FELL CHARTER ELEMENTARY SCHOOL

Enrollment Package for 2011-2012

Please complete the forms in this package and return completed to:

Fell Charter Elementary School

777 Main St.
Simpson, PA 18407

570-282-5199
(fax) 570-282-0930
-------------------------------------------------------------------------------------------------------------------

(FOR OFFICE USE ONLY)

Student Name Grade

Date

____ Birth Certificate *

____ Social Security Card *

____ 4x Proof of Residency (Example: Driver’s License, Utility Bill, Lease/Mortgage) *

____ Student Enrollment Notification Form

____ Emergency Contact/ Permission Form*

____ Parental Registration Statement

____ Receipt & Acknowledgment of Student Handbook*

____ Home/School Compact

____ Home Language Survey

____ Photo/Videotape Release Form

____ Volunteer Form

____ Certificate of Immunization*

____ Child Health Assessment* ____ Med Admin Form ____ Dental Form* ____ Mobile Dentists Form

____IEP (If applicable)*

* - MANDATORY DOCUMENTS

An Equal Opportunity Education Institute

Acceptance Notification 11-05
 THANK YOU FOR CONSIDERING
FELL CHARTER ELEMENTARY SCHOOL
Home of the

Open since September 2002 and located on Rt. 171 in Simpson, Pennsylvania, Fell Charter
Elementary School is a tuition free public school that offers a safe learning environment and a
research-proven effective curriculum that is both rigorous and college-prep.

We work with the management company Mosaica Education Inc. Our school offers a proven
curriculum, with a hands on learning approach. We currently offer placement in full day
Kindergarten through Eighth (8) Grade Classes.

The recent overwhelming increase of enrollment has warranted us to operate on a space-

available basis (a waiting list).

Please be aware that the practiced features and standards of our school are indeed more
aggressive, therefore requiring more parental/guardian involvement than other public schools.
Some of our strict school guidelines are as follows:

• School hours are 7:45 AM until 3:30 PM

• Limit of twenty-five (25) students per classroom
• Technology in every classroom
• Student discipline and dress codes strictly monitored and enforced
• Longer than average school year
• Strong student accountability measured by national standardized tests
• Teacher/Staff accountability measured by yearly parent satisfaction surveys
• Parent/Guardian volunteer requirement; two (2) hours monthly

Parental involvement and volunteer time is not only a requirement at Fell Charter Elementary
School, but is also an important foundation that supports great parent/school – parent/student
bonds, positively benefiting our school community. Some examples of opportunities to fulfill
your two hours of monthly service are;

• Lunch hour/Cafeteria Duty (helps to assist our children at lunchtime, example –

opening snacks and thermos)
• Teacher-requested Classroom Help (assist with projects, classroom events)
• Paragon Night assistance/donations (supplies and clean up help are needed on
monthly basis)
• Committee Work Sessions (scheduled sessions to help our school grow and develop)

If you have any questions about our school or enrollment, please contact our school
Principal, Mary Jo Walsh, at (570) 282-5199 or visit www.fellcharter.org

An Equal Opportunity Education Institute

 Charter School Student Enrollment Notification Form
For School Year 2010-2011
2011-2012
2009-2010
Warning: A child enrolled in another public school or a nonpublic or private school cannot, at the same time,
enroll in a charter school.
Name of Charter
School: FELL CHARTER ELEMENTARY SCHOOL
Address: 777 Main Street, Simpson, PA 18407

Charter School
Contact Person: Mary Jo Walsh - Principal/CAO
Email
Telephone: 570-282-5199 Address: MJWalsh@fellcharter.org

I. Student Information:
Last First
Name: Name: MI:
Home
Address:
City: State: Zip Code:
County: Telephone:
Mailing Address
(If Different From
Home Address)

City: State: Zip Code:

Date Of Birth: Age:

II. School District of Residence and Former School Information

School District of
Residence:
Former School Information (Other Than Pre-School):
Public Charter Home
School School School Nonpublic School
Student Not Enrolled in School Preceding Enrollment in Charter School Because:
Entering
Kindergarten Re-Enrolling Dropout Other
Name of Former School:
Address of Former
School:

Previous Withdrawal Date From Former

Grade: School:
Was Your Child Receiving Special Education Services Based On An
Iep? Yes No
If Yes, Do You Have The Child’s Special Education Records
(Iep)? Yes No

