0320-E (

(1) Keeps the BOE informed on the conditions of
the district’s educational system
(2) Assures preparation of agendas for Board meetings
w/supportive materials
(3) Assists the BOE w/developing the overall goals
for the educational system
(4) Assists the BOE with long range planning consistent
with population trends, educational needs and
the appropriate use of district facilities
(5) Develops/provides specific regulations & programs
to implement the policies established by the Board of Education
(6) Serves as Chief Executive Officer and
executes all decisions of the Board of Education
(7) Serves as liaison between the Board and staff
(8) Recommends the appointment, promotion, retirement
and release of district personnel
(9) Offers professional advice to the BOE
on items requiring Board action
(10) Remains impartial toward the Board treating
all BOE members alike
(11) Honors confidentiality for items discussed in executive sessions

B. Job Related Functions

(1) Recruits/assigns the best available personnel
(2) Administers procedures for seeing that all funds, physical assets & other property of the district are appropriately safeguarded
(3) Promotes high standards of performance throughout the district
(4) Approachable by staff/students/community to listen and/or respond to needs and concerns
(5) Delegates authority to staff appropriate to their positions
(6) Maintains professional development by reading, conference attendance work on professional committees, visiting other districts & superintendents
(7) Encourages participation of appropriate staff members in professional growth experiences
(8) Demonstrates ability to make effective decisions
(9) coordinates with the administrative personnel a planned program of staff evaluation and improvement
(10) Assures preparation and administration of annual budget in compliance with Board and state guidelines
(11) Maintains high standard of ethics, honesty & integrity in all professional matters
(12) Demonstrates ability to work welt with individuals and groups

ADOPTED: October 22, 1997 WAYNE CENTRAL SCHOOL DISTRICT

0320-E-2

C. Superintendent’s Yearly Priorities
(To be mutually developed and agreed upon each year by Board & Superintendent. The number of priority items may range from 1-5.)
Accomplished Comments

1.

2.

3.

4.

5.

ADOPTED: October 22, 1997 WAYNE CENTRAL SCHOOL DISTRICT

0330-E. 1

WAYNE CENTRAL SCHOOL DISTRICT
POST-OBSERVATION CONFERENCE REPORT
Teacher_________________________ Date of Observation___________________
Subject___________________________ Time of Observation___________________
Class ___________________________ Scheduled________ Unscheduled________
Date/Time of Conference__________ Length of Conference__________________

Summary of Observation:

Observer Reaction to Lesson:

Teacher Reaction to ObservationlConference:

I have read and understand the above post-observation report:
Signature_______________________________ Date______________________
Teacher
Signature_______________________________ Date______________________
Observer
cc: Superintendent of Schools
Principal
Supervisor
Teacher

0330-E.2

ANNUAL TEACHER EVALUATION AND PLANNING GUIDE

Name of Teacher_______________________________ School_______________ Grade or Subject Assignment_____________ Name of Evaluator

A. EVALUATION CATEGORIES:

1. Instructional Competence

2. Interpersonal Relationships

3. Professional Responsibilities

PERFORMANCE:
___Satisfactory ___Satisfactory, Needs Improvement Unsatisfactory

B. IMPROVEMENT PLAN andior GOAL-SETTING
(Areas in which the administrator and teacher will work together for improvement)

1420-E

REQUEST FOR RECONSIDERATION OF
INSTRUCTIONAL OR LIBRARY MATERIALS
Title
Author________________________________ Type of Material__________________
Publisher
Request Initiated by ________________________ Telephone __________________
Address_________________________ City ________________ Zip ____________
Complainant represents: _________________________ Himself/Herself
_______________________ Name of Organization
Identify other group

1. To what do you object? (Please be specific. Cite pages if a book)
2. What do you feel might be result of using this material?_________________
3. For what age group would you recommend this material, if at all?_______
4. Did you see or read all the material?__________________________________

5. Are you aware of what professional critics think about this material? (If you have specific reviews, please attach them to this request.)

