Meadowlark Elementary School
On-‐Line Enrollment Step 2 Document 2011/2012
WELCOME BACK TO MEADOWLARK ELEMENTARY New Students Enroll Monday, August 8 (8 a.m. to 12 p.m. & 1 p.m. to 4 p.m.) (in the Meadowlark Office)
Returning Students Enroll Tuesday, August 9 (12:30 p.m. to 7 p.m.) (in the Meadowlark Office)
Meet Your Teacher Night Tuesday, August 16 (5:30 p.m. to 6:30 p.m.)
First Day - Grades 1st thru 5th Thursday, August 18 (8:35 a.m.)
First Day - Kindergarten (Monday, August 22) All Day 8:35a.m. to 3:35 p.m. Half Day 11:35 p.m. to 3:35 p.m.
Kindergarten Screening Thursday, August 18 Friday, August 19
2011-2012 Meadowlark Elementary Fees Student Name: Grade: Required Fees $65.00 - Half Day Kindergarten Textbook Fee st th $75.00 - All Day Kindergarten, 1 thru 5 Grade Textbook Fee st
th
$25.00 - All Day Kindergarten, 1 thru 5 Grade Technology Fee $12.50 - Half Day Kindergarten Technology Fee
Elective Fees $100.00/1 student - Transportation Fee (for for all students who live less than 2.5 miles from their school and choose to ride the bus) $150.00/family - Transportation Fee (for all students in one family who live at the same address) $275.00 – Monthly Fee for or All Day Kindergarten
Food Service Fees $1.50 – Breakfast $2.05 – Lunch $0.40 – Snack Milk (kindergarten only)
Required Fee Payment Options • •
Check or money order payable to Meadowlark Elementary School Pay online at www.usd385.org
Elective Fee Payment Options • •
Check or money order payable to USD #385 Pay online at www.usd385.org
Food Service Payment Options • •
Check or money order payable to USD #385 Food Service Pay online at www.usd385.org
Applications for free and reduced fee assistance are available online. The following forms will need to be printed off and returned to the school off office ice before enrollment is complete. Please check off that you are returning the following forms: _____ Request for Transcript (new new students only) _____ Placement Information (new students only) _____ Proof of Residence (new students only) _____ School Directory Form (optional) _____ PTO Committees (optional) _____ Request for Paper Copy opy of Newsletter (optional) _____ Free & Reduced Application (if applicable) _____ Student Requiring Special Meals (ifif applicable applicable) _____ Birth Certificate (new students only)
Office Use:
Amount $_______________Check#_____________Cash__________Online__________
Volunteer Sign-up Sheet All Meadowlark parents and staff are members of the school’s Parent-Teacher Organization (PTO). The PTO coordinates more than 30 different school activities and services which cannot happen without our wonderful Meadowlark parent volunteers! Please consider being involved. Mark the box next to the committees you could help with. Thank you! Name:_______________________________________Primary/Secondary Phone Numbers: _____________________________________ E-mail address:________________________________Name of Child/Children & grade(s)_______________________________________ General Volunteer
Receive e-mails when help is needed for any PTO activity. Help when you can.
Home Room Parent
Become the home room parent in your child’s class; plan the fall and spring parties with other parents’ help.
Helping Hands
Greet and direct students to their class and to/from the bus on the first few days of school. Help in the lunchroom during the first week of school.
Welcome Wagon
Help plan the September Welcome Wagon Coffee to welcome all families back to Meadowlark for another great year. Greet new families during the year at PTO meetings.
Spring Fund Raiser
Help organize and work the fundraiser in April.
GAD Parade
Help design and build the float for the Greater Andover Days Parade on October 1, 2011.
Parent/Teacher Conferences
Provide food and other items for teacher meals during conferences in October and February.
Box Tops/Tyson
Help to collect, count and forward box tops to General Mills and Tyson labels to Tyson. This is a great fundraiser for the school. All money received from Boxtops goes to the Staff Grant Program.
Family Fun Night
Help plan and work at a fun school social in September.
Bulletin Board
Help decorate the PTO bulletin board in the front lobby monthly or as needed.
Book Fair
Help to set up and sell books at one or more shifts during the 2011 Scholastic Book Fair in October.
Picture Day
Help photographer and school staff take pictures of students in the fall and spring.