Charter School Student Enrollment Notification Form PDE 2/2008

Instructions for this can be found at www.pde.state.pa.us. Under the K-12 Schools folder, click on Public Schools, then Charter
School, then Reporting.
III. Parent/Guardian Information:
Both Both Parents Mother Father
Child Lives With: Parents Alternately Only Only
Legal Foster
Guardian Parents Other Adult
Special Custodial Court Instructions:
(If Yes, Please Provide a Copy of
Court Order.) Yes No

Complete Parent/Guardian Name and Address Information As Applicable

Father’s Name
Address:
City: State: Zip Code:
Home Telephone: Work Telephone:

Mother’s Name
Address:
City: State: Zip Code:
Home Telephone: Work Telephone:

If The Student Is Not Living With Parents, Please Complete This Section.
Guardian’s Name Or Foster Parent’s Name Or Other Adult Name
Name:
Address:
City: State: Zip Code:

My signature on this form indicates my decision to have my child attend the charter school named on
page 1 of this form and signifies my request that appropriate school records be forwarded from the
school district to the charter school. My signature also certifies that my child is not, and will not be,
enrolled in another public school, a nonpublic school or a private school at the same time he or she
is enrolled in this charter school.
Signature of
Parent/Guardian: Date:

IV. To Be Completed By Charter School:

Verification of Date of Birth: Birth Certificate Other
Proof of Mortgage Utility
Residency Statement Lease Bill Other
Official Enrollment Date: Anticipated Date of Attendance:
Grade Student Is Entering:
Signature of Charter School
Representative:

Page 2 of Charter School Student Enrollment Notification Form PDE 2/2008

 FELL CHARTER ELEMENTARY SCHOOL
Emergency Contact/Permission
I/We understand that providing current emergency contact information is critical to the safety and well-being of my/our child. My/Our signature on
this form certifies my/our understanding and commitment to provide updates (in writing) of any and all changes in contact information, within 24
hours of any change to the school administrative assistant/secretary and my child’s classroom teacher(s).

1. Name of Child: Age: Date of Birth:

2. Address: City State Zip

Street Number and Name Apt. #

3. Home Phone: Family Email address:

4. Mother/Guardian: Address: Check if Same as Above

Address if different than above:

Occupation: Employer:

Cell Phone: Work Phone:

5. Father/Guardian: Address: Check if Same as Above

Address if different than above:

Occupation: Employer:

Cell Phone: Work Phone:

6. Local Emergency Contacts: Adult persons other than parents/guardians (18 years or older) who may be contacted in
the event of an emergency:

Name: Relationship: Phone:

Name: Relationship: Phone:

7. I/We hereby give permission to the staff of the Fell Charter School to secure emergency medical
treatment by a qualified physician for the above named child while under their supervision: YES NO (circle one)

8. Name of child’s physician or health clinic:

Address: City State Zip

Phone Number After-Hours Emergency Number

9. Hospital preferred for Emergency Treatment:

10. Health Insurance Policy Name and Number:

11. Please list any special services your child has received in the last three (3) years:

12. Please list any allergies: Date of last Tetanus Shot: / / .

13. Name(s) of Person other than Parent or Legal Guardian to Whom Child maybe released (must be 18 years or older)
One name per line:

In the event that I/we can not be contacted and if my designated emergency contact is not available, I/we understand
and agree that Fell Charter School will telephone 911 for emergency medical assistance and will follow their directives.

Parent/Guardian Signature: Today’s Date: / /

 FELL CHARTER ELEMENTARY SCHOOL
777 Main Street
Simpson, PA 18407
(570) 282-5199 Fax – (570) 282-0930

PARENTAL REGISTRATION STATEMENT

Student Name

Date of Birth Grade Telephone Number

Parent/Guardian Name

Address

Pennsylvania School Code 13-1304-A states in part, “Prior to admission to any school entity, the
parent/guardian and other person having control of charge of a student shall, upon registration, provide a
sworn statement or affirmation stating where the pupil was previously suspended or expelled from any
public or private school of this Commonwealth or any other state for an act or offense involving weapons,
alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violence committed
on school property.”

