, glider flying, flight in an ultra light aircraft, parasailing, sail plamrlng, b ungee jumping, bob-sledding, or
b oon1ng.
• Suicide or attempt tbereo( while sane or insane (mcluding drug overdose); intentionally self-inflicted Injuries; :fighting.
• Supplies, except as specifically provided in the Policy.
• While committing or attempting to commit an assault or felony, or to which a contnoutory cause was the Insured being e:ngaged in an illegal
occupation.
• Participation in terrorism..
Policy Form SA-Th.TD-11-12-TX
BRAZOS HIGH SCHOOL
LOCKER USE CONTRACT
2016-2017
1. Lockers are not to be slammed open or closed. Lockers should only be closed by
a hand.
2. Lockers should not be kicked.
3. Lockers surfaces are to remain extremely clean. Taped and affixed items are
not allowed both inside and outside of the lockers.
4. Food and perishable items are not allowed in the lockers.
5. Students are not allowed to step inside or place any individual in the lockers.
6. Students are not allowed to adjust locker doors to keep them from locking.
7. Any other rule regarding lockers set forth by the campus administration must be
followed.
8. Before receiving grades at the end of the spring semester, all students will have
their locker inspected in accordance with the above.
9. Any damage to lockers may include Criminal Mischief or Vandalism Charges.
Moreover, violating the above will result in campus disciplinary actions and
monetary compensation if necessary.
My signature below verifies that I have read and understand the 2015-2016 Brazos
High School Locker Use Contract.
_______________________________________
Printed Student Name
________________________
Grade
_______________________________________
Student Signature
________________________
Date