Librarian Helper
Assist librarians throughout the year, shelving books and other duties as needed. Commitment could be once or twice per month, once per week or other schedules.
Sunshine Committee
Help recognize staff members on their birthdays throughout the year.
Holiday Staff Meal
Provide items (drinks, food, paper products) to create a nice meal for the staff in December.
Staff Appreciation Week
Help organize and provide food, decorations and gifts the first week in May.
All Star Reading
With a staff member, watch students on the playground at the extra 15 minute recesses at the end of each quarter. Help with the All Star Reading T-shirt design contest in the spring.
Holiday Caring & Sharing
Help organize the collection of toys and money for the under-privileged in Andover starting after Thanksgiving and finishing before Christmas break.
Office Helper
Help office staff with getting Friday folders out and other duties as necessary. Serve once per month or more.
Art Helper
Help Art Teacher hang artwork in the school hallways throughout the year.
Music Helper
Help decorate for school music programs (all grades) and make signs and create costumes as needed.
Year Book
Help take and gather pictures for the school yearbook throughout the year. At least one picture chairperson per grade level is needed.
T-Shirts
Design, order and sell Meadowlark T-shirts, especially during August and September.
Nurse Helper
Help nurses check in students for dental check up day, height/weight day and other duties as needed.
Counselor Helper
Help as needed with Drug Free Red Ribbon week in the fall, Careers on Wheels day in the spring and Counselor Appreciation Day in February.
Reading Lab Helper
Help Reading Specialist plan and work during Read Across America activities in early March.
PE Helper
Help PE teacher with Fun in the Sun Field Day in May and sometimes other PE events throughout the year.
Outdoor Habitat
Help maintain our beautiful outdoor habitat by volunteering to weed and plant as needed.
Future All-Stars Playgroup
Be notified of upcoming playgroups for future Meadowlark students.
Recycling
Help with the recycling program at Meadowlark throughout the year.
Staff Grant Program
Serve once per year or more on the monthly rotating committee to vote on staff applications for PTO-funded classroom projects.
MEADOWLARK ELEMENTARY DIRECTORY PERMISSION Dear Parents, A 2011-12 school directory will be published for parents containing Meadowlark student contact information. Please fill out this permission form and return it to the school office with your enrollment packet. Students who do not have a permission form turned in will not be in the school directory. Ordering information will go home with students at a later date. Even if you will not be ordering a directory, we still need this form from you. If you have a child who has more than one household, please fill out two forms and indicate the difference between the addresses. If you have any questions, please contact Chris Steward, PTO President, at kujhawks@sbcglobal.net. Thank you for your help! MEADOWLARK ELEMENTARY SCHOOL DIRECTORY FORM Name(s) of Child: _____________________________________ Grade: _____ Child: _____________________________________ Grade: _____ Child: _____________________________________ Grade: _____ Child: _____________________________________ Grade: _____ Parents Name(s): ______________________________________________________________________ Address: ______________________________________________________________ City, State, Zip: _________________________________________________________ Home or Primary Phone #: (____)____________________________ Check one of the following: _____I give permission for my address and family names to be published in the Meadowlark Elementary School Directory. _____I do not wish to have my address or family names published in the Meadowlark Elementary School Directory. __________________________________________ Signature
_________________ Date
WE ARE ON THE WEB! In an effort to reduce the time and expense involved in distributing paper copies of school notes and newsletters, we will be posting links to each classroom or department. Teachers have been asked to post their class information, such as schedules, newsletters, and handbooks. The Elementary Family Handbook will be available on our school website as well. The monthly parent newsletter will be posted on the school website along with a lunch menu. Our school website can be accessed by going to www.usd385.org. By going to the district website, you will have access to all our Meadowlark links, lunch menu, district calendar, Powerschool and much, much more! If you do not have access to the internet, please return the completed form below to the school office. A paper copy of any information you may need will be sent home with your child.