Please complete the following:

I hereby swear or affirm that my child was was not previously suspended or expelled from
any public or private school of this Commonwealth or any other state for an act or offense involving
weapons, alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violence
committed on school property. I make this statement subject to the penalties of 24 P.S. 13-1304-A (b)
and 18 PA C.S.A. 4904, relating un-sworn falsification to authorities, and the facts herein are true and
correct to the best of my knowledge, information, and belief.

Signature of Parent/Guardian Date

Name of the school from which your student was suspended or expelled and the reason for suspension
and/or expulsion.

School Date

Reason

School Date

Reason

Any willful false statement made about shall be a misdemeanor of the third degree. This information shall be maintained
as part of the student’s disciplinary record.
 FELL CHARTER ELEMENTARY SCHOOL
Receipt and Acknowledgement
of Student Handbook

By signing below, we acknowledge that we have received a current Fell Charter Elementary School
Student Handbook, that we have fully read the handbook, and that we understand and agree to abide by
all the policies specified within.

______________________________ ______________________________
(Student – Please print name) (Parent/Guardian – Please print name)

Date: ___________________

Learning Methodology Questions

Please take a moment to answer the following questions as completely as possible so we can better
serve your child’s learning needs.

1. How do you believe your child(ren) learns best?

2. How many times a week do you assist with your child’s homework?

3. What is your academic goal for your child?

4. What do you believe is your child’s best academic subject?

5. Why?
 FELL CHARTER ELEMENTARY SCHOOL
Home/School Compact

To help all children achieve high standards…

Parents/Guardians must…
• Check their child’s backpack daily
• Schedule a regular time for homework and provide a quiet place to work
• Communicate with teachers about their child’s needs
• Support their child’s teachers
• Encourage their child to read daily
• Read to their child
• Sign and return notes, progress reports, and report cards to school in a timely manner
• Schedule time in their routine to become active and attend school functions
• Ensure that their child is not over-scheduled with extracurricular activities
• Make learning a family-oriented process

Students must…
• Write their homework assignments in a planner
• Complete their homework/classwork and return it on time
• Come to school prepared with all necessary materials
• Follow directions
• Respect staff and peers with words and actions
• Respect and follow school rules so that all students can learn
• Work efficiently and take pride in their work
• Ask for help when needed
• Take notes and reports home to parents

Student Name (Please Print)

Student Signature Date

Fell Charter Elementary Staff have agreed to do the following (but not limited to)…
• Always put the child first
• Provide a safe and secure learning environment
• Communicate regularly with families:
o In a constructive manner
o On school happenings
o On academic progress
o On behavior issues
• Teach to the individual needs and level of every student by developing and implementing
Personalized Student Achievement Plans
• Use a variety of learning methods
• Asses student progress frequently and in a variety of ways
• Welcome parents and community members into the school and classrooms

An Equal Opportunity Education Institute

 FELL CHARTER ELEMENTARY SCHOOL
Home Language Survey
This form must be completed for all students registered at
Fell Charter Elementary School

Student Name
Last First Middle

Date of Birth

Parent/Guardian:

Please answer the questions below accurately and completely. This information is necessary to provide
the most appropriate placement and instruction for your child and will not be used for any other purposes.
Thank you for your cooperation.

1. Is there a primary language other than English spoken at home? Yes No

2. Does your child speak a language other than English? Yes No

If yes, what language(s)?

Parent/Guardian Signature Date

An Equal Opportunity Education Institute

 FELL CHARTER ELEMENTARY SCHOOL
Photograph/Videotape Permission

Dear Parent/Guardian:

From time to time Fell Charter Elementary School records student activities through the use of
photography and/or videotape. Generally the resulting material is used internally to serve as a form of
documentation of school/student activity and as a learning tool for both students and faculty. On occasion
photographs and/or videotapes may be used for advertising purposes to promote enrollment at Fell
Charter Elementary School or as a backdrop to employment recruitment efforts.

In order for the school to produce materials for both internal and external uses we need your permission
to use photo and/or video images of your child. Please put a check in the appropriate box and sign below
to indicate your preference of permission for the following:

1. I/We (do) give permission for my/our child to be photographed/videotaped and the resulting
photographs/videotape to be used and displayed within the school as well as, to be used for
public display and/or published for the benefit of the school.

2. I/We (do not) give permission for my/our child to be photographed/videotaped and the
photographs/videotape to be publicly displayed and/or published.

Please Note: There is no payment or any other form of compensation for use of your child’s image if a
photograph and/or video image of your child is used either internally or externally as explained in the
examples above.