6. What do you believe is the theme of the material in question? Or why do you think this material exists?_________________________________________________

7. Please indicate below what you would like our school to do about this material?

________________________________________ Do not assign it to my child ________________________________________ Do not assign it to any child _____________________________________ Withdraw it from the school district

_____________Send it back to a reliable educational source for re-evaluation

8. What better quality material would you recommend in its place?

Signature

Date

Adoption date: July 24. 1996

4531-E.l

FIELD TRIP EXHIBIT

PARENT PERMISSION FOR A SCHOOL DAY
FIELD TRIP

Each student must secure the permission of his/her parent or legal guardian in order to participate in a school sponsored field trip.

Parents or legal guardians are required to sign and return this form to their child’s teacher at least one week prior to the date on which the school day field trip will be taken.

I, the undersigned parent or legal guardian of ______________________________ give my permission for him/her to participate in a school sponsored field trip to _______________________________________________ on _________________(date).

Transportation will be provided by ___________________

Time leaving school __________________________________________________

Approximate time of return to school ______________________________

Student needs to bring own lunch? Yes__ No

__________________________________ will be the supervising Wayne Central staff member on this field trip.

Additional instructions or comments specific to this field trip are attached.

Will your child require any form of medication to be taken while he/she is on this field trip? Yes_________ No_________ If “Yes”, please contact the school nurse at once so appropriate and timely arrangements may be made with you for the proper handling and administration of your child’s medication during the field trip.

I understand that all school policies, regulations and rules will be in effect and will apply to my child for the duration of the field trip.

_________________________________________________________________________________ / ___________________________________
Signature of Parent/Legal Guardian Date

On the day of this field trip I can be reached at telephone number:

4531-E.2

FIELD TRIP EXHIBIT

EXTENDED FIELD TRIP MEDICAL RELEASE FORM

In the event of an emergency, my signature below constitutes permission for my child to receive medical evaluation and necessary treatment to ensure his/her safety. Such treatment may come from either my child’s physician or another physician or medical facility as deemed appropriate by the supervising Wayne Central staff member. As my Attorney In Fact, I give the supervising Wayne Central staff member my permission to execute any necessary documents in connection with the medical treatment including any required guarantee of payment.

Parent’ s/legal guardian’s insurance carrier:____________________________________ Insurance ID No.____________________________________
Signature of Parent/Legal Guardian Date

EMERGENCY INFORMATION

Student’s Name:
Last First

Address:

Parent’s/Legal Guardian’s name:____________________________________________ Home telephone number:________________________________________
Father’ s/Guardian’s workplace:
Workplace telephone number:______________________________________ Mother’s/Guardian’s workplace:
Workplace telephone number:____________________________________ If you plan to be away while we are gone on the extended field trip, please indicate how we may contact you if the need arises:_________________________

Emergency contact (other than parent or legal guardian):

Name:________________________________ Phone number:
Address:
Relationship to student:________________________________________________

Physician’s name:______________________ Phone number:____________

Dentist’s name:_______________________ Phone number:___________

Medical insurance plan:________________ ID number:______________

Page 2 of 3

4531-E.2

FIELD TRIP EXHIBIT

EXTENDED FIELD TRIP HEALTH INFORMATION

1. Does the student have any allergies (including allergies to medication) ______ If so, please explain

2. Do you have concerns about your child walking strenuously for long distances if required to do so on this extended field trip’?

If so, please explain__________________________________________________________

Does your child have, or ever had, seizure disorders? _______ If so. please explain

4. Please explain any dietary restrictions your child has______________________

5. Does your child have motion sickness?_______ If so. will it require medication to be used on this extended field trip? Yes_____________ No_________ If “Yes,” please contact the school nurse at once so appropriate and timely arrangements may be made with you for the proper handling and administration of your child’s medication during the extended field trip.

6. Please explain any concerns you have about potential homesickness or sleep problems your child may experience on this extended field trip______________

7. Date of child’s last Tetanus immunization___________________________________

8. Please explain any medical condition or situation pertaining to your child we should be aware of during the time of this extended field trip:______________

9. Please attach any additional information you wish the school to be informed about conceming your child and this extended field trip.