I do not have access to the internet and will need a paper copy of the newsletters, handbooks, and school notes. Parent Name__________________________________________________ (Please print) Name of Children _________________________ Teacher__________________ Grade____ _________________________ Teacher__________________ Grade____ _________________________ Teacher__________________ Grade____ _________________________ Teacher__________________ Grade____
1st Grade
Kindergarten
#2 Dixon Ticonderoga pencils -24ct. Pink bevel eraser (2) Crayola crayons – 24 ct. (2) Crayola Classic thick washable markers 8 ct. (1) Crayola 8 color washable watercolors (1) Chisel tip dry erase marker – black (4) Glue stick (4) Fiskar sharp scissors – 5” (1) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – yellow (1) Pocket only folder – green (1) Pocket only folder – blue (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (2) 12 ct. colored pencils (Art) 1 disinfecting wipes backpack
#2 Pencil (6) Crayola crayons – 24 ct. (2) Crayola Classic thick washable markers - 8 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (4) Fiskar sharp scissors – 5” (1) Pocket only folder – any color (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (1) Black Sharpie (Fine pt.-Art) (1) Pop-up wipes (1) Backpack
2nd Grade #2 Dixon Ticonderoga pencil (12) Pink bevel eraser (1) Highlighter – fluorescent yellow (1) Chisel tip dry erase marker – black (3) Crayola crayons – 24 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (3) Fiskar sharp scissors – 5” (1) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – green (1) Pocket & brad folder – blue (1) Pocket & brad folder – yellow (1) Plastic school box – approx. 8” x 5” (1) Kleenex – approx. 120 ct. (2) Clorox Wipes Sharpie Extra Fine – black 1 (Art) Crayola Markers Classic Colors (10 ct) Backpack
4th Grade # 2 pencil (12) Pink bevel eraser (1) Pen style highlighter – pink (1) Pen style highlighter – yellow (1) Sharpie Fine marker – black (1) Sharpie Extra Fine marker – black (1) Chisel tip dry erase markers – 4 pk (black or assorted color) 1 Crayola Classic thick washable markers – 8 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Elmer’s school glue – 4 oz. (1) Ross glue stick – 1.23 oz. (2) Fiskar sharp scissors – 7” (1) Ruler – 12” clear plastic (1) 3 x 5 ruled index cards – 100 ct. (1) Filler paper wide rule – 100 ct. (2) Spiral comp. book wide rule – 70 ct. (1) Pocket & brad folder – red (1) Pocket & brad folder – yellow (1) Pocket & brad folder – green (1) Clip board – standard letter size (1) Kleenex – approx. 120 ct. (1) Crayola crayons – 24 ct. 1 (Art) 13 pocket expandable folder Backpack
5th Grade 3rd Grade #2 Pencil (24) Pink bevel eraser (1) Bic medium stick pen – red (2) Pen style highlighter – yellow (1) Chisel tip dry erase marker – black (4) Crayola crayons – 24 ct. (1) Crayola 7” colored pencils – 12 ct. (1) Ross glue stick – 1.23 oz. (2) Fiskar sharp scissors – 7” (1) Filler paper wide rule – 200 ct. (2) Spiral comp. book wide rule – 70 ct. (2) Pocket & brad folder – red (1) Pocket & brad folder – green (1) Pocket & brad folder – blue (1) Pocket & brad folder-orange (1) Pocket & brad folder --yellow (1) Kleenex – approx. 120 ct. (2) 8 ct. Crayola Markers (Art) Glue Bottle Backpack
#2 pencil (24) Bic medium stick pen – blue (3) Sharpie Fine marker – black (1) Pen style highlighter – yellow 2 Chisel tip dry erase marker – black (4) Crayola Classic thick washable markers – 8 ct. (1) Crayola 7” colored pencils – 24 ct. (1) Ross glue stick – 1.23 oz. (1) Fiskar sharp scissors – 8” (1) Ruler – 12” clear plastic (1) 3 x 5 plain index cards – 100 ct. (1) Filler paper wide rule – 200 ct. (2) Spiral comp. book wide rule – 70 ct. (2) Pocket & brad folder – assort. colors (6) Pencil bag – 8 x 10 see- thru plastic (1) Kleenex – approx 120 ct. (2) Glue bottle-4oz. (2) Clorox wipes Sandwich sized baggies zip close hand sanitizer paper towels Backpack
August 2011
August 8 9 10-11 12 15-17 18 19 22
New Students Enroll (8 am to 12 pm & 1-4 pm) Returning Students Enroll (12:30 pm to 7 pm) New Teachers Report .1.0 Flex Work Day (Outside of Contract time) All Teachers Report—Building/District Inservice First Day-Grades 1st-5th, 6th, & 9th First Day For Grades 7th, 8th, 10th, 11th & 12th First Day for Early Childhood and Kindergarten
September 5 26
October 14 17
All Schools Closed-Labor Day Building/District Inservice
Sun
7 14 21 28
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September 2011 Sat
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January 3 16
February 20
March 8 9
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April 6 8
May
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All Schools Closed-Thanksgiving Break
