Leesville Road High School

8409 Leesville Road

Raleigh, N.C. 27613

 

 

The mailing list for this document has been created from the Wake County Public School System database. If you receive this document and plan to attend another school, please call 870-4250 and leave a message with your name, address, and the school you plan to attend.

 

 

Dear Leesville Road High School Students and Parents:

 

It is my hope that the summer months provide time for our students and parents to rest and recuperate from the 2004-2005 school year.  However, despite the time away from school, I encourage all students to investigate areas of interest for the future with regard to educational plans and/or career choices after high school.  The summer months, free from the daily routines and assignments of school, provide many opportunities for such cooperative action on the part of students and their parents. 

 

I strongly recommend visits to college campuses during the summer to meet with admissions counselors.  In addition, our school’s Career Center will be open Monday through Thursday from 9 a.m.-3 p.m. during the summer.  The Career Center will not be staffed during the summer; however, a large number of college catalogues will be available for students and parents to review.  Information pertaining to military careers and other career opportunities after high school also will be available. 

 

The purpose of this mailing is to foster a smooth opening of school on August 25 for our students.  This packet includes important information such as PSAT and SAT dates, senior portrait regulations, dates for ordering graduation announcements and class rings, summer assignments for AP courses, start dates for a variety of athletic teams, and information from different groups in our Performing Arts Department.  In addition, the following applications are included:  the 2005-2006 Course Selection Change Form, the 2005-2006 Student Parking Form, the 2005-2006 Off-Campus Lunch Form, and the 2005-2006 Student Medical Survey Update Form.  Please review this information and return any forms that address your needs to the school by the noted deadlines.  This entire packet also is posted on the school’s website at www.leesville.org in case students and parents need additional copies of it.

 

On a side note, the majority of our Advanced Placement (AP) classes will be scheduled on a year-long,     “A day/B day” schedule for the 2005-2006 school year due to changes resulting from our later starting date of August 25.  The only AP classes to be taught in a single semester during the 2005-2006 school year will be scheduled for the Fall 2005 semester.  This scheduling plan will not affect the total number of courses a student can take during the 2005-2006 school year.  Our August 11 summer mailing with students’ class schedules will contain an insert to aid in the interpretation of class schedules containing AP courses.

 

I hope all Leesville Road High School families have a great summer.  It is a pleasure working with all members of our school community.  I look forward to the return of our students on August 25.

       

Respectfully,

 

Stephen Gainey

Principal

 

Summer Hours

 

On June 6, the main office of Leesville Road High School began observing the summer schedule. As a result, the staff will operate according to a four-day workweek from June 6 through August 5.  During this time period, the main office will be open Monday through Thursday from 7 a.m. to 3:30 p.m. The building will be closed on the following Fridays:  June 10, June 17, June 24, July 1, July 8, July 15, July 22, July 29, and August 5.

The Student Services Department will observe the same schedule. For Student Services information, please call 870-4260. The Athletic Department may be reached at 870-4270. 

 

Updated  information of interest also can be found on our school’s website at www.leesville.org.

 

Important Calendar Dates

 

Student schedules will be mailed on August 11.  New Student Orientation is scheduled for August 23 at 10 a.m.  Our Fall 2005 Semester Open House will be held on September 12 at 7 p.m.

 

PSAT Date

 

The PSAT will be administered on October 12.  Sophomores may register for the test from September 19 - 30.  There is no charge for juniors. Sophomores will pay a test fee of $13.00. The PSAT provides useful information in preparation for the SAT.

 

 SAT Registration

 

Registration booklets for the SAT will be on campus in August.

 

 

 

2005-2006 SAT Schedule

 

Test Date                                               Registration Deadline                          Late Registration Deadline

Oct. 8                                                      Sept. 7                                                    Sept. 14

Nov. 5                                                    Sept. 30                                                  Oct. 12

Dec. 3                                                     Oct. 28                                                    Nov. 9

Jan. 28                                                    Dec. 22                                                   Jan. 4

Apr. 1*                                                   Feb. 24                                                   Mar. 8

May 6                                                     Apr. 3                                                     Apr. 12

Jun. 3                                                      Apr. 28                                                   May 10

 

*Only the SAT I is offered on this day; all other days include both the SAT I and SAT II.

 

         Students may register for the SAT via the College Board on line at www.collegeboard.com

 

 

ACT test dates will be available in the Student Services office.

