2011-2012 Scholar Registration Packet
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
2011-2012 Scholar Registration Packet
Congratulations on your successful acceptance into the Amani Public Charter School!
To ensure your child’s successful registration,
please review and complete the enclosed forms by the listed deadline.
You may return completed forms to:
Amani Public Charter School
P.O. Box 3022
Mount Vernon, NY 10553
If you have any questions, please contact our Office Manager, Ms. Parker,
at aparker@amanicharter.org or (914) 610-4900.
Thank you in advance, and welcome to our community!
DOCUMENT DUE DATE
1. Contact and Emergency Information Form
2. School-Scholar-Family Accountability Covenant
3. Release of Information Form
4. Media Release and Scholar Displays
5. General Field Trip Permission Form Saturday, June 25, 2011
6. Scholar and Family Information Survey
7. Residency Questionnaire (McKinney-Vento)
8. Home Language Survey
9. Free and Reduced Price Lunch Questionnaire
10. Medical Requirements:
• Physician’s Health Certificate
• Immunization Record
• MVCSD Annual Health and Emergency
Information Form
• Parent and Presriber’s Authorization for Monday, August 15, 2011
Administration of Medication in School Form
• Self-Medication Release From
• BMI Information Release Form
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Contact & Emergency Information
______________________________________________________ ___________________
Scholar Last Name First MI Grade 2011-2012
___________________________________ _____________________________________
Name of Parent/Guardian 1 Name of Parent/Guardian 2
___________________________________ _____________________________________
Parent/Guardian 1 relationship to child Parent/Guardian 2 relationship to child
___________________________________ _____________________________________
Parent/Guardian 1 home phone number Parent/Guardian 2 home phone number
___________________________________ _____________________________________
Parent/Guardian 1 work phone number Parent/Guardian 2 work phone number
___________________________________ _____________________________________
Parent/Guardian 1 mobile phone number Parent/Guardian 2 mobile phone number
___________________________________ _____________________________________
Parent/Guardian 1 e-mail address Parent/Guardian 2 e-mail address
Child’s Primary Residence: Other Parent/Guardian Residence:
___________________________________ _____________________________________
Street Address Street Address
___________________________________ _____________________________________
City, State Zip City, State Zip
Other Emergency Contacts
___________________________________ _____________________________________
Name & Relationship to Child Name & Relationship to Child
___________________________________ _____________________________________
Above person’s contact number(s) Above person’s contact number(s)
Please list below the people who have permission to pick up your child from school. If a person
who is not listed will be picking up your child, you must notify the school office.
___________________________________ _____________________________________
Name & Relationship to Child Name & Relationship to Child
___________________________________ _____________________________________
Name & Relationship to Child Name & Relationship to Child
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Amani Public Charter School—Scholar—Family Accountability Covenant
2011-2012
When you joined the Amani Public Charter School community, you joined a team. The goal of this team is getting our
scholars/children the education they deserve. To achieve our goal, we must work together. We all need to have a full and clear
understanding of the responsibilities of the members of this team. This contract spells out many of the most important
responsibilities.
School Commitment
HIGH QUALITY EDUCATION
1. We will work tirelessly to ensure that our scholars get the excellent education they deserve. We will neither make nor
accept excuses.
2. We will work longer school day, longer school year, offer scholars extra help and support, and always offer our
scholars the best we have.
RESPECT and FAIRNESS
3. We will encourage and respect every scholar. We will listen to scholars and their needs. We will not tolerate scholars
disrespecting each other.
4. We will teach and enforce Character Counts values consistently and fairly. We will communicate with families when
scholars fail to meet expectations just as when they exceed expectations. Decisions, including consequences, will be
made in the best interest of our scholars.
5. We will give scholars recognition, incentives and privileges if they do well and give consequences and remove
privileges if they do not.
COMMUNICATION
6. We will communicate regularly with families about their child’s progress and make ourselves available in person and
on the phone.
7. We will return parent phone calls as soon as possible, usually within 24 hours.
HOMEWORK and ACADEMIC SUPPORT
8. We will assign quality homework every night to reinforce and support skills and concepts learned in class.
9. We will support scholars with excellent teaching and additional help during the school day and after/before school as
needed.
SAFETY
10. We will always work to provide a safe learning environment. We will always work to protect the safety, dignity and
rights of all individuals.
