Select Sample Forms and Documents
from Lifeline: A Handbook for Small School Success. North American Division Office of Education. 2011
The sample forms and documents listed below are found on the pages that follow. There are no page numbers to allow customization of the online forms for your school. The documents are in alphabetical order and in Word format.
Acceleration Request
Acceptable Use Policy
Application for Admission
Budget
Consent to Treatment
Daily Schedule Analysis
Field Trip and Outing Planner
Field Trip Permission Form
Financial Agreement
Incident Report Form
Lesson Plans
Medication Authorization and Administration Form
Over-the-Counter Medication Permission to Administer Form
Parent Release Form for Students with Special Academic Needs
Photo Release
Release of Student Records (transferring students)
Retention Request
Room Parent Request
School Handbook
Student Led Conference Narrative Form
Unit Plans
Yearly Plans
Acceleration Request
(See Union Education Code Book for complete instructions)
Student Name / Birthdate / Present GradePresent Age (Years/Months) / Age When Entered 1st Grade (Years/Months)
1. Reason for acceleration:
2. Last achievement test administered:
Date administered:
Composite Grade Equivalent:
Composite Percentile:
A student is expected to have 90th percentile or above in each sub-test.
Attach copy of student’s Individual Performance Profile.
3. Teacher evaluation of daily work, tests, etc.:
4. Teacher evaluation of present social and emotional development:
Acceleration Request – Page 2
5. Survey of past history in school:
6. Teacher evaluation of physical development:
7. Report of communication with parents (include dates, parents’ reactions, etc.):
8. Recommendation of teacher:
9. Brief summary of suggested acceleration program:
Teacher’s Signature Date / Principal’s Signature DateWe have discussed our child’s academic achievements with the classroom teacher and understand that this is not to be interpreted as “skipping a grade,” since all levels of academic work are to be covered. We support the placement of our child in an accelerated program, understanding that such a placement is subject to approval by the Conference Office of Education and the school leadership.
Parent or Guardian Signature Date / Parent or Guardian Signature Date
Education Committee Action: / Approved / Denied
Date / Superintendent’s Signature
Acceptable Use Policy
Information Technology Resources
Anytown Adventist School
The Anytown Seventh-day Adventist School is pleased to offer students access to the school’s information technology resources, including the computer and Internet, for educational purposes. To gain access to these resources, the legal parent/guardian and student must sign and return this form to the school.
The Internet is a powerful resource for expanding the educational experience of each student. Access to the Internet will enable students to explore thousands of libraries, databases, and bulletin boards while exchanging messages with internet users throughout the world. Unfortunately, it is true that some materials accessible via the Internet may contain items that are illegal, defamatory, inaccurate, or offensive. We believe, however, that the benefits to students in the form of information resources and opportunities for collaboration exceed any disadvantages and, therefore, choose to make the Internet available to our students. But because parents and guardians are ultimately responsible for setting and conveying the standards that their children should follow when using media and information sources, we respect each family’s right to decide whether or not to apply for access.
The school’s information technology resources are for educational purposes only. Since they are provided for students to conduct research and communicate with others, access is given to students who agree to act in a considerate and responsible manner. Parental permission is required. Access is a privilege—not a right. Access entails responsibility. School staff may review files and communications to maintain system integrity and ensure that users are using the system responsibly.
Students will adhere to Christian principles and will:
· Respect and safeguard the privacy of themselves and others.
o Use only assigned accounts.
o Not view, use, or copy passwords, data, or networks to which they are not authorized.
o Not share private information about others or themselves.
· Respect and safeguard the integrity, availability, and security of all electronic resources.
o Observe all posted security practices.
o Report security risks or violations to a teacher.
o Not destroy or damage data, networks, or other resources that do not belong to them, without clear permission of the owner.
o Conserve, protect, and share these resources with other students and internet users.
· Respect and safeguard the intellectual property of others.
o Not infringe copyrights.
o Not plagiarize.
· Respect and practice the principles of community.
o Communicate only in ways that are kind and respectful.
o Report threatening or discomforting materials to the teacher.
o Not intentionally access, transmit, copy, or create materials that violate Christian principles or that are illegal (such as messages that are threatening, rude, discriminatory, harassing, stolen, illegal copies of copyrighted works, etc.).
o Not use the resources to further other acts that are criminal or violate the school’s principles.
o Not send spam, chain letters, or other mass unsolicited mailings.
o Not buy, sell, advertise, or otherwise conduct business, unless approved as a school project.
Acceptable Use Policy – Page 2
Violations of these rules may result in a loss of a student’s privileges to use the school’s information technology resources, as well as other disciplinary or legal action.