End of 2nd Quarter (43 Days) Dismiss 2 hrs. early (meet teacher credit time) .5 Flex Work Day All Schools Closed-Holiday Break
All Schools Closed-President’s Day
End of 3rd Quarter (46 Days) No School - Morning Building Inservice/ Afternoon Flex Work Day All Schools Closed-Spring Break
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2011-2012 Visit us online at www.usd385.org! Legend
Commencement ACHS & AHS Dismiss 2 Hrs. Early for building Inservice Last Day for Students End of 4th Quarter (47days) Morning Flex Work Day Last Day For Teachers
Yellow-School in Session Red-All Schools Closed, Teachers Inservice White-All Schools Closed, Teachers off Duty Blue-All Schools Closed, Teachers Flex Day Brown-All Schools Closed, Conference Credit Day
The policies of the Board of Education of USD 385 prohibit discrimination on the basis of race, color, national origin, disability, religion and sex in all programs and activities of the district. Additionally, discrimination on the basis of age is prohibited in employment.. Equal Opportunity Employer. Approved 3/14/11
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Andover Central High Cheryl Hochhalter, Principal Doug Carr, Asst. Principal Brian Gregoire, Asst. Principal (316) 218-4700
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Andover High Robert Baier, Principal Gary Merritt, Asst. Principal Amanda Grier, Asst. Principal (316) 218-4600
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District Office Mark A. Evans, Superintendent Dr. Andrew Koenigs, Associate Superintendent Tom Ostrander, Assistant Superintendent. Jim Freeman, Business Manager/Treasurer Keturah Austin, Communications (316) 218-4660
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USD 385 PROFESSIONAL CALENDAR No School—Conference Credit Day Easter
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School Resumes Inservice All Day/MLK Day
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February 2012
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January 2012
December 2011 End of 1st Quarter (40 days) No School - Morning Building Inservice/ Afternoon Flex Work Day All Schools Closed - Conference Credit Day
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October 2011
8 9 15 16 22 23 29 30
Andover Middle Brett White, Principal Brent Jones, Asst. Principal (316) 218-4610 Andover Central Middle Tim Hayden, Principal Debra Regier, Asst. Principal (316) 218-4710 Cottonwood Elementary Shari Rooks, Principal (316) 218-4620
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10 11 12 13 14 17 18 19 20 21 24 25 26 27 28 31 Sunflower Elementary Rita Decker, Principal (316) 218-4730 Wheatland Elementary Elton Armbrister, Principal (316) 218-4820 Food Service Ann Katt, Director (316) 218-4603
Transportation Julie Clopton, Director Robert M. Martin Elementary (316) 218-4621 Dr. Crystal Hummel, Principal Operations (316) 218-4720 Bruce Sanderson/Exec Dir. Meadowlark Elementary Jody Baker, Principal (316) 218-4630 Prairie Creek Elementary Shelley Jonas, Principal (316) 218-4830
of Operations (316) 218-4604
Technology Rob Dickson, Director (316) 733-3686
The following pages only apply to students new to Andover Public Schools.
ANDOVER USD #385 PROOF OF RESIDENCE This form must be accompanied by a verification of residency. Acceptable forms of verification are: Utility Bills, Lease Agreement or Homeowner Contract
Date: _______________________
School: ________________
Student(s) Name(s):
Grade:
______________________________________
______________
______________________________________
______________
______________________________________
______________
______________________________________
______________
I, ___________________________________, the parent/guardian declare that the above students reside with me at the following address: Street Address: ______________________________________________________________ City, Zip: ____________________________________________________________________
I understand that the accuracy of the above information is important to the continued enrollment of my child(ren).
Parent/Guardian Signature: _________________________________________________
Meadowlark Elementary USD # 385 1411 N. Main – Andover, KS 67002
Ms. Jody Baker – Principal Mrs. Tammy Clarkson – Counselor
Phone: 316-218-4630 Fax: 316-218-1000
Request for Transcript Date: _________ Student: ___________________________________ Grade: ________
Registrar: Please send us at your earliest convenience, all official records, transcript of grades, cumulative records, birth certificate, test results, health records, athletic eligibility, psychological test results and any other data directly related to this student. Thank you for your time.
