Peoria Heights Grade School 2014-2015
Student Schedule, Fees, and Other Important Information:
PHGS Registration Dates:
Tuesday, August 5th - 9:00 A.M. - 12:00 Noon & 4:00 P.M. - 7:00 P.M.
Wednesday, August 6th - 9:00 A.M. - 12:00 Noon & 4:00 P.M. - 7:00 P.M.
Monday, August 18th –First, opening FULL day of school with hot lunches served. Note: Early student
dismissal today 2:10 P.M. for all bus riders and K-4 children and 2:20 P.M. for 5-8 remaining students!
Class lists with students’ names will be posted on each classroom teacher’s door on the first day of school.
(Check class lists 8:30 A.M. – 8:40 A.M. and report to your classroom). Teachers will be in hallways to assist.
Bus transportation service begins on Monday, August 18th for all students. (All students must board busses only
at their assigned student bus stop).
Grades K-8 lunches may be purchased daily or weekly. Send lunch money to your student’s classroom or
homeroom teacher; not the school office. Individual cartons of milk may also be purchased. Lunch service
begins on Monday, August 18th. Please request a copy of the Free or Reduced Student Lunch Application Form
if you think your family income may make your student(s) eligible to receive a Free or Reduced price student
breakfast or lunch. The School Breakfast Program is at 8:15 A.M. daily in the PHGS cafeteria – student
breakfast entry is at the rear door, off the gym at 8:15 A.M.
Grade K-8 Breakfast is $1.25. Student Lunch price is $2.25 per day. Student milk price is 40 cents per carton.
Textbook rental fees are $65.00 per year, per student and are payable at the time of student registration.
These fees may be paid by credit card at the PHGS website at http://www.phcusd325.net/ (Click on EPAY)
We are required to have a copy of your child’s legal birth certificate on file. Your hospital “souvenir” birth
certificate is not a legally recognized document. We will temporarily accept the hospital birth certificate at
registration. Please secure a legal copy of the birth certificate no later than October 15th. (These can be
purchased at the Health Department or at the Court House/County Clerk/Vital Records) We will copy the legal
birth certificate for school use and return the original document to you for you to keep for family use.
All students new to PHGS are required to submit proof of student residency AT THE TIME OF
REGISTRATION. No child’s school registration will be finalized until proof of residency
documentation is provided to the PHGS Office.
(Please see back of this sheet,…Thank You!)
06/14
SCHOOL DAY TIMES
Bright Futures Pre-School Program / Early Childhood Education (ECE) Blended Classrooms
Two morning and two afternoon sessions (Hartman / Ingersoll).
Morning Session Schedule - 9:00 A.M. – 11:30 P.M., …Afternoon Session Schedule - 12:30 P.M. - 3:00 P.M.
(Both sessions are held 5 days weekly, subject to ISBE grant program, funding)
Kindergarten Program (A.M., 1/2 day option),….Morning Session - 8:45 A.M. - 12:00 P.M.
Grades K - 8 Full Day Program
Full Day Schedule - 8:45 A.M. - 3:20 P.M.
No student arrival at school before 8:30 A.M.
(All Grade K-4 students and All Grade 5-8 bus riders are dismissed at 3:10 P.M.)
(All Grade 5-8 students that are NOT bus riders are dismissed at 3:20 P.M.)
Additional more detailed information about PHGS policies and procedures is available for
your review in the PHGS Parent-Student Handbook available on line at the Peoria
Heights Public Schools Web site @ http://www.phcusd325.net
(Click on “Schools”, click on “PHGS Photo”, click on “Information,
Click on PHGS Parent Student Handbook!)
If you have questions, please call the Peoria Heights Grade School Office at 686-8809!
06/14
Important Health and Immunization requirements for 2014-2015 are as follows:
If your child is entering Preschool he/she will need:
o A physical exam including a Diabetes screening and Lead screening
o 4 DtaP shots (Diphtheria, Tetanus, Pertussis)
o 3 Polio shots
o 1 HIB shot (Meningitis)
o 3 Hepatitis B shots
o 1 MMR shot (Measles, Mumps, Rubella)
o 1 Varicella shot (Chicken Pox) or proof of immunity
o Proof of age appropriate Pneumococcal shots
o TB screening
If your child is entering Kindergarten he/she will need:
o A physical exam including a Diabetes screening and Lead screening
o An eye exam performed by a licensed eye doctor
o A dental exam
o A DtaP (Diphtheria, Tetanus, Pertussis) booster shot after age 4
o Polio booster shot after age 4
o 2 MMR shots (Measles, Mumps, Rubella) New for the 2014-2015 school year!
o 2 Varicella shots (Chicken Pox) New for the 2014-2015 school year!
If your child is entering 2nd Grade he/she will need:
o Dental Exam
If your child is entering 6th Grade he/she will need:
o A physical exam including a Diabetes screening
o A dental exam
o TDaP shot
o Proof of 2 MMR shots (Measles, Mumps, Rubella) New for the 2014-2015school year!
o Proof of 2 Varicella Shots (Chicken Pox) or proof of immunity. New for the 2014-2015 school year!
o Proof of Hepatitis B series completed (3 shots total). New for the 2014-2015 school year!
