Pbsd 0636 Form PDF Details

Are you familiar with the “0636 form”? If so, then you know that it is an important part of obtaining paperwork and medical records from a former employer-sponsored health insurance. This document, also known as the Proof of Coverage Summary or Former Employer Plan Release Form, is designed to provide employees with information they may need to continue insurance coverage after leaving their existing plan. In this blog post, we'll cover what's included in the PBSD 0636 form, how to complete the form accurately, and why having one on hand can be beneficial for your future health care needs. Ready to learn more about this useful form? Let's dive in!

QuestionAnswer
Form NamePbsd 0636 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namespbsd online, palm beach 0636, new returning student registration, pbsd new fill

Form Preview Example

THE SCHOOL DISTRICT OF PALM BEACH COUNTY

TEACHING AND LEARNING

New and Returning Student Registration

Student Number

OFFICE USE ONLY

School Number

Transportation

Grade

EN CD

FLEID

 

 

 

 

 

Entry Date

SIS Entry

Birth Verification Address Verification

Complete ALL AREAS on this form. Do not leave any area unanswered. Correct any preprinted information. A registration must be completed for each student each school year.

Student First Name

MI

Last Name

Suffix Student Former Name or AKA (if applicable)

Student Address

City

State

Zip Code

Social Security # (optional)

Student Birth Date Gender

Male Female

Country of Birth

Place of Birth

Student Resident Status

 

 

 

 

 

 

 

 

 

 

 

In county resident

 

 

 

Out of county resident

 

Out of state resident

 

 

Foreign exchange student

 

 

 

 

 

 

 

 

 

 

 

 

Student Ethnic Origin (must check Yes or No)

 

 

 

 

Date Entered USA School

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, Hispanic or Latino

 

 

 

No, not Hispanic or Latino

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student Race (must check at least one, and check all that apply)

 

 

American Indian or Alaskan Native

 

 

 

Asian

 

 

 

 

 

 

 

Black or African American

 

 

 

Native Hawaiian or Other Pacific Islander

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student lives with:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent

 

 

Guardian

 

Other

 

 

 

 

 

 

 

Foster Parent

 

 

 

 

Group Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/guardian is an active member of the military.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

Student resides with a parent/guardian on active duty or an accredited foreign government official and military officer.

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student resides with a parent/guardian who lives or works on federal military installations or NASA property.

 

 

 

 

Yes

 

No

Student resides on federally owned Indian lands.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is student in physical custody of parent/guardian?

 

 

 

 

 

Yes

 

No

Is the student who is enrolling a single parent?

 

 

 

 

 

 

If "No", student telephone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the parent/guardian work in agriculture or fishing?

 

 

 

 

 

Yes

 

No

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does student have sibling(s) enrolled in Palm Beach County schools?

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the names and birth dates of student's sibling(s).

Indicate where the student lives (check only if applies)

 

 

Hotel/Motel

 

Shelter

 

 

Shared Housing Hardship

 

Space Not Designed for Human Habitation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS A-D BELOW MUST BE ANSWERED

 

 

 

 

A. Is there a court order barring either parent from removing the student from school?

 

 

Yes

 

No

 

 

 

B. Do parents have shared (or joint) parental rights and responsibility?

 

 

Yes

 

No

 

 

 

C. Does one parent have final decision making authority regarding educational decisions for the student?

 

Yes

 

No

 

 

D. Is there a Temporary Restraining Order, Permanent Restraining Order, Order of No Contact, or other

 

Yes

 

No

 

 

 

 

court order that restricts or impacts access to the student by anyone, including the other parent?

 

 

 

 

 

 

 

 

Provide the school with a copy of any applicable court orders.

 

 

 

 

STUDENTS NEW TO PALM BEACH COUNTY

Is a language other than English used in the home?

Does the student have a first language other than English?

Does the student most frequently speak a language other than English?

 

Yes

 

No

Student primary language?

 

Yes

 

No

Parent primary language?

 

 

 

Yes

 

No

Parent preferred verbal language?

 

 

 

 

 

 

 

Parent preferred written language?

PBSD 0636 (Rev. 6/1/2019)

RECORD COPY - Student Cumulative Record Folder

Page 1 of 3

The School District of Palm Beach County New and Returning Student Registration

Student Legal Name (first, middle initial, last)

Student ID #

CONTACT PICKUP INFORMATION

Parent or Guardian

E-mail address (optional)

Address if not the same as student (house #, street name, apartment no., city, state, zip code)

Home Telephone

Cell Telephone

Accept automated non-emergency school, District and community

related messages :

 

 

 

Phone

Text

Both

None

Parent or Guardian

E-mail address (optional)

Address if not the same as student (house #, street name, apartment no., city, state, zip code)

Home Telephone

Cell Telephone

Accept automated non-emergency school, District and community related messages :

 

Phone

 

Text

 

Both

 

None

Provide a password that will be used when picking up the student.

