Welcome to the 2019-2020 Open House - CSA Elementary Campus - Charyl Stockwell ...
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Welcome to the 2019-2020 Open House
CSA Elementary Campus
This is a checklist of tasks to accomplish while you visit our Open House.
indicates that the form is also available at the CSA District website www.csaschool.org. Log in
and then click on the yellow OPEN HOUSE FORMS button for all forms. If you are not registered at
the District website, go to www.csaschool.org, click on the Family Login (top right) click on Register,
complete the form and press SUBMIT. Your account will be activated in approximately 48 hours.
STUDENT / FAMILY OFFICE
Drop off any student medications with the required documentation (please be sure to speak with a staff
member to insure that everything is ready for the first day of school)
Fill out a Volunteer Form and provide a copy of your driver’s license
Pick up copies of:
Lunch order forms
Free & Reduced Lunch Application (if applicable)
IN THE CLASSROOM: Please complete the following forms before you leave the building
Library Contract ALSO
Gym Participation Drop off shared supplies
Concussion Form Review Student information and Medical Form
Photo / Publicity Release
Voyager & Explorer students: Network and Internet Acceptable Use Agreement
Library Volunteer Sign-Up
Information Opt Out Form
LIBRARY
Visit our carpool staff and view the CSA carpool DVD
Pick up Carpool tags
Register for SEP programs
GYMNASIUM
Voyager & Explorer students, purchase planners and sketch books
Quality Work binders (white) can be purchased for all students
Get information about the CSA Education Foundation
Information tables will be setup for Scouting, Parent Council and other school activities
AT HOME
Register at the CSA District website (www.csaschool.org) under Family Login
Review the CSA Family Handbook
Return the Family Handbook signature page to your child’s classroom, one per student
Review and sign all forms and return to your classroom teachers
Register each of your students in PowerSchool at http://csadistrict.powerschool.com/public
CSA Specific Dress Code/Uniform Policy
Elementary
Educators have long recognized the relationship between dress, grooming and the learning environment
within the school. Uniform policies make a statement about the standards and expectations of the
school. The intent of the dress code/uniform policy at Charyl Stockwell Academy is to promote optimum
learning opportunities throughout the school day and to help ensure a safe environment for all. Our
School Board empowers the administration to make decisions and interpretations concerning the dress
code/uniform policy and enforcement thereof.
Purchasing School Uniforms
Uniforms are available for purchase online from JRyan & Associates at http://csa.jryanonline.com. All
of the items on the website meet our uniform guidelines and can be purchased from the comfort of
your home and shipped directly to you. The uniform link can also be found on the family log-in
section of our website: http://wwwcsaschool.org.
Elementary School Uniform items are also available at Land’s End; uniform items must be listed under
the CSA uniform link that includes the only items that are in alignment with the CSA general uniform
Dress Code, The online code for CSA Elementary is csa-900031212.
Elementary Uniform Policy (Kindergarten, Navigator, Voyager, and Explorer Students)
• All clothes should be neat, clean, and have no visible holes, patches and/or frayed edges.
• In order to achieve uniform consistency, CSA District recommends uniform purchases at JRyan
& Associates and Land’s End.
• Students need to arrive to school in uniform and depart in uniform
Shirts: Shirts will be the following solid colors: white, light blue, or red. Shirts must be tucked into pants
at all times. Only solid white short sleeve undershirts can be worn under uniform shirts. Types of shirts
acceptable are from JRyan & Associates or Lands’ End:
• Polos (must have a CSA logo on the upper left side)
• Oxfords, long or short sleeve (only available in white or light blue)
• Turtlenecks
• Peter-pan blouse (only available in white or light blue)
Sweaters/Cardigans/Vests: Sweaters/Cardigans/Vests are solid navy blue and are intended to go over
the uniform shirt. They must be neat, appropriately sized. They may have the CSA logo on the upper left
side. Types acceptable are from JRyan & Associates and Lands’ End:
[1• Sweaters/Cardigan: long sleeved, solid navy crew or v-neck pullover or cardigan
• Vests: the solid navy v-neck sweater vest or the solid navy fleece vest
Pants: Classic-style navy pants that are neat and appropriately sized must be worn. Pants must fit at the
waist and be properly hemmed or cuffed. No undergarments of any kind should be visible. No cargo,
zipper or cell phone pockets. Types acceptable are from JRyan & Associates, Lands’ End.
Belts: A solid black or brown belt must be worn at all times if belt loops are present (with the exception
of Kindergarten students). Belts must contain a belt buckle that is gold or silver. Designs or decorations
on the belt or belt buckle are not allowed.