All students 6th through 12th Grade will need:
o Proof of completed Hepatitis B series: 3 shots
o Proof of one dose of TDaP shot
o Proof of 2 MMR shots. New for the 2014-2015 school year!
If your child is entering 9th Grade he/she will need:
o A physical exam including a Diabetes screening
o Proof of 2 Varicella Shots (Chicken Pox) or proof of immunity. New for the 2014-2015 school year!
o Proof of 2 MMR (Measles, Mumps, Rubella) shots. New for the 2014-2015 school year!
o Proof of one dose of TDaP (Tetanus, Diptheria, and Pertussis) shot.
These records are required by Illinois State Law to be turned in to the school office by October 15th 2014. As
required by Illinois State Law, students in non-compliance will be excluded from school on October 16th 2014
Contact your family physician or the PHGS nurse’s office at 686-8809 if you have questions about the state
requirements.
(Please see back of this sheet,…Thank You!)
06/14
Health Issues & Habits
(Should I send My Child to School?)
Peoria Heights Grade School is fortunate to have access to a school nurse who provides
any needed care here at our school for children. The nurse maintains school medical and
immunization records and will contact you with any needed health examination forms that
are required for your child to attend school after October 15th (State Law). Please feel free
to contact the nurse at our school if you have any health related questions or information
to share with our school nurse.
Your child attending school while ill may pose a health risk to other children.
Please keep a few simple rules in mind when deciding whether or not to send your
child to school.
o Children should be fever-free (without the aide of medication) for 24 hours.
o Children should be free of stomach flu symptoms for 24 hours.
o Children taking doctor prescribed antibiotics should have been on the medication for
24 hours.
Please follow these healthy habits to ward off student illness:
o
o
o
o
o
o
o
o
Wash hands with warm soapy water
Cough & sneeze into tissue
Use hand sanitizer
Drink lots of fluids / Eat healthy foods
Get plenty of sleep
Dress warm enough for the weather
Check regularly (daily) for head lice
Report communicable illness to the school office
Questions? Call PHGS at 686-8809 and ask to speak to the school nurse.
Thanks for your efforts and support to keep ALL children at PHGS healthy!
Our Common Goal = ALL children attending school and healthy every day!
06/14
PEORIA HEIGHTS GRADE SCHOOL LIST OF SCHOOL SUPPLIES (Grades K-8)
NOTE: Students in grades K-4 have small cubby areas available for use in classrooms. Please do not send your child to
school with a book-bag or backpack that is too large to fit in the classroom cubby. Cubby spaces are 12 inches deep and 7
inches wide. Students in Grades 5-8 have lockers available for use to place personal items under lock to discourage items
being taken by others. The lockers are 11 inches wide by 10.5 inches deep, with a diagonal measurement of about 13.5
inches. Please do not send your student to school with a book-bag or backpack that is too large to fit in the locker.
KINDERGARTEN
2 Boxes of Crayons - 8 Colors
1 Change of Clothes, Sealed in a Baggie
1 Pair of Gym Shoes, Non Marking Soles
1 Large Elmer's White Glue (Orange Cap)
1 Pencil Box
FIRST GRADE
2 Plastic Pocketfolders (No Trapper Keepers)
2 Large Elmer's White Glue (Orange Cap)
1 Pair of Gym Shoes, Non Marking Soles
2 Erasers (Pink Pearl or Similar)
1 Hand Wipes / Sanitizer
1
2
5
1
1
10
1
1
2 Pocket Folder
Large Boxes of Kleenex
#2 Pencils
Hand Wipes / Sanitizer
1
1
1
1
Flash Drive (4G or Larger)*
Book Bag
Pair Fiska Scissors
Adult T-Shirt, for Painting
Box of Crayola Crayons
#2 Pencils, Not Jumbo
Adult T-Shirt, for Painting
Pair of Pointed Scissors
1
1
2
1
Flash Drive (4G or Larger)*
Pencil Box (Cigar Size)
Large Boxes of Kleenex
Water Color Paint Set
SECOND GRADE
2 Wide Ruled Spiral Notebooks
1 Eraser (Pink Pearl or Similar)
1 Large Elmer's White Glue (Orange Cap)
1 Pair of Gym Shoes, Non Marking Soles
1 Gallon Size Zip Lock Plastic Bag
5
1
1
1
1
#2 Pencils
Pair of Pointed Scissors
Large Elmer's Glue Stick
Hand Wipes / Sanitizer
Large Box of Crayons
1
1
1
2
Flash Drive (4G or Larger)*
Large Box of Kleenex
Water Color Paint Set
2 Pocket Folders
THIRD GRADE
1 Large Elmer's White Glue (Orange Cap)
1 Eraser (Pink Pearl or Similar)
1 Ruler (Metric/English)
1 Pair of Gym Shoes, Non Marking Soles
2 Pkgs, Wide Ruled Notebook Paper
2
1
2
1
3
Large Boxes of Kleenex
Pair of Pointed Scissors
Spiral Notebooks
Box of Water Colors
2 Pocket Folders
1
1
4
1
1
Flash Drive (4G or Larger)*
Box of Crayons
#2 Pencils
Box of Colored Pencils
Hand Wipes / Sanitizer
FOURTH GRADE
1 Box of Crayons (24)
1 3-Hole, Wide Ruled Notebook Paper
1 Box of Non-Toxic Markers (Optional)
1 Eraser (Pink Pearl or Similar)
1 Ruler (Metric/English)
1 Pair of Gym Shoes, Non Marking Soles
3
1
4
1
2
1
Spiral Notebooks
Small Pencil Sharpener
#2 Pencils
Large Box of Kleenex
2 Pocket Folders
Red Pen
1
1
1
1
1
1
Flash Drive (4G or Larger)*
Elmer's Glue (8 oz)
Pair of Scissors
Box of Colored Pencils
Hand Wipes / Sanitizer
Highlighter
LABEL ALL MATERIALS WITH STUDENT’S NAME
Please see back of this page, also….Thank You!