Provide additional persons allowed to pick up (first, middle initial, last)

Relationship to student

Daytime Telephone

 

 

 

PREVIOUS EDUCATION INFORMATION

Last School Attended (including preschool)

City

County

State

Country

Telephone

Type (check one only)

 

 

Public / Charter

Private

Home Education

Educational Plan - Provide a copy.

Individual Education Plan (IEP) 504

 

Grade Level Last Year

Grade Level This Year

Last Date Attended

Did student attend public school in Palm Beach County before?

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The student has been arrested or prosecuted for a violation of a criminal statute resulting in a charge.

 

 

Yes

 

No

 

 

 

The student has been expelled from school.

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Students Entering Kindergarten Only - Preschool Enrollment Information (check all program(s) attended)

 

 

 

 

 

School District ESE Pre-K

 

Private Child Care Center

 

 

School District VPK

 

 

 

 

Head Start

 

Did not attend preschool

 

Other

 

 

 

 

 

 

 

 

HEALTH INFORMATION

As scheduled in the School Health Services Plan, students will receive non-invasive health screenings, vision, hearing, scoliosis, HT/ WT/BMI, pursuant to Florida Statute 381.0056(6)(e). If you DO NOT WISH your child to participate, initial the following:

____________ I DO NOT WISH TO HAVE MY CHILD PARTICIPATE IN THE SCREENINGS.

Sodium Fluoride Program: This program is offered at schools without fluoride in the local water supply. I give permission for my

 

child to participate in the sodium fluoride program to prevent tooth decay.

 

 

 

 

 

 

 

 

Yes (permission is valid through grade 5)

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student health insurance (check all that apply):

 

Medicaid

 

Healthy Kids/Kid Care

 

Private

 

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student has life threatening allergies?

Allergy

 

 

 

 

 

 

Physician Name

 

 

Telephone

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List medical concerns.

Student takes medication?

 

Yes

 

No List all medications.

Has the student ever been referred for mental health services?

 

Yes

 

No

 

Not Known

PBSD 0636 (Rev. 6/1/2019)

RECORD COPY - Student Cumulative Record Folder

Page 2 of 3

The School District of Palm Beach County New and Returning Student Registration

Student Legal Name (first, middle initial, last)

Student ID #

Read the following carefully. Check available appropriate boxes below statements and sign below.

Notice of Technology Acceptable Use Policy For Students: Your child may have access at school for many school-related activities to certain District technology resources, including the Internet and the District's Intranet. Your child's school's access to the Internet is filtered to comply with the Children's Internet Protection Act and School Board Policy 8.125. Your child will be required to follow the acceptable use standards and guidelines that are stated in Policy 8.123, the referenced Manual, and the Notice of Conditions for Student Use of District Technology and be bound by their terms. There is only a limited expectation of privacy to the extent required by law related to a student's use of these technology resources. Before your child uses these District resources, he/she will read, be read to, and/or explained these documents and will electronically acknowledge that he/she understands, and agrees to follow, them.

You are invited to read this Policy, Manual and Notice. If you need assistance reading the documents, you may ask the school for assistance. The policy is available at: https://www.boarddocs.com/fl/palmbeach/Board.nsf/Public, click Policies, under chapter 8 --Policy 8.123.

Notice of medical records disclosure: Your child's medical records or medical information that have been provided to the school are student records which are subject to the requirements of FERPA, 20 U.S.C.A. 1232g. Accordingly, that information can be disclosed without the written consent of the parent/guardian as allowed by FERPA, including if used by a teacher or other school official, who has

alegitimate educational interest, or if disclosure is to an appropriate party and is necessary to protect the health or safety of the student or other individuals.

Parental consent for release of student photograph and information: I hereby give permission for the school or District to use my child's photograph, video image, writing, voice recording, name, grade level, school name, participation in officially recognized activities and sport, weight and height of members of athletic teams, dates of attendance, diplomas and awards received, date and place of birth, and most recent previous school attended, in annual yearbooks, graduation programs, playbills, school productions, web sites, social media sites, etc. and/or similar school or District sponsored publications or in school or District approved news media interviews, releases, articles, and photographs. I also provide permission for the release by the school or District to the media and governmental entities of my child's name, grade, school name and honors my child has received for public announcement of recognition of my student's accomplishments. I understand that without checking the permission box my child's name and photograph cannot and will not be included in any publications or presentation, including a school yearbook.