Shorts: Students may wear classic style Navy shorts. The shorts should come no more than three inches
above the knee. No undergarments of any kind should be visible. Shorts must fit at the waist and be
properly hemmed or cuffed. No cargo, zippered or cell phone pockets. Types acceptable are from JRyan
& Associates, Lands’ End.
Skirts/Skorts/Jumpers: Skirts, skorts, and jumpers are navy in color and need to be neat and
appropriately sized. They must come no more than three inches above the knee. If belt loops are
present, a belt must be worn. All jumpers require a uniform shirt under them. Types acceptable are from
JRyan & Associates and Lands’ End
Shoes: Students may wear dress shoes or tennis shoes that meet the following descriptions only.
• Dress shoes: allowed in the following solid colors only; black, brown, or navy. They can be slip-
on, tied, buckle, or velcro, but must cover the heel and toe. Shoes may have up to a 1 ½ inch
heel.
• Tennis shoes must be solid in color and are allowed in the following colors only; black, white,
navy, and grey. Tennis shoes may have a modest logo, but the logo needs to be small and one of
the colors listed. Shoe laces must match the main color of the shoes.
Socks/Tights: Socks or tights must be worn with shoes. They must be solid white or solid navy (no
designs or patterns). Socks need to be crew or knee high. Leggings or footless tights are not permitted.
Uniform Guidelines for All Students
Gym Shoes
All elementary students are required to have a pair of “non-marking” gym shoes, which will remain in
the student’s locker for the duration of the school year. Gym shoes must not have been previously worn
outside. Light colored soles are preferred. Shoe laces must match the main color of the shoe.
Clothing and Accessories
All clothes should be neat, clean and have no visible holes, patches and frayed edges. The general
expectation is that all clothing and accessories are school and age appropriate. The following is a list of
clarifications as well as items of clothing and accessories that are not permissible during the school day:
• Short sleeved plain white t-shirts may be worn as an undergarment, but must not be visible at
the sleeve or have any writing or graphics.
[2• Students may not wear or bring to school any items that contain violent or non school
appropriate pictures. Examples include but are not limited to backpacks, coats, folders, etc.
• No rolling backpacks are permitted.
• Uniform shirts must remain buttoned up to an appropriate level.
• Navy is not a uniform shirt color option, only a sweater/vest color option.
• When wearing a navy sweater or vest, it is expected that a uniform shirt will be under it.
• Navy dresses are not allowed, only jumpers.
• Jumpers and skirts must be worn with navy or white socks or tights; leggings or footless tights
are not permitted.
• There is no layering of shirt over shirt. (This applies to layering of uniform tops as well.)
• Hats, hoods, scarves and bandanas are not to be worn in the building (unless it is for religious
reasons and approved by the administration or expressly allowed for a special event or Spirit
Day). Please note that all acceptable solid navy sweaters listed at JRyan & Associates and Lands’
End do not have a hood.
• Flip-flops, sandals, hunting boots, steel-toed boots, hiking boots, shoes/boots with roller wheels,
boots above the ankle, or other foot-wear not expressly described in the dress code/uniform
policy are not permitted.
• Clothing or belts must not have attached studs, chains, designs, etc.
• Hair that is bizarre or unnatural in color is not allowed. Extreme haircuts (i.e., Mohawks, spikes,
asymmetrical) are not allowed. For boys, hair length must be no longer than a standard shirt
collar. No students’ hair will come below the eyebrows or hang in their face.
• Hair accessories need to be modest in size and one the following colors only; red, light blue,
Navy blue, white, brown, black.
• No tattoos may be visible. Writing on self or clothing is not permissible.
• Body piercing of any kind is discouraged. Jewelry worn in body piercings is not permitted, with
the exception of girls wearing earrings in their ears. (Up to 2 piercings in each ear is allowed.)
Boys may not wear earrings or nail polish.
• No excessive jewelry or make up is permitted.
• If your child has special dress code needs, please meet with a member of the Leadership team.
Special Events
From time to time, students will be able to wear items other than those specified in the dress
code/uniform policy. During these days, students are still expected to dress school appropriate and
follow the guidelines listed under “Clothing and Accessories.” These times will include:
• Spirit Days (i.e., favorite sports team day, Crazy hair/hat day, etc.) The expectation is that
students will follow the guidelines for that particular Spirit Day or wear CSA spirit wear. Uniform
bottoms are a requirement on all Spirit Days.
• Days when students will meet with their Girl Scout or Boy Scout troop, they may wear their
Scout uniform including scout dress pants or skirts. The Girl Scouts have a written document
that outlines acceptable Girl Scout wear. This document has been given to all Girl Scout Leaders
and will be shared with parents and students at the beginning of each school year.