06/14
PEORIA HEIGHTS GRADE SCHOOL LIST OF SCHOOL SUPPLIES (Continued)
FIFTH GRADE
3 Pkgs. Loose Leaf, Wide Ruled, Notebook Paper
1 Box of Washable-Colored Markers (Non-toxic)
1 Ruler (Metric/English)
1 Pair of Gym Shoes, Non Marking Soles
1 Elmer Glue-8 oz (Liquid, NOT stick)
3 Pkgs. #2 Pencils NO MECHANICAL)
2 Pkgs. Note Cards
1 Quart Size Ziploc Bag
1
1
1
2
1
1
1
1
Large Box of Kleenex
Box of Colored Pencils
Solar Powered Calculator
Erasers (Pink Pearl or Similar)
Pair of Scissors
Spiral Notebook (Wide Ruled)
Pocket Folder
Hand Wipes / Sanitizer
1
1
1
1
2
2
1
1
Flash Drive (4G or Larger)*
Gallon Size Ziploc Bag
Box of Crayons (16)
Clear Plastic Protractor
Red Pens
Blue Pens
Compass
Highlighter
SIXTH GRADE
1 Elmer Glue-8 oz (Liquid, NOT stick)
1 Box of Washable-Colored Markers (Non-toxic)
1 Pkg. Loose Leaf, Wide Ruled, Notebook Paper
1 Box of Colored Pencils
1 Pair of Gym Shoes, Non Marking Soles
1 Eraser (Pink Pearl or Similar)
1 Solar Powered Calculator
1
1
1
1
1
2
1
Ruler (Metric/English)
Clear Plastic Protractor
Ehle Extra Fine Tip Marker
Compass (Metric/English)
3-Ring Notebook (8 1/2 x 11)
Medium Ball Point Pens
Hand Wipes / Sanitizer
1
1
1
4
2
5
1
Flash Drive (4G or Larger)*
Box of Crayons (16)
Pair of Scissors
2 Pocket Folders
Spiral Notebooks
#2 Pencils
Large Box of Kleenex
SEVENTH and EIGHTH GRADE
4 Medium Ball Point Pens (Black or Blue)
1 Box of Watercolor Markers (Non-toxic)
10 Spiral Notebooks (8 1/2 x 11)
1 Pair of Gym Shoes, Non Marking Soles
1 PE Uniform-REQUIRED (Purchase at School)
1 100-Pack of Index Cards (3 x 5)
1
12
1
1
4
1
Highlighter
#2 Pencils
Box of Colored Pencils
Eraser (Pink Pearl or Similar)
Medium Ball Point Pens (Red)
Large Box of Kleenex
1
3
1
1
1
1
Flash Drive (4G or Larger)*
Glue Sticks
Ruler (Metric/English)
3 Ring Binder (1-inch) for English
Solar Powered Calculator
PE/GYM Bag (Optional)
*Flash Drive may kept at home for shared home/school use – Teacher will announce when needed at school
All PHGS students and their family members are encouraged to secure a Peoria Heights Public Library, “Library
Membership Card”. The card entitles your students to check out library materials and make use of other library services
that have definite educational benefit to the work our teachers coordinate with your child here at PHGS and PHHS.
Library staff members often coordinate units of study with our teachers and can provide invaluable research assistance.
Electronic access enables your Peoria Heights Public Library to link and share with other libraries throughout the United
States. Open up your child’s world of learning with frequent visits to the Peoria Heights Public Library. It’s a great and
FREE community resource!
Additional supplies for special class activities may be requested during the school year. The special nature of these
supplies makes it impractical to list them separately.
