SMITH COUNTY SCHOOLS STUDENT ENROLLMENT FORM SY 16-17 1s your child currently suspended or expelled stom another school system? YES NO Js your child currently placed in an alternative school or any other type of special placement? © YES NO Previous School System: city State ‘Student Legal Name: Parent mais: Tat Fist Middle Date Entored: Race (irc): Asian Black Hispanic White Indian Other Grade: Birthdate Social Security Number: Sex (Circ): | MF Morning Bus #: ____ Afternoon Bus #: ‘Approx. Miles Ridden on a bus: Car Rider: Student Driver: Custody (Circle); Both Mother Father Other ‘Note: Ifa child is in any custody other than both parents, a copy of custody papers MUST be included in child’s records. ‘With whom does the student live? Parents (both) Parent (only one) Parent and another adult Alone with no adults A relative, friend), or other adults) ‘adult that is not the parent oF the legal guardian DCS or Foster Parent ‘Where does the student stay at night? Home/Apartment owned or ented by the Parent(sGunrdian(s) In a motel/notel Ina shelter Atacampsit Tn an automobile In housing that is inadequate (Le. no electcty, running water, ect.) ‘With a relative or friend (amily does not have a residence) Other (please explain) Beecacas e Parent/Guardian 1: ___Relation: Parent/Guardian 2: __Relation: |= 911 Home Address: SEsee cigs ee State: Zip: Primary Phone f__ oe Secondary Phone #8). aoe. Pate ‘Do you or your spouse work on federally owned property? _Yes __No : Mother's Employer Phone Father's Employer Phone ‘Student's Mother's Maiden Last Name ‘Sudent’s City of Birth Student’s County of Birth Student's State of Birth Student's Country of Birth ees School Last Attended Address ~ Persons to call when parents cannot be reached. ‘Name. Phone Relation Name. Phone Relation, Is your child in: RTI (Remedial Reading or Math) _YES NO SPECIALED. (Resourse)__YES_NO Please include IEP from previous school.i sone ACCEP TAI 2 eSiiiterCeunity Senoate ©. ase SE, MEDIA'RELEASE, AND INTERNET SAFETY GUIDELINES, 0001050 PURPOSE, iri ‘Smith Codnty-Séhbols provide siudéh te and employes accdse fo, the Jnieinélas a means to increase leauiln roduc. toward-achieving:21® oantury aor The purpose ot tils Contract is to AsSire that users recognize the procetluree Whleh the ‘schoo! IniBases.on thelr use of Internet, slectronic mediarrésauroes, end release of-student information, ln! adcitlen;thiswcontecct reqGed moe aoe © atovl) gd Sin COU Suite coho edtesior pulces, cade organ Online Paatedton Ret 47 USC Seaton 281 (COPPA), the Fafnly Educalion Rights and Pavegy,Act (FERIA) and the Childrens internatfolsction Act (CIPAY'Se Well as Laws pertaifiig te stalking and harassment, The policy /s promiuigaled. 6 ae fo bean compliance: With the public records laws of the State of Tennessee, : favorit: Steer yt THE CONTRACT i euros seals de armies «* Sinith Esuty Schods has outined the following gudetines as required for of technology user. The district AsAleAL HL Maa in téidate:porletitaddiéssing appopilete'eiid dete online bekNct.Indlusing Intoacting with other incivididle eee sites and in chat roams and.eyberaulljing alWereriess antl résporige, (REF, S.7458— 1th Congress 12007)'Broadband Data Irtordvar! Sand parents. af encourage to discuss same at home. The distict uses the étatewide ENA Intoriet filer and firewall designed fo protect sturlents frst fox eg an ot ae nomalor ade eoee mates a tase vse ora Hae ter minors however, ts impossile forthe Smith County Schoo! System to complelalyoravant students for sings Waele Cexees SOMONE materials, and will not be held responsible for materials acquired an the natwerk, Fallure to folow al or pat of hese guidelines, ox ary action that may expose Smith County Schoo's to risks of unauthorized access to deta, csclosure of infomation, lal itty, tet str fly, or compromise the safety of users is prohibited and may result in disciptinary action up to and including loss of network st aabs, Confiscation of compUlter écuipmetit, euepencion, termination of smployment and/orcriminal prosedution! in order to! Rea ‘povadteensit, te student's parentigtlafdian (or the student who is at least “8 years old) must provide the Superintendentidestgnes with a wrilai request, 1.Empioyes Compliance ‘ seg area scart git. th Al eriplo/ees must comply with te Smith County Board of Education Use ofthe Internet policy and these. Guidelines, Every.userhas ey responsiblity’ hraiftain arid erthartos the Distiat's public image end to-use Distict e-mall and access fo the Internet in a productive and professionel manner. 