[3• CSA teams or groups may have days to wear their specific uniform top. Uniform bottoms are
required.
• Halloween party day. Please avoid costumes that project violence or gore (no fake weapons of
any type), ethnic, and gender or religious discrimination or costumes that project a provocative
image. In other words, use your good judgment when selecting a costume with your child. For
safety reasons, please do not have students wear masks to school. Halloween costume
guidelines are published each year in the Tuesday Times.
Policy Compliance
If a student’s attire for the school day or school-related activity is found to be unacceptable according to
the dress code/uniform policy standards, the teacher will notify the parent and ask them to bring the
appropriate item of clothing to school. CSA may be able to loan the item from the school clothing
inventory for the rest of the day. If an item is loaned to the student, the item will need to be washed and
returned to CSA. Accepting the premise that compliance with the CSA dress code/uniform policy begins
at home, the school encourages parents to have a contingency plan for times they may not be able to
bring a clothing item to school. This contingency plan, similar to the one you would follow if your
daughter/son becomes sick during the school day, might involve a relative or neighbor who would act
on your behalf. Repeated violation of the dress code/uniform policy will be viewed as insubordination
and persistent disobedience.
[4CSA Library Volunteers
We are looking forward to a spectacular year with our CSA parents! Below is a list of different
volunteer opportunities that are available in the CSA library. Please let us know if you are interested.
Contact Person:
Debbie Thor 810-632-2200 ext. 104
dthor@csaschool.org
Book Leveling – help on “as needed” basis ELVs (Early Literacy Volunteers) – weekly commitment for 30
minutes to 1 hour in Navigator unit.
Scholastic Book Fair – occurs in Fall and Spring for a
5 day period; flexible days/times Early Math Groups – weekly commitment for 30 minutes – 1
hour in Navigator unit.
Please circle day preference and time available:
Monday Tuesday Wednesday Thursday Friday
CSA Library – weekly commitment; 3 ½ hour shifts
Please circle day preference:
Monday Tuesday Wednesday Thursday FridaCy
AM or PM
Name: Phone:
Child’s Classroom: _ Email address:
*All volunteers are required to have a background check.
Please fill out a Volunteer Form in the Student and Family Office.LIBRARY CONTRACT
Students are obligated to learn and observe the policies and procedures of the CSA
Library. Use of the library is a privilege that can be revoked if these policies and
procedures are not followed.
I, (print student name) , agree to
be a responsible borrower of the library. I understand that I must care for all items
borrowed from the library and return them when they are due.
• I have read the policies and procedures of the library and will adhere
to them.
• I will respect the books and treat them gently.
• If I damage or lose a book, my family and I will be responsible for
replacing the book.
Student Signature Date _
Class Name:
===========================================================
I, _( print parent name), the parent/guardian of the
above, agree that my son/daughter may borrow books from the library and have read the policies and
procedures for the CSA Library. I also understand that I will be responsible for the replacement costs of
any book(s) that are damaged or lost by my son/daughter.
Signature of Parent/Guardian Date_
E-mail address:
By providing us with your e-mail address, you agree that we may send you e-mail notifications regarding
your child’s CSA Library account such as overdue and hold notices.
Rev. 8/01/19PARENT & ATHLETE CONCUSSION
INFORMATION SHEET
WHAT IS A CONCUSSION?
A concussion is a type of traumatic brain injury that
changes the way the brain normally works. A concussion
is caused by a bump, blow, or jolt to the head or body that
causes the head and brain to move quickly back and forth.
Even a “ding,” “getting your bell rung,” or what seems to be
a mild bump or blow to the head can be serious.
WHAT ARE THE SIGNS AND
SYMPTOMS OF CONCUSSION? SYMPTOMS REPORTED
BY ATHLETE:
Signs and symptoms of concussion can show up right after
the injury or may not appear or be noticed until days or • Headache or “pressure” in head
weeks after the injury. • Nausea or vomiting
• Balance problems or dizziness
If an athlete reports one or more symptoms of concussion • Double or blurry vision
after a bump, blow, or jolt to the head or body, s/he should • Sensitivity to light
be kept out of play the day of the injury. The athlete should • Sensitivity to noise
only return to play with permission from a health care • Feeling sluggish, hazy, foggy, or groggy
professional experienced in evaluating for concussion. • Concentration or memory problems
• Confusion
• Just not “feeling right” or is “feeling down”
DID YOU KNOW?