Signature of Parent/Legal Guardian Date Page 3 of 3

Adoption date: May 21. 1997

5020.3-R

SECTION 504 REGULATION

The purpose of these regulations and procedures is to carry out the policy of the Board of Education of the Wayne Central School District to provide a free and appropriate public education to all disabled students regardless of the type of disability or its severity. Wayne Central School District does not discriminate against persons with disabilities in accordance with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA).

Students who are disabled consistent with the definitions set forth in Section 504 and ADA will be identified, evaluated, and provided with appropriate instruction, educational services and accommodations. The Acts define a person with disability as anyone who “has mental or physical impairment which SUBSTANTIALLY LIMITS one or more major life activities; has a record of such impairment; or is regarded as having such an impairment. Major life activities include activities such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.”

It should be clearly understood by all parties that evaluating and providing specialized education, related services or aids to students under Section 504/ADA is a separate and distinct process from when a student is suspected of being disabled under the Individuals with Disabilities Act (IDEA). When it is suspected that a student has a disability and is in need of special education and related services under IDEA, that student should be referred directly to the Committee on Special Education. However, some students with disabilities that do not require special education and related services may receive accommodations under Section 504/ADA. Students who qualify for Section 504/ADA should be referred to the principal of the building they attend.

Compliance Officer

The Wayne Central School District will appoint a Section 504 Compliance
Officer who will have the overall responsibility for insunng compliance with Section
504/ADA regulations. The Compliance Officer for the district is the Director of
Pupil Personnel Services who may be reached at 524-0209. The office is located in
the District Office located in the High School building on Ontario Center Road in
Ontario Center.

Notice

A copy of policy 5020.3 shall be included in the annual Wayne Central School District Calendar. A copy shall also be included annually in each employee and student handbook. A copy shall also be given to each family new to the school district at the time of their registration.

Identification and Referral

I .1 The building principal will insure that typical school records are reviewed to determine whether a student has a history of a physical or mental impairment or is regarded as having such an impairment which substantially limits one or more major life activities. This occurs when teachers and others routinely review records in the day to day activities of the school.
1.2 Typical school records which may be reviewed include Early Start. Kindergarten screening results, new entrant screening results, reports from classroom teachers, routine physical examinations, reports from outside agencies. parent conferences, state testing results, reports from private physicians and the like.

5020.3-R( ~

1.3 If after a review of the records, it is suspected that a student may be disabled and may require special education and related services, that student should be referred to the Committee on Special Education (CSE). If it is suspected that the student may be impaired but may not require special education and related services, that student shall be referred to the principal in order to initiate an evaluation under 504. (The CSE may act as the 504 Team and develop a 504 Accommodation Plan at the CSE meeting. (See item 2.7 below)).
1.4 At any point that a parent, eligible staff member or student suspects a disabling condition, a referral may be made to the CSE for consideration under IDEA or to the 504 Team (CSE) for consideration under 504.
1.5 The 504 referral should be made in writing utilizing the district provided 504 referral form.
1.6 Upon receipt of the 504 referral form, the principal or his/her designee will notify the parents. The notification will include a copy of the due process procedures and a parental consent for evaluation.
1.7 If the parent (or student over age 18) does not give consent for evaluation within ten days of notice, the principal will insure that the appropriate due process notices were received by the parents. If consent is not received, the district may commence an impartial hearing to override the failure to obtain consent, or may refer the student to the building Pupil Personnel Services (PPS) team for consideration.
1.8 If consent is received, the principal will direct the building staff to conduct an assessment, the results of which will be forwarded to the 504 Team.

