P.S./I.S. 217 Family Homework 2020
Forms must be completed prior to the start of in person instruction on 9/21/20
Email address *
Student's Full Name (First, Middle, Last) *
Student's Date of Birth *
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Student's Grade Level *
Student's home address *
Student's ethnicity & language(s) spoken *
Student's Hair Color *
Student's approx. height & weight *
Student's distinguishing features *
Siblings that attend P.S./I.S. 217 (name and grade) *
Siblings that do NOT attend P.S./I.S. 217 (name and grade) *
Parents/Guardians and Emergency Contact Information
Student will be released ONLY to persons named below.
Parent/Guardian's (whom student resides with) name and relationship to the student *
Parent/Guardian's Email *
Parent/Guardian's Primary Phone Number *
Parent/Guardian's Alternate Phone Number *
Other Parent/Guardian's Name and relationship to the student *
Other Parent/Guardian's Email *
Other Parent/Guardian's Preferred Phone Number *
Other Parent/Guardian's Alternate Phone Number *
Other Parent/Guardian's Address (if different from student's) *
If there is a person who MAY NOT have access to student, please indicate the name and relationship to child *
Order of protection exists? *
Emergency Contacts
Minimum 3 emergency contacts (OTHER THAN PARENT/PRIMARY GUARDIAN) MUST be listed.Please include babysitter(s), family friends, and/or afterschool program(s) as emergency contacts if they wil be picking up your child. Emergency contacts will only be contacted if Parent/Guardian and Other Parent/Guardian cannot be reached first.
By typing my name, I, parent/legal guardian, authorize persons listed below to pick up my child from school and to be contacted in case of emergency when I or other parent/guardian cannot be reached *
Emergency Contact 1's name and relationship to the student. MUST BE OTHER THAN PARENT/GUARDIAN. *
Emergency Contact 1's (other than parent and guardian) Primary & (if available) Alternate Phone Number(s) *
Emergency Contact 1's (other than parent and guardian) email *
Emergency Contact 2's (other than parent/guardian) name and relationship to the student *
Emergency Contact 2's (other than parent/guardian) primary phone number & (if available) alternate phone number *
Emergency Contact 2's (other than parent/guardian) email *
Emergency Contact 3's (other than parent/guardian) name and relationship to the student *
Emergency Contact 3's (other than parent/guardian) Primary Phone Number & (if available) alternate phone number *
Emergency Contact 3's (other than parent/guardian) email *
IMPORTANT MEDICAL INFORMATION
Parents/Guardians of students with allergies, asthma, or other medical condition MUST see the school nurse EACH school year and notify the teacher and main office in writing.
Does your child have asthma? *
If yes, does your child require asthma medication to be kept by the nurse? *
Does your child have any food allergies? *
If yes, please descibe your child's food allergies *
Does your child have a prescribed Epi-Pen? *
No student may carry their own medication in any grade. It must be kept in the nurse’s office.
Does your child have any medical conditions other than asthma and/or allergies? *
If yes, please describe *
Is your child on any permanent medications? *
If yes, please describe your child's permanent medications *
If your child has a medical condition, your doctor MUST complete a 504 plan and submit to the nurse. Have you completed a 504 plan with your doctor regarding any medical conditions? *
In case of emergency, if none of the listed contacts (Parent/Guardian, Other Parent/Guardian, Emergency Contact 1, 2 or 3) can be reached, what do you wish the school to do if your child is sick or injured? *
By typing my name below, I, parent/legal guardian, acknowledge that I understand that in the final disposition of an emergency case, the judgement of the school authorities will prevail. My recommendation as indicated above will be respected as far as possible.
Parent/Guardian's Name *
Consent to Photograph, Film, or Videotape a Student for Non-Profit Use
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video recordings of the student named above by P.S./I.S. 217.I also grant to P.S./I.S. 217 the right to edit, use, and reuse said products for non-profit purposes including use in print such as our newsletter and brochures, on the internet (school website), and all other forms of media. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. *
ROOSEVELT ISLAND WALKING TRIPS PERMISSION FORM
As part of the learning experience this year, P.S./I.S. 217 students will be taking walking trips as a class to various locations in the neighborhood during the school day. Neighborhood trips may include walking, playing, running, playing at playgrounds or parks on Roosevelt Island within walking distance of school. By signing below, you are giving permission for your child to participate in all class neighborhood trips for the 2020-2021 school year AND ALLOWS YOUR CHILD TO PARTICIPATE IN OUTDOOR INSTRUCTION AND LUNCH DURING this year.
By typing my name below, I, parent/legal guardian, give my permission for my child to participate in all class neighborhood trips for the 2020/2021 school year. *
At dismissal, students in Pre-K through Grade 3 must be picked up by a parent/guardian, one of the emergency contacts listed in this form, or a person indicated below.
My child can be released to their sibling(s) write in siblings' name, grade, and phone number
By typing my name below I, parent/legal guardian, allow my child to be released on their own.
Students in Grades 4 through 8 will be released on their own unless indicated below.
By typing my name below I, parent/legal guardian, DO NOT allow my child in Grade 4 -8 to leave school at dismissal independently. The student will be picked up daily by a parent, guardian or emergency contact.
When students come to school on the wrong day during blended learning, we are unable to accept students in Pre-K to Grade 3 from you. Students in Grade 4-8 will be advised to return home and the school will notify you. Written consent from a parent or guardian is required via email.
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