Parent/Guardian Commitment
ATTENDANCE and PROMOTION
1. I will ensure that my child comes to school every day at 7:30am if they eat breakfast or 7:45am to be able to begin the
day’s activities.
2. I will not schedule family vacations during school time. I will do my best to schedule important appointments for out
of school time.
3. I will make alternative transportation plans if my child is required to stay at school until 5:15 (Monday-Thursday) for
tutoring or homework club.
4. After school commitments are mandatory. My child will only be excused in case of an emergency, a maximum of one
time per quarter.
5. I understand that my child will be automatically retained if he/she fails 2 or more core academic classes, or is absent
for more than 10 days of the school year. If my child fails 1 class, he/she must successfully complete our summer
program and pass the exam in order to be promoted.
HOMEWORK and ACADEMIC SUPPORT
6. I will provide a quiet place to study and see that my scholar completes around 2 hours of homework or more and 20
minutes reading nightly.
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
7. I will check my child’s planner and homework every night. If, and only if, APCS standards have been met, I will sign
my child’s planner.
8. I will help my child study for tests and quizzes and give them support when they need help and praise when they do
well.
9. I will arrange for my scholar to be at Saturday Academy if assigned by my scholar’s teacher or teachers.
BEHAVIOR and DRESS CODE
10. I understand that my child will serve Administrative Consequences on Monday 4:00pm – 5:00pm if his/her weekly
Paycheck is below $30. I further understand that my scholar will receive Homework Club for three missing homework
assignments in any one-week.
11. I understand that my child will be In-Class Suspended or Out-of-School Suspended if they violate the code of
conduct.
12. If scholar behavior requires it, I will come to school immediately. If Out-of School Suspended, I will remove my child
from the building.
13. I understand that my child may be recommended for an expulsion hearing if they earn more than 3 suspensions.
14. I will send my child in proper dress code everyday. If my child arrives out of uniform, I’ll arrange for a family member
to bring proper attire.
FAMILY SUPPORT and COMMUNICATION
15. I agree to work to as part of a team for the academic success and behavioral growth of my child. I will return phone
calls, review and sign documentation sent home including progress reports and Paycheck Reports. I will attend parent-
teacher conferences and meetings about my child.
Scholar Commitment
EFFORT and HELP
1. I understand that my education is paramount. Being a scholar is my job. I will always work, think and behave in the
best way I know how.
2. I will do whatever it takes for my fellow scholars and me to learn. I will do all homework. I will work to exceed the
school’s expectations.
3. If I need help, I will ask for it. If I can give help, I will give it. I won’t criticize other scholars.
ATTENDANCE and UNIFORM
4. I will come to school and ready to learn by 7:45am in order to complete my morning responsibilities.
5. If I need to miss class or school, I will ask for and make up all assignments. I will stay after school if/ when I am
required to do so.
6. I will wear the proper uniform everyday and remain in uniform throughout the day.
COMMUNICATION
7. I will listen to directions. I will read and re-read directions before asking for help. If I cannot solve the problem
myself, I will raise my hand and ask for help. I will help my classmates if they need help. I will not make excuses. I will
be honest with my teachers and myself.
RESPONSIBILITY and HONESTY
8. If I make a mistake, I will tell the truth and accept responsibility for my actions. I will do the right thing, even when no
one is watching.
PAYCHECK EXPECTATIONS
9. I will respect my teachers, my peers and myself. I will refrain from all disrespectful behavior including smacking teeth,
rolling eyes, etc.
10. I understand our Paycheck expectations. I will follow the school rules to protect they safety and rights of all
individuals and not detract from the educational opportunities of others. I’ll accept the consequences if I don’t meet
our Paycheck expectations.
Scholar Signature Date
Parent Signature Date
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Release of Information
2011-2012
______________________________________________________
Scholar Last Name First MI
I hereby authorize the Amani Public Charter School to share and/or request any and all records, data or
information determined to be relevant to the education of my child, the above-named scholar, within the
Mount Vernon City School District, the New York State Education Department, any other schools and
school systems in which my child has previously been enrolled, and any governmental departments, health
or social service providers or other offices whose activities bear directly on the programs or services with
which my child is provided at the Amani Public Charter School. I understand that all such information
will be kept strictly confidential.