Evaluation and Determination

2.1 A student referred under regulations of 504 will receive a multidisciplinary evaluation through the 504 Team. Persons on the team will include those persons qualified to administer and interpret the evaluation material.
2.2 Tests selected for use in evaluation will have been validated for the purposes for which they are used. Tests and other assessment instruments and materials will include those tailored to assess educational need rather than a single intelligence quotient or medical diagnostic label. Evaluation methods shall seek to accommodate disabilities that may impair the student’s capacity to be evaluated.
2.3 Upon completion of the assessment, the 504 Team will meet to consider the results of the assessment and a determination. Persons on the team will be knowledgeable about the evaluation data and its meaning, currently teaching or providing instructional services to the student, and knowledgeable of decisions. The team will carefully consider information from a variety of sources including aptitude and achievement tests, teacher accommodations, physical condition of the student, social cultural back~ound, and adaptive behavior if appropriate. The team will be comprised of a minimum of three people in addition to the parent/guardian and student (when appropriate). Members of the CSE may constitute the 504 Team.
2.4 The parent/legal guardian and student (when appropriate) will be invited to participate in the 504 Team meeting. A standard invitation form will be used, which includes the parent/student due process rights. Other parties who are knowledgeable about the student’s educational needs may participate in the meeting at the request of the parent/student or the schoo. If the p are nt/legal guardian and/or the student do not attend the meeting, the team may proceed with the necessary deliberations and decisions.

5020.3-RC3)

2.5 The 504 Team will document the results of the meeting. The determination of the team will indicate whether the student is disabled under 504/ADA. If the student is eligible and in need of accommodations, these accommodations will be noted on the 504 Accommodation Plan. Accommodation could include, but are not limited to, specialized equipment, architectural, instructional, non-academic, extracurricular, and/or physical plant modifications.

NOTE: If the student with a disability requires special education and/or special education related services to receive an appropriate education, the student must be referred to the CSE.

2.6 The evaluation, findings and determinations of the 504 Team will be completed within 30 days from the consent for the evaluation. This time requirement may be extended by written agreement of both parties.

2.7 If the CSE has determined that a student has a disability but does not need special education and related services under IDEA, the CSE may act as the 504 Team and may develop a 504 Accommodation Plan, which will be forwarded to the building pnncipal for implementation.

The S04 Accommodation Plan and Implemenation

3.1 The 504 Accommodation Plan is the vehicle used to document the modifications to meet the needs of the student. The Plan will include the following components:
a. A description of the specialized equipment, architectural, instructional, nonacademic, extracurricular, or physical plant modifications, and/or other supplementary aids and services;
b. The beginning and ending dates of accommodations, services and/or adaptations;
c. Assurances that all accommodations, services, and/or adaptations are provided with nondisabled students to the maximum extent appropriate;
d. Set the date that the plan will be reviewed;
e. Written consent of the parent and/or student, if appropriate, is required prior to implementing the 504 Plan. If consent is not received, the district may initiate an impartial hearing to override the failure to obtain consent or may refer the student to the building’s PPS team for consideration;
f. Names and titles of the participants in the development of the 504 Plan.
3.2 The 504 Accommodation Plan will be sent to the district’s 504 Compliance Officer who will assure that the Plan is consistent with the district’s obligation pursuant to Section 504/ADA. The 504 Compliance Officer will reconvene the 504 Team within five days to develop a new Plan with the Compliance Officer in attendance if the initially submitted 504 Plan is not consistent with these obligations. In addition, the 504 Compliance Officer may refer the student to the CSE if it is believed that the student requires special education and related services in order to receive an appropnate education.
3.3 The 504 Accommodation Plan will be implemented within seven days following submission to the 504 Compliance Officer.

502 0.3-R c~)

3.4 The Compliance Officer will insure that the determination of the 504 Team. including the 504 Accommodation Plan, are communicated to the parent/student and that a copy is mailed to the parent/student. A copy of Due Process Ri hts (see 5020.3-E.2) will be included. The Compliance Officer will insure that all policies and procedures to pursue mediation or respond to impartial hearing requests are followed in the event that the paren student disagrees with or does not give consent for the Plan. In such cases. the principal will notify the 504 Compliance Officer of these proceedings in wnting.