SIGNS OBSERVED
• Most concussions occur without loss of
consciousness. BY COACHING STAFF:
• Athletes who have, at any point in their lives,
had a concussion have an increased risk for • Appears dazed or stunned
another concussion. • Is confused about assignment or position
• Young children and teens are more likely to • Forgets an instruction
get a concussion and take longer to recover • Is unsure of game, score, or opponent
than adults. • Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior, or personality changes
• Can’t recall events prior to hit or fall
• Can’t recall events after hit or fall
“IT’S BETTER TO MISS ONE GAME
THAN THE WHOLE SEASON”
Rick Snyder, Governor
James K. Haveman, DirectorCONCUSSION DANGER SIGNS WHY SHOULD AN ATHLETE REPORT
THEIR SYMPTOMS?
In rare cases, a dangerous blood clot may form on the
brain in a person with a concussion and crowd the brain If an athlete has a concussion, his/her brain needs time to
against the skull. An athlete should receive immediate heal. While an athlete’s brain is still healing, s/he is much
medical attention if after a bump, blow, or jolt to the more likely to have another concussion. Repeat concussions
head or body s/he exhibits any of the following danger can increase the time it takes to recover. In rare cases,
signs: repeat concussions in young athletes can result in brain
swelling or permanent damage to their brain. They can even
• One pupil larger than the other be fatal.
• Is drowsy or cannot be awakened
• A headache that gets worse
• Weakness, numbness, or decreased coordination
• Repeated vomiting or nausea
• Slurred speech
• Convulsions or seizures
• Cannot recognize people or places
• Becomes increasingly confused, restless, or agitated STUDENT-ATHLETE NAME PRINTED
• Has unusual behavior
• Loses consciousness (even a brief loss of consciousness
should be taken seriously)
STUDENT-ATHLETE NAME SIGNED
WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?
DATE
1. If you suspect that an athlete has a concussion,
remove the athlete from play and seek medical
attention. Do not try to judge the severity of the
injury yourself. Keep the athlete out of play the day
of the injury and until a health care professional,
experienced in evaluating for concussion, says s/he is
symptom-free and it’s OK to return to play. PARENT OR GUARDIAN NAME PRINTED
2. Rest is key to helping an athlete recover from a
concussion. Exercising or activities that involve a
lot of concentration, such as studying, working on PARENT OR GUARDIAN NAME SIGNED
the computer, and playing video games, may cause
concussion symptoms to reappear or get worse.
After a concussion, returning to sports and school is
a gradual process that should be carefully managed
and monitored by a health care professional. DATE
3. Remember: Concussions affect people differently.
While most athletes with a concussion recover
quickly and fully, some will have symptoms that last
for days, or even weeks. A more serious concussion
can last for months or longer.
JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp
TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION
Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the
National Operating Committee on Standards for Athletic Equipment (NOCSAE).9758 Highland Road
Howell, Michigan 48843-9008
Office # 810-632-2200 Fax # 810-632-2201
Consent for child to participate in physical education in the
CSA District
I understand that my child will be participating in a physical education program at
Charyl Stockwell Academy.
□ My child has no known medical / physical limitations that would prevent
him / her from participating.
□ My child has the following limitations:
Child’s Name:
Parent’s Name:
Parent’s Signature:
Date2019/2020 Family Handbook
Signature Page
(Please complete a separate form for each student)
We have read the CSA and/or CSPA Family Handbook. Our signature below indicates our
understanding of the procedures and policies contained therein and our intent to abide by them.
Student Name Signature of Student Date
Parent/Guardian Name Signature of Parent/Guardian Date
revised August 2019Information Opt Out Form
(THIS FORM IS OPTIONAL - If you do not wish to opt-out of any information
you do not need to complete this form or take any other action)
Academy name:
Student name:
Student grade:
Parent or guardian name:
I understand that the Family Educational Rights and Privacy Act (FERPA), a federal law, allows the Academy to
disclose designated “directory information” to third parties without my written consent, unless I inform the
Academy otherwise. “Directory information” is information that is generally not considered harmful or an
invasion of privacy if released.
The Academy may not share my child’s directory information for the following purposes as checked below:
o Academy publications, including but not limited to, a yearbook, graduation program, honor roll or
other recognition lists, theater playbill, athletic team or band roster, newsletter, and other Academy
publications
o U.S. Military recruiters
o Colleges and other educational institutions
o Prospective employers
o National Student Clearinghouse
o News media outside the Academy
o Academy PTA or parent organization
o Other groups and entities outside of the Academy, including community, advocacy and/or parent
organizations
o Official Academy-related websites or social media accounts
The Academy may not share any of the following checked directory information for the purposes indicated
above:
o Student name
o Student address
o Telephone numbers (e.g., home, cell, etc.)