Please Print:

Student’s Name:

Grade: Teacher’s Name:

Parent/Guardian Name:

Sign Below:

/ /
Parent/Guardian Signature Date Signed

An Equal Opportunity Education Institute

 FELL CHARTER ELEMENTARY SCHOOL
Volunteer Form

Volunteers may be involved in on-campus activities, but are also encouraged to contribute their time and talent to
organizing extracurricular activities and community outreach projects. All parents/guardians are expected to volunteer
2 hours each month per parent/guardian in the household. Any family member – parent, sibling, grandparent, or family
friend – may complete the hours for the family. A number of volunteer options are available both in the school and from
home or work. Volunteer hours are logged and records are kept on file. Contact the school administrative team for
volunteer suggestions. Also, refer to the school newsletter throughout the year for ways to be of service. The following
is a partial list of ways to fulfill the volunteer commitment.

During School Hours Volunteers* May . . .
 Assist with any content area
 Share about your work or career
 Work with a student one on one
 Help teachers with classroom décor -- posters,
bulletin boards, hallway art displays
 Organize completed work into folders
 Photocopy homework or project packets
 Assist or play with children during lunch/recess
 Work in the main office
 Clean school equipment or school grounds
 Answer office phone
 Volunteer with the Student Leadership
 Volunteer with the student musicals
 Tutor students after school
 Pick up and return books from the public library
After School Hours Or From Work Or Home
Volunteers* May . . .
 Assist with the school website
 Host a talk at work to promote the school
 Organize a family drive to enlist in Target, Office
Depot, or Wal-Mart Card Programs that donate to
the school
 Share any fund raising experiences and ideas
 Provide general grounds maintenance
 Buy or send in Paragon supplies
 Organize Scholastic book orders for teachers
 Pick up and return books from the public library
 Shop for school supply donations – pencils, pens,
paper towels, wet wipes, bleach wipes, Ziploc bags
are needed throughout the year
 Request your office to donate art supplies
 Photocopy homework and project packets

*All types of volunteer service require successful completion of a criminal & child abuse background check, with copies
submitted to the school, prior to volunteering.

All volunteers must complete volunteer application, and may be fingerprinted (for federal and state clearance).
Volunteers receive structured training, and must follow all policies and procedures defined by the School. The Chief
Administrative Officer (CAO) reserves the right to relieve the volunteer of his or her responsibilities at any time.

I/We understand that Volunteering is a requirement.

/ /
Parent/Guardian Signature Date

An Equal Opportunity Education Institute

 FELL CHARTER ELEMENTARY SCHOOL
School Health Services

School Registration Health Forms

Dear Parents/Guardian:

Attached are the health forms required for each student. A copy of immunization
dates, the Health Data Form, and the Emergency Contact Form must be presented
at the time of registration. Please notify the Fell Charter Elementary School nurse of
any changes to this information that may occur during the school year.

A physical examination is a required Pennsylvania State mandate for students first

entering school either in Kindergarten or as a new student, and again in sixth grade. An
examination done by the family physician within twelve months prior to the opening of
school or during the school year will be accepted as the required examination and must
be recorded on the enclosed physical form.

Our school health program also recommends regular dental examinations. Dental
examinations are required for students first entering school either in Kindergarten or as
a new student, and also in third grade, and seventh grade. An examination done by a
private dentist within twelve months prior to the opening of school or during the school
year will be accepted as the required examination and must be recorded on the
enclosed dental form.

All immunizations must be up-to-date. If the student is not current with his/her
immunizations, he/she will not be admitted until they are updated. Any student 13 years
and older must have a second dose of the varicella vaccine. Please see the attached
form for the new vaccine regulations for the 2011-2012 school year. These
requirements do allow for medical and religions exemptions.

Children who need medication during school hours or who have other special needs are
advised to speak with the school nurse. Please refer to the medication policy forms in
this packet.

Thank you for your cooperation and attention in completing these very important forms.
Please contact the school nurse if you have any questions.

An Equal Opportunity Education Institute

 FELL CHARTER ELEMENTARY SCHOOL
School Health Services
Health Data Form 2011-2012

Information provided on this form will enable school personnel to deal most effectively with your child’s
health considerations and allow him/her to receive the maximum benefits from his/her educational
experience. Attach additional paperwork if necessary.