Parent/Guardian Name: ___________________________________________________________
Parent/Guardian Signature: ___________________________________ Date: ______________
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Media Release and Scholar Displays
2011-2012
I give permission for the Amani Public Charter School to record, film, photograph, interview and/or
publicly exhibit, display, distribute or publish my child’s name, appearance and spoken words during the
2011-2012 school year, whether undertaken by school staff, scholars or anyone outside the school,
including the media. I agree that the school may use, or allow others to use, those works without
limitation or compensation. I release the Amani Public Charter School staff from any claims arising out of
my child’s appearance or participation in these works.
______________________________________________
Scholar’s Name
______________________________________________
Name of Parent/Guardian (please print)
______________________________________________ _________________________
Signature of Parent/Guardian Date
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
General Field Trip Permission Form
2011-2012
Please complete the form below to give your child permission to participate in school-sponsored field
trips during the 2011-2012 academic year. You will be notified of each field trip off school-grounds in
advance, and will be asked to sign additional permission slips for specific trips. This form is required in
order for your child to participate in physical education classes, which will take place at a site adjacent to
the school grounds.
I give my child, ______________________________________________, permission to attend field
trips as a component of the Amani Public Charter School program during the 2011-2012 academic year. I
understand that all field trips will be planned and chaperoned by Amani Public Charter School staff, with
additional parent chaperones as need to ensure proper supervision of all attending scholars. I understand
that my child may travel during field trips on public transportation, by chartered bus, or with my
permission in a chaperone’s private vehicle. I will communicate with my child’s teacher regarding any
questions or concerns about field trips that are planned for my child.
________________________________________________
Name of Parent/Guardian
________________________________________________ _____________________
Signature of Parent/Guardian Date
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Scholar and Family Information Survey
At Amani Public Charter School, we are committed to creating a safe academic environment where all
children will succeed in meeting the school’s high standards. We understand that in order to best assist all
scholars, communication lines between the school and families must always remain open. To start that
dialogue, we request your candid responses to the following questions. Your answers will help us create
learning environments that will most accurately match the needs of your child and his/her classmates. We
know that middle school children rapidly mature academically, physically and emotionally. Therefore, the
more we know about your child’s past and present experiences, the more we can help your child
successfully start off the new year.
Scholar Personal Background
Please check the general racial category that most clearly reflects the scholar’s recognition of his/her
community or with which the scholar most identifies:
_____ American Indian or Alaskan Native – A person having origins in any of the original peoples of North America, and
who maintains cultural identification through tribal affiliation or community attachment.
_____ Asian or Pacific Islander – A person having origins in any of the original peoples of the Far East, Southeast Asia,
the Indian subcontinent or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the
Philippine Islands, and Samoa.
_____ Black – A person having origins in any of the black racial groups of Africa.
_____ White – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
_____ Hispanic – A person of Mexican, Puerto Rican, Cuban, Central, South American or other Spanish culture or origin,
regardless of race.
What is the primary language spoken at home? (Check one)
_____ English _____ Spanish _____English and Spanish equally _____ Other (specify)_________
Scholar Services
Yes No Not
Sure
Is your child currently eligible for free or reduced-priced lunch at school?
Is your child currently enrolled in a bilingual program?
Has your child been screened for Special Education?
Has your child ever received Special Education services?
Does your child currently have an Individualized Education Plan (IEP)?
Does your child currently receive special services in school?
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
If your child receives special services, please explain what they are:
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________
Does your child have any medical, learning, physical or other special needs of which we should be
aware?
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________
Is there any other information you think would be helpful for us to have about your child?
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________
Parent/Guardian Educational Background
What is the highest level of education the scholar’s mother/female guardian has obtained?
(Check One)
___Did not complete high school ___Attended some four-year college
___Graduated from High School/GED ___Graduated from four-year college
___Attended some two-year college ___Attended some advanced-degree program
___Graduated from two-year college ___Graduated from advanced-degree program
What is the highest level of education the scholar’s father/male guardian has obtained?
(Check One)
___Did not complete high school ___Attended some four-year college
___Graduated from High School/GED ___Graduated from four-year college
___Attended some two-year college ___Attended some advanced-degree program
___Graduated from two-year college ___Graduated from advanced-degree program
Parent/Guardian Statement
I certify that the information above is true and understand that false statements may be grounds for
dismissal of my child from the Amani Public Charter School. I will inform Amani Public Charter School
administrators of changes to the information listed above.
