Hadley Elementary School - 2021-2022 Back to School Checklist
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Hadley Elementary School
2021-2022 Back to School Checklist
Please fill out one set of forms per child.
Return entire packet to the office ASAP.
Your Back-to-School packet contains the following documents:
____ Acceptable Use Agreement – Signed
____ COPPA/Google Suite Form – Signed
____ Student Handbook Sign Off Sheet – Signed
____ Notice of Possible Publication of Certain Student Information (if desired)
____ Notice of Possible Publication to Website or School-Related Websites (if desired)
____ Student Accident Insurance (informational)
____ Free/Reduced Lunch Directions and Forms (only need to submit one per household)
____ Student Emergency Information Sheet (Nurse)
- Signed and return in a sealed envelope, ATTN: SCHOOL NURSE21 River Drive Hadley, MA 01035 Jennifer Dowd Tel: (413)584-5011 Principal Fax: (413)582-6457 Dear Parents and Guardians, This letter is to inform you that students in grades K-6 will be using Google Suite for Education, an integrated communication and collaboration solution, on Chromebooks or iPads in their classrooms this year. In order to log into GSuite products students will be provided with a Google username and password. Students will have access to Google Drive and Google Sites. Students in Grades 3-6 may be assigned Gmail, with restricted messaging to or from teachers and approved HPS staff only. In addition to the core Google Suite for Edu products, we will also be using a selection of Chrome extensions, Google Earth and Google My Maps. Your child’s usernames and passwords will be shared with you, so that you may monitor this account at home if you wish. In order to allow monitoring of student accounts it is imperative that students do not change their passwords. It is important for students to begin to understand how to utilize digital tools in their schoolwork by having an account that is only to be used for school. We encourage students to effectively and ethically use these tools for their schoolwork. Google’s terms of service (TOS) includes a clause that users must be at least 13 years old or have parental permission. This also applies to many of the other services we will be using. Google Apps TOS (http://www.google.com/apps/intl/en/terms/education_terms.html) We will also be using various Web tools and websites with all students. Some of these will be shared accounts. If your child’s teacher uses online sites in his/her lessons and your child is given a username and password, it will also be sent home. We will begin posting some of this digital student work online. We will follow the same guidelines used for publishing photographs, etc. Students will be identified by first name and last initial (if needed). Teachers will use avatars or alternate ways of displaying work, if a student is not allowed to be photographed or videoed. No material, including documents, slide decks or video, etc. distributed via school accounts may be repurposed in any part or published to the web in order to both respect privacy and copyright laws. If you have questions about this policy, please let me know. Sincerely, Jennifer Dowd Principal ______________________________________________________________________________________________ Please return the bottom half of this form as soon as possible. _______I understand that my student will be using Google Suite for Education Suite at school. In addition to the core products, Google Earth, Google My Maps and a selection of Chrome extensions will be used. My student will also use other educational websites at school. A copy of all account information will be sent home and the TOS and privacy statements will be available online. Please sign and return one form per student. Student name______________________________________________ Parent signature _____________________________________________
HADLEY ELEMENTARY SCHOOL
21 RIVER DRIVE
HADLEY, MA 01035
PHONE: 413-584-5011 FAX: 413-582-6457
HANDBOOK SIGN-OFF SHEET
Dear Parent/Guardian:
Hadley Elementary School is an excellent school with strong students and a dedicated faculty and staff.
A school must be a place where students feel safe and supported, and where parents, faculty, and staff
work together to promote academic, physical, social, and emotional growth in students. With this goal
in mind, we present our Handbook, with the sincere hope that you read it, discuss its contents, and use it
as a guide. If you have any questions, please feel free to contact the school. Together we will strive to
make the 2021-2022 school year a happy and successful experience for each student.
Please complete and return this form to the homeroom teacher.
Sincerely,
Jennifer Dowd
Principal
I have read the Hadley Elementary School 2021-2022 Handbook and understand all material and rules
set forth therein.