Former School: _____________________________________ _____________________________________ _____________________________________
Parent/Guardian Signature: ___________________________________ Send Records To: Meadowlark Elementary school 1411 N. Main Andover, KS 67002 Parental permission is no longer required when records are requested by authorized school personnel. Family Education Rights and Privacy Act, Final Rule on Education Records, Federal Register June 17, 1976, Vol. 41, No. 118, page 24673
MEADOWLARK ELEMENTARY New Student Placement Information Form 2011-2012 School Year
Student Name: ___________________________________________
Male or Female (Please circle)
To better help us place your student, please provide the following information:
1. Was your child ever retained? If so, which grade(s)?
2. How was your child performing academically at his/her previous school?
3. Was your child involved in any special programs and what were they? (Example: Title I reading, and math programs, speech, language, learning disabilities, special classroom placement, gifted, enrichment, etc.)
4. Please describe your child’s personality. (Is he/she excitable, creative, very active, quiet, etc.)
5. Would you say your child would benefit from (please circle): A. A structured classroom B. A flexible classroom C. Either type of classroom
Please use the back of this form to add any additional information about your child that would help with your child’s placement. Thank you.
___________________________________________ Parent/Guardian Signature
_________________ Date
USD 385 DEPARTMENT OF HEALTH SERVICES ANDOVER, KANSAS IMMUNIZATION STATEMENT Please sign and return with enrollment forms.
Name of Student: _________________________________________ Date of Birth: _____________________________________________ I have been notified that Kansas Law (K.S.A. 72-5208, 72-5209, 725210, 72-5211 and 72-5211a) requires every pupil enrolling in any school for the first time, prior to admission, to present proof from a physician or local health department that the pupil has received such tests and inoculations as are deemed necessary. In USD 385, proof of each inoculation received must be presented prior to admission. Also, mandatory booster inoculations in all required series must be received (within 30 days for students admitted after September 1). If transferring into USD #385, it is the parents obligation to make sure proof of inoculations are received within 30 days. Required inoculations include the following: DTP, DTaP and/or DT/Td OPV or IPV MMR Hepatitis B Varicella
Additions for Early Childhood Hib PCV7 (pneumococcal) Hepatitis A
Parents will be notified of any additional requirements. Parent/Guardian Signature Indicating Receipt of Notice: _______________________________________Date:_________________ Student is transferring from: _____________________________________ Name of School
Date Student Entered USD #385:
City
St.
_______________________________
KANSAS CERTIFICATE OF IMMUNIZATIONS (KCI) This record is part of the student's permanent record and shall be transferred from one school to another as defined in Section 72-5209 (d) of the Kansas School Immunization Law (amended 1994.)
Student Name:
Address:
Parent or Guardian Name: Phone: Birthdate (MM/DD/YYYY):
1st
2nd
3rd
4th
5th
7th
State Type
If additional doses are added, please initial the dose and sign below:
Required for school entry.
HEP B
(Hepatitis B) Required for school entry through Grade 10 for 20102011 school year. Recommended for all children.
Varicella
Hx of Disease: Physician Signature:
(Chickenpox) Required for school entry through Grade 10 for 2010-2011 school year. Recommended for all children.
MMR
6th
(Diphtheria, Tetanus, Pertussis) Required for
school entry.
Polio
County
RECORD THE MONTH, DAY, AND YEAR THAT EACH DOSE OF VACCINE WAS RECEIVED
VACCINE DTaP/DT/Td/Tdap
Ethnicity:
Race:
SEX: [ ] MALE [ ] FEMALE
(Measles, Mumps, and Rubella combined) Required for school entry.
Influenza (Flu) Recommended annually for ages 6mo - 18 yrs. Not required for school entry.
HIB
(Haemophilus Influenzae Type B) Required < 5 years of age for preschool or child care operated by a school.
PCV7
(Pneumococcal Conjugate) Required < 5 years of age for preschool or child care operated by a school.
HEP A
(Hepatitis A) Required < 5 years of age for preschool or child care operated by a school.
MCV4
(Meningococcal) Recommended at 11 years of age. Not required for
school entry.