_____________________________________ _____________________________________ ___________________
Parent/Guardian Name Parent/Guardian Signature Date
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Address
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575!
www.amanicharter.org
"#$!%$&!'()*!+,-.!/$01)-2$3-!(4!56781-,(3!
Home Language Survey
91)$3-:;71)6,13!71>$!?6$3-,4,81-,(3!@7)A$.
!
(English)
!
%"(+%+?!).!+@$+@%!!
! "-$0"1)?"-$,-",@@/%0&!"A(",')-$0*"/,'26,20"%&"6&0P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900 !
"#$!%$&!'()*!+,-.!/$01)-2$3-!(4!56781-,(3! fax: (914) 798-2575
www.amanicharter.org
91)$3-:;71)6,13!71>$!?6$3-,4,81-,(3!@7)A$.
!"!"#$%!&$'()$(*!+,!,-./*'!+'!%#*!0#+&12,!#.3*!.4!4*,+1*'0*!!"#$%"&%$'(%$)!(5!
6'(&+,#!!!!! 7%#*4!!!8!
#"!"#$%!&$'()$(*!1.*,!%#*!0#+&1!,-*$/!9+%#!-$4*'%,:()$41+$',!!"#$%"&%$'(%$)!(5!
6'(&+,#!!!!! 7%#*4!!!8!
$"!"#$%!&$'()$(*!1.*,!%#*!0#+&1!,-*$/!9+%#!;4.%#*4,*,!.4!0$4*(+>*4,!?*@(@*!
Q.33)'+0$%+.'!L*>+0*!?*@(@P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Home Language Survey
!"#$%&$'"(&)*+"*,+-.$./0(*+"*1$*2/-+$+*+"*3-"4$*5)%6*7*89"*3":*5)%6*2/&;*!"#$%&'"(&*)!2&#$!&'$/*E&/I/*]#!'%+/!%'.!$&$2/!
5)&*+,1#%617!,;*+,#%61!)+'47!4,5$-+'!)1!,4!)03,$%?)!(,!&'1$,1,+4)! L'!IH%$!2%'?4%?/Q!
%1@)+&'()7!$'&0%91!1,5,#%$'&)#!#'0,+! L(!%'!&'$/*5*/$/*!&#!5*)E&./.>!2&#$!'%+/!%'.!
,1!8-9!%(%)&'!(,#,'!-#$,(!+,5%0%+!4'! 5)#&$&)'R*/2%$&)'#H&5U!
%1@)+&'5%61!%&*)+$'1$,!8-,!4,!,1?A'!4'! L#!$H/!&'$/*5*/$/*!$*%&'/.R34%2&(&/.!8/B?B>!J&2&'?4%2!$/%,H/*>!
G*%'#2%$&)'!a!L'$/*5*/$%$&)'!b'&$!#$%((AQ!!c/#!!!!!!!X)!!!!
,#5-,4'=!B*+,5%'+,&)#!&-52)!4'!'!5)*!(%E)*!/#5/,&(F34/2)!/'!
&'?2@#B!
GH&#!&'()*+%$&)'!I&22!/#$%J2&#H!/2&?&J&2&$K!()*!$H/!"'?2&#H!9%'?4%?/!:##/##+/'$!;%$$/*KCDE@AQ!
L'?2@#!R!"'?2&#H!!! "#5%P)2!R!D5%'&#H!!! T$*)!R!T$H/*!!U!
VB) NO4@!&.&)+%!FEGHE!/2!'&P)Q!R!SH%$!2%'?4%?/!.)/#!$H/!,H&2.!C=?EIQ!
L'?2@#!R!"'?2&#H!!! "#5%P)2!R!D5%'&#H!!! T$*)!R!T$H/*!!U!
WB) NO4@!&.&)+%!H??!/2!'&P)Q!R!SH%$!2%'?4%?/!.)/#!$H/!,H&2.!>?EAQ!
L'?2@#!R!"'?2&#H!!! "#5%P)2!R!D5%'&#H!!! T$*)!R!T$H/*!!U! X)!2//!R!Y)/#!')$!*/%.!!!
ZB) N"'!34@!&.&)+%!?C:>JG?!/2!'&P)Q!R!SH%$!2%'?4%?/!.)/#!$H/!,H&2.!K>JD?Q!