LABEL ALL MATERIALS WITH STUDENT’S NAME
06/14
PEORIA HEIGHTS COMMUNITY UNIT SCHOOL DISTRICT #325
2014 - 2015 SCHOOL CALENDAR
August 14
August 15
Teachers Institute
Teachers Institute
August 18
First Day of School-Hot Lunches served
September 1
Labor Day
September 18
Half-Day Parent/Teacher Conferences
September 19
Full-Day Parent/Teacher Conferences
September 24
Half Day School Improvement
October 13
Columbus Day
1st Grading Period Ends
Early Dismissal
October 17
October 31
Half-Day School Improvement
November 11
November 26-28
December 22-Jan. 4
January 19
Veterans Day
Thanksgiving Break
2nd Grading Period Ends
Early Dismissal
Winter Break
Martin Luther King's Birthday
January 28
Half-Day School Improvement
February 13
February 16
Full-Day Parent/Teacher Conferences
President's Day
February 25
Half-Day School Improvement
December 19
March 20
3rd Grading Period Ends
Early Dismissal
County Institute
March 25
Half-Day School Improvement
March 30 - April 6
Spring Break
May 6
Half-Day School Improvement
May 25
Memorial Day
Last Day of School for Students
*if any emergency days are used, the last
day of school will be moved
March 6
May 26
May 27*
No School
No School
HS dismissed @ 2:00 p.m.
GS dismissed @ 2:20 p.m
No School
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00
No School
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00 n oon
No School
HS dismissed @ 2:00 p.m.
GS dismissed @ 2:20 p.m.
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00 noon
No School
No School-Wednesday, Thursday, Friday
HS dismissed @ 2:00p.m.
GS dismissed @ 2:20p.m.
No School – Classes resume January 5th
No School
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00 noon
No School
No School
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00 noon
HS dismissed @ 2:00 p.m.
GS dismissed @ 2:20 p.m.
No School
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00 noon
No School - Classes resume April 7
HS dismissed @ 11:30 a.m.
GS dismissed @ 12:00 noon
No School
HS dismissed@ 2:00 p.m.
GS dismissed @ 2:20 p.m.
*if emergency days are not used, the day
Teachers Institute - Last Day for Teachers for Teachers Institute will be held on May
27
* May be changed by Board Action
06/14
PEORIA HEIGHTS COMMUNITY UNIT SCHOOL DISTRICT #325
CURRENT ENROLLMENT INFORMATION
GRADE ______________________
(The one you are going into.)
DATE __________________________
NAME OF STUDENT_______________________________________________________________
LAST
FIRST
MIDDLE
Birth date proven by birth certificate _______________________________
NAME OF MOTHER OR GUARDIAN _________________________________________________
FIRST
LAST
MOTHER/GUARDIAN- HOME # ____________________ CELL# _________________________
NAME OF FATHER OR GUARDIAN__________________________________________________
FIRST
LAST
FATHER/GUARDIAN- HOME # ____________________ CELL# _________________________
ADDRESS OF STUDENT ___________________________________________________________
PLACE OF EMPLOYMENT OF PARENT OR GUARDIAN
MOTHER ___________________________________ WORK# _____________________________
FATHER ___________________________________ WORK# _____________________________
NAME OF FAMILY PHYSICIAN _______________________ PHONE # ____________________
06/14
Bus Routes and Times
Peoria Heights Grade School
Bus Rider Eligibility and Bus Route Information
Children Eligible to Ride the School Bus Include:
Children living “above the hill” in Peoria Heights, south of the south side of Lake Street, East of
Prospect Road, and south of Grandview Drive east of Prospect Road, will be bussed to Peoria Heights
Grade School.
and….
Children living “below the hill” in Peoria Heights, on Galena Road, or on streets off Galena Road, will
be bussed to Peoria Heights Grade School.
and…
All Early Childhood students living anywhere in Peoria Heights, will be bussed to Peoria Heights Grade
School.
It will take a week of school before an approximate time for the pick-up of children at bus stops is
known by parents. Until the route is established and you have a better idea of the exact pick-up time,
please have children ready at the bus stop at 8:00AM.
Bus stops are made at:
Above the Hill:
London and
Boulevard and
Cox and
Division and
Monroe and
Hines and
Atlantic and
Glen and
Columbus and
Atlantic, Central and Boulevard
Division and Cox
Illinois
Atlantic and Monroe
Cox and Hines
Atlantic
Rouse
Constantine and Marietta
Duryea, Seiberling, Kelly and Moneta
Below the Hill:
Galena Road and
Gardner Lane and
Poplar Lane, Longshore, Derby, Koch, Sankoty Drive, Terrace Ct.,
Terrace View Lane, St. Jude Ct., Riverview Ct. and Roosevelt Hill
Forest Park Apartments (Bus Stop), Eugenia Ln. and Cord Ct.
Bus rider behavior rules that all students are required to follow, are listed in the Parent-Student
Handbook. Please review these rules with your student, explain to the child your expectation that all
these rules are to be followed, and emphasize the inconvenience that would be created if the student lost
the bus riding privilege by breaking rules.