2, Student Compliance Users shall nct attempt to meke use of material or attempt io locate material wrich would not be acceptable in a school setting, Students wll be, suprised by fecuity during use of online resources. All students must comply with'tre Smth Courlty:Boart¢F liste’ tetintemit pally and these Guidelines.-Stidents shell report to school personnel any personel electronically transmitld attackoinanyrforirmeds by cers ‘over the internet or local network using any Smath County Schools’ technology, Students shall understand information obtained vi the Internet may or may not be comect and therefore needs to be valdated before quoting. : 3, Prohibited Behavior ‘The following behaviors are not permitted on District workstations, networks, emcils or Internat access: ane Using cht pacouorisi' = ste 8 sn Sei teal fide indosago cx ites Se ee s h . Organizing paitical armpaigne T inteional enttonaly wasting limited rasouroes et neon ees J) Employing the networkiforccomteeiat purposes ws? d. Harassing, insulting, of attacking others ae ke Violating regulation preserlood bythe network provider Any practices that threaten the network (e.g. loading files IT Gendusing boy eaties Suragioa Raune shal may.tntradvag.. virus, senting Email Chain letters, ¥ Propaning cr gseerbing mater pela ete.) : religious purpose: rier £,._,,.Mlolating copyright laws See e 4, Notwork Security” ee Bote = Only useronithivaleeSmith County:Schoo! network accounts'are authorized to use the Smith County Scheat's akc arid comple equipment. Employees ard students must only use their assigned network account. Users ere prohibled! framing anos cut network password or network account Information other than to authorized personnel. Do not allow anyone to use-a computer While you ara logged in All computer users should always logoff from the network bofore Isaving thelr roam er office. es x ts For tho protection and security of Sm County Schoois data, ell computers attached to the Smith County Schosle physical network (a ‘computer locaied et & Smith County Schools facity ether wired or véreless), must bo the property of Smit County Schools. itis prohibited to attach a computer thet Is not property of Smith County Schools to the network witout first receiving aparovel from IT Deperiment management, Use of software designed to gain passwords or access beyond the rights asslaned-te « user or computer isitoly protibited, Use of such progrars risk the securlly of the network and ls considered “hacking”. “The irtent to control unauthorized! access isa Violation of State and Federal ay, Vidalors will be prosecuted. Should you Inadvertently.4lscover pasawords.or any other mea@ure.sed to contro] unauthorized access, teportto supervisory personel in the room (in the case of studerts) orT personnel (In the cee of staf), No user shell encrypt files or folders cr attempt to hide les or folders stored on a network server or logeltorestation. Any enctyptactor hidden flies will be deleted. All network users may be moritored at any time by authorized personnel forthe purpose and inspeation of complies to ‘these guidelines, 5, Workstation/Computer Use All employees and students are prohibited from installing/downloading eny software, screensavers, toolbars, search tools, PC leanup/optimizer tools, sn virusiacware/spyware prevention tools on any computer uniass authorized in weting by a member ofthe ITStudent health information within the sche STUDENT HEALTH HISTORY 001 is limited to the information necessary to serve the student's educational and health interests. mi Please contact jor asthe or EpiPen tex severe eliegic reactions. Your chile Student Name, Please let us know your child?s health needs by completing this form. C1 my child has no health problems which would affect.hisiher school day. | C1 Wy child's health needs include the conditions checked (xX). ame-ofSturtent’s doctor [Does your child see wapecialist? UYes DNe Wame- Grade, Date. 4 Bus™. Clalleraies, pieave bet What haprins?, Satan esses eee eeeee eee is EpiPen Prescribed? Yes CINo (ff yes, parent must provide EpiPen} j (0 Bee Sting Allergy, What happens? © ip EpiPen Prescrited? DYes DINO (i yes, 1D Asthine |s inhalerused? Des DNo Hf yes, how often ‘What medizations are taken for asthma? parent must provide EpiPen) 2, Di Dishetes What medications are teken?, ‘Any special procedures curing the school day? D Hearing Problem, Piease desctibe, : D Vision Problem. Weare glasses? Yes ONo Wears contacts? Des CMO DD AnD or ADHD Dingnosed, What mesications are taken? ae Will medicaticn be needed in, school? Des ONa, « Wher’ is DBoneiioind problen or Hactines? Which bore dr joint? ® dae ipa