Forms



FORMS TO BE COMPLETED AND RETURNED TO YOUR CHILD'S TEACHER Parents, In keeping with our //Going Green// (paperless) theme, we have put many of the forms that need to be filled out by you onto this wiki page. Below you will see several forms that need to be completed and returned to your child's teacher, as soon as possible. We ask that you complete these forms online and e-mail them back to us at your earliest convenience.  We hope that this will reduce the barrage of papers that come home and require your attention! A completed form with your name typed on the signature line will be considered electronically signed and valid when it comes to us in an e-mail from you.

Please note that none of the forms on this page replace the paper copy of forms originating from the district office or school office. 

Probably the easiest way to fill in these forms and get them back to us is for you to copy the forms on this page and either: 1) Paste the forms into a Word document, fill in the blanks, create a new e-mail addressed to Ms. Hensley or Mrs. West, and attach the Word document to the e-mail; or 2) Paste the copied forms directly into an e-mail, fill in the blanks, and send the e-mail directly to Ms. Hensley or Mrs. West.

If you have any difficulty with this, feel free to e-mail either teacher and we will send the forms to you in an e-mail. You will then be able to fill in the forms and send them back to us in the form of a reply to our e-mail. Please do not hesitate to contact either teacher if you need additional assistance.

Thanks for your timely attention to this matter and for your support of our //Going Green//  efforts.

Ms. Hensley's e-mail link: [|ahensley@waynesville.k12.mo.us]

Mrs. West's e-mail link: [|candicewest@waynesville.k12.mo.us]

REVIEW OF PICK 5TH GRADE WIKI
= = Student's Name: (insert student's name here) ........  <span style="font-family: 'Comic Sans MS',cursive;">

I, <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert parent name here) <span style="font-family: 'Comic Sans MS',cursive;">, along with my 5th grader have reviewed each page of the Wikispaces site pick5thgrade.wikispaces.com. Together we have carefully read through the Student Handbook page and have discussed the expectations spelled out in this handbook.

Parent Signature: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your signature here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="font-family: 'Comic Sans MS',cursive;">Date: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert date here) <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">5TH GRADE STUDENT INFORMATION
<span style="font-family: 'Comic Sans MS',cursive;"> While we realize that we ask for a great deal of information on this form, there is a very good reason for this: It is probable that during the school year your child will spend more of his/her waking hours with us than with you. The more information we have about your child the better we can tailor the learning experience to ensure the most positive and productive outcome possible for him/her. Thank you for taking the time to provide us with all the information requested.

Student's Name: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert student's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Birthdate: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert birthdate here) <span style="font-family: 'Comic Sans MS',cursive;"> Age as of August 1st: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert age here) <span style="font-family: 'Comic Sans MS',cursive;"> Student's Physical Address: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert street address, city, state, and zip code here) <span style="font-family: 'Comic Sans MS',cursive;"> <span style="font-family: 'Comic Sans MS',cursive;">Student lives with: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(delete any that do not apply) mother and father, mother only, father only, mother and step-father, father and step-mother, grandparent, other <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(please explain) <span style="font-family: 'Comic Sans MS',cursive;">. <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;"> Preferred e-mail address for parent of this student: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert the email address you wish for us to use to contact you) <span style="font-family: 'Comic Sans MS',cursive;"> Does this student wear glasses? <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(delete the one that does not apply) Yes No <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(If yes, please explain when the glasses should be worn, i.e., all the time, when reading/doing work, when working from the board)

<span style="font-family: 'Comic Sans MS',cursive;">We will be using a variety of food products, common household chemicals (alum, food coloring, corn starch, vinegar, ammonia, Lysol wipes, sanitizers, etc.) over the course of the year. Please list everything to which your child is allergic (medically diagnosed). <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(List all medically substantiated allergies here) <span style="font-family: 'Comic Sans MS',cursive;">

Has this student ever be retained?<span style="font-family: 'Comic Sans MS',cursive;"><span style="font-family: 'Comic Sans MS',cursive;"> <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;"> (delete the one that does not apply) Yes No <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(If yes, please indicate what grade was repeated and the reason for the retention.) <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">Academic and personal strengths of this student: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(list strengths here) <span style="font-family: 'Comic Sans MS',cursive;">

Do you have any academic, social, or behavioral concerns for this student? <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(delete the one that does not apply) Yes No <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(If yes, please explain.) <span style="font-family: 'Comic Sans MS',cursive;">

Is there anything in your student's academic and/or personal background that might impact his/her performance at school? <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(delete the one that does not apply) Yes No <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(If yes, please explain.) <span style="font-family: 'Comic Sans MS',cursive;">

How does your student get to and from school? <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(delete all that do not apply) <span style="font-family: 'Comic Sans MS',cursive;">Walks/rides bike, parent delivery/pick-up, SAS bus, other <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(please explain.) <span style="font-family: 'Comic Sans MS',cursive;">. Please notify the school (573-329-6262) __before 3:00 p.m.__ if you wish to change the way your child gets home on a particular day.