NOTE: All students must board busses only at their assigned bus stop. The privilege of riding the
school bus may be revoked if the student refuses to follow bus rider rules, or exhibits conduct that
places the safety and welfare of others present on the bus in jeopardy.
06/14
All students in Grades K-4 will be released at the same time @ 3:10 P.M. Bus riders will exit the front of
the school to board busses. The remaining K-4 students will exit the rear of the school as usual. All other
parking and pick-up rules in place to promote student safety remain in place. The only change is that
students in Grades K-4 who are picked up by parents will be released 10 minutes earlier at 3:10P.M.
Bus riders in grades 5-8 will be released at 3:10P.M. All other 5-8 students* will be released at 3:20.
Staggering the release time should reduce traffic in the rear of the school as parents are picking up Grade
K-4 students. Parents may exit the parking lot earlier and leave more space for parents picking up
students in Grades 5-8 ten minutes later.
A Grades 5-8 student MUST HAVE supervision responsibilities with a Grade K-4 student to be released at
3:10P.M.
*NOTE: If you are here picking up students in Grades K – 4 at 3:10 and also need to pick up a
Grade 5-8 student at the same time, we need you to complete the form below giving the name, grade,
and homeroom teacher of ALL students you are picking up. The additional student(s) you list will
be released from Grades 5-8 at 3:10 to enable you to pick up all your children at once. Complete the
form below as needed and return it to your grade 5-8 homeroom/classroom teacher by the first full
day of school.
RETURN THIS FORM TO YOUR CLASSROOM/HOMEROOM TEACHER
THE FIRST FULL DAY OF SCHOOL AS NEEDED
To: The Grade 5-8 Classroom I Homeroom teacher of (student name) ___________________________
Homeroom Teacher: ________________________ Grade ________________ Date ____________________
I am a parent who needs to pick up students from Grades K-4 and Grade 5-8 both at 3:10P.M.
The Grade 5-8 student(s) listed below is being picked up by me at 3:10 P.M. or is assisting in getting a child
in Grades K-4 home from school at the 3:10 dismissal:
Name: __________________________ Grade __________ HR/Classroom Teacher________________________
Name: __________________________ Grade __________ HR/Classroom Teacher________________________
Name: __________________________ Grade __________ HR/Classroom Teacher_________________________
Name: __________________________ Grade __________ HR/Classroom Teacher_________________________
Name: __________________________ Grade __________ HR/Classroom Teacher_________________________
Parent Name/Signature_____________________________________ Phone # _____________________________
If you have questions please call Mr. Carroll @ PHGS @ 686-8809. Thanks for your help!
06/14
Residency Proof- Peoria Heights Grade School
Note: Residency proof must be provided before a new student will be registered. The student
must be residing in Peoria Heights at the time of registration.
Sadly, each year we have families attempt to declare false residency in Peoria Heights to have their
children attend Peoria Heights Grade School. We have an obligation to the taxpayers in the
community, whose tax dollars fund our schools, to ensure that children attending PHGS have a legal
right to do so. We diligently check student residency to meet the obligation owed to those who pay
for the schooling of Peoria Heights children attending Peoria Heights schools.
Illinois law requires that students attend school in the school district w here· they and/or their custodial
parent(s) or legal guardian reside. A Peoria Heights Grade School registered student must
legally meet the Illinois School Code definition of residing at the Peoria Heights address for
school attendance purposes. Student residency may also be established based on meeting the state
criteria for being a "homeless child". Parents may also apply for student admission to, and if accepted,
pay tuition for a child to attend a public or private school, a public school outside their legal residency
school district, or may choose to home school their own child. Residency may not be falsely declared
with relatives, babysitters, etc., who live in Peoria Heights, solely for-the purpose of having students
attend Peoria Heights schools. It is illegal to declare false residency in the community of Peoria
Heights, for purposes of enrolling a student in Peoria Heights schools, and to defraud the school
district of tuition ·fees it is rightfully owed. If attempts to do this are reported or suspected, the school
district will require specific proofs of residency. Residency proofs are required of all new students
enrolling at Peoria Heights Grade School, or may be required of anyone, at any time we suspect false
residency has been declared by a parent. Students failing to meet residency requirements will be
removed from school, and reported as "truants" to the Peoria County Superintendent of Schools office.
Residency proof must be provided before-the student will be registered. Residency proof
Peoria Heights Grade School will accept include:
1. Rental property
(A) The Property Owner or Owner Agent form (This blank form is provided by the school
office) completed, signed, and notarized by the legal property OWNER, not renter, for
verification of Peoria Heights student residency. Parents must return the completed form, to
the school office, BEFORE student may register.
(B) A current executed rental agreement or lease agreement for verification of Peoria
Heights student residency. (PHGS confirms property ownership via the Peoria County
Recorder o.f Deeds Office.)
2. Privately owned residential property
A current utility (CILCO, Water) bill o r c u r r e n t t a x b i l l bearing the Peoria Heights
address and name of the resident adult enrolling a child in Peoria Heights Grade School.
If you have any questions, please call the PHGS office at 686-8809. Thank You!