Student’s Name Grade DOB M/F

Father’s Name Mother’s Name

Guardian (if other than parent)

Student’s Physician Student’s Dentist

Does your child take medication on a daily basis? Yes / No

Medication Reason
Will he/she need to take the medication during school hours? Yes / No

Has your child ever had an allergic reaction to any medication? Yes / No
Name of medication Reaction
Treatment in case of exposure

Is your child allergic to specific foods or other substances? Yes / No

Food/Substance Reaction
Treatment in case of exposure

Has your child ever had an allergic reaction to Bee/Wasp stings? Yes / No
Medication Reaction
Treatment in case of exposure

Does your child have any other health problems? Yes / No

Condition(s)
Condition(s)

Has your child been hospitalized for surgery, serious illness, or accident? Yes / No
Comments

Does your child have difficulty with Vision? Yes / No

Does your child have difficulty with Hearing? Yes / No
Does your child have difficulty with Speech? Yes / No

Is there anything more about your child’s health that you believe is important for the school to know?
Yes / No

May this information be shared with other school personnel, as necessary for the health of your child?
Yes / No
Signature of Parent/Guardian Date
 CERTIFICATE OF IMMUNIZATION
Last Name: First Name: Middle Name:

Child’s Date of Birth: Home Phone: Parent/Guardian Name:

______/______/______
Home Address: Grade:

VACCINE ENTER MONTH, DAY. AND YEAR EACH IMMUNIZATION WAS GIVEN
CIRCLE APPROPRIATE ITEM DOSES
Diphtheria and Tetanus
1) ___/___/___ 2) ___/___/___ 3) ___/___/___ 4) ___/___/___ 5) ___/___/___
(DtaP, DTP, Td, or DT)
1) ___/___/___ 2) ___/___/___ 3) ___/___/___ 4) ___/___/___
Polio (OPV or IPV)

1) ___/___/___ 2) ___/___/___ 3) ___/___/___

Hepatitis B

Or Measles Serology:
1) ___/___/___ 2) ___/___/___ Date: ___/___/____ titer:
Measles – Mumps – Rubella (MMR)

Rubella Serology:
1) ___/___/___ 2) ___/___/___ Date: ___/____/____ titer:
Varicella (Vaccine or Disease)

1) ___/___/___ 2) ___/___/___ Mumps disease diagnosed by a physician: Yes

Other
Date: ____/____/____

Doses required by law for new school enterers (K or 1st Grade) are shaded in gray.
Age appropriate dose(s) of varicella vaccine or history of disease and 3 doses Hepatitis B vaccine required for entry into
7th grade.

To the best of my knowledge, this child has received the minimum required immunizations. Source: Written Verbal Both

Signed:______________________________________________________________________ Date: ______/______/______

(PHYSICIAN, PUBLIC HEALTH OFFICIAL, SCHOOL NURSE, OR OTHER DESIGNEE)

Statement For Exemption To Immunization Law (If applicable)

MEDICAL EXEMPTION

The physical condition for the above named child is such that immunization would endanger life of health.

Signed: __________________________________________Date: _____/______/______

Physician’s Signature

RELIGIOUS EXEMPTION
Includes a strong moral or ethical conviction similar to a religious belief

The parent or guardian of the above named child adheres to a religious belief whose teachings are opposed to such
immunizations. State your reasons for requesting religious exemption: ___________________________________
____________________________________________________________________________________________

Signed: _________________________________________Date: _____/______/_____

Parent/Guardian Signature
 CHILD HEALTH ASSESSMENT
Student Information: Page 1 of 2
Last Name: First Name: Middle Name:

Child’s Date of Birth: Home Phone: Parent/Guardian Name:

______/______/______
Home Address:

Check Present Grade: K 1 2 3 4 5 6 7 8 9 10

SP ED
RACE/ETHNICITY: African American (Non-Hispanic) American Indian / Alaskan Native Asian / Pacific Islander

Hispanic Multiracial White (Non-Hispanic)

Consent:

I/We hereby give my/our consent as the parent/guardian of the above named child to release, discuss or
otherwise inform the school of my/Our child’s health condition and any health concerns:

Parent/Guardian Signature: ______________________________Date Signed: ____/_____/_____

Heath History and Medical Information Pertinent to Routine Care:

Emergency Care: None Yes; describe:

Allergies to Food or Medicine: None Yes, describe:

Height Weight Head Circumference Blood Pressure

_______IN/CM %of ILE ______ ______LB/KG %of ILE ______ ______IN/CM %of ILE ______ ______/______

Physical Examination: Date of Exam: _____/______/_____

Physical Examination Normal Abnormal Comments

Head/Ears/Eyes/Nose/Throat

Teeth

Cardio/Respiratory

Abdomen/GI

Genitalia/Breasts

Extremities/Joints/Back/Chest

Skin / Lymph Nodes

Neurological / Tone

Developmental (E.G. DDST)

An Equal Opportunity Education Institute
 CHILD HEALTH ASSESSMENT
Child’s Name: Page 2 of 2

Screening Tests:
Normal Abnormal Comments
Screening Tests
LEAD

ANEMIA (HGB/HCT)

URINALYSIS (UA)

HEARING

VISION

DATE OF DENTIST’S
LAST EXAMINATION

Recommendations/Health Care Provider’s Signature:

HEALTH PROBLEMS OR SPECIAL NEEDS Recommended Treatment – Medication - Special Care

(Attach Additional Sheets as Necessary)
NO Problems YES, Describe:

Medical Care Provider:

NEXT APPOINTMENT: (MONTH/YEAR)

Address:
________/_________

Phone:

______________________________________________________ Date: _____/______/_____ MD

Signature of Attending Physician or CRNP DO
CRNP

NOTE: Age appropriate health services and immunizations must follow the schedule recommended by
The American Academy of Pediatrics.

An Equal Opportunity Education Institute

 FELL CHARTER SCHOOL
School Health Services Medication Policy
It is the policy of the Fell Charter School that medication is to be given outside of school
hours whenever possible. However, if it is essential that a student receive medication during
school hours, the following criteria MUST be met before medication may be administered:

1. The physician and parent/guardian must sign a medication request/consent

forms for each prescription and nonprescription medication.
a. If a parent/guardian completes and signs the Parent Consent Form, a
prescription label will be accepted for 5 (five) school days in lieu of the
Physician’s Request Form. This allows the parent/guardian ample time
to have the physician form completed. A faxed order from the
physician will be accepted.
b. Include name of student, name of medication, dosage, time to be
given, duration of order.
2. All medication must be in the original container/package. Prescription
medication must have a current prescription label attached, with the
student’s name on the label.
3. All medications must be delivered to the school by an adult and given to a
nurse, teacher, administrator, or secretarial staff member along with the
proper consent/request paperwork. Parents/Guardians should make every effort to
speak with the nurse about the medication.
4. All medications must be kept in the custody of the school nurse.
a. In certain circumstances, students may carry their asthma medication
on their person if the following criteria are met :
1) The physician must indicate on the Physician Request Form that
the student may carry the asthma medication on his/her person
and that he/she is has demonstrated the ability to self-administer
the medication.
2) The parent/guardian must indicate on the Parent Consent Form
that the
student may carry the medication on his/her person and that
he/she is capable of self-administration.
3) The student must demonstrate to the nurse that he/she uses
proper technique when administering medication.
4) The student must notify the school nurse following each use of
the asthma inhaler.
5) If the asthma medication is made available to other children, the
medication will be confiscated. Parents/Guardians will be
notified. This action will result in the handbook policies
regarding distribution of drugs to be followed.
b. With this self-administration of asthma medication policy, the Fell
Charter
School bears no responsibility for ensuring that the medication is
taken.
Medication requests must be renewed each school year and medications
should be picked up at the end of each school year, or they will be disposed
of 10 days after the last day of school.

*Fell Charter School is not responsible for injury/damages that result from the
administration of medication in accordance with Parent/Guardian and Physician request.
 FELL CHARTER SCHOOL
School Health Services

PHYSICIAN/PARENT’S
REQUEST FOR MEDICATION ADMINISTRATION

Dear Physician:
Please fill out the form below for your patient to receive medications during school hours.
This form may be faxed to the school nurse @ 282-0930. Thank you.