Persons (besides parent/legal guardian) allowed to pick up your student from school: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert person's name and contact phone #) (insert person's name, and contact phone #) <span style="font-family: 'Comic Sans MS',cursive;"> Siblings of your student that attend Pick Elementary School: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert sibling's name, grade, and teacher's name here) (insert sibling's name, grade, and teacher's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Siblings of your student that attend a different school in the Waynesville School District : <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert sibling's name, grade level, and school name) (insert sibling's name, grade level, and school name)

<span style="font-family: 'Comic Sans MS',cursive;">__**CONTACT INFORMATION**__ Mother's home e-mail: <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(insert your home e-mail here) <span style="font-family: 'Comic Sans MS',cursive;">Mother's work e-mail: <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(insert your work e-mail here) <span style="font-family: 'Comic Sans MS',cursive;"> Branch of service: Air Force, Army, Marines, National Guard, Navy, None <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(delete all that do not apply) <span style="font-family: 'Comic Sans MS',cursive;">Mother's commanding officer: <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(If applicable, insert commanding officer's name and phone # here)
 * Mother**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert mother's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">**Father**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert father's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;"> Father's home e-mail: <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(insert your home e-mail here) <span style="font-family: 'Comic Sans MS',cursive;">Father's work e-mail: <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(insert your work e-mail here) <span style="font-family: 'Comic Sans MS',cursive;"> Branch of service: Air Force, Army, Marines, National Guard, Navy, None <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(delete all that do not apply) <span style="font-family: 'Comic Sans MS',cursive;">Father's commanding officer: <span style="font-family: 'Comic Sans MS',cursive; color: rgb(255, 0, 0);">(If applicable, insert commanding officer's name and phone # here) <span style="font-family: 'Comic Sans MS',cursive;"><span style="font-family: 'Comic Sans MS',cursive;"> Emergency contact**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert contact's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">**Emergency contact**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert contact's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #)
 * Please list two additional people we can contact should we be unable to get in touch with either parent.

I will immediately notify my child's teacher by e-mail if any of the above information should change.

Parent Signature: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your signature here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="font-family: 'Comic Sans MS',cursive;">Date: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert date here) <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">TECHNOLOGY
<span style="font-family: 'Comic Sans MS',cursive;">Student's Name: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert student's name here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;"> <span style="font-family: 'Comic Sans MS',cursive;">

I, <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert parent name here) <span style="font-family: 'Comic Sans MS',cursive;">, understand that using technology (computers/internet, word processing software, educational software, etc.) is an integral part of the 5th grade learning experience at Pick Elementary School. I give my student permission to use the computers and other technology at Pick Elementary School in connection with learning goals specified in the district curriculum. I give my permission for my student to do internet searches, as needed, under the supervision of a teacher or an aide. I have discussed the importance of appropriate use of the internet with my student. My student and I understand that should (s)he choose to use any of the technology at Pick Elementary School in an inappropriate manner, (s)he will no longer be allowed to use any of the technology tools belonging to the school and that any future work requiring the use of technology will have to be done at home.

Parent Signature: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your signature here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="font-family: 'Comic Sans MS',cursive;">Date: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert date here) <span style="font-family: 'Comic Sans MS',cursive;"> Student Signature: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your signature here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="font-family: 'Comic Sans MS',cursive;">Date: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert date here) <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">FIELD TRIP PERMISSION
<span style="font-family: 'Comic Sans MS',cursive;">Student's Name: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert student's name here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;"> <span style="font-family: 'Comic Sans MS',cursive;">

I, <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert parent name here) <span style="font-family: 'Comic Sans MS',cursive;">, understand that my student may have the opportunity to go on one or more field trips during the school year and that the field trip(s) will require that my child ride a school bus to and from the destination, unless I choose to personally provide transportation for him/her. (If I choose to provide transportation for my child, I will notify my child's teacher at least 24 hours before the scheduled trip.) I have discussed appropriate field trip behavior with my child, including the following: 1. Remain seated at all times while on the bus. 2. Follow all directions given by an authorized adult (teacher, aide, bus driver, tour guide, etc.). 3. Whenever a student participates in a school activity, (s)he serves as an ambassador for Pick Elementary School and the Waynesville School District. Observers judge our school and school district based on the way they see students behave. It is expected that students will always behave in a manner that would cause anybody to realize that Pick Elementary School is a proud supporter and participant in the PBS initiative [|pbismissouri.org]. 4. If a student chooses to engage in inappropriate behavior while on a field trip, his/her parent may be called and asked to come get the student. It is very likely that any student who chooses to misbehave will not be allowed to go on any future field trips.