06/14
Property Owner or Owner Agent (NOT RENTER)
VERIFICATION of STUDENT(S) and PARENTS - PEORIA HEIGHTS RESIDENCY
Peoria Heights Grade School VERIFIES all new student residencies with the assistance of
the Peoria Heights Police Department and the Peoria County Recorder of Deeds Office.
Parents, Custodial Parents, Foster Parent, Legal Guardian or Permanent Caretaker
Name: _________________________ Student Name:________________________ Grade: _______
Student Name: ________________________Grade: _______
Student Name: ________________________Grade: _______
Student Name: _______________________ Grade: _______
Declared Peoria Heights Residency Address: _____________________________________________
I am the____ Property Owner or _______ Property Renter or ____ Reside with family/friend.
PLEASE CAREFULLY READ ALL INFORMATION
BELOW BEFORE SIGNING THIS FORM
I certify by signing below, that I am the property owner or owner agent (NOT RENTER), of the Peoria Heights
Address shown above. I confirm that the parent or legal guardian named above, and or student named above,
is/are residing at the listed Peoria Heights address, located within the Peoria Heights School District residency
attendance area. I understand, as outlined below, the possible criminal consequences of falsifying residency
information.
NOTE: A parent who designates another adult as "Permanent Caretaker" of their child, must attach to this
form, an explanation of the reason for establishing residency for your child in Peoria Heights with the caretaker
you have chosen. The reason for establishing your child 's residency with the caretaker must be approved by
District #325 administration for your child to be enrolled in a Peoria Heights school.
I confirm by signing this form, that I understand that attempts by anyone attempting to, or being party to, falsely
establishing Peoria Heights residency solely for the purpose of attending Peoria Heights Schools, with the intent
and/or result of defrauding the school district of tuition money it is entitled to by students and their families who
are NOT Peoria Heights residents, is a criminal act that may result in criminal prosecution.
"Enrollment Fraud" is a criminal act, which is punishable by 30 days in jail, a $500
fine, and tuition reimbursement restitution to the Peoria Heights Public School District.
Signed By: __________________________ (_____________________________) Date:______________
(Property Owner or Agent – NOT RENTER)
(Printed Name)
Property Owner/Agent Address: ___________________________________
Phone # _______________
Notary Name Signature and Seal: __________________________________
Date: _________________
THIS PROOF OF RESIDENCY FORM MUST BE NOTARIZED
06/14
Peoria Heights School District #325 Student Health Information Sheet
Students Name : __________________________________________________
Gender: M / F
Birthdate: ________________________________ Grade _________ Teacher ________________________
Please check any condition(s) your child may have:
______Asthma
______Bowel problems
______Nosebleeds
______Diabetes
______Heart problems
______Skin problems
______Ear infections/tubes ______Blood pressure problems ______Emotional/Behavior problems
______Hearing problems
______Bone disease or injury
______Speech problems
______Vision problems
______Blood disorders
______Urinary problems
______Epilepsy/Seizures
______Other
Allergies: What is your child allergic to? Please be specific _______________________________________________________
_______________________________________________________________________________________________
Circle the type of reaction that may occur: Hives Swelling Breathing Difficulties
Other reactions: __________________________________________________________________________________
Please list any emergency medication or treatment that may be needed at school:_______________________________
_______________________________________________________________________________________________
Please check here if your child has NO KNOWN ALLERGIES_______
Asthma: What triggers an episode? __________________________________________________________________________
What medication is used? _________________________________________________________________________
Circle when medication is needed: Daily
Before P.E./Sports
Only when symptoms occur
Diabetes: If insulin is needed at school, what parameters are followed? ______________________________________________
_______________________________________________________________________________________________
When are blood sugar checks required? _______________________________________________________________
If snacks are needed at school please list what and when: _________________________________________________
Seizures: How often do seizures occur? ______________________________________________________________________
Does anything proceed or trigger the seizures? _________________________________________________________
What type of seizures? ____________________________________________________________________________
Is medication needed at school to treat any seizures? ____________________________________________________
Vision Problems: Does your child wear glasses or contacts? Yes/No Is special seating needed? Yes/No
Hearing Problems: Does your child have a known hearing loss? Yes/No Is special seating needed? Yes/No
Does your child wear a hearing aid? Yes/No
Please list any dietary restrictions: ___________________________________________________________________________
(We must have a note from your physician on file to follow through with this)
Please list and explain any other health, serious illness, injuries, conditions, past operations, learning or behavioral problems you feel
that the school should be aware of: ___________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please list any medication that your child takes on a regular basis: ___________________________________________________
________________________________________________________________________________________________________
(If your child needs medication at school, please see the Nurse to verify times, dosages, and fill out the proper paperwork)
I give Peoria Heights School District permission to keep this information sheet on file in the medical files. I realize that my child’s teachers have
access to this information. In the event of an emergency where in the judgment of school authorities urgent medical care is indicated and I cannot be
reached, I also give permission for my child to be transported by ambulance to a hospital and for a doctor or medical personnel to give emergency
treatment.