o Academy assigned email address
o Date and place of birth
o Participation in officially recognized activities or sportso Weight and height of members of athletic teams
o Photograph, DVD, video or electronic image
o Honor roll, awards received
o Dates of attendance
o Grade level and/or classroom assignment
o All of the above
Parent/Guardian signature (if student is under 18):
Student signature (if student is over 18):
Date:
revised August 2017EMERGENCY / MEDICAL INFORMATION
Last Name Student M.I. First Name Birth Date
Gender Male Female Primary Ethnicity Secondary Ethnicity
Street Address City State Zip
Parent/Guardian#1 Last Name First Name
Street Address City State Zip
Home Telephone# Cell# Work #
Parent/Guardian#2 Last Name First Name
Street Address City State Zip
Home Telephone# Cell# Work #
Aller gies/M ed ical Con d it ion s (please ch eck all th at ap p ly and give d et ails in t h e “E xp
lan at ion s” are a).
1 No known problems 2 Medical Waiver 3 Arthritis 4 Cardiac
5 Hemophelia 6 Diabetes 7 Aspirin Allergy 8 Penicillin Allergy
9 Iodine Allergy 10 Multiple Allergies 11 Epilepsy 12 Contact Lenses
13 Blood Condition 14 Sulfa Allergy 15 Frequent Nosebleeds 16 Asthma (is inhaler required)
17 Hearing Impaired 18 Animal Allergy 19 Codeine Allergy 20 Environmental Allergy
21 Food Allergy (list below) 22 Insect Allergy 23 Daily Medications 24 Special Needs (list below)
25 Medical Alert 26 Other 27 Other 28 Other
Explanations from above ( Please Reference the Condition Number)
In the event we need to reach you and are unable to do so, please list two local persons that we may contact and release your child to.
Last Name First Name Home# Cell#
Last Name First Name Home# Cell#
In addition to the parent(s)/guardians(s) and alternative contacts, the child named above may be released to the following people upon verification
of ID.
Last Name First Name Home# Cell#
Last Name First Name Home# Cell#
Please list the name(s) of any person who should be EXCLUDED from picking up the child named on this form
Last Name First Name Home# Cell#
Parent/Guardian Signature DateNETWORK AND INTERNET ACCEPTABLE USE AGREEMENT
The Academy is committed to the effective use of technology to both enhance the quality of student learning and the
efficiency of Academy operations. It also recognizes that safeguards have to be established to ensure that the
Academy’s investment in both hardware and software is achieving the benefits of technology and inhibiting negative
side effects.
In order for anyone to use the local and wireless network, Internet connection and/or data and exchange servers,
he/she must read these guidelines and sign this Agreement.
A user name and password will be issued to users upon receipt of this signed Agreement. Until then network use will
not be allowed. The use of the Internet is a privilege, not a right. Inappropriate behavior or violation of the acceptable
use agreement may lead to penalties including the revocation of a user’s account, disciplinary action, including
suspension and/or expulsion, and/or legal action.
Inappropriate Internet and network use is not limited to the following:
• using offensive or inappropriate language or language that would promote violence or hatred;
• revealing one’s (or other’s) personal address, phone number or credit card information;
• harassing anyone by sending uninvited communication;
• sending or accessing electronic information from accounts that do not belong to you without the owner’s
authorization;
• accessing unauthorized or inappropriate areas of the network and changing or interfering with information
found in the network;
• accessing areas blocked by the Academy’s firewall without authorization;
• soliciting or distributing e-mail for non-educational or non-business purposes;
• misrepresenting oneself or others;
• making unauthorized copies of software or information, such as software pirating;
• printing of materials excessively;
• downloading and/or installing unauthorized software, including games, on Academy computers;
• accessing, uploading, downloading, distributing, or transmitting pornographic, obscene, sexually explicit, or
threatening material or other materials harmful to minors;
• violating federal copyright laws or otherwise using the property of another individual or organization without
permission. All work must be original work. Copy and pasted material may only be used as a resource when
properly cited;
• violating any local, state or federal statute; and
• accessing personal social networking sites, such as but not limited to Facebook, Twitter, MySpace, YouTube,
Instagram, Snap Chat, Tumblr, Pinterest, Vine, Yik Yak, VK, Google+, Linkedin, Flickr etc. without specific
permission from the Administration.
I agree to comply with these Network and Internet Acceptable use guidelines as stated in this Agreement and the
Academy Student/Family Handbook.
I understand that the Academy administration reserves the right to change these rules at any time.
