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Lauderdale County Schools



Student: _____________________________________________
School: ______________________________________________ Grade: ______

All Parents\Guardians and students in the Lauderdale County School System must acknowledge by
signing this form that they have access to, and responsibility for the following items:
• An awareness and understanding of the contents of the School System Parent\Student
Handbook found online at www.lcschools.org.
• An awareness and understanding of all local school policies.
• An awareness that parents\guardians may view their child’s student information online.
Information such as grades, schedule, and attendance may be viewed by obtaining a password
from the local school.
• That permission is given for the student to participate in the system-wide 1 to 1 mobile device
program including having access to networked educational computer applications.
• That parent\guardians are financially responsible for lost\damaged textbooks, library books,
school equipment and mobile devices.
• That permission is given to use the child’s photograph, video image, and photographic likeness
for school purposes including videotapes, yearbook, social media and advertisements. (You
may send a letter to the school principal if you do not want your child photographed for school

Student Signature: ______________________________________________

Parent\Guardian Signature: _______________________________________
Date: ______________

Student Residency Questionnaire

Name of School __________________________

Name of Student _____________________________________________ Sex: □ Male

Last First MI □ Female

Birth Date _____/_____/_____ Age _____ Grade _____


This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to
this residency information help determine services the student may be eligible to receive. Information
provided on this form is confidential.

Check the following living situation that applies to the student named above:

_____ Living in own home, rented home, or apartment

_____ Living with friends or relatives temporarily due to loss of housing or economic

_____ Living in a shelter (emergency/transitional)

_____ Living in a hotel/motel/campground or other similar situation

_____ Unaccompanied youth (alone with no adult)

_____ Other (Please explain)_____________________________________________

The undersigned certifies that the information provided above is accurate.

Printed name of parent/guardian/unaccompanied youth

______________________________ Date _______________

Signature of parent/guardian/unaccompanied youth

* Please
return this completed form to your school or the Lauderdale County Board of Education office located at 355
County Road 61 Florence, Alabama 35634, Attention: Homeless Coordinator.

Lauderdale Co School District


Student Name: ____________________________________________ Birth Date: ___________________ Sex: ❏ Male ❏ Female

Parent/Guardian Name: ________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Home Telephone: __________________________________________ Work Telephone: ____________________________________

School: __________________________________________________ Grade: ______________________ Date: ________________

1. Was your child born in the United States? ❏ Yes ❏ No

If yes, in which state? ___________________________________
If no, in what other country? ___________________________________

2. Has your child attended any school in the United States

for any three years during their lifetime? ❏ Yes ❏ No
If yes, please provide school name(s), state, and dates attended:
Name of School ____________________________________________ State ________ Dates Attended________________
Name of School ____________________________________________ State ________ Dates Attended________________
Name of School ____________________________________________ State ________ Dates Attended________________

3. What language is spoken by you and your family most of the time at home? ___________________________________

4. If available, in what language would you prefer to receive

communication from the school? ___________________________________

5. Please check if your child is:

A. ❏ Native American Indian C. ❏ Native Pacific Islander
B. ❏ Alaska Native D. ❏ Native U.S. Virgin Islander

6. Is your child’s first-learned or home language anything other than English? ❏ Yes ❏ No

If you responded “Yes” to question number 6 above, please answer the following questions:

7. What language did your child learn when he/she first began to talk? ___________________________________

8. What language does your child most frequently speak at home? ___________________________________

9. What language do you most frequently speak to your child? (Father) ___________________________________

(Mother) ___________________________________

10. Please describe the language understood by your child. (Check only one)
A. ❏ Understands only the home language and no English.
B. ❏ Understands mostly the home language and some English.
C. ❏ Understands the home language and English equally.
D. ❏ Understands mostly English and some of the home language.
E. ❏ Understands only English.

______________________________________________ ___________________________________
Parent or Guardian's Signature Date


Student ID # Date Distributed Date Received

00NCLB-B1a (Rev. 05/08 US) © 2008 TransACT Communications, Inc.



School Year: _ _____

_ __ _

To Parent or Guardian:
The purpose of this form is to provide the school nurse with additional information regarding your child's health needs The school nurse may contact you for
further information The information requested is essential for the school nurse to meet the health needs of your child

This information will be kept confidential.