L'?2@#!R!"'?2&#H!!! "#5%P)2!R!D5%'&#H!!! T$*)!R!T$H/*!!U! X)!/#,*&J/!R!Y)/#!')$!I*&$/!!)
[B) NO4@!&.&)+%!#/!H%J2%!/'!/2!H)?%*!)!*/#&./',&%!./2!'&P)!:;@&&M>?:B?@:JEQ!
SH%$!2%'?4%?/!&#!#5)\/'!&'!$H/!,H&2.]#!H)+/!)*!*/#&./',/!P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
!"#$%&$'"(&)*+"*,+-.$./0(*+"*1$*2/-+$+*+"*3-"4$*5)%6*7*89"*3":*5)%6*2/&;*!"#$%&'"(&*)&S25& !&T,&>&T,&
].5&8/2&4/*1+&.882%+2+&54/,,1&*%&.%,8/27&4,(%87J9&
& ?:&KU&O$?VQ$?WU&$?&UZ:O_UW:YUA&>&:Z&S$?A&
& #[N%+2&52&2%4,%87.0.&1.&254(21.&.&1.&'(2&.5*58R.9&
\/272&+*+&/2>5/2&&:Z&S$?A&\/.8&1.%P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Free and Reduced Price Meal Information
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Medical Requirements Checklist
2011-2012
In order to keep your scholar’s health records up to date and to provide proper health services, your
scholar will need a Physical Examination by your family physician. Use the following checklist to ensure
you have completed all the required medical documents.
Have your physician conduct a Physical Examination of your scholar. Please be sure your physician
includes:
________ 1) Annual Health and Emergency Information Form
________ 2) Fully Completed Physician’s Health Certificate (attached)
________ 3) Complete Immunization Record, with doctor’s stamp (see required immunizations)
________ 4) Parent and Prescriber’s Authorization for Administration of Medication in School
Form. Your physician will need to sign this form.
________ 5) Self-Medication Release Form (if applicable). Your physician will need to sign this form.
________ 6) Body Mass Index Reporting Exclusion (optional)
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Immunization Requirements
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Parent and Prescriber’s Authorization for
Administration of Medication in School
A. To be completed by the parent or guardian:
I request that my child, _________________________________ grade _______ receive the medication
as prescribed below by our licensed health care provider. The medication is to be furnished by me in the
properly labeled original container from the pharmacy. I understand that the school nurse or other
assigned person will administer the medication.
Parent/Guardian Name (print): ______________________________________________________
Parent/Guardian Signature: _____________________________________ Date: ______________
Home Telephone: ________________________ Work Telephone: _______________________
B. To be completed by the licensed health care provider:
I request that my patient, as listed below, receive the following medication.
Name of scholar: ________________________________________ DOB: ______________
Diagnosis: ______________________________________________________________________
Name of Medication: ______________________________________________________________
Prescribed Dosage, Frequency and Route of Administration:
_______________________________________________________________________________
Time to be taken during school hours: _________________________________________________
Duration of treatment: _____________________________________________________________
Possible Side Effects and Adverse Reaction (if any): ______________________________________
_______________________________________________________________________________
Other Recommendations: __________________________________________________________
Name of Licensed Prescriber and Title (print): ___________________________________________
Prescriber’s Signature _______________________________________ Date: ______________
Address: ____________________________________ Phone: _________________________
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Self-Medication Release Form
Date __________________________________
(Child’s Name) ____________________________________________________________________
has been instructed in the proper use of the following medication procedures:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
We (physician’s signature) ____________________________________________________________
and (parent’s signature) ______________________________________________________________
request that (child’s name) ____________________________________________________________
be permitted to carry the medication on his/her person or to keep same in his her personal belongings as
we consider him/her responsible. He/she has been instructed and understands the purpose and
appropriate method and frequency of use.
Note: This form must be completed in addition to routine district medication form for those students
who request permission to carry their own medication on campus or keep this medication in a school
storage unit.
To educate and inspire; to uplift and transform. Every scholar. Every year.P.O. Box 3022
Mount Vernon, New York 10553
ph: (914) 610-4900
fax: (914) 798-2575
www.amanicharter.org
Body Mass Index
Reporting Exclusion (Optional)
To educate and inspire; to uplift and transform. Every scholar. Every year.You can also read