Rev. August 2019I understand that the assignment of a password does not guarantee confidentiality. There is no expectation of privacy as to prevent examination or monitoring. I understand that the Academy reserves the right to examine all data stored in the machines and/or network (including e-mail) to make sure that all users are in compliance with these regulations. The Academy reserves the right to monitor or review Internet files, including web pages and usage logs. Any flash drive used at the Academy must also be free of any inappropriate content. I agree not to participate in the transfer of inappropriate or illegal materials or material that may be considered treasonous or subversive through the Network and Internet connection. I realize that in some cases, the transfer of such material may result in legal action against me. I understand that the Academy monitors the on-line activity of all users in an effort to restrict access to child pornography and other material that is obscene, objectionable, inappropriate and/or harmful to minors in accordance with the Children’s Internet Protection Act (CIPA). Should I happen to find materials that may be deemed inappropriate, I shall refrain from downloading this material, immediately leave the Internet site, shall not identify or share the location of this material, and will immediately report it to a teacher or the Administration. I am aware that the transfer of certain kinds of materials is illegal, and punishable by fine or jail sentence. I understand that all computers, local and wireless network, Internet connection and/or data and exchange servers are the Academy’s property and shall only be used for educational and business purposes. I understand that computer hardware (monitors, terminals, keyboards, mice, etc.) are Academy property and any mistreatment or damage will be considered destruction of property or vandalism. I understand that the Academy makes no guarantees, implied or otherwise, regarding the reliability of the data connection. The Academy and any of the sponsoring organizations shall not be liable for any loss or corruption of data resulting while using the Internet connection. I understand that the Academy strongly condemns the illegal distribution of software otherwise known as pirating. I understand that software piracy is a Federal offense punishable by fine or imprisonment. I agree not to allow other individuals to use my account or use other individuals’ accounts for Network and Internet activities. I understand that through the use of the Internet any actions taken by me will reflect upon the Academy system as a whole. As such, I shall behave in an ethical and legal manner. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ********************CSPA STUDENTS ONLY: CHECK APPLICABLE BOX BELOW*************************** My student would like to bring a personal electronic device to school. My student will only be accessing Academy-owned electronic devices while at school. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Signature of Student _______________________________________________ Date _________________ A parent or legal guardian must also sign the following section: I, __________________________________ (print name), the parent/guardian of ______________________ (print student’s name), agree to accept all financial and legal liabilities that may result from my son’s/daughter’s use of the Academy’s Network and Internet connection. I release and agree to hold the Academy, and all other sponsoring organizations related to the Internet connection, from any and all liability foreseeable or unforeseeable for damages or injury resulting directly or indirectly from the use of the Internet connection. I also agree to defend, indemnify, and hold harmless the Academy, its Board members, staff and agents from and against any such claims, demands, suits, damages, liability, costs, and expenses (including reasonable attorney fees) incurred as a consequence either directly or indirectly of the granting of this agreement. Signature of Parent/Guardian ________________________________________ Date ___________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- This policy and all its provisions are subordinate to local, state, and federal statutes. Rev. August 2019
1032 Karl Greimel Dr.
9758 E Highland Rd.
Brighton, MI 48116
Howell, MI 48843 School Year 810-225-9940 phone
810-632-2200 phone
810-225-9941 fax
810-632-2201 fax
Parent/Guardian Permission for OVER-THE-COUNTER (OTC) Medication
Only one medication per form
Name
Classroom Age_
Date of Birth Weight (if required for dose)
Medication name Exact Dose
Condition for use (such as headache)
_YES NO Medicine to be taken with food?
Other directions
YES NO Parent/Guardian to be notified with every use of this medication
For High School or Middle School students only: (please check option 1 or 2 below)
1. Student can self-administer medication(s) in the presence of an authorized staff member
EXCEPT AT MIDDLE SCHOOL CAMP.
2. Student can keep the medication(s) in his/her possession and self-administer as needed
EXCEPT AT MIDDLE SCHOOL CAMP.
Other times to call or special instructions-
OTC medication without a doctor’s written permission will have limited use at school – SEE PAGE 2 F0R RULES
Parental Permission
It is my understanding that the Academy has taken every precaution to safeguard my child. I release and agree to hold the Academy,
its Board members, staff working at the Academy, volunteers, and agents harmless from any and all liability foreseeable or
unforeseeable for damages or injury resulting directly or indirectly from the administration of the medication/treatment.
I also agree to defend, indemnify, and hold harmless the Academy, its Board members, staff working at the Academy, volunteers and
agents from and against any such claims, demands, suits, damages, liability, costs, and expenses (including reasonable attorney fees)
incurred as a consequence either directly or indirectly of the granting of this authorization to administer the medication/treatment.
I have read the guidelines on page three of this form for the administration of over-the-counter medication at school. I give my
permission for the above named medication (supplied by me) to be given by school staff as directed on this form.