______________________________________ _____________ _________________
STUDENT NAME (PRINT) GRADE DATE
______________________________________
STUDENT SIGNATURE
______________________________________ ______________
PARENT/GUARDIAN SIGNATURE DATE
Updated 3/8/2021
S:\DISTRICT SHARE\DISTRICT FORMS - 2021\HES Forms - 2021\BACK TO SCHOOL\6_HES HANDBOOK
SIGN OFF SHEET 2021.doc _WHADLEY ELEMENTARY SCHOOL
21 RIVER DRIVE
HADLEY, MA 01035
PHONE: 413-584-5011 FAX: 413-582-6457
NOTICE OF POSSIBLE PUBLICATION OF CERTAIN STUDENT
INFORMATION DURING THE SCHOOL YEAR
Dear Parent/Guardian:
Under Department of Education regulations 603 CMR 23.07 (4) (a), the school may release for
publication certain information from officially recognized school activities or functions concerning your
child from time to time without first obtaining your consent, unless you indicate now that we should not
do so. The information which may be released for publication includes a student's name, class,
participation in officially recognized activities, honors and awards, photographs, videotaping and news
films. Telephone numbers and addresses will not be released.
Please return this form to the main office by September 8, 2021 ONLY if you do NOT want your
student's information published.
1. _____ I do NOT wish this information concerning my student to be released for publication without
my consent while attending Hadley Elementary School for the 2021-2022 school year.
Check all that apply:
_____ Student's name _____ Photographs, videotaping
_____ Class (year of graduation) _____ Honors and awards
_____ Grade & Homeroom _____ News films
_____ Participation in officially recognized activities
2. _____ I do NOT wish for my child's picture and name to be published. I understand that this
includes the class picture.
_____________________________________________ ___________________
STUDENT NAME (PLEASE PRINT) GRADE
_____________________________________________ ____________________
PARENT/GUARDIAN SIGNATURE DATE
Updated 3/8/2021
S:\DISTRICT SHARE\DISTRICT FORMS - 2021\HES Forms - 2021\BACK TO SCHOOL\7_HES
NOTICE OF POSSIBLE PUBLICATION STUDENT INFO 2020-21.doc (Gold)HADLEY PUBLIC SCHOOLS
[X] Hadley Elementary School Hopkins Academy
21 River Drive 131 Russell Street
Hadley, Massachusetts 01035 Hadley, Massachusetts 01035
(413) 584-5011 | fax (413) 582-6457 (413) 584-1106 | fax (413) 582-6455
NOTICE OF POSSIBLE PUBLICATION TO SCHOOL WEBSITE OR
SCHOOL-RELATED ONLINE SITES
Dear Parent/Guardian:
In the beginning of the year packets, parents/guardians can choose not to have their student's name, picture or
information released to the press or our "Do Not Publish" list. Under Department of Education regulations 603 CMR
23.07 (4) (a), the school may release certain information for publication from officially recognized school activities or
functions concerning your student from time to time without first obtaining your consent, unless you indicate now that
we should not do so. In particular, we are interested in obtaining your consent specifically related to use of your child's
picture on our school district's website and other school-related online sites, such as teacher blogs and classroom
websites.
Please return this form to the main office by September 8, 2021 ONLY if you DO NOT want your student's
picture/video and schoolwork published on our school district's website and other school-related online sites,
such as teacher blogs and classroom websites.
If we do not receive this form by the date mentioned above, we will assume it is ok to publish your student's
picture/video and schoolwork.
__________ I DO NOT wish for my student's picture and name to be published on the school district's website and
other school-related online sites, such as teacher blogs and classroom websites.
__________ I DO NOT wish for my student's schoolwork to be published on the school district's website and other
school-related online sites, such as teacher blogs and classroom websites.
____________________________________________ _____________
STUDENT NAME (PLEASE PRINT) GRADE
____________________________________________ _________________
PARENT/GUARDIAN SIGNATURE DATE
Updated 3/8/2021
S:\DISTRICT SHARE\DISTRICT FORMS - 2021\HES Forms - 2021\BACK TO SCHOOL\8_HPS NOTICE OF
POSSIBLE PUBLICATION WEBSITE 2021-2022.doc (Blue)Parents & Guardians: Do you have adequate insurance coverage for
your child in the event of an unforeseen accident?
If not, Bob McCloskey Insurance has Got You Covered!
Depending on which program your child’s school offers, you may be able to purchase
one or more of the following insurance products on a voluntary basis with easy
online enrollment and purchase.
At-School Student Accident Coverage – Limits as high as $500,000
Around the Clock – 24 Hour Accident Coverage - Limits as high as $500,000
Accident Dental Coverage – Limits as high as $50,000
Please visit www.bobmccloskey.com/K12Voluntary to review your
school’s available options and purchase coverage with ease.
When on the site, please search for your school system to view the plan options,
plan brochures, and purchase coverage. Should you have any questions, you can
contact our office at 800.445.3126 or BMI@bobmccloskey.com.