Review and Implementation

4.1 Accommodation Plans will be reviewed when a student is moving from elementary to middle school, middle school to high school, and in the final semester of anticipated completion of diploma requirements. Other review requests may be submitted in writing to the building principal or the 504 Compliance Officer by persons defined in Section 200.4 of the NYS Commissioner’s Regulations. The 504 Compliance Officer will notify the 504 Team of the need to reconvene within 20 days of the receipt for review.
4.2 A student identified under 504 will be re-evaluated periodically, and prior to any significant change of placement.

Parent and Student Rights under Section 504

5.1 The principal will be familiar with all due process rights of the parent/student. These are clearly stated in the Parent/Student Rights Notice.
5.2 TheDue Process rights referred to in the document above will include:
a. Parent/student notice will be provided
� before the school identifies, assesses, or places a student requiring accommodation due to a disability;
� be ore changes in identification, assessment, or placement are made;
b. Written consent will be sought from the parent, or the student if over age 18, before the school will conduct an evaluation.
� If consent is not received, the district may initiate an impartial hearing to override the failure to obtain consent.
� Written consent also will be sought before the implementation of a 504 Accommodation Plan.
c. An individualized evaluation will be conducted before the student can receive accommodations.
d. The student will be educated, to the maximum extent appropriate, with students who are not disabled.
e. The student’s placement must be reviewed consistent with th~ date specified on the 504 Accommodation Plan.
f. Parent/student has the right to inspect the student’s records and receive, upon request, a list of the types of education records kept on the student, where they are maintained, and how to gain access to them.
g. The confidentiality of the student’s education records will be protected in accordance with the Family Education Rights and Privacy Act (FERPA).

5020 .3~R(~)

h. The parent has the right to mediation and/or an impartial hearing before an impartial hearing officer regarding any matter related to the identification, evaluation or placement of the student or the provision of “free appropriate public education” (FAPE). This right includes the opportunity for participation by the student’s parents and representation by counsel. The district will appoint the mediator or hearing officer who may not be an employee of the district or anyone who has a personal or professional interest which would conflict with objectivity in the mediation and/or hearing.

Grievance Procedure; Mediation and Impartial Hearing

If, for any reason, the district and parent and/or student are in disagreement
with regard to the identification, evaluation or placement of the student under 504,
the parent and/or student has the right to initiate a grievance to request mediation
an or an impartial hearing under the following procedures. (see 5020.3-E.3)

6.1 Mediation
a. The 504 Compliance Officer (or designee) will offer informal mediation within 21 days of written notice of known disagreement.
b. If informal mediation does not bring resolution to the disagreement within 15 days following its initiation, the 504 Compliance Officer (or designee) will offer formal mediation to the parent and/or student. Formal mediation offers will be accepted or rejected by the parent and/or student in writing within 10 days following the date of offer to mediate. Offers of third party formal mediation in no way implies that either party has surrendered the right to an impartial hearing as a consequence of mediation attempts.
c. When both parties have agree to ormal mediation, the 504 Compliance Officer (or designee) will arrange for mediation and provide the mediator with documents requested after securing appropnate releases from the parent and/or student. Confidentiality procedures set forth by the district consistent with IDEA provisions will apply. The 504 Compliance Officer (or designee) will ensure the notification of parent an or ents, in writing, of the date, time and location for me iation proceedings along with the name and address of the mediator.
d. After reviewing all pertinent information, considering the concerns and differences between the parties and other exploratory inquires, the mediator will engage the parties in an attempt to resolve the disagreement. If an agreement is reached, the substance of the agreement will be put in writing and signed by both parties. The district will provide copies of the agreement to the parent and/or student and maintain the original agreement in the student’s file. Any unresolved matters may still be the subject of an impartial hearing.
e. All formal mediation efforts will be completed within 30 days, following the date of agreement by both parties to pursue formal mediation. While formal mediation efforts are employed, all time limits for the initiation of an impartial hearing will be suspended; that is, the time limits will not apply when the issues in dispute are in the process of formal mediation.
f. If formal mediation does not bring resolution to the disagreement, either party may ask for an impartial hearing pursuant to the requirement under Part 200.5 of the Commissioner’s Regulations.