I give permission

I do not give permission

ESE STUDENT ONLY: In accordance with FERPA, at 34 CFR §99.30 and IDEA requirements, I authorize the School District of Palm Beach County, Florida, to release and exchange my child's confidential student information to agencies of the State of Florida which would allow Palm Beach County Public Schools to receive Medicaid reimbursement for health related exceptional student services it provides to my child while at school. I understand my consent is voluntary and may be revoked at any time. My child will continue to receive services as per his/her IEP whether or not I give consent. In addition, I understand that I am not required to enroll in any public benefits or insurance program and that no out of pocket expense will be incurred for services provided as a part of FAPE, and that there is no impact to my Medicaid benefits as a result of the school district's reimbursement for services.

 

 

I authorize release

 

I do not authorize release

 

 

 

 

 

HIGH SCHOOL STUDENT ONLY - Opt-out for the release of information to military: The NCLB Act of 2001 requires that school districts provide military recruiters access to the names, addresses and phone numbers of high school students. Parents have a right to OPT-OUT from sending this information. If you do not want your child's information released to the military without prior written parental consent, check below. Although we will accept the opt-out any time during the year, sending it the first 10 days of the school year will ensure that no information is sent this school year.

I do not authorize release of my child's information to the military

By signing below, I understand and agree it is my responsibility to contact my child's school immediately to inform them of any changes to my contact information including name, address, home or cell phone numbers or e-mail address. If I agreed to accept text messages on my cell phone, I understand standard messaging rates with my cellular phone provider may apply. If I opted out of informational messages, I will continue to receive emergency phone messages from or on behalf of the School District of Palm Beach County at the telephone number(s) provided on page 2, including a wireless number if applicable. If you received non-emergency messages without consenting and/or would like to opt out of future calls, contact (855) 502-7867.

Under penalties of perjury, I declare that I have read the foregoing form and that the facts stated in it are true and accurate. Florida Statutes Sec. 92.525 (3) provides that whoever knowingly makes a false declaration under penalties of perjury is guilty of a felony of the third degree.

REGISTRATION IS NOT VALID WITHOUT SIGNATURE AND DATE.

Parent/Guardian Signature (unless student is emancipated)

Date

PBSD 0636 (Rev. 6/1/2019)

RECORD COPY - Student Cumulative Record Folder

Page 3 of 3

THE SCHOOL DISTRICT OF PALM BEACH COUNTY

TEACHING AND LEARNING

New and Returning Student Registration

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This document needs specific information; in order to ensure accuracy and reliability, be sure to take heed of the suggestions hereunder:

1. Begin filling out your palm beach 0636 with a number of necessary blanks. Note all of the required information and be sure not a single thing left out!

Filling out part 1 in palm student registration

2. Once the previous segment is completed, you'll want to insert the necessary details in Student resides on federally owned, Yes, Is student in physical custody of, Yes, Is the student who is enrolling a, If No student telephone, Does the parentguardian work in, Does student have siblings, Yes, Yes, Yes, Provide the names and birth dates, Indicate where the student lives, HotelMotel, and Shelter so you can move forward further.

palm student registration completion process described (portion 2)

3. In this specific part, have a look at Is a language other than English, Yes, Student primary language, STUDENTS NEW TO PALM BEACH COUNTY, Does the student have a first, Yes, Parent primary language, Does the student most frequently, Yes, Parent preferred verbal language, Parent preferred written language, PBSD Rev, RECORD COPY Student Cumulative, and Page of. Each of these need to be completed with utmost precision.

A way to prepare palm student registration portion 3

4. It is time to complete the next segment! In this case you'll get all these The School District of Palm Beach, Student Legal Name first middle, Student ID, Parent or Guardian, Email address optional, CONTACT PICKUP INFORMATION, Address if not the same as student, Home Telephone, Cell Telephone, Accept automated nonemergency, Phone, Text, Both, None, and Parent or Guardian form blanks to fill out.

Part # 4 of filling out palm student registration

5. To conclude your form, the particular part features a few extra fields. Entering Last School Attended including, City, County, State, Country, Telephone, Type check one only, Educational Plan Provide a copy, Public Charter, Private, Home Education, Individual Education Plan IEP, Grade Level Last Year Grade Level, The student has been arrested or, and The student has been expelled from is going to wrap up the process and you'll be done very fast!

The best way to complete palm student registration stage 5

In terms of Private and The student has been expelled from, make sure you review things in this section. Both of these are considered the most important ones in this file.

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