Student Name: __________________________ DOB: ____________ Grade: ______

Diagnosis: ______________________________________________________________

Name of Medication: _______________________________________

Dosage: __________________________________________________
Route of Administration: ___________________________________
Time to be Given: _________________________________________
Possible Side Effects: ______________________________________
Duration of Medication Order: ______________________________

If PRN, describe indications: ______________________________________________

_______________________________________________________________________

Significant side effects: ___________________________________________________

_______________________________________________________________________

Contraindications: ______________________________________________________

Curtailment of specific school activity (gym, recess): __________________________

Is student capable of self-administration supervised by a responsible adult if the

nurse is not available? ___________________________________________________

Is student able to carry asthma medication on his/her person and correctly self-
administer this medication within guidelines of school medication policy?
_______________________________________________________________________

Special instructions: _____________________________________________________

_______________________________________________________________________

Date: _____________ Physician Signature: _____________________________

***********************************************************************
I hereby release the Fell Charter School and its employees from any liability
for any injury that may result out of the administration of the above medication in
accordance with this request.
Date: _____________ Parent/Guardian Signature: _______________________
Thursday, February 05, 2009 (2).MAX
Thursday, February 05, 2009 (3).MAX
 FELL CHARTER ELEMENTARY SCHOOL
FREE & REDUCED LUNCH APPLICATIONS

Fell Charter Elementary School is proud to be a member of the National School Lunch
Program, and follows the guidelines laid out by the US Department of Agriculture. As part of
this program, students may be eligible for free or reduced breakfast and lunch meals.

Applications for free/reduced lunch will be available after August 1, 2011. It is very important
that each family enrolled at Fell Charter complete an application listing all the children in your
household. All information must be filled out on the application in order for it to be processed.
Applications are evaluated using the Federal Income Chart. Children receiving Food Stamps
or TANF, and most foster children, qualify for free meals and do not have to apply.

You may also fill out an application for free/reduced lunches on-line at:
www.compass.state.pa.us

It is very important to keep your child's lunch account current. Therefore, any student
with a negative balance of $12.00 or more on his/her lunch account will receive an
alternate lunch consisting of a cheese sandwich, fruit, and milk until the balance is
paid in full.
FELL CHARTER ELEMENTARY
Third Grade 6th - 8th Grades
SCHOOL 1 (24) pack of crayons #2 pencils
CLASS SUPPLY LIST 1 (8) pack of washable markers black or blue pens
1 pack colored pencils 1 box of tissues
2011-2012
1 package of pencils 2 binders
1 pair school scissors 1 pack colored pencils
** - items appreciated as donations 1 highlighters 1 pack crayons
4 two-pocket folders 1 pack washable markers
4 spiral notebooks 1 small pencil sharpener
Kindergarten 1 glue stick 2 glue sticks
1 pair round tip children’s 1 pencil box 1 bottle glue
scissors 1 marbled composition notebook 1 ruler
1 two-pocket plastic folder 1 ½” binder 6 notebooks
2 boxes of baby wipes or 1 12” ruler with cm & in 4 folders
disinfectant wipes 1 oversized old t-shirt or smock 1 flash drive (thumb drive)
1 box of tissues **1 box of tissues
1 oversized T-shirt or smock **1 box of baby wipes
4 glue sticks
1 (24) pack crayons
1 (8) pack washable markers Fourth Grade
1 pack of large beginner pencils 4 one subject notebooks
4 2-pocket folders
1 marble composition book
First Grade Supply List 1 pack pencils
1 (24) pack of crayons 1 art/pencil box containing:
1 package of pencils -crayons or colored pencils
1 pair of school scissors -scissors
3 two-pocket folders -small sharpener
5 spiral notebooks -glue (stick or bottle)
1 1” 3-ring binder -eraser(s)
1 oversized old t-shirt or smock **paper towels
2 glue sticks **tissues
1 pencil box
1 boxes of tissues
1 box of baby wipes Fifth Grade
1 (8) pack washable markers 1 (24) pack of crayons
1 pack of washable markers
2 pens
Second Grade 1 package of pencils
1 5-subject notebook 1 pack colored pencils
1 pencil box 1 highlighter
1 (24) pack crayons Dry Erase Marker
1 (8) pack washable markers Erasers
1 pack colored pencils 6 two-pocket folders
1 pack pencils 6 spiral notebooks per half year
1 pair of school scissors (12 total)
4 2-pocket folders 1 pair of scissors
1 oversized T-shirt or smock 2 glue sticks
1 old sock or washcloth for 1 box of tissues
whiteboard 1 small personal dictionary
1 box baby wipes 1 calculator
1 box tissues 1 Protractor