5020.3-R

6.2 Impartial Hearing

a. A parent and/or student, or district representative if appropriate, must make a written request to the Board of Education for an impartial hearing. If the district representative makes the request, the parent and/or student will be notified in writing immediately.
b. The Board of Education will appoint immediately an impartial hearing officer who will hear both sides of the case and render a written decision within 45 calendar days of the date that the Board of Education received the initial hearing request.
c. The procedures of Part 200.5 of the Commissioner’s Regulations will apply to the conduct of impartial hearings under the 504 procedures.

6.3 Review

If either party disagrees with the impartial hearing officer’s decision, the party has the right to appeal to the Office of Civil Rights and/or federal court.

Adoption date: May 21, 1997

Exhibit 5151 -E-1
WAYNE CENTRAL SCHOOL DISTRICT
Ontario Center, New York 14520

RESIDENCY AFFIDAVIT OF EMANCIPATED STUDENT

STATE NEW YORK (
COUNTY OF WAYNE (si:
TOWN OF______ (
I, the undersigned being duly sworn, depose and say that the information provided herein is inie and complete to

the best of my knowledge:

1) Name

2) Date & Place of Birth________________________________________________
3) Grade (19..9 ____________ Age ____________

.1) Present Full-time Adress:__________________________________________________

5) Names & Address(es) of Parent(s):

6) Date on which you no longer resided with your parent(s): _________________________________

7) Please indicate as fully as possible the reasons why you are no longer residing with your parents:

8) Will you be staying in the home of your parents at any time:
Dunng the ~h~iol y~~~r? Yes No 0 During ~huol vmztiun pcnud~? Yes 0 No 0

If YES, indicate when & ~vhy:

Indicate as fully as possible the means by which you are supporting yourself financially:
It)) Are ‘.‘ou receiving any financial assistance or support from your parents? Yes 0 No 0

If so. ~hat ponion of your total financial support are your parents pwviding and what is the nature of that supporV’
~4/1 2/00 (continued)

I
Exhibit 5151-E-1

I
11) Please describe your current relationship with your parents (example: the daze of your last contact i’ida
them and the nature and de~ee of future contact you e.’cpect to have with them):

12) In case of medical or other emergency, who should be contacted for decisions affecting you?
NAME:
ADDRESS:
TELEPHONE: (Home) rw~)
13) Where did you reside last year’⁷14) What school have you been attending?
DISTRICT NAME BUILDING:__________________
ADDRESS (Street & Post Office)
15) Have you previously attended Wayne Central School District? Yes 0 No 0

If Yes, please list latest date & school:

CERTIFICATiON BY STUDENT

I hereby certify that I am an emancipated minor living beyond the custody and control of my parents and that I am full’ responsible for all decisions pertaining to my health, welfare and education.

In the event that I am permitted to enroll in the Wayne Central School district, I agree to promptly notify the supenniendent of schools in the event there are any change in the information provided in this affidavit.

SI ONED ____________________________________ DATE:______________________
STREET ADDRESS TOWN: ZIP:
(do not usaPO. Box)

Subscribed and sworn before me on the

~~—~day of

Notary Pubhc

(Please affi\ stamp)

N
WAYNE CENTRAL 504001 O~Rjcr Exhibit 5151 E-2
Ont2rio Center, New York 14520

CUSTODY & CONTROL OF A STUDENT
( ACCEPTING AFFIDAVIT OF PERSON(S)
STATE NEW YORK (
COUNTY’ OF WAYNE ( ss.:
TOWNOF (

I (we), the undersigned, being duly sworn, depose and say that the student named below is currently residing with me/us on a full-time basis and that the information provided herein is tnie and complete to the best of my (our) knowledge:

1)1/We reside at

2) Student’s Name:___________________________ Grade (lt~-l9.....,)

2)Age

3) What is your.relationship to this student?