Parent/Guardian Date
Signature
Phone Number Alternative number
revised November 2017Guidelines for parents and school staff regarding over-the-counter (OTC) medication at school
without an order from a physician/licensed prescriber:
• All medication must be in the original container and an unopened container is recommended.
• Write the exact dose (amount of medication to be given, not a range) on page 1 of this form.
• Write your child’s name on the medicine bottle or packaging without covering the label.
• Only one medication per form. You will need a separate form for every over-the-counter medication.
• Write the exact name of the medication to be given on page 1 of this form.
• Write the condition for use (such as, headache or menstrual cramps.)
• Aspirin will not be given to students without a doctor’s order on a “Prescription Medication” form due to its
association with Rye’s Syndrome.
• Stomach pain will not be treated with acetaminophen, ibuprofen or naproxen without a medical order on the
“Prescription Medication” form due to lack of indication. Menstrual cramps are not considered stomach pain.
• No over-the-counter medication will be given frequently or for a prolonged period of time. If your child is
experiencing the need for frequent or regular administration of this medication at school, you will be notified. To
continue giving this over-the-counter medication, a physician or licensed prescriber’s order will be required. This is
to help insure that a serious condition is not being ignored or a more appropriate treatment is not being overlooked.
• If your child is sick it is not appropriate to treat the symptoms at school. Medication may help symptoms briefly
or reduce a fever, but he or she is still contagious and should go home.
• Cough drops have the potential to be a choking hazard and should only be used for short period of time. If your
child’s cough persists, a medical professional should be consulted.
• Over-the-counter Benadryl or other antihistamines ordered for a potentially life threatening allergy (anaphylaxis)
must be ordered as part of the Severe Allergy Medical Action Plan (MAP) and signed by the physician.
• Over-the-counter Benadryl or other antihistamines for mild food allergies must be ordered by a licensed
prescriber and can be done on the “Prescription Medication” form without completing a Medical Action Plan for
severe allergy. Parent/guardians may order over-the-counter antihistamines only for mild allergies that are not
caused by food, such as hay fever.
• For the purpose of this form, over-the-counter medication includes vitamins and homeopathic remedies.
NOTE:
• The very first dose of this medication type may not be given at school since it is not known how your child may react to the
medicine.
• Unused medication may be picked up by a parent/guardian anytime before the end of the school year. Medication remaining
after the last day of school will be properly discarded.
Parents/guardians have the right to come to school and give medication to their child without an order form on file. However,
all sick children should be home to help protect others.
If you have questions regarding the guidelines above, please feel free to contact the school.
Parent/Guardian Signature Date
revised November 2017Student Residency Questionnaire
This questionnaire is intended to address the McKinney-Vento Act, in regards to children and youth in transitional living
arrangements. Your answer will help the administration determine residency documents necessary for enrollment and additional
services available to your family. This questionnaire will be kept separately from the student’s permanent record and filed by the
Homeless Education Liaison.
School:_
Name of Parent/Guardian:_
Address:_
Phone:_
Student Names:_
Signature of Parent/Guardian: Date
1. Presently, where is the student living? Please check one:
in a shelter
with more than one family in a house or apartment
in a motel, car or campsite
with friends or family members (other than parent/guardian)
awaiting foster care placement
none of the above. If you checked this item, skip number 2 and go directly to number 3.
2. The student lives with:
1 parent
2 parents
1 parent & another adult
a relative, friend(s) or other adult(s)
alone with no adults
an adult that is not the parent or the legal guardian
3. Mark one of the following:
Parent(s)/Guardian(s) is NOT an active member of the military
Parent(s)/Guardian(s) is an active member of the military
Parent(s)/Guardian(s) was in the military but no longer active (Veteran)
Revised 8-9-2017Photograph and Publicity Release Form I, __________________________, give Charyl Stockwell Academy District and its agents, if any, permission to use my and or my child(ren)’s name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of Charyl Stockwell Academy District. I agree that Charyl Stockwell Academy District may have complete ownership of such pictures, etc. including the entire copyright and may use them for any purpose consistent with Charyl Stockwell Academy District’s mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or other materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Charyl Stockwell Academy District and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. I have read and understood this consent and release. I give my consent to the Charyl Stockwell Academy District to use my and or my child(ren)’s name and likeness as described above. ______________________________________ __________________________ Signature Date ______________________________________ __________________________ Parent/Legal Guardian (if age 17 or below) Date I do not give my consent to Charyl Stockwell Academy District to use my and or my child(ren)’s name and likeness as described above. ______________________________________ __________________________ Signature Date ______________________________________ __________________________ Parent/Legal Guardian (if age 17 or below) Date Checking this box indicates that you also do not want your child’s picture in the yearbook. When you are attending a CSA District public event, photography, audio and video recording may be taken. By entering this event, you are consenting to such recording and its publication. Please list all CSA District students: _________________________________________________________________________ _________________________________________________________________________
Volunteer Form 2019 / 2020
(Must be completed each year.)