brace wam? OYes No CO Seieures What type? : Medication taken, eee ao a 1) Episode of logs of sanseiotsness When?" Retr f ~ ‘ay special treatment! D) Emotional conpams List — — | to be aware of List any other recurrent medical problam or flness you would Iike-the scheo! Phone Phone_ hilo needs medication at school, including inhalers 100 personnal for medication farmsif your may cary 2n inhaler if medically suthorized anc developmentally appropriale, ailer informing schoo! personnel ‘Your signature gives permission fo sjgasroam and io foster academic success. siormation with schoo! —“leaith Histon Informed Consent 1 school staff ia take precautions and procedures to protect your child in the “Your signature is an informed consentto share this health history staff on a need-to-know.basis for emergency plans. Date, rentiguardian:sig nature, Zl “Phene numibes, | :Smith County Board of Education Transportation Department 302 Upper Ferry Road, Carthage, TN 37030 (615) 735-2893 Bus_____ School Teacher Grade Student’s Name: Parent’s Name: See Home Address; (911 addresses), a City: State: Zip Code: Home Phone: = ____ Alternate Phone: ~ This student will be a car rider ONLY AM. PM BUS # FOR HOME ADDRESS (EVEN IF STUDENT IS A CAR RIDER) Write no bus iffthere is no bus transportalion from home address to schoo! student attends. 1 Authorized Bus Stop If Different from Home Address: (911 address) BUS # ADDRES Ee geet . ___ Grand Parent, Aunt or Uncle AM: Mon Tue Wed __Thu__ Fri Baby Sitter or Day Care PM: Mon Tue Wed” Thu Pri_~ “Parents work other —. 2"! Authorized Bus Stop 4f Different from Home Address: (911 address) BUS #: c.g. 30 pADDRESS: y “** Grand Parent, Aunt or Uncle AM: Mon__Tue__Wed__Thu__Fri__ Baby Sitter or Day Care PM: Mon Tue Wed. Thu Fti_____ Parents work _ other Emergency Contact: _ pee Phone No Does The Student Have Any Special Needs Or Special Situations We Need To Be Aware Of? Examples (Allergic Reactions, Asthma Attacks) Parents Signature: Date: 2016-2017REQUEST FOR WAIVER OF SCHOOL FEES Dear Parent or Guardian: You do not have to complete the form below to get free and reduced price meals. ‘You do have to complete it to receive the benefits listed below. If your student is eligible for free or reduced meal benefits, the Smith County Board of Education will not charge fees for him/her to participate in certain programs for which other students are charged. The Smith County Board of Education will provide the following to students who qualify: a maximum of $30.00 per stuclent K-8 and $40.00 per student 9-12 for fees for courses and/or activities that are required, ‘There ate other supplies and materials, however, that all children are expected to furnish for themselves, such as paper, pencils, etc Sincerely, Pl daadl Barry H. Smith Director of Schools ‘To receive these benefits, you are required to check the benefits you want to receive and sign the following pormission: T want my student’s fees waived for the activities. I want my student’s fees waived for the supplies. fl Funderstand thas Iwill be releasing inforniation that will show that Lam applying for free and reduced price benefits under the National School Lunch Program, School “officials may verify all information used to determine my student's free and reduced price lunch eligibility, If my social security number ig included on the application, it may only be used by the Board of Education in the verification process. 1 give up my rights to confidentiality for these purposes only. certify that Lam the parent/guardian of the child for whom application is being made. Signature of Parent/Guardian Date ‘audent Name School Grade APPROVED BY SCHOOL STAFF FOR FEE WAIVER YE! NO.Before/after-school Program ‘The before/after-school program will offer a program b 29%, We will meet Monday through Friday mornings from 7:00-7:45 and Monday through Thursday afternoons from 3:00-4:30. You will have a choice to attend mornings, afternoons, or both. This program is offered to students in grades 7-12. Students participating in the morning program will: * be allowed to get breakfast in the cafeteria as normal «be offered open computer lab and credit recovery Students participating in the afternoon program will: receive a nutritious snack participate in activities such as art, community service, games, ete practice math and computer skills get homework help/tutoring/credit recovery ¢ interact socially Af you would like for your child to participate in the program, please sign and return this form by August 21". If you are not interested in your chitd participating please leave blank or throw