PLEASE complete both sides of this form (Return to the School Nurse)

Name of Student (Last, First, Middle) Birth Date Sex School

Address (Street)

Home Telephone Number: Cell Phone Number: Additional Phone Number: Grade Teacher/Homeroom

Name of ParenUGuardian (Last, First Middle) Work Phone Number:

D Bus Rider Bus Number: D Car Rider D Special Needs Bus D After School

Part I - Health Information

Place your child receives health care: Your child's Insurance Information: Place your child receives dental care:

Physician's Name: ______ 0 ALL KIDS Dentist's Name: ___ __

_ _

Address: _________ D Medicaid Address:___ ____

_ _

Phone:_________ _ D No Insurance Phone:____ ____

_ _
D Community tiealth Center D Other _ __ D Community Health Center
D Health Department D Private Insurance D Health Department
D Hospital Clinic D Hospital Clinic
D No Regular Place D No Regular Place
D Private Doctor /HMO D Private Dentist /HMO

Preferred Hospital: ___________

Part II - Medical History Medical Equipment /Procedures Required at School

o Catheter o Gastric Tube o Nebulizer Treatments o Oxygen Supplement o Tracheostomy

o Vagal Nerve Stimulator (VNS) o Ventilator o Wheelchair o Walker

o Other Please exolain.

Medications and Procedures at School require a Prescriber/Parent Authorization Form (one for each medication or
procedure) Please see your school nurse.

Please Complete Back of Form (Signature Required)

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Rev 5-2014
re,;)>--_... _.-•.. _-,,.,\

Part Ill - Medical History

If NO, go directly to the bottom of the page and provide parenUguardian signature
If YES, and diagnosed by a physician, answer each question below.
o YESo NO Attention Deficit Disorder (ADD)
o YESo NO Attention Deficit Hyperactivity Disorder (ADHD)
Requires medication o At school o At Home
o YESo NO Allergies: o Hives/rash o Medications
o Food
o Insects o Breathing difficulty o Epi-pen
o Environmental
o Medications o Other:
o YESo NO Asthma o Uses an inhaler at school o Uses an inhaler at home

o YESo NO Blood/Bleeding Problems: oHemophilia, oVon Willebrand's, oOther

o Requires medication Please explain:

o YESo NO Frequent Nose Bleeds: Please explain

o YESo NO Cancer/Leukemia: Please explain
o YESo NO Cerebral Palsy: Please explain
o YESo NO Cvstic Fibrosis: Please explain
o YESo NO Dental Problems: Please explain:
o YESo NO Diabeteso Type 1 Diabetes o Monitors Blood Sugars at school o Requires Insulin at school
o Insulin pump
o Glucagon order
o Type 2 Diabetes o Managed with diet o Oral medication

o YESo NO Emotional/Behavioral/Psvchological: Please explain:

o YESo NO Gastrointestinal/Stomach Problems: Please exalain:
o YESo NO Genetic I Rare Disorders: Please explain:
o YESo NO Headaches: Please exalain:
o YESo NO Hearing Problems: o Right Ear o Left Ear o Both ears o Hearing loss o Hearing aid
o Tubes o Cochlear Implant
o YESo NO Heart Condition: o Activity restrictions: o Medications taken at home.:
Please explain.
D YES D NO Hvaertension IHiah Blood Pressure): Please exalain:
o YESo NO Juvenile Arthritis/Bone-Joint Problems: Please exalain:
o YESo NO Kidney/ Bladder/ Urinary Problems: Please explain:
o YESo NO Scoliosis: o No Treatment o Wears Brace o Surgerv o Familv Historv
o YESo NO Seizures/Convulsions: Type of seizure:
Medications o Diastat o Klonopin o Versed o Medication taken at home o Other
Please exalain:
DYES D NO Sickle Cell: o Anemia 0 Trait
0 YES D NO Shunt: o VP shunt Please explain:
DYES D NO Spina Bifida:
o YES o NO Special Diet: Please explain:
o YESo NO Vision Problems: o Wears glasses o Wears contacts o Other
o YESo NO Other Medical Conditions: Please include anv medications tal<en at home only.
Required Signatures

Signature of parent(s) or guardian:__________________

. Date : __________

Signature of school nurse: Date:

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Rev 5.2014