4)Have you assumed financial support of this student in addition to

poviding a home? EJYE~SE1NO

F M2T, what portion of financial support have you assumed?

Who prtwk~es the remaining financial support? ________________________ 5) Has this student lived with you before⁷ED YES EDNa

il YES. When & Why?

6) How kng will the student be living with you

7 In ca~ of med,cal or other emergency, who will be responsib4e for decisions affecting this student?
NAME(s) ADDRESS
Phone: (Home) (Work) _____________________________

8) What school has this student most recently attended?
NAME(s) ADDRESS
(continued....)

O41~2/OO

N
WAYNE CENTRAL SCHOOL DISTRICT Exhibit 5151 E~~2

Ontario Center, New York 14520
( ACCEPTII~G AFFIDAVIT OF PERSON(S)
CUSTODY & CONTROL OF A
STATE NEW YORK (
COUN1Y OF WAYNE ( ss..:
TOWN OF_____

I (we), the undersigned, being duly sworn, depose and say that the student named below is currently residing with me/us on a full-time basis and that the information provided herein is true and complete to the best of my (our) knowledge.

I) I/We reside at ___________________________________________________________________

2) Student’s Name:___________________________ Grade (l9~-l9..J

2)Age

3) What is your relationship to this student?

4)Have you assumed financial support of this student in addition to

provdrng a home? El YES El NO

F M)T, what portion of financial support have you assumed?

Who provides the remaining financial support? ________________________
5) HaS this student lived with you before? EJYEsEJNo

~ YES, When & Why? ____________________________________________

6) How kng will the student be living with you

7 In ca~ of medical or other emergency, who wilt be responsible for decisions affecting this student?
NAAE(s) ADDRESS
Phone: (Home) (Work) _____________________________

8) What school has this student most recently attended?
NAME(s) ADDRESS
(continued....)

04/1 2J00

Exhibit 5151

14) Will this student reside in the home of anyone else at any time during the tol~w,ng periods:

El During the Week El ~ Weekerx~ El During School Recess Periods IF YES, when & why

15) Please indcate as fully as possible the rea~ns why this student will no longer reside with his or her parents:

CERTIFICATION

I (we) hereby certify that: I (we) have assumed full responsibility for and custody and control over the student named in item 2, above, including the right to make decisions pertaining to the health, welfare and education of the student If the student is perin~tted to attend Wayne Central School Dtstnct, I (we) agree to promptly notify the Superintendent of Schools in the event that there is any change in the information provided herein.
Sugnature _____________________________________________ _____________________________

Signature _____________________________________________

Subscribed and sworn before me on this

________________ 19

Notary Public

(Please affix stamp)

Exhibit 5151 E-3

WAYNE CENTRAL SCHOOL DISTRICT
Ontario Center, New York 14520

(RESiDENCY AFFIDAVIT OF PARENT(S))

STATE NEW YORK C.
CC(*J1Y OF WAYNE ( ss.:
TOWN OF_____

I (we), the undersigned, being duly sworn, depose and say that: I (we) am (are) the parent (s) of the student named below and certify that the information provided herein is true and complete to the best of my (our) knowledge:

1) Student’s Name: _______________________________ Grade (IL-19..J _____________

2) Student’s Date & Place of Birth: ______________________________________

3) Student’s Present Full-Time Address:

4) Name & Address of Student’s Father. ___________________________________________

5) Name & Address of Student’s Mother: ____________________________________

6) Name(s) & addresses of other children in student’s family-.
NAME(s) ADDRESS

I

7) What school has this student most recently attended?
NAME(s) ADDRESS

8) Where did this student resident during the previous school year?
P44JUNG AE*X~ESS: ___________________________________________

9)AreyouresponsibleforthefuUfinancialsupportofthisstudent? YES ~NO ~ FPA2T,whatpercentageofsupportdoyouorwiflyouprovide? —

10) In case of medical or other emergency, who will be responsible for decisions affecting this student?
NAME(s) ADDRESS

Phone: (Home) ________________________(Work) _____________________________ 04/12100 (continued....)