HPV
(Human Papillomavirus) Recommended for females and provisionally recommended for males at 11 years of age. Not required for school entry.
Rotavirus
Recommended < 8 mo. Not required for school entry.
DOCUMENTATION
LEGAL ALTERNATIVES TO VACCINATION REQUIREMENTS "KSA 72-5209"
KCI MAY ONLY BE SIGNED BY A PHYSICIAN (MD/DO), HEALTH DEPT, OR SCHOOL.
q
I certify I reviewed this student's vaccination record and transcribed it accurately.
Agency Name: Authorized Representative: Address: The record presented was:
q q
Kansas Immunization Record
1. "Annual written statement signed by a licensed physician (Medical Doctor/M.D. or Doctor of Osteopathy/D.O.) stating the physical condition of the child to be such that the tests or inoculations would seriously endanger the life or health of the child." Medical exemption shall be validated annually by physician completion of KCI Form B and attachment to the KCI. KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf
Date:
2. "Written statement signed by one parent or guardian that the child is an adherent of a religious denomination whose religious teachings are opposed to such tests or inoculations."
Other Immunization Record (Specify)
KANSAS IMMUNIZATION PROGRAM 1000 SW Jackson, Suite 210, Topeka, KS 66612-1274 PHONE 785-296-5591 FAX 785-296-6510 WEB SITE www.kdheks.gov/immunize
I give my consent for information contained on this form to be released to the Kansas Immunization Program for the purpose of assessment and reporting.
Parent/Legal Guardian's Signature
Date
Rev. 02/01/2010
KANSAS IMMUNIZATION REQUIREMENTS: Based on age of child as of September 1 of current school year. As per Kansas Statute 72-5209, all children upon entry to school must be appropriately vaccinated. In each column below, vaccines are required for all ages listed in that column. Ages 0-4 Recommended Schedule
Birth
HEP B
2 Months
DTaP/DT POLIO HEP B HIB PCV7 ROTAVIRUS
4 Months
DTaP/DT POLIO HIB PCV7 ROTAVIRUS
6 Months
12-15 Months
DTaP/DT POLIO HEP B HIB PCV7 ROTAVIRUS DTaP/DT MMR VAR HIB PCV7 HEP A
Recommendations are based on the ACIP recommended schedule.†
Ages 5-6 DTaP/*DT: 5 doses
a) 4 week minimum interval between doses, with at least 6 months between dose 3 and dose 4. b) 4 doses acceptable if dose 4 given on or after the 4th birthday. c) If dose 4 is administered before the 4th birthday, a 5th dose must be given at 4-6 years of age. * If 1st DT dose given at <12 months of age, 4 doses recommended; acceptable only when Pertussis component is contraindicated by the physician. * If 1st DT dose given at 12 months or older, 3 doses complete primary series; acceptable only when Pertussis component is contraindicated by the physician. The limit for DTaP vaccine is 6 doses, regardless of schedule. POLIO: 4 doses of POLIO are acceptable IF:
a) 4 week minimum interval between doses, regardless of age given. 3 doses of POLIO (all IPV) are acceptable IF:
a) 4 week minimum interval between each dose, with 1 dose given on or after the 4th birthday. The limit for POLIO vaccine is 5 doses, regardless of schedule. MMR: 2 doses
Ages 7 and Older Tdap/Td: 3 doses if DTaP/DT series not completed previously† One of the doses must be Tdap if student is without a Pertussis medical exemption.
a) 4 week minimum interval between dose 1 and dose 2. b) 6 month interval between dose 2 and dose 3. Booster dose of Tdap is required at 7th grade if more than 2 yrs since previous dose of Td. Tdap booster required 10 years after the completion of the primary series or previous dose. Only one dose of Tdap is needed during adolescence. KCI Form B Medical Exemption should be completed by a physician if pertussis is contraindicated. POLIO - All IPV or OPV Schedule 4 doses of POLIO are acceptable IF:
a) 4 week minimum interval between doses, regardless of age given. 3 doses of POLIO are acceptable IF:
a) 4 week minimum interval between each dose, with 1 dose given on or after the 4th birthday. POLIO - IPV/OPV Combination Schedule 4 doses of POLIO are acceptable IF:
a) 4 week minimum interval between each dose, regardless of age given. Three doses of a combination schedule are NOT acceptable. The limit for POLIO vaccine is 5 doses, regardless of schedule.
a) First dose must be on or after the 1st birthday. b) 4 week minimum interval between doses. Single antigen measles vaccine will not meet requirements without the addition of mumps and rubella vaccine. VARICELLA: 2 doses required for Kindergarten and Grade 1 for 2010-11 school year; 1 dose required for Grades 2-10 for 2010-11 school year
a) b) c)
First dose must be on or after the 1st birthday. None required if prior varicella disease verified. Two doses are recommended for all children.