 

Senior Portraits

 

It is already time to begin thinking of having your senior portraits made.  Please keep in mind the following information when planning your senior portraits:

 

1)       For the yearbook portrait, you will need to go to Prestige Studio off Glenwood Avenue (behind the Oak Park Shopping Center with Casa Carbone and The Peddler restaurants).  You may, of course, purchase senior portraits for your family from any studio, but the yearbook portrait must come from Prestige.  This is the company with which Leesville Road High School has a contract, and is therefore, the ONLY studio from which the yearbook staff can accept yearbook portraits.

 

2)       All senior portraits should be taken at Prestige Studio by September 30, for your photo to be included in the senior section of the 2005-2006 yearbook.  The phone number is 571-0075.  Due to yearbook color deadlines, if your portrait is not taken by this date, the yearbook staff cannot guarantee the inclusion of your photo in the senior section or that you will have the choice of which tux/drape photo you would like in the yearbook.  DO NOT WAIT to set up your photo appointment with Prestige.  Prestige Studio photographs every school in Wake County and will book up quickly.  We suggest calling by July 22 at the latest.

 

3)       In order to be consistent, the only pose that can be accepted for the yearbook photo is a vertical TUX/DRAPE, though you may have flowers or any color background you wish.  Please be aware of this as you are planning your senior portraits and making your yearbook photo selection.  Also, the photo must be vertical in format, rather than horizontal.

 

POINTS TO REMEMBER:

       Yearbook portraits must be from Prestige.

v       

           Yearbook portraits must be a vertical Tux or Drape pose.

v       

Call soon, preferably by June 30, to make your appointment (571-0075)

v       

When you receive your proofs in the mail, return them quickly and

indicate which Tux/Drape photo you would like in the yearbook.

 

We thank you in advance for your cooperation with senior portraits.  If you have any questions, please call the school at 870-4250 and leave a message for the yearbook staff adviser.

 

Graduation Announcements

 

It is never too early to start thinking about graduation. Seniors may order their announcements on October 25 during lunch. A make-up day will be offered on November 1, also during the lunch periods. A deposit of sixty dollars is required to place an order, and seniors will receive a packet from Josten’s approximately one week prior to the October date.  Questions regarding graduation announcements should be directed to Josten’s at 789-8500.

 

Class Ring Orders

 

Jostens will be on campus on September 8 during lunch to accept ring orders. Parents are invited to the main lobby on the evening of September 8 to view the selections and place orders.  September 9 also has been designated as a ring order date.  Questions regarding rings should be directed to Josten’s at 789-8500.  A sixty dollar deposit is required to order a ring.

 

AP Biology

 

All students who have enrolled in AP Biology should complete the summer assignment for the course.  Students new to the course and/or new to Leesville should pick up their assignment sheet at the school or online at http://blackboard.wcpss.net (select course sites → high schools → type in AP Biology in search for course box → find course with Zoe Welsh as the instructor → select preview or enroll).  Students will be preparing for the course by reading Bill Bryson's A Short History of Nearly Everything and completing various activities related to the text.  Summer work is due the first day of school.

 

It is strongly recommended that the AP Biology Laboratory Manual be purchased.  Details on where to find this text are included on the assignment sheet.  If you are unable to purchase the lab manual, then alternative arrangements will be made.  If possible, please try to have the lab manual before school begins.

 

If you have any questions, then please email them to Mrs. Welsh at pridebiology@hotmail.com.

 
AP Calculus AB

 

All students enrolled in AP Calculus AB are expected to complete six assignments over the summer that cover the first two chapters of the Calculus textbook.   Assignments can be mailed to Mrs. Kolb at the high school (postmarked by the due date) or may be placed in a box in the Student Services office.  If you still need a textbook and a list of assignments, please pick one up in the Guidance Office.  Mrs. Kolb may be reached at jkolb@wcpss.net

 

Advanced Placement Spanish Language

 

All registered students have received the summer assignments for our AP Spanish class. The AP curriculum requires that students have a strong background in speaking, reading, writing and listening skills.   The summer assignments are designed to enhance these skills.  Students will master an extensive vocabulary list, write a composition, read two short stories and tape a narration of a picture sequence and a self-description. All assignments are due upon return to school August 25.  If you have any questions or concerns, Ms. Oldham or Ms. Moss may be reached at doldham@wcpss.net  or kmoss@wcpss.net.