Volunteer Information:
Last Name First Name Middle Initial
Street Address City Zip Code
Email Address
Home Phone Cell Phone
Date of Birth Race Male / Female
Parent / Guardian / Other: Student’s Name
MI Driver’s License Number Date of Expiration
Any other last names used: Any other first names used:
Will your volunteer service include driving Academy students? yes no
Vehicle Information:
Name of Owner
Owner’s Street Address City Zip Code
Year/Make Model License Plate #
Insurance Information:
Insurance Company
Policy # Expiration Date
Please check one:
1. I have not been convicted of, or pled guilty or nolo contendere (no contest) to any crimes.
2. I have been convicted of or pled guilty or nolo contendere (no contest) to the following crimes
(use separate sheet to explain nature of conviction, date and court):
a.
b.
Certification of Policy & Authorization:
I understand and agree that the Academy will be requesting a criminal history background check on my behalf from the Internet
Criminal History Access Tool (ICHAT). As a chaperone, I will not purchase any items for any students during field trips. I
understand that as a volunteer driver, I must be 21 years of age or older, hold a valid driver’s license, have enough working seat belts
for each child I transport, and have the required coverage in effect on any vehicle used to transport the children during the current
school year. I may only transport the children from the Academy to the destination and back and will not be making any other stops.
Copy of driver’s license is required.
Signature: Date:_Early Math Volunteers
The Early Math Volunteers support students with early math skills in the Navigator unit.
Volunteers provide individuals or small groups of students with opportunities to practice basic
addition and subtraction math facts using a variety of activities and games. Parent volunteers
meet with individuals one-on-one or in a small group weekly for 15-30 minutes.
What are Math Facts?
A math fact is a math problem that a child needs to "just know". For example, 5+8 is an addition
math fact, and 9-4 is a subtraction math fact. Children need a lot of practice with math facts so
that they have instant recall of each math fact rather than relying on various counting strategies to
solve basic addition and subtraction problems.
Why are Math Facts Important?
Math Facts are important because they form the building blocks for higher-level math
concepts. For example, adding and subtracting larger numbers, telling time, counting money,
measurement, and long multiplication and division are all concepts that are significantly easier for
a child to learn once he has mastered his math facts and has developed a keen number sense.
The Quick Recall of Math Facts is Critical.
Research proves that higher-level math is more difficult to learn when children have not mastered
their math facts. There is strong evidence that time on task with math drill and practice will help
build a solid math foundation that children will be able to build on in the future.
What is involved? All it takes is 30 minutes to 1 hour per week. The time can be adjusted to your
schedule due to the flexibility of the program. You would work with either individual students or a
small group of students, helping them to build their math fact knowledge through games and
other fun experiences. Please join us for a rewarding experience!
If you are interested in volunteering to support students as an Early Math Volunteer,
please contact Debbie Thor at 810-632-2200 ext. 104.
If interested, please fill out the form below and return to Debbie Thor’s mailbox.
------------------------------------------------------------------------------------------------------------------------------
Yes! I want to be an Early Math Volunteer at CSA!
Name: ____________________________________________________________
Phone #: __________________________________________________________
Email address: ______________________________________________________
Day Preference: Monday Tuesday Wednesday Thursday Friday a.m. or p.m.ELVs WANTED!
(Early Literacy Volunteers)
ELVS is a reading enrichment program designed to assist early readers in
the Navigator classrooms. The program provides one-on-one tutoring to the
early reader. Volunteers help students develop the skills to become strong
readers. For our children, these are very important years to develop a love
for reading and learning. When children learn to read it helps them in all
aspects of learning and it builds a confident student.
The ELVS program is in need of volunteers (parents, senior citizens, and
high school students). We need your support!
What is involved? All it takes is 30 minutes to 1 hour per week. The time
can be adjusted to your schedule due to the flexibility of the program.
Please join us for a rewarding experience.
For volunteer and training information, please call:
Debbie Thor at 810-632-2200 ext. 104
If interested, please fill out the form below and return to Debbie Thor’s mailbox.
--------------------------------------------------------------
Yes! I want to be an Early Literacy Volunteer at CSA!
Name: ___________________________________________
Phone #: _________________________________________
Email address: _____________________________________
Day preference: Mon. Tues. Wed. Thurs. Fri. a.m. or p.m.
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