* 1. USE OF TYLENOL:

* 2. USE OF MEDICATIONS OTHER THAN TYLENOL:

Roberts School Administrative Staff is authorized to dispense the following medicines other than Tylenol, to my child for current school year.  Dosage will be given in accordance with the directions on the bottle.  In the case of a prescription medication the bottle with the directions should be given to the school.

* 3. PARTICIPATION IN ATHLETICS – ACTIVITIES - FIELD TRIP  - INJURY AWARENESS:

In consideration of permission granted my child or ward to participate in activities during the school year in progress, I hereby authorize school personnel of Roberts School District, in case of injury to said child, to consent to any x-ray examination, anesthetic, medical or surgical diagnoses or treatment, and hospital care, to be rendered to the minor under the general or special supervision and advise of any physician or surgeon licensed to practice in the United States of America.

It is understood I will be notified of the injury at the earliest possible opportunity but this authorization will allow treatment until I arrive.  I further understand that the expenses incurred from any such treatment will be my responsibility.

I am aware there is a risk of being injured as a result of participation in any school sport or activity.  I am aware that the injury may be severe including, but not limited to: death, fractures, brain injuries, paralysis, neck or spinal injuries, damage to virtually all internal organs, serious injury to ligaments, muscles, tendons, and other aspects of the muscular system.

Nevertheless, I want my child to participate in school athletics and activities.  I also understand that the school district is not responsible for payment of any kind of injuries received while participating in such activities unless found negligent.

I also understand that to compete in interscholastic activities my son or daughter must complete a Montana High School Association Physical.  The Form can be found by clicking here.

PERSONAL INSURANCE STATEMENT: Select all that Apply

* 4. PARENT CONSENT FORM TO CONDUCT HEARING AND VISION SCREENING:
Hearing and vision screening are conducted at your child’s school as part of the Office of Public Instruction’s Hearing  and Vision Conservation Program. Pure tone screening is mandated for students in grades K, 1, and 10. This screening is designed to determine a child’s ability to hear varying pitches, from low to high pitch. The tones are presented at a level that is very quiet and the child is asked to indicate when they hear a tone by, for example, raising their hand. If a child does not hear these soft tones, his or her hearing may be impaired. A hearing impairment may, and often does, affect a child’s speech and language development or school performance.

If your child is absent, unable to complete the pure tone screening, or does not pass the pure tone screening; they will be referred for a hearing rescreen. John Keener, the Hearing Conservation Program audiology assistant, will be coming to the school for the hearing rescreen. At that time, in addition to the pure tone screening described above, he may also conduct one or both of the following:

 Otoacoustic Emissions (OAEs) Screening: This is a measure of cochlear (inner ear) function that does not require the child to respond behaviorally. It is used with infants or children who are unable to indicate when they hear a tone. Certain pitches are screened and a passing response indicates that hearing levels are at least 30 dB or better. This does not replace pure tone screening but does provide useful information when pure tone results cannot be attained.

 Immittance Screening: This screening measures the movement of the eardrum and assesses the condition of the middle ear by putting positive and negative pressure into the ear canal. It is a very sensitive test and can identify the presence of a middle ear problem. A common middle ear problem is fluid behind the eardrum. If fluid builds up behind the eardrum, it may act as a plug, impairing a child’s ability to hear.

This screening will not be done without your written consent. Your signature gives consent for your child, whose name appears below, to have their hearing screened during the current school year.

* 5. F.E.R.P.A. (Family Educational Rights and Privacy Act) and consent to release student records

In regard to student records, federal law requires that “directory information” on my child be released by the District to anyone who requests it unless I object in writing to the release of any or all of this information.  Directory Information ordinarily includes the student’s name, address, telephone number, date and place of birth, honor roll, college and military acceptances, scholarships, participation in officially recognized activities and sports, weight and height of members of athletic teams, photographs, dates of attendance, awards received in school, most recent previous school attended.  Examples of places your child’s information may be released are the school newsletter, honor roll lists, school newspaper, yearbook, athletic rosters, music programs, graduation activities, military personnel. This is not an all inclusive listing, just some examples.  Pursuant to federal law, the District is required to release the names, addresses and telephone numbers of all high school students to military recruiters and institutions of higher education upon request.  This notification to parents and students concerning school records will inform them of their right to object to the release of this information.  In exercising my right to limit release of this information I have:

Select all that apply

* 6. STUDENT HANDBOOK 

As an informed parent, your signature below indicates that you have read the rules and regulations of the Roberts Public School Student Handbook and understand the rules and regulations as approved by the Trustees of School District #5.

Click Here to View The Handbook 

* 7. Families of Four Making Under $45,500 will qualify for Free and Reduced Lunches.

Click Here for Free and Reduced Cut Offs

Click Here for Free and Reduced Forms to Fill Out and Print Off

* 8. School Vaccination Laws 

State of Montana Required Vaccinations 

Religious Exemption Form

* 9. I Certify that the above information is correct to the best of my abilities.  I agree that the information above is correct and by typing my name with a date it will act as my official signature.

If you are an out of district family, please click here and fill out the attached form. It must be submitted to the school office.

* 10. Does your son or daughter have an allergies the school should be aware of?

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