I understand that I will be notified of any upcoming field trips in two ways: 1) an e-mail from one of the 5th grade teachers and 2) a notification posted to the Announcements page on the Pick 5th grade wiki pick5thgrade.wikispaces.com/Announcements.

My student has the following health and/or behavioral concerns that may become an issue while on a field trip: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(Please list any health or behavioral issues you child has __**AND**__ how you wish for these issues to be handled, should they occur). <span style="font-family: 'Comic Sans MS',cursive;">Concerns to be included in this list should include any tendency toward motion/car sickness, allergies, any chronic medical condition such as asthma or diabetes, ADHD, ODD (Oppositional Defiance Disorder), and/or a serious conflict with another student who might be attending the field trip.

<span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(Please decide which of the following best describes your child's swimming ability then delete the other two descriptors.) <span style="font-family: 'Comic Sans MS',cursive;">My child cannot swim. My child can swim, but is not a strong swimmer. My child is a strong swimmer. <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;"> <span style="font-family: 'Comic Sans MS',cursive;">

__**CONTACT INFORMATION**__ <span style="font-family: 'Comic Sans MS',cursive;"> Emergency contact**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert contact's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">**Emergency contact**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert contact's name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #)
 * Mother**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">
 * Father**: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your name here) <span style="font-family: 'Comic Sans MS',cursive;"> Home phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Work phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #) <span style="font-family: 'Comic Sans MS',cursive;">Cell phone #: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(phone #)
 * Please list two additional people we can contact should we be unable to get in touch with either parent.

I will immediately notify my student's teacher by e-mail should the list of health/behavioral concerns or the contact information change in any way.

Parent Signature: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your signature here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="font-family: 'Comic Sans MS',cursive;">Date: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert date here) <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">PERMISSION TO ATTEND AFTER-SCHOOL ACADEMIC ASSISTANCE
<span style="font-family: 'Comic Sans MS',cursive;">Student's Name: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert student's name here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;"> <span style="font-family: 'Comic Sans MS',cursive;">

I understand that one or both 5th grade teachers will be available after school at least one day a week* to provide Academic Assistance (tutoring) for any 5th grade student who could benefit from additional instruction or assistance. There is no charge for this service. Academic Assistance will be held from 3:30 - 4:45 p.m. To be sure that everybody is safe and where they are supposed to be, students who stay for Academic Assistance will not be permitted to leave early unless a parent calls or notifies a teacher by e-mail ahead of time.

It will be left to the student and parent to determine whether a student will stay for Academic Assistance. Please be sure your student knows **before (s)he leaves home in the morning** if (s)he is or is not to stay for Academic Assistance. (Unless there are extenuating circumstances, students may not call a parent to get permission to stay for Academic Assistance. Such arrangements should be made **before a student leaves for school** on Academic Assistance day.) If your 5th grader is responsible for walking home with siblings, those siblings are welcome to come to the Academic Assistance room and read, do homework, or engage in any other quiet activity that does not disturb students staying for Academic Assistance.

All students who attend Academic Assistance will be released through the front door of the school at 4:45 p.m. If nobody is there at 4:45 p.m. to pick up a student, that student will be released to walk home. If your student is expecting you to pick him/her up from Academic Assistance and an emergency should occur that prevents you from being at the school at exactly 4:45 p.m., call Mrs. West's cell phone (573-528-5948) and alert us to the situation.

In the event of impending or actual inclement weather, we will not have Academic Assistance. Please call the school if the weather is questionable and you want to know whether we will be having Academic Assistance.

Parent Signature: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert your signature here) <span style="color: rgb(255, 255, 255); font-family: 'Comic Sans MS',cursive;">........ <span style="font-family: 'Comic Sans MS',cursive;">Date: <span style="color: rgb(255, 0, 0); font-family: 'Comic Sans MS',cursive;">(insert date here) <span style="font-family: 'Comic Sans MS',cursive;">


 * Please check the Announcements page pick5thgrade.wikispaces.com/Announcements to see the day of the week that has been reserved for Academic Assistance. This posting will be done after meeting schedules have been set for the year. Academic Assistance will begin after we return from the Labor Day holiday.