away. Students who return this signed letter will receive additional information and an enrollment packet, A Parent Orientation meeting is scheduled for August 24" in the school library at 3:15. Parents are not required to attend this orientation and can call anytime for further information. If you have questions, please contact Shawn Frye at GHS (613) 683-8245 or Stephanie Johnson at Smith County Board of Edueation (615) 735-9625. Shawn Frye, Site Coordinator ____I would like for my child to attend Student Name: Grade_ Parent Signature:Tennessee Department of Education (TDOE) Title |, Part C of the Elementary and Secondary Education Act (ESEA) Migrant Education Program Occupational Survey Student Informatior DATE: ‘ast Name First Name Gender Race District: School: Grade: Schoo! Year: Migrant students may be eligible for additional services and assistance. Please answer the following questions and raturn the survey to the school so that we can determine if your child qualifies for migrant services, 1. Bid you or someone in your family come to Tennessee looking for temporary or seasonal wark in a factory processing foods or working in agriculture, fishing, or dairy (examples: working with tobacco, tomatoes, cotton, strawberries, nurseries, trees, pork, chickens, vegetebles, et YES, No. IF yes, please mark which member of the family does or did this kind of work: Mother. Father: Children Other 2. Do you or someone in your family currently work in @ factory processing foods or in agriculture, fishing, or dairy? (examples: working with tobacco, tomatoes, cotton, strawberries, nurseries, trees, pork, chicken, vegetables, atc) YES, No. If yes, please mark which member of the family does or did this kind of work: Mother. Father Chitdren___ Other 3. If your current job is not temporary work in agriculture or fishing, did you or somedrié in yout family work ii'a temporary or seasonal agriculture ot fishing in the last 3 years? ves No. Ifyes, whidre? — City State Country lF you answered “yes” to any of the questions above, please answer questions 4, 5, and 6, 4. How long have you been in this county in Tennessee? mantis years 5. Whatis your current address? ‘Sreet Aderess ky Sia Zpcote 6. Whatis your current telephone number with the area code? NOTETO THE SCHOOL; Please send al! surveys with at least one “yes” response to your district migrant lason, Please ‘moke sure the form is filled out completely. NOTE TO DISTRICT MIGRANT LIAISON: Ail surveys with at least one “yes” answer should be uploaded to the TNMEP site upon receipt. Please emul migronted@blomand.net to inform Jessica Castofieda that new surveys have been uploaded, dune 2015, TN form #05438,INFORMATION AN FOR STUDENT-ATHLETES & PARENTS/LEGAL GUARDIANS (Adapted from CDC “Heads Up Coneussion in Youth Sports”) Public Chapter 148, effective January 1, 2014, requires that school and community organizations sponsoring youth athletic activities establish guidelines to inform and educate Coaches, youth athletes and ther adults mvolved in youth athletics about the nature, risk and symptoms of concussiow/head injury Read and keep this page, Sign and return the signature page. A concussion is «type of traumatic brain injury that changes the way the brain normally works. A. concussion is caused by a bump, blow or joit to the head or body that causes the head and brain to move rupidly 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. Did You Know? + Most concussions occur without loss of consciousness, © Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion. © Young children and teens are more likely to get « concussion and take longer to recover than adults, WHAT ARE THE SI iS AND SYMPTOMS OF CONCUSSION? Signs and symptoms of concussion cen show up right after the injury or may not appear or be noticed until days or weeks after the injury i TE-as athlete reports one or more syruptoms of concussion listed below aera bumpy blawsordglte the ene head or body, s/he should be kept oat of play the day ofthe injury and unti abealth'¢are provider® says s/he is symptom-free and it’s OK to return to play. ‘SIGNS OBSERVED BY COACHING STATE SYMPTOMS REPORTED BY ATHLETES Health care provider means @ Tennessee liconsed madical doctor, osteopathic physician or a clinical neuropsychologist with concussion treiningStudent-athlete & Parent/Legal Guardian Concussion Statement Must be signed and returned to school or community youth athletic activity prior to participa tion in practice or play. Student-Athlete Name: Paren/Legal Guardian Namo(s): After reading the information sheet, | am aware of the following information: ‘Studeni- Athlete initials ParentiLegal Guardian initials ‘A conoussion is @ brain injury which should be reported fo my parents, my coach(es) or a medical professional if one is available. ‘A concussion cannot be “seen.” Some symptoms might be present right away. Other symptoms can show up hours or days after an injury. Twill tell my parents, my coach and/or.a medical professional about my injuries and illnesses. NIA Twill not return to play In a game or practice fa hit to my head or body causes any concussion-related symptoms. NA Twillimy child will need written permission from a health care provider* to retum to play or practice after a concussion. Wiost concussions take days or weeks to get better. A more serious ‘concussion can last for months or longer. ‘After a bump, biow or jolt to the head or body an athlete should receive immediate medical attention if there are any danger signs such as.ioss of consciousness, repeated vorniting or @ headache that gets worse. "Alter a. coricussion, thé brain needs time lo Real. [understand that | ‘amimy child is much more likely to have another concussion or more serious brain injury if return to play or practice occurs before the concussion symptoms go away. ores leaner. ‘Sometimes repeat concussion can cause serious and long-lasting problems and even death Thave read the concussion symptoms on the Concussion Information Sheet, * Health dare provider moans @ Tennessee licensed medical docior, osteopaiive physiolan or a clinical neuropsychologist with cancussion training Signature of StudentAthiote Bate Signature of PareniLegal guardian Baie“deci they will be allowed to attend Prom. Gordonsville High School 110 E, Main Street Gordonsville, TN 38563 Phone (615) 683-8245 Fax (615) 683-5193 Ronnie Scudder Principal Prom Team Membershi All high school students that plan to attend Prom their junior or senior year are required to pay a membership of $25.00 per year for the first 3 years (9 thru 11” grade) they attend school at Gordonsville High School. Prom is sponsored by the junior class Prom team members each year for all 11" & 2" grade students at Gordonsville High School who have paid their Prom Team Membership. If a student doesn’t plan to attend Prom their junior or senior year they are not required to pay this membership. If a student’s membership is not paid their junior year and then the student s tovattend’Prom their senior year they fats pay this aide before _- The balance of this membership will be used to cover the cost of their Graduation ceremony. (such as: chair rentals, graduation programs, gifts for speaker, & decorations) Fee waiver money cannot be used for Prom team membership, as this membership is not required for any classroom credit.Smith County School System ‘The Family Educational Rights and Privacy Act (FERPA), a Federal law, roguires that Smith County School System, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s education records. However, ‘Smith County Schoo! System may disclose appropriately designated “directory information” ‘without written consent, unless you have advised the District to the contrary in accordance with District procedures, ‘The primaty purpose of directory information is to allow the Smith County School System to include this type of information from your child’s education records in certain school publications. Examples include: | Family Educational Rights and Privacy Act (FERPA) + A playbill, showing your student's role in a drama production; + The annual yearbook; © Honor roll orother recognition lists; : + Graduation programs; and + Sports activity sheots, such as for wrestling, showing weight and height of team members. Directory information, which is information that is generally not considered harmful or an inyasion of privacy if released, can elso be disclosed to outside organizations without a parcat's prior written consent. Outside organizations include, but are not limited to, companies that ‘manufacture class rings or publisb yearbooks, In addition, two federal laws require local ‘educational agencies (LEAs) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESBA) to provide military recruiters, upon request, with three directory information categories ~ names, addresses and telephone listings ~ unless parents have advised the LEA that-~ they do not want their student's information disclosed without their prior writter consent, 1 If you do not want the Smith County School System to disclose directory information from your + child’s education records without your prior written consent, you must notify the District in writing by