P.O. Box 511 Matawan, NJ 07747
Phone: 800.445.3126 | Fax: 732.583.9610
www.bobmccloskey.com
Leaders in Student & Sports Insurance Administration Since 19752021-2022 Massachusetts Application for Free and Reduced Price School Meals
If you have received a Notice of Direct Certification – FREE from the school district for free meals, do not complete this application. If you have received a Notice of Direct Certification – REDUCED PRICE from the
school district for reduced price meals, this application may be submitted. DO let the school know if any children in the household are not listed on the Notice of Direct Certification – FREE letter you received.
STEP 1 List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)
Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.” Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply
for Free and Reduced Price School Meals for more information.
Student? Foster Homeless Migrant Runaway
Child’s First Name MI Child’s Last Name School Name
Grade
Circle
Yes or No Check all that apply
Y N
Y N
Y N
Y N
Y N
Y N
STEP 2 Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
Write the Agency ID Number, then go to STEP 4 (Do not complete STEP 3) EBT number not accepted; SNAP award letter may be requested Agency ID Number: ______________________________
Review the charts titled “Sources of Income” for more information. The “Sources of Income for Children” chart will help you with the Child Income section.
The “Sources of Income for Adults” chart will help you with the All Adult Household Members section How often?
Child Income Weekly Bi-Weekly 2x Month Monthly
A. Child Income
Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here: $
B. All Adult Household Members (including yourself)
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If
they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
How often? Public Assistance/ Child How often? Pensions / Retirement / How often?
Name of Adult Household Members (First and Last) Earnings from Work Weekly Bi-Weekly 2x Month Monthly
Support/ Alimony
Weekly Bi-Weekly 2x Month Monthly
All Other Income
Weekly Bi-Weekly 2x Month Monthly
Total Household Members Last Four Digits of Social Security Number (SSN) of
(Children and Adults) Primary Wage Earner or Other Adult Household Member XXX-XX- Check if no SSN
“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my
children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available) Apt # City State Zip Daytime Phone and Email (optional)
Printed name of adult signing the form Signature of adult Today’s date Error proneINSTRUCTIONS Sources of Income
Sources of Income for Children Sources of Income for Adults
Sources of Child Income Example(s) Public Assistance / Alimony / Pensions / Retirement / All Other
Earnings from Work
- A child has a regular full or part-time job where they Child Support Income
- Earnings from work
earn a salary or wages
- Salary, wages, cash bonuses - Unemployment benefits - Social Security (including railroad
- Social Security - A child is blind or disabled and receives Social Security benefits - Net income from self- - Worker’s compensation retirement and black lung benefits)
- Supplemental Security Income (SSI) - Private pensions or disability
- Disability Payments - A Parent is disabled, retired, or deceased, and their child employment (farm or business)
If you are in the U.S. Military: - Cash assistance from State or local benefits
- Survivor’s Benefits receives Social Security benefits
- Basic payandcashbonuses (do NOT government - Regular income from trusts or estates
includecombatpay,FSSA,or privatized - Alimony payments - Annuities
-Income from person outside the household - A friend or extended family member regularly gives housing allowances) - Child support payments - Investment income
a child spending money - Allowancesforoff-base housing,food - Veteran’s benefits - Earned interest
andclothing - Strike benefits - Rental income
-Income from any other source - A child receives regular income from a private - Regular cash payments from outside
pension fund, annuity, or trust household
Ethnicity (check one): Race (check one or more):
We are required to ask for information about your children’s race and ethnicity. This information is
Hispanic or Latino American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander important and helps to make sure we are fully serving our community. Responding to this section is
Not Hispanic or Latino Asian White optional and does not affect your children’s eligibility for free or reduced price meals.
Black or African American
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to
audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.
give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at
include the last four digits of the social security number of the adult household member who signs the application. The
(800) 877-8339. Additionally, program information may be made available in languages other than English.
last four digits of the social security number is not required when you apply on behalf of a foster child or you list a
Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found
Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and
when you indicate that the adult household member signing the application does not have a social security number. provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992.
We will use your information to determine if your child is eligible for free or reduced price meals, and for Submit your completed form or letter to USDA by:
administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information mail: U.S. Department of Agriculture
with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410
programs, auditors for program reviews, and law enforcement officials to help them look into violations of program
fax: (202) 690-7442; or
rules.
email: program.intake@usda.gov.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and
This institution is an equal opportunity provider.
policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA
programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age,
political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded
by USDA.