 
AP U.S. History

 

Is your son/daughter reading about early American History and completing written assignments during the summer?  If so, they are probably registered for the LRHS AP U.S. History course.  These assignments help students become accustomed to the reading and writing expectations of an AP course.  Students received their textbook and chapter study guides in late May.  If students did not pick up a packet, or have recently enrolled at Leesville, all information can be obtained from the Guidance Office.  All completed summer work is due by Friday of the first week of school. Students are also encouraged to purchase an AP U.S. History review text available at any bookstore or from a former student.  Students with questions or problems should contact Mrs. Propes at 844-7046 or by email, mpropes@wcpss.net

 

AP English 11 and 12

 

Summer reading assignments for AP English 11 and 12 can be found on the Leesville Road High School web page.  Detailed information concerning due dates for assignments and summer reading tests are noted. If you have questions regarding summer assignments, please e-mail yanderson@wcpss.net concerning AP English 11 concerns and rfloyd@wcpss.net for AP English 12 questions.

 

Fall Athletic Tryouts

 

Fall sports begin prior to the first day of school, and many new students are unaware of this fact. Plan ahead in order to be present at the designated site on the appointed day with the proper paperwork!

 

Football (Varsity and JV)                                                    August 1 (J.V.’s 8 a.m. – Varsity 5 p.m.)

Women’s Golf                                                                      August 10, 11, 15 at 2:30 p.m., Wildwood Green

Soccer (Varsity and JV)                                                       August 8 at 8 a.m.

Cross Country                                                                      August 8 at 5 p.m.

Tennis                                                                                    August 8 at 9 a.m.

Volleyball                                                                              August 8 at 6 p.m.

Cheerleading (Varsity and JV)                                           August 1 at 6 p.m.

 

All athletes MUST provide a completed athletic form prior to the first day of tryouts.  This includes an up-to-date physical exam.  Also, a permission to treat form must be completed.  All paperwork must be turned in to the Athletic Trainer by July 15 at 3 p.m.

 

The physical form is valid for one calendar year from the date of your exam.  Athletic forms are available in the main office.  All forms may be returned to the main office for forwarding to the Athletic Trainer.  Please realize that all tryout sessions are mandatory.

 

Students interested in running cross country should participate in the summer conditioning program.  Coach Scioli can be reached at 291-0077 for a schedule of these meetings.

 

Candidates for football need to participate in the summer conditioning program.  Coach Green can be reached at 870-4271 for a schedule of these meetings.

 

Choral Notes

 

We are looking forward to the 2005-2006 school year.  Our first Performing Arts Booster meeting (for parents and choral students) will be held on Tuesday, August 30 at 7:00 p.m. in the chorus room.  Everyone is encouraged to attend this meeting and become active in supporting our choral endeavors.

 

Below are some contact numbers that you may need during the summer:

 

PAB President:                                     Mary MacDougal                                844-6531

Grocery Certificates:                            Robin Small                           781-4799

Durham Bulls:                                       DeeAnn Cherveny               848-6683

Uniforms:                                               Carol Resovsky                    783-7302

 

Please visit our website at lrhspad.net for additional information.

 

Band News & Notes

 

The Concert and Symphonic Bands enjoyed a very successful year! Both Bands were awarded straight Superiors in the State Music Festival and both gave outstanding concerts throughout the year!

 

The 2005-2006 LHS Band Program is well on its way for another truly outstanding year. The new officers have been appointed and are already starting their duties.  The Symphonic Band had its first summer rehearsal on Tuesday, May 31 and will meet at school for Pre-Band Camp during the week of July 26-29. The Seniors teach the fundamentals of marching during these sessions. The 9th Band Camp for the Symphonic Band will be held in Banner Elk at Lees-McRae College from Sunday, July 31 through Saturday, August 6. The purpose of Band Camp is to learn the Fall Marching Show!

 

Those who might be interested in becoming a member of the Band Program must speak to Mr. Albert to schedule an audition. You may call 870-4297 or email dalbert@wcpss.net to do so. To find out more about the activities of the Band Program, please visit our website, leesvilleband.org

 

Pride Productions

 

Leesville Road High School is proud of its Theatre Department. Our play season includes two main stage productions, a straight play in the fall and the spring musical. A thriller/comedy is scheduled for October 27-29 with curtain at 7 p.m. Open auditions will be held August 31 and September 1. Our musical which will be running May 11-13, has not been named yet. The Theatre Arts III/IV class will be competing at NCTC play competition in November and will also be performing Canterbury Tales for the English classes. On February 10, the Theatre Arts classes will perform Voices from the High School at Pride Productions' annual "Eat Your Heart Out" dessert theatre in the food court. We will end the year with an original play written and performed by a Leesville senior in our traditional Senior Showcase production.