I prefer my child to be treated at ______________________________________________ Hospital
Parent/Guardian Signature _______________________________________________________ Date : ________________________
If your child needs medication, special diet or P.E. restrictions at school, please contact the school nurse or office staff.
Additional forms signed by the doctor will be necessary.
06/14
Fiscal Year 2015 INCOME ELIGIBILITY GUIDELINES
The United States Department of Agriculture has issued the following income guidelines for the period July 1, 2014, through June 30, 2015:
income eligibility Guidelines
effective from July 1, 2014, to June 30, 2015
Free Meals
130% Federal Poverty Guideline
Household Size
Annual
Monthly
Twice Per
Month
Every
Two
Weeks
Reduced-Price Meals
185% Federal Poverty Guideline
Weekly
Household Size
Annual
Monthly
Twice
Per
Month
Every Two
Weeks
Weekly
1
15,171
1,265
633
584
292
1
21,590
1,800
900
831
416
2
20,449
1,705
853
787
394
2
29,101
2,426
1,213
1,120
560
3
25,727
2,144
1,072
990
495
3
36,612
3,051
1,526
1,409
705
4
31,005
2,584
1,292
1,193
597
4
44,123
3,677
1,839
1,698
849
5
36,283
3,024
1,512
1,396
698
5
51,634
4,303
2,152
1,986
993
6
41,561
3,464
1,732
1,599
800
6
59,145
4,929
2,465
2,275
1,138
7
46,839
3,904
1,952
1,802
901
7
66,656
5,555
2,778
2,564
1,282
8
52,117
4,344
2,172
2,005
1,003
8
74,167
6,181
3,091
2,853
1,427
7,511
626
313
289
145
For each
additional
family member,
add
5,278
440
220
203
For each
additional
102 family member,
add
The following is the definition of income:
Income is defined as any monies earned before any deductions such as income taxes, social security taxes, insurance premiums, charitable contributions, and bonds.
It includes the following: (1) monetary compensation for services including wages, salary, commissions, or fees; (2) net income from non-farm self-employment; (3)
net income from farm self-employment; (4) social security; (5) dividends or interest on savings or bonds or income from estates or trusts; (6) net rental income; (7)
public assistance or welfare payments; (8) unemployment compensation; (9) government civilian employee or military retirement or pensions or veteran payments;
(10) private pensions or annuities; (11) alimony or child support payments; (12) regular contributions from persons not living in the household; (13) net royalties; and
(14) other cash income. Other cash income would include cash amounts received or withdrawn from any source including savings, investments, trust accounts, and
other resources which would be available to pay the price of a child’s meal.
ISBE 67-45 IEG14 (3/14)
APPLICATION FOR FREE MILK/MEAL AND REDUCED-PRICE MEALS-Complete One Application Per Household Per School District Instructions on
1.
back.
NAMES OF ALL HOUSEHOLD MEMBERS
Fir.>~ Middle Initial. Last
School Name
Gmde
be provided below.
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Homeless
3. Total
D
Migrant
D
D
Runaway
Head Start
D
D
D
D
D
D
-
D
D
D
D
D
0
Stgnature of Your SChOOl Homeless Uaison, Migrant Cooid1nator, or Head Start Dtrector
bate
Household Gross Income (before deductions) You must tell us how much and how often.
A.
GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month; $100 /twice a month; $100/every other week; $100/Week)
NAMES
(LIST ALL HOUSEHOLD MEMBERS
'MTH INCOME)
Earnings From Work
(Before Deductions)
B.
Amount
Welfare, Child
Support, Alimony
How often?
c.
Amount
Pensions, Retirement,
Social Security
How often?
D.
Amount
Worker's Comp., UnemploySSI, etc. (An other income)
men~
How often?
E.
i.
s
s
s
$
ii.
$
s
$
$
iii.
s
$
s
iv.
$
s
s
s
v.
s
s
s
s
4.
Chec;kif CheckK
NO
Foster
Income Child•
• A foster child is the legal responsibility of a welfare agency or court.
2. Homeless, Migrant, Runaway, or Head Start (Categorically eligible)
0
Check ~ Error Prone Application
SNAP OR TANF CASE NUMBER Skip lo Part 4 ~ ~ou
(forso-•.nr• Hst
a SNAP orTANF case number. At least one SNAPITAN must
<tor-onr)
I
SCHOOL USE ONLY
D
All H ousehold Members
Amount
How often?
Signature and Social Security Number (Adult must sign)
Anadulthouseholdmembermustsigntheapplication. lfPart3iscompletedorifno income ischecked
in Part 1 the adult signing the form must also list the last four digits his or her social security number
or mark 1he I do not have a social security number box.
-
X X X - X X -
- soa·al Secun·ty Number -
D
-
I do not have a social
security number.
I certify (promise) all information on this application is true and all income is reported. I understand the school will get Federal funds based on the information I give. I understand school officials may verify (check) the information. I understand if I purposely give false information, my children may lose meal benefits and I may be prosecuted.