For School Use Only
2021-2022 Massachusetts Application for Free and Reduced Price School Meals
Total Income Household Size
Annual Income Conversion:
Eligibility: Categorical Eligibility
Weekly x 52
Every 2 Weeks x 26 Free Reduced Denied
Twice A Month x 24
Only annualize income if there are multiple pay frequencies
Monthly x 12
How often?
Weekly Bi-Weekly 2x Month Monthl Annually
y
Date Confirming Official’s Signature Date Verifying Official’s Signature Date
Determining Official’s SignatureGrade______
Hadley Public Schools Student Health Information Form
Last Name: _______________________ First: ______________________ DOB:________Age:______
Address __________________________________________________ Home Phone: _______________
Street Town
Parent/Guardian #1 _____________________________Home Phone ___________ Cell ____________
Place of Employment ______________________________ Work Hours ______ Phone ____________
Parent/Guardian #2 _____________________________Home Phone ___________ Cell ____________
Place of Employment _______________________________Work Hours ______ Phone ____________
Child Resides with ____________________________________________________________________
Emergency Contact (if parent/guardian cannot be reached):
1st ___________________________________ Relationship ________________ Phone _____________
2nd __________________________________ Relationship ________________ Phone _____________
Child’s Healthcare Provider__________________________________________ Phone _____________
Child’s Dentist ____________________________________________________ Phone _____________
Child's Other Health Care Providers (including mental health and other specialty providers)
_____________________________________________________________ Phone_________________
Child’s Health Insurance Provider: _______________________________________________________
ALLERGIES (including drug, food, environment) ___________________________________________
Hadley Public Schools has standing orders for the following treatments/medications. Please indicate whether or
not you give your permission for them to be administered to your child by the school nurse.
Acetaminophen Yes / No Ibuprofen Yes / No
Aloe Vera Yes / No Moisturizing Lotion Yes / No
Benedryl Yes / No Alcohol-based hand sanitizer Yes / No
Calamine Lotion Yes / No Petroleum Jelly Yes / No
Cough drops Yes / No Saline Solution Yes / No
I give permission for the school nurse and the above listed health care providers to communicate regarding
pertinent health care information. Yes / No
I give permission to the school to treat and/or transport my child in the event of a serious illness or injury as
appropriate if I am unable to be reached. Yes / No
I give permission for the school nurse to share my child’s healthcare diagnosis and information relative to
the prescribed treatment for his/her condition with appropriate school personnel. Yes / No
____________________________________________________ ___________________________
Parent Signature Date
OVER CONFIDENTIAL - Only seen by School Nurse
Please fill out as accurately as possible.
Medications taken by student on a regular basis including OTC and prescription:
(Please turn in medication forms if medication to be taken at school)
_____________________________ _____________________________
_____________________________ _____________________________
Health Conditions:
(Please check all that apply for your student)
ADD/ADHD Heart Condition
Anxiety
Asthma Explain:_________________________
Rescue Inhaler ___________________________________
Other Treatments: Migraines
__________________________ Mononucleosis (within past year)
Allergies Neurological Conditions:
Explain: _________________ Spina Bifida
__________________________ Cerebral Palsy
EpiPen Seizure Disorder
Autism Neuromuscular Degenerative Disorder
Bleeding Problems Other: ___________________________
Explain: _________________ Orthodontics
__________________________ Explain: _________________________
Cancer ____________________________________
Explain:_________________ Orthopedic Issues
__________________________ Recent Fractures:__________________
Concussion / Head Injury ____________________________________
List Dates:_______________ Recent Surgery: ___________________
Chronic or Recurring Condition ____________________________________
Explain:_________________ Other: __________________________
__________________________ Scoliosis
Cystic Fibrosis Skin Disorders /Conditions
Depression Explain: _________________________
Diabetes ____________________________________
Type 1 Surgery
Type 2 Explain: _________________________
Insulin Pump ____________________________________
Eating Disorder
Explain: ___________________ Vision Impairment
____________________________ Glasses
Emotional Issue Contacts
Explain:___________________ Other information:
_____________________________ _______________________________________
Gastrointestinal Issue _______________________________________
Celiac Disease _______________________________________
Irritable Bowel Syndrome _______________________________________
Crohn’s Disease _______________________________________
Other: ________________________
Hearing Impairment
Left Ear
Right Ear
Devices:___________________
Parent/Guardian Signature Date
*Please place updated form in an envelope addressed to the school nurse (for confidentiality) and return to your child's teacher as soon as possible. Thank
you!You can also read