Exhibit 5151 E-3
11) lf this student will reside in the Wayne Central School District, but not with his or her parent(s) or guardian(s), please indicate with whom he or she will reside?
NAME(s) ADDRESS
Phone: (Home) (Work)

12) Date on which this student ceased or will cea~ to reside with his or her parent(s) or guardian(s) or will begin residence with the person(s) noted in item 11, above:

13) How long will this student reside with the person(s) noted in item 11, above? ________

14) Will this student reside in the home of his or her parent(s) or guardian(s) at any time dunng the following periods:

During the Week On Weekenc~ During School Recess Periods IF YES, when & why?

15) Please indicate as fully as possible the reasons why this student will no longer reside with his or her parents:

~T(s)’CERTlFlCATlON

I (we) hereby certify that: I (we) have relinquished aN custody and control over the student named in item 1, above, to the person(s) named in Item 11, including the right to make decisions pertaining to the health, welfare and education of the student If the student is permitted to attend Wayne Central School District, I (we) agree to promptly notify the Supenntendent of Schools in the event that there is any change in the information provided
herein.

Signature ____________________________________________ _____________________________ Signature _______________________________________________

Subscnbed and sworn before me on this

dayof__________ 19

Notary Public

(Please affix stamp)

5152.1-E

ADMISSION OF FOREIGN EXCHANGE STUDENTS
EXHIBIT
INCOMING FOREIGN EXCHANGE STUDENT APPLICATION

This application form must be completed annually by the sponsoring organization and submitted to the High School Principal not later than June 30 for consideration for the followina school year.

1. Name of sponsoring organization:

2. Name of sponsoring organization’s local coordinator:__________________
Address:
Telephone Number: ( /
3. a. Proof of designation as an “Exchange Visitor Program~~ by the United
States Information Agency:
b. Proof of approval by the Council of Standards on International Educational Travel(CSIET):__________________________________

4. Name of potential student:________________________________________ Date of Birth:___________________________________________________
Nationality:

5. Name of potential host family:_____________________________________
Address:
Telephone:( /

6. A copy of the Wayne Central School Distnct policy and regulations on the admission of foreign exchange students is attached to this application for your information for the sponsoring organization and the potential host parent(s).

7. The signatures of the local coordinator and the host parent(s) signify they have received the policy and regulations and that they agree to meet and comply with all requirements set forth in those documents and to submit all required documentation and information.

Signatures:
local coordinator of potential host parent(s)
sponsoring organization
date date

5152.1-E
8. Principal’s Recommendation:

I have reviewed this application and any other supporting information. All of the requirements in the policy and regulations have/have not been met. It is my recommendation that this application be approved/rejected for the ____________ school year.

Comments:
9. Superintendent’s Action: Approve/Reject
_______________________________________ Date:_______________

Adoption date: May 21, 1997

5191 -E

STUDENTS WITH HI V-RELATED ILLNESS EXHIBIT
The University of the State Authorization for Release of Confidential HIV*
of New York Education Department Related Information to the Superintendent of
Approved b’: Schools and the Board of Education
New York State Department of Health

OC-l (6/89)

Confidential HIV Related Information means any information indicating that a person had an HIV related test, or has HIV infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.

Under New York State Law, except for certain people, confidential HIV related information can only be aiven to persons you allow to bave it by signing this form. You may ask for a list of people who can~be given confidential HIV related information even without this form.

If you sign this form. HIV related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.

If you experience discrimination because of the release of HIV related information, you may contact the New York State Division of Human Rights at (212) 870-9624 or the New York City Cozhmission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.

NAME OF PERSON WHOSE HIV RELATED INFORMATION WILL BE RELEASED

NAME AND ADDRESS OF PERSON SIGNING THIS FORM (IF OTHER THAN ABOVE)

PROCEDURES

A. Superintendent-Board Relationship Demonstrates Possible area

Competence* of Growth