HEPATITIS B: 3 doses required through Grade 10 for 2010-11 school year
a) b) c) d)
4 week minimum interval between dose 1 and dose 2. 8 week minimum interval between dose 2 and dose 3. 16 week minimum interval between dose 1 and dose 3. Dose 3 must be given after 24 wks of age.
MMR: 2 doses
a) First dose must be on or after the 1st birthday. b) 4 week minimum interval between doses.
VARICELLA: 1 dose required through Grade 10 for 2010-11 school year
a) First dose must be on or after the 1st birthday. b) None required if prior varicella disease verified. c) Two doses are recommended for all children. HEPATITIS B: 3 doses required through Grade 10 for 2010-11 school year a) 4 week minimum interval between dose 1 and dose 2. b) 8 week minimum interval between dose 2 and dose 3. c) 16 week minimum interval between dose 1 and dose 3. d) Dose 3 must be given after 24 wks of age.
† - The ACIP Schedules may be accessed at: http://www.cdc.gov/vaccines/recs/schedules Vaccine doses given up to 4 days before the minimum interval or age may be considered valid. With the exception of Hepatitis B vaccine, immunizations given before 6 weeks of age are not considered valid. Half doses or reduced doses of vaccine are not considered valid.
PARENTS AND/OR GUARDIANS ARE NOT AUTHORIZED TO COMPLETE KCI FORMS. KCI FORM B - MEDICAL EXEMPTION is located at http://www.kdheks.gov/immunize/imm_manual_pdf/KCI_formB.pdf BLANK VERSION OF KCI FORM is available at http://www.kdheks.gov/immunize/download/KCI_Form.pdf A ROSTER WITH THE NAMES OF ALL EXEMPT STUDENTS SHOULD BE MAINTAINED. PARENTS OR GUARDIANS OF EXEMPT CHILDREN SHOULD BE INFORMED THAT THEIR CHILDREN SHALL BE EXCLUDED FROM SCHOOL IN THE EVENT OF AN OUTBREAK OR SUSPECTED CASE OF A VACCINE-PREVENTABLE DISEASE.
ANDOVER PUBLIC SCHOOLS USD 385
HEALTH EXAMINATION REPORT Pupil’s Name_____________________________________ SS#__________________ Birth Date_____________ Grade___________ Last First To Parents: For maximum health your child should have a periodic health Immunization – Please attach green Kansas examination. If your child is entering Kindergarten (or is new to Kansas Certificate of Immunization (KCI) with all dates Schools and is under 9 years of age) please obtain an examination of for DPT, Polio, MMR, Varicella, and Hepatitis B your child by your family doctor. Gender: M______F_______ recorded - with Physician Signature and Date. Height_____ Weight_____ BP_____ T_____ P_____ R_____ Central Nervous System________________________________________ Epilepsy?__________ Emotional Disturbance?______________ Cardio-Vascular System________________________________________ Optional other vaccines or tests:____________________ Heart Disease?____________________ Limitation?__________ Yes No EENT (Eye, Ear, Nose & Throat)_________________________________ Are routine medications prescribed? Myringotomy?____________________ Glasses?____________ Endocrine System_____________________________________________ NOTE: If medication is to be given at school, please Diabetes Mellitus?_____________________________________ provide written physician/parental request. Gastrointestinal System________________________________________ Nutritional Status______________________________________ Physical Education: Genitourinary System__________________________________________ Regular_______________________________________ Musculo-Skeletal System_______________________________________ Limited (explain)_______________________________ Scoliosis?____________________ Arthritis?________________ None (explain)_________________________________ Respiratory System____________________________________________ Date__________________________________________ Asthma?_____________________ Allergies?_______________ Social Development (family, peer, school if appropriate)______________ Recommendations:____________________________________________ MAY USE BACK OF CARD FOR ADDITIONAL SPACE Physician’s Signature__________________________________________