School administrators and other authorized individuals monitor the use of information technology resources to help confirm that uses are secure and in conformity with this policy. Administrators reserve the right to examine, use, and disclose any data found on the school’s information technology resources in order to further safeguard the health, safety, discipline, or security of any student or other person, or to protect property. They may also use this information in disciplinary actions, and will furnish evidence of crime to law enforcement.
Your signature below affirms your understanding of, and agreement to abide by, this Acceptable Use Policy. Any violation of the standard as set forth herein may result in the immediate termination of the student’s access to the school’s information technology resources and/or other disciplinary action.
Student Name (please print) / Student Signature / Grade / DateParent/Guardian Name (please print) / Parent/Guardian Signature / Date
Application for Admission
Anytown Adventist School
Today’s DateChild’s Full Legal Name:
Last / First / MiddleGrade Entering / Gender / Child’s NAD Student ID / Place of Birth / Date of SDA Baptism
/ /
Month/Day/Year
Date of Birth / /
Years/Months
Age / Ethnic Origin
(For Federal Government and North American Division purposes only)
Family Information:
Legal name of parent or guardian with whom the student is living: / Father / MotherHome Address
City, State/
Province, Zip
Phone and
Email / Home / Business / Home / Business
Mobile / Email / Mobile / Email
Occupation
Church Membership / Denomination/Church / Denomination/Church
Brothers and Sisters / Full Name / Birth Date
Initial / In case of emergency, accident, or serious illness, if the school is unable to contact me, I hereby authorize the school to take my child to the physician, emergency room, and/or to the relative or neighbor indicated.
Doctor’s name / Phone / Address
Relative’s or Neighbor’s Name / Phone / Address
Application for Admission – Page 2
References: Please give two (2) references (pastor, friend, neighbor, nonrelative, etc.):Reference #1 (Name, Address, Phone)
Reference #2 (Name, Address, Phone)
Please initial each line below:
I agree to meet my monthly financial obligations to the school.I agree to cooperate with the school board and teachers by avoiding adverse criticism of any teacher or school policy in the presence of the students.
I have read the school handbook and agree to support each regulation of the school.
I hereby authorize the school board to send, upon request, the permanent records to the next school to which my child may enroll.
Signature of Parent or Legal Guardian / Date
Budget
Anytown Adventist School
______
School Year
Anticipated Enrollment by Grade:
K ____ / 1 ____ / 2 ____ / 3 ____ / 4 ____ / 5 ____ / 6 ____ / 7 ____ / 8 ____ / 9 ____2010-2011
Budget / 2009-2010
Actual / 2009-2010
Budget
Annual Income:
Entrance Fees / $ ______/ $ ______/ $ ______
Special Fees
(music, art, etc.) / $ ______/ $ ______/ $ ______
Tuition / $ ______/ $ ______/ $ ______
Church(es) Subsidy / $ ______/ $ ______/ $ ______
Special Projects / $ ______/ $ ______/ $ ______
Other / $ ______/ $ ______/ $ ______
Total Income / $ ______/ $ ______/ $ ______
(should equal or exceed total expenses)
Annual Expenses:
Conference Education Fund / $ ______/ $ ______/ $ ______
Locally Funded Employees / $ ______/ $ ______/ $ ______
Utilities (Heat, Electricity, Water, etc.) / $ ______/ $ ______/ $ ______
Telephone / $ ______/ $ ______/ $ ______
Custodial Equipment and Supplies / $ ______/ $ ______/
$ ______
Budget – Page 2
ANNUAL EXPENSES (CONTINUED):
2010-2011
Budget / 2009-2010
Actual / 2009-2010
Budget
Textbooks / $ ______/ $ ______/ $ ______
Media Center—Books, Periodicals, Software (Minimum $35/student) / $ ______/ $ ______/ $ ______
School/Office Supplies / $ ______/ $ ______/ $ ______
Technology Plan (Upgrades/Purchases) / $ ______/ $ ______/ $ ______
New Equipment and Furniture / $ ______/ $ ______/ $ ______
Plant and Grounds Improvement / $ ______/ $ ______/ $ ______
Plant Insurance / $ ______/ $ ______/ $ ______
Student Accident Insurance / $ ______/ $ ______/ $ ______
Miscellaneous Expenses / $ ______/ $ ______/ $ ______
Other Expenses
(Please specify)
______/ $ ______/ $ ______/ $ ______
______/ $ ______/ $ ______/ $ ______
______/ $ ______/ $ ______/ $ ______
Bad Debt (Anticipated Delinquent Accounts) / $ ______/ $ ______/ $ ______
Total Expenses / $ ______/ $ ______/ $ ______
Consent to Treatment
Anytown Adventist School
Only designated staff will have access to the completed form. This form will be stored in a locked file. This form must be filled out at the beginning of each school year to cover the activities for the school year. A copy of each student’s form must be taken on off-campus activities.