 

Students may get involved in theatre in several ways. They may take theatre arts classes, as well as technical theatre ones. In addition, they may audition for both main stage productions. Pride Ensemble is one of Leesville's honor clubs open to all interested students. The International Thespian Society is an honor club whose membership is earned by students who put a minimum of one hundred hours in the theatre. Hours can transfer from other schools, as well as memberships from other troupes. Parents are encouraged to get involved in our theatre booster club, Pride Productions. It is an excellent way to give support to this thriving program. For more information concerning the theatre program, contact the Artistic Director- Lou Whitmire at lwhitmire@wcpss.net.

 

 

 

2005-2006 Course Selection Change Form

 

 

Course selections for the 2005-2006 school year were made during the Spring 2005 semester.  You may request changes to your course selections by completing this form.  Please remember that some courses require a teacher’s recommendation.  If you wish to waive the teacher recommendation requirement for a particular course, please check the box at the bottom of this form.  (Please note that requests during the 2005-2006 school year to drop a course for which a waiver was granted will not be honored.)  All requests to change course selections for the 2005-2006 school year must be mailed or delivered to the Student Services Office no later than July 22.

 

Students with conflicts in their class schedules will be contacted in July and early August.  Math and English courses will be automatically changed to reflect course failures during the 2004-2005 school year.  Math and English courses also will be changed to reflect successful completion of summer school courses.

 

We will not have a school-wide “Drop/Add Day” prior to, or after, the start of the school year.  In addition, the only student schedule change requests to be honored outside of the process employed by the use of this form will be ones involving graduation issues, restart issues involving previous failures of sequential courses, and incomplete student schedules missing courses in one or more class periods.

 

 

 


Course to DROP                 Course #                                                              

 

__________________      __________________

 

__________________      __________________

 

__________________      __________________

 

__________________      __________________

 

Course to ADD                    Course #

 

 

__________________      __________________

 

__________________      __________________

 

__________________      __________________

 

__________________      __________________

 


Please check the box below if appropriate.

 

 

 
Please waive the “teacher recommendation requirement” for the course(s), if one exists, and place my child in the course(s) requested.   (I understand that requests during the 2005-2006 school year to drop a course for which a waiver was granted will not be honored.)

 

 

 

_____________________________      ______     ___________________________         ______________

                   Student Name          Grade                     Parent Signature                                    Date

 

 

Daytime Telephone____________________________________________________________________

 

  

E-Mail Address:______________________________________________________________

 

 

 

 

 

 

2005-2006 Student Parking Form

 

 

Dear Leesville Road High School Student:

 

Students who possess a valid North Carolina driver’s license may request a parking space by mail.  The parking fee established by the Wake County Board of Education for the 2005-2006 school year is $120. Fees will be reduced by $10 per whole month not used.  To request a space, please read the rules on the back of this form governing the operation of a vehicle on the campus and fill out the requested information.

 

Name_______________________________________         Grade for ‘05-’06__________

Address _____________________________________        Date of Birth ____________

Home Phone ________________________   N.C. Driver’s License Number __________

Expiration Date of License _______________________         Date of Issue ____________

 

Car(s) to be parked on Campus:

First:        Year/Make/Model/Color __________________________________________

               License Plate Number ____________________________________________

Second:  Year/Make/Model/Color __________________________________________

               License Plate Number  ___________________________________________

 

Please return this form in a business size envelope to the following address by August 8 and mark the envelope “Parking Request”:  Leesville Road High School, 8409 Leesville Road, Raleigh NC 27613.  Student Council representatives will randomly draw for the spaces on August 9 and parking tags will be mailed to students on that date.  Please make a photocopy of your North Carolina Driver’s License and attach it to this form.  Your application will not be processed without (1) the application, (2) a check made payable to Leesville Road High School, and (3) the photocopy of the license.

 

Spaces not issued through this process will be made available to students throughout the 2005-2006 school year.