Date
5.
Printed Name of Adult Household Member
Signature of Adult Household Member
Contact Information (Optional)
IM1rlc Telephone Number (Include Area Code)
Home Telephone Number (Include Area Code)
Home Address (Number. Street, City, State, Zip Code)
6. Children's Racial and Ethni c Identities (Optional)
Mark one ethnic identity:
0 Hispanic/latino
0 Not Hispanic/Latina
7.
Mark one or more racial identities:
0 Asian
0 Black or African American
0 \Nhite
0 American Indian or Alaska Native
Sharing Application Information With
0 Native Hawaiian or Other Pacific Islander
All Kid~A/1 Kids program is a complete healthcare program for every child in Illinois.
Sign here:
No! I DO NOT want information from my Household Eligibility Application shared with A// Kids.
- THE FOLLOWING SEC nONS ARE FOR SCHOOL USE ONLY-
TOTAL
INCOME$
Per:
O
Week
0
Every 2
Twice a
0
Weeks
Month
0 Month
0 Year
NUMBER IN
HOUSEHOLD:
CHANGE IN
STATUS:
Date
LEAs must annualize income only when multiple incomes, at vatying frequencies, are reported.
Annual Income Conversion Weekly X 52 Every 2 Weeks X 26 Twice a Month X 24
Once a Month X 12
0 Free based on:
Ohomeless
0 migrant
0 runaway
0 Head Start
0 SNAP or TANF
0 foster child
0 household's income
0 Reduced based on:
D household's income
0 D enied-Reason:
D income too high
0 incomplete application
0 Non-qualifying SNAP/TANF
g;tt::VIIIthdrawn: - - - - - -- - -
Signature of Determon1ng Off1c1al
THE FOLLOWING SECTIONS ARE NOT REQUIRED FOR SCHOOLS/DISTRICTS THAT ONLY PARTICIPATE IN IWNOIS FREE AND/OR SPECIAL MILK PROGRAMS
CONFIRMATION (Prior to verification and only for those applications selected for verification.)
DIRECT VERIFICATION COMPLETED
DATE VERIFICATION NOTICE SENT:
INITIAL DETERMINATION
0
Free based on SNAP/
TANF case number
'D"A"'T"'E"R"'E"'S"P"'O:;;:N-;<S'<'E"o"u"E"F"'R"'O"-M~----;0 Free based on income
HOUSEHOLD:- - - - -- - - 0 Reduced based on
(recommend 10 calendar days)
income
DATE. METHOD, RESULTS OF
0 Mail
~~;;:e~:~"bU:C:s"'ln;:;e:;:s;:-s""da::;-y:;:s)r---- Results
68-03 School Year 2014-2015 NSSTAP (6114)
0
Telephone
VERIFICATION RESULTS:
ONoChange
OFree to Reduced
0 Free tl PaKl
0 Reduced to Free
0 Reduced to Paid
0
Signature of Conftrmmg Off1c1al
0
0
0
_ _ _ _ _ _ _ _ _ _.Date;._ __ _ _
REASON FOR CHANGE:
Income; $ _ _ _ __ _ __
Household Size: - - - -- Change in SNAP/TANF
0 Did not respond
O Other.
DATE NOTICE OF STATUS
CHANGE SENT: -- - - EFFECTIVE DATE OF STATUS
CHANGE : _ __ _ _ ____
Personal Contact
Date;
I
For Free or Reduced Lunches
First Name __________________________________________
Last Name __________________________________________
Birth Date __________________________________________
Grade ______________________________________________
SNAP or TANF Case Number __________________________
06/14
Peoria Heights
Community Unit School District 325
OFFICE OF THE SUPERINTENDENT
________________________________________________________________________________________________________________________
500 E. Glen Avenue
Phone: 309-686-8800
Peoria Heights, IL 61616
FAX: 309-686-8801
Eric M. Heath, Superintendent
Eric.heath@ph325.org
AFFIDAVIT OF INABILITY TO PAY
(Textbooks and/or Fees)
Student’s
Name ____________________________________________ Address __________________________________________________
Student’s
Name ____________________________________________ Address __________________________________________________
Student’s
Name ____________________________________________ Address __________________________________________________
Parent or
Guardian _________________________________________ Address __________________________________________________
Father
Approximate
Employed at _______________________________________________________ Earnings per Month $ ________________
Mother
Approximate
Employed at _______________________________________________________ Earnings per Month $ ________________
Monthly income from
Welfare Agencies $ _________________________
Monthly income from
any other source (Pensions, Social Security, etc.) $ _______________
Reason for inability to pay:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I hereby certify that the above statements are true and aid is necessary.
Date: __________________________ Signature of Parent/Guardian ____________________________________________
===============================================================================================
For Office Use Only:
Approved _________________________________________
________________________________________
Principal
Superintendent
NOT
Approved _________________________________________
________________________________________
Principal
Superintendent
Reason for
Non-Approval _________________________________________ ________________________________________
Principal
Superintendent
06/14