Friday, September 2, 2016, Smith County School System has designated the . «~~ -followiag-information.as directory information... he HO GO cans A ba OMIA gs. HEE He [Stident’s nae i) ius J ebdya tplibeapation in otfietalipa nis wom. f “Address recognized activities and sports “Telephone listing Weight and height of members of “Blectronic mail address athletic teams “Photograph “Degrees, honors, and awards “Date and place of birth received ‘Major fild of study The most recent educational “Dates of attendance agency or institution Grade level attended | These laws are: Section 9528 of the ESEA (20 U.S.C. 7908), as amended by the No Child Left Behind Act of 200) (P.L, 107-110), the education bill, ancl 10 U.8.C. 503, as amended by section 544, the National Defense Authorization Act for Fiscal Yoar 2002 (P.L. 107-107), the legislation that provides funding fer the Nation’s armed forces.Smith County Schools Parent Information Under the Elementary and Secondary Education Act (ESEA) Do not return to school. No signature required. ‘The Smith County School System is committed to providing the best education possible for each student, We realize that parents play a vital role in the accomplishment of this mission so we encourage their involvement and strive to keep them informed of their rights, ‘The Elementary and Secondary Education Act (BSBA) makes it clear that Congress expects Local Ediicational Agencies (LEAs) and schools réveiving federal funis to onsure that parents are actively involved and knowledgeable about their schools and their children’s eduoation. The law requires schools 7 to give parents many different kinds of information and notices inva uniform and understandable format . ‘and, to the extent practicable, in a language thet the parents can understand, Listed below are some of these required notices that must be made to parents by schoo! districts or individual publie schools. * Smiti County Schoo! System does not discriminate on the basis of race, sex, color, national origin, age, religion, or handicap in the provision of educational opportunities, activities, or other administered programs. © A parental involvement policy and parert-teacher-student compact will be distributed to parents by. each Title I school, A copy of cach document may also be obtained by contacting the schoo! offic. in schools eligible for Title I funds, a written parental involvement policy will be developed jointly with and distributed to parents of children participating in Title T programs. Each Title J school will also hold at least one annual meeting for parents to inform them of the schoo!?s participation in programs funded under the BSEA. All eleinentary and middle schools in Smith County are identified agsehgolewide Title] Schools: ‘© Parents have the right to request information regarding the professional qualifications of classroom teachers who instruct their children, If students are provided services by paraprofessionals, parents ‘may also request inforthation regarding the qualifications of paraprofessionals. Teacher certifications can be found by accessing the Tennessee Department of Education Teacher Licensing website or by contacting the school principal or the schoo! system’s federal projects director. © Parents must receive notifieation if their child has been assigned or has been taught for four or more consecutive wooks by a teacher who is not highly qualified. ‘+ Parents will be notified of their child’s eligibility for service in the migrant or homeless program, * Parcnts will have access fo systom andl school report cards as developed by the State Department of Education (usaally available in late fall of each’ year) through the website (www.state.tn.usfeducation) or at the school and/or system office. Results will also be publicized through iocal media.{Students dismissed 10:00 AM, Teachers Dismissed at 10:18) August 3 2048; ‘Deoember 162016 ° + ‘May 26" 2017 ! 179° “Stidont Bays SB Spring rs 41 Professional Development ¥4'= Student Heif Day 2. Scheduled inSenicss IS = Required InService 3. OstionalinServce Das Mg= Mid 9 Week Report ce 20° Holidays ES = End § Weeks 4 Adninistrtive Days Re = Report Card 2 8 4 QB <1 PLCanference 55 oprate 18 0m 2 200. Days ‘ofessionst Devereprmen git |su:Ko: TW We Theor, 12348 Teowmug | Required In-Service Days (81 ‘August 48 & 42016 ‘Aaministtasive Days (8:00 ~ 3:00) August 2m & 52026 January 32017 May 25 2017 Professional Davelanmant Day (No Schoo! for Students) Employees Report 7:45 - 3:15 Nov. 82016 Octoder 13% 2016 (3:15 - 8:18) October 26 2036 (3:15 ~ 4:15) By Appointment Only Smith County Schools 2016/17