 

No request will be processed without signed validation of the following statement:

 

As evidenced by my signature, I agree to all of the enclosed rules pertaining to operating a vehicle on the Leesville Road High School campus.  Furthermore, I am aware that towing a vehicle at the expense of the owner is one option that may be exercised for failing to abide by these rules.

 

 

Student Signature _______________________________________Date __________

Parent Signature ________________________________________Date __________

 

Student E-mail Address: _________________________________

Parent E-mail Address: __________________________________

 

 

 

Please see reverse page for rules pertaining to this privilege.

 

 

 

 

 

 

 

2005-2006 Leesville Road High School Parking Regulations

 

1.        The parking fee established by the Wake County Board of Education for the 2005-2006 school year is $120.  Fees will be reduced by $10 per whole month not used.

2.        Parking permit applications will be available to licensed drivers only as announced by the principal.

3.        All students who park a motor vehicle on the Leesville Road High School campus must display the current hanging tag permit.  The tag must be hung from the inside rear view mirror facing the front of the vehicle. Students who fail to properly display the tag will be ticketed or have their tags revoked.

4.        Vehicles must be parked in assigned spaces.  The only spaces available for student parking are located in the student parking lot.  Students may not park on the roads on, or surrounding, the campus.  Furthermore, students may not park in campus intersections and driveways or on the campuses of Leesville Road Elementary School or Leesville Road Middle School.  Vehicles parked in the wrong space, or in unauthorized areas, will be towed at the owner’s expense and the permit will be subject to revocation without refund.

5.        Vehicles should be parked front-end first.  Backing into spaces is not permitted.

6.        The safe operation of motor vehicles is required.  Vehicles must not travel in excess of 10 miles per hour on campus.  Seat belts are required for drivers and all passengers.

7.        Speeding and reckless driving are prohibited.  Exiting from the student parking lot in the afternoon will be held until buses clear the area.  Citations will be issued as necessary.

8.        Supervision is provided for parking lots; however, Leesville Road High School and the Wake County Public School are not responsible for damages to, or theft from, vehicles.  Students are cautioned NOT to leave valuables in their vehicles.  Parked vehicles should be left with windows closed and doors locked.

9.        A student’s vehicle is subject to search in the case of reasonable suspicion regarding the presence of drugs, alcohol, stolen property, or other contraband in the car.

10.     Disabled vehicles may not be left on campus overnight.  If necessary, towing should be arranged by the student.

11.     Refunds for parking fees will be made if the student moves away from the Wake County Public School System.  All refunds will be made prorata, based on a “$10 per whole month not used basis.”

12.     If a student holding an assigned parking space transfers within WCPSS during the year, he or she will be assigned a space at the new school with no further payment of fees provided the original parking tag has been returned to the office of the previous school.  If no space is available at the new school, the originating school will make the refund.

13.     Parking fees will NOT be refunded for

a.        voluntary withdrawal from school (dropping out);

b.       long-term suspension from school;

c.        school-based disciplinary action related to loss of parking privilege;

d.       loss of driving privilege due to revocation of operator’s license; OR

e.        any reason not specified above.

14.     Only one tag will be issued per student.  Students may register up to two of their family vehicles.  The tag may be moved from one registered family vehicle to another, but may NOT be sold or loaned to another student for his or her use.  The penalty for so doing is revocation of parking privileges.  Spaces may NOT be shared by students.

15.     Inform the office immediately of any vehicle or license plate changes.

16.     Lost parking tags will be replaced for a $10 fee.  Report losses to the office promptly.

17.     School Board Policy 6410 prohibits the possession and/or use of tobacco products on campus.  Students may not possess tobacco products or smoke in cars at any time while on the school campus.

18.     Loitering in the parking lot is prohibited. Students need to leave the parking lot immediately upon arriving to school. Written permission from an administrator must be obtained to be in the student parking lot during school hours.

19.     Students who operate a motor vehicle on campus should fully understand their duties and responsibilities.  Under School Board Policy 7180, students who violate parking regulations are subject to any or all of the following consequences:

a.        Revocation of parking privilege

b.       Ticketing

c.        Towing and storage of the vehicle, at the owner’s expense

d.       Disciplinary action

e.        Criminal charges as prescribed by law

20.     Handicapped parking is only available as needed on an assigned basis.

21.     Parking a vehicle on school property is a privilege, not a right.  Please review all parking regulations and call the school for clarification of any matter about which there are questions.