Student’s Full Name:
____ / ______/ ______Age / Date of Birth (month/day/year) / Social Security Number (United States)
Address:
Parent/Guardian Information:
Father/Guardian:
______/ ______/ ______/ ______Business Phone / Home Phone / Mobile Phone / Social Security Number
Email:
Mother/Guardian:
______/ ______/ ______/ ______Business Phone / Home Phone / Mobile Phone / Social Security Number
Email:
Please describe allergies to substances and medications:
If on regular medication, please specify: ______/ ______Date of Last Tetanus Shot
Please give the name of your local family physician to be called in case your child becomes ill or has an accident at school and you cannot be reached:
______/ ______Family Physician Name / Office Phone
Physician’s Office Address:
Hospital Preference: ______/ ______Hospital Phone
Please give the name of a relative or friend who has consented to assume the responsibility of your child in case of illness or accident until you can be reached. In case of any changes in the named person, notify the school in writing.
Name:______/ ______Phone
Address:
The above named student is ______is not ______covered by health insurance.
______/ ______Present Health Insurance Company / Policy Number
If emergency service involving medical action or treatment is required and neither the parent not the family physician can be reached for consent, the parents hereby consent to the rendering of such emergency medical service for the above named student as shall be necessary in the medical opinion of the doctor rendering service.
______/ ______Signature of Parent or Guardian / Date
Daily Schedule Analysis
(Grades 1-2)
Name
School
Conference
Grades or Subjects Taught
Subject / Total MinutesPer Week / Recommended Minutes / Recommended
Number of Days
Weekly / Daily
Worship / ______ / 50 / 10 / 5
Bible / ______ / 200 / 40 / 5
Mathematics / ______ / 250 / 50 / 5
Pathways / ______ / 725
Daily Routine / ______ / 285
Daily Read Aloud / ______/ 75 / 15 / 5
Daily Oral Language / ______/ 50 / 10 / 5
Phonics/Word Study / ______/ 60 / 15 / 4
Handwriting / ______/ 40 / 10 / 4
Spelling / ______/ 60 / 15 / 4
Reading Instruction / ______ / 300
Thematic Instruction / ______/ 150 / 30 / 5
Guided Reading / ______/ 150 / 30 / 5
Workshops / ______ / 140
Reading / ______/ 80 / 20 / 4
Writing / ______/ 60 / 15 / 4
Science / ______ / 160 / 40 / 4
Social Studies / ______ / 160 / 40 / 4
Fine Arts / ______ / 80
Art / ______/ 40 / 40 / 1
Music / ______/ 40 / 40 / 1
Physical Education / ______ / 100 / 20 / 5
Recess / ______ / 75 / 15 / 5
Grand Total / ______ / 1800
Minimum 1800 minutes weekly required
Lunch is not included in the minimum required minutes and must be at least 30 minutes per day
Daily Schedule Analysis
(Grades 3-4)
Name
School
Conference
Grades or Subjects Taught
Subject / Total MinutesPer Week / Recommended Minutes / Recommended
Number of Days
Weekly / Daily
Worship / ______/ 50 / 10 / 5
Bible / ______/ 200 / 40 / 5
Mathematics / ______/ 250 / 50 / 5
Pathways / ______/ 725
Daily Routine / ______/ 225
Daily Read Aloud / ______/ 75 / 15 / 5
Daily Oral Language / ______/ 50 / 10 / 5
Focus on Words / ______/ 20 / 5 / 4
Handwriting / ______/ 40 / 10 / 4
Spelling / ______/ 40 / 15 / 4
Reading Instruction / ______/ 300
Thematic Instruction / ______/ 150 / 30 / 5
Guided Reading / ______/ 150 / 30 / 5
Workshops / ______/ 200
Reading / ______/ 80 / 20 / 4
Writing / ______/ 120 / 30 / 4
Science / ______/ 160 / 40 / 4
Social Studies / ______/ 160 / 40 / 4
Fine Arts / ______/ 80
Art / ______/ 40 / 40 / 1
Music / ______/ 40 / 40 / 1
Physical Education / ______/ 100 / 20 / 5
Recess / ______/ 75 / 15 / 5
Grand Total / ______/ 1800
Minimum 1800 minutes weekly required
Lunch is not included in the minimum required minutes and must be at least 30 minutes per day