 

2005-2006 Off-Campus Lunch Form

 

 

Wake County School System policy requires parents to come to school to sign permission forms for juniors and seniors to leave campus for lunch.  However, if a parent can not come to the school, he/she may choose to complete this “2005-2006 Off-Campus Lunch Form.”  This form must be signed by the parent and notarized.  It can be mailed to the school or sent back with the student.  Regardless of the chosen option, all lunch passes will be distributed on August 22 in the school’s main lobby.  The time of distribution will be 5:00 p.m. – 6:30 p.m.  Additional copies of this form will be available in the school’s main office.

 

Please read the 2005-2006 Off-Campus Lunch Rules on the back of this form.

 

A student who leaves campus must follow the checkout procedure if he/she is unable to return to class.  Failure to follow this procedure will void this agreement.  The procedure involves having the parent/guardian of the student contact the school attendance office immediately after determining that the student can not return following lunch.

 

I hereby request a lunch permit and agree to comply with the conditions set forth and any other policies which may be announced at a later date.

 

Student Name (Please print)_______________________________________

 

Student Signature_________________________________Date_________ E-mail Address___________________

 

 

I _______________________________ hereby request that my son/daughter named above be issued a lunch permit to leave campus during his/her regularly-scheduled lunch period according to the conditions and policies set forth by Leesville Road High School.

 

Parent Signature_________________________________Date _________ E-mail Address___________________

 

 

 

 

Sworn to and subscribed before me this _____ day of__________________, ______

 

 

             Seal

                                                                __________________________________________

                                                                                Notary Public

 

 

My commission expires _______________________.

 

 

 

 

 

 

 

Please see reverse page for rules pertaining to this privilege.

 

 

 

 

 

 

 

 

2005-2006 Off-Campus Lunch Rules

 

 

Please note the following stipulations regarding lunch passes:

 

  1. The provision of off-campus transportation for students who do not have a lunch permit is prohibited during lunch periods.  Consequences for such actions include loss of the lunch pass and revocation of parking privileges.

 

  1. The lunch pass is the property of Leesville Road High School and may be revoked at any time in cases of inappropriate use.

 

  1. The lunch pass is expected to be displayed each day the student leaves campus.

 

  1. Exit and entry of the campus must take place from the student parking lot.

 

  1. Duplicate lunch passes will be issued through the main office. However, a  one-week time frame will be observed before a duplicate lunch pass will be issued.  All requests for a duplicate lunch pass must be accompanied by a written parental request.

 

  1. The lunch pass allows the junior or senior to leave campus during his/her regularly-scheduled lunch period, provided he/she has the lunch permit in his/her possession at the time.

 

  1. The student and parent are responsible for transportation to and from campus during lunch periods.

 

  1. The school assumes no liability for any accident or injury incurred in the exercise of this lunch pass.

 

  1. Students exercising off-campus lunch privileges are subject to the rules of student conduct as applicable to the regular school day adopted by the Wake County School Board and Leesville Road High School.

 

  1. Littering of public or private property will result in the revocation of the lunch pass and disciplinary action.

 

  1. Lunch passes will be distributed on August 22 in the school’s main lobby from 5:00 p.m. – 6:30 p.m. Students may obtain a lunch pass by being accompanied by a parent or bringing the signed and notarized form, if not accompanied by a parent.   Students who mailed in the notarized form may pick up their lunch passes on the same evening.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2005 – 2006 Student Medical Survey Update Form

Wake County School Nurse Program

 

 

Name ____________________________________DOB ________________ Grade ____

 

This survey seeks to identify those students who have a chronic disease.  If you have one of the following diseases, please circle the name or add any others that have been diagnosed by your doctor.

 

                                DIABETES

 

                                ASTHMA

 

                                EPILEPSY

 

If you have circled one of these diseases or have any others, please describe your medication routine.

 

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Doctor’s Name _____________________________ Phone Number _________________

 

Parents’ Names ___________________________________Home Phone _____________

 

Father’s Work Phone ____________________Mother’s Work Phone ________________

 

Siblings _____________________________ School ____________________________

 

              _____________________________             ____________________________

 

 

Insurance ____________________________ Other ______________________________

 

Medicaid ____________________________

 

This form should be completed and mailed to the following address prior to August 19:  Leesville Road High School, 8409 Leesville Road, Raleigh NC 27613.  It will be accessible to teachers and staff through the school nurse.